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A STUDENT-DRIVEN INITIATIVE
Volume 1 | Issue 1 | August 2022
Volume 1, Issue 1, August 2022
DISCLAIMER
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Journal of Medical Sciences at NEOMED © 2021
Welcome Note From the Editor-in-Chief
I am thrilled to introduce the first edition of the Journal of
Medical Sciences (JMS) at NEOMED. The JMS is a peer-reviewed,
and multidisciplinary journal run by medicine, graduate, and pharmacy
students at Northeast Ohio Medical University. Fayez Safadi, Ph.D.,
and I created this student-led medical journal with the goal to foster
the research and ideas of University students, faculty members,
consortium hospital trainees, and affiliates, as well as to provide them
with the tools and platform to publish their findings. We are excited
by the outstanding opportunity the JMS provides for students in
leadership (editorial board) and authors in publication. I am excited to
share the work of our outstanding community in the first edition. The
first edition of the JMS is published both online and in print.
To find more information regarding the JMS at NEOMED visit our
website at neomed.edu/journal-of-medical-sciences/.
This project could not have been as successful without the unwavering
support I received from my mentor, Dr. Safadi. Thank you, Dr. Safadi,
for the immense amount of time you’ve dedicated to this endeavor
helping to bring the idea of a student-led medical journal to fruition. I
cannot wait to see what the future holds for the JMS, a future I am
certain will be bright.
Trinity Samson
Editor-in-Chief Journal of Medical Sciences
M.D./ Ph.D. Student at NEOMED
President/Editor-in-Chief:
Faculty and Affiliate Reviewers:
Trinity Samson (COM/COGS)
Khaled Adjerid, Ph.D. (NEOMED)
Brooke Babyak, M.D. (Summa Health)
Marquita Belen, M.D. (NEOMED)
Faculty Advisor:
John Boltri, M.D. (NEOMED)
Fayez Safadi, Ph.D. (NEOMED)
Rachel Bracken, Ph.D. (NEOMED)
David Drevna, M.D. (Mercy Health)
Vice President:
Stacey Gardner-Buckshaw, Ph.D., MPA (NEOMED)
Yoleetah Ilodi, M.D. (NEOMED)
Gabriel Mirhaidari (COM)
Paul Lecat, M.D. (NEOMED)
Andrew McElroy, M.D. (Wayne State University) Joseph
Editors:
McShannic, M.D. (Summa Health)
Sanjay Jinka (COM)
Neel Parekh, MD (Cleveland Clinic Foundation) Priya
Cooper Johnson (COM)
Raman, Ph.D. (NEOMED)
Ain Shajihan (COM)
Fayez Safadi, Ph.D. (NEOMED)
Keval Yerigeri (COM)
Mate Soric, Pharm.D., BCPS, FCCP (NEOMED) Yong Lu,
Ph.D. (NEOMED)
Peer Reviewers:
Katie Bretland (COGS)
Special Thanks:
Alexandra Brooks (COM)
John Langell, M.D., Ph.D., M.P.H., M.B.A.
Hirva Joshi (COM)
Steven Schmidt, Ph.D.
Kelly Kimball (COM)
Maria Schimer, J.D.
Rommel Morales (COM)
Roderick Ingram
Steven Shalenberger (COP)
Lacey Madison, M.B.A., M.Ed
Aditya Sharma (COM)
Jared Slanina
Ernesto Solorzano (COGS)
Scott Rutan
Brian Harrell, M.A.
Ashley King
Compliance Board Members:
Samantha Bliss
Hope Ball, Ph.D. (NEOMED)
Todd Wallwork, MLIS
Stanley Dannemiller, D.M.V (NEOMED)
Simon Robins, MLIS
Yoleetah Ilodi, M.D. (NEOMED)
Steven Kuerbitz, M.D. (Akron Children’s Hospital) Ashley
Mohrman, Ph.D. (Akron Children’s Hospital)
Julie Aultman, Ph.D.
Pratyusha Ghanta
Max Gilliland
Dominique Cox
Gwendolyn Richner
Anjali Agarwal
Geoffrey Sarpong
Meghana Chanamolu
COM College of Medicine / COP College of Pharmacy / COGS College of Graduate Studies
TABLE OF CONTENTS
Original Papers
1 A Histological and Qualitative Analysis of Muscle Spindle Density in the Distal Head of M.
Extensor Longus Digiti Majoris
Arjun Pandya and Tobin Hieronymus
Surveys
6 Telehealth Access of Geriatric Patients During COVID-19: A Provider Team Survey
Sohi Mistry, Siddhartha Singh, Alisha Gupta, Sanjay Jinka, Maahi Mistry, and Mariquita Belen
14 Burnout and Wellness in the College of Medicine at Northeast Ohio Medical University
Arjun Pandya, Akanksha Dadlani, Alexander E. Isla, Amy Adik, and Randon Welton
Reviews
27 Using Ancient Spices to Treat Chronic Diseases: Turmeric’s Potential to Modulate Disease
Pathogenesis in Rheumatoid Arthritis and Inflammatory Bowel Disease
Kelly M. Kimball†, Giovanna Leone †, and Bina Mehta †Joint First Authorship
32 Chemical and Histopathologic Effects of COVID-19 on Virchow’s Triad
Jay P. Natarajan, Ashorne K. Mahenthiran, and Gary W. Lemmon
Case Reports
38 Efficacy of the Glasgow Coma Scale in Determining the Severity of Traumatic Brain Injury
Vihanga Perera, Hiram Imam, and Percival Pangilinan
41 Robotic Assisted Laparoscopic Prostatectomy Post-Prostatic Urethral Lift Implants
Matthew R. DeSanto and Daniel J. Ricchiuti
Commentaries
45 Improving Community Health by Encouraging Remote Office Visits
Rachel Krevh and Eliot Mostow
48 Enhancing Diversity in Medical Education Representation of Cutaneous Disease: VisualDx
Skin-of-Color Atlas
Arjun Pandya, Jay Patel, Sarah Eley, Rachel Krevh, Kishan Pandya, Rahul Mal, Kelly Kimball, and Eliot
Mostow
Letter to the Editor
51 Human Connection Through Wi-Fi: Is it possible?
Sanaa Mansoor
Abstract
52 Cardiac Metabolism in the Disease of Acute Myocardial Infarction
Nikhil Datla, Chwen-Lih Chen, Patrick Kang,Yeong-Renn Chen, Takhar Kasumov, and Sergei Ilchenk
Journal of Medical Sciences at NEOMED
Volume 1, Issue 1, August 2022
A Histological and Qualitative Analysis of Muscle Spindle Density in the Distal Head of M.
Extensor Longus Digiti Majoris
Arjun Pandya, MD, MBA1* and Tobin Hieronymus, PhD1
1.
Northeast Ohio Medical University, College of Medicine, Rootstown, OH, 44272
* Corresponding author
ABSTRACT
Inconspicuous muscles in avian taxa have been previously discussed as vestigial remnants, however, evidence
has shown that such muscles may hold a function in flight. Further investigations into inconspicuous muscles,
such as M. coracotriceps, have demonstrated a muscle spindle density much greater than surrounding
muscles. A higher density of muscle spindles suggests a proprioceptive function during flight. We
investigated another diminutive muscle that may bear a similar function, the distal head of M. extensor longus
digiti majoris (ED). Studies included a qualitative histological analysis comparing the density of muscle
spindles in the ED to the adjacent proximal head of the M. extensor longus digiti majoris (EP) in 15 total
samples excised from Columba livia (rock pigeon) and Gallus gallus (jungle fowl). EP is a functional muscle
that serves as an osteo-pulley for the major digit, which we analyzed the ED against. Based on our qualitative
histological analysis of ED, this muscle does not demonstrate a greater muscle spindle density compared to
the EP. Although further research of this muscle in other Avian species may be necessary to discern its
function, our research demonstrates no evidence of a proprioceptive function.
Keywords: Avian Species, Histology, Muscle Spindles, Flight
that act across a joint in parallel to a larger, longer muscle
(5).
INTRODUCTION
Muscle spindles are intrafusal fibers that function to
provide proprioceptive cues to the central nervous system
for coordination via stretch receptors and provide reflex
activity for motor neurons (1). Higher densities of muscle
spindles are reported in avian muscles presumably to
serve as kinesiological monitors during flight (2).
Muscles with higher spindle density generally function in
fine movements, postural control, and provide important
mechano-sensory feedback to the central nervous system,
indicating a proprioceptive function (3). Muscle spindles
have also been seen in higher densities within avian
skeletal muscles with slow-twitch fibers as opposed to
their fast-twitch counterparts (4). This demonstrates that
muscles with a higher density of muscle spindles are
likely involved in sustained flight as opposed to the fast
twitch muscles involved in takeoff and landing (4). These
kinesiological monitors are often smaller, shorter muscles
An example of a muscle with a proprioceptive function is
the inconspicuous M. coracotriceps (6). This is a minute
muscle that extends between the tendons of M. expansor
secundarium and tendon of M. humerotriceps, and
because of its size, it was previously regarded as vestigial.
Eventually, research and analysis of this muscle
discovered that M. coracotriceps was a slow tonic muscle
with a muscle spindle density significantly greater than
the adjacent, parallel, and functional M. humerotriceps
(7). This discovery demonstrated that small and
undervalued muscles can play an important role during
flight.
Another example of a similar anatomical system in Aves
is the distal head of M. extensor longus digiti majoris
(ED). The ED has a tendinous insertion onto the tendon
of the proximal head of the M. extensor longus digiti
majoris (EP), which is located along the proximal end of
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Pandya & Heironymyus
the major metacarpal (8). This orients the smaller muscle
belly, ED, in parallel with the larger muscle belly, EP
(Fig. 1). The EP functions as an osteo-pulley to guide
muscle tendons and change the direction of pull of the
major digit (8). However, there are limited details
available on the function of the ED and ideas on its
function have been varied among sources with some
researchers regarding it as nonfunctional or rudimentary
(6). Alternatively, the use of ED as a kinesiological
monitor with a dense concentration of muscle spindles is
an additional possibility. There is limited evidence to
support either argument, as there are few details available
describing the function of the muscle.
METHODS
The ED and EP were excised from five frozen Columba
livia (rock pigeon) and four Gallus gallus (jungle fowl).
Four samples of ED and 4 EP were excised from Columba
livia while 3 ED and 4 EP were excised from Gallus
gallus. In total, we excised 7 ED and 8 EP (15 total
samples). Each muscle belly was isolated and left
overnight in 10% formalin, then washed two times in PBS
solution, and finally dehydrated and stored in 70%
ethanol. Next, the muscle bellies were processed in the
Leica ASP300 Enclosed Tissue Processor (Leica
Biosystems, Buffalo Grove, IL) for 24 hours. The
following day, the muscle tissue was embedded in
paraffin blocks and sectioned at 5-7µm thickness using a
microtome and left overnight to dry on microscope slides.
The sections were next stained using Hematoxylin and
Eosin (H&E). The muscle tissues were examined under a
light microscope. Fifteen sections were qualitatively
examined for muscle spindles, 8 ED and 7 EP. The
muscles were qualitatively inspected to examine the
muscles under a light microscope and record if there were
any obvious differences in muscle spindle density
between the EP and the ED in both species. Based on the
results of muscle spindle density in the M. coracotriceps,
6.33 muscle spindles per gram of muscle, we kept our
threshold at six muscle spindles per gram of muscle to
qualify it as a kinesiological monitor. We estimated
muscle mass based on linear measurements. Samples
were approximately 1 cm in length and diameter. Based
on published estimates of muscle density at 1.06g/cm^3
we estimated mass of ED to be 1.06g (12).
Figure 1. Shown is a figure of muscle architecture of the forelimb in
Columbia Livia. The elongate proximal head of the M. extensor longus
digiti majoris (EP), labeled above mELDMp , can be visualized here
with its tendon course into the major digit. The ED, labeled above
mELDMd, is a tiny muscle belly located adjacent to the EP with a
tendinous insertion into the tendon of EP. Copyright 2016. Adapted with
permission (15).
Additionally, the ED is present in only certain avian taxa.
Distal limb reduction is an evolutionary pattern used by
certain birds to eliminate unnecessary weight that is costly
to takeoff, inertia, and landing during flight (9, 10). The
evolutionary pattern depicts that birds that had distal limb
reduction have lost the ED, while those without distal
limb reduction have retained it. Species such as swifts and
members of the “ground bird” assemblage, Cavitaves,
have eliminated this muscle belly (11). These birds also
have a flight style of greater wingbeat frequency.
However, this muscle is preserved in rock pigeons, which
do not exhibit distal limb reduction nor have a pattern of
high wingbeat frequency (11). This evolutionary pattern
raises additional unanswered questions about the function
of ED. To investigate the function of the ED, we
examined the quality of muscle spindle density to
determine if it is a feasible kinesiological monitor during
flight.
RESULTS
Examination of the 8 samples of ED showed no
qualitative difference in muscle spindle density in
comparison to the 7 samples of EP. We did not find
muscle spindles in the density expected of a
kinesiological monitor. Out of the 15 samples examined,
we did not notice a higher density of muscle spindles in
the ED in comparison to the EP. Each muscle belly
demonstrated approximately 0-2 total muscle spindles
(Fig. 2), with consistent results across the ED and EP. The
lack of a large quantitative count of muscle spindles
allowed for quick inspection for each section. This finding
was consistent across both species and there were no
qualitative differences between them.
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Pandya & Heironymyus
is not of use in Aves with distal limb reduction, however,
it may still serve a function in Aves that have retained it.
Figure 2. Pictured is a light microscopic photograph of a muscle spindle
(red arrow) in the proximal head of the M. extensor longus digiti majoris
(EP) in Columba livia (rock pigeon). Stained with hematoxylin and
eosin. 20X objective. Image courtesy of Dr. Tobin Hieronymus.
DISCUSSION
Given the relative muscle spindle density in ED not
exceeding that of EP, this muscle is unlikely to be a
kinesiological monitor. This contrasts with the M.
coracotriceps which showed a total muscle spindle
density of over 14000 spindles per 2300 grams of muscle
(15 times greater than any other muscles in the avian
species) (7). This is a much higher density than the total
0-2 spindles examined in each of 15 samples of ED and
EP, which were in the same order of magnitude in size as
1 gram of M. coracotriceps.
Figure 3. Phylogenetic Tree of the ED retention. Character states drawn
from Livezey and Zusi (2007). Silhouettes from PhyloPic.org :
Hemiprocne mystacea by Jerry Oldenettel (vectorized by T. Michael
Keesey). Passer domesticus by Andrew Butko (modified). All
silhouettes CC BY-NC-SA 3.0. creativecommons.org/licenses/by-ncsa/3.0/. All other silhouettes public domain (11).
Another possible function of ED is based on its
anatomical characteristics and relationship with EP. The
tract of the muscle tendon of the EP is from the forearm
to the major metacarpal in the hand and serves as the
insertion point for the distal head (Fig. 1). The distal head
inserts into the tendon at the proximal head of the major
metacarpal. The EP has a dual function of digit extension
and wrist flexion (8). ED inserts directly in the middle of
the tract of the tendon for EP, therefore, for EP to produce
the action of wrist flexion, ED may be serving a function
to decouple digit extension from EP to wrist extension.
The evolutionary pattern of ED shows both preservation
and loss in different bird species. The presence of this
muscle belly is preserved in species that do not have distal
limb reduction, such as jungle fowl and rock pigeons (11).
This muscle is not retained in species such as perching
birds (Passeriformes), swifts, members of the ground bird
assemblage (Cavitaves), and members of the “metavian”
assemblage (cuckoos, cranes, and allies) some of which
show a pattern of distal limb reduction (Fig. 3) (11,13).
Species that have undergone distal limb reduction have a
flight style which demonstrates high beat wing frequency
(13). There is reasoning that extra weight with vestigial
structures in avian hands may be costly to inertia during
flight (10). It has been previously demonstrated that
higher intensity action of distal wing musculature is
present during takeoff and landing for Aves during flight
(10). During active flight, birds are efficient in
minimizing muscle contractions and saving metabolic
energy (10). A vestigial structure present in many clades
would go against the efficiency of birds in flight.
Therefore, this evolutionary pattern suggests that the ED
A similar example is the quadratus plantae, which
corrects the tendon tract of the flexor digitorum longus in
the feet of humans (Fig. 4). This also is a smaller muscle
which has a tendinous insertion onto a larger muscle’s
tendon in a similar structure (avian hand vs human
foot). Quadratus plantae realigns the tendon of flexor
digitorum longus in human feet and allows it to properly
flex the second through fifth digits in the foot.
The architectural resemblance between ED and EP in
Aves and Quadratus plantae and flexor digitorum longus
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Pandya & Heironymyus
in humans supports the idea that ED may be performing a
similar role as Quadratus plantae.
research does not demonstrate any evidence of a
proprioceptive function. Phylogenetic distribution
suggests this muscle is not of use in Aves with distal limb
reduction, however, it may still hold a function in the
Aves that have retained it. A plausible function of ED is
that it decouples digit extension of the EP to wrist
extension, further supported by a similar anatomical
architecture in the Quadratus plantae in the foot of
humans. Future directions include gathering more
evidence on the characteristics of the ED by expanding
the study across more species of Aves with different flight
patterns, and include testing the anatomical function of
the ED.
Figure 4. Quadratus Plantae
(labeled as 2) inserting on the
tendon of the flexor digitorum
longus, allowing for proper
flexion of digits 2-5. This file
is licensed under the Creative
Commons Attribution-Share
Alike
4.0
International
License. Image courtesy of
Powellle
2020.
https://commons.wikimedia.o
rg/wiki/File:2__quadratus_plantae.png (16)
REFERENCES
There are several limitations to our study. Firstly, we did
not examine the muscle tendons under a light microscope,
as we narrowed our focus on the muscle belly during the
study. Although muscle spindles are the primary organ
involved in proprioception, muscle tendons may contain
Golgi Tendon Organs (GTO) which can also serve as
proprioceptive monitors (14). Additionally, our sample
size was only 15 total samples, and statistical analysis was
not performed (due to the qualitative approach);
additional samples and access to additional species would
have made this study more effective. A quantitative
analysis rather than a qualitative analysis would have
allowed for a more thorough analysis and the inclusion of
a statistical evaluation to definitively prove our findings;
however, a qualitative analysis was performed due to time
constraints and limited access to samples. Despite this,
qualitative research on topics not previously explored,
such as the ED and EP, can still provide meaningful
insight for future studies. Therefore, future steps of this
study include to expand it to multiple species with
different flight patterns, such as perching birds and swifts,
and additionally gathering a larger number of samples. In
addition, testing the function of the muscle based on the
anatomic characteristics mentioned above with
techniques such as in-vitro contracture testing could help
identify the function of the ED.
CONCLUSIONS
Our findings do not demonstrate increased muscle spindle
density in the ED, in comparison to the EP, of Gallus
gallus and Columba livia. Since muscles with
proprioceptive functions typically demonstrate a high
amount of muscle spindles, the ED is not likely to
function as a kinesiological monitor. While we believe
that further quantitative research on the ED among a
wider variety of species may show different results, our
4
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Hulliger M, Durmuller N, , Prochazaka A, Trend P.
Flexible fusimotor control of muscle spindle
feedback during a variety of natural movements.
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James NT, Meek GA,. An electron microscopical
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Physiopedia. 2019. Accessed November 7, 2020.
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Dow PR, Ovalle WK, Nahirney PC. Structure,
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Peck D, Buxton DF, and Nitz A. A comparison of
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George JC, Berger AJ. Avian myology. New York:
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Rosser BW, George JC. An Exceptionally High
Density of Muscle Spindles in a Slow-Tonic Pigeon
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Vazquez, RJ. Functional anatomy of the pigeon hand
(Columba Livia): A muscle stimulation study.
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9.
Maxwell EE, Larsson HC, Osteology and myology of
the wing of the Emu (Dromaius novaehollandiae),
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AUTHOR CONTRIBUTIONS
Conceptualization: AP, TH
Methodology: AP, TH
Investigation: AP, TH
10. Ehrlich P, Dobkin D, Wheye D. Adaptations for
Flight. Published 1988. Accessed November 18,
2021. https://web.stanford.edu/group/stanfordbirds/
text/essays/Adaptations.html.
Supervision: TH
Writing – original draft: AP, TH
Writing – review & editing: AP, TH
11. Livezey BC, Zusi RL. Higher-order phylogeny of
modern birds (Theropoda, Aves: Neornithes) based
on comparative anatomy. II. Analysis and discussion.
Zool J Linn Soc. Jan 2007;149(1):1-95. doi:10.
1111/j.1096-3642.2006.00293.x.
12. Mendez, J. and Keys, A. Density and Composition of
Mammalian Muscle. Metabolism. 1960; 9 (2): 184188.
13. Britannica, The Editors of Encyclopeadia. Ground
cuckoo. Encyclopædia Britannica. Published May
27, 1999. Accessed November 18, 2020. https://
www.britannica.com/animal/ground-cuckoo.
14. Leython Williams PT. Proprioception: Making Sense
of Body Position. Sports. Published June 18, 2018.
Accessed March 29, 2021. https://www.sportshealth.com/sports-injuries/general-injuries/
proprioception-making-sense-body-position
15. Hieronymus TL. Flight feather attachment in rock
pigeons (Columba livia): covert feathers and smooth
muscle coordinate a morphing wing. Journal of
Anatomy. Nov 2016; 229(5): 631-656. doi:10.1111/
joa.12511
16. Powelle (2020). Quadratus plantae. This file is
licensed under the Creative Commons AttributionShare Alike 4.0 International License. https://
commons.wikimedia.org/wiki/File:2-quadratus
plantae.png. Link to license https://creativecommons
.org/licenses/by-sa/4.0/deed.en
ACKNOWLEDGMENTS
I sincerely thank the NEOMED Department of
Anatomy and Histology for their contributions in my
education and truly appreciate their willingness to
always help when needed.
CONFLICTS OF INTEREST
All authors declare no conflicts of interest.
5
Journal of Medical Sciences at NEOMED
Volume 1, Issue 1, August 2022
Telehealth Access of Geriatric Patients During COVID-19: A Provider Team Survey
Sohi Mistry, MD1*, Siddhartha Singh, BS1, Alisha Gupta, MD1, Sanjay Jinka, BS1, Maahi Mistry,
BS1, Mariquita Belen, MD2
1.
2.
Northeast Ohio Medical University, College of Medicine, Rootstown, OH, 44272
Department of Geriatrics, Department of Family and Community Medicine, Northeast Ohio Medical University;
Rootstown, OH, 44272
* Corresponding author
ABSTRACT
The COVID-19 pandemic has prompted the rise in the use of virtual healthcare through Telehealth. The
importance of Telehealth is multi-fold, from communicating with patients virtually to providing care when
in-person services are unavailable. Although this virtual platform has significant benefits, the geriatric
population is underutilizing this resource. Our initial objective was to understand the perceptions of healthcare
providers and their assessment of the comfort level and the utility of telehealth software for geriatric patients.
We surveyed Geriatric specialists, Social Workers, Registered Nurses, and healthcare management team
members regarding their perceptions of the rise and utility of telehealth before and after the pandemic. The
survey was conducted in Northeast Ohio, specifically from Summa Health Akron City Hospital and the
Direction Home Akron Canton Area Agency on Aging and Disabilities. 72.7% of those invited completed
the survey, specifically five (33.3%) were physicians. Additionally, we surveyed participants regarding
patient capability and understanding of telehealth software. A large subset of participants using telehealth
(69.2%) stated that their patients fell between “somewhat uncomfortable” to “completely uncomfortable” in
utilizing telehealth. Regarding their use of blood pressure and glucose monitors, 76.9% felt their patients had
a “medium comfort” level. Finally, 92.3% would find a volunteer service to help train patients and caregivers
in the use of telehealth software and medical devices “extremely helpful.” These data demonstrate a
perception among geriatric providers that patients have difficulties using telehealth. Our goal is to develop a
student-led virtual program to better assist patients and providers in the use of telehealth modalities.
Keywords: Telehealth, COVID-19, Geriatrics, Telemedicine
INTRODUCTION
empowerment of patients to manage chronic conditions
(1).
From house calls to the increased use of larger institutionbased practice, the delivery of healthcare is everchanging. A new and rising mode of delivery— especially
since the onset of COVID-19— is Telehealth, which
allows the doctor to gain virtual connection with patients
while maintaining physical distance. Video conferences,
custom applications, web-based services, and remote
monitoring are all encompassed within the broad
approach. Advantages of incorporating these techniques
include ease of use, improved communication, low cost,
decreased travel time, increased access to care, and
Despite the clear benefits of using this system, there are
difficulties that plague broader use of telehealth, such as
availability, cost, technology dysfunction, trust, and
impersonality (2). A 2012 Health Information National
Trends Survey demonstrated that older male adults with
low socioeconomic status (SES) had decreased
interactions with telehealth. While 30% of patients below
64 years use telehealth, less than 10% of patients above
65 use it (3). In a qualitative interview study conducted in
Manchester, geriatric patients described barriers to
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Mistry, et al
telehealth, including lack of technical competence.
Patients expressed that they find it difficult to remember
and manage technical machinery, such as keyboards and
keypads. Patients also have uncertainty when using the
internet and lack adequate training to use blood pressure
monitors and medical devices on themselves (4,5).
Software database and imported into Microsoft Excel to
compute the appropriate descriptive statistics. Data were
reported as mean (standard deviation), median
(interquartile ratio), and proportions (6).
Although practices can incorporate various forms of
telehealth, there are concerns regarding whether the
geriatric patient population has the capability to use the
software. In this prospective observational survey, we
surveyed geriatricians and healthcare providers working
at Summa Health Akron City Hospital and the Direction
Home Akron Canton Area Agency on Aging and
Disabilities about their current use of telehealth in the
delivery of healthcare before and after the spread of
COVID-19. Further, we want to explore whether
practitioners believe that patients can and have knowledge
of how to use telehealth and medical devices at home or
in independent living facilities. We plan to use data from
this survey to develop a medical student-led virtual
program to aid patients in using medical devices and
telehealth modalities.
General Participant Information (Table 1)
RESULTS
Of 22 potential participants, 16 (72.7%) completed the
survey. Percentages are reported per number of
participants that answered the question. Five (33.3%)
participants were practicing geriatricians at Summa
Health Akron City Hospital. Eleven (21.4%) were social
workers, registered nurses, and healthcare management
team members at the Direction Home Akron Canton Area
Agency on Aging and Disabilities. Eleven (73.3%) of the
participants reported that less than 25% of their patients
resided in nursing homes. Ten (71.4%) of the participants
reported that less than 25% of their patients resided in
independent living facilities. Three participants (20.0%)
reported that less than 25% of their patients resided at
home. Most of the patients resided at home or in
independent living facilities.
METHODS
Telehealth Utility (Table 2)
A 23-item survey was developed with questions regarding
provider background, patient population, telehealth utility
among providers, and perceived level of comfort using
telehealth and medical devices among patients for
providers. The study was sent to healthcare providers to
understand their perception of patient comfort with
telehealth to better understand providers’ need for
software coaching. The questions were in Yes/No,
multiple-choice, and single best-answer type formats,
with space for a final comment at the end of the survey.
The study protocol was approved by the Northeast Ohio
Medical University Institutional Review Board in
Rootstown, Ohio. Informed consent was implied by the
subject’s willingness to complete the survey. All the
responses were anonymously collected to eliminate any
potential bias. The 45-item, English-language, web-based
survey tool (Qualtrics Survey Software, Provo, UT) was
administered online from November 2020 to December
2020.
Nine (60%) of the participants utilized telehealth to
communicate with their patients, of whom five (55.6%)
had utilized telehealth for less than six months. Of the
nine participants, all saw less than 25% of their patients
using telehealth prior to February 2020. After February
2020, three (33.3%) saw less than 25% of their patients
using telehealth and two (22.2%) saw greater than 75% of
their patients using telehealth. Among all participants,
multiple modalities of telehealth were employed. Four
people utilized FaceTime, two utilized Zoom, seven
utilized Doxy, seven utilized telephone, one utilized
Webex, and one utilized Skype.
Four (30.7%) participants reported that less than 25% of
their patients had access to mobile devices at home. Nine
(69.2%) of the participants reported that less than 25% of
their patients had access to tablets at home. Thirteen
participants reported that their patients used blood
pressure monitors, twelve reported that their patients used
blood glucose monitors, and five reported that their
patients also used pulse oximetry machines, weighing
scales, and INR machines at home.
Twenty-two potential participants were identified as
geriatricians from Summa Health Akron City Hospital
and healthcare providers from the Direction Home Akron
Canton Area Agency on Aging and Disabilities, an entity
of the Ohio Department of Health. An e-mail invitation
with an explanation of study protocol and consent was
sent to study participants, with a subsequent e-mail
invitation sent weekly to non-responders for a total of four
weeks. All responses were entered into a Qualtrics Survey
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Respondents
Participant role in practice:
Response
15 (93.8)
Social Worker
4 (26.7)
Nurse Practitioner
0
Physician
5 (33.3)
Health facility management
6 (40)
Description of administration of the practice:
15 (93.8)
Community-based hospital
Healthcare aging facility
5 (33.3)
10 (67.7)
Length in practice:
14 (87.5)
<5 years
3 (21.4)
5-15 years
5 (35.7)
>15 years
6 (42.9)
Perceived percentage of patients residing in a nursing home:
14 (87.5)
<25%
25-50%
11 (73.3)
50-75%
2 (13.3)
>75%
2 (13.3)
0
Perceived percentage of patients residing in an independent living
facility:
14 (87.5)
<25%
10 (71.4)
25-50%
2 (14.3)
50-75%
2 (14.3)
>75%
0
Perceived percentage of patients residing at home:
15 (93.8)
<25%
3 (20)
25-50%
3 (20)
50-75%
4 (26.7)
>75%
5 33.3)
Table 1: General participant information
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Respondents
Participants who use TeleHealth:
Response
15 (93.8)
Length of TeleHealth utility:
9 (60)
<6 months
5 (55.6)
6-12 months
4 (44.4)
1-5 years
0
>5 years
0
Patients seen using TeleHealth prior to February 2020:
<25%
9 (100)
Patients seen using TeleHealth after February 2020:
<25%
3 (33.3)
25-50%
3 (33.3)
50-75%
1 (11.1)
>75%
2 (22.2)
Method of TeleHealth employed (check all):
14 (87.5)
FaceTime
4
Zoom
2
Doxy.me
7
Telephone
7
Webex
1
Skype
1
Perceived percentage of patients with access to mobile devices at
home:
13 (81.3)
<25%
4 (30.8)
25-50%
4 (30.8)
50-75%
4 (30.8)
>75%
1 (7.7)
Perceived percentage of patients with access to tablets at home:
13 (81.3)
<25%
25-50%
9 (69.2)
50-75%
4 (30.8)
>75%
0
0
Devices patients use to monitor health at home:
13 (81.3)
Blood pressure monitors
13
Glucose monitors
12
Other: Pulse oximetry monitors, scales, INR machines
5
Table 2: TeleHealth Utility
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Telehealth Comfort (Table 3)
Respondents indicated highest utility for a program
providing education for services such as Facetime, Zoom,
Doxy, Telephone, Email, and Skype. We identified
another possible intervention through provision of
Telehealth-capable devices; 61% of providers reported
50% or less of their patient base had access to mobile
devices at home and 100% of the providers indicated that
less than half their patient base had access to tablets.
Participants were also asked to assess their patients’
comfort level with utilizing telehealth on a Likert scale of
1-5 (1= very uncomfortable, 5=very comfortable). Three
(23.1%) perceived their patients to be at a 1 and zero
perceived their patients to be at a 5. In asking how useful
the participants thought a volunteer service would be in
helping patients utilize telehealth on a Likert scale of 1 to
5 (1=very un-useful, 5=very useful), one (7.7%)
perceived the service to be a 1 and 10 (76.9%) perceived
the service to be a 5.
This work extends the findings of previous literature in
identifying problematic areas for geriatric patients with
respect to accessing telehealth treatment, particularly in
the greater Akron area. In a review by Bashshur et al. in
2014., empirical evidence was identified supporting the
use of telehealth in chronic disease management for
reducing hospital admissions, length of hospital stays,
emergency department visits, and even mortality (7). This
comes alongside acknowledgement of interventions
showing that technology-based healthcare management
can be implemented with notable results in older adults,
especially as they often suffer from chronic disease (8, 9).
