Physician Assistant Scholarly Project Posters

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  Comparison of Pharmacologic Treatments for Postmenopausal Osteoporosis

  Kaitlyn Wirtz

  The prevalence of osteoporosis in the United States in adults > 50 years of age is “more than 10 million people overall and 33 million have low bone mineral density (BMD) at the hip” (DynaMed Plus, 2018).

   To combat postmenopausal osteoporosis, two treatment options include bisphosphonates and the anti-receptor activator of nuclear factor kappa β ligand (RANKL) agent (denosumab).

   The purpose of this scholarly project is to determine if there is a statistical significance regarding safety, efficacy, and preference between bisphosphonates and denosumab.

   Three databases were searched: PubMed, CINAHL, and Cochrane Database of Systematic Reviews. Topics researched included: postmenopausal osteoporosis, bisphosphonates, antiRANKL agent, treatment outcome, adverse effects, and efficacy. Research was conducted from September 12, 2018 to January 29, 2019. All works published within the last 10 years.

   The most effective treatment for postmenopausal osteoporosis is denosumab. It is just as safe, more efficacious, better adhered to, and more preferred than bisphosphonates.

   This scholarly project compares the treatment options available to providers and allows them to choose the best option based on the patient’s needs, safety, efficacy, preference, and cost

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  Comparison of Pharmacologic Treatments for Postmenopausal Osteoporosis

  Kaitlyn Wirtz

  • The prevalence of osteoporosis in the United States in adults > 50 years of age is “more than 10 million people overall and 33 million have low bone mineral density (BMD) at the hip” (DynaMed Plus, 2018).

  • To combat postmenopausal osteoporosis, two treatment options include bisphosphonates and the anti-receptor activator of nuclear factor kappa β ligand (RANKL) agent (denosumab).

  • The purpose of this scholarly project is to determine if there is a statistical significance regarding safety, efficacy, and preference between bisphosphonates and denosumab.

  • Three databases were searched: PubMed, CINAHL, and Cochrane Database of Systematic Reviews. Topics researched included: postmenopausal osteoporosis, bisphosphonates, anti-RANKL agent, treatment outcome, adverse effects, and efficacy. Research was conducted from September 12, 2018 to January 29, 2019. All works published within the last 10 years.

  • The most effective treatment for postmenopausal osteoporosis is denosumab. It is just as safe, more efficacious, better adhered to, and more preferred than bisphosphonates.

  • This scholarly project compares the treatment options available to providers and allows them to choose the best option based on the patient’s needs, safety, efficacy, preference, and cost.

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  Treatment of Undifferentiated Connective Tissue Disease by Primary Care Providers Using csDMARDs

  Leslie A. Anderson

  •Undifferentiated connective tissue disease (UCTD) is an autoimmune disease that presents similarly to other rheumatic conditions but fails to meet laboratory requirements which indicate a specific disease such as rheumatoid arthritis, systemic lupus erythematous, Sjogren's or scleroderma.

  •UCTD presentation can include arthralgias, myalgias, fatigue, fever, Raynaud’s phenomenon and sicca like symptoms with a positive antinuclear antibody (ANA) test.

  •Patients with UCTD symptoms are normally referred to rheumatology but a shortage exists leaving primary care providers to treat UCTD patients.

  •Using disease modifying antirheumatic drugs (DMARDs) such as hydroxychloroquine is an option but it is not commonly prescribed by PCPs.

  •The study’s purpose is to determine if PCPs can effectively initiate and appropriately manage UCTD patients using DMARDs, such as hydroxychloroquine, to reduce the patient’s symptoms and functional impairment.

  •Using DMARDs, NSAIDs and low dose corticosteroids in UCTD patients provided by PCPs can improve arthralgias, myalgias, fever, and functional limitations.

  •Majority of rheumatologists and PCPs feel UCTD patients should be referred to rheumatology for treatment, yet there is some evidence that PCPs can also initiate and manage the treatment effectively.

