SELECTED ABSTRACTS - North Shore-LIJ Health System

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					SELECTED ABSTRACTS                                                         several autoimmune diseases. Accordingly, we hypothesized that
                                                                           CXCL13 is upregulated during SS progression, and may serve as a
PAPERS                                                                     valuable biomarker of disease. Methods: We quantified CXCL13 by
                                                                           quantitative PCR and ELISA at early and late stage disease using SS
BASIC SCIENCE RESEARCH                                                     murine models. Results: Salivary and serum CXCL13 levels correlate
                                                                           with disease severity in pSS and sSS models. Moreover, CXCL13 co-
Selective Inhibition of Cyclooxygenase-2 (Cox-2) Suppresses                localizes with lymphocytes within salivary tissue in a pSS model, and
Metastatic Disease Without Affecting Primary Tumor Growth in a             serum CXCL13 correlates with saliva levels during late stage disease.
Murine Model Of Ewing’s Sarcoma. Amir S. Gendy, MD, Richard                Conclusion: These data indicate that CXCL13 in salivary tissue and/or
D. Glick MD, Bettie M. Steinberg PhD, Morris Edelman MD, Samuel            sera may be pathogenetically involved in SS disease and may serve as
Z. Soffer MD; Department of Pediatric Surgery, North Shore-Long            a marker of SS progression and severity. Therapeutic targets of
Island Jewish Health System/Cohen Children’s Medical Center                CXCL13 may provide an innovative approach in the management of
Purpose: The mammalian target of rapamycin (mTOR) is a central             this debilitating disease, resulting in significant improvements in the
signaling mechanism found in most human cancers and directly               health of afflicted individuals.
stimulates angiogenesis via a COX-2-mediated mechanism. mTOR
suppression by rapamycin inhibits tumor growth and                         Dynamics of Large Dense Core Vesicle Transport are Regulated
neovascularization but not lung metastases in a murine model of            by Neuronal Stimulation. Jacqueline A. Sobota DMD PhD, William
Ewing’s sarcoma. We hypothesize that combining a selective COX-2           A. Mohler PhD, Ann E. Cowan PhD, Betty A. Eipper PhD, Richard E.
antagonist (celecoxib) with rapamycin would decrease lung                  Mains PhD; Department of Dental Medicine, North Shore University
metastases. Methods: Ewing’s sarcoma cells (SK-NEP-1) were                 Hospital
surgically implanted into the left kidney of athymic mice (n=40). The      Background: Peptidergic neurons store and secrete the contents of
mice were divided into 4 treatment groups (control, rapamycin only,        large dense core vesicles (LDCVs) from axon terminals and dendrites.
celecoxib only and combination). All mice were sacrificed at 6 weeks       Secretion of peptides requires a highly regulated exocytotic
and the organs were harvested. Primary tumors were weighed and             mechanism as well as coordinated synthesis and transport of LDCVs to
vasculature was examined using lectin angiography and                      their sites of release. Although these trafficking events are critical to
immunohistochemistry for endothelial cells. Lung metastases were           function, little is known regarding the dynamic behavior of LDCVs
examined with a pediatric pathologist using H&E and                        and mechanisms by which their transport is regulated. Objective:
immunohistochemistry for Ewing’s markers. Tumor weights were               Since LDCVs cannot be refilled locally after their contents are
analyzed with the unpaired t-test and lung metastases with factorial       secreted, our goal was to investigate how neurons support regulated
design. Results: Mean primary tumor weights were significantly             release of peptides. Alteration of LDCV delivery could be used to
reduced in the rapamycin treated groups (control 3.5 grams ± 0.58          meet cellular demands; therefore, we assessed changes in vesicle
SEM; rapamycin only, 1.02 grams ± 0.2, p<0.001; combination, 0.81          dynamics in response to neuronal stimulation. Methods: Vectors
grams ± 0.26, p<0.001) but not in the celecoxib only group (3.6 grams      encoding a soluble LDCV protein, p                       -hydroxylating
± 1.2). Lectin angiography and immunostaining for endothelial              monooxygenase (PHM), fused to green fluorescent protein (GFP) and
markers (platelet endothelial cell adhesion molecule-1, alpha smooth       pHluorin (a pH-sensitive GFP variant) were constructed to address
muscle actin, collagen-4) showed markedly decreased vascularity in         these questions in cultured primary peptidergic neurons of the rat
the rapamycin treated groups but not in the celecoxib only group. Lung     trigeminal ganglion. Time lapse confocal microscopy was used to
metastases (CD99 positive) in the celecoxib treated groups showed          track individual vesicles in axons and growth cones of transfected
statistically significantly fewer metastases than non-celecoxib treated    neurons, and the effects of two secretagogues, high K+ and phorbol
groups. (control 9/10 + for lung metastases; celecoxib only 3/9 +,         ester, were assessed. Exocytosis was assayed via biochemical assay,
p<0.02; combination 3/10, p<0.02; rapamycin only 7/10 +, NS).              immunocytochemical detection of internalized antibody, and real-time
Conclusion: Celecoxib prevents lung metastasis in a murine model of        confocal visualization of changes in PHM-pHluorin fluorescence
Ewing’s sarcoma with no effect on tumor size or neovascularization.        following secretagogue stimulation. Results: The time course of
COX-2 may represent a future potential target for metastatic disease       release differs with secretagogue; the secretory response to
prevention.                                                                depolarization with K+ is rapid and terminates within 15 minutes, while
                                                                           phorbol ester stimulation of secretion is maintained over a longer
CXCL13 in Sjögren’s Syndrome: A Novel Biomarker of Disease.                period. The data demonstrate fundamental differences between LDCV
Jill M. Kramer DDS PhD, Thomas L. Rothstein MD PhD; Division of            dynamics in axons and growth cones under basal conditions.
Oral Pathology, Department of Dental Medicine, Long Island Jewish          Furthermore, LDCV motility in axon segments preceding growth
Medical Center                                                             cones is regulated by secretagogue, with more LDCVs moving in the
Introduction: Sjögren’s Syndrome (SS) is a rare autoimmune                 anterograde direction after K+ stimulation and more LDCVs pausing
dyscrasia. Primary SS (pSS), or sicca syndrome, affects salivary and       after stimulation by either secretagogue. Quantification of enzyme
lacrimal glands predominantly, while secondary SS (sSS) occurs in          secretion, data from antibody uptake, and appearance of pHluorin
conjunction with other autoimmune connective tissue disorders, most        fluorescence demonstrate distributed release of peptides throughout
commonly rheumatoid arthritis (RA) or systemic lupus erythematosus         both axons and growth cones. Conclusions: These results suggest an
(SLE). In addition to reduced salivary and lacrimal function, serious      important role for cytoskeletal components and their associated motor
systemic aspects of the disease such as lymphoma and                       proteins in sustaining peptide secretion. Moreover, fusion events are
musculoskeletal, pulmonary, and renal manifestations are recognized.       widely distributed, consistent with a role for non-synaptic peptide
Currently, care for SS patients is palliative, as no established           release.
therapeutics target the immune dysfunction directly. While significant
strides have been made in understanding the contributions of               CASE REPORTS
lymphocytes to SS pathogenesis, it is crucial to identify immune
mechanisms that drive disease development and the factors                  Severe Acute Myocarditis Following 2009 Novel H1N1 Influenza
contributing to its progression. Although T cells were initially thought   Infection. Robert M. Bramante MD, Angela Cirilli MD, Christopher
to be key mediators of disease, an important role for B cells is           Raio MD; Department of Emergency Medicine, North Shore
emerging, as B cell abnormalities have been identified systemically        University Hospital
and within salivary glands. However, the contribution of these cells to    Myocarditis is an uncommon diagnosis that must be considered in
SS initiation and                                                          patients with acute myocardial dysfunction. There has been much
                                                                           morbidity associated with the 2009 novel H1N1 influenza pandemic.
                                                                           Most morbidity is related to pulmonary complications. We are
                                                                           reporting a unique case of myocarditis with severe cardiac dysfunction
                                                                           due to novel H1N1 influenza. An otherwise healthy 7 year old female
                                                                           presented with abdominal discomfort and flu like symptoms. The
progression is not well understood. In order for B cells to function       patient became unresponsive and hypotensive in the ED. A bedside
most efficiently, they must be recruited to specific sites where they      FAST ultrasound was performed by the ED staff displaying a moderate
interact with other cells and secrete mediators to orchestrate effective   sized pericardial effusion without tamponade and significant
immune responses. CXCL13 is a B cell chemokine that is elevated in
contractile dysfunction. Ionotropic support was initiated. The patient      extrapulmonary manifestations of tuberculosis. We describe a case
was found to have diffuse ST elevations on ECG and an elevated              report of peritoneal tuberculosis mimicking carcinomatosis in a 40 year
troponin. Viral panel returned with influenza A unsubtypable probable       old Bangladeshi man with no contributory past medical history who
novel H1N1. The patient underwent PICU admission, had mechanical            presented to the LIJ ED with 12 days of worsening abdominal pain and
ventilation, and had IVIG treatment. Due to persistent shock the            distention. He described a dull epigastric pain that did not radiate
patient was transferred to a cardiac transplant center for transplant       without any other gastrointestinal symptoms. On physical exam the
evaluation and ECMO therapy. While cardiac function improved based          patient was found to have tense ascites. The patient had a history of
allowing the discontinuation of ECMO therapy, a number of                   negative PPDs. Chest X-ray revealed pleural effusions. Abdominal CT
morbidities were experienced including compartment syndrome,                with contrast revealed tense ascites and was read as peritoneal
rhabdomyolysis, and acute renal failure requiring dialysis. Viral           carcinomatosis. The patient was negative for AFP, CEA, and CA-19-9.
myocarditis has been associated with influenza infection in prior           CA-125 level was highly elevated at 904. Repeat PPD was negative.
literature. To our knowledge this is the first reported case associated     Paracentesis fluid yielded a straw-colored lymphocyte-predominant
with novel H1N1 influenza. Cardiac dysfunction is associated with           exudate with elevated LDH. Both paracentesis and IR-guided omental
vasculature injury, immune mediated damage and/ or viral cell               biopsy were negative for malignant cells and AFB. The patient
invasion based on animal studies. Pericardial effusion and associated       received a biopsy of the peritoneum via laparoscopy. On examination
pericarditis have been noted in the literature as well. While definitive    the surfaces of the peritoneum and the serosa of the bowel were
diagnosis is based on endocardial biopsy, available literature supports     covered in multiple, round, white dome-shaped plaques. ACE level
a clinical diagnosis of viral myocarditis with viral symptoms, an ECG       was high normal. Surgical pathology was obtained from the omentum
with ST segment abnormalities, elevated cardiac enzymes, and                and the peritoneum, both of which revealed florid non-necrotizing non-
evidence of hypokinesis in the absence of acute ischemia. Emergency         caseating granuloma. Quantiferon was positive for tuberculosis. In
department ultrasonography has support in the literature in cases of        patients with abdominal symptoms but no risk factor for cancer,
medical hypotension. In this case it altered the clinical thought process   Quantiferon is a useful and highly sensitive and specific method to
of septic shock requiring vasopressor support and fluid resuscitation.      determine tuberculosis in populations at risk. Commonly ordered tests
We believe bedside ultrasound allowed for the rapid appropriate             such as PPD and AFB staining have very low sensitivity. In this report
diagnosis of cardiogenic shock requiring ionotropic support, and it         we discuss the utility of commonly available testing methods for the
guided consultation and management in this case.                            diagnosis of abdominal tuberculosis in a large urban medical center
                                                                            and a review of the etiology, epidemiology and treatment of
Utility of Immunocytochemistry in Diagnosing Leptomeningeal                 extrapulmonary tuberculosis.
Metastases from an Intrahepatic Cholangiocarcinoma. Shweta
Chaudhary MBBS, Bhoomi Mehrotra MD, Nora J Morgenstern MD;                  An Unusual Case of Bartholin Gland Abscess Caused by Group A
Department of Pathology & Laboratory Medicine, North Shore-Long             Beta Hemolytic Streptococci. Niti Manglik MD, Yvonne A. Lue PhD
Island Jewish Health System                                                 D(ABMM); Department of Pathology & Laboratory Medicine, North
Introduction: Pure Spinal Leptomeningeal metastasis (LMM) without           Shore-Long Island Jewish Health System
brain metastases is infrequent accounting for about 1% of all solid         Bartholin gland abscess is a common gynecological infection.
tumors. In LMM, Cerebrospinal Fluid (CSF) analysis is abnormal but          Historically Neisseria gonorrhoeae was believed to be the only
only a positive cytology or demonstration of intrathecal tumor markers      etiological agent responsible for this infection. However, the recent
is diagnostic. To the best of our knowledge this is the first case report   literature documents that this infection has a polymicrobial etiology
of cytologically confirmed LMM from an intrahepatic                         with a predominance of anaerobic bacteria such as Bacteroids spp,
cholangiocarcinoma while the patient was on treatment. Case                 Peptostreptococcus spp and Eubacterium spp. Additionally, genital
Description: A 75 year old female with history of intrahepatic              mycoplasmas, gram-negative bacilli and enterococci are other
cholangiocarcinoma presented with progressive right lower extremity         organisms isolated from these patients. We hereby report a very
weakness and numbness. MRI showed osseous metastatic involvement            unusual case of bartholin gland abscess caused by group A beta
of T10-12 vertebral bodies with epidural, paraspinal and right neural       hemolytic streptococci in a young female with no evidence of systemic
foraminal extension, associated epidural and paraspinal tumour along        infection.      Group A beta hemolytic streptococci is frequently
with abnormal enhancement of cauda equine nerve roots and surface of        implicated in pharyngitis, skin infections, myositis, necrotizing
lower thoracic cord which was suggestive of extensive leptomeningeal        fasciitis and toxic shock syndrome. Bartholin gland abscess due to
carcinomatosis. Cytospin preparations were sparsely cellular with few       group A beta hemolytic Streptococci is extremely rare. An extensive
singly lying malignant cells in a background of acute and chronic           review of the literature yielded only one reported case of bartholin
inflammatory cells. The tumor cells showed high nucleocytoplasmic           gland abscess due to Group A beta hemolytic streptococci in a patient
ratio, round to oval nuclei with prominent atypical elongated nuclei        who had toxic shock syndrome. Our patient was a 17-year-old female
and moderate amount of ill defined cytoplasm. On                            with no significant past medical history who presented with
immunocytochemical staining, tumor cells were positive for CK7 and          progressively worsening right bartholin gland swelling along with
                                                                            cellulitis of right inner thigh. There was no other evidence of systemic
AE1/AE3. Discussion: The initial CSF cytology is false negative in up       infection or symptoms of toxic shock syndrome. The patient was
to 40-50% of patients with pathologically proven LMM on autopsy. In         initially treated with doxicycline and advised to have sitz bath and
our case of intrahepatic cholangiocarcinoma which was CK7, CK 19,           apply warm compress to area. However, due to worsening pain and
AE1/AE3 positive and CK 20, Hep par 1, Synaptophysin, TTF 1                 cellulitis the cyst was marsupialized. The purulent fluid removed
negative, spinal LMM was confirmed using CK7 and AE1/AE3                    during surgery was cultured and processed for the recovery of aerobic
immunocytochemical studies on paucicellular cerebrospinal fluid             and anaerobic bacteria. Group A beta hemolytic streptococci was the
cytospin preparation. Given the paucicellularity of the smears and          only organism recovered. Histologically the diagnosis of bartholin
difficult morphologic categorization, immunocytochemistry is vital for      gland abscess was confirmed. The patient responded well to the
confirmatory diagnosis and can help reduce the false negative results.      abscess marsupialization and doxicycline.
One prior study retrospectively reviewed the initial false negative
cytology after autopsy findings of leptomeningeal involvement by            First Reported Case of Autoimmune Pancreatitis Associated with
poorly differentiated adenocarcinoma in a patient with history of           CFTR Gene Polymorphism. Henna Patel DO, Toba Weinstein MD,
cholangiocarcinoma and found them to be positive for malignant cells        Jeremiah Levine MD; Division of Pediatric Gastroenterology &
using immunocytochemical staining. To conclude, in all patients of          Nutrition, Department of Pediatrics, North Shore-Long Island Jewish
LMM, immunocytochemistry is a useful adjunct in CSF cytology.               Health System/Cohen Children’s Medical Center
                                                                            Autoimmune (AIP) and idiopathic pancreatitis are rare causes of
Peritoneal Tuberculosis with Elevated CA-125 Level Mimicking                chronic pancreatitis in the pediatric population, with chronic
Peritoneal Carcinomatosis. Michael Kadoch MD, Jesse T. McCann               pancreatitis itself being uncommon in children. It is even more
PhD MS-III, Judah Goldschmiedt MD, Moshe Weinstock MD, Nancy                infrequent to have idiopathic pancreatitis associated with CFTR gene
Zeitoun MD; Department of Medicine, Long Island Jewish Medical              polymorphism. There are no reported cases of AIP associated with
Center                                                                      CFTR gene variance to date. We report a case of a 16-year-old male
Tuberculosis should always be considered in those who have lived in         with chronic pancreatitis and a history of multiple hospitalizations for
endemic areas. Abdominal tuberculosis is one of the most common             episodes of acute pancreatitis. Initial workup revealed a CFTR gene
polymorphism of undetermined clinical significance- R75Q. R75Q is a           +/- septic component. Abdom sono ordered to look for source of bleeding
CFTR gene variant that has been linked to COPD, but no clear                  – found large 6.5 x 13.4cm right subcapsular renal hematoma and large
association with pancreatitis. The patient was diagnosed with                 right retroperitoneal bleed. Abdominal angiography performed for
idiopathic pancreatitis attributed to his CFTR gene variance.                 possible embolization – found irregularities of the renal and superior
Conservative medical management of this patient's pancreatitis by             mesenteric arteries compatible with either FMD, Segmental Arterial
dietary restriction resulted in improvement each time. Progressive            Mediolysis or Vasculitis (PAN), but in combination with clinical course
chronicity led to further investigation, including radiological studies,      suggestive of the segmental arterial mediolysis (SAM) rather then FMD
ERCP, equivocal ANA, and elevated IgG-4 level, which raised and               or PAN. Segmental arterial mediolysis (SAM) is an uncommon non-
supported the diagnosis of AIP. AIP is an uncommon cause of chronic           atheroslerotic, non-vasculitic disease of the vasculature that causes
pancreatitis, as is idiopathic pancreatitis associated with CFTR gene         massive hemorrhages. SAM is not distinguishable from FMD or
polymorphism. The average presenting age for AIP is 63 years with             polyarteritis nodosum on angiogram and must be ruled out in these cases.
