Physician Assistant Scholarly Project Posters

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  Direct Factor Xa Inhibitors Versus Warfarin in Non-Valvular Atrial Fibrillation: Efficacy, Safety, Cost, and Reversibility

  Cory D. Jacobs

  Atrial fibrillation is a common cause for stroke. Vitamin K antagonists such as warfarin are an effective prophylactic medication to prevent stroke in patients with atrial fibrillation. Warfarin, however, has a narrow therapeutic index, reacts with certain foods, increases bleeding risks, and requires frequent monitoring. New medications have been developed to prevent clot formation while avoiding the negative effects of warfarin. The purpose of this study was to compare direct factor Xa inhibitors (rivaroxaban, apixaban, and edoxaban) versus warfarin in stroke prevention, safety, and cost.

  The review of literature analyzed studies comparing warfarin and direct factor Xa inhibitors in patients with atrial fibrillation. Study outcomes included stroke prevention, bleeding risks, and cost. Analysis on antidote/reversal agents were also examined.

  Direct factor Xa inhibitors decreased stroke compared with warfarin with an odds reduction of 0.81 and decreased intracranial hemorrhages with an odds reduction of 0.56 (Bruins & Berge, 2013). Direct factor Xa inhibitors were more cost effective, but with higher out of pocket expense. Direct factor Xa inhibitors have no reversal agent. Despite no antidote, research showed lower rates of fatal bleeding deaths associated with direct factor Xa inhibitor use compared to warfarin.

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  PCSK9 Inhibitors: A Review of the Efficacy, Safety and Current Literature Recommendations

  Lacey L. Jandrin

  Atherosclerotic cardiovascular disease is the leading cause of morbidity and mortality in developed counties. It is estimated that 60 million Americans have LDL-C levels > 160 mg/dl. Only about 1/3 of these patients meet treated LDL cholesterol goals of < 70 mg/dl indicating a need for greater control. High dose statins have been the mainstay in treatment of dyslipidemia, however, up to 20% of patients are statin intolerant indicating a need for secondary treatment strategies. This lead to the development of monoclonal antibodies to proprotein convertase subtilisin/kexin type 9 (PCSK9) inhibitors. PCSK9 inhibitors result in decreased destruction of the low-density lipoprotein receptor (LDL-R) which leads to an increase in the transport of LDL-C to its destruction effectively reducing LDL-C levels in the blood. The purpose of this study is to analyze the literature available on the efficacy and safety of new PCSK9 inhibitors. The results of this literature review indicated that PCSK9 inhibitors effectively lowered LDL-C by an average of approximately 50%. The evidence reviewed by this analysis indicate that 70% of patients treated with PCSK9 inhibitors met LDL-C goals. The findings also indicate that the side effects associated with this new class of medications are comparable to current side effects seen with traditional cholesterol lowering agents. The largest side effect seen in up to 10% of patients were injection site reactions and did not require discontinuation of the medication. The results of this analysis indicate that PCSK9 inhibitors may be of benefit in patients who are statin intolerant, do not meet LDL-C goals on traditional statin therapy or have familial hypercholesterolemia. Education in use of injectables, cost and insurance coverage and dosing schedule are likely to be areas of continued research and may affect use of this new class of cholesterol lowering agents.

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  Does Adherence to a Plant-Based Diet Cause a Statistically Significant Decrease in the Risk of Cardiovascular Events?

  Amber H. Johnson

  • One of the current problems in many affluent societies is the straightforward access to convenience and fast foods. Although these selections have suitability for today’s fast-paced world, overall nutritional value becomes the martyr of such practices. It is a logical thought that there could be a correlation between this nutritional pattern and the ever-increasing presence of obesity, cardiovascular disease, type 2 diabetes mellitus, hypertension, dyslipidemia, cancer, and other conditions carrying a proverbial death sentence.

  • The intent of this review of the literature was to determine the effect a plant-based diet versus an omnivorous diet would have on adults, aged 18-65, and ultimately, seek out statistically significant information that would point to proving the benefits a plant-based diet can have in producing an overall reduced risk of a cardiovascular event.

