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Background: Status epilepticus (SE) affects 17–23/100,000 children per year. Refractory SE (rSE) ensues when SE does not respond to initial antiseizure medications (ASMs), and the outcome is often worse. Current SE guidelines recommend administration of the first benzodiazepine (BZD) within 5–10 min from seizure onset and transitioning to non-BZD antiseizure medications (non-BZD ASMs) at 10–20 min. No studies have focused on BZD administration patterns before escalating to non-BZD ASMs in rSE.

Hypothesis: Patients will receive a higher number of BZD doses than recommended before transitioning to non-BZD ASMs, with applications frequently outside the most efficacious timeframe.
Methods: This retrospective multicenter study in the United States and Canada used prospectively collected observational data from children admitted with rSE between 2011 and 2020. Outcome variables were the number of BZDs given before the first non-BZD ASM, and the number of BZDs administered after 30 and 45 min from seizure onset and before escalating to non-BZD ASMs.
Results: We included 293 patients with a median age of 3.8 years. Thirty-six percent received more than two BZDs before escalating, and the later the treatment initiation was after seizure onset, the less likely patients were to receive multiple BZD doses before transitioning. Patients received BZDs beyond 30 and 45 min in 57.3% and 44.0% of cases, respectively. Patients with out-of-hospital seizure onset were more likely to receive more doses of BZDs beyond 30 min and beyond 45 min, compared to patients with in-hospital seizure onset. Intermittent SE was a risk factor for more BZDs administered beyond 45 min, compared to continuous SE. Forty-seven percent of patients (n = 94) with out-of-hospital onset did not receive treatment before hospital arrival. Among patients with out-of-hospital onset who received at least two BZDs before hospital arrival (n = 54), 48.1% received additional BZDs at hospital arrival.
Conclusions: Failure to escalate from BZDs to non-BZD ASMs occurs mainly in out-of-hospital rSE onset. Delays in the implementation of medical guidelines may be reduced by initiating treatment before hospital arrival and facilitating a transition to non-BZD ASMs after two BZD doses during handoffs between prehospital and in-hospital settings.

Background: Depression is a leading cause of illness among adolescent populations. The United States Preventive Services Task Force (USPSTF) recommends screening for depression in 12-18 year-olds with the Patient Health Questionnaire-9 (PHQ-9). Early data is showing a negative impact on mental health among adults due to the ongoing COVID-19 pandemic. However, there remains a paucity of studies that use standardized measures to compare mental health among adolescents in the United States before and during the pandemic.

Objective: The objective of this study was to compare cumulative trends in PHQ-9 scores among adolescents within two periods comprising two pre-pandemic years and the first twelve months during the pandemic.

Hypothesis: Mean depression scores would significantly differ among sex, race, rural vs non-rural, and insurance type matched adolescents pre-pandemic and within the first year of the pandemic.

Methods: Generalized Linear Mixed Models statistical analysis was used to analyze a retrospective, de-identified chart review of adolescents ages 12-18 who were screened with PHQ-9s throughout Colorado between March 2018 and March 2021. Pre-pandemic timeframe was defined as March 2018-March 2020 and during pandemic timeframe was defined as March 2020-March 2021. Patients were further sub grouped by sex, race (Black, Latino, White and other), identifying as LGBTQ or heterosexual, rural or non-rural, and insurance type.

Results: Four hundred twenty-four PHQ-9 observations from 206 patients were included in the analysis. Among all individuals the mean PHQ-9 score significantly decreased from 9.01 to 4.6 (p<0.001). Females scored higher in both pre and during pandemic time frames (p<0.001). All racial groups had decreases in PHQ-9 scores during COVID, however, white adolescents had a smaller decrease and scored higher with pre-pandemic score of 11.7 (p<0.001) and during pandemic score of 6.9 (p<0.001). In comparison to Black adolescents who scored 5.2 (p<0.001) pre-pandemic and 3.1 (p = 0.005) in pandemic time. Sexual orientation, rural or non-rural, and insurance type had no statistically significant changes to PHQ-9 scores.