80% of the patients with AIP being over 50 years old. Despite the             PAN is treated with immunosuppresents and corticosteroids. Case reports
possibilty that CFTR gene variance may be an incidental finding, there        of SAM patients mistakenly treated with these medications has proven to
are several historical findings suggesting that the patient’s                 be fatal. Anticoagulation is contraindicated in case of SAM.
symptomatology may at least partially be attributable to it. The
combination of this patient’s age, presence of CFTR gene variance,
and features of AIP make this case first of its kind.                         CLINICAL SCIENCE RESEARCH

Ketamine Cystitis: A New Syndrome From An Old Drug. Eboni                     Burn Bed Availability. Riccardo Benvenuto DO, Kevin Munjal MD,
Woodard MD, Marina Ruzimovsky NP, Robert Moldwin MD; Smith                    Bradley Kaufman MD, David Prezant MD, David Ozimek;
Institute for Urology, North Shore-Long Island Jewish Health System           Department of Emergency Medicine, Long Island Jewish Medical
Introduction: Ketamine is an N-methyl-D-aspartic acid receptor                Center
antagonist developed as a short-acting general anesthetic in humans.          Introduction: Disaster preparedness necessitates adequate planning
Ketamine, also known as ‘Special K,’ gained popularity as a                   for the care of large numbers of burn patients. As part of New York
recreational drug in the 1990s among young adults in the setting of           City emergency preparedness, New York City assesses burn bed
night clubs and raves. Its effect on the nervous and cardiovascular           variability every 8 hours. It is believed that this is superior to once
systems have been well studied, however its effects on the                    daily collection of burn bed availability data as performed by many
genitourinary system are just recently being investigated. Case               other large cities. The objective of the study was to determine if there
Description: We describe the cases of three young adults, one male,           is a significant intraday variability of burn bed availability that
two females, aged 28-29 with a history of ketamine abuse who                  warrants such frequent assessments. Methods: FDNY Emergency
presented to our urology clinic with complaints of severe dysuria,            Medical Dispatch collects burn bed availability data via phone calls to
urgency, and frequency. Symptom duration was greater than one year            each of the local burn specialty centers 3 times a day. This
and all patients had been previously treated in some form with no             information is entered manually into the Computer Aided Dispatch
significant improvement in their symptoms. On exam, all patients had          system and made available to incident commanders making transport
either suprapubic or pelvic muscle tenderness. Urine analyses revealed        decisions. Data was obtained from February 1st-28th 2009 which
occasional white and red blood cells and urine cultures were repeatedly       reported burn bed availability status from 7 different city hospitals 3
negative. Urine cytologies were negative for malignant cells. CT              times per day (8am, 4pm, and 12am). A statistical analysis of variance
examinations performed on two patients showed focal bladder wall              (one-way ANOVA) was performed on individual hospital data and on
thickening and one patient had significant bladder wall calcifications.       the system as a whole. Results: There was no significant difference in
Cystoscopic examinations revealed grossly inflamed bladders with              the number of burn beds reported available at different times of day for
decreased capacity as often seen in patients with interstitial cystitis       either an individual hospital or for the group as a whole
(IC). As such, in addition to discontinuation of ketamine, these patients     (p=0.110). There was a significant difference between the numbers of
are being managed with many of the same therapies used in IC                  beds reported available at each hospital between days (p<0.000).
patients,     including     antihistamines,    pentosan      polysulfate,     However, there was no significant difference in bed availability
antidepressants, and intravesical anesthetic instillations. Discussion:       between days in the overall system. Discussion: This study showed
An association between recreational ketamine abuse and bladder                that there was no significant intraday variability in burn bed
dysfunction was first reported in 2007. The etiology is currently             availability. Therefore, it may not be necessary to conduct more than
unknown. In early disease, cessation of ketamine use may resolve              once daily assessments of bed availability. The larger issue of creating
lower urinary tract symptoms, but in most cases patients are presenting       greater bed availability and surge capacity remains and requires greater
with more chronic symptoms of ulcerative cystitis and in some cases           attention.
renal impairment and may require individualized therapies on a long
term basis.                                                                   Imaging-Related Radiation Exposure in Pediatric Patients with
                                                                              Inflammatory Bowel Disease (IBD): Are We Increasing the
Case of Segmental Arterial Mediolysis (SAM) Presenting as ICA                 Likelihood of Malignancy in a Group Already at Risk? Yonathan
Dissection/Occlusion with Subsequent Embolization to the Left MCA             Fuchs MD, James Markowitz MD, Toba Weinstein MD, Nina Kohn
Treated with Anticoagulation and Induced Hypertension. Anna Shor              MBA MA, Jeanne Choi-Rosen MD, Jeremiah Levine MD; Division of
MD; Department of Neurology, North Shore-Long Island Jewish Health            Pediatric Gastroenterology & Nutrition, Department of Pediatrics,
System                                                                        North Shore-Long Island Jewish Health System/Cohen Children’s
70 yo M presented with acute onset R hemiparesis, R HHA, L gaze               Medical Center
deviation and aphasia with subsequent clinical improvement. Still was         Increasing use of diagnostic radiography has led to concern over the
globally aphasic (expressive>>receptive), following some commands,            malignant potential of ionizing radiation. Recent studies in adults with
dysarthric, had central facial droop on right with rest of the exam normal.   IBD have demonstrated that it is common for patients to receive a
CTA head done, showed left carotid dissection with irregular tortuosity of    cumulative effective dose (CED) >50 millisieverts (mSv) from
the vessel - most likely representing fibromuscular dysplasia. P-t started    diagnostic tests, a dose associated with increased cancer risk. Children
on a heparin drip dosed by weight without a bolus with recommendations        are thought to be at increased risk for radiation related malignancy
to keep p-t hypertensive: SBP 160-210 DBP 90-115. Several hours later         when compared to adults, yet the imaging-related radiation exposure
p-t worsened: worsening receptive aphasia- not following commands, R          (IRRE) in the pediatric IBD population has not been quantified. Aim:
HHA, cannot move eyes past midline, right arm plegic, right leg – barely      To estimate the CED from diagnostic imaging studies in children with
moves in plane but no antigravity. BP low (approximately 130s systolic).      IBD, and to identify which children are at greatest risk for high
Patient placed on NS with minimal elevation of BP . Required                  amounts of IRRE. Methods: A retrospective chart review was
neosynephrine to elevate SBP to 200s. Next day p-t complains of               conducted for all children with IBD seen between 1/1/08 – 6/30/08.
abdominal pain w/ tenderness on exam. Overnight pt frankly hypotensive        The effective dose of radiation received from each x-ray, contrast
w/ SBP in 50s. HR 140. Febrile 101.9, decreased pulses, diaphoretic,          study, and nuclear imaging test was estimated for each patient using
labored breathing. Levophed added on top of neosynephrine. Patient            typical effective doses in the published literature. CT doses were based
became oliguric and developed ARF with creatinine 4.5 (Cr on admission        on our institution’s computed tomography dose index (CTDI) values.
0.8) – started on hemodialysis. Pt determined to be in hemorrhagic shock      High cumulative exposure to diagnostic radiation was defined as a
CED ≥50 mSv. Results: Complete records were available for 257 of            the severe depression group was vastly different from the other two
372 screened patients. 171 had CD, 86 UC (mean age at diagnosis: CD         groups. After controlling for covariates, those with severe depression
11.5 ±3.4 yrs, UC 10.5 ±4.3 yrs, mean duration of follow-up CD 5.3          experienced 1.4 more ADL deficits (p= 0.02) than the group with no
±3.5 yrs, UC 5.4 ±3.4 yrs). Mean CED was greater for children with          depression at the end of one year. Conclusions: Severe depression has
CD vs UC (20.5 ± 17.5 vs 11.7 ± 9.9 mSv, P <0.0001). 15 children            a negative effect on functional recovery after hip fracture among older
(5.8%) had a CED ≥50 mSv, including 14/171 (8.2%) with CD and               adults. This may reflect the lack of motivation among the severely
1/86 (1.2%) with UC (P=0.02). Conclusions: A small but important            depressed hip fracture patients to recover and regain independent life.
percentage of children with IBD are exposed to doses of ionizing            Identification of depression early in the course of rehabilitation can
radiation that have malignancy-inducing potential. Physicians caring        help optimize functional recovery. Measures taken to identify
for children with IBD must seek to limit radiation exposure whenever        depression among the hip fracture patients can direct the rehabilitation
possible to lessen the lifetime risk of malignancy.                         plan for severely depressed patients. Interventions to treat depression
                                                                            after 6 months can improve functional recovery in this group. Further
Perioperative Outcomes in the Management of Renal Tumors in                 studies to identify the precise causes of deterioration of function
the Elderly. Arvin K. George MD, Amin S. Herati MD, Sandeep S.              among depressed patients after the first 6 months can help tailor
Saluja BS, Manish A. Vira MD; Smith Institute for Urology, North            rehabilitation programs and ensure optimal functional recovery among
Shore-Long Island Jewish Health System                                      severely depressed hip fracture patients.
Introduction: Improved life expectancy combined with an aging
population has led to an increase in operative interventions in patients    Women vs. Men: How Gender Differences in                      Coronary
traditionally managed conservatively. There is currently a paucity of       Calcification May Impact Cardiovascular Therapeutic Regimens.
data regarding perioperative outcomes in patients >75 years of age.         John N. Makaryus MD, Jay V. Doshi MD, Julia Tai MA, and Amgad
Age-related co-morbidities place this group of individuals at a greater     N. Makaryus MD; Department of Medicine, North Shore University
risk of perioperative morbidity and mortality. We seek to characterize      Hospital
the complications of surgical extirpation versus minimally invasive         Background: Arterial calcium as measured by 64-slice computed
cryoablative and radiofrequency therapies. Methods: Retrospective           tomography coronary angiography (64-CTA) is a reliable predictor of
chart review was conducted to identify 108 patients over the age of 75      cardiovascular disease risk. Lipid-rich plaques with lower degrees of
that presented to a single institution for the surgical management of       calcification may pose greater risk for adverse coronary events than
renal masses. Demographic, clinicopathologic, and perioperative             more stabilized, calcified plaques as a result of the increased risk of
factors of patients undergoing open resection (N=31), laparoscopic          plaque rupture, migration, and subsequent acute coronary syndrome.
resection (N=46) and percutaneous ablation (N=31) were analyzed.            We sought to examine coronary artery calcium scores as measured via
Results: The mean age of patients in the 3 groups was 80.4 years.           64-CT to assess the extent of calcification and plaque distribution in
Those patients undergoing percutaneous treatment had the lowest             women compared to men. Methods: Between May 2005-December
overall transfusion rate 12.9% (4/31), followed by laparoscopic 19.5%       2007, 138 patients referred for 64-CT were evaluated. CTA was
(9/46) and open resection 67.7% (21/31). The postoperative                  performed using the GE LightSpeed VCT (GE Healthcare). Subgroup
complication rates of the open, laparoscopic, and percutaneous groups       analysis comparing male and female data (including demographic
were 41.9% (13/31), 19.5% (10/46), and 32.3% (10/31) respectively.          data) was performed. All major coronary arteries were analyzed for
An increased rate of complications was noted with open surgery              coronary stenosis/plaque characterization as well as total vessel
though this was not significant.Mean follow-up was 37.9 months with         calcium (Agatson) score quantification. Patient demographics an
58.1%, 86.9%, and 80.6% alive on follow-up in the open,                     coronary risk recorded. Results: A total of 552 coronary arteries were
laparoscopic, and percutaneous groups respectively. Length of stay          evaluated in 138 patients (85 men, 53 women). The average age for
was greatest with open surgery and shortest with percutaneous ablative      females was 64.4 ±12.8 years and for the males, 60.0 ±10.8. On
therapy and was highly significant (p<0.0001). Survival was improved        comparison of all total vessel calcium scores, males had a higher total
in the laparoscopic versus open groups on bivariate analysis.               mean calcium score than females in each individual vessel. The results
Conclusions: Perioperative outcomes in patients >75 years of age            were as follows for males vs. females, respectively: left main total
among various treatment modalities is an important determination in         vessel calcium score 47.6 vs. 26.8 (p=0.34); left anterior descending
choice of intervention. Open resection was associated with an               266.7 vs. 107.5 (p=0.007); left circumflex 132 vs. 38.9 (p=0.034);
increased EBL and transfusion requirement when compared to the              right coronary 213.5 vs. 72.8 (p= 0.009). On average, men had 1.21
other 2 groups. Ablative techniques had the greatest complication rate,     coronary artery calcium scores between 101-400 (indicating that
but the least amount of intraoperative blood loss. Laparoscopic             significant coronary narrowing was likely) as opposed to women who
extirpation demonstrated a reduced transfusion requirement and              had an average of 0.66 (p=0.01).Conclusion: There are clear
complication rate, possibly being the optimal surgical strategy in          differences between males and females regarding total vessel calcium
patients of this age group. Additional studies are warranted to assess      scores and therefore risk of future adverse coronary events. Males
potential contributing factors and long term outcomes in this ever          tended to have higher average calcium scores in each coronary artery
growing population.                                                         than females, with a greater tendency to have multiple vessel
                                                                            involvement. Using this information, more large-scale, randomized-
Effect of Depression on Functional Recovery Among Older Adults              controlled studies should be performed to correlate differences in the
with Hip Fracture. Sumant Inamdar MD, Yuchi Young DrPH,                     extent of coronary calcification with the observed variance in clinical
Lawrence Lessner PhD, Edward L. Hannan PhD; Department of                   presentation during coronary events between males and females as a
Medicine, Long Island Jewish Medical Center                                 means to potentially establish gender-specific therapeutic regimens.
Objective: This longitudinal study examines the effects of depression
on functional recovery among older adults with hip fracture. Methods:       Are Second Trimester Minor Sonographic Markers for Down
Participants (n = 287) were community-dwelling adults at least 65           Syndrome Useful in Patients Who Have Undergone First
years of age who sustained a hip fracture, and received surgical repair     Trimester Combined Screening? Monica Sood MD, Burton
and post-acute rehabilitation. Data were collected at baseline, 2, 6 and    Rochelson MD, David Krantz MA, Rachel Ravens BS, Hima Tam
12 months after post-acute rehabilitation. Functional recovery was          Tam MD, Nidhi Vohra MD, Dawnette Lewis MD, Bidisha Ray MD;
measured by using two important functional status outcomes: (a)             Division of Maternal Fetal Medicine, Department of Obstetrics &
activities of daily living (ADL) and (b) instrumental activities of daily   Gynecology, North Shore-Long Island Health System
living (IADL). The independent variable in the study was depression.        Objective: To determine the efficacy of minor markers for T21 in a
It was measured using the long version Geriatric Depression Scale           population prescreened with FTS. Study Design: IRB approved,
(GDS) which was developed as a basic screening measure for                  retrospective study of 3845 women (2004-2007) who underwent FTS.
depression in older adults. Associations were examined in a                 We evaluated the performance of six minor markers for T21 risk
multivariate context using the mixed-effects modeling, controlling for      assessment (Pyelectasis, Increased nuchal fold, Echogenic intracardiac
the effects of age, gender, vision, baseline functional deficit and         focus, Echogenic bowel, Short femur, Short humerus). Likelihood
comorbidity. Results: Participants’ mean age was 80 years, 74% were         ratios (Nyberg) were used to adjust first trimester risk to generate a
female, 90% were Caucasian, and 82% had more than 12 years of               new composite risk (NCR). FTS and the NCR were considered
education. Over the one-year study period, none of the groups returned      elevated if risk was ≥ 1 in 300. Fisher’s exact test was used to
to their pre-fracture ADL and IADL function. The recovery pattern for       determine the effectiveness of minor markers as an additional
screening test. Results: 390 of 3845 women had one or more minor            proxy information, advanced directives, and discussing death and
markers. There were 10/3845 cases of T21. Of these, 3 cases were            dying significantly improved throughout training. PGY-3’s aptitude
among patients with a low risk FTS (n=3727). Use of the NCR                 score was higher than PGY-2’s, which was higher than PGY-1’s based
adjusted the risk status from low to high in 55 of these patients without   on a 5-point Likert scale (p<0.01). Self-assessed competence in
increasing the detection rate. The NCR did not modify risk to allow for     obtaining DNR status and delivering bad news also improved year to
detection of the 3 cases of T21 among patients with low risk FTS even       year (p<0.01). No significant differences in knowledge or skills
though 2 of these 3 fetuses had one minor marker each. Using a criteria     between control and intervention groups were found—but the mean
of one minor marker to identify these two fetuses would have required       difference in self-assessed competence in discussing advance
an additional 369 invasive procedures, with a false positive rate of        directives, death and dying was greatest for residents exposed to the
9.9%.There were 7 cases of T21 among patients with a high risk FTS          chaplain (p < 0.05). Overall, residents strongly agreed that physicians
(n= 118). Use of the NCR increased the positive predictive value of         should receive more medical school and residency training in religious,
T21 from 7/118 to 7/53. (p=0.003). NCR adjusted the risk from high to       spiritual and cultural beliefs and practices. Conclusions: Residents
low in 56 patients, none of whom had T21. Conclusion: Screening for         improve their aptitude and attitudes towards EOLC as they progress in
minor markers is a useful adjunct in patients with a high risk FTS. Its     their residency training. However, incorporating a certified chaplain
use in patients with a low risk FTS is of questionable benefit.             into daily MICU activities does not improve residents’ knowledge or
                                                                            skills in EOLC.