Participants were then asked to evaluate their patients’
comfort level using devices to monitor health at home on
a Likert scale of 1 to 5 (1=very uncomfortable, 5=very
comfortable). Two (15.4%) perceived their patients as a 4
and zero perceived their patients as a 5. In asking how
helpful a volunteer service would be to aid patients and/or
caregivers in utilizing telehealth on a Likert scale of 1 to
5 (1=very unhelpful, 5= very helpful) nine (69.2%)
believed their patients were at a 5.
Despite successful applications of telehealth in broader
populations, geriatric patients face increased barriers to
adoption, such as access to appropriate devices and low
technological literacy. Sivakumar et al. note that
successful deployment of interventions in India had to
overcome low digital literacy, sensory issues, and
cognitive impairment in administering geriatric
telepsychiatry (10). Parker et al. attributed low patient
response via telehealth to a multitude of factors: lower
intrinsic motivation, health literacy, and efforts to engage
patients in newer forms of health technologies by the
provider (11). Due to the varied factors that contribute to
the effectiveness of telehealth, it may be difficult for a
geriatrician to transition employing newer technologies to
reach patients.
Finally, we asked the participants which modes of
telehealth they would find a student-led volunteer
program useful for. Four (28.6%) reported they could use
help in teaching patients how to use Zoom, eight for
FaceTime, four for Facebook Messenger, seven for Doxy,
eleven for telephone, six for e-mail, and four for other
services such as Skype.
DISCUSSION
Our results emphasize the challenges faced by health care
providers to reach geriatric patients, especially during a
pandemic, when the need to maintain physical distance
between the practitioner and patient is paramount. Table
2 demonstrates that healthcare practitioners are
incorporating telehealth services to connect with their
patients. In fact, most responding participants reported
seeing less than 25% of their patients via telehealth prior
to February 2020, then transitioning to over two-thirds of
participants seeing more than 25% of their patients via
telehealth after the beginning of the COVID-19
pandemic. The disparities in providing telehealth access
may be demonstrated through the patient demographics of
the geriatric providers: most patients live in private
residences and have limited access to the support a
nursing home or independent living facility may provide.
This is underscored as most survey participants indicated
that their patients’ perceived comfort level using
telehealth and telemonitoring devices was low.
Consequently, many responders requested a student-led
volunteer program, with 92% of participants estimating
outcome of an intervention as beneficial to their practice.
Major strengths of our study include the fact that
participants involved with the survey were all from the
local community, focusing on the needs of the nearby
geriatric population. Additionally, the high response rate
(73%) of potential participants stresses the importance of
the content of the survey to the participants. This is further
supported by ardent request for student-led volunteer
programs to target health literacy across a variety of
disciplines, ranging from geriatric physicians at Summa
Akron City Hospital to the staff at Direction Home Akron
Canton Area Agency on Aging and Disabilities, including
social workers, registered nurses, and healthcare
providers.
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Perceived patient comfort using
uncomfortable, 5=very comfortable):
TeleHealth
(1=very
13 (81.3)
1
3 (23.1)
2
6 (46.2)
3
3 (23.1)
4
1 (7.7)
5
0
Perceived patient aid in use of a mobile TeleHealth volunteer
service (1=very un-useful, 5=very useful):
13 (81.3)
1
1 (7.7)
2
0
3
0
4
2 (15.4)
5
10 (76.9)
Perceived patient comfort using devices to monitor health at home
(1=very uncomfortable, 5=very comfortable):
13 (81.3)
1
2
0
3
1 (7.7)
4
10 (76.9)
5
2 (15.4)
0
Perceived patient aid in use of a medical health device volunteer
service (1=very un-useful, 5=very useful):
13 (81.3)
1
0
2
0
3
1 (7.7)
4
3 (23.1)
5
9 (69.2)
Methods of TeleHealth participants suggest a volunteer service for:
13 (81.3)
Zoom
FaceTime
4
Facebook Messenger
8
Doxy.me
4
Telephone
7
E-mail
11
Other: Skype, Doximity
6
4
Table 3: TeleHealth Comfort
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There are also limitations to this study. Even though this
survey was designed with the interests of pertinent
stakeholders in mind, we identified potential participants
from only two local institutions, resulting in a low sample
size. In addition, the number of participants was limited
to those interested in seeing the implementation of a
program to aid their patients; this is indicative of selfselection bias. Finally, close-ended questioning can lead
to loss of internal validity and objectivity. To address
these limitations, we incorporated options to provide
type-in-responses.
The results of the study were all estimates of patient
comfort by providers. Further studies may incorporate
patient feedback on utilizing telehealth at home. We are
utilizing this data to develop a student-led virtual program
to aid patients with using medical devices and assistance
with Telehealth. Student volunteers will be trained to
effectively communicate, educate, and formulate guides
to aid the geriatric population in better understanding the
technology necessary to use telehealth. Students will be
able to answer questions related to using the software as
well as home medical devices. This intervention aims to
address the gaps noted by the geriatric providers. We hope
to facilitate improved patient-provider communication
and improve adherence to medical treatment and therapy.
Further studies could determine the impact of this
volunteer-led program in improving telehealth access and
utilization.
2.
3.
4.
Neter E, Brainin E. eHealth literacy: extending the
digital divide to the realm of health information. J
Med Internet Res. 2012;14(1): e19. doi:10.2196/jmir.
1619
6.
Mistry S, Alaber O, Chandar AK, et al. A survey of
physician training and credentialing in endoscopic
submucosal dissection in the United States. Surg
Endosc. 2022 May; 36 (5): 2794-2800. doi:
10.1007/s00464-021-08565-0.
7.
Bashshur RL, Shannon GW, Smith BR, et al. The
empirical foundations of telemedicine interventions
for chronic disease management. Telemed J E
Health.2014;20(9):769-800. doi:10.1089/tmj.2014.
9981
8.
Batsis JA, Petersen CL, Clark MM, et al. Feasibility
and acceptability of a technology-based, rural weight
management intervention in older adults with
obesity. BMC Geriatr. 2021;21(1):44. doi:10.1186/
s12877-020-01978-x
9.
Rasheedy D, Mohamed HE, Saber HG, Hassanin HI.
Usability of a self-administered geriatric assessment
mHealth: Cross-sectional study in a geriatric clinic.
Geriatr
Gerontol
Int.
2021;21(2):222-228.
doi:10.1111/ggi.14122
10. Sivakumar PT, Mukku SSR, Kar N, et al. Geriatric
Telepsychiatry: Promoting Access to Geriatric
Mental Health Care Beyond the Physical Barriers.
Indian J Psychol Med. 2020;42(5 Suppl):41S-46S.
doi:10.1177/0253717620958380
REFERENCES
1.
5.
Kruse CS, Krowski N, Rodriguez B, Tran L, Vela J,
Brooks M. Telehealth and patient satisfaction: a
systematic review and narrative analysis. BMJ Open.
2017;7(8). doi:10.1136/bmjopen-2017-016242
11. Parker S, Prince A, Thomas L, et al. Electronic,
mobile and telehealth tools for vulnerable patients
with chronic disease: a systematic review and realist
synthesis. BMJ Open. 2018;8(8): e019192.
doi:10.1136/bmjopen-2017-019192
Bull TP, Dewar AR, Malvey DM, Szalma JL.
Considerations for the Telehealth Systems of
Tomorrow: An Analysis of Student Perceptions of
Telehealth Technologies. JMIR Med Educ.
2016;2(2): e11. doi:10.2196/mededu.5392
ACKNOWLEDGMENTS
Sanders C, Rogers A, Bowen R et al. Exploring
barriers to participation and adoption of telehealth
and telecare within the Whole System Demonstrator
trial: a qualitative study. BMC Health Services
Research. 2012; 12(1): 220. doi:10.1186/1472-696312-220
Dr Mariquita Belen, Department of Family and
Community Medicine
Kontos E, Blake KD, Chou WY, Prestin A.
Predictors of eHealth usage: insights on the digital
divide from the Health Information National Trends
Survey 2012. J Med Internet Res. 2014;16(7): e172.
doi:10.2196/jmir.3117
AUTHOR CONTRIBUTIONS
CONFLICTS OF INTEREST
All authors declare no conflicts of interest.
Conceptualization: SM
Methodology: SM
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Mistry, et al
Investigation: SM, SS
Visualization: SM, SS, SJ, AG, MM
Project administration: M, SS, SJ, AG, MM
Supervision: MB
Writing – original draft: SM, SS, SJ, AG, MM
Writing – review & editing: SM, SS, SJ, AG
13
Journal of Medical Sciences at NEOMED
Volume 1, Issue 1, August 2022
Burnout and Wellness in the College of Medicine at Northeast Ohio Medical University
Arjun Pandya, MD, MBA1*, Akanksha Dadlani, MD, MPH1, Alexander E. Isla, MD1, Amy Adik,
BS1, Randon Welton, MD1,2
1.
2.
Northeast Ohio Medical University, College of Medicine, Rootstown, OH, 44272
Department of Psychiatry, Northeast Ohio Medical University, Rootstown, OH, 44272
* Corresponding author
ABSTRACT
Burnout is a syndrome of professional distress defined by symptoms of emotional exhaustion,
depersonalization, and a sense of reduced personal accomplishment. Previous surveys (Wellness Surveys) at
Northeast Ohio Medical University (NEOMED) seemed to have demonstrated low scores in the wellness
categories. As such, we sought to investigate further the frequency and factors of medical student burnout
symptoms, the quality of medical student wellness, and contributing stressors at NEOMED. Over three
weeks, an anonymous 8-question survey was sent out via e-mail to all NEOMED College of Medicine
students. This survey included a novel scale created by the authors to measure burnout, wellness, and
contributing stressors. The survey was done on Qualtrics SM Survey software and was statistically analyzed
by class using Microsoft Excel. The survey was completed by 166 students (participation = 28%). Results
demonstrated statistically significant differences in burnout and multiple components of wellness when
stratified by class. Burnout and suboptimal wellness were most severe in preclinical (M1-M2) years. Groups
rating higher frequencies of burnout also rated lower qualities of wellness. Nearly 50% of all respondents feel
the challenge of medical school was more difficult than expected. At NEOMED, peak burnout frequencies
and suboptimal wellness ratings are in the preclinical years. Groups that scored higher frequencies of burnout
also scored poorer on wellness ratings. A systematic approach dedicated to promoting wellness at NEOMED
may lead to lower frequencies of burnout.
Keywords: Burnout, Wellness, Education, Mental Health
rates of burnout may threaten to compromise
compassionate and effective healthcare. Thus, burnout is
an issue that requires close investigation to reveal where
and how safeguards may be implemented at all levels. For
medical providers, burnout may begin during the first
years of medical training (5). As such, it is important to
consider intervention at this stage.
INTRODUCTION
Burnout is a syndrome of professional distress defined by
symptoms
including
emotional
exhaustion,
depersonalization, and a reduced sense of personal
accomplishment (1,2). This syndrome is highly prevalent
in the medical field, affecting many physicians and
physician trainees in the United States. Emerging research
shows that nearly 50% of medical students, residents, and
attending physicians in the US have experienced burnout;
these rates are significantly higher than those observed in
the general US population (2). Burnout has been linked to
increased risk of anxiety, depression, and medical error
(3,4). In a profession dedicated to caring for others, high
Medical student wellness is a topic of increasing
discussion nationwide. Wellness encompasses mental,
physical, and emotional health (6). It has been shown to
be a quality indicator that may inversely correlate to levels
of burnout (6). The Liaison Committee for Medical
Education (LCME) aids in the oversight of allopathic
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medical student education. The LCME Standard 12.3
requires that “A medical school has in place an effective
system of personal counseling for its medical students that
includes programs to promote their well-being and to
facilitate their adjustment to the physical and emotional
demands of medical education” (7). Specialty training
following medical school is largely governed by the
Accreditation Council for Graduate Medical Education
(ACGME). ACGME has a growing recognition that
“Psychological, emotional, and physical well-being are
critical in the development of the competent, caring, and
resilient physician and require proactive attention to life
inside and outside of medicine. Well-being requires that
physicians retain the joy in medicine while managing
their real-life stresses” (8). Every residency seeking
ACGME accreditation must have “policies and programs
that encourage optimal resident and faculty member wellbeing” (8).
The global pandemic of 2020 undoubtedly added
considerable burdens to already stressed medical
providers (11). Individuals throughout the world faced
issues of fear, grief, and loss during a time of decreased
social support. Medical professionals were not spared
these personal struggles while caring for suffering
individuals. All of these challenged individual providers’
senses of wellness and pushed toward ever higher and
earlier rates of burnout (11). For medical students at
NEOMED, there were unprecedented changes in training,
evaluations, and applications for post-graduate training.
With increasing literature throughout the medical field
regarding burnout and wellness, we sought to explore if
burnout and suboptimal wellness are issues at NEOMED.
To train high-quality patient care-centered physicians, we
felt it would be advantageous to examine our environment
and determine points of quality improvement. We believe
that identifying of these possible issues can lead to
targeted improvement projects and additional resource
acquisition within NEOMED that can help improve
student experience and wellness and ultimately prepare
better physicians. We hypothesize that preclinical
students will have the highest rates of burnout and that
there will be a statistically significant difference between
burnout symptom frequency and wellness quality
depending on students’ class year.
The individual components of wellness (mental health,
physical health, and emotional health) can significantly
contribute to medical students’ quality of life, academic
performance, and clinical performance (9). For example,
inadequate sleep, one of the physical health
subcomponents of wellness, can contribute to medical
error, depreciating test results, and cognitive decline (9).
Within the wellness subcomponent - emotional health, a
strong sense of purpose has been linked to longer, happier,
and more fulfilled lives (10). During postgraduate medical
training concerns over the worsening of provider mental
health led the ACGME to mandate screening for anxiety,
depression, and substance abuse disorders. Assessing
components of burnout and wellness as a means of
developing strategies to reduce burnout and promote
wellness should be a standard part of modern medical
training.
METHODS
An anonymous 8-question survey was sent out via e-mail
to all NEOMED College of Medicine students over a 3week span. This survey included a novel scale created by
the authors to measure burnout, wellness, and
contributing stressors. The survey was done on Qualtrics
SM Survey software and was statistically analyzed using
Microsoft Excel. Data were analyzed by class. The eight
questions administered through the survey are discussed
below.
Based in Rootstown, Ohio, NEOMED has a mission to
train patient care-centered physicians while aiming to be
a national leader in community-centered medicine. Over
the last two years, NEOMED has begun a series of
dramatic changes in its curriculum. Student feedback had
led to a complete overhaul of the NEOMED curriculum
deemphasizing lectures and markedly increasing
interactive teaching modalities, especially Peer
Instruction. NEOMED has also begun devoting more time
and resources to wellness-related topics and has created
several initiatives to improve student wellness such as
opening a Center for Student Wellness and Counseling
Services, offering wellness days for first-year students,
and integrating wellness exercises and discussions in the
curriculum. Despite these initiatives, concerns exist about
the rates of burnout and wellness among the NEOMED
medical student population.
Our first objective is to identify burnout and related
stressors at NEOMED by determining: 1. the frequency
of burnout symptoms among NEOMED College of
Medicine students, stratified by class (M1, M2, M3, M4)
2. The rating of wellness among NEOMED College of
Medicine students, stratified by class (M1, M2, M3, M4).
3. Major stressors among NEOMED College of Medicine
students 4. Expected challenges of medical school at
NEOMED versus experienced challenges in medical
school at NEOMED and, 5. Targeted improvement
strategies based on identified areas within wellness and
burnout subcomponents and at which specific stage of
medical training they are occurring in. Our second
objective is to measure the degree of burnout symptoms
and the quality of wellness stratified by demographic
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information to determine if any specific group of people
is not achieving wellness and how we may help them.
The sixth question sought to explore additional factors
that may contribute to burnout. To accomplish this, we
composed a list of nine potential stressors: finances,
COVID-19, political climate, family issues, academic
performance, relationships, health concerns, geographic
environment, and discrimination. Participants were asked
to select the three that were most contributory stressors at
the time of participation. The final two questions were
extended responses to allow further comments on the
survey and potential areas of improvement for NEOMED.
The estimated completion time was approximately 10
minutes.
*M1 denotes first-year medical student; M2 denotes
second-year medical student etc. It is of note that M1-M2
spend most of their time doing preclinical work
(classwork and lectures), and M3-M4 spend most of their
time in the clinical setting with patients.
Data Collection
In order to conduct our primary and secondary aims, we
created an online survey. To investigate burnout, we
proposed measuring three categories of our own
conception that we believe represent the dimensions of
burnout: detached, drained, and defeated. We elected to
use the novel terms detached, drained and defeated, as we
felt these more sufficiently captured the feelings medical
students at NEOMED would potentially experience in
response to a year in medical school during the COVID19 pandemic. These terms were defined within the survey
(Fig. 1A). To investigate wellness, we separated it into
three categories proposed by Wallace et al.: mental,
physical, and emotional health (6). Likewise, as for
burnout, we proposed to measure three subcategories of
our conception (emotional, mental, physical health) for
each larger category proposed by Wallace (9
subcategories total).
After the survey, participants were asked to share limited
demographic information, including race, gender, and
class year. Completing this section was optional and did
not affect prior responses in the overall analyses. Lastly,
this project meets the criteria for a Quality Improvement
project and did not require IRB approval.
Participation
The survey was distributed to all 599 students in the
NEOMED College of Medicine. Participation was
optional and anonymous (n =166; participation = 28%).
The study was single blinded as the participants were
aware of researchers, study goals, and the survey group
they were in, and researchers were not aware of individual
subject identities. The survey was open for three weeks
from, January 18, 2021 to February 8, 2021, and was
administered via Qualtrics SM Survey software. The
timeframe of three weeks was selected to give participants
ample time to take the survey and for the researchers to
have the ability to address results promptly. The survey
was emailed to all actively enrolled NEOMED College of
Medicine students, with a weekly reminder email each of
the following two weeks. The email also contained an
information sheet that detailed the purpose of the survey,
participation as being anonymous and optional, researcher
contact information, the definitions of terms, and
instructions for participation. No compensation was
provided for survey completion.
The questionnaire included eight questions and was
administered in January 2021. Question 1 asked
participants to provide separate ratings of the frequency
they experienced the three components of burnout over
the past two weeks (Fig. 1A). The two-week time frame
was selected to provide insight into symptoms at that
specific time range during the beginning of a medical
school semester. Of the questions asked, Questions 2
through 4 asked participants to rate their satisfaction with
each of the nine subcategories of wellness (Fig. 1B). The
fifth question asked participants to compare the level of
challenge they have experienced in medical school to
what they expected before beginning (Fig. 1C). These
first five survey questions were rated on scales of one to
five, though the scales were distinct for each question (see
Fig. 1). Herein, we refer to answers pertaining to burnout
as frequency ratings, answers pertaining to wellness as
satisfaction ratings, and answers pertaining to
experienced versus expected challenge of medical school
as disparity ratings. For this manuscript, students who
reported frequency ratings of 4 or 5 for burnout metrics
were considered at risk of burnout or experiencing
burnout. Students who reported satisfaction ratings of 1 or
2 for wellness metrics were considered to have
suboptimal wellness.
Data analysis
The ordinal data collected for the first five survey
questions was treated as numeric for the sake of
comparative statistical analysis. We believe that this
assumption is justified as the perceived difference
between answer choices in the survey should be equal
(e.g., the difference between very rarely and rarely should
be equal to the difference between rarely and
occasionally). Comparative statistical analyses were
conducted within Microsoft Excel using a two-tailed,
unpaired, two-sample t-test that assumed equal variances
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and single factor analysis of variance tests as appropriate.
A threshold of p ≤ 0.05 was used to determine statistical
significance. When single factor ANOVA testing
revealed statistical significance, post-hoc two-tailed ttesting was conducted to determine which classes
specifically differed from one another.
A
B
C
Figure 1. Sample survey scales and verbiage used in assessing numerical ratings. A) Novel scale created by
authors to rate burnout based on frequency of feeling Detached, Drained, or Defeated over the past 2 weeks.
B) Novel scale created by authors to rate overall quality of wellness determined by the 3 categories, Mental
Health, Emotional Health, and Physical Health, and 9 subcategories of wellness. C) Question used to determine
experienced versus expected challenge in medical school.
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3.68 (Table 2B). Satisfaction with work/life balance was
lowest among M2 participants, with a mean satisfaction
rating of 2.47. The percentages of students reporting a
suboptimal work/life balance in each class were 43.2% of
M1s, 58.3% of M2s, 36.1% of M3s, and 16.2% of M4s.
The ability to make and meet life goals was highest among
M4 participants, with a mean satisfaction rating of 3.69
(Table 2C). The ability to make and meet life goals was
lowest among M2 participants, with a mean satisfaction
rating of 2.82. The percentages of students reporting a
suboptimal ability to make and meet life goals in each
class were 41.2% of M1s, 44.4% of M2s, 34.0% of M3s,
and 15.7% of M4s.
RESULTS
Respondents included 51 M1s, 36 M2s, 46 M3s, and 32
M4s. There were no significant findings between groups
when stratified by race and gender.
Burnout
Survey respondent data about our three categories of
burnout is summarized in Table 1. The feeling of being
drained was most frequently experienced among M2
participants, with a mean frequency rating of 3.83 (Table
1A). Being drained was least frequently experienced
among M4 participants, with a mean frequency rating of
3.00. The percentages of students experiencing/at risk of
feeling drained in each class were 56.9% of M1s, 63.9%
of M2s, 44.7% of M3s, and 38.7% of M4s. Feelings of
detachment were most frequently experienced among M1
and M2 participants, with mean frequency ratings of 3.14
for both classes (Table 1B). Feelings of detachment were
least frequently experienced among M4 participants, with
a mean frequency rating of 2.31. The percentages of
students experiencing/at risk of detachment in each class
were 37.2% of M1s, 41.7% of M2s, 17.1% of M3s, and
18.8% of M4s. The feeling of defeated was most
frequently experienced among M2 participants, with a
mean frequency rating of 3.25 (Table 1C). The feeling of
being defeated was least frequently experienced among
M4 participants, with a mean frequency rating of 2.39.
The percentages of students experiencing/at risk of
feeling defeated in each class were 35.2% of M1s, 55.6%
of M2s, 21.3% of M3s, and 16.2% of M4s.
ANOVA testing revealed statistically significant
differences between mean group satisfaction ratings for
all three categories of mental health: overall mood
(p=0.01), satisfaction with work/life balance (p<0.001),
and the ability to make and meet life goals (p=0.01). Posthoc two-tailed t testing revealed the following pairs of
individual classes to differ significantly for overall mood:
M1 and M4, M2 and M4, M3 and M4; satisfaction with
work/life balance: M1 and M4, M2 and M3, M3 and M4;
ability to make and meet life goals: M1 and M4, M2 and
M4, M3 and M4.
Components of Wellness: Emotional Health
Survey respondent data pertaining to our three categories
of emotional health are summarized in Table 3. Quality of
relationships was highest among M4 participants, with a
mean satisfaction rating of 3.75 (Table 3A). Quality of
relationships was lowest among M1 participants, with a
mean satisfaction rating of 3.08. The percentages of
students reporting a suboptimal quality of relationships in
each class were 41.2% of M1s, 33.3% of M2s, 25.6% of
M3s, and 18.8% of M4s. The ability to take time for
oneself was highest among M4 participants, with a mean
satisfaction rating of 3.84 (Table 3B). The ability to take
time for oneself was lowest among M2 participants, with
a mean satisfaction rating of 2.67. The percentages of
students reporting a suboptimal ability to take time for
oneself in each class were 41.1% of M1s, 52.8% of M2s,
31.9% of M3s, and 9.40% of M4s. Satisfaction with a
sense of purpose was highest among M4 participants, with
a mean satisfaction rating of 3.78 (Table 3C). Satisfaction
with a sense of purpose was lowest among M2
participants, with a mean satisfaction rating of 3.11. The
percentages of students reporting a suboptimal sense of
purpose in each class were 39.2% of M1s, 36.1% of M2s,
25.5% of M3s, and 15.7% of M4s.
ANOVA testing revealed statistically significant
differences between mean group frequency ratings for all
three categories of burnout: drained (p=0.004), detached
(p=0.006), and defeated (p=0.03). Two-tailed t testing
revealed the following pairs of individual classes to differ
significantly for feelings of detachment: M1 and M3, M1
and M4, M2 and M3, M2 and M4; feeling drained: M1
and M3, M1 and M4, M2 and M4; feeling defeated: M2
and M3, M2 and M4.
Components of Wellness: Mental Health
Survey respondent data pertaining to our mental health
categories are summarized in Table 2. The overall mood
was highest among M4 participants, with a mean
satisfaction rating of 3.72 (Table 2A). The overall mood
was lowest among M2 participants, with a mean
satisfaction rating of 2.86. The percentages of students
reporting a suboptimal overall mood in each class were
33.3% of M1s, 41.7% of M2s, 31.9% of M3s, and 15.7%
of M4s. Satisfaction with work/life balance was highest
among M4 participants, with a mean satisfaction rating of
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ANOVA testing revealed a statistically significant
difference between mean group satisfaction ratings for the
ability to take time for oneself (p<0.001). The differences
between mean group satisfaction ratings for quality of
relationships (p=0.13) and sense of purpose (p=0.057)
were not statistically significant. Post-hoc two-tailed t
testing revealed the following pairs of individual classes
to differ significantly for ability to take time for oneself:
M1 and M4, M2 and M4, M3 and M4.
A
Number
Mean
of
Rating Responses
Drained (%)
Class
1
2
3
4
5
M1
0.0
9.8
33.3
21.6
35.3
3.82
51
M2
8.3
5.6
22.2
22.2
41.7
3.83
36
M3
2.1
17.0
36.2
29.8
14.9
3.38
47
M4
16.1
19.4
25.8
25.8
12.9
3.00
32
B
Number
of
Mean
Responses
Rating
Detached (%)
Class
1
2
3
4
5
M1
9.8
23.5
29.4
17.6
19.6
3.14
51
M2
16.7
22.2
19.4
13.9
27.8
3.14
36
M3
19.1
27.7
36.2
12.8
4.3
2.55
47
M4
34.4
25.0
21.9
12.5
6.3
2.31
32
C
Number
Mean
of
Rating Responses
Defeated (%)
Class
1
2
3
4
5
M1
15.7
27.5
21.6
17.6
17.6
2.94
51
M2
22.2
16.7
5.6
25.0
30.6
3.25
36
M3
23.4
23.4
32.0
14.9
6.4
2.57
47
M4
25.8
32.3
25.8
9.7
6.5
2.39
32
Table 1: Percent of NEOMED Medical Student Response for Symptoms of Burnout. Scale Based on Frequency of Symptoms Over
Previous 2 Weeks: 1- Very Rarely, 2- Rarely, 3- Occasionally, 4- Frequently, 5-Very Frequently. A) Percent Drained, B) Percent
Detached, C) Percent Defeated
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A
Mean
Rating
Overall Mood (%)
Class
5
Number
of
Responses
1
2
3
4
M1
17.6
15.7
21.6
39.2
5.9
3.00
51
M2
13.9
27.8
22.2
30.6
5.6
2.86
36
M3
6.4
25.5
17.0
44.7
6.4
3.19
47
M4
6.3
9.4
6.3
62.5
15.6
3.72
32
B
Mean
Rating
Satisfaction Work/Life Balance (%)
Class
5
Number
of
Responses
1
2
3
4
M1
15.7
27.5
33.3
23.5
0.0
2.65
51
M2
33.3
25.0
11.1
22.2
8.3
2.47
36
M3
19.1
17.0
27.7
25.5
10.6
2.91
47
M4
9.7
6.5
12.9
48.4
22.6
3.68
32
C
Class
Ability to Make and Meet Life Goals (%)
Mean
Rating
5
Number
of
Responses
1
2
3
4
M1
13.7
27.5
25.5
29.4
3.9
2.82
51
M2
25.0
19.4
13.8
27.8
13.9
2.86
36
M3
10.6
23.4
19.1
38.3
8.5
3.11
47
M4
9.4
6.3
12.5
50.0
21.9
3.69
32
Table 2: Percent of NEOMED Medical Student Respondents Rating Quality of Mental Health based on Overall Mood, Satisfaction
with Work/Life Balance, and Ability to Make/Meet Life Goals. Scale: 1- Poor, 2- Fair, 3- Neutral, 4- Good, 5- Excellent. A) Overall
Mood Rating Percent B) Satisfaction with Work Life Balance Rating Percent, C) Ability to Make and Meet Life Goals Rating Percent
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A
Class
Sense of Purpose (%)
Mean
Rating
Number
of
Responses
1
2
3
4
5
M1
15.7
23.5
11.8
31.4
17.6
3.12
51
M2
11.1
25.0
19.4
30.6
13.9
3.11
36
M3
6.4
19.1
12.8
38.3
23.4
3.53
47
M4
6.3
9.4
9.4
50.0
25.0
3.78
32
B
Mean
Rating
Ability to Take Time for Yourself (%)
Class
5
Number
of
Responses
1
2
3
4
M1
17.6
23.5
29.4
25.5
3.9
2.75
51
M2
25.0
27.8
13.9
22.2
11.1
2.67
36
M3
12.8
19.1
23.4
31.9
12.8
3.13
47
M4
9.4
0.0
12.5
53.1
25.0
3.84
32
C
Quality of Relationships (%)
Class
Mean
Rating
Number
of
Responses
1
2
3
4
5
M1
11.8
29.4
13.7
29.4
15.7
3.08
51
M2
19.4
13.9
8.3
44.4
13.9
3.19
36
M3
12.8
12.8
6.4
57.4
10.6
3.40
47
M4
12.5
6.3
12.5
31.3
37.5
3.75
32
Table 3: Percent of NEOMED Medical Student Respondents Rating Quality of Emotional Health. Scale: 1-Poor, 2-Fair, 3-Neutral, 4Good, 5-Excellent. A) Quality of Relationships percent, B) Ability to Take Time for Yourself percent, C) Sense of Purpose percent
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Components of Wellness: Physical Health
all three mental health components were significantly
different when separated by class, being most commonly
ranked as suboptimal by the M2 class. Third, the only
emotional health factor that differed significantly between
classes was the ability to take time for oneself. There were
no statistically significant differences in physical health
between classes, however, a high percentage of all three
factors were ranked suboptimal. Finally, there were no
statistically significant differences between experienced
and expected challenges of medical school amongst the
classes, however, a high percentage of respondents rated
their experience as somewhat or much more challenging
than expected. Thus, our findings suggest that the
preclinical stage at NEOMED may contribute to a higher
frequency of burnout symptoms and poorer mental health
quality. M1s and M2s experience significantly greater
burnout symptoms than M3/M4s. Additionally, rating
their experience as much more challenging/somewhat
more challenging than expected (49% of M1 respondents,
50% of M2 respondents, 52% of M3 respondents, and
57% of M4 respondents) is a concerning finding.
Survey respondent data pertaining to our three categories
of physical health are summarized in Table 4. Satisfaction
with diet was highest among M3 participants, with a mean
satisfaction rating of 3.11 (Table 4A). Satisfaction with
diet was lowest among M2 participants, with a mean
satisfaction rating of 2.83. The percentages of students
reporting a suboptimal diet in each class were 41.2% of
M1s, 41.6% of M2s, 36.1% of M3s, and 31.2% of M4s.
Satisfaction with sleep was highest among M4
participants, with a mean satisfaction rating of 3.22 (Table
4B). Satisfaction with sleep was lowest among M1
participants, with a mean satisfaction rating of 2.65. The
percentages of students reporting suboptimal sleep in each
class were 45.1% of M1s, 41.7% of M2s, 40.4% of M3s,
and 28.2% of M4s. Satisfaction with exercise was highest
among M4 participants, with a mean satisfaction rating of
2.75 (Table 4C). Satisfaction with exercise was lowest
among M1 participants, with a mean satisfaction rating of
2.41. The percentages of students reporting suboptimal
exercise in each class were 53.0% of M1s, 41.7% of M2s,
49.0% of M3s, and 43.8% of M4s.