  •In the absence of rheumatology, PCPs using DMARDs such as hydroxychloroquine can safely and effectively provide treatment for these patients

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  Comparing Prevalence of Medication-Related Osteonecrosis of the Jaw (MRONJ) Due to Denosumab and Bisphosphonates as a Side Effect of Osteoporosis Treatment

  Kendra Apland

  As the baby boomer generation continues to age, the diagnosis of osteoporosis and its side effects will continue to increase. Denosumab and bisphosphonates (BPs) are some of the most common medication classes used to treat osteopenia and osteoporosis, but it is believed that both medications have the possible side effect of medication-related osteonecrosis of the jaw (MRONJ). The purpose of this paper is to uncover if MRONJ is a side effect of osteoporosis treatment and which medication carries the highest incidence rate. Through a review of several electronic databases and several peer reviewed research articles, a wide range of reported incidence rates of MRONJ for both medications were uncovered, along with many compounding possible risk factors. There is a wide range of reported incidence rates among different studies. My research found that denosumab carries a slightly higher risk of MRONJ versus bisphosphonates, but the difference was found to be statistically insignificant. Uncovered risk factors include increasing age, gender, recent dental procedures, history of oral disease, and corticosteroid use. My research is impactful in the fact that as providers, we can be better informed about the differences between denosumab and bisphosphonates and the possible risk factors of MRONJ. We can use the information, along with possible other risk factors and our patient’s history, to make joint decisions about what osteoporosis medication is right for our patients.

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  The Efficacy and Safety of Statins in the Primary Prevention of Cardiovascular Disease

  Kayla M. Ashton

  Atherosclerotic plaques can form in the blood vessels from particles of cholesterol. These plaques are a major cause of cardiovascular disease and have the ability to result in fatal cardiovascular events. In researching this topic, PubMed, the Cochrane Library, DynaMed, and ClinicalKey were all utilized in finding articles published from 2002 to 2018. There are several organizations with conflicting guidelines recommending the use of statin medications in the primary prevention of cardiovascular disease. The research evaluated discovers data is inconclusive on the benefit of statin medications in this primary prevention as well as the safety of long-term statin use. Some experts have suggested statins are over-prescribed as it is one of the most commonly prescribed medications in the United States. Statin medications continue to be extremely beneficial in the secondary prevention of cardiovascular events, but caution should be applied by providers when prescribing this medication to their patients for primary prevention when referring to conflicting population based guidelines. Providers should identify key risk factors and have conversations with their patients on the risks and benefits of statin medications when they are being utilized for the primary prevention of cardiovascular disease.

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  The Safety and Efficacy of Creatine Supplementation in the General Public

  Cody Baxter

  The purpose of this study was to determine whether supplementation with creatine monohydrate is efficacious beyond the realm of its most popular use, which is in athletics. This study investigated the safety of creatine supplementation in the general population. References were collected through a review of PubMed and Scopus databases. Initial keywords searched were creatine supplementation and creatine safety. Where possible, trials with human subjects were utilized. Studies focused on creatine’s effects in athletes or weightlifting parameters were eliminated. Topics were further narrowed down by conditions with the most amount of research and medical concerns recognized as common to primary care.Creatine supplementation showed potential benefits in treatment for major depressive disorder, diabetes, bone density, and osteoarthritis. Mild weight gain due to the osmotic effect of creatine was the only side effect noted in the evidence. Kidney function is not affected by creatine supplementation. Creatine supplementation has potential benefits for many different patient populations, with the only side effect of creatine supplementation being mild weight gain due to the osmotic effect of increased creatine saturation in the body. Clinicians should consider creatine supplementation without fear of potential serious adverse effects based on the available evidence.

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  Childhood Trauma: An Analysis of Associated Co-Morbidities and Various Psychotherapies

  Brittney L. Benson

  American and European studies suggest that anywhere from 14 to 67% of children have experienced at least one traumatic event throughout their life. Furthermore, about 13.4% of them go on to develop post-traumatic stress disorder (PTSD) or symptoms (Diehle, J., Opmeer, B.C., Boer, F., Mannarino, A.P., & Lindauer, R.J., 2015). One study suggests that as many as 63.9% of adults suffer from ACEs (Adverse Childhood Experiences) (CDC, 2016). The 4th Edition of the Diagnostic and Statistical Manual (DSM-IV) states that PTSD is the most common Axis I disorder in children that are victims of abuse with statistics ranging from 20% (PTSD only) to 53% (PTSD or complex PTSD)(Chard, 2005). First line treatment for PTSD includes psychotherapy. Cognitive Behavioral Therapy (CBT) has been established as the “gold standard” for the treatment of PTSD. However, a good percentage of children still present with symptoms post treatment. Therefore, a need for other forms of psychotherapy has been made apparent. This paper attempts to highlight the various detrimental effects of childhood trauma, explore the various types of psychotherapies used to treat PTSD in children as well as adults {CBT, Eye Movement Desensitization and Reprocessing (EMDR), Cognitive Processing Therapy (CPT), and Prolonged Exposure}, and determine which therapy is most effective. The research gathered mostly supports the use of CPT in adults suffering from ACEs. However, in children, the most supported therapy for the treatment of PTSD is CBT, followed by prolonged exposure and EMDR.

