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... Using wiki assignments in medical school Erin McClelland, PhD Assistant Professor of Microbiology and Immunology Marian University College of Osteopathic Medicine Abstract A wiki is a collection of pages that allow collaborative modification and management (eg, Wikipedia). First-year MUCOM medical students designed a Wiki that outlined the major concepts covered in Immunology during the Scientific Foundations of Medicine class. The first three deadlines were peer-reviewed where each student turned in their wiki and then anonymously reviewed another students wiki content and suggested feedback. For the final deadline, all participating students were placed into groups that collaborated to collate the individual wikis into one. Thus, each student created and received peer feedback for their Immunology study guide for the Board Exam. Design Each optional assignment included 24 lectures that chunked material into an appropriate size Students were instructed to complete the learning objectives for each lecture to outline the major concepts covered Each assignment was designed to be peer-reviewed so that students would receive constructive feedback The last assignment was a group project designed to allow individuals to collate their wikis to provide active and collaborative learning What worked What did not work Students liked the idea of creating their own study guide for the Board exams Of 150 students, 17 students turned in the first assignment that covered 2 lectures Some students completed the peer-review assignment Because the Immunology wiki was optional, not every student did the assignments Due to the Immunology lecture schedule and trying to chunk material into manageable sizes, the 2nd and 3rd assignment deadlines were too close together, so many students only completed the 1st assignment Because there was not a hard deadline for the peer review (they were directed to give feedback within 24 hours), some students did not complete that part of the assignment so some students did not receive feedback Feedback from students on the Immunology wiki There was really poor timing with the second exam The deadlines should not be hard deadlines Students had to prioritize balancing other class work and exams Students suggested that an assignment between students in the class where they could all contribute to a page may be more beneficial and more students would participate Some students never received feedback, so there was essentially no benefit to completing the assignment What I will change for next year The Immunology wiki will not be optional and course points will be available for those students that complete the wiki assignment The Immunology lecture schedule will be more spaced out, allowing better integration of the wiki assignments into the course The deadlines will be suggested deadlines to facilitate keeping students on track All assignments will be group projects where the students can work together on the wiki  ...

... John A. Lucich, MD, FACP Professor and Chair of Internal Medicine Abstract Clinical medicine courses often attempt to develop skills in applying biomedical sciences instruction to clinical situations. This goal can be accomplished in many different ways, but such techniques often require the learner to exercise levels of clinical judgment that they do not yet fully possess. This can lead to increased anxiety during clinical simulations and levels of performance that are lower than desired. I describe a method to close the gap between what the student knows how to do and what they are being expected to demonstrate by combining the techniques of online/asynchronous education, flippedclassroom techniques and real-time pre-briefs. Flipping, Focusing and Efficiency in Clinical Education PRE-BRIEF Covers background info + Clinical algorithm WEEKLY REVIEW Several days after the Pre-Brief, a review session addressed any outstanding questions and posed specific clinical questions to evaluate readiness for an upcoming OSCE (Objective Structured Clinical Examination). OSCE The OSCE provided an opportunity to summatively evaluate the competency of the students. The OSCE sessions in this course were clearly connected to the broader instructional content. Response Option Strongly Agree Agree Neither Agree nor Disagree Disagree Strongly Disagree Weight Frequency Percent 5 24 69% 4 10 29% 3 1 2% 2 1 0 0 0% 0% The OSCE Sessions in this course furthered my understanding of the subject matter. Response Option Strongly Agree Agree Neither Agree nor Disagree Disagree Strongly Disagree Background PRE-BRIEF During the Spring 2021 semester, the Introduction to Clinical Medicine 2 course (required of first year medical students) attempted to get students functioning effectively with less stress by providing background information and a prescribed clinical strategy for managing clinical complaints. Quantitative Feedback (22.58% of Class) WEEKLY REVIEW Answers questions and allows mentored, group practice OSCE (Objective Structured Clinical Examination) Provides summative assessment of clinical skills Weight Frequency Percent 5 25 71% 4 10 29% 3 0 0% 2 1 0 0 0% 0% Qualitative Feedback (10.34% of Class) The OSCEs were so fun and educational! As far as the OSCEs go, I love the setup and schedule of the course. Overall, I felt like the OSCE's were a great experience to learn how to take a H & P. I thought the course was run very well. Dr. Lucich did a fantastic job with pre-briefs and all the OSCE material needed prior to the actual OSCE. OSCE experiences were great and the encouragement we received beforehand was always uplifting. I think the course content was lined up very well with timing of CPR content delivery and helped me form a more clinical understanding of the material.  ...

... Students-as-Teachers: Integrating Student Designed Curriculum and Novel Technology to Improve Learning Outcomes By: Dr. Erica Ausel, Assistant Professor of Anatomy, Marian University, College of Osteopathic Medicine Purpose and Goal In December of 2020, Marian University acquired an Anatomage Table, a virtual dissection tool, to supplement biomedical education. This technology offers a broad range of tools including virtual dissection of four once living donors, 3-dimensional (3D) cadaveric prosections, 3D physiological pathways, and thousands of pathological case studies with supplemental medical imaging. Acknowledgements: Thank you to Mona Kheiry for providing the pedagogical training modules for the students who participated in this project. Thank you to Allison Seacat for allowing me to showcase her Masters work in this poster. Finally, thank you to MU-COM for providing the tools to explore this novel teaching method for the benefit of our students. Example of Student Designed and Created Anatomage Learning Activity by Allison Seacat 1 2 3 4 As the course director of Anatomy, Histology, and Embryology I and II (AHE) in the Biomedical Science Masters (BMS) program, my goal was to integrate this expansive tool into the course. With no laboratory component for this course, transferring an understanding of complex, 3D anatomy to the students is a challenge. Therefore, my primary goal for this work was to supplement gross anatomical identification. Pairing with my venture into the science of teaching and learning, I wanted to measure the impact the Anatomage Table had on students taking the courses, as compared to the 2D images currently in use. To accomplish this goal, I enlisted the help of 11 BMS students who used the Table to complete their Capstone projects. It is my experience with these students-turned-teachers that I address in this poster. Methods The student and I worked together to outline project goals and requirements. They were as follows: 1. Explore relevant literature to develop an understanding of successful pedagogical applicable to the project. 2. Design and create an active learning activity on the Anatomage Table for future AHE students using Backwards Design to: Reinforce current lecture material and course learning objectives. Create goals and objectives for the activity prior to its design. Provide direction, via metacognition, for future students. 3. Create a module in Canvas that follows a common structure, providing consistency for future users. Include a module introduction, activity instructions, and a brief assessment to test the outcomes of stated learning objectives. (Images 1-6) 4. Write a manuscript reviewing associated pedagogical methods, outlines the project goals and methods, and reflects on the activitys creation. 5 1: Canvas module built using a common design. 2: Activity overview including learning objectives. 3: Activity instructions. 4: Assessment created to test learning objectives. 5-6: Submission by AHE students during Fall 2021 semester Results, Future Directions, and Reflections All 11 students completed their respective projects, which are now being integrated into the AHE curriculum. On a voluntary basis, 24 current AHE students complete one activity per-exam block (4 per semester). For this pilot program, our goal is to test the activities before requiring their completion for the course. Four of the eleven students have continued to work with me on the project. Results thus far have shown that students who participated in the pilot program scored higher on exams overall and on exam questions related to Anatomage activities; significantly so for certain material. In addition, the perception of students regarding the use of this technology in anatomical education has become more positive throughout the semester. We have submitted abstracts to present at one national (American Association of College of Osteopathic Medicines Educating Leaders 2022 Conference) and one international (International Association of Medical Science Educators Annual Conference) conference to present the project and the results of the pilot study. After peer review and critiques from these presentations, we plan to submit manuscripts to the journal Medical Science Educator. Reflecting on the project as whole, I encountered a few minor challenges primarily related to the level of experience students had with succinct instructions as well as technological glitches. However, it has been a joy to work with these students overall. Their unique perspectives for creating activities that fit the needs of the students have changed the course for the better. I look forward to continuing this work alongside these students-turned-teachers. 6  ...