Respondents were asked for factors that might be
worsening burnout and suggestions that might improve
resilience. Preclinical students’ suggestions regarding
burnout include: isolation (secondary to pandemic), a
newly redesigned and intense curriculum, and the
USMLE Step 1 Exam. Although the new curriculum had
been instituted because of previous students’ desire for
more active and interactive learning experiences, the
current students had concerns about this approach. The
M1 class disliked the frequent graded quizzes that
accompanied the Peer Instruction methodology. The M2
class suggested that mandatory class and lecture work
interfered with preparation for the USMLE Step 1 Exam.
These comments likely correlate with “Academic
Performance” being listed as the most significant stressor
for these classes. Clinical students experiencing burnout
at less frequent rates may be due to different demands
based on their stage of training and/or improved coping
strategies.
ANOVA testing revealed there to be no statistically
significant differences between mean group satisfaction
ratings for all three categories of physical health: sleep
(p=0.17), diet (p=0.70), and exercise (p=0.62).
Experienced vs. Expected Challenge
Survey respondent data pertaining to experienced versus
expected challenges in medical school is summarized in
Table 5. The disparity between experienced versus
expected challenge was least severe among M1
participants, with a mean disparity rating of 2.6. The
disparity between experienced versus expected challenge
was most severe among M4 participants, with a mean
disparity rating of 2.34. ANOVA testing revealed there to
be no statistically significant differences between mean
group disparity ratings (p=0.65).
DISCUSSION
In the wellness categories, all three subcomponents of
mental health - overall mood, satisfaction with work/life
balance, and ability to make/meet life goals - showed a
statistically significant difference between classes
[overall mood (p=0.01), satisfaction with work/life
balance (p<0.001), and the ability to make and meet life
goals (p=0.01)], with lower scores in the preclinical years.
Burnout, Wellness, and Stressor Analysis
In this study of burnout and wellness in the NEOMED
College of Medicine, we sought to investigate further the
frequency and factors of medical student burnout
symptoms, the quality of medical student wellness, and
contributing stressors at NEOMED. We were able to
discover several notable findings. First, all three
symptoms of burnout are most frequently experienced in
the first two (preclinical) years of medical school. Second,
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A
Class
Diet (%)
Mean
Rating
5
Number
of
Responses
1
2
3
4
M1
21.6
19.6
17.6
35.3
5.9
2.84
51
M2
19.4
22.2
19.4
33.3
5.6
2.83
36
M3
10.6
25.5
19.1
31.9
12.8
3.11
47
M4
15.6
15.6
28.1
37.5
3.1
2.97
32
Mean
Rating
Number
of
Responses
B
Class
Sleep (%)
1
2
3
4
5
M1
25.5
19.6
19.6
35.3
0.0
2.65
51
M2
25.0
16.7
16.7
41.7
0.0
2.75
36
M3
17.0
23.4
10.6
40.4
8.5
3.00
47
M4
9.4
18.8
15.6
53.1
3.1
3.22
32
Mean
Rating
Number
of
Responses
C
Class
Exercise (%)
1
2
3
4
5
M1
41.2
11.8
17.6
23.5
5.9
2.41
51
M2
38.9
2.8
30.6
22.2
5.6
2.53
36
M3
27.7
21.3
14.9
23.4
12.8
2.72
47
M4
25.0
18.8
18.8
31.3
6.2
2.75
32
Table 4: Percent of NEOMED Medical Student Respondents Rating Quality of Physical Health. Scale: 1-Poor, 2-Fair, 3-Neutral, 4Good, 5-Excellent. A) Quality of Sleep percent B) Quality of Diet percent C) Quality of Exercise
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Table 5: Percent of NEOMED Medical Student Respondents Rating Experienced vs Expected Challenge of Medical School (based on
lectures, exams, patient care and remote learning). Scale: 1- Much Worse Than Expected 2-Somewhat Worse than Expected, 3-About
What I Expected, 4-Somewhat Easier Than Expected, 5-Much Easier Than Expected
“wellness” days. Despite these initiatives, with the high
rates of burnout and suboptimal wellness coupled with the
medical school experience being more challenging than
expected, there is room for further improvement.
NEOMED should continue considering student feedback
for iterative curricular implementation and improvement.
Implementing a new curriculum will present a challenge
to any university. During the pre-clinical years, the Peer
Instruction emphasis is a valuable learning system;
however, based on student feedback, improvements can
still be made to this curriculum (13). Student feedback
from this study requested fewer hours of Peer Instruction
and no quizzes on the day following an exam. Members
of the M2 class requested limiting lectures to run up to the
USMLE Step 1 board exam. Continuing to meet with
students and understanding their perspectives on the
curriculum can help create and adjust a curriculum
conducive to learning and student wellness.
Once again, the students on clinical rotations may have
been partially protected by increased resiliency with
accumulated experience of high stress and work demands
in medical school. Within emotional health, the only
statistically significant difference between groups was the
ability to take time for oneself, which may also be related
to a fixed schedule and fewer exams in clinical years.
Physical health factors displayed no statistically
significant differences between classes. However, nearly
50% of respondents rated their sleep and exercise as
suboptimal, and nearly 40% rated diet is suboptimal.
These findings may be due to the rigorous academic
demands taking up most of the students’ time (12).
Overall, classes that demonstrated higher scores on
metrics of burnout tended also to demonstrate poorer
scores pertaining to wellness metrics.
Finally, almost 50% of total respondents rated their
experienced challenge of medical school at NEOMED as
much worse or somewhat worse than expected. These
results did not significantly vary by stage in medical
school. This is an issue that may be due to perceived
expectations of medical school, changes due to remote
learning during the COVID-19 pandemic, and factors
controlled by NEOMED (e.g., curricular structure).
NEOMED may benefit from a large project dedicated to
promoting the components of wellness, mental health,
physical health, and emotional health. As a specific
example to improve mental health, NEOMED can
provide free access to meditation apps such as Headspace,
which has been demonstrated to have reduced stress by
14% (14). A larger-scale initiative on physical health and
spreading awareness on the importance of its
subcomponents: sleep, diet, and exercise may also be
beneficial as many students are suboptimal in these
categories. Examples include: virtual Zumba or yoga
classes, meditation classes, or dietitian/chef-led cooking
classes. Finally, emphasis on the components of
emotional health by continuing to improve
communication and consideration of students’ lives
outside of school can also be of benefit. A promising new
initiative, which began in 2020, is the Exceptional Student
Experience, a comprehensive initiative designed by
NEOMED faculty to deliver a student-centered medical
How can NEOMED respond?
As previously stated, NEOMED has taken steps in student
wellness. NEOMED opened the Center for Student
Wellness and Counseling Services (CSWCS), which
offers free care for students. The CSWCS began
providing telehealth and evening appointments to expand
accessibility to students. Many students praised the
CSWCS. NEOMED students have access to the Sequoia
Wellness Center on the NEOMED campus, which offers
a full range of gym equipment and aerobics classes as part
of enrollment. NEOMED students are permitted to take
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school curriculum with a focus on patient care with
humanistic values, clinical competence, board exam
performance, residency competitiveness, and readiness,
and personal wellness.
CONCLUSION
The medical school appears to be a stressful experience
for NEOMED College of Medicine students, with peak
burnout frequencies and suboptimal wellness ratings in
the preclinical years. The effects of burnout can be
detrimental to medical students, physicians, and to the
entire healthcare system. Our findings demonstrated that
the groups that scored higher frequencies of burnout also
scored lower on wellness ratings, therefore, a systematic
approach dedicated to promoting wellness at NEOMED
may lead to lower frequencies of burnout.
How can students respond?
In addition to NEOMED responding to factors outside a
student’s control, there are also several actions that
students may take to improve symptoms of burnout. As
demonstrated by our results, groups with higher scores on
metrics of burnout also tended to demonstrate lower
scores pertaining to wellness metrics. Therefore, these
students may benefit by prioritizing components of
wellness. For example, a sleep of an optimal duration (79 hours) is associated with higher test scores (15).
Therefore, students may benefit by prioritizing this
subcomponent of physical health, which can help improve
a major stressor, academic performance (15).
REFERENCES
Additionally, it should be noted that there may be a reason
to believe that experience at NEOMED may build
resilience, demonstrated by improved metrics of burnout
and some metrics of wellness in the later clinical years.
1.
Suicide among health-care workers: Time to act. The
Lancet. 2017; 389(10064):2. doi: 10.1016/S01406736(17)30005-3
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Dyrbye LN, Thomas MR, Huntington JL, et al.
Personal life events and medical student burnout: a
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doi:10.1097/00001888-200604000-00010
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Koutsimani P, Montgomery A, Georganta K. The
Relationship Between Burnout, Depression, and
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fpsyg.2019.00284
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Tawfik DS, Profit J, Morgenthaler TI, et al. Physician
Burnout, Well-being, and Work Unit Safety Grades
in Relationship to Reported Medical Errors. Mayo
Clin Proc. 2018;93(11):1571-1580. doi:10.1016/j.
mayocp.2018.05.014
5.
Dyrbye LN, West CP, Satele D, et al. Burnout among
U.S. medical students, residents, and early career
physicians relative to the general U.S.
population. Acad Med. 2014;89(3):443-451. doi:10.
1097/ACM.0000000000000134
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Wallace JE, Lemaire JB, Ghali WA. Physician
wellness: a missing quality indicator. Lancet. 2009;
374(9702):1714-1721.doi:10.1016/S01406736(09)61424-0
7.
Liaison Committee on Medical Education. Functions
and Structure of a Medical School: Standards for
Accreditation of Medical Education Programs
Leading to the MD Degree. Published March 2020.
Accessed on February 22, 2021. https://lcme.org/
publications.
Lessons and limitations?
Our study has several limitations. The most significant
potential factor is the low response rate. Our sample size
of 166 out of 599 total students only captured 28% of the
total student population. There may be a response bias
based on the students who answered the survey.
Responding students may be experiencing burnout and
suboptimal wellness at more significantly different rates
than nonparticipants of the survey. They may be seeking
help to deal with these issues and view the survey as a
platform for them to be heard. They were also given three
weeks to respond, which may not have been a sufficient
timeframe. Additionally, certain demographic factors
including age and marital status were not collected to
protect subject privacy. This limited our ability to
determine how representative our respective samples
were from each class. Finally, the timing of the survey in
the middle of demanding preclinical semesters and the
COVID-19 pandemic may have generated more
unfavorable responses as it has shown to be a significant
contributing factor to stress in the medical profession
(11).
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JMS, August 2022 – Volume 1, Issue 1
8.
CONFLICTS OF INTEREST
9.
Accreditation Council for Graduate Medical
Education.
ACGME
Common
Program
Requirements (Residency) 2020. Published Feb 3,
2020. Accessed Feb 22, 2021. https://www.acgme.
org/Portals/0/PFAssets/ProgramRequirements/CPR
Residency2020.pdf
All authors declare no conflicts of interest.
AUTHOR CONTRIBUTIONS
Conceptualization: AP, AD, RW
Veasey S, Rosen R, Barzansky B, Rosen I, Owens J.
Sleep loss and fatigue in residency training: a
reappraisal. JAMA. 2002;288(9):1116-1124. doi:10.
1001/jama.288.9.1116
Methodology: AP, AD, AI, AA, RW
Investigation: AP, AD, AI, AA, RW
Project administration: AP, AD, RW
10. Alimujiang A, Wiensch A, Boss J, et al. Association
Between Life Purpose and Mortality Among US
Adults Older Than 50 Years. JAMA Netw Open.
2019;2(5):e194270. doi:10.1001/jamanetworkopen.
2019.4270
Supervision: RW
Writing – original draft: AP, AD, AI, RW
Writing – review & editing: AA
11. Young KP, Kolcz DL, O'Sullivan DM, Ferrand J,
Fried J, Robinson K. Health Care Workers' Mental
Health and Quality of Life During COVID-19:
Results From a Mid-Pandemic, National Survey.
Psychiatr Serv. Feb 2021 ;72(2):122-128. doi:
10.1176/appi.ps.202000424.
12. Stewart SM, Lam TH, Betson CL, Wong CM, Wong
AM. A prospective analysis of stress and academic
performance in the first two years of medical
school. Med Educ. 1999;33(4):243-250. doi:10.
1046/j.1365-2923.1999.00294.x
13. Parmelee D, Trout M, Overman I, Matott M. 12 TIPS
for Implementing Peer Instruction in Medical
Education. MedEdPublish. 2020;9,[1], 237. doi:10.
15694/mep.2020.000237.1
14. Economides M, Martman J, Bell MJ, Sanderson B.
Improvements in Stress, Affect, and Irritability
Following Brief Use of a Mindfulness-based
Smartphone App: A Randomized Controlled
Trial. Mindfulness (N Y). 2018;9(5):1584-1593.
doi:10.1007/s12671-018-0905-4
15. Zeek ML, Savoie MJ, Song M, et al. Sleep Duration
and Academic Performance Among Student
Pharmacists. Am J Pharm Educ. 2015;79(5):63.
doi:10.5688/ajpe79563
ACKNOWLEDGMENTS
We sincerely thank Mr. Robert Larson and Dr. Julie
Aultman for assistance with implementation of this
survey.
26
Journal of Medical Sciences at NEOMED
Volume 1, Issue 1, August 2022
Using Ancient Spices to Treat Chronic Diseases: Turmeric’s Potential to Modulate Disease
Pathogenesis in Rheumatoid Arthritis and Inflammatory Bowel Disease
Kelly M. Kimball, BS1*†, Giovanna Leone, BS1†, Bina Mehta, MD2
1.
2.
Northeast Ohio Medical University, College of Medicine, Rootstown, OH, 44272
Akron General – Cleveland Clinic, Akron, Ohio
* Corresponding author
†
Joint first authorship
ABSTRACT
This review aims to highlight two major health conditions that could benefit from regular supplementation of
turmeric, as well as to discuss the importance of more widespread uses of this natural therapeutic in commonly
used multivitamins and multi-drug regimens. There is a wide range of potential benefits patients could gain
from this supplement, but we will be focusing only on the effects on inflammation in two of the most prevalent
chronic inflammatory diseases, rheumatoid arthritis (RA) and inflammatory bowel disease (IBD). We
propose that turmeric supplementation could be more commonly used in a healthcare setting as an adjuvant
treatment in these inflammatory conditions. Future studies investigating turmeric’s role for treatment in RA
and IBD must aim to further evaluate the effects of curcumin on the human microbiota and how its
bioavailability can be increased to provide therapeutic results.
Keywords: Turmeric, Anti-inflammatory, Irritable Bowel Disease, Rheumatoid Arthritis
soluble vitamins, B vitamins, and other micronutrients
(1).
INTRODUCTION
Turmeric is a rhizomatous herb that has been utilized in
various capacities in both Chinese and Ayurvedic
medicine for almost 4000 years (1). This spice has been
utilized in the management of many anti-inflammatory
disease processes throughout the world and has been
documented in Ayurvedic medicine as a remedy for
respiratory conditions, such as asthma, as well as for
rheumatism, muscle aches, and wounds (2). The ancient
Chinese documented similar usages, along with relief for
abdominal pain (2). There is much evidence supporting
the multiple health benefits of turmeric, suggesting the
potential for it to serve as a more widespread option for
inclusion in the treatment regimen for certain diseases,
especially chronic inflammatory diseases (3). Modern
medicine has slowly been catching on to the benefits of
turmeric described by ancient civilizations. Today, many
over-the-counter multivitamin supplements incorporate
small doses of turmeric amongst their ingredients of fat-
27
Oxidative stress has been proven to be the pathological
process behind many chronic diseases and cancers,
making routine utilization of this natural antiinflammatory herb something to consider in a healthcare
setting (3). The mechanisms of turmeric’s effects utilize
antioxidant mechanisms similar to vitamins E and A, as it
can neutralize free radicals that are damaging to normal
body functions (1). The active component of turmeric is
curcumin, and it is a compound that possesses many
different actions in vitro and in experimental animal
models (4). It has been shown to favorably affect lipid
metabolism, antioxidant concentrations, multiple antiinflammatory reactions, and numerous signaling
pathways (4). Additionally, recent literature suggests that
turmeric not only benefits those in inflammatorymediated diseased states, but also healthy individuals, as
well. A study by DiSilvestro et al. illustrated that low
doses of lipidated curcumin promote a diverse range of
health-promoting effects, such as lowering serum
JMS, August 2022 – Volume 1, Issue 1
Kimball, et al
triglycerides and proinflammatory cytokines, in healthy
individuals without any underlying medical conditions
(4). This has led investigators to believe that
supplementation with low doses of curcumin could be of
benefit in healthy individuals, as well. Additionally,
curcumin has been shown to exert a multitude of effects
on the human microbiome and intestinal system, which
will be explored throughout this paper.
known mechanisms involve the machinery seen in the
body’s own defense mechanisms against foreign
pathogens, including innate and adaptive immune systems
(9). Turmeric may have the ability to tone down these
widespread inflammatory effects, potentially relieving
symptoms and slowing the destruction of tissue.
RA has multiple treatment options that come with various
side effects. One option being methotrexate, which is
often of clinical benefit but comes with many systemic
side effects such as myelosuppression, mucositis,
hepatotoxicity, and more (10, 11). Furthermore, exploring
effective treatment options that have fewer side effects,
such as turmeric, is very desirable considering the harsh
effects drugs like methotrexate have on the body
(11). Moreover, several studies on curcumin have shown
effects in reducing proinflammatory biomarkers (11). A
recent study revealed that curcumin, the active component
of turmeric, has biochemical effects that can inhibit
inflammation, synovial hyperplasia, and other aspects of
CIA-induced rats via the mTOR pathway. (CIA-induced
rats are collagen-induced arthritis specimens, a widely
used animal model for rheumatoid arthritis) (12).
Furthermore, curcumin inhibited the increased levels of
proinflammatory cytokines and proteinases such as
interleukin-1 beta (IL-1β), tumor necrosis factor alpha
(TNF-α), matrix metalloproteinase-1 (MMP-1), and
MMP-3 in CIA rats (12). A meta-analysis published in
2014 consisting of 342 subjects reveals a significant
difference in CRP levels between curcumin and control
groups. CRP directly correlates to bodily inflammation,
further suggesting curcumin use can combat
inflammation. This effect seemed to depend on the
bioavailability and duration of supplementation (13).
Additionally, a meta-analysis conducted in 2016
determined there is compelling evidence supporting the
use of curcumin adjuvant to conventional RA therapy
(12).
Despite these numerous potential benefits, the efficacy of
turmeric as an anti-inflammatory agent has been
questioned and seldom recommended clinically due to its
poor bioavailability (4). For this reason, it is often
combined with piperidine, a component found in black
pepper, which increases its bioavailability by 2000% (5).
The DiSilvestro study also managed to navigate its low
bioavailability by utilizing a lipidated curcumin, which
was able to enhance its anti-inflammatory effects (4).
Therefore, it is clear that when bioavailability is
increased, curcumin possesses its most potent and
promising effects as an anti-inflammatory agent (5). Due
to this, researchers have been investigating ways in which
oral turmeric supplements can be chemically modified in
order to increase the bioavailability of curcumin.
Therefore, the low natural bioavailability should not
dissuade its use, as there will likely be ways in which this
can be adequately addressed in the near future.
This review aims to highlight two major health conditions
that could benefit from regular supplementation of
turmeric, as well as to discuss the importance of more
widespread uses of this natural therapeutic in commonly
used multivitamins and multi-drug regimens. There is a
wide range of potential benefits from this supplement, but
we will be focusing only on the effects on inflammation
in two of the most prevalent chronic inflammatory
diseases, rheumatoid arthritis (RA) and inflammatory
bowel disease (IBD). We propose that turmeric
supplementation should be more commonly used in a
healthcare setting as an adjuvant treatment in these
inflammatory conditions.
In addition to RA, inflammatory bowel disease has been
increasing in prevalence over the last twenty years (14).
According to the CDC, IBD, which includes Crohn’s
disease and ulcerative colitis, now affects approximately
3 million people or 1.3% of adults in the United States
(14). While the pathogenesis of IBD remains largely
unknown, it is thought to arise due to a dysfunctional or
overly sensitive host immune response to bacterial and
dietary antigens (15). The result is the breakdown of the
microbiome and intestinal barrier, which is usually due to
excess production of pro-inflammatory cytokines, such as
TNF-α, IL-1 β, IL-6, and interferon-gamma (IFN-γ), all
of which are triggered by the activation of nuclear factor
kappa beta (NF-κB) (15). This ultimately results in
unchecked intestinal inflammation and can lead to
changes in the intestinal microbiome (15). If left
TURMERIC’S USE IN CHRONIC
INFLAMMATORY DISEASES
Rheumatoid arthritis (RA) is the most common systemic
inflammatory diagnosis. The prevalence of this chronic
inflammatory disease is as high as 0.6% in North America
(6, 7). Markers of this disease include anti-citrullinated
protein, rheumatoid factor, elevated erythrocyte
sedimentation rate (ESR), and C-reactive protein (CRP),
all of which contribute to the destructive inflammatory
component seen in this disease process (8). There are
several proposed mechanisms of the inflammation seen in
RA, and many that have not been explored yet. Most
28
JMS, August 2022 – Volume 1, Issue 1
Kimball, et al
untreated, this inflammation can become chronic, result in
systemic inflammation and even serve as a nidus for
cancer (15).
curcumin, must be administered or it must be
administered with compounds that help prevent its
metabolism and increase its concentration in the body (5).
As previously mentioned, curcumin is often combined
with various organic compounds to drastically increase its
bioavailability (5). Recent studies have shown that
lapidated curcumin mixtures increase its availability, as
do mixtures with piperidine, the active component of
black pepper (5).
The anti-inflammatory effects of curcumin have been
viewed as a potential adjuvant treatment for those
suffering from IBD since it has been shown to reduce the
proposed inflammatory response implicated in IBD, help
restore the integrity of the intestinal barrier and resist the
degradation of intestinal epithelial tight junctions (15).
Normally, the nitric oxide (NO) that is present at the
physiological baseline serves to protect the
gastrointestinal mucosa. However, the substantial
amounts of NO that is released via inducible nitric oxide
synthase (iNOS) during gastrointestinal inflammatory
disease can result in tissue injury and subsequent necrosis
(15). During inflammation, iNOS produces NO in
pathogenic quantities. Therefore, it is likely that the
chronic inflammation found in gastrointestinal
inflammatory disease states may lead to the dissolution of
the intestinal wall integrity due to the generation of
reactive nitrogen species (RNS). Normally, curcumin
reduces levels of reactive oxygen species (ROS), such as
NO, in the intestinal mucosa (6). In a mouse model of
ulcerative colitis, curcumin was able to inhibit the
generation of iNOS by reducing the T-helper-1 (Th1)
cytokine response, which ultimately led to reduced tissue
damage (6).
Endogenously, curcumin is rapidly metabolized by the
Blautia spp, a bacterium native to the human microbiome
(5). One could also glean that those future research
directions focusing on downregulating the colonization of
Blautia spp could also serve to inhibit the metabolism of
curcumin, thus increasing its concentration in the body.
However, further altering the microbiota possesses its
own challenges and could allow for further dysregulation
of the immune response in those suffering from
inflammatory diseases like RA and IBD. Another route
that could potentially increase curcumin’s bioavailability
is altering its structure or combining it with lipidated or
piperidine compounds, as previous groups have done
(4,5). Investigating ways in which oral turmeric
supplements can be chemically modified to increase the
bioavailability of curcumin is an active area of research.
Therefore, the low natural bioavailability should not
dissuade its use, as there will likely be ways in which this
can be improved in the near future.
Curcumin has been shown to exert a multitude of effects
on the human microbiome and intestinal system. One
study demonstrated that curcumin possessed bactericidal
effects by eradicating H. pylori colonization in vivo
through a proposed mechanism of inhibited bacterial cell
division (15). In addition to these bactericidal effects,
curcumin has been shown to promote and maintain a
healthy gastrointestinal microbiome. One possible
mechanism is curcumin’s ability to promote the growth of
short-chain fatty acid (SCFA)-producing bacteria. In a
murine study conducted by Feng et al., curcumin
supplementation promoted the diversity of SCFAproducing bacteria which have well-described protective
effects on gastrointestinal mucosa by inhibiting
inflammation (15, 16, 17).
In general, natural and alternative medicine continues to
be less explored than modern medicine, despite some
evidence working in its favor (4,5). Turmeric, a natural
supplement that has been used for thousands of years,
works to decrease systemic inflammation and better
disease trajectory. As discussed in this review, both RA
and IBD could benefit from adjuvant turmeric
supplementation. While the supplements may not often
stand on their own as a sole treatment, the simple addition
of one to a complex drug regimen can potentially improve
disease trajectory. Furthermore, after validation through
more clinical trials, this affordable addition could
improve the disease trajectory of patients struggling with
these inflammatory diseases (18). Due to a lack of human
research trials on these supplements, they are often
overlooked by healthcare providers, but there may
certainly be a role for them in certain clinical situations.
Since each person’s immune system is unique, responses
to turmeric supplementation may vary widely on a
patient-to-patient basis. As such, physicians treating
individuals with chronic inflammatory conditions such as
RA or IBD might consider adding turmeric to their
treatment plan.
DISCUSSION
Before definite conclusions can be made, future studies
must further evaluate the effects of curcumin on the
human gastrointestinal microbiota, as most existing
studies focus on its effects in animal models. One
explanation for the lack of studies exploring this concept
is the poor bioavailability of pure curcumin. For patients
to be able to reap the anti-inflammatory rewards of
turmeric, high doses (500 mg) of the active ingredient,
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REFERENCES
1.
Slika L, Patra D. Traditional Uses, Therapeutic
Effects and Recent Advances of Curcumin: A MiniReview. Mini Rev Med Chem. 2020;20(12):10721082. doi: 10.2174/1389557520666200414161316.
11. Howard SC, McCormick J, Pui CH, Buddington RK,
Harvey RD. Preventing and Managing Toxicities of
High-Dose Methotrexate. Oncologist. 2016;21(12):
1471-1482. doi:10.1634/theoncologist.2015-0164.
2.
Prasad S, Aggarwal BB. Turmeric, the Golden Spice:
From Traditional Medicine to Modern Medicine. In:
Benzie IFF, Wachtel-Galor S, editors. Herbal
Medicine: Biomolecular and Clinical Aspects. 2nd
edition. Boca Raton (FL): CRC Press/Taylor &
Francis; 2011. Chapter 13.
12. Dai Q, Zhou D, Xu L, Song X. Curcumin alleviates
rheumatoid arthritis-induced inflammation and
synovial hyperplasia by targeting mTOR pathway in
rats. Drug Des Devel Ther. 2018; Volume 12:40954105. doi:10.2147/dddt.s175763.
3.
Khan I, Samson S, Grover A. Antioxidant
Supplements and Gastrointestinal Diseases: A
Critical Appraisal. Medical Principles and Practice.
2017;26(3):201-217. doi:10.1159/000468988.
4.
DiSilvestro R, Joseph E, Zhao S, Bomser J. Diverse
effects of a low dose supplement of lipidated
curcumin in healthy middle aged people. Nutr J.
2012;11(1). doi:10.1186/1475-2891-11-79.
5.
Hewlings S, Kalman D. Curcumin: A Review of Its
Effects on Human Health. Foods. 2017;6(10):92.
doi:10.3390/foods6100092.
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Ukil A, Maity S, Karmakar S, Datta N, Vedasiromoni
J, Das P. Curcumin, the major component of food
flavour turmeric, reduces mucosal injury in
trinitrobenzene sulphonic acid-induced colitis. Br J
Pharmacol. 2003;139(2):209-218. doi:10.1038/sj.
bjp. 070524.1
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13. Sahebkar A. Are curcuminoids effective C-reactive
protein-lowering agents in clinical practice?
Evidence from a meta-analysis. Phytother Res. 2014
May;28(5):633-42. doi: 10.1002/ptr.5045.
14. Data and Statistics. Cdc.gov. Published 2021.
Accessed January 1, 2021. https://www.cdc.gov/ibd/
data-statistics.html
15. Burge K, Gunasekaran A, Eckert J, Chaaban H.
Curcumin and Intestinal Inflammatory Diseases:
Molecular Mechanisms of Protection. Int J Mol Sci.
Apr 2019;20(8):1912. doi:10.3390/ijms20081912.
16. Feng W, Wang H, Zhang P, et al. Modulation of gut
microbiota contributes to curcumin-mediated
attenuation of hepatic steatosis in rats. Biochim
Biophys Acta Gen Subj. 2017;1861(7):1801-1812.
doi:10.1016/j.bbagen.2017.03.017.
17. Scheppach W, Weiler F. The butyrate story: old wine
in new bottles? Curr Opin Clin Nutr Metab Care.
2004;7(5):563-567. doi:10.1097/00075197-2004090
00-00009.
Otón T, Carmona L. The epidemiology of established
rheumatoid arthritis. Best Practice & Research
Clinical Rheumatology. 2019;33(5):101477. doi:10.
1016/j.berh.2019.101477.
18. Gopinath H, Karthikeyan K. Turmeric: A condiment,
cosmetic and cure. Indian J Dermatol Venereol
Leprol.
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2018;84(1):16-21.
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10.4103/ijdvl.IJDVL_1143_16. PMID: 29243674.
Daily J, Yang M, Park S. Efficacy of Turmeric
Extracts and Curcumin for Alleviating the Symptoms
of Joint Arthritis: A Systematic Review and MetaAnalysis of Randomized Clinical Trials. J Med Food.
2016;19(8):717-729. doi:10.1089/jmf.2016.3705.
CONFLICTS OF INTEREST
All authors declare no conflicts of interest.
9.
Croia C, Bursi R, Sutera D, Petrelli F, Alunno A,
Puxeddu I. One year in review 2019: pathogenesis of
rheumatoid arthritis. Clin Exp Rheumatol. 2019;37
(3):347-357.
AUTHOR CONTRIBUTIONS
Conceptualization: KMK, GL
Investigation: KMK, GL
10. Wasserman AM. Diagnosis and management of
rheumatoid arthritis. Am Fam Physician. 2011;84
(11):1245-1252.
Visualization: KMK, GL
Project administration: KMK, GL
30
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Kimball, et al
Supervision: BM
Writing – original draft: KMK, GL
Writing – review & editing: KMK, GL, BM
31
Journal of Medical Sciences at NEOMED
Volume 1, Issue 1, August 2022
Chemical and Histopathologic Effects of COVID-19 on Virchow’s Triad
Jay P. Natarajan, BS1, Ashorne K. Mahenthiran, BA2, Gary W. Lemmon, MD, FACS3*
1.
2.
3.
Northeast Ohio Medical University, College of Medicine, Rootstown, OH, 44272
Feinberg School of Medicine, Northwestern University, Chicago, IL
Division of Vascular Surgery, Indiana University School of Medicine, Indianapolis, IN
* Corresponding author
ABSTRACT
Although COVID-19 is known primarily as a respiratory disease, infected patients have been known to
experience COVID-19-associated coagulopathy from overactivation of immune response resulting in
cytokine storm. As a fundamental principle of venous thromboembolism, Virchow’s triad – consisting of
stasis, hypercoagulability, and endothelial injury – remains the foundation for increased clotting risk which
can often precipitate life-threatening complications, such as pulmonary embolism, if left untreated. We
conducted a literature search using PubMed for evidence to explain the increased coagulopathy in COVID19 positive patients in relation to the three pillars of Virchow’s triad. Hypercoagulability in COVID-19
patients is increased due to cytokine-induced fibrin clot formation. Infected patients also have decreased
ADAMTS13, which leads to endothelial injury. Lastly, the increased blood viscosity combined with patient
immobility promotes vascular stasis. These factors put COVID-19 patients at an increased risk of acquiring
blood clots. In conclusion, we have defined a plausible mechanism by which COVID-19 may induce venous
thrombosis using the three components of Virchow’s triad. Due to the fatal nature of vascular complications,
it is important to consider prophylactically treating these patients with a low molecular weight heparin
regimen in order to mitigate the effects of hypercoagulability.