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  Integrative Medicine in Primary Care

  Ashley M. Bjornerud

  Integrative medicine (IM) is an approach to care that puts the patient at the center and addresses the full range of physical, emotional, mental, social, spiritual and environmental influences that affect a person’s health (Rakel, 2017). Commonly, IM is associated with complementary and alternative medicine therapies (CAM). These are two separate entities. CAM is one of the modalities used in integrative medicine.

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  Screening Techniques for Alzheimer's Disease

  Christina Nicole Brooks

  Alzheimer’s disease is a neurodegenerative disease that affects more than 55 million Americans. By the year 2050, experts project this disease will have increased three fold. Many screening techniques have been investigated to detect this disease early and begin treatment to slow its progression. The purpose of this study was to explore which medical modalities are the most effective for screening of Alzheimer’s disease. This literature review includes three databases, including PubMed, CINHAL, and Cochrane Database of Systematic Reviews. Topics that were researched include: cognitive screening tests, neuroimaging, laboratory diagnostic testing, DNA, and combined studies. Research was conducted from October 8, 2017 to January 3, 2018. All resources were published within the last ten years. Limitations and strengths were considered within each modality. In each category, the following were found to be the most effective in screening for Alzheimer’s disease: cognitive screening tests: MOST and MoCA testing; neuroimaging: PET scanning; laboratory diagnostic testing: biomarkers; DNA: DNA methylation and APOE genotyping; and combined studies: PET scanning. This review demonstrates that there are many screening modalities available to providers. This allows providers to choose their screening technique based on their site’s availability, provider preference, and cost.

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  A Bridge Too Far? Risks and Benefits of Perioperative Bridging Therapy

  Jordan Buchholz

  The long-term use of oral anticoagulants is common among certain high-risk patient populations for the prevention of thromboembolic events such as stroke, pulmonary embolism (PE), and other systemic events. According to Garwood et al. (2017) it is estimated that 15-20% of chronically anticoagulated patients will undergo a surgery or procedure that will require anticoagulation interruption annually. During this interruption period, “bridging” anticoagulant therapy is often utilized with unfractionated heparin or low-molecular weight heparin to ensure adequate anticoagulation is achieved (Ayoub et al., 2016). However, there has been an ongoing debate whether or not the benefits of perioperative anticoagulant bridging therapy outweigh its risks.

  This literature review focuses on whether or not forgoing anticoagulant bridging therapy increases the risk of postoperative thromboembolic events. It also focuses on the whether or not initiating bridging therapy places patients at a higher risk for postoperative bleeding. Finally, it focusses on the current recommendations and whether or not utilization of individualized risk assessment tools increases efficacy and safety in regards to determining appropriate bridging therapy.

  The results of this literature review conclude that in low risk patients there is sufficient evidence to support the statement that non-bridging therapy is equally as efficacious to bridging therapy in the prevention of peri/postoperative thromboembolic events. There is also evidence to support the statement that traditional bridging therapy may place low risk patients at an increased risk for peri/postoperative bleeding events. Finally, there appears to be sufficient support to encourage the use of individualized risk assessment tools to help guide clinicians in their decisions to use or forgo anticoagulant bridging therapy.

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  Obesity: Modern Medicine vs. Lifestyle

  Jenny Christianson

  Obesity is a rising epidemic, and is one of the most common, costly and preventable health problems the world is experiencing today (Center for Disease Control and Prevention, [CDC], 2017).

   From this, it is important to establish an effective treatment plan that can be implemented across the nation for maximum patient benefit.

   Lifestyle changes such as diet and exercise are important to any health care plan and are equally necessary to reduce health risks. However, in certain patients, lifestyle changes are not enough due to the maladaptive biologic process in their brain. Thus, additional treatment options need to be available to these patients.