... Death Cafe : Campfire Experience Lorie Hacker, DNP, MSNed, NP-C, RN, CNE Assistant Professor, Leighton School of Nursing Ground Rules Course: NSG 427 Bereavement & Loss Elective Course Description This course provides the student with knowledge to assist the patient, family, and other healthcare professionals addressing issues related to bereavement and end of life care. Course Objectives Listen when others are talking. Respect others views and confidentiality. Summary of the Experience All students enrolled in the course as well as students in another elective course were invited to the Oriental Gardens Fire Pit to participate in the Death Caf Experience in the fall 2021. 1. Examine factors (i.e. legal, ethical, cultural, economic, and spiritual) that influence end of life care for patients and families. After the welcome and invitation for Smores and snacks the Death Caf movement was introduced and discussed. A time of memorial was made where students lit candles in 2. Discuss the impact of a health professionals attitudes, values, feelings, and memory of those who have died. Students then broke into small groups around the expectations about death in dealing with diverse beliefs and customs in end of life campfire to have open discussion regarding death and dying. Use of the One Slide care. Project handout was provided with question prompts if needed. The experience 3. Explore a holistic interdisciplinary approach to improve quality for patients and concluded with a time of sharing and reflection as a larger group. families facing end of life decisions. 4. Examine methods to assist patients, families, colleagues, and ones self to cope with suffering, grief, and loss experienced in end of life care. Module Level Objectives 1. Define the importance of ongoing and therapeutic communication in end-oflife issues. 2. Identify factors that influence communication at the end of life. 3. Explore important factors in communicating bad news to patients and families. 4. Identify common pitfalls healthcare providers make when communicating about end-of-life issues. Background After the experience, the students completed the Death Caf Reflection Assignment with the following writing prompts. 1. What do we learn from death? 2. What do you say to a friend who is facing death? 3. Have you ever seen a person take their last breath? What impact did that have on you? 4. What emotions did you notice while participating in the death cafe'? Was this uncomfortable for you? Why do you think that is? 5. How important is it for nurses to have self-awareness of emotional triggers around death and dying? 6. Do you think that normalizing death as a part of life will help patients and families reach goal-concordant care? Sample of Student Reflections I most definitely think that normalizing death as a part of life will help patients and families reach goal concordant care. The Death Caf' objective is 'to increase awareness of death with a view to helping During the death caf, I felt many emotions. I felt relief, peace, sadness etc. I appreciated talking to other people make the most of their (finite) lives'. students about their experiences and their views. Started in 2010, in East London. Death Cafs have spread quickly across Europe, North America and Australasia. As of today, there have been over 13,230 Death Cafes in 80 countries since September 2011. If 10 people came to each one that would be 132300 participants (Death Caf, 2021). It is very important for nurses to have self-awareness of emotional triggers around death and dying as it is something we will be around a lot in our career. I do believe that normalizing death as part of life will help both patients and families.. I really enjoyed the death cafe. It was nice getting out of the classroom and having an open environment to talk about death I think that humans learn empathy for others through death. References: Death Caf. (2021) . What is a Death Caf. Retrieved from https://deathcafe.com/what/ End-of-Life Nursing Education Consortium (ELNEC). (2021). ELNEC undergraduate module 2: Communication in palliative care. Retrieved from https://elnec.academy.reliaslearning.com/. Institute for Healthcare Improvement (IHI). (2021). The conversation project. Retrieved from https://theconversationproject.org/nhdd/advance-care-planning/  ...

... A PARTNERSHIP IN PRISON EDUCATION The Marian / Bard Womens Collaboration Project The Curriculum The Womens Collaboration Project Marian Steering Committee oversees and connects the Program Director with key personnel and resources on campus The Bard Prison Initiative began classes in 2001 Program challenges conventional wisdom about incarcerated individuals and outcomes of the criminal justice system; 2.5% recidivism rate for graduates Students complete the Associates in Liberal Arts Specialization: Organizations & Society Marian partnered to offer classes at the Indiana Womens Prison, Spring 2019 May continue to complete the Bachelors in Liberal Arts 2 cohorts of students now taking classes 39 classes have been offered Spring 2019-2022 Program Director facilitates the process for faculty to teach campus classes at the Indiana Womens Prison with the same content, innovation, and rigor First Year Seminar Students learn college success skills, how to communicate with 'specificity' in writing & speaking, and how to build community Scholarships available for students to continue degree at Marian after release Gender Studies Students learn to think critically about gender, race, class, and sexuality as the they pertain to our lived realities Sample Assignment: After reading Lois Gibbs Love Canal, create a work of found poetry that: 1) Captures the power of story and 2) Emphasizes personal / social empowerment Sample Assignment: Research a selected subject from the major course themes and present findings in the form of a poem, graphic novel, short story, dramatic performance or an artistic rendering WCP Modification: On campus, students carry out a Story Corp project, interviewing the campus community. WCP students interview each other and read Love Canal by Lois Gibbs. Not all students have computer access for typing and adding imagery WCP Modification: On campus, students have access to the internet to conduct their research and select their own sources. WCP students complete a Research Request Form that indicates the specific research question they need resources on and the specific kinds of sources they would like to examine. Instructors then work with the program librarian to provide them materials Writing to Learn and Think Students learn academic expectations of writing and practice ways of writing to foster learning, inquiry, and creative problem-solving Sample Assignment: Within Portfolio 3: The Pursuit of Knowledge, you will produce a research essay that combines narrative and exposition that explores the knowledge you hope to gain as a WCP student, connects this knowledge to a real-world application or personal outcome, and articulates a rationale for why you believe this knowledge is important for yourself and others. WCP Modification: Students use class techniques (poetic inquiry, writing in the zones, dialogic notebook) to make connections, deepen understandings, and apply knowledge from other classes. Here, a learning community takes on a new level of meaning. Black Out Poetry, a poetic inquiry technique, used to examine the U.S. Declaration of Independence  ...

... Using Photovoice to Teach Qualitative Research Methods Christina Pepin PhD RN CNE The Course NSG 343: Nursing Research & Informatics is where undergraduate nursing students learn about both quantitative and qualitative research methods in order to become good consumers of research. The intent is not to turn them into bench or eld scientists, but rather be savvy about how to nd and critique the evidence found in the literature. This is to prepare them to provide evidence-based practice to their patients and spearhead evidence-based practice initiatives in their workplace. The course also gives them the foundation to aid them in graduate school research courses and participate on research teams within their work facilities. Photovoice Photovoice is a qualitative research methodology that can be used as a visual methodology or community participatory action research. It was rst developed as a methodology in 1994 and has become a very powerful method for community research for policy change. Photovoice is a unique methodology in qualitative research as the participants can also participate in the analysis and dissemination of the data. Steps to Photovoice: 1. Gain entry to the community 2. Train participants about photography and any guidelines 3. Participants take the photographs 4. The participants select the nal photo(s) and create a narrative for each 5. Researchers code the data and develop themes and look for iconography 6. Focus group with participants for validation of results 7. Participants create and participate in an exhibit to disseminate results 8. Focus group debrief (Langly-Brady, 2019) The Question The Assignment What does it mean to be a Marian University Student? To assist students in viewing qualitative research as both participant and researcher, the photovoice activity was developed. This class activity demonstrates key aspects of maintaining trustworthiness, qualitative analysis techniques, and practice disseminating results. Before Class Take a picture that represents what the question means to you individually. The pictures can be of anything, literal or abstract. The only rules are that you take them yourself, no faces, and dont depict anything inappropriate to display in the Evans Center. Place picture in a word document and provide a 2-3 sentence caption that describes the photo and why it answers the question During Class The class will split into two groups. Each group will receive a packet of pictures with captions that have been deidentied. As a group, look at the pictures / captions and place into categories (codes). Then group codes until you get 2-4 themes. Review the other groups results are they the same? Are they different? Make changes to yours as you see t. (Triangulation) Report to the class what your themes were and provide an exemplar to demonstrate the theme (Credibility & Dissemination) Do the results resonate with you? (Debrief) References Langley-Brady, D. (2019) Photovoice: Using photography to understand lived experience. AHNA Beginnings 39(5), 18-22.  ...