Keywords: COVID-19, Virchow’s triad, venous thromboembolism, hypercoagulability, endothelial injury, venous
stasis, anticoagulation
INTRODUCTION
pulmonology and must be understood by specialists in
cardiovascular and hematologic fields, as well.
On March 11, 2020, the World Health Organization
(WHO) declared novel coronavirus disease caused by
severe acute respiratory syndrome coronavirus 2 (SARSCoV-2), herein labeled COVID-19, to be a global
pandemic (1). Although bats are the primary vector for
SARS-CoV-2, this is an RNA virus that is easily
transmitted via respiratory droplets between humans (2).
Although the clinical course of COVID-19 is most
commonly associated with fever, viral pneumonia, and
acute respiratory distress syndrome (ARDS), this disease
has an additional relevance to the field of vascular surgery
due to its adverse effects on coagulation (3). The
prothrombotic state acquired due to COVID-19
demonstrates that its effects extend beyond the realm of
Around the world, multiple medical centers have noted
that arterial and venous clotting may complicate the
disease course of COVID-19. Helms, et al. noted that in a
French hospital, 28 out of 29 dialysis patients with
COVID-19 experienced thrombosis, which obstructed
dialysis filter function thus compromising renal
replacement therapy in critically ill patients (4). In the
United States, a study of over 3,000 hospitalized COVID19 patients revealed a rate of thrombotic complications
over 10% for non-ICU patients and almost 30% for ICU
patients (5). Since the venous thrombosis rate in COVID19 patients is higher than that in uninfected individuals
(21% vs. 0.5%), it is crucial to investigate the underlying
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Natarajan, et al
mechanisms of pathologic thrombosis due to COVID-19
(6,7). A deeper understanding of the vascular
pathophysiology could potentially guide clinical solutions
for affected patients.
screening criteria. Altogether, we compiled a total of 21
articles regarding the components of Virchow’s Triad.
Virchow’s triad is a well-recognized axiom in venous
thromboembolism (VTE). Rudolf Virchow was a 19th
century German physician who defined clotting as the
combination of three factors: hypercoagulability,
endothelial injury, and stasis. Kushner et al. define
hypercoagulability as a condition in which blood is at a
greater propensity to clot often due to oral contraceptive
use, chemotherapy drugs, or thrombophilia. Any insult to
the wall of the blood vessel can produce an endothelial
injury, promoting activation of the clotting cascade for
vessel repair and disruption of laminar blood flow, which
can initiate thrombosis. Lastly, stasis is a reduction of
flow, which permits blood to pool and clot (8). As earlier
studies have demonstrated increased thrombosis in
COVID-19 patients, we sought to explain these findings
as they relate to Virchow’s triad. Hypercoagulability and
endothelial injury are directly affected by the coronavirus
due to its usage of spike (S) protein to infiltrate (9). We
reason that stasis is a contributing factor to thrombosis in
COVID-19 patients likely due to prolonged bed rest and
immobility. In this paper, we will explore the pathology
of COVID-19 at the cellular and biochemical level, with
a focus on Virchow’s triad and shed light on possible
treatments for patients.
Hypercoagulability
RESULTS
SARS-CoV-2 belongs to a family of coronaviruses that
infect human host cells. However, these family members
differ in virulence and have unique thrombotic activity.
Based on initial investigations, Gabutti et al. postulate that
the S protein for SARS-CoV-2 has a higher affinity for
human angiotensin converting enzyme 2 transmembrane
receptor (ACE-2R) than the previous SARS-CoV
reported in 2002 (10). Although the specific differences
between SARS-CoV-2 and SARS-CoV S proteins are still
under investigation, it is known that the higher ACE-2R
affinity for the current virus has allowed for lower viral
loads to produce symptoms in the host (10). Despite the
differences between the two strains, SARS-CoV-2 spike
protein shares approximately 75 percent amino acid
sequence homology with the SARS-CoV spike protein
(11).
Similar to its predecessor, SARS-CoV-2 uses a
transmembrane protease, serine 2 (TMPRSS2) enzyme as
a primer for the surface unit of its S protein, which binds
to the ACE-2R and achieves viral entry into host
respiratory epithelium (12). Since SARS-CoV-2 shares a
high degree of amino acid sequence homology with
SARS-CoV, it is logical that there are similarities in
biological pathogenesis (13). SARS-CoV-2 causes tissue
damage and vascular leakage due to cytotoxic T cell and
neutrophil activation, coupled with upregulation of proinflammatory cytokines interleukin 6 (IL-6), tumor
necrosis factor alpha (TNFα), interleukin 1 beta (IL-1β),
and C-C motif chemokine ligand 2 (CCL2) (12).
Furthermore, COVID-19 increases activation of profibrotic genes transforming growth factor beta 1 (TGFβ1),
connective tissue growth factor (CTGF), and platelet
derived growth factor subunit A (PDGFA). The
combination of pro-inflammatory cytokines and profibrotic genes leads to the coagulation cascade cleavage
of prothrombin to thrombin and subsequent
transformation of fibrinogen to fibrin (12). The cytokineinduced cascade of fibrin clot formation generates the
abnormal hypercoagulation associated with COVID-19,
which is similar to chronic (compensated) disseminated
intravascular coagulation (DIC), with rapid consumption
of endogenous coagulation factors promoting blood clots
(14). It is important to note that COVID-19-associated
coagulopathy (CAC) is a preliminary stage, which could
further progress to DIC (15). The primary notable
difference between CAC and sepsis-induced DIC is that
initially, fibrinogen remains elevated in CAC as an acute
phase response. Eventually, as CAC progresses,
METHODS
A literature search was performed to investigate the
effects of COVID-19 on Virchow’s triad. Using PubMed,
we conducted individual searches on the components of
Virchow’s Triad. The inclusion criteria used were as
follows: 1) published within the last year to ensure
relevance, 2) written in English, and 3) full-text must be
available. The primary exclusion criterion was case report
articles, as these were not considered to be adequate
evidence for evaluating widespread effects on Virchow’s
Triad. The search terms “COVID-19” and
“hypercoagulation” resulted in 411 articles. These were
then screened by two of the investigators (JN, AM) based
on their pertinence to elucidating biochemical
mechanisms and/or histopathology. Articles without this
focus were removed from our search. This yielded 9
studies describing the mechanism of action for
hypercoagulability in COVID-19. We repeated this
process with the other two components of Virchow’s
triad, yielding 132 articles involving “endothelial injury”
and 5 articles each involving “cytokine injury” and
“stasis”. However, we chose to expand this search to
“COVID-19” and “stasis” in order to yield greater results.
We had a total of 16 results after expanding the search and
included 7 of these stasis-related studies after applying the
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The third element of Virchow’s triad is venous stasis.
Although current literature does not have a quantitative
measure of the degree to which venous stasis is associated
with COVID-19 infection, behavioral and physical
explanations for a potential association exist. Fatigue is a
common clinical presentation of COVID-19, and it is
hypothesized that this symptom occurs due to an IL-6
cytokine surge, which is known to influence skeletal
muscle fatigability in mice (24). In addition, most patients
experience respiratory difficulties, such as dyspnea,
pleurodynia, cough, and expectoration (25). The
constellation of symptoms (common to most viralinduced respiratory infections) likely occur due to the
viral destruction of lung parenchyma and interstitial
inflammation (25). COVID-19 is known to cause mast
cell degranulation (26). As a result, histamines are
released, increasing vascular permeability of pulmonary
endothelial cells. The subsequent leakage of transudative
fluid in the pulmonary interstitium is associated with
dyspnea from increased work of breathing and discomfort
(26). Pulmonary edema reduces the lung’s ability to
oxygenate blood, resulting in an increased arterialalveolar gradient. Combining this increased respiratory
effort with IL-6-induced systemic fatigue, COVID-19infected persons are less likely to be mobile. With
immobility, venous blood begins to pool due to reduced
velocity and decreased muscle activity, which can
promote higher risks of venous thromboembolism (27). It
has been shown in the past that those who are in a
stationary position for a prolonged time are at a higher risk
of developing blood clots (28). One study by Murugesan
et al. mentions that post-operative deep venous
thrombosis (DVT) in Caucasian populations occurs in 1540% of hospitalized patients (28). While the exact cause
of this is unknown, it can be hypothesized that postsurgical bed rest is a contributing factor, since immobility
is a common cause of thrombosis in obese populations
and video game users (29).
fibrinogen decreases to low levels in DIC (15). The
underlying mechanism of this difference is not yet well
understood. Additionally, platelet aggregation and
abnormal thrombus formation rapidly causes tissue
hypoxia (16). Vascular events predominantly reported in
COVID-19 patients with severe infection include VTE
and pulmonary embolism (PE). Patients have developed
rare complications such as venous gangrene of the
extremities, which can lead to critical limb ischemia, but
the more common and potentially worrisome event of
VTE is a PE presenting with dyspnea, syncope and/or
palpitations (17). Rapid deterioration has been noted and
if left untreated, is fatal (18).
Endothelial Injury
Weibel-Palade bodies (WPB) stored in endothelial cells
contain P-selectin and ultra-large Von Willebrand Factor
(ULVWF) (19). Based on current knowledge of the
mechanisms of COVID-19-induced cytokine storms, IL8 and TNFα have particular importance due to their
impact on endothelial cells. Specifically, their activation
causes the release of P-selectin and ULVWF from WPBs,
thereby accelerating clotting and contributing to the
development of VTE (20). P-selectin plays a vital role in
the leukocyte adhesion cascade by binding to P-selectin
Glycoprotein Ligand-1 (PSGL-1) on neutrophils (21).
With regards to coagulation, ULVWF is known to initiate
clotting by promoting the glycoprotein Ib receptor to bind
to glycoprotein IIa receptors on platelets (22). This step of
clotting is known as platelet aggregation, in which
platelets can connect to one another.
Homeostatic autoregulation of the clotting process is
facilitated by the ADAMTS13 enzyme, which works by
cleaving endothelial-bound ULVWF into smaller
components such that thrombi do not form (22).
Deficiencies in ADAMTS13 can present as thrombotic
thrombocytopenic purpura, which produce microthrombi
dispersed throughout the body (22). In COVID-19
infection, IL-6 generation downregulates ADAMTS13,
thus increasing the propensity for ULVWF to aggregate
and create thrombi (22). Similar to IL-6, activated
neutrophils have adverse effects on ADAMTS13 activity.
Activated neutrophils and neutrophil extracellular traps
(NETs) produce reactive oxygen species (ROS) in the
process of fighting viral infections such as COVID-19.
Increases in ROS levels prevent ADAMTS13 from
cleaving ULVWF along the endothelium (23). The
subsequent cytokine storm propagates endothelial
dysfunction and hypercoagulation, two of the three
components of Virchow’s triad, and serves as a plausible
framework to understanding the presentation of VTEs in
COVID-19 patients.
Stasis is also impacted by hyperviscosity, which is
strongly associated with COVID-19. A study from Emory
University involving a cohort of 15 COVID-19 patients
identified blood viscosities exceeding 95% of the normal
limit (30). One potential explanation for this phenomenon
is the correlation between severity of COVID-19 disease
course and increased plasma fibrinogen levels,
fibrinogen-to-albumin ratio (FAR), and D-dimer levels.
Specifically, one cohort study found that patients with
severe disease were in a hypercoagulable state with
shortened prothrombin time (PT) and activated partial
thromboplastin time (aPTT), which stabilized as patients’
condition improved (31). As a result, there may be a
critical threshold of FAR that can serve as a predictor of
the severity of disease (31).
Treatments
Stasis
34
JMS, August 2022 – Volume 1, Issue 1
Natarajan, et al
As of January 2021, the American Society of Hematology
and American College of Chest Physicians have provided
guidelines stating that all adult patients admitted to the
hospital for COVID-19 infection should be placed on
prophylactic low molecular weight heparin (LMWH)
over unfractionated heparin (UFH) and direct oral
anticoagulant, unless contraindicated (32,33). Studies in
China have shown clinical benefits of this therapy. In a
cohort of 449 COVID-19 patients in Tongji hospital, 99
patients were placed on a LMWH regimen. In patients
who had a D-dimer score greater than six times the normal
limit, a LMWH regimen for at least 7 days improved the
28-day mortality risk (34).
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In a cohort study with over 2,500 patients at the Mount
Sinai Health System, the benefits of systemic treatmentdose anticoagulation for hospitalized patients were
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not receive anticoagulation when compared to 29.1% for
patients that did (35). However, the potential benefits of
anticoagulation need to be weighed against the potential
risk of major bleeding on an individual patient basis prior
to initiating systemic treatment-dose anticoagulation. For
those
who
experience
heparin-induced
thrombocytopenia, it is beneficial to use non-heparin
anticoagulants such as bivalirudin or argatroban as
prophylactic treatment over fondaparinux or rivaroxaban
(36). In more critically ill COVID-19 patients, the use of
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pneumatic
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Malas MB, Naazie IN, Elsayed N, Mathlouthi A,
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CONCLUSION
For each component of Virchow’s triad, we have provided
a plausible mechanism by which COVID-19 may induce
venous and, rarely, arterial thrombosis. Similar to its
predecessor, SARS-CoV, the infection caused by SARSCoV-2 virus is thought to recruit pro-inflammatory
cytokines and cause excess stimulation of the coagulation
cascade resulting in hypercoagulability. As a result of the
cytokine storm response to COVID-19 infection, the
production of IL-6 and ROS downregulated ADAMTS13
enzyme allowing ULVWF to contribute to endothelial
injury and in situ thrombosis. Finally, COVID-19
infection may promote venous stasis, the final component
of Virchow’s triad, as infected patients experience fatigue
and immobilization during hospitalization, which further
increases the risk of adverse thrombotic events due to
reduced blood flow. Anticoagulation drugs should be
considered a front-line therapy for patients requiring
hospitalization and empiric therapeutic dosing for those
needing ICU admission. In conclusion, COVID-19
patients are at a greater risk of blood clotting due to the
mechanisms defined by Virchow’s Triad.
10. Gabutti G, d’Anchera E, Sandri F, Savio M, Stefanati
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N, Herrler T, Erichsen S, Schiergens T, Herrler G,
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14. Lawrence LLK. Disseminated intravascular
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23. Chen J, Fu X, Wang Y, et al. Oxidative modification
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2020;33(4):e00028-20. doi:10.1128/CMR.00028-20
26. Malone RW, Tisdall P, Fremont-Smith P, et al.
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17. Ho WK, Hankey GJ, Lee CH, Eikelboom JW.
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19. Varatharajah N. COVID-19 Clot: What Is It? Why in
the Lungs? Extracellular Histone, “Auto-Activation”
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ACKNOWLEDGMENTS
29. Kohorst MA, Warad DM, Nageswara Rao AA,
Rodriguez V. Obesity, sedentary lifestyle, and video
games: The new thrombophilia cocktail in
adolescents. Pediatr Blood Cancer. 2018;65(7):e27
041. doi:10.1002/pbc.27041
We would like to thank our primary investigator, Dr.
Gary Lemmon, for this opportunity. As a retired
vascular surgeon, his commitment and passion for
academia is admirable. We would not have been able
to accomplish this work without his constant
guidance and critiques along the way.
30. Maier CL, Truong AD, Auld SC, Polly DM,
Tanksley CL, Duncan A. COVID-19-associated
hyperviscosity: a link between inflammation and
thrombophilia?. Lancet. 2020;395(10239):17581759. doi:10.1016/S0140-6736(20)31209-5.
We would like to also thank our parents for the
inspiration behind this work. As frontline fighters,
they have fought the grueling battle against COVID19 in efforts to save patients day in and day out. Their
constant support and love have brought us to where
we are today. Thank you.
31. Bi X, Su Z, Yan H, et al. Prediction of severe illness
due to COVID-19 based on an analysis of initial
Fibrinogen to Albumin Ratio and Platelet count.
Platelets. 2020;31(5):674-679. doi:10.1080/095371
04.2020.1760230
CONFLICTS OF INTEREST
All authors declare no conflicts of interest.
AUTHOR CONTRIBUTIONS
32. Kreuziger LB, Lee A, Garcia D, et al. COVID-19 and
VTE/Anticoagulation: Frequently Asked Questions.
COVID-19 and VTE-Anticoagulation - Hematology.
org. Published September 18, 2020. Accessed
October 15, 2020. https://www.hematology.org/
covid-19/covid-19-and-vte-anticoagulation.
Conceptualization: GWL
Methodology: JPN, AKM, GWL
Investigation: JPN, AKM, GWL
Project administration: GWL
Supervision: GWL
33. Moores LK, Tritschler T, Brosnahan S, et al.
Prevention, Diagnosis, and Treatment of VTE in
Patients With Coronavirus Disease 2019: CHEST
Guideline and Expert Panel Report. Chest.
2020;158(3):1143-1163. doi:10.1016/j.chest.2020.
05.559
Writing – original draft: JPN, AKM, GWL
Writing – review & editing: JPN, AKM, GWL
34. Tang N, Bai H, Chen X, Gong J, Li D, Sun Z.
Anticoagulant treatment is associated with decreased
mortality in severe coronavirus disease 2019 patients
with coagulopathy. J Thromb Haemost. May
2020;18(5):1094-1099. doi: 10.1111/jth.14817.
35. Paranjpe I, Fuster V, Lala A, et al. Association of
Treatment Dose Anticoagulation with In-Hospital
Survival Among Hospitalized Patients With COVID19. J. Am. Coll. Cardiol. 2020;76(1):122-124.
https://doi.org/10.1016/j.jacc.2020.05.001
36. Zhai Z, Li C, Chen Y, et al. Prevention and Treatment
of Venous Thromboembolism Associated with
Coronavirus Disease 2019 Infection: A Consensus
Statement before Guidelines. Thromb Haemost.
2020;120(6):937-948. doi:10.1055/s-0040-1710019.
37
Journal of Medical Sciences at NEOMED
Volume 1, Issue 1, August 2022
Efficacy of the Glasgow Coma Scale in Determining the Severity of Traumatic Brain Injury
Vihanga Perera, MD1*, Harris Imam, MD2, Percival Pangilinan, MD3
1.
2.
3.
Northeast Ohio Medical University, College of Medicine, Rootstown, OH, 44272
Parkview Health; Fort Wayne, IN
Michigan Medicine; Ann Arbor, MI
* Corresponding author
ABSTRACT
Mr. D, a 52-year-old male, was in an un-helmeted motorcycle collision with a concrete barrier resulting in
polytrauma and traumatic brain injury. Mr. D was assessed by emergency services to be unresponsive with a
Glasgow Coma Scale (GCS) of 13. He sustained an open skull injury, subdural hematoma, multiple facial
fractures, and traumatic vitreous humor hemorrhage with unresponsive, dilated pupils. He received CT and
X-ray imaging before undergoing multiple surgeries for repair and debridement of injuries. After being
weaned off sedation, he entered a state of post-traumatic amnesia lasting two months. Fifteen days postaccident, he began a regimen of amantadine to stimulate interaction and participation in physical therapy. Mr.
D remained for two months until he progressed with physical therapy and was independent with his mobility.
He was admitted to an inpatient traumatic brain injury facility because he was mentally unable to care for
himself.
Keywords: Traumatic Brain Injury, Glasgow Coma Scale, Physical Medicine & Rehabilitation
further classify TBIs as severe (GCS 3-8), moderate (GCS
9-13), or mild (GCS 14-15). This is meant to be an
objective measure to gauge clinical status and outcome at
the time of injury as well as progression over time. Serial
GCS can be used to follow patients and assess their
improvement or deterioration following a TBI (3).
INTRODUCTION
Traumatic brain injury (TBI) is abnormal brain
functioning resulting from an external injury (1). TBIs are
characterized by three periods – impaired consciousness,
post-traumatic amnesia (PTA), and functional recovery
(2). PTA is defined as a period of time when a person is
unable to retain new information following a TBI (2). It is
an important indicator of long-term outcomes post-TBI
(2). The duration of PTA is closely tied with functional
outcomes with long durations of PTA correlating with
decreased functionality (2). The initial severity of TBI is
evaluated with the Glasgow Coma Scale (GCS) whereas
PTA can be assessed with the Galveston Orientation and
Amnesia Test (GOAT) and the Orientation Log (O-Log).
The GOAT is a 10-item questionnaire measuring the
patient’s orientation to time, place, and person in addition
to assessing PTA and retrograde amnesia. PTA differs
from retrograde amnesia in that PTA describes an
inability to form new memories for a period of time
following the TBI, while retrograde amnesia is the loss of
memories just prior to the accident. The GOAT is scored
out of 100 with scores of less than 75 indicating ongoing
PTA. Emergence from PTA is indicated by two
consecutive scores of greater than 75 on the GOAT (2).
The GCS is composed of three parts – eye opening (scored
1 to 4), verbal response (scored 1 to 5), and motor
response (scored 1 to 6). Lower scores on each part
indicate decreased functioning and, therefore, a more
severe injury. The sum of the three scores is used to
The O-Log is also a 10-item questionnaire that measures
orientation more specifically than the GOAT; the O-Log
assesses orientation to city, kind of place, name of
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Perera, et al
hospital, month, date, year, day of week, clock time,
traumatic event/accident, and injury/deficits resulting
from the accident. Each of these measures are scored out
of three for a total of 30 points. The goal of the O-Log is
to follow orientation improvements over time (4). This
case report seeks to highlight the limitations of GCS in
predicting the duration of PTA and prognosis post-TBI
and to consider how the initial GCS can be improved to
better evaluate patients at the scene of trauma.
DISCUSSION
Mr. D is a 52-year-old male who sustained a TBI and
polytrauma after an un-helmeted high-speed motorcycle
collision with a concrete barrier. His TBI was initially
judged to likely be mild at the time of presentation, though
his GCS of 13 indicated a moderate TBI. His hospital
course was prolonged with PTA and agitation lasting two
months, an indication of severe TBI and a poor prognosis
of decreased functional recovery.
CASE DESCRIPTION
There are several factors of TBI that make assessment of
injury and treatment difficult. Patients are often assessed
with the GCS soon after traumatic injuries, which also
gives a rough estimate of the severity of TBI (3). The
patient’s initial GCS was scored at 13, indicating a
moderate TBI. His recovery in the hospital was
prolonged, and his orientation was assessed every few
days with the O-Log and GOAT to determine the duration
and severity of PTA. He remained in PTA for just over
two months, suggesting that the TBI he incurred was
severe. This can be assumed because patients with severe
TBI often have PTA, the length of which can be used as a
prognostic indicator of long-term outcomes post-TBI (2).
The length of time the patient remained in PTA, just over
two months, suggests that he will have less functional
outcomes and goals and is unlikely to ever be able to
return to work or recover fully from this accident.
Mr. D, a 52-year-old male, was an un-helmeted
motorcycle driver who presented to the Emergency
Department following a high-speed collision with a
concrete barrier. His initial GCS was 13, and he tested
positive for alcohol, amphetamines, cocaine, and opiates.
He had sustained a frontal open-skull injury, bilateral
frontal subdural hematomas with small contusions, minor
brain contusion, multiple facial fractures, proximal ulnar
and humeral medial epicondylar fractures of the left
elbow, and traumatic vitreous humor hemorrhage with
dilated pupils unresponsive to light. He underwent several
surgeries to clean wounds, beginning a lengthy treatment
process. Surgeries included tracheostomy, facial fracture
repair, maxillomandibular fixation to wire his jaw shut,
washout of the left elbow fracture with external fixation,
irrigation and debridement of left elbow open fracture,
and partial extensor tendon repair to left middle finger.
The disconnect between the patient’s GCS and resulting
estimated prognosis was found to be highly inaccurate
compared to the reality of his prolonged hospital stay and
duration of PTA. The GCS is commonly used to assess
TBI in emergent situations because it is easily
administered. However, the inconsistency of the initial
GCS and the patient’s outcomes in this case has raised
concerns about whether GCS is the best scale for initial
assessment of TBI. A highly inaccurate prognosis given
too early to patient families can cause distress when
patients do not recover as quickly or as completely as
estimated. The GCS will need modification to improve its
accuracy in determining TBI severity. GCS needs to give
a more accurate representation of severity of TBI and
better estimation of functional recovery. O-Log and
GOAT both include measures of orientation whereas GCS
only assesses body functions – do the eyes open? are they
responsive to light? – which fail to account for mental
functioning and orientation. In the initial patient
assessment with GCS, it would be helpful to include parts
of the GOAT or O-Log to create a more accurate modified
GCS and allow for a better assessment of patients
following trauma.
An initial assessment by the Physical Medicine &
Rehabilitation (PM&R) physician predicted a mild TBI
with short-lived, if any, agitation. This proved to be an
inaccurate prediction. The patient remained sedated for
three days after his accident. After being weaned off
sedation, he continued to be somnolent and difficult to
arouse. During his hospital stay, the patient required nonviolent restraints at several points. He was in a state of
PTA and had difficulty paying attention and following
commands. After being in the hospital for 15 days, the
patient was given 100-mg Amantadine twice a day to help
stimulate interaction and his participation in therapies. He
remained in a PTA state for approximately two months.
He was not qualified for admission into inpatient
rehabilitation because adequate supervision after
discharge is required at the time of admission, so he
remained in the acute care surgery unit for the entirety of
his hospital stay. He progressed with therapies during his
hospitalization to the point where he became independent
with his mobility and no longer had any physical therapy
goals necessitating an inpatient rehabilitation admission.
The PM&R physician recommended that Mr. D be
transferred to an inpatient TBI facility for further care.
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Perera, et al
CONCLUSIONS
CONFLICTS OF INTEREST
The length and severity of PTA is a good indicator of
long-term functional outcomes following a TBI. The GCS
is quick and easily administered, though it is not always
adequate in determining the severity of a TBI and is not
always accurate in estimating prognosis. In the future,
research should evaluate whether the GOAT or the O-Log
are better measures for determining severity and length of
PTA and which allows for better monitoring over time.
More precise protocols are needed for the treatment of
patients with severe TBI, and future controlled studies
should work to improve the efficacy of the assessments as
well as the treatments used.
All authors declare no conflicts of interest.
AUTHOR CONTRIBUTIONS
Conceptualization: VP, PP
Methodology: VP, PP
Investigation: PP, HI, VP
Visualization: VP
Funding acquisition: VP
Project administration: PP, HI
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Cline DM, Thomas SH. eds. Tintinalli's Emergency
Medicine: A Comprehensive Study Guide, 9e.
McGraw-Hill; Accessed March 08, 2021.
https://accessmedicine-mhmedical-com.neomed.
idm.oclc.org/content.aspx?bookid=2353§ionid=
221181086.
4.
Jackson WT, Novack TA, Dowler RN. Effective
serial measurement of cognitive orientation in
rehabilitation: the Orientation Log. Arch Phys Med
Rehabil. June 1998;79(6):718-720. doi:10.1016/
s0003-9993(98)90051-x.
Writing – review & editing: VP, HI, PP
FUNDING
Academy of American Physiatrists Medical Student
Summer Clinical Experience (VP)
40
Journal of Medical Sciences at NEOMED
Volume 1, Issue 1, August 2022
Robotic Assisted Laparoscopic Prostatectomy Post-Prostatic Urethral Lift Implants
Matthew R. DeSanto, MD1,2* and Daniel J. Ricchiuti, MD1
1.
2.
Northeast Ohio Medical University, College of Medicine, Rootstown, OH, 44272
Department of Urology, Charleston Area Medical Center, Charleston, WV, 25304
* Corresponding author
ABSTRACT
Prostate cancer is the second most commonly diagnosed form of cancer in men. While there are several
treatment options for prostate cancer, robotic assisted laparoscopic prostatectomy is a customary option in
the treatment of clinically localized disease. It entails prostate removal using the Intuitive da Vinci surgical
system. Another very prominent urologic condition affecting older males is benign prostatic hyperplasia
(BPH); BPH has an increased lifetime prevalence reaching 80% of men by the 9th decade of life. It is
characterized by lower urinary tract symptoms due to prostatic enlargement. These conditions often develop
concomitantly in males given the high prevalence of each. Surgical advancements such as the prostatic
urethral lift (PUL) system are becoming more commonly utilized. However, patients with benign prostatic
hyperplasia who independently develop clinically significant prostate cancer may necessitate definitive
management, namely prostatectomy. In this case report, we discuss a 67-year-old male presenting with
Gleason group 2 (3+4=7) prostate cancer with previous PUL implants, who then underwent robotic assisted
laparoscopic radical prostatectomy. Prostatectomy following prior PUL implantation has never been fully
discussed in the literature, and there are no intraoperative or postoperative complications from prostatectomy
to report thus far.
Keywords: Prostatectomy, Prostate Cancer, Benign Prostatic Hyperplasia, Prostatic Urethral Lift
4+3=7, Grade 4 is 4+4=8, and Grade 5 is any score
equating to 9 or 10 total. Gleason scoring, prostatespecific antigen, patient history, and physical exam are all
essential for the diagnosis and treatment plan of prostate
cancer.
INTRODUCTION
Prostate cancer is one of the most pervasive oncologic and
urologic conditions that males endure. It is the second
most commonly diagnosed cancer in males, second only
to lung cancer (1). Depending on patient presentation and
prostate cancer grading, options such as prostatectomy or
radiation therapy may be pursued. There are many factors
for clinicians to consider in the course of prostate cancer
workup, and grading methods such as the Gleason grade
and score remain the gold standard. Gleason grading is
comprised of two Gleason scores. The Gleason system is
a scoring system from 1-5, where 1 most histologically
represents normal prostate cells and 5 is most resemblant
of high-grade cancerous cells (2). The first number is the
most predominant type of cell from the biopsy, and the
second number is the second most predominant. Grade 1
is a scoring of 3+3=6, Grade 2 is 3+4=7, Grade 3 is
BPH is another frequently diagnosed urologic condition.
As the name suggests, BPH is a proliferation of smooth
muscle and epithelial cells within the prostatic transition
zone typically due to increased levels of androgens (3).
Due to this enlargement, outflow from the bladder to the
proximal urethra can be greatly diminished. Men may
experience more lower urinary tract symptoms (LUTS) as
the prostate tissue grows. LUTS constitutes symptoms of
urinary urgency, frequency, straining, nocturia, and
intermittency of urinary stream (4). The prostatic urethral
lift system is a novel therapy intended for the treatment of
BPH.
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DeSanto & Ricchiuiti
The PUL system was first studied in 2011 and since then
has obtained FDA approval in the United States and the
United Kingdom as a minimally invasive therapy for BPH
(5). The PUL procedure is unique in comparison to other
endoscopic treatments for BPH in that the technology is
mechanical rather than cavitating or ablative, such as
transurethral resection of the prostate (TURP) (6,7).
TURP has historically been the “gold standard” surgical
procedure for relief of BPH. As mentioned, TURP is an
ablative procedure that entails highly charged
electroresection to remove prostate tissue (8). With PUL,
non-absorbable implants are placed transurethrally to lift
and hold enlarged prostate tissue in order to increase the
urethra’s lumen and decrease outflow obstruction (Fig. 1).
This system has become increasingly more popular as an
alternative to TURP and other surgical BPH treatment
options, given the lower incidence of side effects coupled
with favorable sexual, urinary, and functional outcomes
(9). Now, if patients have a large median prostatic lobe or
if total prostate volume is greater than 80 grams, patients
are not candidates for PUL. Regardless, PUL has become
increasingly more utilized.
standard recommendations of 4-6 implants. The patient
continued to experience LUTS such as hesitancy,
nocturia, and weak urinary stream. Three supplementary
PUL implants were placed in 2020 in response to his
persistent symptomology.
Given the concerning MRI findings, the patient was rebiopsied for evaluation of prostate cancer approximately
three months after the additional implants. The repeat
biopsy revealed Gleason grade 2 (3+4=7) prostate cancer.
Furthermore, Decipher testing, which is a genomic test to
help further stratify biopsied prostate cancer and guide
treatment management, indicated the cancer was
clinically significant high-risk disease (13). The results of
this test further ascertained the need for definitive prostate
cancer treatment.