   Both medical therapies, pharmacological and surgical, were found to be beneficial in augmenting lifestyle changes in multiple studies. Therefore, it was concluded that pharmacologic and surgical therapies are valid options in resistant obesity in addition to lifestyle changes such as diet and exercise.

   This study was a systematic literature review which evaluated studies from CINAHL, Clinical Key, Cochrane Library, and PubMed to formulate a conclusion. Research focused on two pharmacotherapy options, phentermine and orlistat, in addition to two surgical options, gastric bypass and sleeve gastrectomy, for added weight loss treatment when compared to lifestyle alone.

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  Exercise Therapy for Chronic Low Back Pain

  Jeanmarie Dahl

  Chronic low back pain (CLBP) is currently ranked as the 13th most frequent diagnosis in family practice (DynaMedPlus, 2017). The severe nature of the pain in this condition often leads providers to prescribe narcotics. While effective in the short term, opiates have significant side effects when used chronically. Other forms of management for CLBP need to be identified and utilized. The purpose of this review was to determine the role exercise therapy plays in the management of CLBP.

  Four databases were searched in order to find high quality systematic reviews, meta-analyses, and randomized controlled trials (RCT) looking at exercise therapy in the management of CLBP. These databases included SPORTDiscus, Cochrane Database of Systematic Reviews, CINAHL, and PubMed. Studies chosen for this review were adult-only populations and included pain as an outcome measurement. All of the studies were published between 2010 and 2017.

  After reviewing the current literature on the effects of exercise therapy in the management of CLBP, it does appear that certain forms of exercise are efficacious for pain control. The most effective forms of exercise therapy seem to be those that include a strengthening component. This is encouraging data regarding the future of CLBP management.

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  Glycemic Control and Type 1 Diabetes Mellitus: Current Standard Treatment vs. Closed-Loop Insulin Pumps

  Kelsey Daley

  As of 2015, 9.4% of the US population had a diagnosis of Diabetes Mellitus (DM). Although most of the data sets studied encompass type 1 (T1) and type 2 (T2) DM data in all ages of patients, the focus of this project will be primarily on T1DM.

  There are effective methods currently available for the management of T1DM patients. These methods include: closed-loop insulin pumps that integrate a continuous glucose monitor (CGM) and insulin pump into one effective system that calculates the needed insulin doses through complicated algorithms, CGM with self-blood glucose monitoring calibrations (SBGM) and insulin administration, and SBGM with insulin administration.

  Literature reveals that closed-loop insulin pumps have the potential to provide better disease management and improved disease outcomes for those patients who are motivated to use them as directed and find them a desirable option.

  When patients can effectively manage their blood glucose, and practice healthy lifestyle and dietary choices, they can avoid unnecessary hospitalizations and long-term diabetic complications. This will simultaneously reduce healthcare-related costs, increase longevity and can improve the patient’s quality of life.

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  Exercise in the Treatment of Major Depressive Disorder

  Larissa Ann Haug

  Objective

  The purpose of this systematic literature review is to determine how exercise can be incorporated into the treatment of major depressive disorder (MDD) and its efficacy.

  Methods

  In this review, four databases were searched including SportDiscus, Pubmed, Cochrane Database of Systematic Reviews, and PsycInfofrom October 1 to January 5, 2018. A variety of key terms were used when searching. Works chosen for review were published after the year 2000, were peer reviewed, and included randomized control trials (RCTs), pilot studies, systematic reviews, and meta-analyses. Sources that were excluded included those published prior to the year 2000, had poor study design, and included comorbid psychiatric conditions varying from MDD.

  Results

  For this review, 17 resources were selected. Much of the research presented shows evidence for the use of exercise in the treatment of MDD. However, most of the research points to exercise as more of a beneficial augmentation strategy for MDD versus a first line therapy involving pharmacotherapy with selective serotonin reuptake inhibitors (SSRIs) and psychotherapy in disease treatment.

  Conclusion

  Current research on the topic of exercise as therapy for MDD does show promise; however, more research still needs to be done in order to place exercise as an equivalent treatment to pharmacotherapy or psychotherapy.