Conclusion: These results follow trends previously noted among adolescents such as females scoring higher than males and white racial groups having higher overall depression rates. Surprisingly, overall depression scores decreased among all groups during the pandemic time frame. This study revealed surprising statistically significant trends of overall decreasing depression rates during the first year of the pandemic. Possible explanations include decreased academic and social pressures during social isolation, increased time spent with family, and pause of responsibilities, or other factors. These results indicate that, contrary to the common belief that depression among adolescents was worsening during the pandemic, depression screening in our study population showed improved scores among all groups studied. Further investigation with expanded cohorts is needed to fully understand the factors that lead to these results.

In the state of Utah, homelessness is becoming an increasing concern; within Washington county alone nearly 1,015 individuals reported living in a shelter in 2019, an increase of 62% from the previous year. While it is well known through quantitative data that these individuals have a fundamental lack of resources, it is still in question that this data captures the full narrative of the underserved. This project aims to identify the missing pieces to best serve this disadvantaged population in Washington county. With information gained from interviews, this project will bridge the gaps in knowledge and provide targeted aids that were being glanced over, consequently supporting local shelters like SwitchPoint Community Resource Center (SCRC) to fit the needs of their specific population. Phase I of this project will consist of meetings with SCRC leadership and other key informants to determine what information they have been collecting and to become more informed about what is missing. Phase II will consist of qualitative interviews with residents at SCRC in order to understand additional gaps in resources and potential solutions they wish they had access to. After identifying the gaps, we would propose new projects and solutions that SCRC can initiate to better fit the true needs of the residents with support from the local government and Rocky Vista University. We are currently in Phase I and will be initiating conversation with the key informants of SCRC to be more aware of what they have and what they seek to get out of this research. Afterward, we will continue our conversation with the residents of SCRC, who will guide us to identify the additional yet necessary projects that can be initiated at SCRC. We plan to discover these qualitative information gaps with our research, with the hope that they will provide the basis for the development of further interventions to address the significant social and other determinants of homelessness that continue to hinder development of appropriate and effective services.

The trophoblast is the first line of defense against pathogens threatening the fetoplacental unit. In
most cases, the trophoblast fends off infection via innate immune mechanisms. RIG-I-like
receptors (RLRs) and Toll-like receptors (TLRs) identify pathogen-associated molecular patterns
(PAMPs) and initiate an inflammatory response. We hypothesized that RLRs and TLRs are
expressed in either one or both of the outer cell layers of the chorionic villi, the syncytiotrophoblast
(STB) or the cytotrophoblast (CTB), during gestation, and that the expression of these receptors
would increase with advancing gestational age. Immunohistochemistry was performed on
placental tissue of varying gestational ages (6-32 weeks and full term) for the antiviral RLRs RIGI,
LGP2 (or DHX58), and MDA5, as well as endosomal TLR7 and TLR8, which detect microbial
ligands and cytoplasmic viral nucleic acids. TLR7 was not present in either the STB or CTB. TLR8
and RIG-I were localized to the CTB cytoplasm. MDA5 and LGP2 were localized to the STB
cytoplasm early in gestation but the CTB cytoplasm later in gestation. Differential expression of
RLRs suggests an innate immune defense system unique to the placenta that protects the conceptus
from viral attack. These findings will complement ongoing work in characterizing the replication
of teratogenic viruses in the placenta.

The 2020-21 influenza season was predicted to coincide with the continued circulation of Covid19. the 2020-21 season, and the CDC strongly encouraged influenza vaccination with the hope that
it would reduce the strain on healthcare systems. Covid-19 has drawn new attention to public health and drastically changed how the world operates including masks, increased handwashing, and social distancing. It was theorized that the changes associated with the pandemic would be a large influence to encourage vaccination. This study took a mixed-methods approach to examine the change in influenza vaccination before and during the pandemic. 129 participants responded to a web-based survey distributed to US residents over the age of 18. Quantitative data compared influenza vaccination rates in the 2019-20 influenza season to those of the 2020-21 season. Qualitative questions sought to explain the reasoning behind the change and how it relates to the pandemic. The results showed a significant increase in flu vaccination from 68.5% of participants in the 2019-20 season to 80.5% in the 2020-21 season. The most common reason given by participants to receive the flu vaccine was to protect their personal health. Identification of the effects of the covid-19 pandemic on vaccine motivation could help providers and public health workers to educate patients and encourage vaccination against influenza, Covid-19, and other diseases.