  • The information obtained was done so through careful systematic review of studies that presented respectable, reproducible, and effective research methods, with the anticipation that there existed noteworthy proof that a plant-based diet, be it vegan, vegetarian, lacto-vegetarian, ovo-vegetarian, etc., can serve as an effective and sustainable means of lowering cardiovascular disease risk. While it is essential that additional studies with larger participant populations be conducted on this subject, current evidence necessitates an emphasis on dietary intervention as a primary vehicle of risk reduction for cardiovascular events, which can lead to both greater quantity and quality of life.

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  Whole Body Cryotherapy vs. Cold Water Immersion

  Brett M. Johnson

  In this country a significant percentage of the population present to clinics with generalized musculoskeletal disorders related to pain. More than one-quarter of Americans (26%) age 20 years and over, or an estimated 76.5 million Americans report a problem with general musculoskeletal disorders related to pain that persisted for more than 24 hours in duration. The treatment for various musculoskeletal disorders related to pain are anti-inflammatory agents or opioid analgesics. Another form of anti-inflammatory /analgesia for such ailments is cold therapy.

  The purpose of this literature review is to compare Whole Body Cryotherapy (WBCt) to Cold Water Immersion (CWI) in well-trained, adult athletes of both genders, between the ages of 18 to 60, to determine which treatment provides the better reduction of symptoms. The review of literature focused on WBCt and CWI studies to determine which cold therapy provides faster/better relief of symptoms from musculoskeletal disorders related to pain.

  The results showed that average and minimum tissue temperatures were lower (p<0.05) immediately after whole body cryotherapy (19.0±0.9°C) compared to cold water immersion (20.5±0.6°C). However, from 10 to 60 min post, the average, minimum and maximum tissue temperatures were lower (p<0.05) following the cold water treatment. While WBCt achieves the lower initial tissue temperature, CWI will maintain the overall lower tissue temperature. Based on the results of this literature review, a practitioner can determine if WBCt is a viable application that the clinic/hospital should have readily available for an alternative treatment for various musculoskeletal disorders related to pain.

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  Sublingual Immunotherapy: Is it a Viable Option to Subcutaneous Immunotherapy when Treating Allergic Rhinitis?

  David Ryan Kesterson

  • Background: Allergic rhinitis (AR) is a very common debilitating disease that can be detrimental to one’s lifestyle, work, and home life. Immunotherapy is the only treatment option that has disease modifying capabilities with a proper therapeutic regimen. Subcutaneous immunotherapy (SCIT) was developed over 100 years ago and has been the gold standard in immunotherapy for many years in the United States. During these years many adverse reactions have been reported with SCIT along with non-adherence to total treatment. The introduction of sublingual immunotherapy (SLIT) over 20 years ago gave providers a promising alternative to SCIT.

  • Method: A review of literature was performed to gain information on studies comparing SLIT to SCIT for treating allergic rhinitis. This review includes head to head clinical outcomes from systematic reviews and meta-analyses. Efficacy, cost, adherence, and adverse reactions was analyzed between SLIT and SCIT to determine if SLIT is a practical treatment option.

  • Results: The results indicate that treatment with SLIT is comparable to SCIT. SLIT significantly reduces the symptoms of AR with -0.49 SMD and SCIT with -0.73 SMD. Both SCIT and SLIT are generally safe medications when administered properly. SCIT demonstrates a higher risk of systemic reactions with anaphylaxis occurring 0.72% versus 0.33% in placebo. Comparative data shows that SLIT is an effective alternative to SCIT and has equivalent to better adherence to treatment.

  • Application: It is important for providers to understand the detrimental effects of AR and treat the disease process aggressively. AR may be commonly misdiagnosed, so understanding the disease process and how it can mimic others will promote better treatment outcomes and patient satisfaction. Ideally, SLIT will be seen as a viable option compared to SCIT for treating allergic rhinitis in patients where symptomatic treatment options do not suffice.