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  Treatment Options for Hidradenitis Suppurativa: Efficacy, Risks, Benefits

  Katherine A. Hennager

  Hidradenitis suppurativa is a chronic, recurrent follicular occlusion disease with painful, sometimes debilitating, cutaneous draining lesions and subcutaneous abscesses (DynaMed Plus, 2016). Hidradenitis suppurativa is understood to be a multifactorial disease that is hard to treat in some patients, especially those with a severe form of the disease. For this project, the efficacy of adalimumab for hidradenitis suppurativa was assessed and whether it is more beneficial than traditional treatments used. Adalimumab is a TNF-alpha inhibitor which belongs to the biologic DMARDs drug class. Kimball et al. (2012) found that at week 16 of their trial 3.9% of the placebo patients, 9.6% of every other week (EOW) dosing of adalimumab patients, and 17.6% of every week dosing of adalimumab patients achieved clinical response. Patient response reports on pain and outcomes were significantly greater in the weekly dosed patients vs. placebo group. A study by Miller et al. (2011) showed a significant reduction in Sartorious score after 6 weeks and an almost significant reduction seen after 12 weeks when compared to the placebo group (-10.7 vs. 7.5, P=0.024 and -11.3 vs. 5.8, P=0.07). Kimball et al. (2016) showed clinical response rates at week 12 were significantly higher for the groups receiving adalimumab weekly than for the placebo groups: 41.8% versus 26.0% in PIONEER I (P=0.003) and 58.9% versus 27.6% in PIONEER II (P<0.001). DynaMed Plus, PubMed, and Cochran Library were searched with key words: hidradenitis suppurativa, adalimumab, and treatment.

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  Superior Capsular Reconstruction in the Active Population with a Massive Irreparable Rotator Cuff Tear

  Emmanuel Hernandez

  The prevalence of rotator cuff tears is a leading cause of upper extremity functional disability and affects people across the lifespan. The primary age groups that are diagnosed include young adults as well as the elderly population. Approximately one-fifth of rotator cuff tears (RCT) are diagnosed as “massive” and prove to be difficult for orthopedic surgeons to repair. If the massive RCT is also diagnosed as “irreparable”, surgical intervention is technically difficult and can be extremely challenging. Historically, treatment options have been limited for the young population to invasive surgical intervention or conservative measures such as physical therapy and pharmacologic measures. Surgical approaches to treatment may include a reverse shoulder arthroplasty (RSA) or a superior capsular reconstruction (SCR). The purpose of this study is to determine if a superior capsular reconstruction is a better surgical alternative than a reverse shoulder arthroplasty in the young, active population with a massive irreparable rotator cuff tear. An SCR has shown successful short-term outcomes and utilizes an anatomical approach. Each surgical option is feasible; however, the postoperative degree of functionality is the substantial difference between either surgical technique. Research has proven the efficacy of the SCR versus the RSA. Although there is limited current evidence-based research in the field of longevity and its potential outcomes, the SCR is the leading surgical option for massive irreparable RCT repairs in the young, active population.

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  The Neuroprotective Effects of Targeted Temperature Management on Post-Cardiac Arrest Patients

  Timothy Hovde

  Novel methods of ensuring survival following cardiac arrest and resuscitation are of supreme importance to the medical community. Targeted temperature management (TTM) has become increasingly utilized pre-hospital, in emergency departments, and within intensive care units to increase the likelihood of survival to hospital discharge. TTM has further been used to attempt to improve neurological functioning. The efficacy and mechanism behind TTM remains poorly understood. In several patient populations it also remains unproven. The purpose of this study is to assess the physiological mechanism, survival, neurological recovery and methodology of TTM use and implementation.

  Literature review was utilized to assess the physiological mechanism by which TTM elicits its neuroprotective effects. Statistics on neurological outcomes and survival rates were further examined. Finally, the proposed method to safely and efficiently induce and maintain TTM in appropriate patients was also assessed through literature review.

  TTM was found to improve survival and neurological functioning in adults suffering cardiac arrest both in-hospital and out-of-hospital. No improvement has been noted in studies on pediatric patients, thus TTM is not indicated in pediatric patients. Animal studies demonstrate a decrease in cerebral edema and mitochondrial apoptosis of neuronal cells with TTM application. Serum biomarkers of brain injury and disfunction of the endothelial lining constituting the brain blood barrier (BBB) have also been found to be decreased in patients undergoing TTM. Finally, serum assay of antioxidants demonstrates a decrease in oxidative damage and increase in antioxidant protection following reperfusion.