K-Complexes (KCs) are a well-known electrographic feature, correlated with consolidation of learning during sleep. KCs are generally thought to be global, morphologically consistent events. However, current knowledge of KCs primarily a product of EEG data, which is collected extracranially and more prone to noise and loss of signal data than electrocorticographical (ECoG) data, collected from intracranial electrodes. Using ECoG data alongside machine learning techniques, we may be able to identify differences that can distinguish subtypes of KCs. We hypothesize there are multiple types of KCs corresponding to distinct neurological sources. The methods we use include: automatic algorithmic detection of KCs, feature identification, and dimensionality reduction using principal components analysis (PCA). We are currently in the process of identifying the most dominant features characteristic of automatically detected KCs, and have completed an initial PCA on selected features. Our results so far suggest amplitude to be the most defining feature of a KC, albeit this may not be the ideal measure to distinguish between KCs. There are likely groupings of KCs that can be distinguished based on timing and morphology. Moving forward, we aim to extend this research by applying more sophisticated source separation and localization, alongside application of clustering algorithms to characterize the distinct KC morphologies.

Background
Although racial disparities in health care have been well documented and well-established, little has been studied about the underlying causes of why these inequalities have been perpetuated in the healthcare system. Several studies identified a relationship between physician implicit bias and clinical treatment as one important factor contributing to racial disparities in health care. However, it is unclear whether these biases are held by medical students, and if medical training and diversity education has any influence on these potential biases. In response to this information deficit and possible connection to the continuing racial disparities in health care, this study was created to identify the role that inclusive medical education plays on medical students' beliefs about biological differences between racial groups in medicine.
Hypothesis
Medical students will have less implicit bias if they have had formal anti-racist and/or diversity
training.
Methods
A secure, web-based Likert scale survey was created with questions pertaining to three major
categories: Race-based Medicine, Diversity Education, and Personal Demographics. To participate in the survey, the individual must be a United States medical student (in year one through four of (training) and be currently enrolled in either an allopathic or osteopathic medical school. The survey was distributed to medical students across the United States between November 2020 and July
2021.
Results
Dimensional analysis was applied to data gathered from the survey, and responses were grouped
into patterns of similarity. Questions that were answered similar were combined and 3 groups were
created to analyze the data on a broader scale: 1. Generalized Race Misconceptions, 2. Social Race
Awareness, 3. Medical Race Misconceptions. Hard data about school perception, diversity training, and inclusivity was analyzed to identify relationships to the respondents’ demographics. Strong connections to diversity training and medical student implicit bias and perceptions were revealed.
Conclusions
As medical education strives to grow and improve in relation to its increasingly diverse student
body, it is important that research continues to evaluate the most effective ways of implementing
diversity training to create impactful and lasting change for both the sake of their students’ future
patients, as well as their campus environment.

Purpose: Characterize the impact of continuous-flow circulatory support, provided by left
ventricular assist devices (LVAD), on cerebral perfusion among patients with advanced heart
failure with reduced ejection fraction (HFrEF).
Methods: Patients with advanced HFrEF (N=11, 10 males) underwent hemodynamic evaluation
prior to, and approximately 3 months following LVAD implantation. Participants completed a
squat-stand maneuver at a frequency of 0.05Hz (five second squat, five second stand) for 5
minutes to force large changes in blood pressure (BP). Middle cerebral arterial velocity (MCAV)
was monitored continuously by transcranial Doppler. BP was continuously monitored by radial
arterial line.
Results: Hemodynamics at rest and during the squat stand maneuver are presented in Table 1.
An example tracing of waveforms is demonstrated in Figure 1. Despite increases in BP during
the squat stand maneuver, there were no observed increases in MCAV. Fourier transformation
of hemodynamic data (using BP as the input and MCAV as the output variables, respectively)
demonstrated that transfer function gain was similar prior to, and following LVAD implantation
Figure 2.
Conclusion: LVAD implantation does not improve cerebral perfusion among patients with
advanced HFrEF and there is no change in cerebral autoregulatory processes.