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  Exercise as the Best Treatment Option for NAFLD

  Amber Kirtley-Perez

  Nonalcoholic fatty liver disease (NAFLD) is an advancing disease in children and adults that has the potential to be reversed. This disease is emerging in the population due to an increase in processed foods in the diet, increase in glucose intake in diet or liquid form, and lack of exercise. It is a growing epidemic in children that may progress into adulthood. The purpose of the literature review is to determine if the addition of daily exercise will decrease the amount of NAFLD and reverse the disease. The review of literature explored studies that are related to increasing exercise into the lives of adults with NAFLD. It is anticipated that an increase in exercise, whether it be sustained cardio exercise like walking or jogging, or high intensity interval training for 30 minutes, will significantly decrease the incidence of fatty liver. The increased awareness of health care providers to the benefit of exercise has upon NAFLD will encourage additional patient education about the disease. It is anticipated that the reduction of fatty liver disease will decrease the incidence of Type II Diabetes Mellitus and metabolic syndrome, decreased liver enzymes and glucose, and decreased anthropometric measurements. One study concluded that the reduction of NAFLD in a specific exercising population was 21% decreased. No study was able to determine the exact amount or type of exercise that was needed to reduce NAFLD, just that exercise itself was a reducer.

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  The Effectiveness of Antibiotic Treatment in Lyme Neuroborreliosis

  Lane Lindeman

  • Lyme disease is caused by human infection with Borrelia burgdorferi, a spirochete transmitted by the Ixodes tick which is indigenous primarily to an increasingly large area of the Northeast and Midwest United States.

  • Manifestations of Lyme disease vary greatly, and can result in significant neurologic symptoms associated with complications of neuroborreliosis or neurologic Lyme disease.

  • Diagnosis and treatment of Lyme disease and its complications has been a source of debate and confusion for providers and patients alike.

  • The purpose of this study was to investigate the effectiveness and efficacy of antibiotic therapy in patients with symptoms of neurologic Lyme disease.

  • Through a review of literature related to the treatment and outcomes of neurologic Lyme disease, it is determined that current evidence based guidelines for pharmacological treatment of neurologic Lyme disease are appropriate when administered correctly. It is also concluded that long term antibiotic therapy is not appropriate for patients with symptoms of chronic Lyme disease due to inadequate evidence to support improved outcomes after antibiotic treatments.

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  Artificial Disc Replacement as an Alternative to Lumbar Spinal Function in the Treatment of Chronic Low Back Pain

  Jennifer Polniak

  Chronic low back pain leads to activity limitations for the patient and widespread burdens on health care systems. Lumbar fusion has been the “gold standard” surgery for severe chronic low back pain non-responsive to conservative treatment, however it has been associated with continued limitations in spinal mobility. This study was executed in order to compare an alternative surgical intervention, artificial disc replacement, with lumbar spinal fusion in the treatment of chronic low back pain in terms of long term spinal function. Literature searches of trials, guidelines and systematic reviews within the past 5 years were completed exploring surgical procedures, associated long term outcomes, cost analyses, and adverse effects of artificial disc replacement as an alternative to lumbar fusion. Chou et al. (2009) found superiority of artificial disc replacement to lumbar fusion on a composite index of success but no statistical differences in disability decrease (p<0.0001). Fritzell et al. (2009) identified potential cost savings with artificial disc replacement but no advantages in terms of overall cost effectiveness (95% CI). Based on these and similar findings, there is not significant evidence to recommend artificial disc replacement over lumbar fusion surgery with regard to long term spinal function. Findings of this study indicate that, while artificial disc replacement may be advantageous in select cases, clinical indications per individual patient remain the deciding factor regarding surgical intervention for chronic low back pain.

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  Vitamin D Supplementation and Systemic Lupus Erythematosus

  Pamela Rangen

  • Patients with systemic lupus erythematosus (SLE) are prone to hypovitaminosis D because of their photosensitivity.

  • Vitamin D has beneficial effects not only on bone metabolism but also on the function of the immune system.

  • Vitamin D levels depend on many variables, including sun exposure, age, ethnicity, body mass index, use of medications and supplements.