Random HbA1c as a Screening Tool for Diabetes Mellitus in the
Emergency Department. Urvi Thakker DO, Tovah Ellman MD, Reed                Journal Publications and Their Historical Impact on the Way Oral
Magleby BS, Kirsten Graff BS, Andrew Sama MD, Jim Kelson PhD,               and Maxillofacial Surgeons Practice (from the Director’s
Robert Silverman MD; Department of Emergency Medicine, Long                 Standpoint). Matthew Paonessa DDS; Division of Oral &
Island Jewish Medical Center                                                Maxillofacial Surgery, Department of Dental Medicine, Long Island
Introduction: The prevalence of diabetes mellitus is rising rapidly         Jewish Medical Center
although 25% of cases remain undiagnosed. The hemoglobin A1c                Introduction: Within the specialty of oral and maxillofacial surgery
(HbA1c) was recently recommended as a diagnostic test for diabetes          the way residents build a knowledge base appears to come from four
by the International Expert Committee. However, it is not clear             sources. First, is their attendings and their first hand experience, as
whether a HbA1c is influenced by stress hyperglycemia of acute              well as, what they have read throughout their respected careers.
illness. Given 120 million annual emergency department (ED) visits          Second, is other more senior residents. It is impossible not to learn
in the USA, an ED visit provides further opportunity for identifying        from your co-residents since we spend so much time together. Third,
undiagnosed diabetes. The main objective is to determine if an ED           we learn from textbooks. These subset of textbook are considered by
HbA1c remains stable over time. Methods: Adult patients with no             most to be required reading and a residents education is incomplete
known history of DM were tested for HbA1c during their ED and a             without having read them. Finally, we learn from journals that are
scheduled follow-up visit within 180 days of the ED visit after             published on either a monthly or bimonthly basis. From my
recovery from the acute illness. The HbA1c differences between the          observations it appears that there are a certain subset of articles that are
two visits were compared using limits of agreement (LOA) with 95%           considered highly revered amongst the specialty, while there are other
confidence intervals; predictive values were also calculated using          articles that are used to propel discussion. It is my intention to survey
HbA1c of 6.5% to diagnose diabetes. Results: 589 patients were              the directors of each respected oral and maxillofacial surgery program
included (average age 50 years), with 57/589 (9.7%) having an ED            in the United States and find out which articles impact both the way
HbA1c ≥6.5%. The mean overall ED HbA1c was 5.67% (±0.86) and                they practices, and the way they teach. Methods: A simple survey
the follow-up HbA1c 5.65% (±0.89), (difference -0.0129%, LOA -              will be distributed via e-mail and/or standard postal mailings
0.740, 0.714). Using the follow-up HbA1c as the criterion gold              to investigate what today's directors of OMFS programs feel the top
standard, the PPV of an elevated ED HbA1c was 70% (40/57) and the           ten articles are and how they have impacted the way they practice and
NPV was 98.9% (526/532). When elevated ED HbA1c values fell                 the way they conduct their programs. Results: Results will be tallied
<6.5% on follow-up, most (14/17) still were in an abnormal range (6.0-      and calculated in a standard statistical fashion and will be made
6.5%). Conclusion: The HbA1c value is not affected by acute illness         available to all who have participated in the study, along with a copy
and remains stable independent of follow-up time. Therefore, a HbA1c        of the original articles. Conclusions: I offer this idea in a hope to
can be used as a screening test in the ED for diabetes.                     encourage reflection on the way we learn and teach. I believe, if done
                                                                            correctly, this type of study will give our profession a small window
                                                                            into how and why we make certain decisions. It may also demonstrate
EDUCATIONAL OUTCOMES RESEARCH                                               regional differences in both practice habits and beliefs. I ultimately
                                                                            hope to reinforce historically significant ideas and reintroduce new
Resident Attitudes, Knowledge and Self-Assessed Skills Regarding            innovations into our profession.
End of Life Care: The Effect of a Focused Educational
Intervention During Residency Training. Lourdes G. Bahamonde                The Demand for Single Degree and Double Degree OMS
DO MS, Frederick Smith MD, Kevin Flannelly PhD, Saima Chaudhry              Residency Positions. The T. Phan, DDS MD; Division of Oral &
MD MSHS; Department of Medicine, North Shore University Hospital            Maxillofacial Surgery, Department of Dental Medicine, Long Island
Purpose: The Accreditation Council of Graduate Medical Education            Jewish Medical Center
(ACGME) mandates that housestaff be trained in the provision of end-        Purpose: This paper explores the recent trends in the selection of
of-life care (EOLC).1 Despite this mandate, residents feel inadequate in    single degree and double degree Oral and Maxillofacial Surgery
providing EOLC. It is unclear if knowledge, skills and attitudes about      (OMS) residency positions among OMS residency applicants over the
EOLC improve by year of residency training or with specific                 past 24 years. Methods: OMS national match statistics were obtained
educational interventions on EOLC. Objectives: 1) To assess                 from the American Association of Oral and Maxillofacial Surgeons
differences in internal medicine residents’ knowledge, skills, and          and included data from each annual OMS residency match from the
attitudes towards EOLC by year of training. 2) To assess the impact of      years of 1986/1987 through 2009/2010. Results: During the match
an educational intervention—incorporating a certified chaplain into         years from ‘01/’02 through ‘09/’10, the proportions of single and
daily rounds in the Medical Intensive Care Unit (MICU), on residents’       double degree positions offered have stabilized with 53.89% + 0.82%
EOLC knowledge, skills, and attitudes. Methods: One full-time               (Mean + SD) positions being single degree while 45.30% + 1.67% of
equivalent chaplain was hired to educate internal medicine residents        positions being double degree. During the match years from ‘96/’97
about EOLC in the MICU. Residents were randomized for exposure to           through ‘09/’10, the proportions of applicants who preferred single
the chaplain by their yearly schedule. A 35-item, non-validated test        degree, double degree, or had no preference for either type of position
measuring EOL knowledge, skills, and attitudes was administered to          stabilized with 50.19% + 2.27% of applicants preferring single degree
all residents in July 2008. An identical post-test was administered after   positions, 24.44% + 2.42% of applicants preferring double degree
residents completed their MICU rotation. Results: Of the 82 residents       positions, and 25.70% + 2.27% of applicants without a preference for
randomized, 81 participated in the study. Ninety seven percent of           either type of position. During the match years from ‘03/’04 through
residents in the control group, and 92% in the experimental group,          ‘09/’10, the demand for single and double degree positions have also
reported having a medical school class which focused on EOLC and            stabilized to a level where there were 1.00 + 0.07 applicants for each
ethics. Aptitude and attitudes towards obtaining patients’ health care      double degree position and 1.62 + 0.09 applicants for each single
degree position. Conclusion: The proportions of single and double             arthritis may result in permanent joint destruction and loss of function
degree OMS residency positions, the applicants’ preference for a              of the affected joint. A timely therapeutic intervention with
single or double degree position, and the demand for single and double        intravenous antibiotics and drainage is a must to prevent such outcome
degree positions have all reached equilibrium. At this steady state,          and avoid patient morbidity.
there is much greater demand for the single degree OMS residency
position as there are approximately 62% more applicants for each              The Financial And Ethical Cost Of Novel Therapies For The
single degree position then there are applicants for each double degree       Treatment Of Metastatic Renal Cell Carcinoma. Nadya M. Cinman
position.                                                                     MD, Carl A. Olsson MD; Smith Institute for Urology, North Shore-
                                                                              Long Island Jewish Health System
Helping the Helper: Empathy Training and the Prevention of                    Introduction and Objective: The treatment of metastatic renal cell
Burnout in Psychiatry Residents. Lamya Touma MD; Department of                carcinoma has dramatically changed over the past several years with
Psychiatry, North Shore-Long Island Jewish Health System/Zucker               the introduction of novel targeted therapies. With new medications,
Hillside Hospital                                                             much debate exists about the financing of these expensive drugs when
Introduction: The informal curriculum can insidiously erode the               the results have been deemed as modest. Methods: Literature searches
humanistic ideals that bring young trainees into medicine. Slowly             were performed via MedLINE and PubMed exploring “metastatic
there is a progressive shift in priorities and the development of self-       renal cell carcinoma” and “treatment”.           Information regarding
centeredness. The caring and compassion that feeds empathy can be             medication dosing and costs was obtained via National Cancer
threatened by self preservative defensive psychological measures as           Institute and Medscape websites. Results: This article seeks to review
trainees face interpersonal challenges. In some there results a               the evidence demonstrating oncologic benefit in patients with
detachment and a cynicism which hardens with time. Without the daily          advanced renal cell carcinoma who previously had limited therapeutic
nourishment of feeling that one is serving others as a fulfillment of         options, to assess the problems of cost that has accompanied the
duty in a way marked by integrity and competence, it is not long              novelty of these medications, and to display some of the current issues
before the first signs of burnout appear. Methods: This is a proposal         urologists have to face in treating these patients. Conclusion: While
that has grown from reflections of residents and my experience as a           urologists have to weigh the economic, political, and ethical
fourth year resident. It is based on a wealth of literature reflecting the    considerations at hand, primary obligation should continue to be
theoretical and clinical work on the phenomenon of burnout, the ethics        directed to the patient, with the ongoing commitment of delivering the
of professionalism, the informal curriculum and empathy. Results:             best care to our patients with strong support of research endeavors that
This proposal is based on the premise that by attending to the internal       favor further advancements.
experience of residents as they face the challenges unique to
psychiatric training in a structured way we can foster in them a deeper,      Effects Of Human Papillomavirus in Squamous Cell Carcinoma of
more nuanced and integrated understanding of their experience. With           the Head and Neck. Jesse C. Doscher DDS MSc; Division of Oral
this new perspective they will emerge from training with their                Pathology, Department of Dental Medicine, Long Island Jewish
humanistic orientation intact and with a foundation for a career marked       Medical Center
by 1) Empathy for self, 2)Empathy for patient, 3)Responsibility,              High risk HPV types are associated with cervical cancer, and the
4)Integrity, 5)Understanding of specific patient challenges in                presence of high risk HPV is a prognostic indicator for progression to
psychiatry, 6)Understanding of health care system and societal factors        dysplasia and carcinoma Therefore, identification of this virus serves
in practice. These goals can be achieved with an integrated curriculum;       as a valuable clinical monitoring aid. HPV has been associated with
attendings are provided with learning objectives, teaching and                the development of certain head and neck cancers. Head and neck
assessment tools as well as guidance on the necessity and technique of        squamous cell carcinomas develop most commonly in males over 40
guided reflection and giving feedback. These goals are also achieved          years of age. Risk factors for this disease include long-term use of
through modules integrated in the didactic material through the four          tobacco products and alcohol. In addition, there is an increasing
years as well as stand alone modules. Conclusions: In all residents are       incidence of head and neck cancer in adults
provided with guided self-reflection and processing of clinical               in the absence of traditional risk factors. Previous studies have shown
experiences in a way that psychological adaptation is healthier.              high risk HPV DNA in head and neck carcinoma, typically
Compassionate care is enhanced and burnout is less likely.                    oropharynx, but its prevalence has varied depending on the detection
                                                                              methods and the tumor type. While the prevalence of HPV in the oral
                                                                              epithelium is poorly characterized, HPV infection of the head and neck
                                                                              is well documented in carcinomas of the oropharynx, particularly
                                                                              tonsils and base of tongue. Patients with HPV positive carcinomas
Literature and Clinical Topic Reviews                                         tend to present at a more advanced stage at time of diagnosis as
                                                                              compared to individuals with HPV negative lesions. The carcinogenic
Approach to Septic Arthritis. Elena Bogachuk DO, Diane Horowitz               effects of HPV on cervical epithelium are well documented, and these
MD, Scott Horowitz MD, Maria-Louise Barilla-LaBarca MD; Division              studies have prompted routine screening tests of the cervix. Screening
of Rheumatology, Department of Medicine, North Shore-Long Island              examinations may reveal clinically evident disease. However, patients
Jewish Health System                                                          may present clinically without evidence of disease and viral infection
Health professional evaluating a patient who presents with acutely            might be suspected based on microscopically identified cytologic
painful, erythematous and swollen joint must always think about               changes or identification of HPV using HPV DNA assays. Such
infectious arthritis. It is a true medical emergency since failure to         assays are not performed routinely in the oral cavity, and further
promptly diagnose infection may lead to cartilage loss and articular          studies are needed to determine whether oral HPV infection has
damage. It is essential to rapidly institute appropriate antibiotics so       clinical significance. This review will focus on the importance of
that normal joint function can be preserved. Virtually any                    characterizing oral HPV infection, and the emerging role of HPV in
microorganism may cause septic arthritis. Bacteria, fungi,                    some head and neck squamous cell cancers. The prognostic
mycobacterium and viruses have all been implicated, each with a               significance of this virus in patient management will be discussed, as
distinct presentation. Gram-positive staphylococci and streptococci           HPV positive head and neck cancer patients appear to represent a
species are the most common pathogens see in patients with bacterial          distinct subset with significant management implications.
arthritis. A complete history and physical can provide clinical clues to
the diagnosis but isolation of the causative agent is definitive and is       Poly(ADP-ribose) Polymerase-1 Inhibition in the Treatment of
made through culture of the synovial fluid. The most common cause             Breast Cancer. Mary K Leung MD, Scott Z Fields, MD, Daniel R
of joint infection is the hematogenous seeding of the synovial                Budman MD; Division of Hematology/Oncology, Department of
membrane during bacteremia. Pathogens may also enter the joint                Medicine, North Shore University Hospital
space as a result of penetrating trauma, arthroscopy, and                     Introduction: Breast cancer is the most common malignancy among
arthrocenthesis or as a result of spread from local infection. Among          women. Triple-negative breast cancer, which comprises of about 15%
the risk factors for development of infectious arthritis include              of all breast cancer diagnoses, has a more aggressive clinical course.
increasing age, joint affected by rheumatoid arthritis or osteoarthritis,     About 85% of all basal-type tumors are triple-negative. About 5-10%
presence of cellulutis, history of intravenous drug use, recent joint         of all breast cancer diagnoses are associated with BRCA1 or BRCA2
surgery, and presence of the prosthetic joint. If left untreated infectious   mutations, and more than half of these patients have triple-negative
disease. As patients with triple-negative disease in general have worse    carry significant risk for metabolic disturbances, cardiovascular
outcomes with a higher rate of developing metastatic disease, more         disease or death. Recent FDA warnings regarding the use of
effective treatment modalities are being investigated. Poly(ADP-           antipsychotics in patients with dementia also limit their clinical utility
ribose) polymerase 1 (PARP-1) is an abundant nuclear enzyme which          in the current medical-legal environment. The purpose of this review
is activated in the presence of DNA single strand breaks. It repairs the   is to examine the existing literature on the use of non-antipsychotics in
DNA damage via the base excision pathway. Recent studies have              the management of agitation in dementia, with the goal of highlighting
shown that PARP-1 can also be activated by phosphorylated externally       possible future research directions in this area. Methods: A selective
regulated kinase (ERK) in the absence of DNA damage. This may be a         MEDLINE search was conducted using the keywords dementia,
possible mechanism of cell proliferation. Inhibition of the PARP-1         behavioral       and     psychological      symptoms,    anticonvulsants,
pathway is a potential target for preventing tumor proliferation and       antidepressants and antipsychotics.              A manual search of
cancer cell kill. In breast cancer, both BRCA1 and BRCA2 genes are         bibliographical       sources was also conducted. Results: The
important in DNA repair via the homologous recombination                   antidepressant citalopram, the anticonvulsant carbamezapine, and the
mechanism. Cancer cells of patients with germ-line BRCA1 or                NMDA antagonist memantine all show some efficacy in the
BRCA2 mutations are more susceptible to inhibition of other DNA            management of agitation in dementia, but the results are preliminary
repair pathways, such as the PARP-1 repair pathway, leading to             and are based on studies with small sample sizes. Conclusions:
selective tumor cell toxicity and death. This ‘synthetic lethality’ is     Larger, federally funded trials are needed to investigate the clinical
being studied extensively to be a new approach to targeted cancer          utility of alternatives to antipsychotics in the management of dementia,
therapy. Methods: A retrospective review of the literature is done         as demographic changes in the general population make this a growing
using the terms ‘PARP inhibitors’ and ‘breast cancer’. Prospective,        public health need.
retrospective, and review articles are evaluated. Results: There are
several PARP-1 inhibitors with ongoing phase I or II trials. PARP-1        Quantitative Electroencephalography: Application in Prediction of
inhibitors were shown to enhance cytotoxic effects of chemotherapy         Response to Selective Serotonin Reuptake Inhibitors in Patients
agents. There are also trials to determine the efficacy of PARP-           with Obsessive-Compulsive Disorder. Neil Mukerji MD, Sheena Xin
inhibitors as single agents in the treatment of breast cancer.             Liu MD PhD; Department of Psychiatry, North Shore-Long Island
Conclusions: The incorporation of targeted therapies with selective        Jewish Health System/Zucker Hillside Hospital
cell kill by PARP-1 inhibitors either as single agent or in combination    Introduction: Obsessive-compulsive disorder causes significant
with chemotherapy may be the future of individualized breast cancer        distress and/or impairment in functioning in 136 million people
therapy.                                                                   worldwide. Although selective serotonin reuptake inhibitors (SSRIs)
                                                                           have been found to be effective for 50% of patients with obsessive-
CAD/CAM Technology and Dental Implants. Isabel Martins DMD;                compulsive disorder, it is currently impossible to reliably predict
Department of Dental Medicine, North Shore University Hospital             which patients are likely to respond to SSRIs. However, patients with
Introduction: CAD/CAM (computer-aided design/computer-aided                OCD have been found to show several different patterns of
manufacturing) systems have been used for over two decades by dental       abnormality in the electroencephalogram (EEG), and it has been
health professionals with the technology still evolving today. The         suggested that these patterns of EEG abnormalities may be useful in
CAD/CAM systems have generally been used for the manufacturing of          predicting response to SSRIs. In this paper, the authors aim to review
prosthetic fixed restorations such as crowns, bridges, inlays, and         the utility of quantitative electroencephalography in the prediction of
onlays. More recently, there has been greater interest in the              response to SSRIs in patients with OCD. Methods: A systematic
CAD/CAM systems for implant supported prosthetics, the                     literature review was performed that searched the OvidSP database
manufacturing of implant abutments and diagnostic templates in             using       the      following     search     criteria:     [(quantitative
implant dentistry. These systems have provided restorations using          electroencephalography) OR (QEEG) OR (Quantitative EEG) OR
materials such as porcelain, composite resin and metallic blocks, which    (quantitative electroencephalogram)] AND [(antidepressant) OR
could not be used previously because of technical limitations. The aim     (SSRI) OR (SRI) OR (selective serotonin reuptake inhibitor) OR
of this review is to give readers an overview of the use of CAD/CAM        (serotonin reuptake inhibitor)] AND [(obsessive-compulsive disorder)
technology for dental implants and their limitations and benefits.         OR (OCD)]. A subset of articles was selected and reviewed, based on
Methods: A search of articles in English using the PubMed database         relevance to the paper’s objective. Results: Studies have shown that
at present was conducted using “CAD/CAM”, “dental implants                 quantitative EEG may identify pathophysiological subgroups of
CAD/CAM” and “surgical guide CAD/CAM” as key words. Results:               patients with OCD. One such subgroup has been characterized as
CAD/CAM implant abutments present the advantages of having a               having excess frontal and frontotemporal relative theta power, while
custom design specific to each patient, providing a better fit and a       another subgroup has been found to have excess relative alpha power.