We discussed with the patient how our literature search
showed minimal information regarding prostatectomy
following PUL implants. The patient was scheduled for
robotic assisted laparoscopic radical prostatectomy at the
end of 2020. Emphasis was made to identify the PUL
implants when dissecting the prostate. In total, seven PUL
implants were identified. There was little difficulty
identifying the urethral end piece and the capsular tab of
each prostatic urethral lift device. The urethral end piece
is considered the inner portion of the device while the
capsular tab is the outer metallic clip. Care was taken to
minimize cautery usage around the clip as this resulted in
arcing. There were no abnormal fibrotic tissue changes
surrounding the implants; dissection and extraction of the
implants were not problematic. The capsular tabs were
disconnected from the suture and were individually
removed. The urethral end pieces and sutures from the
seven PUL implants were left with the prostate specimen.
The remainder of the operation and dissection was
uneventful for robotic prostatectomy. Vesicourethral
anastomosis was achieved without any unexpected
difficulties. There was no other evidence of inflammation
or adherence surrounding the prostate in the surgical field
of view. There was no additional challenge encountered
to nerve-sparing technique.
The TURP procedure, and now PUL, aim to relieve LUTS
secondary to BPH. However, patients undergoing these
procedures may still develop prostate cancer
concomitantly that is unrelated to their BPH. Typical
management options for prostate cancer, such as active
surveillance, prostatectomy and radiation therapy, are
logical to consider for these patients. Specifically, robotic
assisted laparoscopic prostatectomy has become
increasingly employed compared to open prostatectomy.
Robotic prostatectomy offers many benefits such as
improved surgical view, reduced blood loss, and lower
incidence of urinary incontinence and erectile dysfunction
when compared to open technique (10). While the L.I.F.T
study briefly mentions two instances of prostatectomy
after PUL at 2 and 5 year follow-ups, this is not discussed
in depth (11,12). There are currently no case reports in the
literature detailing the full course of prostatectomy after
the placement of PUL devices.
CASE REPORT
DISCUSSION
This case report details a 67-year-old otherwise healthy
male who was in active surveillance for low risk prostate
cancer. He was diagnosed with low volume Gleason grade
3 prostate cancer in 2013, and elected to be managed with
active surveillance. Surveillance magnetic resonance
imaging (MRI) of the prostate seven years later revealed
a 47-gram prostate with a new nodular mass measuring
11mm.
Findings recorded in this case report are significant
because there was an absence of difficulties, and radical
prostatectomy performed as usual despite the prior
placement of PUL implants. It was theorized that there
may be increased adhesions surrounding the prostate
given the presence of foreign bodies, making dissection
more difficult. Moreover, we were unsure how the
implants would affect our ability to use electrocautery for
extraction. This patient also had three additional implants
due to continual LUTS.
Additionally, four PUL implants were placed for BPH
relief at an outside institution in 2019, aligning with
42
JMS, August 2022 – Volume 1, Issue 1
DeSanto & Ricchiuiti
Figure 1. Benign prostatic hyperplasia before prostatic urethral lift implantation (a) and following four prostatic urethral lift implants
(b). (A) Diagram showing an enlarged prostate that significantly obstructs urinary tract outflow from the bladder through the urethra. (B) Placement
of four prostatic urethral lift implants to unobstruct urinary flow.
surgical setting. Prostatectomy was performed for this
patient without deviation from standard operative
technique. Furthermore, there are no intraoperative or
postoperative complications to report following
prostatectomy thus far. This case report will aid urologists
in their decision-making when similar clinical scenarios
arise. Our case shows that prostatectomy in the setting of
prior PUL implantation is feasible and, in this case, added
no additional challenge to robotic prostatectomy.
Usually patients do not require additional PUL implants,
so this did add some consideration in regard to more
adhesions. However, the number of implants did not
greatly impact the decision to pursue prostatectomy as
this was necessary to treat the patient’s prostate cancer.
Ultimately, the patient tolerated the procedure well and
has been seen in the postoperative period. He is currently
without clinical evidence of prostate cancer recurrence.
The patient has had minimal LUTS and incontinence
post-surgery. He has not reported significant worsening of
sexual function following prostatectomy.
REFERENCES
The absence of unexpected events is encouraging as the
prostatectomy was performed safely and efficiently
without compromising surgical technique. Prostate cancer
and BPH are both highly prevalent urologic conditions. It
is common for both pathologies to develop
concomitantly. Therefore, as the PUL procedure becomes
more widely adopted for BPH relief, it is reasonable for
urologists to expect to encounter patients with PUL
implants that have later developed prostate cancer.
It would be advantageous to see additional case reports of
prostatectomy in patients with BPH who received PUL
implants. Specifically, seeing how different Gleason
grades affected the ability to extract the implants during
prostatectomy, if at all, would be beneficial.
1.
American Cancer Society. Key Statistics for Prostate
Cancer. Published January, 12, 2021. Accessed June
25, 2021. https://www.cancer.org/cancer/prostatecancer/about/key-statistics.html
2.
Epstein JI, Egevad L, Amin MB, Delahunt B, Srigley
JR, Humphrey PA. The 2014 International Society of
Urological Pathology (ISUP) Consensus Conference
on Gleason Grading of Prostatic Carcinoma:
Definition of Grading Patterns and Proposal for a
New Grading System. Am J Surg Pathol. Feb
2016;40(2):244-52. doi:10.1097/pas.000000000000
0530
3.
Wein, AJ, Kavoussi, LR, Campbell, MF. CampbellWalsh Urology. 12th ed. Philadelphia, PA: Elsevier
Saunders. 2020.
4.
Parsons JK. Benign Prostatic Hyperplasia and Male
Lower Urinary Tract Symptoms: Epidemiology and
Risk Factors. Curr Bladder Dysfunct Rep. Dec
2010;5(4):212-218. doi:10.1007/s11884-010-0067-2
CONCLUSION
This is the first known case report of radical
prostatectomy in a patient with PUL implants in place.
Without other significant literature, it was uncertain what
complications or challenges would be faced in the
43
JMS, August 2022 – Volume 1, Issue 1
DeSanto & Ricchiuiti
5.
6.
7.
Jones P, Rai BP, Aboumarzouk O, Somani BK.
UroLift: a new minimally-invasive treatment for
benign prostatic hyperplasia. Therapeutic advances
in urology. 2016;8(6):372-376. doi:10.1177/17562
87216671497
CONFLICTS OF INTEREST
All authors declare no conflicts of interest.
AUTHOR CONTRIBUTIONS
Garcia C, Chin P, Rashid P, Woo HH. Prostatic
urethral lift: A minimally invasive treatment for
benign prostatic hyperplasia. Prostate international.
2015;3(1):1-5. doi:10.1016/j.prnil.2015.02.002
Conceptualization: MRD, DJR
Bozkurt A, Karabakan M, Keskin E, Hirik E, Balci
MB, Nuhoglu B. Prostatic Urethral Lift: A New
Minimally Invasive Treatment for Lower Urinary
Tract Symptoms Secondary to Benign Prostatic
Hyperplasia. Urol Int. 2016;96(2):202-6. doi:10.
1159/000441850
Visualization: MRD, DJR
8.
Teo JS, Lee YM, Ho HSS. An update on transurethral
surgery for benign prostatic obstruction. Asian
journal of urology. 2017;4(3):195-198. doi:10.1016/
j.ajur.2017.06.006
9.
Perera M, Roberts MJ, Doi SA, Bolton D. Prostatic
urethral lift improves urinary symptoms and flow
while preserving sexual function for men with benign
prostatic hyperplasia: a systematic review and metaanalysis. Eur Urol. Apr 2015;67(4):704-13. doi:10.
1016/j.eururo.2014.10.031
Methodology: MRD, DJR
Investigation: MRD, DJR
Project administration: MRD, DJR
Supervision: DJR
Writing – original draft: MRD
Writing – review & editing: MRD, DJR
10. Finkelstein J, Eckersberger E, Sadri H, Taneja SS,
Lepor H, Djavan B. Open Versus Laparoscopic
Versus Robot-Assisted Laparoscopic Prostatectomy:
The European and US Experience. Reviews in
Urology. 2010;12(1):35-43.
11. Roehrborn CG, Gange SN, Shore ND, et al.
Durability of the Prostatic Urethral Lift: 2-Year
Results of the L.I.F.T. Study. Urology Practice.
2015;2(1):26-32. doi:doi:10.1016/j.urpr.2014.08.001
12. Roehrborn CG, Barkin J, Gange SN, et al. Five year
results of the prospective randomized controlled
prostatic urethral L.I.F.T. study. Can J Urol. Jun
2017;24(3):8802-8813.
13. Dalela D, Löppenberg B, Sood A, Sammon J,
Abdollah F. Contemporary Role of the Decipher®
Test in Prostate Cancer Management: Current
Practice and Future Perspectives. Reviews in urology.
2016;18(1):1-9.
44
Journal of Medical Sciences at NEOMED
Volume 1, Issue 1, August 2022
Improving Community Health by Encouraging Remote Office Visits
Rachel Krevh, BS1*, Eliot Mostow, MD, MPH2
1.
2.
Northeast Ohio Medical University, College of Medicine, Rootstown, OH, 44272
Akron Dermatology; 566 White Pond Dr, Akron, OH, 44320, USA
* Corresponding author
ABSTRACT
The COVID-19 pandemic has affected patient access to healthcare in the field of dermatology. Due to efforts
to minimize in-person healthcare visits, wait times for dermatology visits have increased, negatively affecting
patients’ finances and furthering concerns about their skin conditions. This commentary highlights how the
pandemic will potentially change the future of dermatology by promoting the use of telemedicine to reduce
office wait times during the pandemic and beyond.
Keywords: Telemedicine, Teledermatology, COVID-19, Dermatology, Remote, Wait Times
like atopic dermatitis, psoriasis, and impetigo can lead to
morbidity and mortality if not detected in a timely fashion
(2). Long wait times for in-person dermatology
appointments were problematic even before COVID-19
and have further worsened for patients whose conditions
are deemed ‘non-emergent’ amid office-visit restrictions
brought upon by the pandemic (1). The extended wait
times have led to quality-of-life issues and financial
burdens such as paying for over-the-counter medications
to maintain the conditions (2). However, the pandemic
has shown that telemedicine is an effective resource to
relieve the burdens experienced by patients and follow-up
with them over time to see treatment progress (2).
INTRODUCTION
The COVID-19 pandemic has affected all aspects of the
healthcare field, particularly in dermatology. Conditions
presented in the field of dermatology may generally be
considered non-emergent during a pandemic.
Furthermore, patients with non-acute conditions such as
alopecia and acne have had their visits and procedures
postponed to maintain social distancing (1). The long wait
times for appointments are problematic due to financial
burdens for patients to self-maintain their skin conditions
while waiting for appointments. There is also added fear
and anxiety when waiting and concerns that skin
conditions will worsen. The pandemic has proven that
dermatology visits can proceed via telemedicine, and
patients can have their skin conditions resolved with
expedience through approved online platforms (2). The
ability for telemedicine to present socially distanced skin
findings in real time can be a way to resolve the long-wait
times even after the pandemic (Fig. 1).
Temporary policy changes in the United States have been
implemented to allow physicians and patients to remain
connected via telemedicine during the pandemic (3).
These changes allow communication without violating
HIPAA, provided that the encounters adhere to certain
regulations. For example, dermatologists may
communicate with patients over “non-public facing”
applications such as FaceTime, Zoom, and iMessage (4).
It is suggested for patients to establish telemedicine visits
with in-state medical practices to allow for easier access
to appointments after the pandemic (5).
DISCUSSION
In dermatology, there is a continued need to screen,
monitor, and treat skin conditions that may affect the
future health of a patient. Skin cancers (melanoma and
non-melanoma types) and other progressive skin diseases
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Krevh & Mostow
Within the private media platforms that allow for
telemedicine, there are several ways for the patient to
present their skin condition to the dermatologist. One is
through the exchange of pictures that target the lesion, and
another is through video visits. This depends on the
request of the dermatologist (6). Although dermatologists
cannot physically examine skin lesions through a screen,
being able to visualize the patient’s general appearance
and extent of disease is helpful in monitoring disease
progression and guiding treatment.
allow a broader range of telemedicine services and
provide appropriate physician compensation is currently
being discussed to address these issues and allow for a
more effective dermatological practice.
Before the pandemic, there were barriers to telemedicine
that prevented its widespread adoption. For example,
physicians invested in costly HIPAA-compliant platforms
to complete the telemedicine visits. Furthermore, the
physician and patient were required to have previously
established care before the telemedicine visit (7). The
temporary cessation of regulations for telemedicine have
shown that visits can still be effective for patient health
and resolve the long wait-time issues for dermatology
visits.
There are efforts to make long-lasting changes to
regulations with telemedicine, which can change the
future of dermatology visits and their long wait times (8).
These efforts include expanding broadband networks,
allowing insurers to provide reimbursement for remote
visits, and increasing digital literacy (8). Insurance
programs and healthcare providers have also supported
the transition to telemedicine during the pandemic. They
offer waivers, flexibility, and reimbursements state-bystate. It is imperative to view state guidelines for
telehealth before beginning telemedicine visits. Also, it is
important to be cognizant of patients’ levels of comfort
with technology. Low income and less educated
populations may need resources to understand and utilize
telemedicine. Hospitals can partner with public libraries
and colleges to design educational programs and
technology classes. These programs should be in multiple
languages and offer 24/7 online help for those who may
not know how to use these resources (9).
CONCLUSION
Although the COVID-19 pandemic has brought along
many uncertainties, it has addressed a long-standing issue
with dermatology visits: a solution to the long wait times
that patients experience when getting their skin conditions
checked. This pandemic has shown that telemedicine is a
valuable resource that should be adopted throughout the
rest of the pandemic and beyond. With the ability to
conduct virtual physical exams, observe skin lesions
through video, and send pictures of skin conditions
through online modalities, these visits can be effective
and address patient concerns. Future legislative action to
Figure 1. Access to dermatology care during COVID-19
REFERENCES
46
JMS, August 2022 – Volume 1, Issue 1
Krevh & Mostow
9.
REFERENCES
1.
Bhargava S, Negbenebor N, Sadoughifar R, Ahmad
S, Kroumpouzos G. Global impact on dermatology
practice due to the COVID-19 pandemic. Clin
Dermatol. 2021;39(3):479-487. https://doi.org/10.
1016/ j.clindermatol.2021.01.017.
2.
Greater Access for Patients Partnership. Patients Are
Waiting: America’s Dermatology Appointment Wait
Times Crisis. Greater Access for Patients
Partnership. Accessed Aug 26, 2020. https://cdn.
ymaws.com/www.dermpa.org/resource/resmgr/GAP
P_Wait_Time_Report_final.pdf.
3.
National Center for Immunization and Respiratory
Diseases (NCIRD), Division of Viral Diseases. Using
Telehealth Services. Centers for Disease Control and
Prevention. Updated Jun 10, 2020. Accessed Aug 26,
2020. https://www.cdc.gov/coronavirus/2019-ncov/
hcp/telehealth.html.
Eruchalu C, Pichardo M, Bharadwaj, M, et al. The
Expanding Digital Divide: Digital Health Access
Inequities during the COVID-19 Pandemic in New
York City. Journal of Urban Health. 2021; 98
(2):183-186. doi:10.1007/s11524-020-00508-9
ACKNOWLEDGMENTS
We would like to acknowledge Northeast Ohio
Medical University for providing physician
mentoring resources, which allowed the medical
student and physician to be introduced and work on
this research project together.
CONFLICTS OF INTEREST
4.
All authors declare no conflicts of interest.
AUTHOR CONTRIBUTIONS
Conceptualization: RK, EM
Formal analysis: RK, EM
Health Resources and Services Administration, U.S.
Department of Health and Human Services. Policy
changes during COVID-19. Health Resources &
Services Administration. Accessed Aug 26, 2020.
https://telehealth.hhs.gov/providers/policy-changesduring-the-covid-19-public-health-emergency/.
Investigation: RK
Methodology: EM
Project administration: RK, EM
Resources: RK
5.
American Academy of Dermatology Association.
COVID-19: Teledermatology. Updated 2021.
Accessed Aug 26, 2020. https://www.aad.org/
member/practice/coronavirus/teledermatology.
Validation: EM
6.
Hanes, E. Dermatologist Visits During the COVID19 Pandemic. healthgrades. Updated Apr 21, 2020.
Accessed Aug 26, 2020. https://www.healthgrades.
com/right-care/coronavirus/dermatologist-visitsduring-the-covid-19-pandemic.
Writing – review & editing: RK, EM
7.
Caravan Health. Is Telehealth Here to Stay? What
you need to know about Medicare’s new virtual care
flexibilities. Caravan Health. Updated Jun 18, 2020.
Accessed May 28, 2021. https://caravanhealth.com/
thought-leadership/articles/is-telehealth-here-tostay-what-you-need-to-know-about-medicares-newvirtual-care-flexibilities/.
8.
Health Resources and Services Administration, U.S.
Department of Health and Human Services.
Telehealth during the COVID-19 emergency. HHS.
Accessed Mar 24, 2021.https://telehealth.hhs.gov/
patients/telehealth-during-the-covid-19-emergency/.
Visualization: RK
Writing – original draft: RK
47
Journal of Medical Sciences at NEOMED
Volume 1, Issue 1, August 2022
Enhancing Diversity in Medical Education Representation of Cutaneous Disease: VisualDx
Skin-of-Color Atlas
Arjun Pandya, MD, MBA1*, Jay Patel, MD1, Sarah Eley, BS1, Rachel Krevh, BS1, Kishan Pandya,
BS1, Rahul Mal, MD1, Kelly Kimball, BS1, Eliot Mostow, MD, MPH1,2
1.
2.
Northeast Ohio Medical University, College of Medicine, Rootstown, OH, 44272
Akron Dermatology; 566 White Pond Dr, Akron, OH 44320, USA
* Corresponding author
Keywords: Perspective, Bias, Dermatology, Medical Education
published in the Journal of the American Academy of
Dermatology. This prompted Adelekun et al. to launch an
investigation on how severely underrepresented SoC truly
is. According to their study published in April 2020, only
4.5% of images in general medicine textbooks illustrate
dermatologic diseases in dark skin (6). It is clear that the
underrepresentation of SoC in medicine is not a new
issue, and physicians worldwide are starting to notice the
injustice.
DISCUSSION
Cutaneous presentations of dermatologic and systemic
disease may vary widely based on a patient’s skin tone
(1). Recent studies have demonstrated that medical
education
resources
display
a
significant
underrepresentation of pathology in individuals with skin
of color (SoC). For example, only 24% of dermatologic
images in common medical school board materials
(Pathoma, Uworld, First Aid) represent pathology in SoC
(2). Another study showed that medical students are more
likely to misdiagnose conditions on images with SoC,
including squamous cell carcinoma, urticaria, and atopic
dermatitis (3). The differences in presentation based on
skin tone can be seen in Figures 1 and 2: two potentially
life-threatening infectious diseases with diagnosis
necessary in a timely manner. Accurately diagnosing
these conditions without proper exposure during medical
training can pose a major challenge. With an expanding
population of approximately 40% of United States
citizens being of SoC, it is crucial that medical students
receive proper training in identifying conditions on
patients of all skin tones (4).
VisualDx is an award-winning diagnostic clinical
decision support system that has taken steps to combat
this healthcare inequality. It is an innovative tool that has
nearly 29% of its leading medical image library
representing presentations in SoC (1). This virtual
platform has a leading SoC atlas with a user-friendly
interface that allows for rapid diagnosis in real-time. By
listing the chief complaint, location of the finding,
symptoms/signs, or other notable findings, VisualDx can
identify differential diagnoses and visual depictions that
match the listings. The SoC atlas allows skin conditions
to be identifiable across several races. The company has
also launched Project IMPACT, a global effort to address
implicit bias in medicine. Project IMPACT hosts monthly
webinars that educate healthcare professionals and
students on cultural awareness in medical practice,
identifying diseases on SoC and new advancements for
treating skin conditions.
The COVID-19 pandemic has recently brought to light
the gross underrepresentation of cutaneous pathology in
SoC. In early 2020, dermatologists created an
international registry to compile cases of dermatological
manifestaions of COVID-19, to gather clues to the disease
and aid diagnosis. Out of the 700 submissions to the
registry, there were only 34 Hispanic patients and 13
black patients represented (5). Despite the pandemic
starting in March, it took until July of 2020 for the first
pictures of "Covid toes" in nonwhite patients to be
At Northeast Ohio Medical University (NEOMED), we
also seek to use innovation to foster diversity and fight
racial disparities in medicine. With the help of a generous
donation and support from the Dermatology Interest
Group (DIG), NEOMED was able to purchase a one-year
subscription to VisualDx for all students in the College of
Medicine. We believe this software can be helpful to
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Pandya, et al
students in all stages of medical training. Preclinical
students can benefit by supplementing course material
with VisualDx and applying it toward relevant clinical
content. Meanwhile, students in their clinical years can
use the tool on rotations in an effort to reduce diagnostic
errors by augmenting a clinician’s point of view. We plan
to incorporate VisualDx into both preclinical and clinical
lectures to highlight the variance of skin pathology
presentation in SoC. We will aim to do this by
incorporating images of dermatopathological conditions
in SoC from VisualDx into the M1 and M2 NEOMED
lectures covering infectious disease and dermatology
topics. Currently, only several lectures explicitly
highlight disease presentations on SoC. We hope that by
bringing awareness to VisualDx as a resource of diversity
and inclusion, lecturers will have an easy way to locate
and incorporate images of SoC reflecting any cutaneous
disease they discuss in their lectures. Additionally, many
medical schools across the country have started
incorporating diversity, equity, and inclusion (DEI)
statements into their lectures and grand round
presentations to foster a more inclusive learning
environment. With the promotion of VisualDx, we hope
all NEOEMD associated faculty will gradually begin to
incorporate these DEIs into their curriculum and utilize
the images from VisualDx to practice inclusivity in
medicine. Ultimately, we hope to expand further
VisualDx access to the College of Pharmacy and
NEOMED postgraduate students to continue our goal of
enhancing diversity and improving healthcare outcomes.
Our research into the present substantial issue of
inequality in medicine has motivated us to make a
difference in the NEOMED community. In a year with a
global pandemic, our system has further shown its cracks
with the COVID-19 morbidity and mortality rate
disproportionately affecting black Americans (7).
However, maybe this enormous flaw in the healthcare
system is what it takes to start the conversation, to create
a movement. This step in improving the gap in medical
education is our small step, a step in the direction of
positive change, a step in the direction of equality in
healthcare.
Figure 1. Acute Meningococcemia in a patient with skin-of-color (SoC) (left) and in white skin (right). Note
difference in the optics of color- presentation of red rash on a dark background (presents as dark brown) versus
a white background. Image reproduced with permission from VisualDx (8).
Figure 2. Rocky Mountain Spotted Fever on patient with SoC (left) and white skin (right). Once again, note
subtle differences again with optics of color- presentation of a red rash on a dark REFERENCES
background versus a white
background. Image reproduced with permission from VisualDx (9).
49
JMS, August 2022 – Volume 1, Issue 1
Pandya, et al
Rochester NY: VisualDx 2021. Accessed April 8th,
2021. https://www.visualdx.com/visualdx/diagnosis/
rocky+mountain+spotted+fever?diagnosisId=52279
&moduleId=101
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Alvarado SM, Feng H. Representation of dark skin
images of common dermatologic conditions in
educational resources: a cross-sectional analysis. J
Am Acad Dermatol. 2021;84(5):1427-1431..
doi:10.1016/j.jaad.2020.06.041
ACKNOWLEDGMENTS
We sincerely thank Mr. Simon Robins, Dr. Erica
Stovsky, Dr. Eliot Mostow, the Dermatology Interest
Group, and the generous anonymous donors for their
contributions in acquiring and implementing
VisualDx to the NEOMED College of Medicine.
Jones VA, Clark KA, Shobajo MT, Cordova A,
Tsoukas MM. Skin of Color Representation in
Medical Education: An Analysis of Popular
Preparatory Materials Used for United States
Medical Licensing Examinations. J Am Acad
Dermatol. 2021;85(3):773-775.. doi:10.1016/j.jaad.
2020.07.112
CONFLICTS OF INTEREST
All authors declare no conflicts of interest.
Fenton A, Elliott E, Shahbandi A, et al. Medical
students' ability to diagnose common dermatologic
conditions in skin of color. J Am Acad Dermatol.
2020;83(3):957-958. doi:10.1016/j.jaad.2019.12.078
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Ghosh I. Visualizing the U.S. Population by Race.
Visual Capitalist. 2020. Accessed February 24th,
2021. https://www.visualcapitalist.com/visualizingu-s-population-by-race/
5.
Rabin RC. Dermatology has a problem with Skin
color. The New York Times. https://www.nytimes.
com/2020/08/30/health/skin-diseases-blackhispanic.html. Published August 30, 2020. Accessed
April 12, 2022.
6.
Adelekun A, Onyekaba G, Lipoff J. Skin color in
dermatology textbooks: An updated evaluation and
analysis. J Am Acad Dermatol. 2021;84(1):194-196.
doi:10.1016/j.jaad.2020.04.084
7.
Freeman EE, McMahon DE, Lipoff JB, et al. The
spectrum of COVID-19-associated dermatologic
manifestations: An international registry of 716
patients from 31 countries. J Am Acad Dermatol.
2020;83(4):1118-1129. doi:10.1016/j.jaad.2020.06.
1016
8.
Song P, Burgin S. Acute meningococcemia In:
Goldsmith LA, ed. VisualDx. Rochester NY:
VisualDx 2021. Accessed April 8th, 2021.
https://www.visualdx.com/visualdx/diagnosis/acute
+meningococcemia?diagnosisId=51948&moduleId
=101#:~:text=The%20clinical%20picture%20of%2
0acute,preceding%20upper%20respiratory%20tract
%20infection
9.
Burgin S, Lederman E, Craft N. Rocky Mountain
Spotted Fever. In: Goldsmith LA, ed. VisualDx.
AUTHOR CONTRIBUTIONS
Conceptualization: AP, JP, SE, EM
Writing – original draft: AP, JP, SE, RK, EM
Writing – review & editing: KK, KP, RM
50
Journal of Medical Sciences at NEOMED
Volume 1, Issue 1, August 2022
Human Connection Through Wi-Fi: Is it possible?
Sanaa Mansoor, MS, MD1*
1.
Northeast Ohio Medical University, College of Medicine, Rootstown, OH, 44272
* Corresponding author
LETTER TO THE EDITOR
Due to the COVID-19 pandemic, all medical student assessments at Northeast Ohio Medical University (NEOMED)
were redesigned to be performed virtually. This included my final standardized patient encounter. As nerve-wracking as
it may feel to perform any aspect of the physical examination, it serves as a rite of passage for medical students
transitioning into clinical rotations all around the country. My biggest concern was that my practice sessions and other
standardized patient encounters had always occurred in person over the course of my first two years of medical school.
Would I be able to successfully examine a patient virtually? Would I be able to connect with my patient to gather the
sometimes personal, yet pertinent, details of medical history through a virtual platform? Knowing specific questions to
review each organ system was not enough, and I knew I needed to identify more strategies to connect with patients.
Empathizing and connecting with my patient through a virtual platform proved to be much harder than I expected. I no
longer had the privilege or security of directly facing my patients. Human connection and empathy were the original
foundation of my history-taking and physical examination skills. Staring at my laptop screen, I practiced. I practiced
using my eyes to gaze with compassion. I practiced keeping my lips sealed to motivate my patient to overcome their
hesitations. I practiced using my hands to encourage my patient to open up and trust me with their problems. I practiced
nodding my head to affirm my patient’s feelings. Every part of my physical nature served to complement my purpose.
This was not so that my encounter would feel scripted. Rather, I did not want my screen to numb my non-verbal
communication skills just because I could hide behind it. On test day, I was able to virtually empathize with my patients
by making eye contact, listening to their problems, and trying to absorb each part of the conversation and guide it in the
direction the patient wanted. In the words of my standardized patient, “I felt you were truly listening and concerned
about me as your patient. When you consistently looked at the screen [maintaining eye contact] … I felt very important
and that I had your 100% attention throughout the encounter.”
During these unprecedented times, this feedback is promising. Although this encounter was different, I am grateful for
the unexpected exposure to telemedicine—a service that most medical students are not typically exposed to. This
experience has prepared me, as a future physician, to engage with patients via telemedicine as human connection is very
much possible with an online platform. For patients who are unable to travel, the elderly, or those whose needs can be
met via telemedicine, this is a great opportunity to receive the undivided attention and care of a physician. To start
honing my skills during my medical school education has been invaluable as the use of telemedicine will only continue
to grow in the field of medicine.
51
Journal of Medical Sciences at NEOMED
Volume 1, Issue 1, August 2022
Cardiac Metabolism in the Disease of Acute Myocardial Infarction
Nikhil Datla, MD1*, Chwen-Lih Chen, PhD1, Patrick Kang, PhD1, Yeong-Renn Chen, PhD1, Takhar
Kasumov, PhD1, Serguei Ilchenko, PhD1
1.
Northeast Ohio Medical University, College of Medicine, Rootstown, OH, 44272
* Corresponding author
ABSTRACT
Overproduced reactive oxygen species (ROS) with decreased oxidative phosphorylation is a hallmark of the
post-ischemic heart, which results in reperfusion-induced oxidative injury of the citric acid cycle (CAC).
During ischemia, hypoxic conditions slow down the CAC resulting in succinate accumulation. Succinate is
then rapidly oxidized during reperfusion, fueling ROS overproduction and contributing to ischemiareperfusion (I/R) injury. We test the hypotheses that 1) reperfusion re-accelerates the CAC to correct succinate
accumulation and 2) a vicious cycle caused by excess ROS can impair and downregulate the CAC plus other
metabolic pathways in the post-ischemic heart. Nine–ten-week-old Sprague-Dawley rats (n=15) were subject
to coronary ligation for 30-min followed by 24-h reperfusion. This process allowed us to closely mimic acute
myocardial infarction (MI) and I/R injury. The non-ischemic and risk-regions of myocardium were excised,
and the mitochondria were isolated. Dimethyl labeling was used to illuminate key metabolic pathways.
Previous studies showed data that I/R impairs ADP-dependent O2 consumption rate and ATP generation via
downregulating CAC and fatty acid β-oxidation. However, a major finding in our study was that I/R
dramatically upregulated the Phosphocreatine (PCr)/Creatine (Cr) shuttle (p<0.05) via upregulation of
mitochondrial S-type creatine kinase (Ckmt2). The increased PCr formed in the mitochondria is transferred
to the cytosol for ATP regeneration in-situ, which therefore increases the bioenergetic support of the postischemic myocardium. Therefore, we conclude that upregulating the PCr/Cr shuttle via increased Ckmt2
serves as feedback regulation of I/R, which can be useful for therapeutic intervention by increasing
oxygenation and bioenergetics of the ischemic heart.
52
Volume 1 | Issue 1 | August 2022
Volume 1, Issue 1, August 2022
DISCLAIMER
The Journal of Medical Sciences at NEOMED (Journal) was created to provide a platform for
students and faculty at Northeast Ohio Medical University (NEOMED) to publish original
research, opinion pieces, editorials, reviews, and other works. The Journal is entirely authored,
reviewed, and edited by NEOMED medical and graduate students working under the guidance of
faculty mentors. It accepts submissions ranging from basic science research and case reports to
personal experience essays. No student or faculty author has received, or will receive, any direct
monetary compensation for the work included in the Journal.
All works included in this Journal are copyrighted. Readers may make fair use of limited portions
of these reports so long as proper acknowledgment is given. Copy and distribution of substantial
portions of any work contained in the Journal may only be done with explicit written permission of
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[year], copyright owner: the Journal of Medical Sciences at NEOMED. Links to the final article on
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While a fully structured review and feedback process is employed for each submission, it is
specifically understood that NEOMED does not endorse, and specifically disclaims, responsibility
for the content of the works incorporated into the Journal.
Journal of Medical Sciences at NEOMED © 2021
Welcome Note From the Editor-in-Chief
I am thrilled to introduce the first edition of the Journal of
Medical Sciences (JMS) at NEOMED. The JMS is a peer-reviewed,
and multidisciplinary journal run by medicine, graduate, and pharmacy
students at Northeast Ohio Medical University. Fayez Safadi, Ph.D.,
and I created this student-led medical journal with the goal to foster
the research and ideas of University students, faculty members,
consortium hospital trainees, and affiliates, as well as to provide them
with the tools and platform to publish their findings. We are excited
by the outstanding opportunity the JMS provides for students in
leadership (editorial board) and authors in publication. I am excited to
share the work of our outstanding community in the first edition. The
first edition of the JMS is published both online and in print.