  • Patients with SLE avoid the sun because of photosensitive rashes and potential for disease flare, so adequate oral supplementation is critical.

  • In addition, to the traditional known metabolic activities, vitamin D has been shown to modulate the immune system, and its deficiency has been linked to the development of several autoimmune disorders including SLE.

  • The purpose of this review was to determine if vitamin D has an immunosuppressive effect and if it can suppress autoimmunity.

  • The findings indicated that repletion of vitamin D has benefits beyond bone health for patients with certain autoimmune disorders, such as SLE.

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  Efficacy in Screening Patients for Lynch Syndrome

  Adria Ridl

  Lynch syndrome is an autosomal dominant syndrome caused by an inherited germline mutation of the MMR proteins. A mutation of any of the MMR proteins, MLH1, MSH2, MSH6, PMS2 and EPCAM increases the risk of developing cancer, specifically colorectal and endometrial cancer. Approximately 3% of colorectal cancers are associated with Lynch Syndrome (LS). Early identification of a patient’s hereditary cancer risk offers the best outcome. To aid clinicians in the identification of a carrier of LS clinical guidelines and risk prediction models are used. In this analysis the Amsterdam II criteria and Revised Bethesda guidelines are compared to the more recent prediction models, PREMM, MMRproand MMRpredictto identify if further tumor testing or germline sequences should be considered. A meta-analysis comparing clinical criteria to the predication models produced results identifying the prediction models with both a specificityand sensitivity of >90% of predicting MMR protein mutations (Win , 2013). The performance of each model compared to Amsterdam or Bethesda guidelines was found to exceed the clinical criteria’s ability to discriminate LS carriers from noncarriers(Katrinos, Balmana,& Syngal, 2013).

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  Predictors of Prolonged Recovery from Concussion

  Patrick W. Riley

  • Sport-related concussion has been thrust to the forefront of medicine in recent years.

  • A high degree of variability in clinical presentation and length of recovery has made management of this condition difficult.

  • This review examines whether pre-existing risk factors or sign and symptom based variables exist to reliably predict a patient’s likelihood to experience a protracted recovery from concussion.

  • The review of literature revealed heterogeneous results.

  • This is due, in part, to the variability in the definition of prolonged recovery, ranging from seven to 90 days. Despite this variability, several factors emerged as having useful prognostic value.

  • History of previous concussions is a factor that may put individuals at increased risk for prolonged recovery.

  • The presenting symptoms of dizziness, migraine symptom cluster, and high symptom burden also provide an indication that a patient is up to 7.3 times (p=0.006) more likely to experience a protracted recovery (Kontos et al, 2013).

  • Contrary to traditional assumptions, loss of consciousness is not predictive of prolonged recovery.

  • Neurocognitive indicators show promise of having prognostic value but the application in primary care is currently impractical.

  • While these factors do not provide means to definitively identify individuals who will suffer from protracted recovery, they do allow for the identification of those at increased risk. Such information can be useful in making timely referrals, effectively managing recovery expectations, and offering anticipatory guidance.

  • Early identification of individuals at risk for protracted recovery can aid in the mobilization of additional support resources.

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  Point-of-Care Testing in Primary Care May Reduce Overall Cost and Improve Both Patient Satisfaction and Efficiency

  Eric A. Sadler

  • Objective: Increased demands for primary care are forcing clinical offices to deliver cost and time efficient care while providing exceptional patient experiences. Traditional lab testing methods require multiple steps for the patient and provider. Test results are not available until a later time which may delay decision making, patient discussion and medical planning. Point-of-care testing (POCT) provides an alternative that allows the patient to have testing, discuss the results and establish a treatment plan during a single office appointment.

  • Design: A review of literature examined studies that compare cost-effectiveness, patient satisfaction and efficiency of POCT with traditional laboratory methods in primary care settings. The top 10 laboratory (phlebotomy) tests ordered in a local family medicine clinic were also identified.