Background:
Currently, there is a dearth of literature on inter-operator and intra-operator reliability with ultrasound shear wave elastography measuring muscle stiffness. Muscle stiffness representing tissue mechanical properties is associated with physiologic and pathologic conditions. The efficacy of Osteopathic Manipulative Treatment (OMT) on muscular somatic dysfunction may be evaluated by quantifying the change in muscle stiffness following OMT. Inter- and intra-operator reliability plays an important role in generating reproducible and reliable data for future muscular and osteopathic research using shear wave elastography.

Hypothesis:
Students who have received training in performing shear wave elastography may demonstrate inter-operator and intra-operator reliability sufficient to conduct data collection for research with reproducible results when measuring tissue stiffness of the lower trapezius musculature.

Methods:
Two student researchers individually measured shear wave velocity of the lower trapezius bilaterally in 10 participants. Each participant was measured laying prone by placing the ultrasound probe lateral from T7 spinous vertebrae in the muscle’s longitudinal plane. Participants were then instructed to place their ipsilateral arm out at 90 degrees on support to ensure a relaxed muscle, then exhale and hold before the measurement was taken for consistency. Each muscle was scanned twice by each student researcher bilaterally with a total of 8 measurements collected per scan. The measurements were evaluated for inter- and intra- reliability by using intraclass correlation coefficient (ICC).

Results:
The inter-operator reproducibility was calculated using ICC and demonstrated significant agreement. The intra-operator repeatability value for operator 1 and operator 2 showed excellent consistency of measured and subsequently re-measured values for each operator.

Conclusions:
Students who receive training on the operation of shear wave elastography may effectively collect shear wave velocity data of the lower trapezius for evaluating muscle stiffness. Good inter- and intra-observer reliability in data collection by trained student researchers can contribute to high confidence for conducting future studies involving OMT.

Background: Black patients are disproportionately mistreated within healthcare systems. Their pain is taken less seriously; consequently, death rates are much higher rates than white patients with similar ailments. There is currently a focus in many medical organizations on acknowledging that racism exists without providing methods to change. We aim to dissect and reconstruct the way that modern medicine is confronting racial bias, and to push these groups and individuals into actively engaging against such bias. Additionally, we want to streamline and objectify the process of instituting anti-racist measures for equity of treatment by focusing on values and ethics of providers. We aim to improve the ethical treatment of patients by training physicians into becoming more ethnically and racially equitable patient advocates by creating and implementing a straightforward intervention program.

Methods: One checklist of initiatives will be used to identify, assess, acknowledge and work towards eliminating implicit and explicit racial bias in treatment prescription. A second published checklist will focus on removing subjective decision-making when providing pharmaceutical pain management to symptomatic minority patients. These checklists incorporate Interprofessional Core Competencies 3 and 4, which focus on a team approach to promoting and delivering patient centered care policies that are equitable. Pre and post checklist implementation surveys will garner the quality of patient experience.

Results: Survey results will illustrate consistent use of checklists and overall improved pain management in Black patients.

Conclusions: We aim to showcase innovative and practical survey initiatives to identify and critically assess existing racial biases in healthcare. This will provide a crucial foundation for mitigating the permeating and injurious effects of racial bias involved in providing appropriate pain management, enabling more equitable care for Black patients.

How does the rate of Buprenorphine prescribed in rural Colorado counties compare to those in
urban Colorado counties when treating neonatal abstinence syndrome and opioid use disorder in
pregnancy?
An infant can develop Neonatal abstinence syndrome (NAS) post-partum if they were exposed
to opioids in utero, specifically in the prenatal period. NAS rates have risen concurrently with
the national epidemic Opioid crisis. While the, rate of prescription opioid negative outcomes
have decreased due to higher awareness of those writing opioid prescriptions, NAS and opioid
use disorder rates have not shown a similar decline in incidences and it is hypothesized that this
is due to illicit opioid use when prescription opioids cannot be obtained. The purpose of this
study is to investigate NAS incidence in relation to access to medication assistance treatment
(MAT), specifically buprenorphine, available to local pregnant patients, primarily in the rural
verse urban setting in the state of Colorado. The Healthcare Cost and Utilization Project
(HCUP) showed significant increases in NAS in all Colorado communities between 2008 and
2019 with a peak incidence of 6.2 births per 1,000 in 2017. Colorado’s rural population had the
largest percent increase of NAS among newborn hospitalizations between 2008 and 2014 at
236% increase and the largest rate of NAS among newborn hospitalizations in 2014 of 3.9 NAS
per 1,000 newborn hospitalizations. The rate of NAS among newborn hospitalizations for
patients in medium metropolitan areas increased by 62% from 2008 to 2014. The rate of NAS
among newborn hospitalizations increased by 54% from 2008 to 2014. Fortunately, the rates of
NAS in Colorado as a whole have declined (5.3/1,000 births in 2018 and 4.5/1,000 births in
2019) but further research is needed to evaluate what methods have helped certain communities
achieve this decline in NAS incidence. We hypothesize that, regardless of other variables, there
will be a decreased rate of NAS in areas of Colorado that have better access to MAT for the local pregnant population.