To find more information regarding the JMS at NEOMED visit our
website at neomed.edu/journal-of-medical-sciences/.
This project could not have been as successful without the unwavering
support I received from my mentor, Dr. Safadi. Thank you, Dr. Safadi,
for the immense amount of time you’ve dedicated to this endeavor
helping to bring the idea of a student-led medical journal to fruition. I
cannot wait to see what the future holds for the JMS, a future I am
certain will be bright.
Trinity Samson
Editor-in-Chief Journal of Medical Sciences
M.D./ Ph.D. Student at NEOMED
President/Editor-in-Chief:
Faculty and Affiliate Reviewers:
Trinity Samson (COM/COGS)
Khaled Adjerid, Ph.D. (NEOMED)
Brooke Babyak, M.D. (Summa Health)
Marquita Belen, M.D. (NEOMED)
Faculty Advisor:
John Boltri, M.D. (NEOMED)
Fayez Safadi, Ph.D. (NEOMED)
Rachel Bracken, Ph.D. (NEOMED)
David Drevna, M.D. (Mercy Health)
Vice President:
Stacey Gardner-Buckshaw, Ph.D., MPA (NEOMED)
Yoleetah Ilodi, M.D. (NEOMED)
Gabriel Mirhaidari (COM)
Paul Lecat, M.D. (NEOMED)
Andrew McElroy, M.D. (Wayne State University) Joseph
Editors:
McShannic, M.D. (Summa Health)
Sanjay Jinka (COM)
Neel Parekh, MD (Cleveland Clinic Foundation) Priya
Cooper Johnson (COM)
Raman, Ph.D. (NEOMED)
Ain Shajihan (COM)
Fayez Safadi, Ph.D. (NEOMED)
Keval Yerigeri (COM)
Mate Soric, Pharm.D., BCPS, FCCP (NEOMED) Yong Lu,
Ph.D. (NEOMED)
Peer Reviewers:
Katie Bretland (COGS)
Special Thanks:
Alexandra Brooks (COM)
John Langell, M.D., Ph.D., M.P.H., M.B.A.
Hirva Joshi (COM)
Steven Schmidt, Ph.D.
Kelly Kimball (COM)
Maria Schimer, J.D.
Rommel Morales (COM)
Roderick Ingram
Steven Shalenberger (COP)
Lacey Madison, M.B.A., M.Ed
Aditya Sharma (COM)
Jared Slanina
Ernesto Solorzano (COGS)
Scott Rutan
Brian Harrell, M.A.
Ashley King
Compliance Board Members:
Samantha Bliss
Hope Ball, Ph.D. (NEOMED)
Todd Wallwork, MLIS
Stanley Dannemiller, D.M.V (NEOMED)
Simon Robins, MLIS
Yoleetah Ilodi, M.D. (NEOMED)
Steven Kuerbitz, M.D. (Akron Children’s Hospital) Ashley
Mohrman, Ph.D. (Akron Children’s Hospital)
Julie Aultman, Ph.D.
Pratyusha Ghanta
Max Gilliland
Dominique Cox
Gwendolyn Richner
Anjali Agarwal
Geoffrey Sarpong
Meghana Chanamolu
COM College of Medicine / COP College of Pharmacy / COGS College of Graduate Studies
TABLE OF CONTENTS
Original Papers
1 A Histological and Qualitative Analysis of Muscle Spindle Density in the Distal Head of M.
Extensor Longus Digiti Majoris
Arjun Pandya and Tobin Hieronymus
Surveys
6 Telehealth Access of Geriatric Patients During COVID-19: A Provider Team Survey
Sohi Mistry, Siddhartha Singh, Alisha Gupta, Sanjay Jinka, Maahi Mistry, and Mariquita Belen
14 Burnout and Wellness in the College of Medicine at Northeast Ohio Medical University
Arjun Pandya, Akanksha Dadlani, Alexander E. Isla, Amy Adik, and Randon Welton
Reviews
27 Using Ancient Spices to Treat Chronic Diseases: Turmeric’s Potential to Modulate Disease
Pathogenesis in Rheumatoid Arthritis and Inflammatory Bowel Disease
Kelly M. Kimball†, Giovanna Leone †, and Bina Mehta †Joint First Authorship
32 Chemical and Histopathologic Effects of COVID-19 on Virchow’s Triad
Jay P. Natarajan, Ashorne K. Mahenthiran, and Gary W. Lemmon
Case Reports
38 Efficacy of the Glasgow Coma Scale in Determining the Severity of Traumatic Brain Injury
Vihanga Perera, Hiram Imam, and Percival Pangilinan
41 Robotic Assisted Laparoscopic Prostatectomy Post-Prostatic Urethral Lift Implants
Matthew R. DeSanto and Daniel J. Ricchiuti
Commentaries
45 Improving Community Health by Encouraging Remote Office Visits
Rachel Krevh and Eliot Mostow
48 Enhancing Diversity in Medical Education Representation of Cutaneous Disease: VisualDx
Skin-of-Color Atlas
Arjun Pandya, Jay Patel, Sarah Eley, Rachel Krevh, Kishan Pandya, Rahul Mal, Kelly Kimball, and Eliot
Mostow
Letter to the Editor
51 Human Connection Through Wi-Fi: Is it possible?
Sanaa Mansoor
Abstract
52 Cardiac Metabolism in the Disease of Acute Myocardial Infarction
Nikhil Datla, Chwen-Lih Chen, Patrick Kang,Yeong-Renn Chen, Takhar Kasumov, and Sergei Ilchenk
Journal of Medical Sciences at NEOMED
Volume 1, Issue 1, August 2022
A Histological and Qualitative Analysis of Muscle Spindle Density in the Distal Head of M.
Extensor Longus Digiti Majoris
Arjun Pandya, MD, MBA1* and Tobin Hieronymus, PhD1
1.
Northeast Ohio Medical University, College of Medicine, Rootstown, OH, 44272
* Corresponding author
ABSTRACT
Inconspicuous muscles in avian taxa have been previously discussed as vestigial remnants, however, evidence
has shown that such muscles may hold a function in flight. Further investigations into inconspicuous muscles,
such as M. coracotriceps, have demonstrated a muscle spindle density much greater than surrounding
muscles. A higher density of muscle spindles suggests a proprioceptive function during flight. We
investigated another diminutive muscle that may bear a similar function, the distal head of M. extensor longus
digiti majoris (ED). Studies included a qualitative histological analysis comparing the density of muscle
spindles in the ED to the adjacent proximal head of the M. extensor longus digiti majoris (EP) in 15 total
samples excised from Columba livia (rock pigeon) and Gallus gallus (jungle fowl). EP is a functional muscle
that serves as an osteo-pulley for the major digit, which we analyzed the ED against. Based on our qualitative
histological analysis of ED, this muscle does not demonstrate a greater muscle spindle density compared to
the EP. Although further research of this muscle in other Avian species may be necessary to discern its
function, our research demonstrates no evidence of a proprioceptive function.
Keywords: Avian Species, Histology, Muscle Spindles, Flight
that act across a joint in parallel to a larger, longer muscle
(5).
INTRODUCTION
Muscle spindles are intrafusal fibers that function to
provide proprioceptive cues to the central nervous system
for coordination via stretch receptors and provide reflex
activity for motor neurons (1). Higher densities of muscle
spindles are reported in avian muscles presumably to
serve as kinesiological monitors during flight (2).
Muscles with higher spindle density generally function in
fine movements, postural control, and provide important
mechano-sensory feedback to the central nervous system,
indicating a proprioceptive function (3). Muscle spindles
have also been seen in higher densities within avian
skeletal muscles with slow-twitch fibers as opposed to
their fast-twitch counterparts (4). This demonstrates that
muscles with a higher density of muscle spindles are
likely involved in sustained flight as opposed to the fast
twitch muscles involved in takeoff and landing (4). These
kinesiological monitors are often smaller, shorter muscles
An example of a muscle with a proprioceptive function is
the inconspicuous M. coracotriceps (6). This is a minute
muscle that extends between the tendons of M. expansor
secundarium and tendon of M. humerotriceps, and
because of its size, it was previously regarded as vestigial.
Eventually, research and analysis of this muscle
discovered that M. coracotriceps was a slow tonic muscle
with a muscle spindle density significantly greater than
the adjacent, parallel, and functional M. humerotriceps
(7). This discovery demonstrated that small and
undervalued muscles can play an important role during
flight.
Another example of a similar anatomical system in Aves
is the distal head of M. extensor longus digiti majoris
(ED). The ED has a tendinous insertion onto the tendon
of the proximal head of the M. extensor longus digiti
majoris (EP), which is located along the proximal end of
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JMS, August 2022 – Volume 1, Issue 1
Pandya & Heironymyus
the major metacarpal (8). This orients the smaller muscle
belly, ED, in parallel with the larger muscle belly, EP
(Fig. 1). The EP functions as an osteo-pulley to guide
muscle tendons and change the direction of pull of the
major digit (8). However, there are limited details
available on the function of the ED and ideas on its
function have been varied among sources with some
researchers regarding it as nonfunctional or rudimentary
(6). Alternatively, the use of ED as a kinesiological
monitor with a dense concentration of muscle spindles is
an additional possibility. There is limited evidence to
support either argument, as there are few details available
describing the function of the muscle.
METHODS
The ED and EP were excised from five frozen Columba
livia (rock pigeon) and four Gallus gallus (jungle fowl).
Four samples of ED and 4 EP were excised from Columba
livia while 3 ED and 4 EP were excised from Gallus
gallus. In total, we excised 7 ED and 8 EP (15 total
samples). Each muscle belly was isolated and left
overnight in 10% formalin, then washed two times in PBS
solution, and finally dehydrated and stored in 70%
ethanol. Next, the muscle bellies were processed in the
Leica ASP300 Enclosed Tissue Processor (Leica
Biosystems, Buffalo Grove, IL) for 24 hours. The
following day, the muscle tissue was embedded in
paraffin blocks and sectioned at 5-7µm thickness using a
microtome and left overnight to dry on microscope slides.
The sections were next stained using Hematoxylin and
Eosin (H&E). The muscle tissues were examined under a
light microscope. Fifteen sections were qualitatively
examined for muscle spindles, 8 ED and 7 EP. The
muscles were qualitatively inspected to examine the
muscles under a light microscope and record if there were
any obvious differences in muscle spindle density
between the EP and the ED in both species. Based on the
results of muscle spindle density in the M. coracotriceps,
6.33 muscle spindles per gram of muscle, we kept our
threshold at six muscle spindles per gram of muscle to
qualify it as a kinesiological monitor. We estimated
muscle mass based on linear measurements. Samples
were approximately 1 cm in length and diameter. Based
on published estimates of muscle density at 1.06g/cm^3
we estimated mass of ED to be 1.06g (12).
Figure 1. Shown is a figure of muscle architecture of the forelimb in
Columbia Livia. The elongate proximal head of the M. extensor longus
digiti majoris (EP), labeled above mELDMp , can be visualized here
with its tendon course into the major digit. The ED, labeled above
mELDMd, is a tiny muscle belly located adjacent to the EP with a
tendinous insertion into the tendon of EP. Copyright 2016. Adapted with
permission (15).
Additionally, the ED is present in only certain avian taxa.
Distal limb reduction is an evolutionary pattern used by
certain birds to eliminate unnecessary weight that is costly
to takeoff, inertia, and landing during flight (9, 10). The
evolutionary pattern depicts that birds that had distal limb
reduction have lost the ED, while those without distal
limb reduction have retained it. Species such as swifts and
members of the “ground bird” assemblage, Cavitaves,
have eliminated this muscle belly (11). These birds also
have a flight style of greater wingbeat frequency.
However, this muscle is preserved in rock pigeons, which
do not exhibit distal limb reduction nor have a pattern of
high wingbeat frequency (11). This evolutionary pattern
raises additional unanswered questions about the function
of ED. To investigate the function of the ED, we
examined the quality of muscle spindle density to
determine if it is a feasible kinesiological monitor during
flight.
RESULTS
Examination of the 8 samples of ED showed no
qualitative difference in muscle spindle density in
comparison to the 7 samples of EP. We did not find
muscle spindles in the density expected of a
kinesiological monitor. Out of the 15 samples examined,
we did not notice a higher density of muscle spindles in
the ED in comparison to the EP. Each muscle belly
demonstrated approximately 0-2 total muscle spindles
(Fig. 2), with consistent results across the ED and EP. The
lack of a large quantitative count of muscle spindles
allowed for quick inspection for each section. This finding
was consistent across both species and there were no
qualitative differences between them.
2
JMS, August 2022 – Volume 1, Issue 1
Pandya & Heironymyus
is not of use in Aves with distal limb reduction, however,
it may still serve a function in Aves that have retained it.
Figure 2. Pictured is a light microscopic photograph of a muscle spindle
(red arrow) in the proximal head of the M. extensor longus digiti majoris
(EP) in Columba livia (rock pigeon). Stained with hematoxylin and
eosin. 20X objective. Image courtesy of Dr. Tobin Hieronymus.
DISCUSSION
Given the relative muscle spindle density in ED not
exceeding that of EP, this muscle is unlikely to be a
kinesiological monitor. This contrasts with the M.
coracotriceps which showed a total muscle spindle
density of over 14000 spindles per 2300 grams of muscle
(15 times greater than any other muscles in the avian
species) (7). This is a much higher density than the total
0-2 spindles examined in each of 15 samples of ED and
EP, which were in the same order of magnitude in size as
1 gram of M. coracotriceps.
Figure 3. Phylogenetic Tree of the ED retention. Character states drawn
from Livezey and Zusi (2007). Silhouettes from PhyloPic.org :
Hemiprocne mystacea by Jerry Oldenettel (vectorized by T. Michael
Keesey). Passer domesticus by Andrew Butko (modified). All
silhouettes CC BY-NC-SA 3.0. creativecommons.org/licenses/by-ncsa/3.0/. All other silhouettes public domain (11).
Another possible function of ED is based on its
anatomical characteristics and relationship with EP. The
tract of the muscle tendon of the EP is from the forearm
to the major metacarpal in the hand and serves as the
insertion point for the distal head (Fig. 1). The distal head
inserts into the tendon at the proximal head of the major
metacarpal. The EP has a dual function of digit extension
and wrist flexion (8). ED inserts directly in the middle of
the tract of the tendon for EP, therefore, for EP to produce
the action of wrist flexion, ED may be serving a function
to decouple digit extension from EP to wrist extension.
The evolutionary pattern of ED shows both preservation
and loss in different bird species. The presence of this
muscle belly is preserved in species that do not have distal
limb reduction, such as jungle fowl and rock pigeons (11).
This muscle is not retained in species such as perching
birds (Passeriformes), swifts, members of the ground bird
assemblage (Cavitaves), and members of the “metavian”
assemblage (cuckoos, cranes, and allies) some of which
show a pattern of distal limb reduction (Fig. 3) (11,13).
Species that have undergone distal limb reduction have a
flight style which demonstrates high beat wing frequency
(13). There is reasoning that extra weight with vestigial
structures in avian hands may be costly to inertia during
flight (10). It has been previously demonstrated that
higher intensity action of distal wing musculature is
present during takeoff and landing for Aves during flight
(10). During active flight, birds are efficient in
minimizing muscle contractions and saving metabolic
energy (10). A vestigial structure present in many clades
would go against the efficiency of birds in flight.
Therefore, this evolutionary pattern suggests that the ED
A similar example is the quadratus plantae, which
corrects the tendon tract of the flexor digitorum longus in
the feet of humans (Fig. 4). This also is a smaller muscle
which has a tendinous insertion onto a larger muscle’s
tendon in a similar structure (avian hand vs human
foot). Quadratus plantae realigns the tendon of flexor
digitorum longus in human feet and allows it to properly
flex the second through fifth digits in the foot.
The architectural resemblance between ED and EP in
Aves and Quadratus plantae and flexor digitorum longus
3
JMS, August 2022 – Volume 1, Issue 1
Pandya & Heironymyus
in humans supports the idea that ED may be performing a
similar role as Quadratus plantae.
research does not demonstrate any evidence of a
proprioceptive function. Phylogenetic distribution
suggests this muscle is not of use in Aves with distal limb
reduction, however, it may still hold a function in the
Aves that have retained it. A plausible function of ED is
that it decouples digit extension of the EP to wrist
extension, further supported by a similar anatomical
architecture in the Quadratus plantae in the foot of
humans. Future directions include gathering more
evidence on the characteristics of the ED by expanding
the study across more species of Aves with different flight
patterns, and include testing the anatomical function of
the ED.
Figure 4. Quadratus Plantae
(labeled as 2) inserting on the
tendon of the flexor digitorum
longus, allowing for proper
flexion of digits 2-5. This file
is licensed under the Creative
Commons Attribution-Share
Alike
4.0
International
License. Image courtesy of
Powellle
2020.
https://commons.wikimedia.o
rg/wiki/File:2__quadratus_plantae.png (16)
REFERENCES
There are several limitations to our study. Firstly, we did
not examine the muscle tendons under a light microscope,
as we narrowed our focus on the muscle belly during the
study. Although muscle spindles are the primary organ
involved in proprioception, muscle tendons may contain
Golgi Tendon Organs (GTO) which can also serve as
proprioceptive monitors (14). Additionally, our sample
size was only 15 total samples, and statistical analysis was
not performed (due to the qualitative approach);
additional samples and access to additional species would
have made this study more effective. A quantitative
analysis rather than a qualitative analysis would have
allowed for a more thorough analysis and the inclusion of
a statistical evaluation to definitively prove our findings;
however, a qualitative analysis was performed due to time
constraints and limited access to samples. Despite this,
qualitative research on topics not previously explored,
such as the ED and EP, can still provide meaningful
insight for future studies. Therefore, future steps of this
study include to expand it to multiple species with
different flight patterns, such as perching birds and swifts,
and additionally gathering a larger number of samples. In
addition, testing the function of the muscle based on the
anatomic characteristics mentioned above with
techniques such as in-vitro contracture testing could help
identify the function of the ED.
CONCLUSIONS
Our findings do not demonstrate increased muscle spindle
density in the ED, in comparison to the EP, of Gallus
gallus and Columba livia. Since muscles with
proprioceptive functions typically demonstrate a high
amount of muscle spindles, the ED is not likely to
function as a kinesiological monitor. While we believe
that further quantitative research on the ED among a
wider variety of species may show different results, our
4
1.
Hulliger M, Durmuller N, , Prochazaka A, Trend P.
Flexible fusimotor control of muscle spindle
feedback during a variety of natural movements.
Progress in Brain Research. 1989; 80: 87-101.
doi:10.1016/s0079-6123(08)62202-5
2.
James NT, Meek GA,. An electron microscopical
study of avian muscle spindles. Journal of
Ultrastructural Research. May 1973; 43: 193-204.
doi:10.1016/s0022-5320(73)80032-2
3.
Physiopedia. 2019. Accessed November 7, 2020.
https://www.physiopedia.com/index.php?title=Musc
le_spindles&oldid=223670
4.
Dow PR, Ovalle WK, Nahirney PC. Structure,
distribution and innervation of muscle spindles in
avian fast and slow skeletal muscle. Journal of
anatomy.
Apr
1999; 194
(3):
381-94.
doi:10.1046/j.1469-7580.1999.19430381.x
5.
Peck D, Buxton DF, and Nitz A. A comparison of
spindle concentrations in large and small muscles
acting in parallel combinations. Journal of
Morphology. Jun 1984; 180: 243-252. doi:10.1002/
jmor.1051800307
6.
George JC, Berger AJ. Avian myology. New York:
Academic Press; 1966.
7.
Rosser BW, George JC. An Exceptionally High
Density of Muscle Spindles in a Slow-Tonic Pigeon
Muscle. The Anatomical Record. Jun 1985;
212(2):118-22. doi:10.1002/ar.1092120203
8.
Vazquez, RJ. Functional anatomy of the pigeon hand
(Columba Livia): A muscle stimulation study.
Journal of Morphology. Oct 1995; 226(1):33-45.
doi:10.1002/jmor.1052260104
JMS, August 2022 – Volume 1, Issue 1
Pandya & Heironymyus
9.
Maxwell EE, Larsson HC, Osteology and myology of
the wing of the Emu (Dromaius novaehollandiae),
and its bearing on the evolution of vestigial
structures. Journal of Morphology. May 2007;
268:423-441. doi:10.1002/jmor.10527
AUTHOR CONTRIBUTIONS
Conceptualization: AP, TH
Methodology: AP, TH
Investigation: AP, TH
10. Ehrlich P, Dobkin D, Wheye D. Adaptations for
Flight. Published 1988. Accessed November 18,
2021. https://web.stanford.edu/group/stanfordbirds/
text/essays/Adaptations.html.
Supervision: TH
Writing – original draft: AP, TH
Writing – review & editing: AP, TH
11. Livezey BC, Zusi RL. Higher-order phylogeny of
modern birds (Theropoda, Aves: Neornithes) based
on comparative anatomy. II. Analysis and discussion.
Zool J Linn Soc. Jan 2007;149(1):1-95. doi:10.
1111/j.1096-3642.2006.00293.x.
12. Mendez, J. and Keys, A. Density and Composition of
Mammalian Muscle. Metabolism. 1960; 9 (2): 184188.
13. Britannica, The Editors of Encyclopeadia. Ground
cuckoo. Encyclopædia Britannica. Published May
27, 1999. Accessed November 18, 2020. https://
www.britannica.com/animal/ground-cuckoo.
14. Leython Williams PT. Proprioception: Making Sense
of Body Position. Sports. Published June 18, 2018.
Accessed March 29, 2021. https://www.sportshealth.com/sports-injuries/general-injuries/
proprioception-making-sense-body-position
15. Hieronymus TL. Flight feather attachment in rock
pigeons (Columba livia): covert feathers and smooth
muscle coordinate a morphing wing. Journal of
Anatomy. Nov 2016; 229(5): 631-656. doi:10.1111/
joa.12511
16. Powelle (2020). Quadratus plantae. This file is
licensed under the Creative Commons AttributionShare Alike 4.0 International License. https://
commons.wikimedia.org/wiki/File:2-quadratus
plantae.png. Link to license https://creativecommons
.org/licenses/by-sa/4.0/deed.en
ACKNOWLEDGMENTS
I sincerely thank the NEOMED Department of
Anatomy and Histology for their contributions in my
education and truly appreciate their willingness to
always help when needed.
CONFLICTS OF INTEREST
All authors declare no conflicts of interest.
5
Journal of Medical Sciences at NEOMED
Volume 1, Issue 1, August 2022
Telehealth Access of Geriatric Patients During COVID-19: A Provider Team Survey
Sohi Mistry, MD1*, Siddhartha Singh, BS1, Alisha Gupta, MD1, Sanjay Jinka, BS1, Maahi Mistry,
BS1, Mariquita Belen, MD2
1.
2.
Northeast Ohio Medical University, College of Medicine, Rootstown, OH, 44272
Department of Geriatrics, Department of Family and Community Medicine, Northeast Ohio Medical University;
Rootstown, OH, 44272
* Corresponding author
ABSTRACT
The COVID-19 pandemic has prompted the rise in the use of virtual healthcare through Telehealth. The
importance of Telehealth is multi-fold, from communicating with patients virtually to providing care when
in-person services are unavailable. Although this virtual platform has significant benefits, the geriatric
population is underutilizing this resource. Our initial objective was to understand the perceptions of healthcare
providers and their assessment of the comfort level and the utility of telehealth software for geriatric patients.
We surveyed Geriatric specialists, Social Workers, Registered Nurses, and healthcare management team
members regarding their perceptions of the rise and utility of telehealth before and after the pandemic. The
survey was conducted in Northeast Ohio, specifically from Summa Health Akron City Hospital and the
Direction Home Akron Canton Area Agency on Aging and Disabilities. 72.7% of those invited completed
the survey, specifically five (33.3%) were physicians. Additionally, we surveyed participants regarding
patient capability and understanding of telehealth software. A large subset of participants using telehealth
(69.2%) stated that their patients fell between “somewhat uncomfortable” to “completely uncomfortable” in
utilizing telehealth. Regarding their use of blood pressure and glucose monitors, 76.9% felt their patients had
a “medium comfort” level. Finally, 92.3% would find a volunteer service to help train patients and caregivers
in the use of telehealth software and medical devices “extremely helpful.” These data demonstrate a
perception among geriatric providers that patients have difficulties using telehealth. Our goal is to develop a
student-led virtual program to better assist patients and providers in the use of telehealth modalities.
Keywords: Telehealth, COVID-19, Geriatrics, Telemedicine
INTRODUCTION
empowerment of patients to manage chronic conditions
(1).
From house calls to the increased use of larger institutionbased practice, the delivery of healthcare is everchanging. A new and rising mode of delivery— especially
since the onset of COVID-19— is Telehealth, which
allows the doctor to gain virtual connection with patients
while maintaining physical distance. Video conferences,
custom applications, web-based services, and remote
monitoring are all encompassed within the broad
approach. Advantages of incorporating these techniques
include ease of use, improved communication, low cost,
decreased travel time, increased access to care, and
Despite the clear benefits of using this system, there are
difficulties that plague broader use of telehealth, such as
availability, cost, technology dysfunction, trust, and
impersonality (2). A 2012 Health Information National
Trends Survey demonstrated that older male adults with
low socioeconomic status (SES) had decreased
interactions with telehealth. While 30% of patients below
64 years use telehealth, less than 10% of patients above
65 use it (3). In a qualitative interview study conducted in
Manchester, geriatric patients described barriers to
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Mistry, et al
telehealth, including lack of technical competence.
Patients expressed that they find it difficult to remember
and manage technical machinery, such as keyboards and
keypads. Patients also have uncertainty when using the
internet and lack adequate training to use blood pressure
monitors and medical devices on themselves (4,5).
Software database and imported into Microsoft Excel to
compute the appropriate descriptive statistics. Data were
reported as mean (standard deviation), median
(interquartile ratio), and proportions (6).
Although practices can incorporate various forms of
telehealth, there are concerns regarding whether the
geriatric patient population has the capability to use the
software. In this prospective observational survey, we
surveyed geriatricians and healthcare providers working
at Summa Health Akron City Hospital and the Direction
Home Akron Canton Area Agency on Aging and
Disabilities about their current use of telehealth in the
delivery of healthcare before and after the spread of
COVID-19. Further, we want to explore whether
practitioners believe that patients can and have knowledge
of how to use telehealth and medical devices at home or
in independent living facilities. We plan to use data from
this survey to develop a medical student-led virtual
program to aid patients in using medical devices and
telehealth modalities.
General Participant Information (Table 1)
RESULTS
Of 22 potential participants, 16 (72.7%) completed the
survey. Percentages are reported per number of
participants that answered the question. Five (33.3%)
participants were practicing geriatricians at Summa
Health Akron City Hospital. Eleven (21.4%) were social
workers, registered nurses, and healthcare management
team members at the Direction Home Akron Canton Area
Agency on Aging and Disabilities. Eleven (73.3%) of the
participants reported that less than 25% of their patients
resided in nursing homes. Ten (71.4%) of the participants
reported that less than 25% of their patients resided in
independent living facilities. Three participants (20.0%)
reported that less than 25% of their patients resided at
home. Most of the patients resided at home or in
independent living facilities.
METHODS
Telehealth Utility (Table 2)
A 23-item survey was developed with questions regarding
provider background, patient population, telehealth utility
among providers, and perceived level of comfort using
telehealth and medical devices among patients for
providers. The study was sent to healthcare providers to
understand their perception of patient comfort with
telehealth to better understand providers’ need for
software coaching. The questions were in Yes/No,
multiple-choice, and single best-answer type formats,
with space for a final comment at the end of the survey.
The study protocol was approved by the Northeast Ohio
Medical University Institutional Review Board in
Rootstown, Ohio. Informed consent was implied by the
subject’s willingness to complete the survey. All the
responses were anonymously collected to eliminate any
potential bias. The 45-item, English-language, web-based
survey tool (Qualtrics Survey Software, Provo, UT) was
administered online from November 2020 to December
2020.
Nine (60%) of the participants utilized telehealth to
communicate with their patients, of whom five (55.6%)
had utilized telehealth for less than six months. Of the
nine participants, all saw less than 25% of their patients
using telehealth prior to February 2020. After February
2020, three (33.3%) saw less than 25% of their patients
using telehealth and two (22.2%) saw greater than 75% of
their patients using telehealth. Among all participants,
multiple modalities of telehealth were employed. Four
people utilized FaceTime, two utilized Zoom, seven
utilized Doxy, seven utilized telephone, one utilized
Webex, and one utilized Skype.
Four (30.7%) participants reported that less than 25% of
their patients had access to mobile devices at home. Nine
(69.2%) of the participants reported that less than 25% of
their patients had access to tablets at home. Thirteen
participants reported that their patients used blood
pressure monitors, twelve reported that their patients used
blood glucose monitors, and five reported that their
patients also used pulse oximetry machines, weighing
scales, and INR machines at home.
Twenty-two potential participants were identified as
geriatricians from Summa Health Akron City Hospital
and healthcare providers from the Direction Home Akron
Canton Area Agency on Aging and Disabilities, an entity
of the Ohio Department of Health. An e-mail invitation
with an explanation of study protocol and consent was
sent to study participants, with a subsequent e-mail
invitation sent weekly to non-responders for a total of four
weeks. All responses were entered into a Qualtrics Survey
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JMS, August 2022 – Volume 1, Issue 1
Mistry, et al
Respondents
Participant role in practice:
Response
15 (93.8)
Social Worker
4 (26.7)
Nurse Practitioner
0
Physician
5 (33.3)
Health facility management
6 (40)
Description of administration of the practice:
15 (93.8)
Community-based hospital
Healthcare aging facility
5 (33.3)
10 (67.7)
Length in practice:
14 (87.5)
<5 years
3 (21.4)
5-15 years
5 (35.7)
>15 years
6 (42.9)
Perceived percentage of patients residing in a nursing home:
14 (87.5)
<25%
25-50%
11 (73.3)
50-75%
2 (13.3)
>75%
2 (13.3)
0
Perceived percentage of patients residing in an independent living
facility:
14 (87.5)
<25%
10 (71.4)
25-50%
2 (14.3)
50-75%
2 (14.3)
>75%
0
Perceived percentage of patients residing at home:
15 (93.8)
<25%
3 (20)
25-50%
3 (20)
50-75%
4 (26.7)
>75%
5 33.3)
Table 1: General participant information
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JMS, August 2022 – Volume 1, Issue 1
Mistry, et al
Respondents
Participants who use TeleHealth:
Response
15 (93.8)
Length of TeleHealth utility:
9 (60)
<6 months
5 (55.6)
6-12 months
4 (44.4)
1-5 years
0
>5 years
0
Patients seen using TeleHealth prior to February 2020:
<25%
9 (100)
Patients seen using TeleHealth after February 2020:
<25%
3 (33.3)
25-50%
3 (33.3)
50-75%
1 (11.1)
>75%
2 (22.2)
Method of TeleHealth employed (check all):
14 (87.5)
FaceTime
4
Zoom
2
Doxy.me
7
Telephone
7
Webex
1
Skype
1
Perceived percentage of patients with access to mobile devices at
home:
13 (81.3)
<25%
4 (30.8)
25-50%
4 (30.8)
50-75%
4 (30.8)
>75%
1 (7.7)
Perceived percentage of patients with access to tablets at home:
13 (81.3)
<25%
25-50%
9 (69.2)
50-75%
4 (30.8)
>75%
0
0
Devices patients use to monitor health at home:
13 (81.3)
Blood pressure monitors
13
Glucose monitors
12
Other: Pulse oximetry monitors, scales, INR machines
5
Table 2: TeleHealth Utility
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Telehealth Comfort (Table 3)
Respondents indicated highest utility for a program
providing education for services such as Facetime, Zoom,
Doxy, Telephone, Email, and Skype. We identified
another possible intervention through provision of
Telehealth-capable devices; 61% of providers reported
50% or less of their patient base had access to mobile
devices at home and 100% of the providers indicated that
less than half their patient base had access to tablets.