  • Results: POCT methods have a higher per unit cost compared to traditional lab methods. However, POCT was found to reduce the overall cost of care when associated expenses are included such as: transportation, patient time away from work and clinician follow-up on test results. Patient satisfaction was overwhelmingly positive regarding convenience, improved medical compliance and stronger patient-provider relationships. Primary care offices found improved efficiency in both time and cost reviewing lab results.

  • Conclusion: The literature concluded that primary care offices who implemented the use of POCT found improved costs as well as increased patient satisfaction and office efficiencies.

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  Impact of Increasing GLP-1 on Markers of Inflammation, Glucose Control and Cardiovascular Risk Factors in Patients With Type 2 Diabetes

  Kristina Sandstedt

  There is a strong established relationship between diabetes and cardiovascular disease. Much of the latest research studies have identified a link between the inflammatory processes and the pathogenesis of both cardiovascular disease and diabetes. Specific inflammatory markers include: Interleukins 1,6,18; C-reactive protein, Fibrinogen, Tumor Necrosis Factor-α, PAI-I and cell adhesion molecules. As a result, there has been an emphasis on identifying therapeutic approaches that would improve both markers of inflammation and glucose control. The endocrine hormones known as incretins, glucagon-like peptide-1 (GLP-1) and glucose-dependent insulinotropicpolypeptide (GIP), are produced in the gastrointestinal tract following ingestion of a meal. In individuals with type 2 diabetes, endothelial dysfunction associated with premature atherosclerosis has been well documented. The purpose of this paper is to determine whether increasing levels of GLP-1 reduce markers of inflammation while improving both glucose control and cardiovascular risk factors. The review of literature explored the impact of increasing GLP-1, either though DPP-IV inhibitors or GLP-1 analogues, on various inflammatory markers in patients with type 2 diabetes. The studies reviewed provided ample support for the use of DPP-IV inhibitors to improve both glycemic control and cardiovascular risk factors. GLP-1 analogues also appear to have a similar impact, but with the added benefit of weight loss. In addition, patients with type 2 diabetes frequently have coagulation abnormalities leading to a prothromboticstate. Thus the reduction in fibrinogen, C-reactive protein and plasminogen activator inhibitor observed during the review of literature supports the potential for DPP-IV inhibitors and GLP-1 agonists to exhibits an antithrombotic effect. These findings are of clinical significance as these treatments may potentially slow the progression of premature cardiovascular disease as well as reduce thrombotic events in patients with type 2 diabetes.

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  A Multimodal Approach to Preventing and Treating Alzheimer’s Disease

  Jason B. Smith

  As of 2015 over 47 million people worldwide are diagnosed with Alzheimer’s disease (AD). The incidence of AD increases with age, and affects males and females equally. Current pharmacologic treatment includes two classes of drugs. The purpose of this study was to determine if a multimodal approach (i.e. diet, exercise, cognitive stimulation) towards the prevention and treatment of AD would be more beneficial than pharmacologic therapy alone. Research methods included reviewing peer reviewed journal articles published within the past five years obtained from PubMed, Dynamed, Cochrane, CINAHL, and Clinical Key. Ehret and Chamberlin (2015) found donepezil (Aricept) increased MMSE scores (95% CI, 1.3 to 2.5; P< 0.001); whereas memantine (Namenda) increased MMSE scores (95% CI, 0.6 to 1.8; P< 0.001). Combination therapy of donepezil and memantine revealed no significant improvement of MMSE scores (95% CI, -0.1 to 1.6; P= 0.07). The MIND diet and FINGER studies evaluated multimodal approaches to preventing and treating AD. Morris et al. (2015) found that participants who adhered to the MIND diet significantly reduced the rate of developing AD over an average of 4.5 years by 53% (HR= 0.47; 95% CI: 0.29, 0.76; P= 0.002) compared to those who were the least adherent to the diet. The FINGER study compared four factors between an intervention and control group. Ngandu et al. (2015) found NTB scores revealed a mean difference between groups of 0.022 (95% CI; 0.002 to 0.042; P = 0.030) per year with the intervention group scoring 25% higher at 24 months. The intervention group revealed differences in executive functioning (P = 0.039) 83% higher, and processing speed (P = 0.029) 150% higher than the control group. Memory scores analysis revealed a mean difference in memory decline between the intervention and control groups 1.31 (95% CI; 1.01 to 1.71; P = 0.036) after 24 months. Drug therapy alone provides nominal and short term improvement in cognitive functioning. A multimodal approach can improve or maintain cognitive functioning in those who are at risk for or who already have AD. Primary care providers should consider a multimodal approach to treating patients who have AD or early cognitive decline. Utilizing a multidisciplinary healthcare team by employing the expertise of other health professionals who are trained in working with older adults may be beneficial in the treatment of individuals who are at risk for, or who have AD.