higher resistance than other abutments available to clinicians.            The former subgroup has been found to be largely SSRI-unresponsive,
CAD/CAM technology uses titanium and ceramics such as aluminum             while the latter subgroup has been found to be largely SSRI-
oxide or zirconium oxide for the fabrication of abutments. The higher      responsive. Furthermore, SSRIs have been found to increase relative
strength of these materials, which can only be shaped by CAD/CAM           theta and beta power, while decreasing relative alpha power.
systems, has increased longevity of these restorations. It was also        Conclusions: Although at this time there is insufficient evidence to
found that milled titanium abutments fabricated with CAD/CAM               recommend that each patient with OCD be referred for quantitative
technology can provide clinicians with significant advantages over         EEG, the available data suggest that QEEG may be found to have
custom metal abutments made with conventional casting technology.          significant utility in predicting whether a particular patient is likely to
The CAD/CAM systems eliminate the process of waxing, casting and           respond to SSRI treatment. Further research in this area is warranted.
finishing of custom abutments, which allows for inaccuracies. Using
stereoliography to manufacture CAD/CAM surgical templates,                 Bisphosphonates and Dental Implants. Nicole Ptak DDS;
accuracy of dental implant placement can be improved. Using this           Department of Dental Medicine, North Shore University Hospital
technology, clinicians can place implants, fabricate restorations and      Introduction: The aim of this literature review is to evaluate the risks
achieve immediate functional loading to implants all in one visit.         for placing dental implants in patients receiving oral and IV
Conclusion: CAD/CAM technology presents dental implant                     bisphosphonates. Patients on these medications are at risk for
professionals with many advantages when compared to conventional           developing bisphosphonate-related osteonecrosis of the jaw (BRONJ)
casting technologies. The system’s surgical templates also allow           after extractions or having dental implants placed. Bisphosphonates
transfer of the software planning to the surgical field.                   work by acting on osteoclasts, inducing their apoptosis and therefore
                                                                           inhibiting bone reabsorption. The terminal cross-linking telopeptide
Managing Agitation in Alzheimer’s Dementia with Alternatives to            type I serum test (CTX), measures bone turnover rate, and may help
Antipsychotics, A Growing Unmet Clinic Need. Daniel McGonigle              determine risks for developing BRONJ. Materials and Methods:
MD; Department of Psychiatry, North Shore-Long Island Jewish               PubMed was searched using keywords “bisphosphonates and dental
Health System/Zucker Hillside Hospital                                     implants” ranging from years 2007-2009, and relevant studies were
Introduction: Alzheimer’s disease is frequently characterized by           reviewed. Results: In 2007, the American Association of Oral and
behavioral and psychological disturbances, such as agitation and           Maxillofacial Surgeons suggested guidelines, based on limited
aggression. Management of such symptoms often entail the use of            amounts of data, for treating patients using IV and oral
antipsychotics, which show modest short-term clinical benefit but          bisphosphonates. The placement of dental implants in patients using
IV bisphosphonates was contraindicated and precautions were placed           based on increasing complexity of the procedure and procedural
on patients taking oral bisphosphonates. Current studies suggest that        complications. In routine PCNLs, we favor placement of an ureteral
the risk of developing BRONJ is rare when taking oral                        stent or a small-bore nephrostomy tube. In problematic and
bisphosphonates. Grant et al found that oral bisphosphonate patients         complicated PCNLs, we think the evidence directs toward placement
in their study did not develop BRONJ following implant placement,            of a nephrostomy tube, small bore being an option in problematic
and the bisphosphonate therapy did not significantly affect implant          PCNLs. Conclusion: We conclude that the optimal renal drainage
success. Madrid et al found that patients taking oral bisphosphonates        method depends on patient characteristics and the operative course;
for less than 5 years did not develop BRONJ or have implant failures.        hence, it should be individualized.
Studies indicate that the chances of developing BRONJ most likely
increases when patients are taking the drug for an increased number of
years and when the patient is immunocompromised or taking steroids
as well. Montoya-Carralero et al discussed using CTX prior to implant        NURSING AND ALLIED HEALTH
placement to evaluate the risk for developing BRONJ. Conclusions:
There is significant risk when placing implants in patients on IV-           The Best Treatment for Chronic Asthma in Children. Plechette
bisphosphonates, and the risk is much lower with oral                        Dey-Foy RN; Department of Nursing/Cardiothoracic Unit, North
bisphosphonates. The chances of developing BRONJ after implant               Shore University Hospital
placement in patients taking oral bisphosphonates increases after            Objectives: To assess the clinical effectiveness of inhaled
taking the drug for greater than 3 years and with immunocompromised          corticosteroids alone and, in combination therapy for the treatment of
patients. More studies are necessary to fully determine the risk. The        moderate to severe asthma in children under 12 years old. Methods:
benefits of using CTX as a pre-screening tool in these patients is           Examination of several comprehensive articles related to children’s
controversial and further research is needed.                                asthma therapy using Medline and Cochrane Database which was
                                                                             searched up to June 2008. Results: There were 67 identified studies
Biopsychosocial Approach to diagnosing Orofacial Pain. Deepthi               through systematic literature search, which involved 17 fully published
Rao DDS; Department of Dental Medicine, Long Island Jewish                   randomized controlled trials, with 1279 children below12 years of age.
Medical Center                                                               The results showed that the use of ICS had provided a higher mean
Patients living with chronic orofacial pain often will wander from           Forced Expiratory Flow Volume (FEV) and Peak Expiratory Flow rate
physician to physician, searching for diagnosis and treatment.               (PEF) than SCG. Patients who used ICS had lower asthma symptoms
Unfortunately this is not an area of focus in traditional medicine;          and less use of rescue medications than SCG users. There were no
physicians will often refer orofacial pain patients to dentistry because     difference in side effects between use of ICS and SCG. ICS were
they believe that traditional dental treatments will be effective. This is   compared with a mast cell stabilizer, and the results favored ICS use
not the case for chronic pain patients. It can be difficult to form          over SCG the mast cell stabilizer. ICS was compared further with ICS
differential diagnoses, because many of these conditions have                and long acting Beta 2 agonists’ combination therapy. The results were
overlapping symptoms. There are no diagnostic laboratory tests. Many         analyzed through meta-analysis and it showed that the patients who
of the patients are middle aged females who will have elevated               were symptomatic after being on ICS benefited from the addition of a
depression rates. In the absence of a definitive test, diagnosis depends     long acting Beta 2 agonist. The rate of asthma exacerbations reduced
on taking an accurate history and physical examination, and having the       to 22% from 27%. Further long-term studies show that there is a
knowledge of the clinical epidemiology associated with the related           decrease in the height of children in the first year of treatment.
conditions. This article defines four syndromes: TMD Pain and                However, all the children attained normal height by the adult age. Most
Dysfunction Syndrome, Orofacial Phantom Pain, Glossodynia or                 of these studies were done on children above 4 years. Conclusion:
burning mouth syndrome, and Trigeminal neuralgia. The definitions            Inhaled corticosteroids have been an established intervention for the
and diagnostic criteria of each are discussed, along with the                treatment of chronic asthma. Though it is very effective, it always has
epidemiology, and treatment. According to the International                  concerns. Pediatric asthma usually has an allergic exposure. So the
Association for the Study of Pain, pain is defined as an unpleasant          first step is to find out the triggers and avoid them. Asthma is also a
sensory and emotional experience associated with actual or potential         disease with inflammatory process. ICS is excellent in decreasing the
tissue damage, or described in terms of such damage. If clinical,            inflammation. Since there is bronchoconstriction there is a need for
radiographic or laboratory tests do not reveal the presence of tissue        bronchodilator as well. Stepwise approach is used for the treatment of
damage, it can be challenging for the clinician to form a diagnosis.         asthma. Based on the severity of the symptoms, patients should be
This article reviews the steps to form a differential diagnosis, as well     treated initially with a low dose corticosteroid. Response to this drug
as classic presentations. Then there is a discussion of the variety of       has to be monitored every three months. If improvement in lung
treatments, including physical (bite blocks, physical therapy),              function is seen then the medicine has to be kept at the same dose and
pharmacological        (anti-inflammatory     drugs,      antidepressants,   then titrated to the lowest dose. If control is not attained then the
anticonvulsants, muscle relaxants) and surgical therapy. By providing        guidelines suggest an increase of corticosteroid dose or an addition of
a descriptive study of four orofacial conditions, this article gives the     another drug. According to the guidelines of National Institute for
clinician a review of the literature to aid in diagnosing, treating, and     Health and Clinical Excellence in Step 4 there may be a need of adding
referring their patients with such syndromes.                                a leukotriene modifier to the ICS. This evidence based on the literature
                                                                             review show that adding LABA is best in Step 4 when they require an
Renal Drainage After Percuteaneous Nephrolithotomy. Arun                     additional drug other than ICS. Currently the guidelines are leaving
Srinivasan MD, Amin Herati BA, Zeph Okeke MD, Arthur D. Smith                this decision to the practitioner.
MD; Institute for Urology, North Shore-Long Island Jewish Health
System                                                                       Predicting Length of Stay in Hospitalized Heart Failure Patients.
Introduction: Exit strategy after percutaneous nephrolithotomy               Deepa Tuli, RPAC; Department of Cardiology, North Shore-Long
(PCNL) is an area of continuing innovation to improve postoperative          Island Jewish Health System
morbidity and operative outcomes for patients. The two important             In this analysis, a multiple regression model is estimated, taking into
components of an exit strategy after PCNL are hemostasis and renal           account such factors as age, ejection fraction (EF), pro-BNP (B-type
drainage. We review the different techniques of renal drainage after         natiuretic peptide), creatinine and co-morbidities, as affecting length of
PCNL-ie, nephrostomy tube, ureteral stents, and totally tubeless             stay in hospitalized acute decompensated heart failure patients. The
strategy with critical discussion of available evidence for and against      final fitted equation can provide for the creation of a benchmark tool to
each of these techniques. Methods: We performed a medline search of          be utilized by health care providers and reimbursers to approximate in-
all articles pertaining to renal drainage after percutaneous                 hospital length of stay for heart failure patients, to facilitate the
nephrolithotomy. We critically review the different techniques of renal      formation of diagnosis and treatment plans, as well as for use in
drainage after PCNL-ie, nephrostomy tube, ureteral stents, and totally       establishing reimbursement, based on patient-specific data. As a result
tubeless strategy with critical discussion of available evidence for and     of the wide variability in the stated factors, the model was unable to be
against each of these techniques. Results: We found that the optimal         validated. However, future attempts to modify the model may lead to
strategy of renal drainage depends on the preoperative stone burden          the development of an advanced algorithm that can be employed to
and operative course of the patient. . To simplify this, we group            predict length of stay in heart failure patients and guide treatment.
patients undergoing PCNL as routine, problematic, and complicated,
                                                                          Innovations in Nursing Orientation: A Competency-Based Model
                                                                          for Maintaining Patient Safety Goals. Launette Woolforde EdD(c)
Redefining the Nurse Transition Experience: A Competitive                 DNP RN-BC; Office of the Chief Nurse Executive, Corporate-North
Strategy for Quality, Safety, and Financial Performance. Launette         Shore-Long Island Jewish Health System
Woolforde EdD(c) DNP RN-BC; Office of the Chief Nurse Executive,          Introduction: Nursing competency is a major contributor to NSLIJHS
Corporate-North Shore-Long Island Jewish Health System                    dashboard outcomes. At NSLIJ: 1. Approximately 70% of newly hired
Introduction: The literature abounds with evidence about three major      nurses are new graduates; a population who has been documented as
safety and quality issues for healthcare through nursing: Up to 50% -     entering the workforce unprepared to perform basic clinical skills and
60% of new nurses leave within the first year of practice costing         apply classroom learning to real-life practice. 2. Each site has
hospitals approximately $250,000 per departed nurse. 1. BSN nurses        historically conducted their own nursing orientation programs which
are linked to better patient outcomes, and 2. Hospitals and academia      varied widely in processes, standards, and competencies and was
need to partner to better support student to professional nurse           costly, redundant and siloed. 3. A systemwide core RN competency
transition. The student nurse transition study (SNTS) introduced a        set, the framework for orientation and practice, did not exist. These
strategic solution by redefining transition and implementing a pre-       factors along with the literature highlighted the need for NSLIJHS
graduate program designed to decrease anticipated turnover, the stage     orientation redesign. Methods: A standardized, centralized,
immediately preceding actual turnover in the Anticipated Turnover         systemwide nursing orientation program was designed and quantitative
Model, while improving self-efficacy and perceived clinical               performance data were collected. The orientation program integrates
competence- factors identified as transition challenges. Methods: The     evidence-based practice and blended learning strategies including e-
SNTS took place in 2008 at NSUH and LIJMC. A subset of SNTS data          learning, didactic, unfolding case studies, skills workshops, and state-
from final semester BSN students from one school of nursing was           of-the-art, video recorded high-fidelity simulation to validate
analyzed. The experimental group participated in the STEP                 competency in areas such as prevention of hospital-acquired infections
intervention, an original workshop series designed based on Benner’s      and pressure ulcers, safe medication practices, communication,
Novice to Expert theory, while the control group did not. The STEP        medication dosage calculation, and other competencies. A pretest-
aimed to increase self-efficacy and clinical competence, and decrease     posttest design is used to measure knowledge acquisition and behavior
anticipated turnover. Results: RMANOVA was performed on data              change through simulation and written tests. Results: All performance
collected over 3 observation points on perceived clinical competence      outcomes were positive. For example 2008 data analysis showed that
using the Scale of Nursing Performance (SNP), self-efficacy using the     only 27.5% and 57.4% of newly hired nurses met expectations in
General Self-Efficacy Scale (GSE), and Anticipated Turnover using         nursing process application and medication dosage calculation. Post
the Anticipated Turnover Scale. Results were that the experimental        program data revealed increased performance scores in these areas to
group demonstrated significantly greater perceived clinical               92.7% and 84.6%, respectively. Additionally, orientation redesign
competence (F = 1,32 = 194.469, p<.001), significantly greater self-      created a systemwide orientation standard and led to a reduction in site
efficacy (F = 1, 32 = 42.20, p<.001), and significantly lower             based orientations from 4-7 days to 1/2 day on average. A systemwide
anticipated turnover (F=1, 32 =5.07, p<.05) over time, than the control   core RN competency set was established and orientation program
group. Conclusions: Pregraduate implementation of the STEP for            variation and redundancy was eliminated. Conclusions: The ability to
BSN student nurses provided an avenue to: 1. Increase self-efficacy       identify nurses performance improvement areas, develop evidence
and perceived clinical competence, while decreasing anticipating          based strategies to address learning needs, and measure the strategies
turnover. 2. Recruit BSN nurses, a population linked to better patient    effectiveness is key for maintaining our patient safety goals.
outcomes, and 3. Foster clinical and academic partnerships.
POSTERS                                                                     controls. Conclusion: Murine ES cell lines with Rps19 and Rpl5 gene
                                                                            trap mutations exhibit protein haploinsufficiency, demonstrate a
BASIC SCIENCE RESEARCH                                                      ribosomal assembly defect in their respective ribosomal subunits and
                                                                            recapitulate the major DBA hematopoietic differentiation defect.
Building a Better Bladder: Pressure-Flow Urodynamic Studies in
Cadaveric Orthotopic Neobladders. Arvin George MD, Arun K.                  Role of MRK Kinase in Radiation-Induced Invasion in High-
Srinivasan MD, Amin S. Herati BA, Sandeep S. Saluja BA, Manish A.           Grade Gliomas. Magimairajan Issaivanan MD MPH, Zhiwan Dong
Vira MD, Louis R. Kavoussi MD, Lee Richstone MD; Smith Institute            PhD, Marc Symons PhD; Center for Oncology and Cell Biology,
for Urology, North Shore-Long Island Jewish Health System                   Feinstein Institute for Medical Research, North Shore-Long Island
Introduction: Complete intracorporeal neobladder construction has           Jewish Health System
been previously described but is limited due to excessive operative         Introduction: High-grade gliomas are one of the most aggressive of
time and the need for an advanced laparoscopic skillset. The aim of         all human cancers, are highly resistant to radiation- and chemo-therapy
this study was to determine the pressure-flow characteristics of            and have either local or distant recurrence after treatment with surgery
neobladders created in various forms that may be constructed                and/or radiotherapy. MRK is a stress-regulated MAP kinase kinase
intraabdominally. Methods: Four neobladder configurations were              kinase (MAPKKK) that is activated by ionizing radiation (IR) and is
constructed, each created with 20cm of human cadaveric small                required for invasion stimulated by growth factors in different types of
intestine. The standard hand sewn Studer pouch was compared with a          tumors. Recently, it has been reported that IR induces glioblastoma
circular loop, W-pouch with stapled anastomoses, and U-pouch with           cell invasion in vitro. Previous studies have also shown that, upon IR
stapled anastmoses. Pressure flow studies were completed using the          treatment, MRK activates the p38γ MAP kinase and contributes to
Aquarius TT UDS system (Laborie Medical Technologies, Toronto,              Chk2 activation. Because MRK is activated by IR and is important for
Ontario) and each neobladder was filled to a pressure of 50cm H2O.          invasion, we examined the role of MRK in IR-induced glioblastoma
Neobladder capacity, change in pressure, and overall compliance were        cell invasion and tested the hypothesis that MRK regulates IR-induced
determined. Results: The cystometric capacities of the stapled U-           cell invasion through the p38γ pathway. Methods: We used SNB19,
pouch, W-pouch, Circle pouch, and Studer pouch were 167.3ml ,               T98G and U87 glioblastoma cell lines in our experiments. To study in
177.5ml, 114ml, and 145.2ml respectively. The first increase in             vitro invasion and migration we used transwell chambers with or
intravesical pressure was at 90.3ml, 103ml, 50ml, and 85ml. The             without extracellular matrix (Matrigel), respectively. RNA interference
greatest compliance of 3.81ml/cmH2O was demonstrated in the U-              was performed using transient transfection of at least two different
pouch, with the W-pouch revealing a compliance of 3.44ml/cmH2O.             siRNA oligonucleotides, to control for off-target effects. Viability of
The least compliant neobladder was the circle pouch (2.24ml/cmH20)          cells post-IR was studied using the MTS assay. Results: We found that
followed by the standard Studer pouch (2.94ml/cmH2O). Conclusion:           siRNA-mediated MRK depletion in glioblastoma cells inhibits IR-
The construction of an orthotopic neobladder must not only be               induced invasion and migration. We also found that depletion of either
technically feasible but maintain adequate capacity and compliance for      p38γ or Chk2 inhibits IR-induced invasion and migration. Moreover,
optimal functioning. Pressure-flow studies demonstrated equivalent          the inhibitory effect of Chk2 depletion on cell migration was reversed
results in alternate neobladder configurations. Additional data is          by blocking cell cycle progression. Conclusions: Our observations
needed to determine feasibility in vivo.                                    establish a critical role for MRK in IR-induced glioblastoma invasion
                                                                            and validate MRK and MRK-controlled signaling elements as novel
Hematopoietic Differentiation Defects in Two Murine Embryonic               therapeutic targets in the treatment of high grade gliomas. Our data
Stem (ES) Cell Models of Diamond Blackfan Anemia (DBA).                     also indicate that Chk2 contributes to IR-induced invasion via control
Tracie Goldberg MD, Sharon Singh MD, Adrianna Henson, Abdallah              of the cell cycle.