Participants were also asked to assess their patients’
comfort level with utilizing telehealth on a Likert scale of
1-5 (1= very uncomfortable, 5=very comfortable). Three
(23.1%) perceived their patients to be at a 1 and zero
perceived their patients to be at a 5. In asking how useful
the participants thought a volunteer service would be in
helping patients utilize telehealth on a Likert scale of 1 to
5 (1=very un-useful, 5=very useful), one (7.7%)
perceived the service to be a 1 and 10 (76.9%) perceived
the service to be a 5.
This work extends the findings of previous literature in
identifying problematic areas for geriatric patients with
respect to accessing telehealth treatment, particularly in
the greater Akron area. In a review by Bashshur et al. in
2014., empirical evidence was identified supporting the
use of telehealth in chronic disease management for
reducing hospital admissions, length of hospital stays,
emergency department visits, and even mortality (7). This
comes alongside acknowledgement of interventions
showing that technology-based healthcare management
can be implemented with notable results in older adults,
especially as they often suffer from chronic disease (8, 9).
Participants were then asked to evaluate their patients’
comfort level using devices to monitor health at home on
a Likert scale of 1 to 5 (1=very uncomfortable, 5=very
comfortable). Two (15.4%) perceived their patients as a 4
and zero perceived their patients as a 5. In asking how
helpful a volunteer service would be to aid patients and/or
caregivers in utilizing telehealth on a Likert scale of 1 to
5 (1=very unhelpful, 5= very helpful) nine (69.2%)
believed their patients were at a 5.
Despite successful applications of telehealth in broader
populations, geriatric patients face increased barriers to
adoption, such as access to appropriate devices and low
technological literacy. Sivakumar et al. note that
successful deployment of interventions in India had to
overcome low digital literacy, sensory issues, and
cognitive impairment in administering geriatric
telepsychiatry (10). Parker et al. attributed low patient
response via telehealth to a multitude of factors: lower
intrinsic motivation, health literacy, and efforts to engage
patients in newer forms of health technologies by the
provider (11). Due to the varied factors that contribute to
the effectiveness of telehealth, it may be difficult for a
geriatrician to transition employing newer technologies to
reach patients.
Finally, we asked the participants which modes of
telehealth they would find a student-led volunteer
program useful for. Four (28.6%) reported they could use
help in teaching patients how to use Zoom, eight for
FaceTime, four for Facebook Messenger, seven for Doxy,
eleven for telephone, six for e-mail, and four for other
services such as Skype.
DISCUSSION
Our results emphasize the challenges faced by health care
providers to reach geriatric patients, especially during a
pandemic, when the need to maintain physical distance
between the practitioner and patient is paramount. Table
2 demonstrates that healthcare practitioners are
incorporating telehealth services to connect with their
patients. In fact, most responding participants reported
seeing less than 25% of their patients via telehealth prior
to February 2020, then transitioning to over two-thirds of
participants seeing more than 25% of their patients via
telehealth after the beginning of the COVID-19
pandemic. The disparities in providing telehealth access
may be demonstrated through the patient demographics of
the geriatric providers: most patients live in private
residences and have limited access to the support a
nursing home or independent living facility may provide.
This is underscored as most survey participants indicated
that their patients’ perceived comfort level using
telehealth and telemonitoring devices was low.
Consequently, many responders requested a student-led
volunteer program, with 92% of participants estimating
outcome of an intervention as beneficial to their practice.
Major strengths of our study include the fact that
participants involved with the survey were all from the
local community, focusing on the needs of the nearby
geriatric population. Additionally, the high response rate
(73%) of potential participants stresses the importance of
the content of the survey to the participants. This is further
supported by ardent request for student-led volunteer
programs to target health literacy across a variety of
disciplines, ranging from geriatric physicians at Summa
Akron City Hospital to the staff at Direction Home Akron
Canton Area Agency on Aging and Disabilities, including
social workers, registered nurses, and healthcare
providers.
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JMS, August 2022 – Volume 1, Issue 1
Mistry, et al
Perceived patient comfort using
uncomfortable, 5=very comfortable):
TeleHealth
(1=very
13 (81.3)
1
3 (23.1)
2
6 (46.2)
3
3 (23.1)
4
1 (7.7)
5
0
Perceived patient aid in use of a mobile TeleHealth volunteer
service (1=very un-useful, 5=very useful):
13 (81.3)
1
1 (7.7)
2
0
3
0
4
2 (15.4)
5
10 (76.9)
Perceived patient comfort using devices to monitor health at home
(1=very uncomfortable, 5=very comfortable):
13 (81.3)
1
2
0
3
1 (7.7)
4
10 (76.9)
5
2 (15.4)
0
Perceived patient aid in use of a medical health device volunteer
service (1=very un-useful, 5=very useful):
13 (81.3)
1
0
2
0
3
1 (7.7)
4
3 (23.1)
5
9 (69.2)
Methods of TeleHealth participants suggest a volunteer service for:
13 (81.3)
Zoom
FaceTime
4
Facebook Messenger
8
Doxy.me
4
Telephone
7
11
Other: Skype, Doximity
6
4
Table 3: TeleHealth Comfort
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Mistry, et al
There are also limitations to this study. Even though this
survey was designed with the interests of pertinent
stakeholders in mind, we identified potential participants
from only two local institutions, resulting in a low sample
size. In addition, the number of participants was limited
to those interested in seeing the implementation of a
program to aid their patients; this is indicative of selfselection bias. Finally, close-ended questioning can lead
to loss of internal validity and objectivity. To address
these limitations, we incorporated options to provide
type-in-responses.
The results of the study were all estimates of patient
comfort by providers. Further studies may incorporate
patient feedback on utilizing telehealth at home. We are
utilizing this data to develop a student-led virtual program
to aid patients with using medical devices and assistance
with Telehealth. Student volunteers will be trained to
effectively communicate, educate, and formulate guides
to aid the geriatric population in better understanding the
technology necessary to use telehealth. Students will be
able to answer questions related to using the software as
well as home medical devices. This intervention aims to
address the gaps noted by the geriatric providers. We hope
to facilitate improved patient-provider communication
and improve adherence to medical treatment and therapy.
Further studies could determine the impact of this
volunteer-led program in improving telehealth access and
utilization.
2.
3.
4.
Neter E, Brainin E. eHealth literacy: extending the
digital divide to the realm of health information. J
Med Internet Res. 2012;14(1): e19. doi:10.2196/jmir.
1619
6.
Mistry S, Alaber O, Chandar AK, et al. A survey of
physician training and credentialing in endoscopic
submucosal dissection in the United States. Surg
Endosc. 2022 May; 36 (5): 2794-2800. doi:
10.1007/s00464-021-08565-0.
7.
Bashshur RL, Shannon GW, Smith BR, et al. The
empirical foundations of telemedicine interventions
for chronic disease management. Telemed J E
Health.2014;20(9):769-800. doi:10.1089/tmj.2014.
9981
8.
Batsis JA, Petersen CL, Clark MM, et al. Feasibility
and acceptability of a technology-based, rural weight
management intervention in older adults with
obesity. BMC Geriatr. 2021;21(1):44. doi:10.1186/
s12877-020-01978-x
9.
Rasheedy D, Mohamed HE, Saber HG, Hassanin HI.
Usability of a self-administered geriatric assessment
mHealth: Cross-sectional study in a geriatric clinic.
Geriatr
Gerontol
Int.
2021;21(2):222-228.
doi:10.1111/ggi.14122
10. Sivakumar PT, Mukku SSR, Kar N, et al. Geriatric
Telepsychiatry: Promoting Access to Geriatric
Mental Health Care Beyond the Physical Barriers.
Indian J Psychol Med. 2020;42(5 Suppl):41S-46S.
doi:10.1177/0253717620958380
REFERENCES
1.
5.
Kruse CS, Krowski N, Rodriguez B, Tran L, Vela J,
Brooks M. Telehealth and patient satisfaction: a
systematic review and narrative analysis. BMJ Open.
2017;7(8). doi:10.1136/bmjopen-2017-016242
11. Parker S, Prince A, Thomas L, et al. Electronic,
mobile and telehealth tools for vulnerable patients
with chronic disease: a systematic review and realist
synthesis. BMJ Open. 2018;8(8): e019192.
doi:10.1136/bmjopen-2017-019192
Bull TP, Dewar AR, Malvey DM, Szalma JL.
Considerations for the Telehealth Systems of
Tomorrow: An Analysis of Student Perceptions of
Telehealth Technologies. JMIR Med Educ.
2016;2(2): e11. doi:10.2196/mededu.5392
ACKNOWLEDGMENTS
Sanders C, Rogers A, Bowen R et al. Exploring
barriers to participation and adoption of telehealth
and telecare within the Whole System Demonstrator
trial: a qualitative study. BMC Health Services
Research. 2012; 12(1): 220. doi:10.1186/1472-696312-220
Dr Mariquita Belen, Department of Family and
Community Medicine
Kontos E, Blake KD, Chou WY, Prestin A.
Predictors of eHealth usage: insights on the digital
divide from the Health Information National Trends
Survey 2012. J Med Internet Res. 2014;16(7): e172.
doi:10.2196/jmir.3117
AUTHOR CONTRIBUTIONS
CONFLICTS OF INTEREST
All authors declare no conflicts of interest.
Conceptualization: SM
Methodology: SM
12
JMS, August 2022 – Volume 1, Issue 1
Mistry, et al
Investigation: SM, SS
Visualization: SM, SS, SJ, AG, MM
Project administration: M, SS, SJ, AG, MM
Supervision: MB
Writing – original draft: SM, SS, SJ, AG, MM
Writing – review & editing: SM, SS, SJ, AG
13
Journal of Medical Sciences at NEOMED
Volume 1, Issue 1, August 2022
Burnout and Wellness in the College of Medicine at Northeast Ohio Medical University
Arjun Pandya, MD, MBA1*, Akanksha Dadlani, MD, MPH1, Alexander E. Isla, MD1, Amy Adik,
BS1, Randon Welton, MD1,2
1.
2.
Northeast Ohio Medical University, College of Medicine, Rootstown, OH, 44272
Department of Psychiatry, Northeast Ohio Medical University, Rootstown, OH, 44272
* Corresponding author
ABSTRACT
Burnout is a syndrome of professional distress defined by symptoms of emotional exhaustion,
depersonalization, and a sense of reduced personal accomplishment. Previous surveys (Wellness Surveys) at
Northeast Ohio Medical University (NEOMED) seemed to have demonstrated low scores in the wellness
categories. As such, we sought to investigate further the frequency and factors of medical student burnout
symptoms, the quality of medical student wellness, and contributing stressors at NEOMED. Over three
weeks, an anonymous 8-question survey was sent out via e-mail to all NEOMED College of Medicine
students. This survey included a novel scale created by the authors to measure burnout, wellness, and
contributing stressors. The survey was done on Qualtrics SM Survey software and was statistically analyzed
by class using Microsoft Excel. The survey was completed by 166 students (participation = 28%). Results
demonstrated statistically significant differences in burnout and multiple components of wellness when
stratified by class. Burnout and suboptimal wellness were most severe in preclinical (M1-M2) years. Groups
rating higher frequencies of burnout also rated lower qualities of wellness. Nearly 50% of all respondents feel
the challenge of medical school was more difficult than expected. At NEOMED, peak burnout frequencies
and suboptimal wellness ratings are in the preclinical years. Groups that scored higher frequencies of burnout
also scored poorer on wellness ratings. A systematic approach dedicated to promoting wellness at NEOMED
may lead to lower frequencies of burnout.
Keywords: Burnout, Wellness, Education, Mental Health
rates of burnout may threaten to compromise
compassionate and effective healthcare. Thus, burnout is
an issue that requires close investigation to reveal where
and how safeguards may be implemented at all levels. For
medical providers, burnout may begin during the first
years of medical training (5). As such, it is important to
consider intervention at this stage.
INTRODUCTION
Burnout is a syndrome of professional distress defined by
symptoms
including
emotional
exhaustion,
depersonalization, and a reduced sense of personal
accomplishment (1,2). This syndrome is highly prevalent
in the medical field, affecting many physicians and
physician trainees in the United States. Emerging research
shows that nearly 50% of medical students, residents, and
attending physicians in the US have experienced burnout;
these rates are significantly higher than those observed in
the general US population (2). Burnout has been linked to
increased risk of anxiety, depression, and medical error
(3,4). In a profession dedicated to caring for others, high
Medical student wellness is a topic of increasing
discussion nationwide. Wellness encompasses mental,
physical, and emotional health (6). It has been shown to
be a quality indicator that may inversely correlate to levels
of burnout (6). The Liaison Committee for Medical
Education (LCME) aids in the oversight of allopathic
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medical student education. The LCME Standard 12.3
requires that “A medical school has in place an effective
system of personal counseling for its medical students that
includes programs to promote their well-being and to
facilitate their adjustment to the physical and emotional
demands of medical education” (7). Specialty training
following medical school is largely governed by the
Accreditation Council for Graduate Medical Education
(ACGME). ACGME has a growing recognition that
“Psychological, emotional, and physical well-being are
critical in the development of the competent, caring, and
resilient physician and require proactive attention to life
inside and outside of medicine. Well-being requires that
physicians retain the joy in medicine while managing
their real-life stresses” (8). Every residency seeking
ACGME accreditation must have “policies and programs
that encourage optimal resident and faculty member wellbeing” (8).
The global pandemic of 2020 undoubtedly added
considerable burdens to already stressed medical
providers (11). Individuals throughout the world faced
issues of fear, grief, and loss during a time of decreased
social support. Medical professionals were not spared
these personal struggles while caring for suffering
individuals. All of these challenged individual providers’
senses of wellness and pushed toward ever higher and
earlier rates of burnout (11). For medical students at
NEOMED, there were unprecedented changes in training,
evaluations, and applications for post-graduate training.
With increasing literature throughout the medical field
regarding burnout and wellness, we sought to explore if
burnout and suboptimal wellness are issues at NEOMED.
To train high-quality patient care-centered physicians, we
felt it would be advantageous to examine our environment
and determine points of quality improvement. We believe
that identifying of these possible issues can lead to
targeted improvement projects and additional resource
acquisition within NEOMED that can help improve
student experience and wellness and ultimately prepare
better physicians. We hypothesize that preclinical
students will have the highest rates of burnout and that
there will be a statistically significant difference between
burnout symptom frequency and wellness quality
depending on students’ class year.
The individual components of wellness (mental health,
physical health, and emotional health) can significantly
contribute to medical students’ quality of life, academic
performance, and clinical performance (9). For example,
inadequate sleep, one of the physical health
subcomponents of wellness, can contribute to medical
error, depreciating test results, and cognitive decline (9).
Within the wellness subcomponent - emotional health, a
strong sense of purpose has been linked to longer, happier,
and more fulfilled lives (10). During postgraduate medical
training concerns over the worsening of provider mental
health led the ACGME to mandate screening for anxiety,
depression, and substance abuse disorders. Assessing
components of burnout and wellness as a means of
developing strategies to reduce burnout and promote
wellness should be a standard part of modern medical
training.
METHODS
An anonymous 8-question survey was sent out via e-mail
to all NEOMED College of Medicine students over a 3week span. This survey included a novel scale created by
the authors to measure burnout, wellness, and
contributing stressors. The survey was done on Qualtrics
SM Survey software and was statistically analyzed using
Microsoft Excel. Data were analyzed by class. The eight
questions administered through the survey are discussed
below.
Based in Rootstown, Ohio, NEOMED has a mission to
train patient care-centered physicians while aiming to be
a national leader in community-centered medicine. Over
the last two years, NEOMED has begun a series of
dramatic changes in its curriculum. Student feedback had
led to a complete overhaul of the NEOMED curriculum
deemphasizing lectures and markedly increasing
interactive teaching modalities, especially Peer
Instruction. NEOMED has also begun devoting more time
and resources to wellness-related topics and has created
several initiatives to improve student wellness such as
opening a Center for Student Wellness and Counseling
Services, offering wellness days for first-year students,
and integrating wellness exercises and discussions in the
curriculum. Despite these initiatives, concerns exist about
the rates of burnout and wellness among the NEOMED
medical student population.
Our first objective is to identify burnout and related
stressors at NEOMED by determining: 1. the frequency
of burnout symptoms among NEOMED College of
Medicine students, stratified by class (M1, M2, M3, M4)
2. The rating of wellness among NEOMED College of
Medicine students, stratified by class (M1, M2, M3, M4).
3. Major stressors among NEOMED College of Medicine
students 4. Expected challenges of medical school at
NEOMED versus experienced challenges in medical
school at NEOMED and, 5. Targeted improvement
strategies based on identified areas within wellness and
burnout subcomponents and at which specific stage of
medical training they are occurring in. Our second
objective is to measure the degree of burnout symptoms
and the quality of wellness stratified by demographic
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information to determine if any specific group of people
is not achieving wellness and how we may help them.
The sixth question sought to explore additional factors
that may contribute to burnout. To accomplish this, we
composed a list of nine potential stressors: finances,
COVID-19, political climate, family issues, academic
performance, relationships, health concerns, geographic
environment, and discrimination. Participants were asked
to select the three that were most contributory stressors at
the time of participation. The final two questions were
extended responses to allow further comments on the
survey and potential areas of improvement for NEOMED.
The estimated completion time was approximately 10
minutes.
*M1 denotes first-year medical student; M2 denotes
second-year medical student etc. It is of note that M1-M2
spend most of their time doing preclinical work
(classwork and lectures), and M3-M4 spend most of their
time in the clinical setting with patients.
Data Collection
In order to conduct our primary and secondary aims, we
created an online survey. To investigate burnout, we
proposed measuring three categories of our own
conception that we believe represent the dimensions of
burnout: detached, drained, and defeated. We elected to
use the novel terms detached, drained and defeated, as we
felt these more sufficiently captured the feelings medical
students at NEOMED would potentially experience in
response to a year in medical school during the COVID19 pandemic. These terms were defined within the survey
(Fig. 1A). To investigate wellness, we separated it into
three categories proposed by Wallace et al.: mental,
physical, and emotional health (6). Likewise, as for
burnout, we proposed to measure three subcategories of
our conception (emotional, mental, physical health) for
each larger category proposed by Wallace (9
subcategories total).
After the survey, participants were asked to share limited
demographic information, including race, gender, and
class year. Completing this section was optional and did
not affect prior responses in the overall analyses. Lastly,
this project meets the criteria for a Quality Improvement
project and did not require IRB approval.
Participation
The survey was distributed to all 599 students in the
NEOMED College of Medicine. Participation was
optional and anonymous (n =166; participation = 28%).
The study was single blinded as the participants were
aware of researchers, study goals, and the survey group
they were in, and researchers were not aware of individual
subject identities. The survey was open for three weeks
from, January 18, 2021 to February 8, 2021, and was
administered via Qualtrics SM Survey software. The
timeframe of three weeks was selected to give participants
ample time to take the survey and for the researchers to
have the ability to address results promptly. The survey
was emailed to all actively enrolled NEOMED College of
Medicine students, with a weekly reminder email each of
the following two weeks. The email also contained an
information sheet that detailed the purpose of the survey,
participation as being anonymous and optional, researcher
contact information, the definitions of terms, and
instructions for participation. No compensation was
provided for survey completion.
The questionnaire included eight questions and was
administered in January 2021. Question 1 asked
participants to provide separate ratings of the frequency
they experienced the three components of burnout over
the past two weeks (Fig. 1A). The two-week time frame
was selected to provide insight into symptoms at that
specific time range during the beginning of a medical
school semester. Of the questions asked, Questions 2
through 4 asked participants to rate their satisfaction with
each of the nine subcategories of wellness (Fig. 1B). The
fifth question asked participants to compare the level of
challenge they have experienced in medical school to
what they expected before beginning (Fig. 1C). These
first five survey questions were rated on scales of one to
five, though the scales were distinct for each question (see
Fig. 1). Herein, we refer to answers pertaining to burnout
as frequency ratings, answers pertaining to wellness as
satisfaction ratings, and answers pertaining to
experienced versus expected challenge of medical school
as disparity ratings. For this manuscript, students who
reported frequency ratings of 4 or 5 for burnout metrics
were considered at risk of burnout or experiencing
burnout. Students who reported satisfaction ratings of 1 or
2 for wellness metrics were considered to have
suboptimal wellness.
Data analysis
The ordinal data collected for the first five survey
questions was treated as numeric for the sake of
comparative statistical analysis. We believe that this
assumption is justified as the perceived difference
between answer choices in the survey should be equal
(e.g., the difference between very rarely and rarely should
be equal to the difference between rarely and
occasionally). Comparative statistical analyses were
conducted within Microsoft Excel using a two-tailed,
unpaired, two-sample t-test that assumed equal variances
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and single factor analysis of variance tests as appropriate.
A threshold of p ≤ 0.05 was used to determine statistical
significance. When single factor ANOVA testing
revealed statistical significance, post-hoc two-tailed ttesting was conducted to determine which classes
specifically differed from one another.
A
B
C
Figure 1. Sample survey scales and verbiage used in assessing numerical ratings. A) Novel scale created by
authors to rate burnout based on frequency of feeling Detached, Drained, or Defeated over the past 2 weeks.
B) Novel scale created by authors to rate overall quality of wellness determined by the 3 categories, Mental
Health, Emotional Health, and Physical Health, and 9 subcategories of wellness. C) Question used to determine
experienced versus expected challenge in medical school.
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3.68 (Table 2B). Satisfaction with work/life balance was
lowest among M2 participants, with a mean satisfaction
rating of 2.47. The percentages of students reporting a
suboptimal work/life balance in each class were 43.2% of
M1s, 58.3% of M2s, 36.1% of M3s, and 16.2% of M4s.
The ability to make and meet life goals was highest among
M4 participants, with a mean satisfaction rating of 3.69
(Table 2C). The ability to make and meet life goals was
lowest among M2 participants, with a mean satisfaction
rating of 2.82. The percentages of students reporting a
suboptimal ability to make and meet life goals in each
class were 41.2% of M1s, 44.4% of M2s, 34.0% of M3s,
and 15.7% of M4s.
RESULTS
Respondents included 51 M1s, 36 M2s, 46 M3s, and 32
M4s. There were no significant findings between groups
when stratified by race and gender.
Burnout
Survey respondent data about our three categories of
burnout is summarized in Table 1. The feeling of being
drained was most frequently experienced among M2
participants, with a mean frequency rating of 3.83 (Table
1A). Being drained was least frequently experienced
among M4 participants, with a mean frequency rating of
3.00. The percentages of students experiencing/at risk of
feeling drained in each class were 56.9% of M1s, 63.9%
of M2s, 44.7% of M3s, and 38.7% of M4s. Feelings of
detachment were most frequently experienced among M1
and M2 participants, with mean frequency ratings of 3.14
for both classes (Table 1B). Feelings of detachment were
least frequently experienced among M4 participants, with
a mean frequency rating of 2.31. The percentages of
students experiencing/at risk of detachment in each class
were 37.2% of M1s, 41.7% of M2s, 17.1% of M3s, and
18.8% of M4s. The feeling of defeated was most
frequently experienced among M2 participants, with a
mean frequency rating of 3.25 (Table 1C). The feeling of
being defeated was least frequently experienced among
M4 participants, with a mean frequency rating of 2.39.
The percentages of students experiencing/at risk of
feeling defeated in each class were 35.2% of M1s, 55.6%
of M2s, 21.3% of M3s, and 16.2% of M4s.
ANOVA testing revealed statistically significant
differences between mean group satisfaction ratings for
all three categories of mental health: overall mood
(p=0.01), satisfaction with work/life balance (p<0.001),
and the ability to make and meet life goals (p=0.01). Posthoc two-tailed t testing revealed the following pairs of
individual classes to differ significantly for overall mood:
M1 and M4, M2 and M4, M3 and M4; satisfaction with
work/life balance: M1 and M4, M2 and M3, M3 and M4;
ability to make and meet life goals: M1 and M4, M2 and
M4, M3 and M4.
Components of Wellness: Emotional Health
Survey respondent data pertaining to our three categories
of emotional health are summarized in Table 3. Quality of
relationships was highest among M4 participants, with a
mean satisfaction rating of 3.75 (Table 3A). Quality of
relationships was lowest among M1 participants, with a
mean satisfaction rating of 3.08. The percentages of
students reporting a suboptimal quality of relationships in
each class were 41.2% of M1s, 33.3% of M2s, 25.6% of
M3s, and 18.8% of M4s. The ability to take time for
oneself was highest among M4 participants, with a mean
satisfaction rating of 3.84 (Table 3B). The ability to take
time for oneself was lowest among M2 participants, with
a mean satisfaction rating of 2.67. The percentages of
students reporting a suboptimal ability to take time for
oneself in each class were 41.1% of M1s, 52.8% of M2s,
31.9% of M3s, and 9.40% of M4s. Satisfaction with a
sense of purpose was highest among M4 participants, with
a mean satisfaction rating of 3.78 (Table 3C). Satisfaction
with a sense of purpose was lowest among M2
participants, with a mean satisfaction rating of 3.11. The
percentages of students reporting a suboptimal sense of
purpose in each class were 39.2% of M1s, 36.1% of M2s,
25.5% of M3s, and 15.7% of M4s.
ANOVA testing revealed statistically significant
differences between mean group frequency ratings for all
three categories of burnout: drained (p=0.004), detached
(p=0.006), and defeated (p=0.03). Two-tailed t testing
revealed the following pairs of individual classes to differ
significantly for feelings of detachment: M1 and M3, M1
and M4, M2 and M3, M2 and M4; feeling drained: M1
and M3, M1 and M4, M2 and M4; feeling defeated: M2
and M3, M2 and M4.
Components of Wellness: Mental Health
Survey respondent data pertaining to our mental health
categories are summarized in Table 2. The overall mood
was highest among M4 participants, with a mean
satisfaction rating of 3.72 (Table 2A). The overall mood
was lowest among M2 participants, with a mean
satisfaction rating of 2.86. The percentages of students
reporting a suboptimal overall mood in each class were
33.3% of M1s, 41.7% of M2s, 31.9% of M3s, and 15.7%
of M4s. Satisfaction with work/life balance was highest
among M4 participants, with a mean satisfaction rating of
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ANOVA testing revealed a statistically significant
difference between mean group satisfaction ratings for the
ability to take time for oneself (p<0.001). The differences
between mean group satisfaction ratings for quality of
relationships (p=0.13) and sense of purpose (p=0.057)
were not statistically significant. Post-hoc two-tailed t
testing revealed the following pairs of individual classes
to differ significantly for ability to take time for oneself:
M1 and M4, M2 and M4, M3 and M4.
A
Number
Mean
of
Rating Responses
Drained (%)
Class
1
2
3
4
5
M1
0.0
9.8
33.3
21.6
35.3
3.82
51
M2
8.3
5.6
22.2
22.2
41.7
3.83
36
M3
2.1
17.0
36.2
29.8
14.9
3.38
47
M4
16.1
19.4
25.8
25.8
12.9
3.00
32
B
Number
of
Mean
Responses
Rating
Detached (%)
Class
1
2
3
4
5
M1
9.8
23.5
29.4
17.6
19.6
3.14
51
M2
16.7
22.2
19.4
13.9
27.8
3.14
36
M3
19.1
27.7
36.2
12.8
4.3
2.55
47
M4
34.4
25.0
21.9
12.5
6.3
2.31
32
C
Number
Mean
of
Rating Responses
Defeated (%)
Class
1
2
3
4
5
M1
15.7
27.5
21.6
17.6
17.6
2.94
51
M2
22.2
16.7
5.6
25.0
30.6
3.25
36
M3
23.4
23.4
32.0
14.9
6.4
2.57
47
M4
25.8
32.3
25.8
9.7
6.5
2.39
32
Table 1: Percent of NEOMED Medical Student Response for Symptoms of Burnout. Scale Based on Frequency of Symptoms Over
Previous 2 Weeks: 1- Very Rarely, 2- Rarely, 3- Occasionally, 4- Frequently, 5-Very Frequently. A) Percent Drained, B) Percent
Detached, C) Percent Defeated
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A
Mean
Rating
Overall Mood (%)
Class
5
Number
of
Responses
1
2
3
4
M1
17.6
15.7
21.6
39.2
5.9
3.00
51
M2
13.9
27.8
22.2
30.6
5.6
2.86
36
M3
6.4
25.5
17.0
44.7
6.4
3.19
47
M4
6.3
9.4
6.3
62.5
15.6
3.72
32
B
Mean
Rating
Satisfaction Work/Life Balance (%)
Class
5
Number
of
Responses
1
2
3
4
M1
15.7
27.5
33.3
23.5
0.0
2.65
51
M2
33.3
25.0
11.1
22.2
8.3
2.47
36
M3
19.1
17.0
27.7
25.5
10.6
2.91
47
M4
9.7
6.5
12.9
48.4
22.6
3.68
32
C
Class
Ability to Make and Meet Life Goals (%)
Mean
Rating
5
Number
of
Responses
1
2
3
4
M1
13.7
27.5
25.5
29.4
3.9
2.82
51
M2
25.0
19.4
13.8
27.8
13.9
2.86
36
M3
10.6
23.4
19.1
38.3
8.5
3.11
47
M4
9.4
6.3
12.5
50.0
21.9
3.69
32
Table 2: Percent of NEOMED Medical Student Respondents Rating Quality of Mental Health based on Overall Mood, Satisfaction
with Work/Life Balance, and Ability to Make/Meet Life Goals. Scale: 1- Poor, 2- Fair, 3- Neutral, 4- Good, 5- Excellent. A) Overall
Mood Rating Percent B) Satisfaction with Work Life Balance Rating Percent, C) Ability to Make and Meet Life Goals Rating Percent
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A
Class
Sense of Purpose (%)
Mean
Rating
Number
of
Responses
1
2
3
4
5
M1
15.7
23.5
11.8
31.4
17.6
3.12
51
M2
11.1
25.0
19.4
30.6
13.9
3.11
36
M3
6.4
19.1
12.8
38.3
23.4
3.53
47
M4
6.3
9.4
9.4
50.0
25.0
3.78
32
B
Mean
Rating
Ability to Take Time for Yourself (%)
Class
5
Number
of
Responses
1
2
3
4
M1
17.6
23.5
29.4
25.5
3.9
2.75
51
M2
25.0
27.8
13.9
22.2
11.1
2.67
36
M3
12.8
19.1
23.4
31.9
12.8
3.13
47
M4
9.4
0.0
12.5
53.1
25.0
3.84
32
C
Quality of Relationships (%)
Class
Mean
Rating
Number
of
Responses
1
2
3
4
5
M1
11.8
29.4
13.7
29.4
15.7
3.08
51
M2
19.4
13.9
8.3
44.4
13.9
3.19
36
M3
12.8
12.8
6.4
57.4
10.6
3.40
47
M4
12.5
6.3
12.5
31.3
37.5
3.75
32
Table 3: Percent of NEOMED Medical Student Respondents Rating Quality of Emotional Health. Scale: 1-Poor, 2-Fair, 3-Neutral, 4Good, 5-Excellent. A) Quality of Relationships percent, B) Ability to Take Time for Yourself percent, C) Sense of Purpose percent
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Components of Wellness: Physical Health
all three mental health components were significantly
different when separated by class, being most commonly
ranked as suboptimal by the M2 class. Third, the only
emotional health factor that differed significantly between
classes was the ability to take time for oneself. There were
no statistically significant differences in physical health
between classes, however, a high percentage of all three
factors were ranked suboptimal. Finally, there were no
statistically significant differences between experienced
and expected challenges of medical school amongst the
classes, however, a high percentage of respondents rated
their experience as somewhat or much more challenging
than expected. Thus, our findings suggest that the
preclinical stage at NEOMED may contribute to a higher
frequency of burnout symptoms and poorer mental health
quality. M1s and M2s experience significantly greater
burnout symptoms than M3/M4s. Additionally, rating
their experience as much more challenging/somewhat
more challenging than expected (49% of M1 respondents,
50% of M2 respondents, 52% of M3 respondents, and
57% of M4 respondents) is a concerning finding.