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  Helmet Therapy vs. Conservative Therapy for the Treatment of Positional Skull Deformations

  Whitney Thompson

  • Plagiocephaly and brachycephaly are skull deformations that occur in nearly half of all infants. These deformities are present at birth or can develop shortly after birth due to head positioning while lying supine. Depending on the severity of the deformity, infants may develop negative long-term developmental outcomes. There are generally two ways to treat such patients; repositioning or with use of orthotics (helmet therapy).

  • A study of systematic reviews and cohort studies was completed to determine if orthotics (helmet) therapy is significantly more effective than repositioning therapy.

  • The study indicated that infants diagnosed with moderate to severe plagiocephaly or brachycephaly will benefit most from helmet therapy in achieving complete correction, compared to those treated with repositioning therapy. Overall, there was a significantly greater mean percentage reduction of diagonal difference (61%) for the orthotic group than the mean percentage decrease for the repositioning group (52%).

  • Positional skull deformations occur in nearly half of all infants today. It is important to be able to diagnose a skull deformation, determine the degree of deformation, determine options for treatment, compare those options for treatments, and the risks associated with the treatment options

  • Primary care health care providers can reduce the long term effects of plagiocephaly or brachycephaly by properly identifying and treating patients in a timely manner.

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  Nrf2 Pathway and the Reduction of Oxidative Stress

  Stephanie Jacobs Uselman

  Oxidative stress has been linked to cellular damage initiating disease processes such as cardiovascular disease, diabetes, and cancer. The Nuclear factor erythroid-derived 2(Nrf2) pathway (Figure 1) aids in age-related cellular decline. The purpose of this study was to define the relationship between Protandim, its activation of the Nrf2 pathway, and decline in oxidative stress and cellular damage. The literature review included journal articles obtained from PubMed, Google scholar, and Cochrane review within the past 5-10 years, and contained both animal and human studies. The methods used in the animal studies included ANOVA, the standardized t-test, and the Neuman-Keuls post-test. P<0.05 was considered statistically significant. The human study included healthy participants, both male and female, age 29-78 with or without a specific medical diagnosis. Statistical analysis was based on the standardized t-test with a value of p<0.05 considered statistically significant. Liu et al. (2009) conducted a study investigating Protandim’s ability to suppress cancer tumor formation. Tumor incidence declined by 33% and multiplicity of skin tumors by 57% with p = 0.003. Superoxide dismutase increased 35%, catalase 58%, and manganese superoxide dismutase 21%. In 2013, Reuland et al. conducted a study to determine if Protandim could activate the Nrf2 pathway and induce antioxidant enzymes, thereby protecting cardiomyocytes from apoptosis. Results indicated that treated cardiomyocytes showed increased levels of Nrf2 nuclear accumulation, activation of endogenous antioxidant enzymes, and protection against cell targeted oxidative stress (p<0.05). Quereshi et al. (2010) completed a study to delineate if Protandim decreased oxidative stress through the Nrf2 pathway. After six months of supplementation, TBARS decreased by 48% (p=.006), and plasma osteopontin decreased by 57% (p=.018). In 2005, Nelson et al. conducted a study to determine if Protandim decreased cellular damage. After 30 days of supplementation, TBARS declined by 40% (p =0.0001), at 120 days, TBARS declined by 40-54% (p =0.002), and superoxide dismutase and catalase increased by 30% and 54% respectively. The results from studies indicate that Protandim’s activation of the Nrf2 pathway increased endogenous antioxidant availability, resulting in decreased oxidative stress and age related cellular damage.