... COVID-19 AND PAH 1 COVID-19 and the PAH patient: A retrospective chart review Ann Schmit Marian University Professors: Dr. Baack and Dr. Fox NSG 708 July 29, 2021 COVID-19 AND PAH 2 Abstract The COVID-19 pandemic has highlighted the need for additional health precautions in medically fragile populations. COVID-19 is a respiratory virus demonstrating increased mortality in individuals with risk factors such as pulmonary and cardiac disease. Pulmonary arterial hypertension, WHO group 1, is a rare condition that leads to cardiopulmonary symptoms. Pulmonary arterial hypertension, WHO group 1 (PAH), leads to constriction of the pulmonary vasculature which increases pressure in the right ventricle, and eventually leads to right heart failure. Additional research is needed to understand the risk PAH patients have with COVID-19 and if they are at a greater risk for disease worsening as evidenced by increased need for medical intervention, hospitalization, or even death. This project explores the relationship between the COVID-19 pandemic and pulmonary arterial hypertension, WHO group 1, patients at a single center. Adult patients diagnosed with PAH prior to March 1, 2019, at the Ascension St. Vincent Pulmonary Hypertension Clinic will be included in the study. A retrospective chart review will index hospitalization events, markers of disease worsening, and mortality in established patients and compare if there is statistical significance between the pre-pandemic period of March 1, 2019, through February 29, 2020, and during the COVID-19 pandemic period of March 1, 2020, through February 28, 2021. This study will increase the information known about the impact of COVID-19 on patients with PAH. Keywords: pulmonary arterial hypertension, PAH, COVID-19 COVID-19 AND PAH 3 COVID-19 Pandemic Impact on Pulmonary Arterial Hypertension Patients Severe acute respiratory syndrome Coronavirus 2 has dominated every aspect of healthcare in the United States in 2020. This syndrome, Sars-CoV2, which became known as the coronavirus 2019, or COVID-19, has a higher rate of morbidity and mortality on medically compromised individuals such as individuals with underlying cardiac or pulmonary disease (Wang et al., 2020). Patients with pulmonary arterial hypertension, World Health Organization (WHO) Group 1, would seem to have a greater risk of poor outcomes from COVID-19 infection. Research is needed to understand the consequences of COVID-19 on patients with pulmonary arterial hypertension, WHO Group 1. Background Pulmonary arterial hypertension, WHO Group 1, is a chronic, uncurable, and progressive disease of the pulmonary vasculature. Pulmonary hypertension is the over-arching term for elevated right heart pressure and is classified into five WHO groups (Gali et al., 2015). WHO group 1 is pulmonary hypertension specific to the pulmonary arteries with hemodynamics from right heart catheterization demonstrating a mean pulmonary artery pressure of greater than or equal to 25 mmHg, a pulmonary arterial wedge pressure or left ventricular end diastolic pressure of less than or equal to 15 mmHg, and a pulmonary vascular resistance of greater than or equal to 3 Wood units, along with no overt lung disease (Gail et al., 2016). The other WHO groups do not include these specific definitions. WHO group 2 pulmonary hypertension is due to left heart disease such as heart failure or valvular disease, WHO group 3 is due to lung disease corresponding with chronic obstructive pulmonary disease (COPD) or interstitial lung disease, WHO group 4 is related to chronic thromboembolic pulmonary hypertension, and WHO group 5 is pulmonary hypertension associated to multifactorial causes (Gali et al., 2016). Pulmonary COVID-19 AND PAH 4 arterial hypertension, WHO Group 1 (PAH), can be the result of idiopathic or hereditary causes, or associated with underlying connective tissue disease, portal hypertension, schistosomiasis, weight loss medication, or substance abuse and is the only WHO Group for which targeted therapy is appropriate (Klinger et al., 2019). Symptoms of PAH include syncope, dyspnea, chest pain, edema in the lower extremities, and ascites (Klinger et al., 2019). It is often undetected or overlooked until symptoms are severe (Klinger et al., 2019). Currently PAH is uncurable, but it can be successfully managed with medication therapy consisting of prostacyclins, endothelin receptor antagonists, phosphodiesterase type 5 inhibitors and/or guanylate cyclase stimulators (Gail et al., 2016). PAH treatment can consist of oral, inhaled, subcutaneous, and intravenous medications that are managed by specialized providers, nurse coordinators, and specialty pharmacies (Gail et al., 2016). Medication therapy is adjusted based on patients symptoms, New York Heart Association (NYHA) functional class, N-terminal pro-brain natriuretic peptide level (NT-proBNP), six-minute walk distance, right ventricular function on echocardiogram, and hemodynamics from right heart catheterization (RHC) (Klinger et al., 2019). PAH can be treated with medication therapy to improve heart function and quality of life for the individual, although patients with PAH may be more susceptible to respiratory and cardiac diseases due to the tenuous nature of their chronic illness even with appropriate treatment. COVID-19 is a novel coronavirus that originated in China in December 2019. This respiratory virus quickly spread around the globe and a pandemic was declared by the World Health Organization on January 30, 2020 (Hu et al., 2020). The COVID-19 virus is highly transmissible through the air and highly infectious (Pascarella et al., 2020). Pascarella et al. note that symptomatic individuals can display cough, fever, loss of taste, loss of smell, fatigue, headache, sore throat, and dyspnea that can lead to respiratory distress (2020). Individuals with COVID-19 AND PAH 5 comorbidities and the elderly, when infected with COVID-19, are extremely susceptible to developing pneumonia, respiratory distress, organ failure, and death (Pascarella et al., 2020). According to Pascarella et al., 80-90% of cases are mild or asymptomatic, while 5% of cases are critical and can end in death (2020). One difficulty with the COVID-19 virus is the infected individual can spread the virus prior to symptoms, or possibly be asymptomatic and still spread the virus (Hu et al., 2020). The symptom free period of infection creates a window for the virus to be unknowingly transmitted and spread exponentially with catastrophic consequences to unsuspecting individuals. The COVID-19 pandemic has challenged researchers to understand the populations most at risk for increased morbidity and mortality from the infection. Wang et al. (2020) completed a meta-analysis on comorbidities most likely to be at increased risk of morbidity and mortality from COVID-19 infection. Wang et al. found diabetes, COPD, hypertension, cardiovascular disease, and cerebrovascular disease were risk factors associated with increased severity of COVID-19 infection outcome (2020). Wang et al. also discovered the conditions of cancer, liver disease, or renal disease were not risk factors of worsened outcome from COVID-19 infection (2020). A study by Potus et al. evaluated the similarities at the molecular level between COVID19 and pulmonary hypertension (2020). Potus et al. performed a systematic literature review to assess how pulmonary vasculature was damaged from respiratory illnesses and found that vasoconstriction, inflammation, and emboli were hallmarks of PAH and COVID-19 (2020). Potus et al. theorized underlying pulmonary vascular disease may increase mortality from COVID-19 infection and that COVID-19 infection may increase risk of subsequent pulmonary vascular disease. The poor outcomes of patients with the comorbidities of cardiovascular disease or COPD highlights the need to identify how the PAH patient population is compromised COVID-19 AND PAH 6 by the COVID-19 pandemic. Current research supports the idea that comorbidities, such as cardiovascular and pulmonary disease, increase the risk of morbidity and mortality from COVID-19 infection. Purpose Problem Statement The consequence of COVID-19 on PAH must be understood to better educate the PAH patient population on COVID-19 disease risk and mitigation strategies. Increased knowledge can also assist in how patients should be monitored and if lower thresholds for appointments and testing is needed to prevent PAH disease worsening and hospitalization. This project researched whether adult patients diagnosed with pulmonary arterial hypertension, WHO group 1, cared for at the Ascension St. Vincent Pulmonary Hypertension Clinic required an increased need in medical interventions and/or hospitalizations for cardiopulmonary issues due to the COVID-19 pandemic when compared to the previous non-COVID-19 year. Comparing the time frame of March 2019 through February 2020 to the time frame of March 2020 through February 2021 provided understanding of disease stability for PAH patients prior to and during the COVID-19 pandemic. The proposed project reviewed the impact of COVID-19 on PAH patients utilizing a retrospective chart review. The sample was comprised of adult patients with known PAH receiving care at the Ascension St. Vincent Pulmonary Hypertension Clinic in Indianapolis, Indiana from