Nihrane PhD, Jeffrey Lipton MD PhD, Steven Ellis PhD, Johnson Liu
MD; Les Nelkin Memorial Pediatric Oncology Laboratory, Feinstein            Role of mTOR in the Development of HIV-Associated
Institute for Medical Research, North Shore-Long Island Jewish              Nephropathy and Its Inhibition as a Therapeutic Strategy. Sridevi
Health System                                                               Konkimalla MD; Division of Kidney Diseases and Hypertension,
Background: Diamond Blackfan anemia (DBA) is one of the rare                Department of Medicine, Long Island Jewish Medical Center
inherited bone marrow failure syndromes, characterized by erythroid         Background: HIV- associated nephropathy (HIVAN) is the leading
hypoplasia, congenital anomalies, short stature and cancer                  cause of end-stage renal disease in HIV-1 seropositive population.
predisposition. Anemia is the most common and prominent feature of          Since glomerular cells show proliferative phenotype in HIVAN, we
DBA, although phenotypic differences are apparent among patients.           asked whether mTOR, a central pathway for cell growth plays a role in
Half of DBA patients have a mutation in a gene encoding a small or          the development of HIVAN in Tg26 mice. Methods: Renal cortical
large     subunit     ribosomal    protein,    resulting    in    protein   sections of three 4 weeks old FVBN (control) and Tg26 (on FVBN
haploinsufficiency. Methods: We studied primary and secondary in            background) mice were immunolabeled for phospho-mTOR (1:200,
vitro differentiation of murine ES gene trap cell lines with mutations in   anti-phospho-mTOR antibody, Cell Signaling, Beverly, MA). Western
Rps19 and Rpl5. For primary differentiation and generation of               blots were prepared from renal cortical tissue of two control and TG26
embryoid bodies (EBs), the ES cells were cultured in a serum-               mice and probed for mTOR as well as downstream signaling. Age and
supplemented methylcellulose-based medium containing stem cell              sex matched six to eight (in each group) Tg-26 (4 wks old) were
factor (SCF). After 7 days, the cultures were fed with a medium             administered either normal saline (A) or sirolimus (5 mg/kg
containing SCF, interleukin-3 (IL-3), IL-6 and erythropoietin (epo).        intraperitoneally; B) every other day for 2 (A1 and B1), 4 (A2 and B2)
EBs were scored on day 6 for total quantity, then again on day 13 for       and 8 (A3 and B3) weeks. FVBN mice were used as control. Renal
hematopoietic       percentage.    For     secondary     (hematopoietic)    histology was scored by a semiquantitative scale; grade 1 = 1–25%, 2 =
differentiation, day 9-11 EBs were harvested and disrupted with             26–50%, 3 = 51-75% and 4=76-100% of tissue showing abnormality
collagenase, and the disrupted cells were suspended in a serum-             Results: Immunoblots of Tg26 mice showed increase in Ser2448 phos of
supplemented methylcellulose-based medium with SCF, IL-3, IL-6              mTOR and Thr389 phos of p70S6 kinase, and reduction in eEF2 phos of
and epo. Hematopoietic colonies were counted on day 10. Results:            Tg26 mice which imply evidence of mTOR activation and stimulation
Haploinsufficient expression (~50% wild-type) of Rps19 and Rpl5             of elongation phase of mRNA translation. Group A2 Tg26 mice
protein was confirmed by Western blot analysis in the mutant gene           showed 4-fold increase in grade 2, 16-fold increase in grade 3, and 11-
trap cell lines. By polysome analysis, we found a selective reduction       fold increase in grade 4 glomerulosclerosis when compared with group
in the 40S subunit peak in mutant Rps19 cells and in the 60S subunit        B2 mice. In group B2 Tg26 mice, majority of the glomeruli (77%)
peak in mutant Rpl5 cells. Both mutants produced a                          showed only grade 1 glomerulosclerosis. Group A2 Tg26 mice showed
                                                                            tubular dilatation grade 2 in 30%, grade 3 in 40% and grade 4
                                                                            dilatation in 30%. Tg26 mice in group B2 showed only grade 1
                                                                            dilatation in majority of tubules. Group A2 Tg26 mice showed
                                                                            microcyst formation of variable severity whereas there were no cyst
significantly decreased number of EBs, particularly hematopoietic           formations in Group B2 (sirolimus-treated) Tg26 mice. FVBN control
EBs, compared with controls.            Furthermore, upon secondary         mice did not reveal any renal lesions. Conclusions: mTOR pathway
differentiation, the ratio of erythroid to myeloid colony formation in      plays a role in the pathogensis of HIVAN. Sirolimus, an inhibitor of
both mutant cell lines was significantly reduced, compared with             mTOR pathway attenuated the progression of renal lesions in mice
transgenic for HIV-1 genes.                                               genetically lacking PGDH. Azoxymethane is a colon carcinogen,
                                                                          which, when given to mice, induces colon tumor formation. In
Differential Microthermometry Reveals that Neoplastic Cells               wildtype mice, celecoxib prevents 85% of azoxymethane-induced
Actively Modulate Microenvironment Temperature: A Novel                   tumors. In PGDH-null mice, however, celecoxib treatment is
Study of Tissue Thermodynamics. Mostafa Sadek MD, Steven                  essentially inactive in preventing tumor induction. In parallel with the
Mercereau MD, Nikhil Waingankar MD, Louis R. Kavoussi                     loss of tumor prevention activity, celecoxib-mediated suppression of
MD,Manish A. Vira MD; Smith Institute for Urology, North Shore-           colonic PGE(2) levels is also markedly attenuated in PGDH-null
Long Island Jewish Health System                                          versus WT mice. Furthermore, we examined PGDH levels in rectal
Introduction: Thermodynamics is the study of the energy state of an       biopsies of individuals who participated in the Adenoma Prevention
isolated object and its conversion to work and heat as a known external   with Celecoxib trial (APC trial). These individuals were all initially
force is applied. The measurement of thermodynamic phenomena              found with colon adenomas, which were cleared by colonoscopy
include temperature, pressure, volume, internal energy and entropy that   before they receive a course of celecoxib and another colonoscopy to
are related to each other by complex formulae. This study is based on     detect new adenomas. In individuals who developed new adenomas
the hypothesis that thermodynamic laws also can be applied to groups      while receiving celecoxib treatment, they were all found with low
of cells (tissue) within an organ. The study of thermodynamic             colonic 15-PGDH levels (P=0.001) Conclusion: In summary, we find
phenomena within cellular systems has the potential to provide novel      that 15-PGDH activity can determine sensitivity to the colon tumor
insight into the structure, function, operation and health of cells and   preventive activity of celecoxib. These observations imply that
tissue. Methods: Hybridoma cells, commonly used for commercial            measurement of 15-PGDH may be clinically useful in selecting
antibody production, were grown in standard media suspension.             patients most likely to benefit from treatment with COX-2 inhibitors
Temperature measurements were obtained using the IT-18 T-type             for colon tumor chemoprevention.
thermocouple calibrated to 0.1°C, range of -20 to 150°C (time constant
0.1 seconds, 0.025 inch diameter, Physitemp Instruments, Inc.). Cells
were placed in suspension media in 10 mL culture tubes.                   CASE REPORTS
Microthermometry of suspension of live cells (96% viable) was
compared to suspension of dead cells (6% viable). Measurements            Isolated Renal Aspergilloma Causing Obstructive Uropathy in
were made both in 37°C water bath and then allowed to cool to             Renal Allograft and Unique Approach to Management. Kellie
ambient temperature. Results: Initial measurements were performed         Calderon MD, Azzour Hazzan MD; Division of Nephrology and
simultaneously in the same environment to verify precision of the         Hypertension, Department of Medicine, North Shore University
thermocouple sensors. At 37°C, suspension of viable hybridoma cells       Hospital
maintained temperature 0.3°C greater than suspension of non-viable        Introduction: Aspergillus is an important opportunistic pathogen in
cells. When both suspensions were allowed to cool to ambient              immunocompromised patients, notorious for causing pulmonary
temperature (~24°C), although temperature of the suspensions              infection and invasive disease. Isolation in the renal collecting system
decreased at a different rate, the suspension of viable cells again       without dissemination is rare. We present a case of renal aspergillosis
equilibrated to a temperature 0.3°C higher than suspension of non-        in the form of a bezoar causing obstructive nephropathy in a renal
viable cells. The culture tubes were placed back into the 37°C water      allograft. Our unique and successful approach to management is
bath and after a short period of equilibration, the viable cells again    presented as an alternative to surgical intervention. Case Report: A 51
maintained a temperature 0.3°C higher than non-viable cells.              y/o man with a history of DM, HTN and ESRD secondary to
Conclusions: This report is the first description of differential         polycystic kidney disease s/p renal transplant who presented ten years
microthermometry in cell culture showing differences in                   later with complaints of fever and decreased urine output for one day.
microenvironment temperature between viable and non-viable                His immunosuppressive therapy included tacrolimus, mycophenolate
neoplastic cells.                                                         mofetil, and prednisone. Physical exam was significant for a febrile
                                                                          male who appeared comfortable. Palpation over transplanted kidney
PGDH Activity Determines Sensitivity to the Colon Tumor                   was unremarkable and had no costovertebral tenderness. The bladder
Preventive Activity of Celecoxib. Min Yan MD, Seung-Jae Myung             was not palpable and insertion of foley catheter yielded no urine.
MD, Stephen P. Fink PhD, Joseph Willis MD, Dawn Dawson MD,                Laboratory studies revealed acute renal failure (creatinine 5.2mg/dL).
Hsin-Hsiung Tai PhD, Jill S. Barnholtz-Sloan PhD, Robert A.               CT scan revealed moderate hydronephrosis of the allograft without
Newman PhD, Monica M. Bertagnolli MD, Sanford D. Markowitz                evidence of calculi/mass. Antegrade pyelogram revealed a proximal
MD PhD; Department of Medicine, Long Island Jewish Medical                ureteral filling defect. Insertion of a nephrostomy tube proximal to the
Center                                                                    obstruction resulted in diuresis. Urine microscopy yielded 50 WBC/
Introduction: Cyclooxygenase-2 inhibitors including celecoxib             hpf. Three days after collection urine culture identified aspergillus
prevents colon adenoma growth. However, a subset of patients are          species. Blood cultures remained negative. Radiography with urine
resistant to the colon tumor preventive activity of celecoxib and still   culture results diagnosed the obstruction as an aspergilloma
grow adenomas with celecoxib treatment. Given the recent finding          obstructing the transplanted kidney’s ureter. Treatment attempts to
that long term use of celecoxib is associated with increased              achieve decompression have included systemic antifungal therapy and
cardiovascular events, finding out who are resistant to tumor             surgical debulking or nephrostomy decompression as needed. Our
preventive activity of celecoxib is even more important, as celecoxib     patient was treated with invtravenous voriconazole for seven days
increase risk of cardiovascular events in these patients without          without improvement. We adapted a method to monitor intrarenal
protecting them from tumor development. In contrast to                    pressure to prevent further hydrostatic damage using intra cranial
cyclooxygenase-2 as key enzyme in producing prostaglandins,               manometer during continuous infusion of intrapelvic amphotericin.
prostaglandin        Dehydrogenase(PGDH) is          key       enzyme     Clinical response was evident by gradual increase in urine flow via the
in degrading protumorigenic              prostaglandins             in    urethra and defervescence. Six days later a third nephrostogram
human. Recently, PGDH is identified as a key tumor suppressor in          showed brisk contrast flow through the collecting system and
colon cancer. Here we will demonstrate that PGDH activity                 resolution of the obstruction. Conclusion: Isolated renal aspergilloma
determines sensitivity to the colon tumor preventive activity of          is extremely rare and timely intrarenal infusion of antifungal therapy is
celecoxib. Methods: Mice with wildtype and PGDH null genotypes at         an alternative to surgical management.
8-12 weeks of age were injected peritoneally with 10mg/kg of
azoxymethane once weekly for 6 weeks and euthanized 24 weeks after        Primary Pituitary Lymphoma. Janna Cohen-Lehman DO, Stuart
last injection. Colon tumors were counted under dissection                Weinerman MD; Division of Endocrinology, Department of Medicine,
microscope and verified by HE staining. The Adenoma Prevention            North Shore-Long Island Jewish Health System
with Celecoxib was reported previously(N Engl J Med. 2006                 Introduction: Lymphoma limited to the pituitary gland has been
;355(9):873-84.). Briefly, patients who had adenomas removed before       rarely reported, yet it has been recently recognized as an integral part
study entry were randomly assigned to receive placebo celecoxib twice     of the differential diagnosis of a pituitary mass. Clinical Case: We
daily. Levels of PGDH were determined from rectal biopsy with             report the case of a 58-year-old female with history of hypertension
quantitative PCR before randomization. Follow-up colonoscopies            who presented with one week of headache, blurry vision, and an
were performed at three years after randomization. Results: First, the    inability to control left eye movement. Left eye exam revealed ptosis,
adenoma-preventive activity of celecoxib is abrogated in mice             mild exopthalmos, non-reactive pupil, no visual field defects and
normal pressure. There were no signs of Cushing’s disease or              With Plasmacytic Differentiation. Tarush Kothari; Department of
acromegaly. MRI revealed a 1.3 cm mass arising from the sella with        Pathology & Laboratory Medicine, North Shore-Long Island Jewish
some draping of the optic chiasm over this mass. The patient              Health System
underwent transsphenoidal surgery to remove the pituitary tumor, and      Posttransplantation lymphoproliferative disorders (PTLDs) are a
histopathological examination was consistent with diffuse large B cell    diverse group of lymphoid proliferations that arise secondary to
lymphoma. The patient was HIV negative and staging showed no              immunosuppression in the setting of solid organ or bone marrow
evidence of disease outside of the CNS. The diagnosis of primary          transplantation. Three primary categories are defined by the WHO:
pituitary lymphoma (PPL) was made, and she was treated with 1 cycle       “early lesions” composed of reactive plasmacytic hyperplasia and
of high-dose methotrexate, whole brain radiation therapy, followed by     infectious mononucleosis-like proliferations, polymorphic PTLD and
6 cycles of rituximab plus CHOP chemotherapy. Follow up PET and           monomorphic PTLD. Most monomorphic PTLDs resemble diffuse
CT scans showed significant tumor shrinkage. Discussion: Primary          large B-cell lymphoma or Burkitt lymphoma. Here we describe the
CNS Lymphoma (PCNSL) is a rare clinical entity accounting for fewer       pathologic and phenotypic features of a rare case of monomorphic
than 5% of all cases of primary intracranial neoplasm. Fewer than         PTLD resembling extramedullary plasmacytoma. A 14 year old male
forty cases of PPL have been fully described in the literature. The       with a past medical history of renal transplantation 12 years ago (for
peak incidence of PPL is the 6th decade of age with a male                polycystic kidney disease) presented with an abdominal mass with
predominance, which is similar to the demographics seen in                associated pain. Biopsy of the mass suggested a post-transplant
immunocompetent patients with PCNSL. In addition to the known             lymphoproliferative disorder involving the small bowel. All
association of AIDS with PCNSL, hypothetical risk factors for the         therapeutic options were discussed with the oncology team and a
development of PPL include lymphocytic hypophysitis and a pre-            decision was made to proceed with resection of the small bowel mass.
existing pituitary adenoma. Radiation and chemotherapy are the            The excised mass measured 7.5 x 7.5 x 5 cm, centered on the
mainstays of treatment for PCNSL, which has been extrapolated to the      mesenteric aspect of the small bowel, with circumferential extension
                  2                                                       around the bowel wall. The tumor involved the mucosa with extensive
treatment of PPL . Because of the lack of established regimens,
                                                                          ulceration. Histologic examination of the mass showed sheets of large
treatment must be determined on an individual basis and continued or
                                                                          tumor cells with plasmacytoid morphology, variably pleomorphic
adjusted based upon the response to treatment. Conclusion: While a
                                                                          nuclei with nucleoli and focally identifiable perinuclear hoffs.
rare cause of pituitary mass, PPL should be considered in the
                                                                          Immunohistochemical staining revealed tumor cells to be strongly and
differential diagnosis of an uncommon etiology of a sellar mass.
                                                                          diffusely positive for CD38, CD138, MUM1 and focally CD79a and
Postoperative management should involve both endocrine and
                                                                          negative for CD20. The Ki67 proliferative index approached 100%.
oncology subspecialties.
                                                                          Flow cytometry showed tumor cells to be clonal and positive for
                                                                          cytoplasmic kappa, CD 45(dim), CD38 and CD138 thus confirming
Colitis Cystica Profunda Presenting as a Large Bowel Obstruction.
                                                                          the diagnosis of plasmacytoma-like PTLD. The in situ hybridization
Bryan Green MD, Arash Shifteh DO; Division of Gastroenterology &
                                                                          for EBV early RNA (EBER) was reported to be negative.