This project aims to produce a more apprehensible and practical dissection guide for the
historically difficult dissection of the human cadaveric head written by students, for students.
Cadaveric dissection has long been a central component of osteopathic medical school curricula.
However, the learning curve in the laboratory is steep, and assumptive and lengthy dissection
instructions in commonly used laboratory guides are often among the limiting factors in
students’ dissection experiences. The ultimate goal of this dissection guide is to allow a student
to have success on their first attempt at dissecting by providing students’ perspective on the
procedures involved. Finally, osteopathic correlations and anatomical considerations are
provided throughout the guide to facilitate enhanced comprehensive learning during traditional
cadaveric dissection.

Background
When applied correctly, the SAM Splint is a versatile tool that is flexible and durable enough to stabilize a variety of musculoskeletal injuries. Its light weight and compact design make it a common tool in wilderness medicine first aid kits. However, there can be a disconnect between the environment in which people are trained to use SAM Splints and the setting in which SAM Splints are actually utilized. It’s vital that those who carry a SAM Splint are confident in its application in both classroom and emergent settings.
Objective
Test the efficacy of SAM Splint use on potential cervical spine injuries in two settings, a controlled setting inside a classroom and an exfiltration wilderness setting, and within two groups, participants who had never been trained on the use of SAM Splints and participants who had previous SAM Splint training.
Methods:
Twenty participants were separated into two groups, beginners and intermediates, based on their self-reported training experience with SAM Splints. Both groups then viewed a live presentation and demonstration based on the SAM Splint User Guide and practiced proper SAM Splint application. Each group was then assessed on their effectiveness applying a SAM Splint to the cervical spine in both a controlled classroom setting and a wilderness setting during a simulated patient scenario. The parameters measured, using a goniometer, were the degree of maximal flexion/ extension, right-left rotation, and lateral flexion. Data was analyzed through Mixed Models.
Results
Setting was significantly associated with flexion/ extension, right-left rotation, lateral flexion, and total angular displacement. The experience level was only associated when the interaction effect of setting by experience was evaluated and not as a main effect. These effects are still evident in most cases when evaluating the data separately by experience group. The intermediate group performed better in the uncontrolled field setting.
Conclusion
The results of this study suggest a participant's previous experience only plays a role in the uncontrolled scenario but not necessarily in a classroom setting. This suggests that training in a chaotic environment is important to be prepared to use a SAM Splint effectively during a true emergency.

Background: Adolescent girls can present with postprandial, episodic symptoms of dizziness and excess sweating, which are often clinically disregarded. These symptoms can be associated with idiopathic reactive hypoglycemia (RH), reproduced with a glucose challenge, and may relate to increased risk of insulin resistance and type 2 diabetes (T2D).

Hypothesis: Following an oral sugar tolerance test (OSTT), adolescent girls with obesity have a high prevalence of RH, which relates to increased early insulin secretion.

Methods: Secondary analysis of 112 adolescent girls with obesity (age 12-21 yrs; BMI≥90th percentile). Participants completed a 4-hr OSTT (75 g glucose, 25 g fructose) and were stratified by glucose nadir after 120 min: ≤60 mg/dL as RH, ≥80 mg/dL as normoglycemic (NG), and 61-79 mg/dL as indeterminate. Area under the curve (AUC) of glucose, insulin, glucagon, and C-peptide and measures of insulin sensitivity and β-cell function including oral minimal model, insulinogenic index, and oral disposition index were calculated. Demographic, physical, and metabolic characteristics between RH and NG were compared with Student’s t-tests or Mann-Whitney U tests. OSTT curves were compared with repeated measures ANOVA.