March 1, 2019, until February 28, 2021. The charts were audited for hospitalizations and instances of disease worsening as evidenced by escalation in PAH targeted therapy. Increased insight into the significance of the COVID-19 pandemic on adult patients with PAH can help the medical community make informed decisions regarding patient care. COVID-19 AND PAH 7 Organizational Gap Analysis of Project Site Research into the significance of the COVID-19 pandemic on the PAH population is appropriate for the St. Vincent Pulmonary Hypertension Clinic site. Currently, there are no robust guidelines specific to the PAH population on the significance of COVID-19 and how to manage these chronically ill and medically fragile patients. Currently, clinicians are evaluating available data and applying it to the PAH population, which coincides with the PARiHS framework. The PARiHS acronym stands for Promoting Action on Research Implementation in Health Services and indicates that robust research, clinician expertise, and a receptive environment increases the likelihood of successful implementation of change (Melnyk et al., 2019). Collecting information on the health of PAH patients at the Ascension St. Vincent Pulmonary Hypertension Clinic prior to and during the COVID-19 pandemic will improve the ability to discuss risk with PAH patients and guide decision making. Review of Literature The COVID-19 pandemic has placed great medical strain on the global community. Medical providers are searching how to understand which patients are at a greatest risk of morbidity and mortality from COVID-19 infection. Patients with underlying chronic conditions including hypertension and lung disease have been found to have worse outcomes with COVID19 infection (Wang et al., 2020; Zheng et al., 2020). Pulmonary arterial hypertension, WHO Group 1, (PAH) is a rare, chronic, progressive, disease of the pulmonary vasculature that leads to right heart failure (Klinger et al., 2019). Due to the fragile pulmonary and respiratory status of PAH patients, additional research is needed to understand the risk COVID-19 has on morbidity and mortality in this patient population. In addition to the physical ramifications of COVID-19 on the patient, the evaluation and treatment of the PAH patient at pulmonary hypertension COVID-19 AND PAH 8 centers is also a considering factor during the pandemic. The COVID-19 pandemic has interrupted all processes for patient care, and increased understanding is needed. Research on COVID-19 and PAH was completed in a systematic manner to locate the most current articles. The literature search consisted of the PubMed, Ovid, and CINAHL search engines and was conducted on April 14, 2021. Search terms included for all three search engines were COVID-19 or coronavirus AND pulmonary hypertension, PAH, or pulmonary arterial hypertension. PubMed returned a total of 22 articles with these search terms, CINAHL returned a total of 146, and OVID returned 93. Articles were only included from Jan 1, 2020, to April 14, 2021. Only articles in English were included in the results. Articles were removed if they did not address the PAH, WHO group 1 population. Articles were removed if they were not case series, studies, trials, or consensus from an expert committee. With these limitations, ten articles addressed the consequences of COVID-19 on the PAH patient and community. PAH Patient Mortality PAH patient mortality from COVID infection was examined by several authors. Nuche et al. compiled a case series of ten PAH patients in Spain that contracted COVID-19 and noted that seven patients required hospitalization, none required intensive care therapy, and all survived (2020). Scuri et al. compiled a case series of four Italian PAH patients requiring hospitalization due to COVID-19 infection and all patients survived (2020). The research noted that prior to infection some of the patients were described as having New York Heart Association functional class two to three symptoms indicating continued cardiopulmonary compromise. Interestingly, escalation of PAH targeted therapy was not required for any patient (Nuche et al., 2020, Scuri et al., 2020). Sulica et al. (2021) completed a case series of 11 known PAH patients that contracted COVID-19 in the beginning of the pandemic in New York City, COVID-19 AND PAH 9 with a reported 46% mortality rate, which is much higher than any other reported mortality rate for this population. Greater details such as hemodynamics or PAH medications prior to infection were not included and would have been helpful to make larger connections to the PAH community. A national survey of pulmonary hypertension centers conducted by Lee et al. found rate of infection from COVID-19 was the same as the general population, but the mortality was much higher at 30% (2020). Belge et al. completed a survey of 47 international PH centers which found a low incidence of COVID-19 infection, only 70 reported cases, but a case-fatality rate of 19% (2020). The disconnect between the case studies and PH center surveys highlights the need for additional research. Pulmonary Hypertension Centers The largest group of research concerned how the pulmonary hypertension community was navigating managing patients during the pandemic. A patient centered study by Zhou et al. (2020) demonstrated that patients were staying healthy at home, with the largest concern being disruption in medication therapy supply. Lee et al. (2020) and Ryan et al.s (2020) investigation of PAH care highlighted how centers moved from in-person evaluation to virtual visits to bridge the gap required to stay socially distant and still provide care. Tamura et al. (2020) investigated the use of telemedicine with PAH patients and found it was helpful in decreasing anxiety caused by the pandemic lockdowns. Yogeswaran et al. (2020) stated a near 50% reduction in therapy starts occurred due to the COVID-19 lockdown in Germany. The research by Lee et al., Ryan et al., and Yogeswaran et al. (2020) conclude the delays in evaluation and treatment for PAH patients could have very detrimental effects and the utmost care is needed to prevent delay in time to treatment or disruption in therapy. The consensus statements by Lee et al. and Ryan et al. state access to PAH evaluation and therapy must still be maintained by pulmonary COVID-19 AND PAH 10 hypertension centers while maintaining safety restrictions. Therapy access is always a great concern, and this is emphasized by patient, program, and expert apprehension for disruption. Currently, there is no consensus on how COVID-19 affects the PAH patient from a disease standpoint. There are concerns of the worsening of PAH due to COVID-19 infection but there are not large studies to investigate this. Studies do show the result of COVID-19 lockdowns can decrease access to healthcare which is a great concern for the PAH patient. A single center study by Kope et al. (2020) demonstrated patients were less likely to contact their PH center with symptoms of disease worsening due to the COVID-19 pandemic and in some cases, this delay of care precipitated a worsened PAH prognosis. Understanding the careful balance between access to therapy and minimizing risk will be the only path forward for PAH patients during the COVID-19 pandemic. The lack of robust research highlights the need for additional studies to evaluate the significance of the COVID-19 pandemic on the PAH patient population. Due to the novel characteristics of COVID-19 this is an evolving area of study and additional research insights should be attained in the months to come. Theoretical Framework A theoretical framework can help guide a research project and assist in implementation of the research findings. The theoretical framework best suited to guide this project is the PARiHS framework. The PARiHS framework was originally created in 1998 by Kitson, Harvey, and McCormack and has subsequently been refined and developed since that time (Melnyk et al., 2019). According to Kitson et al. (2008), the PARiHS framework allows for evaluation of the strength of the individual variables of evidence, context, and implementation (see appendix). Successful implementation occurs when there is strong evidence, a context or environment that is open to change, and it is easy to integrate change in practice (Melnyk et al., 2019). COVID-19 AND PAH 11 The PARiHS framework encases the current project goal which is understanding how COVID-19 is affecting the pulmonary arterial hypertension (PAH) population at St. Vincent Pulmonary Hypertension Clinic in Indianapolis, Indiana. The framework allows for the evaluation of strength of evidence and environment of susceptibility to decide the success of implementation (Melnyk et al., 2019). Since the project focuses on the results of the new and evolving condition of COVID-19 in a single institution with a culture receptive to research there should be few barriers to implement recommendations. Framework Elements Evidence The PARiHS framework defines evidence as research, clinical experience, patient and family experience, and local data (Melnyk et al., 2019). This is appropriate for the PAH population due to the rarity of the disease and the need for highly trained providers to balance research and experience with shared decision making with patients and families. High