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  Limb Salvage for Diabetic Patients with Peripheral Arterial Disease

  Jamie Jesse Johnson

  •According to the Center for Disease Control (CDC) (2017), the total number of patients diagnosed with diabetes is exceeding 30.2 million and rapidly increasing.

  •According to the CDC (2016), approximately 8.5 million people in the United States have peripheral artery disease (PAD), which includes 12-20% of individuals who are older than age 60.

  •According to a study performed by Swaminathan et al. (2014), 186,000 patients underwent lower extremity amputation (LEA). Data also shows that patients undergoing LEA have a mortality rate of 20% noted within one year, and a 40% to 50% mortality rate indicated within 18 months.

  •The review of literature analyzed studies that compared vascularization procedures to determine whether early diagnosis and intervention provide benefit to reduce lower extremity amputation in diabetic patients with PAD and critical limb ischemia (CLI), and to determine cost effectiveness.

  •Research suggests that limb salvage is cost efficient with early detection, proper patient compliance and use of a multidisciplinary approach. However, unpredictable factors such as poor patient compliance may skew cost analyses and validate claims to dispute reduction of costs.

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  Examination of Venous Thromboembolism Prophylaxis in Patients Undergoing Total Knee Arthroplasty

  William Kucera

  Elective total knee arthroplasty (TKA) is the most frequently performed inpatient surgical procedure in the United States (Kurtz, Ong, Lau, Mowat, & Halpern 2007). Complications of this procedure include deep vein thrombosis (DVT) and pulmonary embolism (PE), collectively referred to as venous thromboembolism (VTE). Various pharmacological agents exist for VTE prophylaxis. Warfarin and low-molecular-weight heparin (LMWH) were commonly used for VTE prophylaxis in the past, but with the emergence of novel anticoagulants including factor Xa inhibitors and direct thrombin inhibitors (DTIs), warfarin is used far less frequently. Aspirin is also approved for VTE prophylaxis. The purpose of this study was to determine if a superior drug or combination of drugs exist for VTE prophylaxis based on patient outcomes, cost effectiveness, and risk profile. This review of literature analyzed studies from the past 10 years that compared aspirin, warfarin, Lovenox, and the novel anticoagulants for VTE prophylaxis in post-operative TKAs. Study outcomes included VTE prevention, bleeding risk, and cost. Reversal agents were also examined. Findings of this author’s literature review demonstrated that currently, no one superior medication exists for prophylaxis of VTE events in patients undergoing TKA (Cafri et al., 2017). However, current research indicates that both factor Xa inhibitors and aspirin have emerged as the medications of choice. Of the two, aspirin is commonly favored as it does not require laboratory monitoring, it is cost effective, and it is available over the counter. It also has less risk of major bleeding compared to factor Xa inhibitors.

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  Systemic Therapy versus Catheter Directed Techniques for the Treatment of Acute Massive Pulmonary Embolism

  Lawrence Duane Lee

  •Acute massive pulmonary embolism is characterized by obstruction of the pulmonary arterial tree that exceeds 50% of the cross-sectional area causing acute and severe cardiopulmonary failure from right ventricular overload.

  •Systemic thrombolytic therapy is recommended as standard, first-line treatment in patients with massive pulmonary embolism unless contraindicated and catheter directed therapies, including low dose thrombolytic administration directly into thrombus and mechanical thrombectomy can be adjunctive or used as an alternative to systemic treatments.

  •This literature review researched articles looking at both systemic thrombolysis and endovascular techniques for the treatment of acute massive pulmonary embolism with an emphasis on long term clinical outcomes.

  •Study results demonstrated the efficacy and safety of systemic thrombolysis and catheter directed therapies as well as adverse effects; however, further randomized trials are needed, as acknowledged by many of the authors included in this paper, comparing both treatment options for hemodynamically unstable patients with emphasis on long term sequalae.