Hepatology, Department of Medicine, Long Island Jewish Medical
                                                                          Monomorphic PTLDs with plasmacytic differentiation are rare with
                                                                          less than 30 cases reported in the English literature. They
Colitis Cystica Profunda (CCP) is a rare benign disease characterized
                                                                          characteristically arise late after transplantation (mean, 7.0 years),
by mucous-filled cysts in the submucosa of the colon and rectum. The
                                                                          show a variable association with Epstein-Barr virus and demonstrate
main clinical significance lies in distinguishing CCP from colorectal
                                                                          histologic    and     phenotypic     findings    that  overlap   with
malignancy and preventing unnecessary surgery. Most patients are
                                                                          immunocompetent extramedullary plasmacytomas.
asymptomatic and lesions are incidentally identified on screening
colonoscopy. When symptoms are present hematochezia, diarrhea,
                                                                          Reactive Thyrotoxicosis: Under Diagnosed Complication of
tenesmus, and rectal prolapse may be seen. We discuss an unusual case
                                                                          Parathyroidectomy in the Dialysis Population. Tamim Naber MD,
in which a patient presenting with colonic obstruction was found to
                                                                          Mala Sachdeva MD; Division of Nephrology and Hypertension,
have CCP. A 46 year-old man presented with nausea, vomiting, and
                                                                          Department of Medicine, North Shore University Hospital
obstipation for 1 day. A colonoscopy performed 7 months before
                                                                          Surgical removal of parathyroid glands is the treatment of choice for
admission revealed a polypoid sigmoid mass. Adenomatous changes
                                                                          tertiary hyperparathyroidism and osteodystrophy in patients with
were seen in the polypectomy specimen. Obstructive symptoms
                                                                          chronic kidney disease “CKD” and end stage renal disease “ESRD” on
developed 1 day before admission. A plain abdominal film revealed
                                                                          renal replacement therapy. Although complications peri-operatively
colonic distention. The patient partially improved with nasogastric
                                                                          are rare and well defined; hyperthyroidism and thyrotoxicosis remains
decompression. The patient refused a low anterior resection (LAR)
                                                                          under diagnosed as post operative complication and rarely been
with colostomy for suspected malignancy. He was referred to the
                                                                          reported especially in the dialysis population. We report a 51 year old
gastroenterology service to attempt colonic stent placement and
                                                                          female with history of end stage renal disease “ESRD” secondary to
decompression. If successful, LAR with primary colonic anastomosis
                                                                          IgA nephropathy requiring long term hemodialysis “HD”. Patient
would follow. On colonoscopy, a large polypoid sigmoid mass was
                                                                          developed resistant tertiary hyperparathyroidism requiring total
seen acting as a lead point for intussusception, which was reduced. A
                                                                          parathyroidectomy and re-implantation of the superior parathyroid
rectal tube was placed over a guidewire, beyond the lesion to
                                                                          gland into the sternocleidomastoid muscle without thyroidectomy or
temporarily prevent recurrence of obstruction. Subsequently, the
                                                                          thyroid injury. Surgery was successful with PTH dropped from
patient was able to tolerate a bowel preparation prior to LAR. The
                                                                          1637pg/ml to 178pg/ml. Hungry bone syndrome with hypocalcemia
histology from the resected colon was consistent with CCP.
                                                                          developed immediately post-op and was controlled with calcium and
Malignancy was not present. CCP is a histological diagnosis which
                                                                          vitamin D analogue supplements. Two days post operatively she
must be differentiated from malignancy. Polypoid or ulcerated lesions
                                                                          developed supra ventricular tachycardia with heart rate of 200, which
can be seen on colonoscopy, although mucosal biopsies may be
                                                                          was treated with adenosine. She continued to have tachycardia with
insufficient to obtain tissue from the deeper submucosa. This can lead
                                                                          heart rate ranging 100-120’s associated with palpitations and dizziness.
to diagnostic confusion and repetitive tissue sampling. EUS may
                                                                          TSH, T3, and free T4 were consistent with hyperthyroidism. She have
identify submucosal cystic lesions. Classically, the disease occurs in
                                                                          never had any previous history of thyroid disease and never been
adults without gender predilection. There are three types of CCP;
                                                                          exposed to iodine, lithium, or thyroid medicine previously.
localized, segmental, and diffuse. Localized CCP, also called solitary
                                                                          Conclusion: Hyperthyroidism post parathyroidectomy is not well
rectal ulcer syndrome, is the most common form. It is found in the
                                                                          recognized and under reported. It implies/constitute for many co-
anterior rectum, 5-12 centimeters from the anal verge. Segmental CCP
                                                                          morbidities post operatively and we would suggest to routinely check
has been described in the rectosigmoid region and in the transverse and
                                                                          thyroid stimulating hormone level “TSH” pre and post operatively as a
descending colon. In diffuse CCP, submucosal cysts are found
                                                                          standard of care.
throughout the colon, and may be associated with ulcerative colitis.
Conservative treatment options include a high fiber diet, a bowel
                                                                          Undetectable HIV Infection in a 12 year old Perinatally-Infected
regimen, and hydrocortisone enemas. Many patients report resolution
                                                                          Child. Naba Sharif MD, Susan Schuval MD; Division of Allergy &
of symptoms. As with our patient, severe or persistent symptoms may
                                                                          Immunology, Departments of Pediatrics and Medicine, North Shore-
require surgery.
                                                                          Long Island Jewish Health System
                                                                          Introduction: Early and aggressive highly active antiretroviral therapy
Monomorphic Posttransplantation Lymphoproliferative Disorder
(HAART) may dramatically reduce HIV RNA levels in perinatally-               consideration in the differential.
infected infants. However, most HIV-infected children will continue
to demonstrate positive HIV antibody responses and have detectable
HIV via conventional DNA or RNA PCR. Case Description: A male                CLINICAL SCIENCE RESEARCH
infant was born by uncomplicated vaginal delivery to a 32 year old
previously healthy woman. Newborn screen was positive for                    Fine Needle Aspiration Biopsy of Thyroid Nodules in the Pediatric
antibodies to HIV-1 and the infant was started on zidovudine at 2            Population: a 10-Year Experience. Lori Anderson DO, Daniel Soto
weeks of life. Lamivudine and ritonavir were added when HIV DNA              CT, Chiara Sugrue CT, Melissa Klein CT, Patricia Wasserman MD;
PCR was positive at 2 months of age. HIV RNA level at that time was          Department of Pathology & Laboratory Medicine, North Shore-Long
2786 copies/ml. HIV tests were performed monthly for the first year          Island Jewish Health System
of life, and then quarterly until 12 years of age. These tests included      Background: Thyroid nodules are uncommon in the pediatric
serology, RNA and DNA PCR and peripheral blood mononuclear cell              population and the prevalence of malignancy is higher than in adults.
viral culture. The infant seroreverted at 12 months of age. Although         In order to avoid unnecessary surgery, fine needle aspiration (FNA) is
subsequent HIV RNA levels remained undetectable over the next 11             accepted as one of the most reliable and cost-effective screening tests
years, plasma viremia was detected via “ultrasensitive” HIV RNA              in the evaluation of thyroid nodules in adults. However, the
PCR assays at 17 and 24 months. Most recent HIV testing at age 12            clinicopathologic studies devoted to the pediatric population are
revealed negative HIV serology, undetectable HIV RNA (<20 RNA                limited. In addition, there is no standard classification system used for
copies/mL) and negative HIV DNA PCR. We subsequently isolated                thyroid FNA for the past few decades. The National Cancer Institute
CD4-enriched DNA and ran HIV-DNA PCR, which was positive. The                (NCI) recently published a 6-tier thyroid FNA classification scheme
child remains well without infections on zidovudine, lamivudine, and         for cytologic diagnosis of thyroid lesions.         These categories are
ritonavir. Discussion: We report a 12 year old male in whom current          similar to those we have been using at our Institute. The purpose of the
HIV infection is only detectable via specialized assay using CD4             present study is to analyze our thyroid FNA experience in the pediatric
enriched DNA. In this child, conventional HIV testing after one year of      population. Materials and Methods: Thyroid FNA performed in
life would have failed to detect HIV. This case underscores the              patients >21 years of age during January 1998 and December 2008
limitations of conventional HIV testing and the need for early               were retrieved by a computerized, retrospective search of all thyroid
evaluation and careful follow-up testing of HIV-exposed infants. This        FNA specimens filed at Long Island Jewish Medical Center. The
patient’s viral load has remained undetectable long-term. Most likely,       cytologic diagnoses were classified according to the new NCI
successful HAART has reduced plasma HIV RNA to levels below the              diagnostic categories and clinical follow-up information was reviewed.
conventional standard of detection. It is possible that the virus may        Results: From January 1998 to December 2008, 11,718 cases of
remain sequestered in cellular reservoirs. Further study of similar          thyroid FNA were received at LIJ. Among them, 167 cases (1.0%)
patients may determine the specific host or viral factors that create this   were from patients under 21 years of age. These cases were classified
unique immunologic profile.                                                  into one of the NCI diagnostic categories as follows: non-diagnostic
                                                                             (9.6%), benign (69%), atypical follicular cells of undetermined
A Young Female Presenting with Thrombotic Stroke and Adrenal                 significance (AFCUS) (5.4%), suspicious for follicular neoplasm (FN)
Insufficiency. Min Yan MD, Alan Multz MD, Mathew Kaufman MD;                 (22.2%), suspicious for malignancy (SM) (1.8%) and malignant (M)
Department of Medicine, Long Island Jewish Medical Center                    (13.2%). 58 patients had surgical follow-up, including 16% with
Introduction: Antiphospholipid Syndrome (APS) is defined by                  benign FNA, 8% with AFCUS, 39% with FN, 5% with SM and 29%
vascular thrombotic event and presence of antiphospholipid antibody          with M results. The rates for histologically confirmed malignancy in
including lupus anticoagulant, which prolongs PTT. Here we report a          these categories were 0%, 0%, 40%, 100% and 100%, respectively.
case of a young female presenting with thrombotic stroke and adrenal         The sensitivity and specificity of thyroid FNA for malignancy in
insufficiency secondary to APS. Case Presentation: A 20-year-old             pediatric population were 100% and 100%, respectively. Conclusions:
previously healthy female presented after three episodes of syncope.         Thyroid FNA provides a sensitive and specific diagnostic tool for the
She was shopping when she suddenly lost consciousness and fell               evaluation of thyroid nodules in pediatric population. NCI 6-tier
backward without any prodrome. In thirty seconds she regained                classification scheme standardizes the diagnostic terminology in
consciousness without shaking or incontinence or weakness. In the            thyroid FNA, which is beneficial for the proper clinical management
next two hours two similar episodes occurred. She felt dizzy and             and follow-up of the pediatric patients with thyroid nodules.
lethargic and was sent to emergency room. Her blood pressure was
85/50, with other vital signs in normal range. Physical examination          SNP rs1882832 in CD40 and Rheumatoid Arthritis in an Early
revealed a lethargic young female, sluggish eye-opening to verbal            Arthritis Cohort. Diane Horowitz MD, Annette Lee PhD, Peter
command, too weak to answer questions and exhibiting no focal                Gregersen MD; Division of Rheumatology, Department of Medicine,
neurological deficits. Head CT was negative for bleeding. CBC, BMP,          North Shore-Long Island Jewish Health System
EKG were unremarkable. However, PT/INR/PTT were all elevated                 Introduction: Polymorphisms in CD40, an integral membrane protein
with PT at 18.8 seconds (normal range 10.4-13.4) and INR at 1.5              of the TNF-receptor-super-family, are associated with rheumatoid
(normal range 0.9-1.13) and PTT at 118.5 seconds (normal range 26            arthritis (RA) susceptibility and severity. Previous studies demonstrate
and 36 seconds). DIC was ruled out with normal D-dimer and                   that the minor allele of an intronic single-nucleotide-polymorphism
fibrinogen level. APS was confirmed with prolonged PTT resistant to          (SNP), rs4810485 is protective for RA. Surprisingly, despite its role in
correction with normal plasma, positive anti-cardiolipin antibody and        protection from developing RA, subjects with the homozygous minor
normal clotting factor levels. Meanwhile, patient's blood pressure did       allele and RA have been reported in one to study to exhibit more rapid
not respond to fluid repletion, prompting a check for cortisol level,        progression to bony erosion. This may reflect distinct biological roles
which is extremely low even after cosyntropin stimulation (1.1 ug/dl         for CD40 in RA pathogenesis. Rs1883832, within the kozak sequence
with normal range between 2.3 and 11.9 ug/dl). Abdominal CT scan             of CD40, is in near-perfect linkage disequilibrium with rs4810485 and
showed bilaterally enlarged adrenal glands, consistent with                  correlates with protein expression. This study attempts to confirm the
hemorrhagic infarction of adrenal glands secondary to APS-induced            association of rs1883832 with early erosive disease using the
adrenal vein thrombosis. Later MRI showed multiple acute small               SONORA dataset, a prospective cohort of new onset RA. Methods:
infarcts in bifrontal cortex and subcortical region. Patient was started     SONORA, enrolled subjects between 2000 and 2005, and collected
on hydrocortisone for adrenal insufficiency and low-molecular heparin        clinical, radiographic, and serologic data on an annual basis for 2
for anti-coagulation. Her symptoms gradually improved and she was            years. DNA was collected at baseline. Within the cohort, there is
discharged in one week on coumadin. Discussion: This case illustrates        demographic data for 1011 subjects, DNA for 834 subjects and
the multifaceted manifestations of APS in its initial presentation. A        radiographic data for 769 subjects. 771 patients, who were Caucasian,
thrombotic stroke occurring in a young patient with no apparent risk         had genotype data available were included in this study. These
factors for cerebrovascular disease is the classic setting to suspect        subjects either met criteria for RA and/or had a positive serum anti-
APS. The hypercoagulable state in APS infrequently leads to                  cyclic citrullinated protein antibody(CCP). Genotyping for rs1883832
hemorrhagic infarction of adrenal glands and subsequent adrenal              was performed using pyrosequencing. Results: In 771 subjects, the
insufficiency. The presence of elevated PT/INR/PTT could                     allele frequencies were A=25.7% and G=74.3% and the genotype
reasonably lead to a presumption of a bleeding disorder, rather than a       frequencies were GG=56%, GA=36.6% and AA=7.4%. In the CCP+
hypercoagulable state; in this case it was critical that APS remained a      subjects the allele frequencies were A=24% and G=76% and the
genotype frequencies were GG=57.7%, GA=36.6% and AA=5.7%. In                 recurrent or new onset wheezing. In addition, a higher proportion of
271 published controls, allele frequencies were A=29.5% and G=70.5           patients with novel A:H1N1 were African-American. Gastrointestinal
and the genotype frequencies were GG=49.8%, GA=41.3% and                     symptoms were not more common in the novel A:H1N1 patients
AA=8.9%. Conclusions: SONORA is a unique cohort to evaluate the              compared to the seasonal cohort. Among hospitalized patients there
previously described association of rs4810485 with the risk of RA and        was no significant difference in the severity of illness between the two
erosive disease in RA. Preliminary results confirm the protective            groups.
effect of the minor allele in CCP+ RA. Currently, a mathematical
model is being developed to evaluate the association of rs1883832            Implications of Neuropathic Pain in the Interstitial Cystitis (IC)
with RA risk and erosive disease in RA.                                      Population. Sandeep Saluja BS, Mostafa Sadek MD, Kristene
                                                                             Whitmore MD, Robert Moldwin MD; Smith Institute for Urology,
Intra-Operative Frozen Section on Sentinel Lymph Nodes Is Not                North Shore-Long Island Jewish Health System
Indicated in Patients With Ductal Carcinoma In Situ of the Breast            Introduction: Chronic pelvic pain (CPP) disorders such as interstitial
or in Those Undergoing Prophylactic Mastectomy. Jaya Mahajan                 cystitis often present with neuropathic features. The aim of this study
MD; Department of Pathology & Laboratory Medicine, North Shore-              was to examine a cohort of patients with a primary complaint of CPP
Long Island Jewish Health System                                             for associated neuropathic co-morbidities, presence of true neuropathic
Introduction: The appropriateness and cost-effectiveness of routine          pain symptoms, and to compare the physical and mental health scores
intra-operative sentinel lymph node (SLN) assessment remains to be           of CPP patients with and without neuropathic symptoms. Methods:
defined. We aim to determine whether routine intra-operative frozen          142 patients from two tertiary referral centers with CPP disorders were
section (FS) examination of SLNs is worthwhile in all patients               prospectively evaluated. The prevalence of six neuropathic co-morbid
undergoing surgery for breast cancer. Methods: We conducted a                diagnoses were determined using a brief questionnaire, The Self-
retrospective study, reviewing 184 consecutive cases of SLN biopsy           Administered Leeds Assessment of Neuropathic Symptoms and Signs
performed by a single experienced breast surgeon in 2007 with                survey (S-LANSS) was used to examine pain symptoms primarily of
attention to variations by histologic subtype and tumor size. This           neuropathic origin. All patients also completed the SF-12v2 survey to
number included 91 invasive ductal carcinomas, 22 invasive                   assess mental and physical health domains. A two tailed t-test was
carcinomas with mixed lobular-ductal features, 19 invasive lobular           used to analyze the physical (PCS) and mental (MCS) component
carcinomas, 18 ductal carcinomas in situ and 34 prophylactic                 summaries of the SF-12 survey in CPP patients with and without
mastectomies. All patients underwent SLN biopsy with intra-operative         neuropathic features. Results: The mean age of patients was 45 years
FS evaluation. The nodes negative on FS were further subjected to an         (14-82).     95% were females. Co-morbid conditions included,
enhanced histopathological evaluation protocol with 3 levels of routine      myofascial pain (17.9%), tempromandibular joint dysfunction (11.3%),
hematoxylin-eosin-stained       sections    and     3     levels     of      fibromyalgia (9.9%), neuropathies (9.9%), pudendal neuropathy
immunocytochemical stained sections using pan-cytokeratin antibody           (5.3%), and complex regional pain syndrome (0.67%). 44 patients
(AE1/3). Results: The overall sensitivity of intra-operative FS of           (31%) were identified with neuropathic pain by the S-LANSS survey.
SLNs was 66%. The intra-operative FS of SLNs was negative for all            31.1% of patients with IC (OR 1.16, 95%CI 0.57-2.39). 31.6% with
cases of ductal carcinoma in situ and prophylactic mastectomies. Of 46       high tone pelvic floor dysfunction (OR 1.50, 95%CI 0.62-3.63), and
cases with invasive breast cancer smaller than 1.0 cm, only 2 (4.3%)         38.5% with a vulvar pain disorder (OR 2.65, 95%CI 1.25-5.61) had
cases were found to be positive on intra-operative FS. Conclusions:          neuropathic pain. 75% of CPP patients carried more than one pain
Intra-operative FS of SLNs is not worthwhile for patients with ductal        related diagnosis. Patients with neuropathic pain scored significantly
carcinoma in situ or for those undergoing prophylactic mastectomy.           higher on Likert pain scales than those without neuropathic pain, 6.2
Whether intra-operative FS of SLNs should be performed on patients           vs. 4.6 (P<0.002) Furthermore, patients with neuropathic pain scored
with early (smaller than 1.0 cm) invasive tumors will be discussed. An       4.28 points lower on the PCS (p = 0.053) and 5.45 points lower on the
effort to expand the study by increasing the number of cases is              MCS (p = 0.008). Conclusion: CPP syndromes, including IC, are
currently underway.                                                          often associated with multiple co-morbid conditions and with
                                                                             neuropathic pain. Greater pain severity is reported amongst CPP
Comparison of the Demographics, Clinical Presentation, and                   patients with a neuropathic component. These patients also
Course of Children Hospitalized With Novel A:H1N1 Influenza                  demonstrate a significantly poorer quality of life, particularly as related
Infection With Children Hospitalized With Seasonal Influenza.                to mental health.