Results: In this cohort, 12% of girls had RH (n=13) and 36% had NG (n=40). Groups were similar for age, race, ethnicity, and BMI. Glucose concentrations were lower in RH than NG when fasting (p=0.033), at 210 mins (p=0.001), and 240 mins (p<0.001). In RH, glucose nadir occurred at a median time of 210 mins postprandial. RH had higher glucagon AUC for 90-240 mins of the OSTT (p=0.035) and lower insulin at 240 mins (p=0.007) confirming a counterregulatory response. Insulin AUC (p=0.074) and C-peptide AUC (p=0.054) for 0-120 min trended to be higher. Groups had similar hemoglobin a1c, family history of T2D, insulin sensitivity, and β-cell function.

Conclusions: RH was relatively common in this cohort of adolescent girls with obesity and occurred at 3-4 hrs. Early higher insulin secretion preceded the counterregulatory RH responses but was not related to insulin sensitivity. Future studies should aim to further understand the long-term effects of RH during adolescence and its significance in predicting future hyperglycemia.

Background
Riehl’s Melanosis (RM) is a rare form of contact dermatitis that usually presents in females of Asian descent. Patients usually present with a rash around the neck or facial region after applying cosmetics products to the region, which was the case for our patient. The dermatitis is classified as an increase in the number of melanocytes and as well as an increase in the melanin pigment at the site of irritation. Due to the rarity of RM not much is known about the impact it has on the population. Current treatments include low-fluence qs Nd:YAG laser therapy, photoprotection, and avoidance of the irritants.

Hypothesis
This case study will focus on the treatment of RM using low-fluence qa Nd:YAG laser therapy and how it can be a potential front line treatment in Riehls Melanosis.

Methods
Patch testing was done to confirm the diagnosis of RM, she was placed on strict photoprotective measures and advised to avoid all cosmetics containing the confirmed allergens. She was treated with low-fluence Q-switched: Nd YAG starting at 1 J/cm2 and building up to a max of 2 J/cm2 with a spot of 8mm and frequency of 10 Hz (generally three passes over face and neck twice monthly).

Results
Following 12 treatments with low-fluence qs Nd:YAG, photoprotection, and avoidance of triggers over the course of 6 months there was a noticeable amelioration of her dyspigmentation

Conclusion
Currently there are no standardized treatments for RM, however from our case and the various forms of literature it has been seen that the use of low-fluence qs Nd:YAG has been extremely successful in relieving clinical symptoms. Following this study it is hoped that a standardized treatment for RM will be implemented for future patients.

Hyponatremia is the most common electrolyte abnormality found in hospital patients. Thymomas are the most common type of mediastinal tumor and commonly present with other autoimmunologic disorders such as Myasthenia Gravis, Graves Disease, or syndrome of inappropriate antidiuretic hormone (SIADH). There are many potential causes for an abnormally low sodium level, but a common cause seen in cancer patients is attributable to SIADH. Here, we present a case of SIADH in association with a type A thymoma. Very few cases of SIADH in association with a thymoma exist. We were unable to find any cases specifically associated with thymoma type A. Therefore, this is likely the first published report that isn’t associated with the more common B type Thymoma.

Small Incision Lenticule Extraction (SmILE) is a fairly new refractive surgery
method. As with many new procedures, there are new barriers. SmILE is considered to
be more technical than other refractive surgeries, requiring more physician involvement
and making it difficult for new surgeons to master. As the procedure becomes more
common, the development of new or improved surgical instruments used during surgery
are being recognized. Doctors and medical professionals from around the world have
taken it upon themselves to develop such instruments in order to meet the needs of
patients and physicians.1
Many are attempting to improve existing instruments and surgical techniques,
while others are original creations. One such instrument is The Monson SmILE Fixation
Device (MSFD).
The MSFD is a novel counter-traction device and technique used during
delamination and dissection of the corneal lenticule. The MSFD could potentially lead to
a decrease in hemorrhage associated with the use of forceps, improve patient comfort
during surgery, and allow for faster operation times.2
SmILE has opened the door to a number of surgical instruments, the Monson
SmILE Fixation Device being one of them, all attempting to make SmILE easier for
physicians and improve the patient’s experience and outcomes.