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  Should the Pharmacologic Management for Chronic Hepatitis C Encompass a Response Guided Therapy Treatment Plan?

  Sarah Viscarra

  Pharmacologic advances have been made with the development of new drug therapies that essentially cure the hepatitis C virus, such as sofosbuvir. The purpose of this study is to determine whether sofosbuvir should encompass a response guided therapy treatment plan versus a standard treatment protocol, in efforts to limit the risk of adverse effects and to minimize the cost of treatment. The systematic review of literature retrieved from Pub Med and Cochrane, explored studies that compared a standard treatment protocol of 12 weeks, in male and female adults ages 18-90 years, to response guided therapy treatment plans based on each individual’s sustained virologic response. Reducing the duration of treatment will decrease the risk of adverse side effects, and lower the cost of therapy. This information will help practitioners guide appropriate length of HCV treatment based on each individual patient, to ensure a sustained viral load.

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  Comparing Short Versus Long Term Antibiotics for Reducing Persistent Lyme Symptoms

  Joe Webster

  • Lyme disease is the most common tick borne illness in the United States with over 300,000 cases annually.

  • Two main organizations called the Infectious Disease Society of America and the International Lyme and Associated Diseases Society differ on their opinions in the treatment duration of Lyme disease.

  • A review of the literature explored studies that compared the effectiveness of short term versus long term antibiotics in the treatment of Lyme. Determining the most effective treatment method duration for reducing the long term risk of persistent symptoms of Lyme will be important for the improvement of the delivery of care for patients.

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  A Review of Barrett's Esophagus

  Suzanne M. Zayan

  Barrett’s Esophagus is a premalignant condition that predisposes patients to the development of esophageal adenocarcinoma.

  •Esophageal adenocarcinoma dramatically rising over several decades; survival rates of less than 17% in a five year period.

  •Management and treatment continues to evolve: use of radio-frequency ablation effective to treat low grade dysplasia

  •Studies of risk factors and treatment options explored:

  Efficacy and durability of endoscopic radiofrequency ablation for treatment of low grade dysplasia as option for metaplasia eradication

  –Gastrointestinal pathologist expert reviews ensure identification of dysplasia prior to treatment
  –Appropriate endoscopic surveillance intervals
  –Gastroenterology guidelines for screening and surveillance for long term management
  –Lifelong endoscopic surveillance individualized to monitor for recurrence of metaplasia
  

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  Insulin Patch Pumps in Type 2 Diabetes

  Cristin Altendorf

  • DM is a leading cause of death in Americans

  • A HbA1c above 6.5% is diagnostic for DM because it is at this level the patient is at risk for retinopathy and other microvascular disease

  • The purpose of this study is to determine alternative methods of maintaining tighter control on HbA1c to lessen the effects of type II diabetes.

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  Oral Immunotherapy in IgE-Mediated Cow’s Milk Protein Allergy

  Jody Bauer

  Cow’s milk allergy prevalence in children has been increasing significantly over the last several decades. The diagnosis of a cow’s milk allergy (CMA) can occur through several methods such as signs and symptoms, double blind oral food challenge, skin prick testing, IgE and IgG4 serum levels. Currently, there are no treatments beyond strict allergen avoidance. The patient’s quality of life is impacted with the fear of inadvertent exposure resulting in allergic reactions that may be life threatening. Recent studies have explored desensitization to CM using oral immunotherapy (OIT), subcutaneous immunotherapy, and sublingual immunotherapy (SLIT). Research has found that desensitization will decrease the risk of allergic response to accidental exposures with the hope of lifelong tolerance to CM. The findings indicate means of successful desensitization, lifelong tolerance through maintenance regimens, and methods of increasing safety during desensitization.