Gholamabbas Ostovar MD; Division of Infectious Diseases,
Department of Pediatrics, North Shore-Long Island Jewish Health              Improving the Diagnostic Accuracy of Testicular Torsion by
System/Cohen Children’s Medical Center                                       Urology Residents: Logistic Regression Analysis of History and
Introduction: Little has been published about the clinical features of       Physical Examination Parameters. Arun Srinivasan MD; Smith
children hospitalized with novel A:H1N1 infection or differences in          Institute for Urology, North Shore-Long Island Jewish Health System
clinical features of these patients and inpatients with seasonal influenza   Background: There is growing reliance on imaging studies to evaluate
infection. We compared demographics, clinical presentation, course,          pediatric scrotal pain. However, thorough clinical evaluation should
and outcome of children hospitalized with novel A:H1N1 infection             provide accurate diagnosis that avoids delay of care and organ loss.
with children hospitalized with seasonal influenza. Methods: Cases           We sought to increase the diagnostic yield of history and physical
were identified using microbiology laboratory data and data compiled         examination (H P) by urology residents by identifying parameters
by Infection Control. Patients who were hospitalized from April
through August 2009 and tested positive for non-subtypable A:H1N1            that accurately predict torsion. Methods: Over 5 months, H P
using a PCR assay (Luminex) were enrolled. For the seasonal                  findings by urology residents were prospectively recorded for all boys
influenza cohort, patients hospitalized during the past five years who       presenting with scrotal pain to our ED. Further management decisions
were diagnosed by viral culture or direct fluorescent antibody testing       were made as indicated; i.e., radiological evaluation and surgical
were enrolled. Data was collected by reviewing inpatient medical             intervention. Data were analyzed by ROC and logistic regression
records. Results: Sixty-one patients were enrolled in the novel and 31       analysis in correlation with the eventual diagnosis to identify H P
in the seasonal groups. The median age in the novel A:H1N1 group             parameters most diagnostic of testicular torsion. Results: Of the 79
(6.3 years) was significantly higher than in the seasonal cohort (1.8        boys evaluated by residents over 5 months, 8 (10.1%) had testicular
years; p=0.0012). Forty-nine percent of the patients in the novel
A:H1N1 cohort were African-American compared to 23% of the                   torsion. 22 specific H P parameters were recorded. On ROC analysis,
patients in the seasonal cohort (p=0.014). Fifty-seven percent of the        there were 5 significant parameters [graph]. After adjusting for
patients in the novel A:H1N1 cohort presented with new onset or              confounding effects of co-existing variables by multivariate logistic
recurrent wheezing compared to 19% in the seasonal cohort                    regression, absence of ipsilateral cremaster reflex (p<0.001), presence
(p=0.0005). Differences between the groups in gender, admission to           of scrotal skin changes (p<0.001) or nausea/vomiting (p<0.05) were
PICU, median length of stay, requirement for ventilatory support, new        the only predictors of testicular torsion. Conclusion: Accurate
or recurrent seizure, and nausea and/ or vomiting on presentation were       evaluation of scrotal pain by residents may be increased by
not significant. Conclusions: Compared with patients hospitalized            appreciating clinical parameters most predictive of testicular torsion;
with seasonal influenza, patients with novel A:H1N1 influenza were           namely the presence of nausea/vomiting and scrotal skin changes, and
significantly older and a significantly higher proportion presented with     the absence of ipsilateral cremaster reflex.
Bone Disease In Long Term Post Renal Transplant Patients. Rajiv               training programs. It incorporates narrative and written exercises from
Vij MD, Ashfaq Akhtar MD, Harmut Malluche MD; Division of                     medical literature and the humanities to ensure residency programs
Nephrology and Hypertension, Department of Medicine, North Shore              graduate physicians who are empathetic, altruistic, responsible and
University Hospital                                                           dedicated to their profession.
Background: Bone disease after renal transplant is a common
complication and a cause of significant morbidity. Bisphosphonates
are widely used to prevent bone loss in post transplant patients.             LITERATURE AND CLINICAL TOPIC REVIEWS
Bisphosphonate use can cause over suppression and cause increased
incidence of adynamic bone disease. Bone histopathology provides              Diagnostic Pitfall: Enhancement of Organizing Hematoma on
most accurate information regarding type of bone disease and is a             MRI. Brianne Blumenthal MD, Barak Friedman MD; Department of
useful guide to appropriate treatment of these patients. In this report       Radiology, Long Island Jewish Medical Center
we present the histomorphometric pattern of bone disease after long           Background: Hematoma is typically differentiated from neoplasm by
term transplantation in 14 patients at our institution. Methods: Bone         its characteristic lack of enhancement on post-contrast subtraction MR
biopsies were performed after double tetracycline labeling from               imaging. Although contrary to traditional teaching, occasionally
anterior iliac crest on patients because of abnormal DEXA scan or             peripheral nodular or weak diffuse internal enhancement within
worsening symptoms. Data was obtained regarding age, cause of                 organized hematoma can be seen, likely due to the presence of
ESRD, co-morbid medical conditions and type of immuno-suppression             granulation tissue and neovascularization. Awareness of this finding
and occurrence of fracture. Specimens were analyzed by a pathologist          may prevent the misdiagnosis of hematoma as tumor. To our
without knowledge of patient details. Results: Patients were long term        knowledge there has not yet been a published case series emphasizing
post transplant (2.8-30 years). 28% had diabetes and 71% were                 this diagnostic pitfall in the imaging of abdominal masses. The
females. All were on maintenance steroids, 4 received tacrolimus and          purpose of this case-based educational exhibit is to demonstrate the
cellcept whereas 5 were on cyclosporine based regimens. All patients          typical MR findings of organizing hematoma, highlighting the
were on maintenance steroids. Cumulative steroid dosage was 43 +/-            potential overlap in MR appearance of organizing hematoma with
44 grams. 36% were on bisphosphonates or Vitamin D and 57% on                 neoplasm. Educational Goals/Teaching Points: 1. MR imaging
phosphorus binders. Most had iPTH levels < 200 pg/ml at the time of           characteristics of hematoma and organizing hematoma with histologic
biopsy. 5 patients (35.7%) had documented fractures since transplant.         correlation. 2. Histologic basis for enhancement within chronic
All patients had low bone turnover on histomorphometric analysis. Six         hematomas. 3. Pathology-proven case illustrations of hematomas
patients had also low bone volume/tissue volume. Only one patient             ‘misdiagnosed’ as tumor. 4. Side by side comparison with the
presented with a mild increase in osteoclast surface/bone surface             gadolinium-enhanced subtraction images of neoplastic entities such as
whereas all but one patient showed an increase in erosion depth. None         renal cell carcinoma, adrenal cortical carcinoma, and retroperitoneal
presented with woven bone or peritrabecular fibrosis or bone                  sarcoma.
aluminum accumulation. Data was analyzed using multivariate                   Conclusion: Upon review of this case-based educational exhibit, the
regression analysis, using age, diabetes, BMD, bisphosphonate use,            viewer should be aware of the possibility of enhancement within an
steroid dose as independent variables and occurrence of fracture as           organizing hematoma, including the potential for peripheral or weak
dependent variable. Only diabetes was found to have significant trend         internal enhancement. In the appropriate clinical setting, hematoma
(B= 0.76, t= 2.52, std error 0.29 p<0.05). Conclusion: We demonstrate         should be part of the differential diagnosis for a mass which
increased prevalence of low turn over bone disease in long term post          demonstrates this type of enhancement on subtraction MR imaging.
transplant recipients. Appropriate diagnosis and treatment should be
guided by histopathologic evaluation in these patients.                       ‘All-on-Four.’ Tascha Fuchs DDS; Department of Dental Medicine
                                                                              North Shore University Hospital
                                                                              Introduction: The “All-on-Four” concept is discussed here in a
EDUCATIONAL OUTCOMES RESEARCH                                                 review of recent literature to determine the success of the concept as
                                                                              well as the disadvantages. The use of tilted implants presents several
Teaching Professionalism and Behavioral Ethics in Residency                   benefits, bypassing the maxillary sinus and mandibular nerve, and
Training. Jarid Pachter DO; Department of Medical Education/Family            placing implants at sites with decreased quantity of bone. Placing
Practice, Plainview Hospital                                                  implants at an angle allows more inter-implant distance and longer
Introduction: Among the required core competencies outlined by the            implants to be used providing more anchorage. However, due to the
accrediting bodies of residency education programs, professionalism is        angulations of the distal placed implants there has been debate over the
perhaps the most challenging to integrate and assess during training.         stress placed on peri-implant bone. Methods: Relevant studies
The course described below is an effective and innovative method to           published in English between 2000 and 2009 were reviewed. The
address professionalism and could be applicable to all residency              articles were located through PubMed. Results: Several studies show
programs regardless of discipline. Methods: The course begins with a          the “All-on-Four” Branemark concept is viable with a 96% success
lecture/discussion on professionalism to all trainees. The goal of the        rate. Begg et al. found little difference in stress patterns at low degree
lecture is to inspire a sense of self reflection and examination among        tilts for angled implants but at 45 degree angulations a greater stress
the attendees. It serves as an introduction to the course a resident will     pattern was demonstrated. Bonnet et al also reported that implant
be required to participate in if there is a lapse of professionalism          tilting leads to high stress concentration at bone-implant interface. On
identified during their training. Participation is at the discretion of the   the other hand, Zampelis et al. showed no increase in peri-implant
program director of an individual residency. The class is conducted in        bone stress with implant angulations when implants were splinted by
a small group setting and meets once a week, over four sequential             fixed prosthesis. Studies indicate that distal tilting implants splinted
weeks.       The basis of the discussions comes from pre-reading              in a full prosthesis without cantilevers generate less stress in peri-
assignments from various books selected by the facilitator. Each              implant bone than vertical implants with cantilevered segments in
session focuses on a different aspect of professionalism and begins           similar prosthesis. Conclusions: Through review of this literature, it
with a reflective writing assignment. The content of the four sessions        can be concluded that “All-on-Four” concept has a high success rate.
includes: attributes required to be a physician, patient-physician            While angled implants create greater stress in peri-implant bone, the
relationship, empathy, and accountability. Students are required to           “All-on-Four” concept decreases this stress through splinting the
write a final reflective paper using skills of self-assessment to             angled implants in a full prosthesis and avoiding cantilevers.
demonstrate      understanding of their individual infraction. The
facilitator with the program director determines their level of insight       Transitional Lumbosacral Vertebral Body: Classification, Imaging
and any further remediation required. Results: The results thus far           Findings and Symptomatology. Gabrielle Konin MD, Alissa Burge
have been observational and self-report. Residents who have                   MD, Damon Spitz MD, Tal Rencus MD; Department of Radiology,
participated in the course continue their training with a better sense of     North Shore University Hospital
self. These trainees demonstrate a heightened self- awareness of their        Introduction/Purpose: The purpose of this exhibit is 1) to describe
behavior, and display better understanding of their actions. These            the imaging appearance of transitional lumbosacral vertebral segments,
outcomes are supported by their future performance with colleagues,           2) to define the clinical relevance based on imaging findings and
peers and patients. Conclusion: This course is an effective and               patient symptomatology and 3) to explore controversies regarding
positive way to implement a professionalism curriculum in residency           transitional segments with attention to the use of standardized
nomenclature between radiologists and surgeons. Methods/Approach:          more quit attempts in the past, 57% have a specific plan to quit in the
Through numerous imaging examples, this exhibit will review the            next 30 days, 50% quit for at least 1 week. 57% were interested in an
appearance of transitional lumbosacral segments. The focus will be on      ED Smoking Cessation intervention: specifically, 75% were interested
the relevance of anatomical variance as it relates to the development of   in a prescription and medication to help them stop smoking, 25% were
symptoms. Cases will be shown exemplifying changes that can                interested in a 15 minute ED counseling session, 25% were interested
develop based on vertebral morphology, sacralization or lumbarization      in written info on quitting, and 13% were interested in the quitline,
as well as postsurgical alterations. The importance of correct             referral to SC program, or their PMD for counseling. Conclusion:
nomenclature and numbering of segments will be addressed as it             Most smoking parents of our ED pediatric population are interested in
relates to surgical intervention and agreement between the radiologist     quitting (79% plan to quit in next 6 months) and 75% were most
and surgeon. Results/Discussion: Transitional lumbosacral vertebral        interested in a prescription/medications to help them stop smoking.
segments can be associated with the development of low back pain           60% of our smoking parents enrolled in one year smoking cessation
secondary to altered biomechanics and stress forces within the lower       follow-up program. Efforts should focus on identifying smoking
spine. The morphology and number of mobile segments in the                 parents in the ED and offering them prescriptions/medications and
lumbosacral spine changes secondary to varying degrees of                  follow-up to help them stop smoking.
lumbarization and sacralization. It is important for the radiologist to
understand the potential clinical relevance of this anatomical variation   Caregiver Quality of Life in Huntington’s Disease. Marie Cox DNP
and how it relates to the development of pain and instability. As          RN NP-C, Barbara Napolitano MA; Department of Cardiology-
important is the nomenclature used to describe the spine when such         Research, North Shore-Long Island Jewish Health System
variance is present. Accurate, formalized and consistent description       Introduction: The purpose of this exploratory, descriptive, cross-
allows for reliable agreement between surgeon and radiologist and          sectional study is to describe the quality of life of informal caregivers
avoids dire complications such as wrong level spine surgery.               of persons with Huntington’s disease. Long-term care of persons with
Conclusion/Summary: Transitional lumbosacral segments are                  Huntington’s disease (pHD) rests mainly with family or partner
common and therefore are frequently identified in patients undergoing      caregivers. Quality-of-life (QoL) research of caregivers of pHD is a
spinal imaging. A complete understanding of nomenclature,                  recent area of emphasis. Methods: The Huntington’s Disease Quality
morphology and clinical relevance will allow the radiologist to            of Life for Carers (HDQoL-C) questionnaire was used to collect
correctly diagnose these patients and accurately relay the findings to     information as it relates to the quality of life of this particular
the referring spinal surgeon.                                              population. This study included a convenience sample of 31 caregivers
                                                                           of pHD from the North Shore Long Island Jewish Health System and
Imaging Clues to Distinguish Intraperitoneal and Extraperitoneal           two Huntington’s disease support groups. Responses were analyzed
Processes in the Deep Pelvis. Nija Mathew MD, Lucille Xenophon             from 31 caregivers who completed the 34-item HDQoL-C, provided
MD; Department of Radiology, Long Island Jewish Medical Center             demographic and personal information, and responded to one single
Purpose: 1. Review deep pelvic anatomy, 2. Describe imaging                item question rating overall quality of life, and two open ended
features which assist in correctly localizing pelvic disease processes,    questions about what would improve their quality of life. The HDQoL-
and 3. Present characteristic disease entities associated with the deep    C measures subjective quality of life and incorporates demographic
pelvis. Content Organization: 1. Current anatomic concepts of the          and personal information, practical aspects of caregiving, satisfaction
pelvis -definition of intra- and extra-peritoneal spaces, 2. Description   with life, and feelings about living with Huntington’s disease. Results:
of relevant imaging features: displacement or distortion of structures     The mean score on the 34-item HDQoL-C questionnaire was 55% (SD
such as the urinary bladder relationship to other pelvic structures such   17) indicating a low quality of life score. Spearman correlation
as vessels or musculature location and configuration of pelvic fluid       analyses comparing the single item self-reported quality of life
collections, and 3. Differential diagnosis of pelvic processes.with        question and the total score on the HDQoL-C were significant (r =
examples of disease entities. Summary: Major teaching points: 1.           0.67, p = <0.05), indicating perceptions were consistent when rating
Extraperitoneal masses displace the urinary bladder from laterally and     QoL. The number of hours spent caregiving and working per week
anteriorly while intraperitoneal masses may impress the dome of the        showed a significant negative correlation with feelings about living
bladder. 2. Masses extending posterior to the rectum or associated         with HD (r = -0.43, p = <0.05 and -0.43, p = <0.05). The number of
with its supporting musculature are extraperitoneal. 3. The anterior       times a caregiver socialized per month correlated significantly with
abdominal wall is continuous with the pelvic extraperitoneal spaces. 4.    scores on practical aspects of caregiving (r = 0.41; p = <0.05),
Pelvic extraperitoneal processes may be intimately associated with the     satisfaction with life (r = 0.48; p = <0.05), feelings about living with
external iliac vessels.                                                    HD (r = 0.47; p = <0.05), and the total HDQoL-C questionnaire score
                                                                           (r = 0.51, p < 0.05). Conclusions: Providing respite from caregiving
                                                                           specifically involving social activities may improve HD caregiver
NURSING AND ALLIED HEALTH                                                  QoL. Further studies involving specific interventions to improve HD
                                                                           caregiver QoL are warranted.
Is Smoking Cessation Intervention in the Emergency Department
Effective Among Parents of Children with Respiratory                       Use of FRAX as a Screening Tool in the Ambulatory Care Setting.