levels of evidence increase the likelihood of successful implementation. Context The PARiHS framework characterizes context, or environment, as the culture, leadership, and feedback (Melnyk et al., 2019). A strong environment for the project would include a culture that promotes learning, effective organizational structures, and the use of multiple sources of feedback (Melnyk et al., 2019). A weak project environment would be resistant to change and have poor leadership (Kitson et al., 2008). The dynamic assessment of the environment interconnects with the way the medical community has had to adapt to COVID-19 and how patient outcomes will be measured by multiple data points to determine patient response. COVID-19 AND PAH 12 Implementation Facilitating research into practice successfully requires high quality evidence and a culture receptive to new knowledge. According to Kitson et al., a thorough understanding of the environment and evidence can help tailor the implementation to create success (2008). The environment for the research project is well known to the author, and hopefully will assist in successful implementation of gained knowledge. The complexities of translating research into practice are daunting, especially when dealing with new illnesses or rare diseases. The PARiHS framework is dynamic enough to consider research, clinician and patient experience, leadership, and culture to foster successful implementation of evidence (Melnyk et al., 2019). Conceptual frameworks assist in guiding research to allow for easier implementation of outcomes. The PARiHS framework complements the research on the effects of COVID-19 on the PAH population due to the dynamic approach to evidence and environment. Goals, Objectives, and Expected Outcomes The goal of this study was to quantify the effect of the COVID-19 pandemic on the PAH patient population at the Ascension St. Vincent Pulmonary Hypertension Clinic. The hypothesis is the COVID-19 pandemic negatively affected the health and care of PAH, WHO group 1 patients. The objective was to evaluate for signs of PAH disease worsening as evidenced by worsening functional class, hospitalizations for cardiopulmonary issues, the addition of PAH targeted therapy, or the need for adjustments to diuretics or PAH targeted medicines. This was achieved through a retrospective chart review of the PAH patients of the Ascension St. Vincent Pulmonary Hypertension Clinic completed by this writer. The chart review covered dates March 1, 2019- February 28, 2021. These time frames were compared to see if there was an increase in COVID-19 AND PAH 13 disease worsening because of the COVID-19 pandemic as evidenced by escalation of therapy, additional therapy, increased rate of hospitalization, or death. Project Design and Methods Project Design This project was a program evaluation to increase knowledge on how patients with PAH are affected by the COVID-19 pandemic. The retrospective chart review used the year between March 1, 2019, to February 29, 2020, as a baseline need of medical services and compared it to the March 1, 2020 February 28, 2021, timeframe when the COVID-19 pandemic occurred. Understanding how medical needs and services changed from 2019 to 2021 can help distinguish the impact, if any, on the PAH population. Project Site The project site was the Ascension St. Vincent Pulmonary Hypertension Clinic located in Indianapolis, Indiana. The program was directed by a single PAH-trained cardiologist with the support of full-time and part-time pulmonary hypertension registered nurse coordinators. The site has treated over 170 patients with PAH in the last 8 years. The Ascension St. Vincent Pulmonary Hypertension Clinic was the first program in the state of Indiana to receive accreditation from the Pulmonary Hypertension Association for demonstrating excellence in PAH diagnosis and treatment. All PAH targeted medication therapies are available to patients including oral, inhaled, subcutaneous, and intravenous prostacyclins. The Ascension St. Vincent Pulmonary Hypertension Clinic is also an active site for several PAH research trials. The chosen project site was amenable to a significant catchment of patients to evaluate for the purpose of this retrospective chart review within the chosen time frame. COVID-19 AND PAH 14 Methods A Google spreadsheet was created to track the patients and variables that were studied. The y-axis listed the chart numbers for each patient to allow for patient privacy, data on the patient included age, race, and sex, PAH WHO group 1 subtype, and PAH targeted medication regimen. The x-axis listed the variables being studied, first for the year starting March 2019 and then for the year starting March 2020. Measurement Instruments In order to measure the outcomes of this DNP project a Google spreadsheet to track the variables was used. The variables examined were call with cardiopulmonary concern, start of new PAH targeted therapy, increase in PAH targeted therapy, increase in diuretics, need for urgent appointment (virtual or in-person), testing completed, hospitalization for cardiopulmonary reasons, BNP, NT-proBNP, six-minute walk distance, and New York Heart Association functional class. The 2019 and 2020 variables were compared for each patient. Data Collection Chart reviews were completed by this author. A list of all past and present PAH patients at the Ascension St. Vincent Pulmonary Hypertension Clinic was utilized to identify subjects for the review. Data collection occurred with the use of the electronic medical record utilized by the clinic. Timeline The timeline for this project started with submission to the Institutional Review Board (IRB) and completed with the final report of findings. Submission of the project to the Marian University IRB occurred January 2021. Submission of the project to the Ascension St. Vincent COVID-19 AND PAH 15 IRB occurred February 2021 and was approved April 2021. Completion of data collection occurred in June 2021. The final submission of findings occurred in August 2021. Ethical Considerations The Marian Internal Review Board (IRB) and Ascension St. Vincent IRB approved the proposal prior to data collection. All data collected was aggregated and no personal identifiers were used. No change in care occurred due to the nature of the study. Data Results The purpose of this study was to determine if the COVID-19 pandemic had a negative impact on individuals with PAH due to the increased risk of the disease in individuals with pulmonary and cardiac issues as well as the disruptions to regular medical care as a result of lockdown procedures. Demographics The sample included 64 patients with PAH, WHO group 1, receiving care from the start of March 1, 2019, through February 28, 2021. The sample was 86% female, 14% male. The group was 82.8% white, 15.6% black, and 1.6% Hispanic. Cause of PAH, WHO group 1 was 56.3% idiopathic, 26.6% connective tissue disease, 6.3% drug/toxin induced, 7.8% congenital heart disease, 1.6% portopulmonary, 1.6% heritable. Of the 64 patients, three died during the first year and their data was unable to be matched. Four patients died in the second year, only one from COVID-19 infection. Information on the medication therapy at the beginning of 2019 shows 98.4% were on nitric oxide targeted therapy (64.1% tadalafil, 17.2% sildenafil, 15.6% riociguat, and 1.6% amlodipine), 81.2% of patients were on endothelin receptor antagonists (65.6% macitentan, 14.1% ambrisentan, 1.6% bosentan), and 64.1% of patients were on prostacyclin therapy (34.4% COVID-19 AND PAH 16 selexipag, 20.3% orenitram, 7.8% intravenous or subcutaneous treprostinil, and 1.6% inhaled treprostinil). Results The data obtained from the chart reviews was to track PAH disease worsening. Paired analysis was completed on 61 patients to determine differences between pre-pandemic 2019 and pandemic 2020 markers. These measures are often used in PAH trials as clinical endpoints, such as six-minute walk, NT-proBNP, New York Heart Association (NYHA) functional class, and hospitalization. Six-minute walk distance showed no statistical difference in 15 patients, median walk distance was 1118 ft in 2019 and 1120 ft in 2020 (z=-0.17, p0.87). 