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  Use of Donepezil in Alzheimer's Disease: Suggested Practice Guidelines

  Tamara Berg

  Alzheimer’s disease (AD) is the cause of 60-80% of dementia (2014 Alzheimer’s disease, 2014). AD is estimated to affect over 5 million people over age 65 in the US (2014 Alzheimer’s disease, 2014). With the onset of baby boomers reaching the age of 65 and increased longevity it is estimated that 16 million persons will have Alzheimer’s by 2050. Eighty two percent of persons with AD are over age 85. In 2014 AD is the 6th leading cause of death and the highest cost disease in the US. (2014 Alzheimer’s disease, 2014)

  The predicted increase in prevalence and incidence of Alzheimer’s disease and longevity of the disease represents an increased disease burden on families and society and a need for effective management over many years. The purpose of this study will be to determine the effect of donepezil, a cholinesterase inhibitor, at various stages of the disease compared to placebo and to determine the best clinical practice guidelines.

  The earlier the onset of donepezil therapy, the more significant effect is seen on preserving cognitive function and delayed nursing home placement. Persons at all stages (mild to very severe retain the ability to respond to donepezil. At end stage disease, it may be efficacious to discontinue donepezil.

  These findings indicate that health care providers need to improve the screening and early initiation of donepezil in the management of Alzheimer’s disease as well as monitoring benefits and harm at later stages of the disease.

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  Alpha Lipoic Acid: A Potential Therapeutic Option for Painful Peripheral Neuropathies

  Jessica Curcio

  • Peripheral neuropathy (PN) is a major public health concern.

  • There are many etiologies for PN including injury, infection, toxicity, genetics, metabolic disease and nutritional deficiencies.

  • Alpha lipoic acid (ALA), also known as thioctic acid, is a potent antioxidant and cofactor in many cellular metabolic processes.

  • Oxidative damage plays a significant role in the pathogenesis of both diabetic peripheral neuropathy (DPN) and chemotherapy induced peripheral neuropathy (CIPN).

  • Because of the antioxidant capability ALA has been studied for its potential benefit in preventing and treating PN

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  Migraine Prophylaxis with Petasites Hybridus

  Lena DeLuca

  • Petasites hybridus (butterbur) as an effective prophylaxis for migraine disorders. • Computerized literature searches were carried out in DynaMed, COCHRANE, EBSCO, CINAHL and MEDLINE.

  • The examination of literature will comprise of trials that evaluate Petasites hybridus extract Petadolex® in various dosages and placebo.

  • Petasites hybridus extract Petadolex® demonstrates a decreased frequency of migraine attacks and a greater improvement (>50%) after 3-4 month than placebo.

  • Further studies are indicated to investigate extract recommendation for dosing and duration of treatment in pediatric population.

  • Additional studies are required to confirm effectiveness and safety in long-time use before treatment with Petasites hybridus extract can be suggested as an alternative option for the prophylaxis of migraine.

  • Trials reviewed for this paper suggests that the patented Petasites hybridus extract Petadolex® is a safe and excellently tolerated treatment for migraine prevention.

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  Hypoglossal Nerve Stimulation Therapy in Obstructive Sleep Apnea

  Taylor Fontaine

  • Obstructive sleep apnea (OSA) is a disorder that results in loud snoring, gasping respirations, and excessive daytime sleepiness.

  • OSA also has the potential to progress to other significant diseases such as hypertension, diabetes mellitus, stroke, and pulmonary hypertension.

  • Continuous positive airway pressure (CPAP) has been the first line treatment for OSA since the early 1980’s. Unfortunately, despite the ability of CPAP to significantly improve symptoms of OSA, a large amount of patients struggle to comply with this treatment.

  • A new alternative treatment for OSA is hypoglossal nerve stimulation therapy (HGNS), resulting in an increase in muscle tone to the oropharynx, keeping the airway patent during inspiration.

  • This review of the literature will examine the efficacy and compliance rates of CPAP, as well as the safety and efficacy of HGNS.

  • Research found that there is in fact a need for an alternative therapy for OSA due to high CPAP noncompliance rates.

  • The findings also indicate that despite favorable outcomes in clinical trials, more research is needed to determine the prolonged safety and efficacy of HGNS surgery.