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  The Impact of Circadian Misalignment on Cardiometabolic Health

  Cynthia Marie Mills

  The circadian system is important in all living organisms because it generates a 24-hour rhythm for physiological and behavioral processes enabling anticipation and adaptation to daily changes in the environment. The prevalence of cardiometabolic diseases, which are linked to lifestyle choices, has been rising at an alarming rate. Modernization and globalization are two of many factors to blame for lifestyle changes resulting in circadian disruption. The purpose of this literature review is to explore circadian misalignment with regards to its mechanism and impact on cardiometabolic health and to determine possible interventional measures. The primary focus is on lifestyle change, particularly sleep, as an interventional measure for circadian misalignment. Studies were included if they included a cardiometabolic disease risk factor studied in the context of circadian alignment/misalignment or sleep duration/architecture. The data indicates that circadian misalignment and sleep deprivation impede cardiovascular function and cause a decrease in glucose tolerance and insulin sensitivity; however, restoring circadian rhythmicity and correcting for sleep deprivation improves several health indices including glucose tolerance, insulin sensitivity, blood pressure, and cardiac remodeling.

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  Pre-Participation Physical Exams: Are We Doing Enough?

  Steven Jacob Pietrusza

  •Inclusion of screening electrocardiograms (EKGs) during pre-participation physical examination has been a topic of debate for some time. There is unquestioned usefulness in the ability of a well-trained health care provider in using EKG to identify cardiac abnormalities.

  •Further, there have been several contemporary EKG criteria published that increase specificity and sensitivity of detection of disease. However, these criteria do not account for athletes less than 14 years of age, and that demographic represents a large portion of patients seeking pre-participation screenings in the United States.

  •The lack of research into pediatric cardiac remodeling secondary to activity, coupled with the significant overlap in normal pediatric EKG findings with adult pathological EKG findings create a difficult position for any health care provider.

  •A literature review was performed to determine if screening EKGs are effective both medically and economically in athletes less than 14 years of age.

  •Based on the review, the limitations of contemporary EKG criteria, the inability to prove cost effectiveness in the US healthcare model, and the lack of research into activity modulated pediatric cardiac remodeling should reinforce that the ACC/AHA checklist is an appropriate foundation for conducting pre-participation physical examination.

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  The Effectiveness of Oral Non-Steroidal Anti-Inflammatories versus Steroid Injections in Patients with Shoulder Pain

  Darren Scott Pledger

  - The fact that shoulder pain is the most common musculoskeletal complaint in primary care shows that clinicians must have an arsenal of quality interventions to treat this problem.

  - The need for quality research and evidenced based guidelines are necessary to educate clinicians on their treatment options, the efficacy of those treatments, and their safety profiles.

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  Letrozole vs. Clomiphene Citrate for Infertility in Polycystic Ovarian Syndrome

  Kailey Potratz

  Purpose

  To determine if letrozole is an equal or better alternative to clomiphene citrate for infertility treatment in PCOS patients.

  Literature Review

  Letrozole was found to have higher ovulation rates, fewer twin pregnancies/more single births, higher pregnancy rates, and higher live birth rates compared to clomiphene citrate. There were conflicting results for endometrial thickness and single follicle stimulation. Neither letrozole or clomiphene citrate was superior to the other for ovarian hyperstimulation syndrome. There were no significant differences between letrozole and clomiphene citrate regarding congenital abnormalities and miscarriage rates. The results regarding ectopic pregnancies were comparable between both groups.

  Conclusion

  The results provide information supporting letrozole as an adequate first-line alternative to clomiphene citrate for infertility in patients with PCOS.

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  Cannabinoid Therapy in Chronic Pain Management

  Breanna Joy Privratsky

  In 1996, the state of California was the first in the union to allow for the use of medical marijuana. Since then, 28 more states have enacted similar laws (National Conference of State Legislatures, [NCSL], 2017). With the ever-growing opiate problem that has now been classified as an epidemic by the Centers for Disease Control and Prevention, medical marijuana could be a viable alternative to this problem.

  As of 2014, the CDC reported opioid deaths were up 369%, which is more than 91 deaths per day from overdose (Centers for Disease Control, [CDC], 2017). The purpose of this study is to compare medical marijuana to opiates in safety and addiction; in addition, the efficacy of using cannabis as an alternative for individuals who deal with chronic pain will be investigated.

  A literature review was conducted to find systematic reviews, meta-analyses and randomized controlled trials (RCTs) that evaluated medical marijuana and opiates for the treatment of chronic pain.

  Four databases were surveyed with multiple sources found in CINAHL, Cochrane Database, PubMed and PsycINFO.

  Current literature shows that cannabinoids may provide potential benefit with short-term use, but not without possible adverse effects. With the current lack of research on long-term treatment of chronic pain with cannabinoids, additional research needs to be conducted to further understand the potential adverse effects associated with cannabinoid use.