60 patients had walks in 2019 compared to 15 in 2020 due to increase in virtual appointments. NT-proBNP data was paired for 30 patients, 2019 median 353, 2020 median 333.5 indicating slight improvement in NT-proBNP in 2020 (z=-2.18, p=0.03). Of note if an individual had more than one NT-proBNP measure, the average was used. Several patients had BNP measurements, but no analysis was performed due to only one patient with BNP in both years. Paired analysis of NYHA functional class was completed using the first documented NYHA class for each patient in the year. Statistics indicated statistically significant worsening from 2019 to 2020 (57 pairs, z=-2.07, p=0.04). In 2019, 17.7% NYHA 1, 53.2% NYHA 2, 22.6% NYHA 3, and 6.5% NYHA 4. In 2020, 16.9% NYHA 1, 44.1% NYHA 2, 35.6% NYHA 3, and 3.4% NYHA 4. The average functional class for both years was NYHA class 2, but there was shifting of patients between classes. Additional information was gathered on the ability to continue to see and manage the patient as evidenced by the number of appointments, calls to the clinic for symptoms, diuretics changes, therapy increase, therapy initiation, and testing. Again, analysis was completed looking COVID-19 AND PAH 17 for statistical difference within each patient. Number of appointments had no statistical difference between 2019 and 2020, with a median of 2 appointments per patient (z=-1.23, p=0.22). Virtual appointments did not occur in 2019, but patients had an average of 1 virtual appointment in 2020. Hospitalizations or emergency room visits had no statistical difference between 2019 and 2020, median of 0 for 61 pairs (z=-0.14, p=0.89). Call-ins to the office with worsening PAH symptoms had no statistical difference between 2019 and 2020, even though there was a median of 1 call-in for 2019 and 0 for 2020 (z=0.16, p=0.87). No statistical difference was found between 2019 and 2020 for the need for increase in diuretics (p=0.52), PAH targeted therapy increase (p=0.99), or PAH targeted therapy add (p=0.44). No statistical difference the number of patients receiving echocardiograms was seen, 57.8% had echocardiograms in 2019 and 55.7% had the test in 2020 (p=0.71). Heart catheterizations did see a statistically significant decrease, with 37.5% of patients having the procedure in 2019 compared to 18% in 2020 (p=0.03). Data Analysis The hypothesis that the COVID-19 pandemic would negatively affect PAH, WHO group 1 patients was incorrect. Paired patient analysis shows minimal statistical difference between pre-pandemic 2019 and pandemic 2020. Patients did not have an increase in hospitalizations or emergency room visits. Six-minute walk distance was unchanged, but there was a significant decrease in the ability to complete the test due to an increase in virtual visits in 2020. Patient stability was also seen by a slight improvement in NT-proBNP marker, but only 30 patients had this test in both years. NYHA functional class did show changes between 2019 and 2020, but the average patient was still NYHA functional class 2. COVID-19 AND PAH 18 Patients were able to have continued access to medical care as evidenced by no change in number of office visits or echocardiograms. The number of heart catheterizations did decrease, most likely due to restricted catheterization laboratory access in the beginning of the pandemic. No statistical difference in the ability to adjust diuretics, add targeted PAH therapy, increase targeted PAH therapy, or have echocardiograms. Also, important to note is only one patient died from COVID-19 during the 2020 year. Discussion The ability to continue to provide access to medical care for the medically complex PAH patient during the COVID-19 pandemic was demonstrated by no statistically significant worsening of the patients health or decreased access to care overall. Decreased access to sixminute walks with the initiation of virtual visits should encourage the PAH community to find other means for assessment. Limitations of this project are due to the novelty of the COVID-19 pandemic and the evolving medical response to balance care of medically fragile populations and risk of viral exposure. This was a small sample size and did not include patients at this center with chronic thromboembolic pulmonary hypertension. Additionally, there are no benchmarks for how many hospitalizations, emergency room visits, or how often patients need medication adjustment. Another limitation is the length of time of the study. As the COVID-19 pandemic continues, a larger length of time prior to and during the pandemic may give a more accurate patient picture to the true affects. Research on at-risk populations is on-going, as is the best course of treatment. As the COVID-19 pandemic continues to evolve, the PAH community will need to be guided by research to provide appropriate and personalized care. The use of virtual visits to provide care COVID-19 AND PAH 19 allows for increased access to medical care, but also limits the ability to notice subtle changes in physical assessment or decreases in six-minute walk distance. Conclusion The COVID-19 pandemic has greatly altered how medical care is delivered and it is necessary to understand the impact on patients living with complex cardiopulmonary conditions due to their increased risk of morbidity and mortality. Research is evolving to understand how individuals with pulmonary arterial hypertension, WHO group 1, are compromised by the COVID-19 virus. Comparison of the PAH patients at the Ascension St. Vincent Pulmonary Hypertension clinic prior to and during the COVID-19 pandemic will provide needed insight into the impact of the virus on this population. This single center study indicates no significant clinical worsening due to the COVID-19 pandemic. COVID-19 AND PAH 20 References Belge, C., Quarck, R., Godinas, L., Montani, D., Escribano Subias, P., Vachiry, J. L., Nashat, H., Pepke-Zaba, J., Humbert, M., & Delcroix, M. (2020). COVID-19 in pulmonary arterial hypertension and chronic thromboembolic pulmonary hypertension: A reference centre survey. ERJ open research, 6(4), 00520-2020. https://doi.org/10.1183/23120541.00520-2020 Gali, N., Humbert, M., Vachiery, J., Gibbs, S., Lang, I., Torbicki, A., Simonneau, G., Peacock, A., Noordegraaf, A. V., Beghetti, M., Ghofrani, A., Gomez Sanchez, M. A., Hansmann, G., Klepetko, A., Lancellotti, P., Matucci, M., McDonagh, T., Pierard, L. A., Trindade, P. T., Zompatori, M., Hoeper, M., ESC Scientific Document Group. (2016). 2015 ESC/ERS Guidelines for the diagnosis and treatment of pulmonary hypertension: The Joint Task Force for the Diagnosis and Treatment of Pulmonary Hypertension of the European Society of Cardiology (ESC) and the European Respiratory Society (ERS): Endorsed by: Association for European Paediatric and Congenital Cardiology (AEPC), International Society for Heart and Lung Transplantation (ISHLT), European Heart Journal, 37(1), 67119. https://doi-org.forward.marian.edu/10.1093/eurheartj/ehv317 Hu, Y., Sun, J., Dai, Z., Deng, H., Li, X., Huang, Q., Wu, Y., Sun, L., & Xu, Y. (2020). Prevalence and severity of corona virus disease 2019 (COVID-19): A systematic review and meta-analysis. Journal of Clinical Virology: The Official Publication of the Pan American Society for Clinical Virology, 127, 104371. https://doi.org/10.1016/j.jcv.2020.104371 COVID-19 AND PAH 21 Kitson, A., Harvey, G., & McCormack, B. (1998). Enabling the implementation of evidence based practice: A conceptual framework. Quality in Health Care: QHC, 7(3), 149158. http://dx.doi.org.forward.marian.edu/10.1136/qshc.7.3.149 Kitson, A. L., Rycroft-Malone, J., Harvey, G., McCormack, B., Seers, K., & Titchen, A. (2008). Evaluating the successful implementation of evidence into practice using the PARiHS framework: Theoretical and practical challenges. Implementation Science: IS, 3, 1. https://doi-org.forward.marian.edu/10.1186/1748-5908-3-1 Klinger, J. R., Elliott, C. G., Levine, D. J., Bossone, E., Duvall, L., Fagan, K., Frantsve-Hawley, J., Kawut, S. M., Ryan, J. J., Rosenzweig, E. B., Sederstrom, N., Steen, V. D., & Badesch, D. B. (2019). Therapy for pulmonary arterial hypertension in adults: Update of the CHEST guideline and expert panel report. Chest, 155(3), 565586. https://doi.org/10.1016/j.chest.2018.11.030 Kope, G., Tyrka, A., Jonas, K., Mago, W., Waligra, M., Stpniewski, J., & Podolec, P. (2020). The coronavirus disease 2019 pandemic prevents patients with pulmonary hypertension from seeking medical help. Polish Heart Journal / Kardiologia Polska, 78(9), 916918. https://doi.org/10.33963/KP.15488 Lee, J. D., Burger, C. D., Delossantos, G. B., Grinnan, D., Ralph, D. D., Rayner, S. G., Ryan, J. J., Safdar, Z., Ventetuolo, C. E., Zamanian, R. T., & Leary, P. J. (2020). A survey-based estimate of COVID-19 incidence and outcomes among patients with PAH or CTEPH and impact on the process of care. Annals of the American Thoracic Society, 10.1513/AnnalsATS.202005-521OC. Advance online publication. https://doi.org/10.1513/AnnalsATS.202005-521OC COVID-19 AND PAH 22 Melnyk, B., Fineout-Overholt, E. (2019). Evidence-based practice in nursing & healthcare: A guide to best practice (4th ed.). Wolters Kluwer Health. Nuche, J., Prez-Olivares, C., Segura de la Cal, T., Jimnez Lpez-Guarch, C., Arribas Ynsaurriaga, F., & Escribano Subas, P. (2020). Clinical course of COVID-19 in pulmonary arterial hypertension patients. Revista Espanola de Cardiologia (English ed.), 73(9), 775778. https://doi.org/10.1016/j.rec.2020.05.015 Pascarella, G., Strumia, A., Piliego, C., Bruno, F., Del Buono, R., Costa, F., Scarlata, S., & Agr, F. E. (2020). COVID-19 diagnosis and management: A comprehensive review. Journal of Internal Medicine, 288(2), 192206. https://doi.org/10.1111/joim.13091 Potus, F., Mai, V., Lebret, M., Malenfant, S., Breton-Gagnon, E., Lajoie, A. C., Boucherat, O., Bonnet, S., & Provencher, S. (2020). Novel insights on the pulmonary vascular consequences of COVID-19. American Journal of Physiology. Lung Cellular and Molecular Physiology, 319(2), L277L288. https://doi.org/10.1152/ajplung.00195.2020 Ryan, J. J., Melendres-Groves, L., Zamanian, R. T., Oudiz, R. J., Chakinala, M., Rosenzweig, E. B., & Gomberg-Maitland, M. (2020). Care of patients with pulmonary arterial hypertension during the coronavirus (COVID-19) pandemic. Pulmonary Circulation, 10(2), 2045894020920153. https://doi.org/10.1177/2045894020920153 Scuri, P., Iacovoni, A., Abete, R., Cereda, A., Grosu, A., & Senni, M. (2020). An