Complaints? Elizabeth Barton BA, Ingrid Llovera, MD MPH, Mary              Lee Fiebert PharmD; Pharmacy Services, Long Island Jewish Medical
Frances Ward, RN ANP MS, Mary Breige O'Donnell BS, Lauren                  Center
Houdek BS, Andrew Sama MD; Department of Emergency Medicine,               Introduction: The World Health Organization (WHO) has developed
North Shore University Hospital                                            the Fracture Risk Assessment (FRAX) tool to calculate a patient's
Introduction: To identify smoking parents of our ED pediatric              probability of major osteoporotic and hip fracture by combining basic
patients and their interest in ED smoking cessation (SC) interventions.    demographic information, physical findings, clinical risk factors, and
Methods: Prospective, consecutive survey of smoking parents of our         femoral neck bone mineral density (BMD). In patients where a BMD
ED pediatric patients (presenting during the day shift in 2009)            is unavailable, the clinician is still able to calculate a fracture risk using
followed by enrollment in one year follow-up Smoking Cessation             the FRAX tool. The objective of this study is to determine the
intervention. Survey identified parents who smoke, their smoking           difference in fracture risk using the FRAX tool when calculated with
history (motivation/dependency) and their preferred cessation aides        and without a bone mineral density. This will allow for exploration
(ED counseling, prescription/medications, referrals to cessation           into the use of FRAX, in the ambulatory care setting, as a screening
programs or primary physician). Interested smokers were enrolled in        tool when a BMD is not available. Methods: Prior to the collection of
one year follow-up SC intervention program (emails, telephone calls        any data, all appropriate forms will be submitted to the Institutional
about quitting). Exclusions: child too sick, language barriers,            Review Board (IRB). Pending approval by the IRB, a list of patients
incompetent. University Hospital 70,000 visits/yr. Results: 234            will be generated that have ICD9 codes for osteoporosis or osteopenia
parents were approached, 193 were eligible for survey, 11% were            using the electronic medical records system. The FRAX tool is only
smokers, 60% of smokers enrolled in one year intervention.                 indicated for individuals between the ages of 40 and 90, so those
Demographics of smoking parents: mean age 37+8, 64% female, 69%            outside of this age group will be excluded. In the United States, the
Caucasian, 66% < high school education, Fagerstrom mean                    FRAX tool is only designed for those of caucasian, black, hispanic, or
dependency score 3.3/6, 43% smoke >15 cigarettes/day, 79% plan to          black ethnicity, therefore individuals of other backgrounds must also
quit in next 6 months, 75% have a strong desire to quit, 71% made 1 or     be excluded from this protocol. A data collection sheet will then be
used to record the patient's ethnicity, age or date of birth, sex, weight,   using Chi-square analysis and demographic information between
height, smoking status, and history of previous fracture, parent             groups was compared using two-sample T-tests and Chi-square
fracturing hip, glucocorticoid use, rheumatoid arthritis, type 1 diabetes,   analysis where appropriate. Results: In 2002-2004 and 2006-2008, 25
osteogenesis imperfecta, untreated long-standing hyperthyroidism,            sexual assault victims >14 years old with LOC unrelated to trauma,
hypogonadism, premature menopause, chronic malnutrition or                   alcohol or illicit drugs presented to our ED sexual assault center. The
malabsorption, liver disease, or alcohol consumption, and bone               incidence of LOC unrelated to trauma, alcohol or drugs in 2006-2008
mineral density (including make of machine) or T-score. The FRAX             (8%) was significantly increased over the incidence in 2002-2004
tool should only be used on patients that are not being treated for          (18%, p<0.04). No significant differences were found between the two
osteoporosis, therefore in patients on agents such as bisphosphonates,       groups in terms of age (28 +12 vs. 27+ 12, p<0.37), sex (99% vs. 98%
raloxifene, calcitonin, parathyroid hormone, estrogen, or testosterone,      female, p<0.62) or race (p<0.58). There was no significant correlation
data prior to the initiation of therapy will be used and the age will be     between geographic location or setting of assault (public or private)
adjusted. To protect patient confidentiality, no patient identifiers will    with the incidence of sexual assaults presenting with LOC unrelated to
be recorded and all data collection forms will be kept private by the        trauma, alcohol or illicit drugs. Conclusion: The increased incidence
primary investigator. The patients' 10 year probability of major             of loss of consciousness (not related to trauma, alcohol or illicit drugs)
osteoporotic and hip fracture will then be calculated both with and          found in our sexual assault victims in more recent years suggests the
without the available BMD using the FRAX tool. The difference in             possible increased use of date rape drugs being used in the New York
these probabilities of fracture risk can then be calculated and              metropolitan area. This is an increasing public health issue that
statistically analyzed allowing the investigators to assess the utility of   requires more education of young women in the community in order to
the FRAX tool in the absence of a BMD, a common scenario faced by            decrease the number of drug induced rapes.
the ambulatory care pharmacist. Results: Research in Progress
Conclusions: Research in Progress                                            Does Inferior Vena Cava/Aorta Ratio Correlate with Fluid
                                                                             Therapy in Clinically Dehydrated Children? Lauren Houdek BS,
Measuring Effectiveness of a Tobacco Dependence Treatment                    Mary Breige O’Donnell, BS, Jordana Kaban DO, Christopher Raio,
Educational Intervention for Nursing Students. Patricia Folan RN,            MD RD MS, Meredith Ackerman MS, Mary Frances Ward RN MS,
Evelyn Duffy DNP ANP RN; Center for Tobacco Control, North                   Andrew Sama MD FACEP; Department of Emergency Medicine,
Shore University Hospital                                                    North Shore University Hospital
Introduction: Smoking is the leading cause of preventable morbidity          Introduction: Accurate hydration assessment is essential for
and mortality. Seventy percent of smokers want to quit and state that        appropriate fluid resuscitation therapy in children. The current standard
they would if offered firm advice by their healthcare provider. Studies      uses clinical signs and symptoms; however, these methods have low
indicate that people are more successful quitting smoking with the           sensitivity and specificity. Recent literature has employed ultrasound
advice and support of a healthcare provider. Nurses are the largest          to image inferior vena cava (IVC) diameter and collapsibility to
group of healthcare professionals and can have a tremendous impact           determine fluid status. In the pediatric population, IVC size varies with
on assisting smokers to quit. Tobacco dependence treatment should            several parameters and offers no normal reference values. Aortic
follow the evidence based US PHS Guideline, Treating Tobacco Use             diameter isn’t affected by intravascular volume changes and may serve
and Dependence. This study queried undergraduate nursing students            as a reference for assessing hydration status. Objectives: Look at
to determine their knowledge before and after an intensive four hour         IVC/aorta ratio as a way to evaluate hydration status in children by
educational training program addressing tobacco dependence                   determining the association between IVC/aorta ratio and the amount of
treatment. Methods: A 20 question test was administered to nursing           fluid given over time. Methods: Prospective, observational study,
students before and after the 4 hour educational training (N = 268 pre       convenience sample of pediatric patients (< 18 years old) presenting to
test, N = 276 post test). Results: The results of the chi square test of     the ED with clinical signs of dehydration.                   Longitudinal
association indicated a significant association between pre and post test    anteroposterior diameter measurements of the IVC and proximal
scores following the four hour educational intervention about treating       transverse diameter measurements of the aorta were taken distal to the
tobacco use and dependence. Examination of cell percentages revealed         hepatic vein junction. There was neither compression of the abdomen
nurses’ knowledge increased following the intervention. Pre test scores      nor graded compression to move the bowel. The IVC and aorta
(M = 43.22, SD = 12.14) vs. post test scores ( M = 73.20, SD = 13.63)        measurements were performed at baseline and after administration of
p < .001. The Mann-Whitney test was conducted to evaluate pre and            one 20cc/kg fluid bolus. Descriptive statistics were computed for IVC,
post test scores in the areas of: 1. morbidity and mortality facts; 2.       aorta, and IVC/aorta ratio before hydration, after 20cc/kg bolus, and
evidence based treatment guidelines; 3.behavioral counseling and 4.          the difference between these measures. The Wilcoxon signed rank test
pharmacotherapy. The test was significant from pre to post test in each      was used to determine statistical differences in IVC, aorta, and the
area using chi square p < .001. Conclusions: The results of these tests      IVC/aorta ratio before hydration and after a 20cc/kg bolus. Results: A
indicate that nursing students have little knowledge related to tobacco      total of 8 patients (mean age = 4.53±4.56 years) were enrolled. There
use and dependence treatment. The increased knowledge provided by            was a significant difference in IVC (mm) before hydration and after a
the four hour seminar gives nursing students the information and tools       20cc/kg bolus (IVC difference = 3.87, p<0.0078). There was NO
to counsel their tobacco dependent patients thereby improving their          significant difference in aorta (mm) before hydration and after a
health and decreasing healthcare costs. Our results were statistically       20cc/kg bolus (Aorta difference = 0.40, p<0.3047). There was a
significant; however we intend to continue this study. Repeating this        significant difference in IVC/aortic ratio before hydration and after a
research with a larger sample size pairing the results of individual pre     20cc/kg bolus (IVC/aorta difference = 0.52, p<0.0078). Conclusion:
and post tests will improve validity of the tool and provide evidence        We showed that there is no statistically significant aortic diameter
for recommendations in clinical practice.                                    change with hydration status. Comparing IVC diameter to aorta
                                                                             diameter is a promising method of estimating hydration status without
Increased Incidence of Induced Loss of Consciousness in ED                   having a reference value for each age group. IVC/aorta ratio serves as
Sexual Assaults in the New York Area. Kirstie Fung BS, David                 a statistically significant method for assessing hydration status.
Ozimek, BA, Ingrid Llovera MD, Andrew Sama MD; Department of
Emergency Medicine, North Shore University Hospital                          Effect of a Multifaceted Educational Intervention Program on
Introduction: Despite increasing reports of induced loss of                  Decreasing Noise in the NICU. Ani Jacob RNC; Department of
consciousness (LOC) in sexual assault, little research has                   Nursing Education, North Shore University Hospital
systematically explored this perceived increase. This study examined         Introduction: High noise levels in the neonatal intensive care units
the incidence of induced loss of consciousness unrelated to trauma,          have long been identified as detrimental to the growth and
alcohol or illicit drugs in sexual assault victims presenting to a New       development of preterm infants. The American Academy of Pediatrics
York metropolitan area ED sexual assault center. Methods: Medical            (1997) recommended a noise level of 45 dB or less as optimal for
records of sexual assault victims presenting to a sexual assault nurse       Neonatal Intensive Care Unit (NICU) environment. Noise related
examiner program in a 73,000 visit/year suburban university-affiliated       physiological and behavioral effects on the preterm infants might lead
Emergency Department (ED) from 2002-2004 and 2006-2008 were                  to longer hospital days, increased ventilator days, delayed feeding
reviewed. Cases of sexual assault victims >14 years old with LOC             tolerance, and poor weight gain, to mention a few negative outcomes.
unrelated to trauma, alcohol or illicit drugs were extracted for analysis.   The purpose of this study was to evaluate whether there is a reduction
Frequencies of LOC in 2002-2004 and 2006-2008 were compared                  in the environmental noise levels in the NICU through a multifaceted
educational program and whether any reduction can be maintained             outcomes among geriatric total knee replacement patients who attend a
over a four-week period. Method: A pretest posttest methodology             preoperative education class compared with patients who do not attend
using the same sample was used to measure the noise levels in four          the class. Methods: In 2008 there were 346 total joint replacement
NICU nurseries. Forty-six nurses participated in the one-week (10           operations preformed at a 408 bed Magnet-designated community
sessions) educational in-service and completed the pre and post             hospital on Long Island, New York. Approximately 110 of these cases
knowledge survey questions, the visual analog scale, and a ranking list     received elective total knee replacement and only 70% of these
of perceived barriers for decreased noise levels. Visual reminders,         patients attended preoperative education class. With the approval of
flyers, and articles were posted around the NICU in the following           the Institutional Review Board, the Medical Records of a randomly
week. Noise measurements were taken for one week (six days) prior to        selected cohort of total knee replacement patients who received
the educational in-service, one week after the educational                  preoperative education will be compared to patients who did not
interventions, and four weeks after the second measurements. Results:       receive preoperative education. Outcomes to be examined include pain
Forty-six registered nurses (RN) participated in the educational session    management, participation with Physical Therapy, length of stay and
and survey. Lack of physical space was identified as the most common        patient satisfaction as measured by the Press-Ganey Survey. Results:
barriers in keeping the NICU quiet (>80%). Majority of the RNs (95%)        Data analysis will be completed in February 2010. Conclusions: Due
indicated their intent to change practices that could decrease the NICU     to the small sample size in each comparative group only the possibility
noise levels. There was no difference in the knowledge level of RNs         of trends may be identified. Nevertheless, the goal of this study will be
before and after the educational session. The pre and post educational      to validate the benefits of preoperative education on postoperative
session noise level measurement showed no difference (p= 0.590).            outcomes among patients 65 years and older having elective total knee
there was no difference in the immediate post measurement and               replacement surgery.
measurement after four weeks dB levels (p=1.358). Analysis of the
four rooms separately showed a decrease in the dB levels in nursery D       Resilience, Job Stress, and Organizational Commitment of Staff
(p=0.047). Conclusion: There was no significant decrease in dB              Nurses. Madeline Richez DNP, Mary Quinn Griffin PhDRN, Gail
levels before and after the educational interventions. However, a           Malloy PhD RN; Department of Nursing/Ambulatory Surgical Unit,
reduction in the dB levels was noted in three nursery rooms with            Long Island Jewish Medical Center
significant impact on sound intensity and the perception of noise. The      Introduction: Prolonged exposure to stress can contribute to burnout
NICU census was not comparable during the pre and post                      which is driving the exodus of nurses from hospitals. By the year 2016
measurement period.                                                         the US will be short 1-million RNs. High RN turnover can increase
                                                                            hospital costs by $3.6 million annually. It is therefore essential that
Introducing TeamSTEPPS to Behavioral Health. Kristy                         hospitals become more successful in attracting nurses and enhancing
Loewenstein RN Staff Educator, Margaret Rothberg RN Nurse                   retention. Resilience building may be a useful strategy. Purpose: The
Educator, Department of Nursing Education, Zucker Hillside Hospital         purpose of this study was to describe the resilience level, job stress,
Introduction: How does customization of the TeamSTEPPS initiative           and organizational commitment of staff nurses and to explore the
meet the needs of an acute care behavioral health hospital? The             relationship among these variables. Methods: All full-time RNs
effective functioning of the multidisciplinary team is the crux of          working at the staff level at LIJMC were invited to complete a
patient care in mental health, and thus signifies the importance of team    confidential self-administered online survey. The 3 variables of
work and multidisciplinary collaboration. Methods: A thorough               resilience, job stress and organizational commitment were measured by
review of the literature revealed no documentation on TeamSTEPPS in         3 valid and reliable tools. The 1-time data collection occurred over a
psychiatric settings.       TeamSTEPPS curriculum is geared to              3-week period and took approximately 20 minutes. The survey was
medical/surgical settings, and there are no vignettes, videos or            completed by 125 staff nurses. Results: The findings of this study
scenarios related to behavioral health. There is no published literature    indicate the staff nurses surveyed had a mean resilience score
of TeamSTEPPS in a behavioral health setting. TeamSTEPPS does               comparable with that of a professional group of Australian OR nurses.
allow for customization of its material for any organization. We            However, the score fell below the mean score for the general
developed 20 clinical scenarios to highlight key areas directly             population of the US. The mean score for job stress indicated the
applicable to patient care and safety at ZHH. Real life occurrences and     nurses found their work-place to be ‘occasionally stressful’ overall
breakdowns in communication were utilized to directly impact                with the greatest stress reported in the area of ‘workload’. The
practice. Results: Baseline data from Press Ganey on patient                affective organizational commitment (AOC) mean score, based on the
satisfaction and nurse’s info re: patient’s treatment plan, as well as      employee’s emotional attachment to the organization, indicated a
hospital collected data on staff and patient injuries and our restraint     positive commitment to the hospital. A significant correlation was
index were obtained. We hypothesize that in 6 months post-                  found between resilience and AOC. A significant inverse correlation
implementation of TeamSTEPPS, there will be a reduction in staff and        was found between stress and AOC and between stress and total
patient injuries, a reduction in restraint index, and an increase in        organizational commitment. No significant correlation was found
patient satisfaction scores. Conclusions: It is our recommendation that     between resilience and stress but a significant inverse correlation was
when teaching TeamSTEPPS in a behavioral health setting, the                found between resilience and ‘problems with peers’, a stress subscale.
curriculum reflects the service that is provided. The scenarios will        Single item indicators for job satisfaction and intention to stay were
have a greater impact on the staff members being trained if they are        found to have statistically significant relationships with the variables
applicable to the setting in which they will be using the skills taught.    under investigation. A majority of the nurses surveyed reported being
                                                                            satisfied or very satisfied with their jobs. Conclusion: To enhance
The Positive Effects of a Preoperative Education Class on Patient           organizational commitment and indirectly retention, hospitals may
Outcomes of Geriatric Total Knee Recipients at a Magnet-                    benefit from RN resilience screening, resilience building, and stress
Designated Community Hospital. Julia Macchiaroli RN MS NPBC;                reduction.
Department of Surgical Services, Huntington Hospital
Introduction: People age 65 and over are the fastest growing sector of      Is the Emergency Department (ED) a Feasible Location to
the population. By the year 2030 approximately 21% of the population        Implement a Political Advocacy Program? Richard Tan BA, David
will be age 65 or older. With aging comes the potential for chronic         Lee MD, Mary Frances Ward RN, Andrew Sama MD, Saumil Patel
medical conditions, such as osteoarthritis and degenerative joint           BS, Christopher Polito, Department of Emergency Medicine, North
disease. Total joint replacement has become increasing common in the        Shore                         University                       Hospital
elderly because it allows improved mobility and quality of life.            Introduction: Multiple authors have encouraged political advocacy
Findings have shown that hospital-based preoperative patient                and engagement by physicians. The ED probably has the greatest
education programs improve patient outcomes, such as: the need for          visitor traffic throughout the hospital. Our objective was to determine
analgesics, rates of complications, levels of anxiety, length of stay and   if the ED waiting area is a feasible environment to implement a
readmission rates. Education assists patients feel empowered to be          political advocacy program. Methods: We performed an IRB-
active participants in their recovery process. Despite the positive         approved, convenience-sample, survey study at a suburban teaching
outcomes associated with preoperative education, many orthopedic            hospital ED (73k annual census). Inclusion criteria were: visitors, >17
surgeons and hospitals do not require that their patients attend            years old, English speaking. Exclusion criteria were: overt psychiatric
preoperative education class to prepare them for surgery. Purpose:          illness, prior survey completion. Trained research interns approached
The purpose of this study is to identify differences in the postoperative   visitors in the ED waiting area to complete an anonymous 9-question
survey on healthcare issues. Questions were extracted from a national
joint survey (Kaiser Family Foundation/Gallup Poll). After completing
the survey, visitors were offered information on current healthcare
issues including a 2-page American College of Emergency Physicians
form about the Access to Emergency Medical Services Act of
2007/2009. Finally, visitors were asked to sign and send a letter in
support of this legislation to the local senator. The data was analyzed
by descriptive statistics. Results: 274 eligible subjects were
approached from Jul.-Nov. 2009: 207 (76%) agreed to complete the
survey, 135 (49%) agreed to read the information, 112 (41%) were
willing to sign letters of support, and 103 letters (38%) were mailed.
Conclusion: This political advocacy program yielded significant
participation from eligible visitors. The majority (76%) offered their
opinions on healthcare issues. Approximately half were willing to read
the informational packet. Nevertheless, the majority of the subjects
who were willing to complete the education stage sent a letter of
support. In conclusion, over a third of visitors that were approached in
the waiting area sent a letter to their local politician in support of the
Access to Emergency Medical Services Act. The ED may be a
reasonable location to implement a political advocacy program.


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