unexpected recovery of patients with pulmonary arterial hypertension and SARS-CoV-2 pneumonia: A case series. Pulmonary Circulation, 10(3), 2045894020956581. https://doi.org/10.1177/2045894020956581 Sulica, R., Cefali, F., Motschwiller, C., Fenton, R., Barroso, A., & Sterman, D. (2021). COVID19 in Pulmonary Artery Hypertension (PAH) Patients: Observations from a large PAH COVID-19 AND PAH 23 center in New York City. Diagnostics, 11(1), 128. https://doi.org/10.3390/diagnostics11010128 Tamura, Y., Takeyasu, R., Furukawa, A., Takada, H., Takechi, M., Taniguchi, H., Kawamura, A. (2020). How covid-19 affected the introduction of telemedicine and patient reported outcomes among patients with pulmonary hypertension - A report from a referral center in Japan. Circulation Reports, 2, 526-530. https://dx.doi.org/10.1253/circrep.CR-20-0088 Wang, B., Li, R., Lu, Z., & Huang, Y. (2020). Does comorbidity increase the risk of patients with COVID-19: evidence from meta-analysis. Aging, 12(7), 60496057. https://doi.org/10.18632/aging.103000 Yogeswaran A, Gall H, Tello K, Grunig E, Xanthouli P, Ewert R, et al. (2020). Impact of SARSCoV-2 pandemic on pulmonary hypertension out-patient clinics in Germany: a multicentre study. Pulmonary Circulation, 10, 2045894020941682. https://doi.org/10.1177/2045894020941682 Zheng, Z., Peng, F., Xu, B., Zhao, J., Liu, H., Peng, J., Li, Q., Jiang, C., Zhou, Y., Liu, S., Ye, C., Zhang, P., Xing, Y., Guo, H., & Tang, W. (2020). Risk factors of critical & mortal COVID-19 cases: A systematic literature review and meta-analysis. The Journal of Infection, 81(2), e16e25. https://doi.org/10.1016/j.jinf.2020.04.021 Zhou, H., Zhang, G., Deng, X., Jin, B., Qiu, Q., Yan, M., Wang, X., & Zheng, X. (2020). Understanding the current status of patients with pulmonary hypertension during COVID-19 outbreak: a small-scale national survey from China. Pulmonary Circulation, 10(2), 2045894020924566. https://doi.org/10.1177/2045894020924566 COVID-19 AND PAH 24 Appendix (Kitson et al., 2008)  ...

... Secondary Characteristics of Side Effects Experienced in Pediatric Oncology Patients Receiving the COVID-19 Vaccine Whitney Carroll MS-II1, Seethal A. Jacob MD, MS2, Jennifer A. Belsky DO, MS2 1Marian University College of Osteopathic Medicine 2 Division of Hematology/Oncology, Riley Hospital for Children, Indianapolis, IN Background The Coronavirus Disease 2019 (COVID-19) pandemic led to the swift development of multiple vaccines Common side effects of COVID-19 vaccination include lymphadenopathy and fever in healthy adults Fever and lymphadenopathy are concerning symptoms in children with cancer It is important to distinguish features of reactive lymphadenopathy to the vaccine versus concern for malignant tissue Vaccine hesitancy within the pediatric and adolescent hematology/oncology communities stems in part by a lack of data This study investigated the side effects of the COVID-19 vaccination in children with cancer and Sickle Cell Disease (SCD) Results Lymphadenopathy Results Table 1: Demographics of Children with Cancer and Sickle Cell Disease Characteristic Unique Patients Male Sex Median age years (range) Race White Asian Black Pacific Islander Diagnoses Solid Tumor Leukemia CNS3 Cancer Lymphoma SCD HBSS SCD HBSC Other Cancer Cohort N (%) 122 68 (55.7) SCD Cohort N (%) 37 15 (40.5) 18 (12-30) 17 (13-20) 112 (91.8) 5 (4.1) 4 (3.3) 1 (0.8) 1(2.7) 0 36 (97.3) 0 33 (27.0) 25 (20.1) 25 (20.1) 22 (18.0) 17 (13.9) Retrospective chart review utilizing patient data from Riley Hospital for Children Patients 0-30 years of age with cancer or SCD, diagnosed from January 2017 December 2020 Received any COVID-19 vaccination as of September 1, 2021 3Central Nervous System Characteristic Unique patients with reaction Cancer Cohort N (%) 3 (2.5) SCD Cohort N (%) 3 (8.1) Reported side effects with 8 weeks Fever Chills Myalgia Headache Lymphadenopathy Other Routine Surveillance Imaging 1 (0.82) 1 (0.82) 1 (0.82) 1 (0.82) 1 (0.82) 0 47 (38.5) 0 0 0 0 0 3 (8.1) 11 (29.7) 1 (0.82) 0 Incidental Lymphadenopathy Patient B: Incidentally detected lymphadenopathy on routine CT scan 1 day after 2nd dose of Pfizer 24 (64.9) 12 (32.4) 1 (2.7) Table 2: COVID-19 Vaccine Side Effects in Patients with Cancer and Sickle Cell Disease Methods Patient A: Symptomatic lymphadenopathy detected on PET scan 4 days after 1st dose of Pfizer Discussion and Next Steps The majority of pediatric patients with cancer or SCD who received the COVID-19 vaccination had few side effects Occurrence of side effects were reflective of those seen in the general population Hematologists/oncologists should be aware of the post-vaccine course for patients to appropriately guide patients and families Future studies should continue to track and report side effects of COVID-19 vaccination References and full affiliations available: INDIANA UNIVERSITY SCHOOL OF MEDICINE RILEY HOSPITAL FOR CHILDREN AT IU HEALTH  ...

... A Clinical Conversation on the Progression of Hiatal Hernias to Gastroesophageal Reflux Disease Valerie Schultz, OMS II MU-COM and David Dufeau, PhD MU-COM vschultz384@marian.edu; ddufeau@marian.edu Introduction Hiatal hernias are a very common medical condition and present as the pathologic passage of the foregut through the esophageal hiatus. While most hiatal hernias are asymptomatic, presenting symptoms can easily progress to gastroesophageal reflux disease (GERD). It is important to diagnose and treat GERD to avoid more severe esophageal conditions. Understanding the anatomy of hiatal hernias through 3D visualization analysis can aid medical students in assessing the clinical considerations of hiatal hernias, GERD, and the risk for more severe esophageal conditions. Background Imaging studies (CT and MRI) from the NIH Cancer Imaging Archives were used to create 3D models of a Type I hiatal hernia and relevant anatomy. Software used to create the models included the 3D analytical tools Amira and MeshMixer. Figure 1: 3D-generated anatomical structures of normal anatomy There are four categories of hiatal hernias, each increasing in severity. They are as follows: Type I (most common) Type II Type III Type IV Classification Herniated Organs Sliding Gastroesophageal junction & stomach cardia Paraesophageal Aforementioned & stomach fundus Mixed (sliding & paraesophageal) Aforementioned. Gastroesophageal junction detaches Aforementioned & other Paraesophageal viscera Results Diagnosis - Hiatal Hernia From patient history of symptom severity and frequency Severity: determined by impact on quality of life Frequency: Intermittent = <2 episodes of symptoms / week Frequent = 2+ episodes of symptoms / week Often asymptomatic Symptoms: heartburn, regurgitation, acid reflux, dysphagia, chest pain, etc. Upper endoscopy for diagnosis in certain circumstances Discussion Hiatal hernias are a very common condition involving herniation through the esophageal hiatus. If symptoms occur, they can easily lead to the diagnosis of gastroesophageal reflux disease. There are many levels of treatment available for GERD depending on the severity of symptoms. If GERD goes untreated, it predisposes the patient to developing conditions such as esophagitis, esophageal adenocarcinoma, or Barretts esophagus. Conclusion Figure 2: 3D-generated anatomical representation of a Type I hiatal hernia Progression to Gastroesophageal Reflux Disease (GERD) GERD diagnosis made if frequency or severity of the symptoms become troublesome to the patient or if complications occur. GERD prevalence: 20% of adults Treatment of GERD - Two Approaches Step-Up Therapy Approach = start small, then incrementally increase intensity of treatment 1. Lifestyle and dietary modifications. 2. Histamine 2 receptor antagonist (H2RA) 3. Add proton pump inhibitor (PPI) Step-Down Therapy Approach = start aggressive, then incrementally decrease intensity of treatment 1. Lifestyle and dietary modifications & standard-dose PPI 2. Decrease dosage 3. Discontinue all therapy 3D visualization software allows us better understand the anatomy pertaining to hiatal hernias. In applying this anatomical knowledge to the clinical topic of gastroesophageal reflux disease, a more thorough understanding is achieved because of the foundation of anatomical knowledge. 3D visualizations are a beneficial tool to more completely understand anatomy. Understanding anatomy plays an imperative role in learning about many clinical conditions. Future Developments Figure 3: Coronal CT image interposed with 3D-generated anatomical representation of a Type I hiatal hernia GERD - Risks if Untreated Esophagitis: esophageal mucosa becomes irritated due to the excessive reflux and can eventually undergo necrosis. Esophageal adenocarcinoma: as esophageal cells react to the excessive irritation from the reflux, there is a predisposition for esophageal cells to mutate into cancer cells. Barretts esophagus: metaplasia of the esophageal epithelium due to recurrent irritation, further increasing the risk for esophageal adenocarcinoma. The researchers wish to continue to use 3D anatomical models to aid in clinical comprehension. They plan to promote the use of anatomical models in enriching medical student education. Acknowledgements This project was supported by Marian University College of Osteopathic Medicine 3D Anatomical Research Lab.  ...

... Mechanical stimulation of soft tissue cells regulates osteoblast differentiation and activity through soluble factors Taylor A. Aric 1,2 Anloague, Ross 1,2 Melchior, Jesus 3 Delgado-Calle, Julia M. 1,2 Hum, Jonathan W. 1,2,4 Lowery of Biomedical Science, College of Osteopathic Medicine, Marian University, Indianapolis, Indiana, 46222, USA, 2Bone & Mineral Research Group, Marian University, Indianapolis, Indiana, 46222, USA, 3Department of Physiology & Cell Biology, University of Arkansas for Medical Sciences, Little Rock, Arkansas, 72205, USA, 4Indiana Center for Musculoskeletal Health, School of Medicine, Indiana University, Indianapolis, Indiana, 46202, USA Osteoblast Differentiation Profile Tibiae Explant Differentiation B A B A B 1.5 A: Represents the plate layout of the conditions used for the osteoblast differentiation. These tests were done in duplicate using a 50:50 mix of MSCgo Rapid growth media and conditioned media obtained from our preliminary experiments seen to the left. B: Represents a normal schedule to collect differentiated media tagged with EdU for proliferation studies to be completed. ST MC Po SSDt st- iSm+u In laA jur tLioDn y S In jur y AS LTDM S ++ CI nSjuD rSy In dCu Sc eDdS In duS C cDe Sd 0.0 0.0 A&B: Quantification of these analytes are from the cytometric bead array assay. They are represented as means SEM normalized to Injury Induced Strain; n=3 per condition. *indicates p<0.05 against Injury Induced Strain by paired T-Test Osteoblast Differentiation A B C HSkMCs & C2C12 Myoblasts Preliminary Data Co nt ro lC M S S Po tim TM st ula -I ti nj on ur y 0.5 CM 0.5 * No * 1.0 Enzyme-Linked Immunosorbent Assay (ELISA) results for bone formation marker P1NP (A) and bone resorption marker CTx (B) from neonatal tibiae explants exposed to osteogenic media +/- conditioned media (CM) from dermal fibroblasts subjected to cyclic short duration strain (CSDS) followed by acyclic long duration strain (ALDS) or control. * indicates p<0.05 compared to control conditioned media CM Co nt ro lC M S S Po tim TM st ula -I ti nj on ur y 1.0 IL-6 No IL-8 Fold Change A 1.5 In jur y Conclusions Observing the osteoblast differentiation of W-20-17 cells after being exposed to conditioned media, we see statistically significant increases in proliferation in all three cell lines when comparing our injury induced conditioned media exposed cells to our STM treatment conditioned media exposed cells, with the largest proliferation increase seen in human skeletal myocytes with a 10-fold change. Combining these results with the original data from tibiae explants, which shows a statistically significant increase in bone formation marker P1NP and a statistically significant decrease in bone resorption marker CTx, we are provided key insight into how STM might promote the proliferation of osteoblast cells and eventually leading to the rebuilding of bone. ST M Po S st tim -I ul nj ati ur on y Continuing with this experimental design, we plan to further progress in the work of osteoblast differentiation by obtaining conditioned media through STM stimulation of tissue biopsies using a FlexCell machine. We plan to continue to support the idea that soft tissue manual therapy stimulation of soft tissue cells may influence skeletal homeostasis. If we can continue to prove this hypothesis, it provides hope that STM can one day be used as an alternative treatment of osteoporosis for patients with low bone mass or are high in risk for fractures. ST M Po S st tim -I ul nj ati ur on y Osteoporosis is a disease of low bone mass that places individuals at enhanced risk for fracture, disability, and death. Hospitalizations for osteoporotic fractures exceeds those for heart attack, stroke, and breast cancer combined, and osteoporosis rates are expected to rise significantly in the coming decades. Despite this, there are limited pharmacological treatment options for osteoporosis, particularly for long-term management of this chronic condition, and the drug development pipeline is relatively bereft of new strategies and drug candidates. Consequently, there is an urgent need for new therapeutic strategies for treating osteoporosis. Here, we present a novel line of investigation examining the ability of non-invasive soft tissue manipulation (STM) to exert anabolic effects on the skeleton that may provide therapeutic benefit for individuals with low bone mass. Our rationale is premised on work showing that STM leads to decreased levels of chemokines and pro-inflammatory cytokines (such as Interleukin (IL)-1-alpha, IL-6, IL-8 and CXCL5) known to restrict the differentiation and/or activity of bone-forming osteoblasts. Additionally, STM is associated with increased serum levels of the bone formation marker N-terminal propeptide of type 1 procollagen and decreased serum levels of the bone resorption marker collagen type 1 C-telopeptide in young, healthy women and increased serum P1NP levels in some women with osteoporosis. To advance this work, we hypothesized that STM promotes the differentiation and/or activity of bone-forming osteoblasts and increases bone mass. Consistent with this, we show that conditioned media from primary dermal fibroblasts subjected to STM-like stimulation is bioactive and promotes a) increased osteoprogenitor cell proliferation and differentiation in vitro and b) increased bone formation in an ex vivo bone explant model using neonatal tibiae. Consistent with this, conditioned media from primary skeletal muscle myocyte and satellite cell cultures after STM-like stimulation promotes increased osteoprogenitor cell proliferation in vitro. Collectively, these data support the idea that STM stimulation of soft tissue cells may influence skeletal homeostasis. The experimental application of STM to improving bone mass is novel in its focus, which is significant given the relationship between low bone mass and high fracture risk in patients with osteoporosis and the need for new treatment strategies for this disease. Primary Dermal Fibroblasts Preliminary Data Change Abstract F o ld 1Division 1,2 Hiland, A represents pilot data of HSkMC. B represents pilot data of C2C12 myoblasts. Quantification is by multi-analyte membrane array and is represented by means SEM normalized to control; n=2 per condition. *indicates p<0.05 against control by paired T-Test. A-C represents data obtained using Click-iT Plus EdU Cell Proliferation Kit to quantify proliferation of various cell lines A: Primary Dermal Fibroblasts represented as means SEM normalized to MSCgo Rapid + Injury Induced CM + EdU; n=3 per condition. *indicates p<0.05 against MSCgo Rapid + Injury Induced CM + EdU by paired T-Test. B: C2C12 Myoblasts represented as means SEM normalized to MSCgo Rapid + Injury Induced CM + EdU; n=5 per condition. *indicates p<0.05 against MSCgo Rapid + Injury Induced CM + EdU by paired T-Test. 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