Survey respondent data pertaining to our three categories
of physical health are summarized in Table 4. Satisfaction
with diet was highest among M3 participants, with a mean
satisfaction rating of 3.11 (Table 4A). Satisfaction with
diet was lowest among M2 participants, with a mean
satisfaction rating of 2.83. The percentages of students
reporting a suboptimal diet in each class were 41.2% of
M1s, 41.6% of M2s, 36.1% of M3s, and 31.2% of M4s.
Satisfaction with sleep was highest among M4
participants, with a mean satisfaction rating of 3.22 (Table
4B). Satisfaction with sleep was lowest among M1
participants, with a mean satisfaction rating of 2.65. The
percentages of students reporting suboptimal sleep in each
class were 45.1% of M1s, 41.7% of M2s, 40.4% of M3s,
and 28.2% of M4s. Satisfaction with exercise was highest
among M4 participants, with a mean satisfaction rating of
2.75 (Table 4C). Satisfaction with exercise was lowest
among M1 participants, with a mean satisfaction rating of
2.41. The percentages of students reporting suboptimal
exercise in each class were 53.0% of M1s, 41.7% of M2s,
49.0% of M3s, and 43.8% of M4s.
Respondents were asked for factors that might be
worsening burnout and suggestions that might improve
resilience. Preclinical students’ suggestions regarding
burnout include: isolation (secondary to pandemic), a
newly redesigned and intense curriculum, and the
USMLE Step 1 Exam. Although the new curriculum had
been instituted because of previous students’ desire for
more active and interactive learning experiences, the
current students had concerns about this approach. The
M1 class disliked the frequent graded quizzes that
accompanied the Peer Instruction methodology. The M2
class suggested that mandatory class and lecture work
interfered with preparation for the USMLE Step 1 Exam.
These comments likely correlate with “Academic
Performance” being listed as the most significant stressor
for these classes. Clinical students experiencing burnout
at less frequent rates may be due to different demands
based on their stage of training and/or improved coping
strategies.
ANOVA testing revealed there to be no statistically
significant differences between mean group satisfaction
ratings for all three categories of physical health: sleep
(p=0.17), diet (p=0.70), and exercise (p=0.62).
Experienced vs. Expected Challenge
Survey respondent data pertaining to experienced versus
expected challenges in medical school is summarized in
Table 5. The disparity between experienced versus
expected challenge was least severe among M1
participants, with a mean disparity rating of 2.6. The
disparity between experienced versus expected challenge
was most severe among M4 participants, with a mean
disparity rating of 2.34. ANOVA testing revealed there to
be no statistically significant differences between mean
group disparity ratings (p=0.65).
DISCUSSION
In the wellness categories, all three subcomponents of
mental health - overall mood, satisfaction with work/life
balance, and ability to make/meet life goals - showed a
statistically significant difference between classes
[overall mood (p=0.01), satisfaction with work/life
balance (p<0.001), and the ability to make and meet life
goals (p=0.01)], with lower scores in the preclinical years.
Burnout, Wellness, and Stressor Analysis
In this study of burnout and wellness in the NEOMED
College of Medicine, we sought to investigate further the
frequency and factors of medical student burnout
symptoms, the quality of medical student wellness, and
contributing stressors at NEOMED. We were able to
discover several notable findings. First, all three
symptoms of burnout are most frequently experienced in
the first two (preclinical) years of medical school. Second,
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A
Class
Diet (%)
Mean
Rating
5
Number
of
Responses
1
2
3
4
M1
21.6
19.6
17.6
35.3
5.9
2.84
51
M2
19.4
22.2
19.4
33.3
5.6
2.83
36
M3
10.6
25.5
19.1
31.9
12.8
3.11
47
M4
15.6
15.6
28.1
37.5
3.1
2.97
32
Mean
Rating
Number
of
Responses
B
Class
Sleep (%)
1
2
3
4
5
M1
25.5
19.6
19.6
35.3
0.0
2.65
51
M2
25.0
16.7
16.7
41.7
0.0
2.75
36
M3
17.0
23.4
10.6
40.4
8.5
3.00
47
M4
9.4
18.8
15.6
53.1
3.1
3.22
32
Mean
Rating
Number
of
Responses
C
Class
Exercise (%)
1
2
3
4
5
M1
41.2
11.8
17.6
23.5
5.9
2.41
51
M2
38.9
2.8
30.6
22.2
5.6
2.53
36
M3
27.7
21.3
14.9
23.4
12.8
2.72
47
M4
25.0
18.8
18.8
31.3
6.2
2.75
32
Table 4: Percent of NEOMED Medical Student Respondents Rating Quality of Physical Health. Scale: 1-Poor, 2-Fair, 3-Neutral, 4Good, 5-Excellent. A) Quality of Sleep percent B) Quality of Diet percent C) Quality of Exercise
23
JMS, August 2022 – Volume 1, Issue 1
Pandya, et al
Table 5: Percent of NEOMED Medical Student Respondents Rating Experienced vs Expected Challenge of Medical School (based on
lectures, exams, patient care and remote learning). Scale: 1- Much Worse Than Expected 2-Somewhat Worse than Expected, 3-About
What I Expected, 4-Somewhat Easier Than Expected, 5-Much Easier Than Expected
“wellness” days. Despite these initiatives, with the high
rates of burnout and suboptimal wellness coupled with the
medical school experience being more challenging than
expected, there is room for further improvement.
NEOMED should continue considering student feedback
for iterative curricular implementation and improvement.
Implementing a new curriculum will present a challenge
to any university. During the pre-clinical years, the Peer
Instruction emphasis is a valuable learning system;
however, based on student feedback, improvements can
still be made to this curriculum (13). Student feedback
from this study requested fewer hours of Peer Instruction
and no quizzes on the day following an exam. Members
of the M2 class requested limiting lectures to run up to the
USMLE Step 1 board exam. Continuing to meet with
students and understanding their perspectives on the
curriculum can help create and adjust a curriculum
conducive to learning and student wellness.
Once again, the students on clinical rotations may have
been partially protected by increased resiliency with
accumulated experience of high stress and work demands
in medical school. Within emotional health, the only
statistically significant difference between groups was the
ability to take time for oneself, which may also be related
to a fixed schedule and fewer exams in clinical years.
Physical health factors displayed no statistically
significant differences between classes. However, nearly
50% of respondents rated their sleep and exercise as
suboptimal, and nearly 40% rated diet is suboptimal.
These findings may be due to the rigorous academic
demands taking up most of the students’ time (12).
Overall, classes that demonstrated higher scores on
metrics of burnout tended also to demonstrate poorer
scores pertaining to wellness metrics.
Finally, almost 50% of total respondents rated their
experienced challenge of medical school at NEOMED as
much worse or somewhat worse than expected. These
results did not significantly vary by stage in medical
school. This is an issue that may be due to perceived
expectations of medical school, changes due to remote
learning during the COVID-19 pandemic, and factors
controlled by NEOMED (e.g., curricular structure).
NEOMED may benefit from a large project dedicated to
promoting the components of wellness, mental health,
physical health, and emotional health. As a specific
example to improve mental health, NEOMED can
provide free access to meditation apps such as Headspace,
which has been demonstrated to have reduced stress by
14% (14). A larger-scale initiative on physical health and
spreading awareness on the importance of its
subcomponents: sleep, diet, and exercise may also be
beneficial as many students are suboptimal in these
categories. Examples include: virtual Zumba or yoga
classes, meditation classes, or dietitian/chef-led cooking
classes. Finally, emphasis on the components of
emotional health by continuing to improve
communication and consideration of students’ lives
outside of school can also be of benefit. A promising new
initiative, which began in 2020, is the Exceptional Student
Experience, a comprehensive initiative designed by
NEOMED faculty to deliver a student-centered medical
How can NEOMED respond?
As previously stated, NEOMED has taken steps in student
wellness. NEOMED opened the Center for Student
Wellness and Counseling Services (CSWCS), which
offers free care for students. The CSWCS began
providing telehealth and evening appointments to expand
accessibility to students. Many students praised the
CSWCS. NEOMED students have access to the Sequoia
Wellness Center on the NEOMED campus, which offers
a full range of gym equipment and aerobics classes as part
of enrollment. NEOMED students are permitted to take
24
JMS, August 2022 – Volume 1, Issue 1
Pandya, et al
school curriculum with a focus on patient care with
humanistic values, clinical competence, board exam
performance, residency competitiveness, and readiness,
and personal wellness.
CONCLUSION
The medical school appears to be a stressful experience
for NEOMED College of Medicine students, with peak
burnout frequencies and suboptimal wellness ratings in
the preclinical years. The effects of burnout can be
detrimental to medical students, physicians, and to the
entire healthcare system. Our findings demonstrated that
the groups that scored higher frequencies of burnout also
scored lower on wellness ratings, therefore, a systematic
approach dedicated to promoting wellness at NEOMED
may lead to lower frequencies of burnout.
How can students respond?
In addition to NEOMED responding to factors outside a
student’s control, there are also several actions that
students may take to improve symptoms of burnout. As
demonstrated by our results, groups with higher scores on
metrics of burnout also tended to demonstrate lower
scores pertaining to wellness metrics. Therefore, these
students may benefit by prioritizing components of
wellness. For example, a sleep of an optimal duration (79 hours) is associated with higher test scores (15).
Therefore, students may benefit by prioritizing this
subcomponent of physical health, which can help improve
a major stressor, academic performance (15).
REFERENCES
Additionally, it should be noted that there may be a reason
to believe that experience at NEOMED may build
resilience, demonstrated by improved metrics of burnout
and some metrics of wellness in the later clinical years.
1.
Suicide among health-care workers: Time to act. The
Lancet. 2017; 389(10064):2. doi: 10.1016/S01406736(17)30005-3
2.
Dyrbye LN, Thomas MR, Huntington JL, et al.
Personal life events and medical student burnout: a
multicenter study. Acad Med. 2006;81(4):374-384.
doi:10.1097/00001888-200604000-00010
3.
Koutsimani P, Montgomery A, Georganta K. The
Relationship Between Burnout, Depression, and
Anxiety: A Systematic Review and MetaAnalysis. Front Psychol. 2019;10:284. doi:10.3389/
fpsyg.2019.00284
4.
Tawfik DS, Profit J, Morgenthaler TI, et al. Physician
Burnout, Well-being, and Work Unit Safety Grades
in Relationship to Reported Medical Errors. Mayo
Clin Proc. 2018;93(11):1571-1580. doi:10.1016/j.
mayocp.2018.05.014
5.
Dyrbye LN, West CP, Satele D, et al. Burnout among
U.S. medical students, residents, and early career
physicians relative to the general U.S.
population. Acad Med. 2014;89(3):443-451. doi:10.
1097/ACM.0000000000000134
6.
Wallace JE, Lemaire JB, Ghali WA. Physician
wellness: a missing quality indicator. Lancet. 2009;
374(9702):1714-1721.doi:10.1016/S01406736(09)61424-0
7.
Liaison Committee on Medical Education. Functions
and Structure of a Medical School: Standards for
Accreditation of Medical Education Programs
Leading to the MD Degree. Published March 2020.
Accessed on February 22, 2021. https://lcme.org/
publications.
Lessons and limitations?
Our study has several limitations. The most significant
potential factor is the low response rate. Our sample size
of 166 out of 599 total students only captured 28% of the
total student population. There may be a response bias
based on the students who answered the survey.
Responding students may be experiencing burnout and
suboptimal wellness at more significantly different rates
than nonparticipants of the survey. They may be seeking
help to deal with these issues and view the survey as a
platform for them to be heard. They were also given three
weeks to respond, which may not have been a sufficient
timeframe. Additionally, certain demographic factors
including age and marital status were not collected to
protect subject privacy. This limited our ability to
determine how representative our respective samples
were from each class. Finally, the timing of the survey in
the middle of demanding preclinical semesters and the
COVID-19 pandemic may have generated more
unfavorable responses as it has shown to be a significant
contributing factor to stress in the medical profession
(11).
25
Pandya, et al
JMS, August 2022 – Volume 1, Issue 1
8.
CONFLICTS OF INTEREST
9.
Accreditation Council for Graduate Medical
Education.
ACGME
Common
Program
Requirements (Residency) 2020. Published Feb 3,
2020. Accessed Feb 22, 2021. https://www.acgme.
org/Portals/0/PFAssets/ProgramRequirements/CPR
Residency2020.pdf
All authors declare no conflicts of interest.
AUTHOR CONTRIBUTIONS
Conceptualization: AP, AD, RW
Veasey S, Rosen R, Barzansky B, Rosen I, Owens J.
Sleep loss and fatigue in residency training: a
reappraisal. JAMA. 2002;288(9):1116-1124. doi:10.
1001/jama.288.9.1116
Methodology: AP, AD, AI, AA, RW
Investigation: AP, AD, AI, AA, RW
Project administration: AP, AD, RW
10. Alimujiang A, Wiensch A, Boss J, et al. Association
Between Life Purpose and Mortality Among US
Adults Older Than 50 Years. JAMA Netw Open.
2019;2(5):e194270. doi:10.1001/jamanetworkopen.
2019.4270
Supervision: RW
Writing – original draft: AP, AD, AI, RW
Writing – review & editing: AA
11. Young KP, Kolcz DL, O'Sullivan DM, Ferrand J,
Fried J, Robinson K. Health Care Workers' Mental
Health and Quality of Life During COVID-19:
Results From a Mid-Pandemic, National Survey.
Psychiatr Serv. Feb 2021 ;72(2):122-128. doi:
10.1176/appi.ps.202000424.
12. Stewart SM, Lam TH, Betson CL, Wong CM, Wong
AM. A prospective analysis of stress and academic
performance in the first two years of medical
school. Med Educ. 1999;33(4):243-250. doi:10.
1046/j.1365-2923.1999.00294.x
13. Parmelee D, Trout M, Overman I, Matott M. 12 TIPS
for Implementing Peer Instruction in Medical
Education. MedEdPublish. 2020;9,[1], 237. doi:10.
15694/mep.2020.000237.1
14. Economides M, Martman J, Bell MJ, Sanderson B.
Improvements in Stress, Affect, and Irritability
Following Brief Use of a Mindfulness-based
Smartphone App: A Randomized Controlled
Trial. Mindfulness (N Y). 2018;9(5):1584-1593.
doi:10.1007/s12671-018-0905-4
15. Zeek ML, Savoie MJ, Song M, et al. Sleep Duration
and Academic Performance Among Student
Pharmacists. Am J Pharm Educ. 2015;79(5):63.
doi:10.5688/ajpe79563
ACKNOWLEDGMENTS
We sincerely thank Mr. Robert Larson and Dr. Julie
Aultman for assistance with implementation of this
survey.
26
Journal of Medical Sciences at NEOMED
Volume 1, Issue 1, August 2022
Using Ancient Spices to Treat Chronic Diseases: Turmeric’s Potential to Modulate Disease
Pathogenesis in Rheumatoid Arthritis and Inflammatory Bowel Disease
Kelly M. Kimball, BS1*†, Giovanna Leone, BS1†, Bina Mehta, MD2
1.
2.
Northeast Ohio Medical University, College of Medicine, Rootstown, OH, 44272
Akron General – Cleveland Clinic, Akron, Ohio
* Corresponding author
†
Joint first authorship
ABSTRACT
This review aims to highlight two major health conditions that could benefit from regular supplementation of
turmeric, as well as to discuss the importance of more widespread uses of this natural therapeutic in commonly
used multivitamins and multi-drug regimens. There is a wide range of potential benefits patients could gain
from this supplement, but we will be focusing only on the effects on inflammation in two of the most prevalent
chronic inflammatory diseases, rheumatoid arthritis (RA) and inflammatory bowel disease (IBD). We
propose that turmeric supplementation could be more commonly used in a healthcare setting as an adjuvant
treatment in these inflammatory conditions. Future studies investigating turmeric’s role for treatment in RA
and IBD must aim to further evaluate the effects of curcumin on the human microbiota and how its
bioavailability can be increased to provide therapeutic results.
Keywords: Turmeric, Anti-inflammatory, Irritable Bowel Disease, Rheumatoid Arthritis
soluble vitamins, B vitamins, and other micronutrients
(1).
INTRODUCTION
Turmeric is a rhizomatous herb that has been utilized in
various capacities in both Chinese and Ayurvedic
medicine for almost 4000 years (1). This spice has been
utilized in the management of many anti-inflammatory
disease processes throughout the world and has been
documented in Ayurvedic medicine as a remedy for
respiratory conditions, such as asthma, as well as for
rheumatism, muscle aches, and wounds (2). The ancient
Chinese documented similar usages, along with relief for
abdominal pain (2). There is much evidence supporting
the multiple health benefits of turmeric, suggesting the
potential for it to serve as a more widespread option for
inclusion in the treatment regimen for certain diseases,
especially chronic inflammatory diseases (3). Modern
medicine has slowly been catching on to the benefits of
turmeric described by ancient civilizations. Today, many
over-the-counter multivitamin supplements incorporate
small doses of turmeric amongst their ingredients of fat-
27
Oxidative stress has been proven to be the pathological
process behind many chronic diseases and cancers,
making routine utilization of this natural antiinflammatory herb something to consider in a healthcare
setting (3). The mechanisms of turmeric’s effects utilize
antioxidant mechanisms similar to vitamins E and A, as it
can neutralize free radicals that are damaging to normal
body functions (1). The active component of turmeric is
curcumin, and it is a compound that possesses many
different actions in vitro and in experimental animal
models (4). It has been shown to favorably affect lipid
metabolism, antioxidant concentrations, multiple antiinflammatory reactions, and numerous signaling
pathways (4). Additionally, recent literature suggests that
turmeric not only benefits those in inflammatorymediated diseased states, but also healthy individuals, as
well. A study by DiSilvestro et al. illustrated that low
doses of lipidated curcumin promote a diverse range of
health-promoting effects, such as lowering serum
JMS, August 2022 – Volume 1, Issue 1
Kimball, et al
triglycerides and proinflammatory cytokines, in healthy
individuals without any underlying medical conditions
(4). This has led investigators to believe that
supplementation with low doses of curcumin could be of
benefit in healthy individuals, as well. Additionally,
curcumin has been shown to exert a multitude of effects
on the human microbiome and intestinal system, which
will be explored throughout this paper.
known mechanisms involve the machinery seen in the
body’s own defense mechanisms against foreign
pathogens, including innate and adaptive immune systems
(9). Turmeric may have the ability to tone down these
widespread inflammatory effects, potentially relieving
symptoms and slowing the destruction of tissue.
RA has multiple treatment options that come with various
side effects. One option being methotrexate, which is
often of clinical benefit but comes with many systemic
side effects such as myelosuppression, mucositis,
hepatotoxicity, and more (10, 11). Furthermore, exploring
effective treatment options that have fewer side effects,
such as turmeric, is very desirable considering the harsh
effects drugs like methotrexate have on the body
(11). Moreover, several studies on curcumin have shown
effects in reducing proinflammatory biomarkers (11). A
recent study revealed that curcumin, the active component
of turmeric, has biochemical effects that can inhibit
inflammation, synovial hyperplasia, and other aspects of
CIA-induced rats via the mTOR pathway. (CIA-induced
rats are collagen-induced arthritis specimens, a widely
used animal model for rheumatoid arthritis) (12).
Furthermore, curcumin inhibited the increased levels of
proinflammatory cytokines and proteinases such as
interleukin-1 beta (IL-1β), tumor necrosis factor alpha
(TNF-α), matrix metalloproteinase-1 (MMP-1), and
MMP-3 in CIA rats (12). A meta-analysis published in
2014 consisting of 342 subjects reveals a significant
difference in CRP levels between curcumin and control
groups. CRP directly correlates to bodily inflammation,
further suggesting curcumin use can combat
inflammation. This effect seemed to depend on the
bioavailability and duration of supplementation (13).
Additionally, a meta-analysis conducted in 2016
determined there is compelling evidence supporting the
use of curcumin adjuvant to conventional RA therapy
(12).
Despite these numerous potential benefits, the efficacy of
turmeric as an anti-inflammatory agent has been
questioned and seldom recommended clinically due to its
poor bioavailability (4). For this reason, it is often
combined with piperidine, a component found in black
pepper, which increases its bioavailability by 2000% (5).
The DiSilvestro study also managed to navigate its low
bioavailability by utilizing a lipidated curcumin, which
was able to enhance its anti-inflammatory effects (4).
Therefore, it is clear that when bioavailability is
increased, curcumin possesses its most potent and
promising effects as an anti-inflammatory agent (5). Due
to this, researchers have been investigating ways in which
oral turmeric supplements can be chemically modified in
order to increase the bioavailability of curcumin.
Therefore, the low natural bioavailability should not
dissuade its use, as there will likely be ways in which this
can be adequately addressed in the near future.
This review aims to highlight two major health conditions
that could benefit from regular supplementation of
turmeric, as well as to discuss the importance of more
widespread uses of this natural therapeutic in commonly
used multivitamins and multi-drug regimens. There is a
wide range of potential benefits from this supplement, but
we will be focusing only on the effects on inflammation
in two of the most prevalent chronic inflammatory
diseases, rheumatoid arthritis (RA) and inflammatory
bowel disease (IBD). We propose that turmeric
supplementation should be more commonly used in a
healthcare setting as an adjuvant treatment in these
inflammatory conditions.
In addition to RA, inflammatory bowel disease has been
increasing in prevalence over the last twenty years (14).
According to the CDC, IBD, which includes Crohn’s
disease and ulcerative colitis, now affects approximately
3 million people or 1.3% of adults in the United States
(14). While the pathogenesis of IBD remains largely
unknown, it is thought to arise due to a dysfunctional or
overly sensitive host immune response to bacterial and
dietary antigens (15). The result is the breakdown of the
microbiome and intestinal barrier, which is usually due to
excess production of pro-inflammatory cytokines, such as
TNF-α, IL-1 β, IL-6, and interferon-gamma (IFN-γ), all
of which are triggered by the activation of nuclear factor
kappa beta (NF-κB) (15). This ultimately results in
unchecked intestinal inflammation and can lead to
changes in the intestinal microbiome (15). If left
TURMERIC’S USE IN CHRONIC
INFLAMMATORY DISEASES
Rheumatoid arthritis (RA) is the most common systemic
inflammatory diagnosis. The prevalence of this chronic
inflammatory disease is as high as 0.6% in North America
(6, 7). Markers of this disease include anti-citrullinated
protein, rheumatoid factor, elevated erythrocyte
sedimentation rate (ESR), and C-reactive protein (CRP),
all of which contribute to the destructive inflammatory
component seen in this disease process (8). There are
several proposed mechanisms of the inflammation seen in
RA, and many that have not been explored yet. Most
28
JMS, August 2022 – Volume 1, Issue 1
Kimball, et al
untreated, this inflammation can become chronic, result in
systemic inflammation and even serve as a nidus for
cancer (15).
curcumin, must be administered or it must be
administered with compounds that help prevent its
metabolism and increase its concentration in the body (5).
As previously mentioned, curcumin is often combined
with various organic compounds to drastically increase its
bioavailability (5). Recent studies have shown that
lapidated curcumin mixtures increase its availability, as
do mixtures with piperidine, the active component of
black pepper (5).
The anti-inflammatory effects of curcumin have been
viewed as a potential adjuvant treatment for those
suffering from IBD since it has been shown to reduce the
proposed inflammatory response implicated in IBD, help
restore the integrity of the intestinal barrier and resist the
degradation of intestinal epithelial tight junctions (15).
Normally, the nitric oxide (NO) that is present at the
physiological baseline serves to protect the
gastrointestinal mucosa. However, the substantial
amounts of NO that is released via inducible nitric oxide
synthase (iNOS) during gastrointestinal inflammatory
disease can result in tissue injury and subsequent necrosis
(15). During inflammation, iNOS produces NO in
pathogenic quantities. Therefore, it is likely that the
chronic inflammation found in gastrointestinal
inflammatory disease states may lead to the dissolution of
the intestinal wall integrity due to the generation of
reactive nitrogen species (RNS). Normally, curcumin
reduces levels of reactive oxygen species (ROS), such as
NO, in the intestinal mucosa (6). In a mouse model of
ulcerative colitis, curcumin was able to inhibit the
generation of iNOS by reducing the T-helper-1 (Th1)
cytokine response, which ultimately led to reduced tissue
damage (6).
Endogenously, curcumin is rapidly metabolized by the
Blautia spp, a bacterium native to the human microbiome
(5). One could also glean that those future research
directions focusing on downregulating the colonization of
Blautia spp could also serve to inhibit the metabolism of
curcumin, thus increasing its concentration in the body.
However, further altering the microbiota possesses its
own challenges and could allow for further dysregulation
of the immune response in those suffering from
inflammatory diseases like RA and IBD. Another route
that could potentially increase curcumin’s bioavailability
is altering its structure or combining it with lipidated or
piperidine compounds, as previous groups have done
(4,5). Investigating ways in which oral turmeric
supplements can be chemically modified to increase the
bioavailability of curcumin is an active area of research.
Therefore, the low natural bioavailability should not
dissuade its use, as there will likely be ways in which this
can be improved in the near future.
Curcumin has been shown to exert a multitude of effects
on the human microbiome and intestinal system. One
study demonstrated that curcumin possessed bactericidal
effects by eradicating H. pylori colonization in vivo
through a proposed mechanism of inhibited bacterial cell
division (15). In addition to these bactericidal effects,
curcumin has been shown to promote and maintain a
healthy gastrointestinal microbiome. One possible
mechanism is curcumin’s ability to promote the growth of
short-chain fatty acid (SCFA)-producing bacteria. In a
murine study conducted by Feng et al., curcumin
supplementation promoted the diversity of SCFAproducing bacteria which have well-described protective
effects on gastrointestinal mucosa by inhibiting
inflammation (15, 16, 17).
In general, natural and alternative medicine continues to
be less explored than modern medicine, despite some
evidence working in its favor (4,5). Turmeric, a natural
supplement that has been used for thousands of years,
works to decrease systemic inflammation and better
disease trajectory. As discussed in this review, both RA
and IBD could benefit from adjuvant turmeric
supplementation. While the supplements may not often
stand on their own as a sole treatment, the simple addition
of one to a complex drug regimen can potentially improve
disease trajectory. Furthermore, after validation through
more clinical trials, this affordable addition could
improve the disease trajectory of patients struggling with
these inflammatory diseases (18). Due to a lack of human
research trials on these supplements, they are often
overlooked by healthcare providers, but there may
certainly be a role for them in certain clinical situations.
Since each person’s immune system is unique, responses
to turmeric supplementation may vary widely on a
patient-to-patient basis. As such, physicians treating
individuals with chronic inflammatory conditions such as
RA or IBD might consider adding turmeric to their
treatment plan.
DISCUSSION
Before definite conclusions can be made, future studies
must further evaluate the effects of curcumin on the
human gastrointestinal microbiota, as most existing
studies focus on its effects in animal models. One
explanation for the lack of studies exploring this concept
is the poor bioavailability of pure curcumin. For patients
to be able to reap the anti-inflammatory rewards of
turmeric, high doses (500 mg) of the active ingredient,
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Kimball, et al
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Slika L, Patra D. Traditional Uses, Therapeutic
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Prasad S, Aggarwal BB. Turmeric, the Golden Spice:
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12. Dai Q, Zhou D, Xu L, Song X. Curcumin alleviates
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Khan I, Samson S, Grover A. Antioxidant
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DiSilvestro R, Joseph E, Zhao S, Bomser J. Diverse
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CONFLICTS OF INTEREST
All authors declare no conflicts of interest.
9.
Croia C, Bursi R, Sutera D, Petrelli F, Alunno A,
Puxeddu I. One year in review 2019: pathogenesis of
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AUTHOR CONTRIBUTIONS
Conceptualization: KMK, GL
Investigation: KMK, GL
10. Wasserman AM. Diagnosis and management of
rheumatoid arthritis. Am Fam Physician. 2011;84
(11):1245-1252.
Visualization: KMK, GL
Project administration: KMK, GL
30
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Kimball, et al
Supervision: BM
Writing – original draft: KMK, GL
Writing – review & editing: KMK, GL, BM
31
Journal of Medical Sciences at NEOMED
Volume 1, Issue 1, August 2022
Chemical and Histopathologic Effects of COVID-19 on Virchow’s Triad
Jay P. Natarajan, BS1, Ashorne K. Mahenthiran, BA2, Gary W. Lemmon, MD, FACS3*
1.
2.
3.
Northeast Ohio Medical University, College of Medicine, Rootstown, OH, 44272
Feinberg School of Medicine, Northwestern University, Chicago, IL
Division of Vascular Surgery, Indiana University School of Medicine, Indianapolis, IN
* Corresponding author
ABSTRACT
Although COVID-19 is known primarily as a respiratory disease, infected patients have been known to
experience COVID-19-associated coagulopathy from overactivation of immune response resulting in
cytokine storm. As a fundamental principle of venous thromboembolism, Virchow’s triad – consisting of
stasis, hypercoagulability, and endothelial injury – remains the foundation for increased clotting risk which
can often precipitate life-threatening complications, such as pulmonary embolism, if left untreated. We
conducted a literature search using PubMed for evidence to explain the increased coagulopathy in COVID19 positive patients in relation to the three pillars of Virchow’s triad. Hypercoagulability in COVID-19
patients is increased due to cytokine-induced fibrin clot formation. Infected patients also have decreased
ADAMTS13, which leads to endothelial injury. Lastly, the increased blood viscosity combined with patient
immobility promotes vascular stasis. These factors put COVID-19 patients at an increased risk of acquiring
blood clots. In conclusion, we have defined a plausible mechanism by which COVID-19 may induce venous
thrombosis using the three components of Virchow’s triad. Due to the fatal nature of vascular complications,
it is important to consider prophylactically treating these patients with a low molecular weight heparin
regimen in order to mitigate the effects of hypercoagulability.
Keywords: COVID-19, Virchow’s triad, venous thromboembolism, hypercoagulability, endothelial injury, venous
stasis, anticoagulation
INTRODUCTION
pulmonology and must be understood by specialists in
cardiovascular and hematologic fields, as well.
On March 11, 2020, the World Health Organization
(WHO) declared novel coronavirus disease caused by
severe acute respiratory syndrome coronavirus 2 (SARSCoV-2), herein labeled COVID-19, to be a global
pandemic (1). Although bats are the primary vector for
SARS-CoV-2, this is an RNA virus that is easily
transmitted via respiratory droplets between humans (2).
Although the clinical course of COVID-19 is most
commonly associated with fever, viral pneumonia, and
acute respiratory distress syndrome (ARDS), this disease
has an additional relevance to the field of vascular surgery
due to its adverse effects on coagulation (3). The
prothrombotic state acquired due to COVID-19
demonstrates that its effects extend beyond the realm of
Around the world, multiple medical centers have noted
that arterial and venous clotting may complicate the
disease course of COVID-19. Helms, et al. noted that in a
French hospital, 28 out of 29 dialysis patients with
COVID-19 experienced thrombosis, which obstructed
dialysis filter function thus compromising renal
replacement therapy in critically ill patients (4). In the
United States, a study of over 3,000 hospitalized COVID19 patients revealed a rate of thrombotic complications
over 10% for non-ICU patients and almost 30% for ICU
patients (5). Since the venous thrombosis rate in COVID19 patients is higher than that in uninfected individuals
(21% vs. 0.5%), it is crucial to investigate the underlying
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mechanisms of pathologic thrombosis due to COVID-19
(6,7). A deeper understanding of the vascular
pathophysiology could potentially guide clinical solutions
for affected patients.
screening criteria. Altogether, we compiled a total of 21
articles regarding the components of Virchow’s Triad.
Virchow’s triad is a well-recognized axiom in venous
thromboembolism (VTE). Rudolf Virchow was a 19th
century German physician who defined clotting as the
combination of three factors: hypercoagulability,
endothelial injury, and stasis. Kushner et al. define
hypercoagulability as a condition in which blood is at a
greater propensity to clot often due to oral contraceptive
use, chemotherapy drugs, or thrombophilia. Any insult to
the wall of the blood vessel can produce an endothelial
injury, promoting activation of the clotting cascade for
vessel repair and disruption of laminar blood flow, which
can initiate thrombosis. Lastly, stasis is a reduction of
flow, which permits blood to pool and clot (8). As earlier
studies have demonstrated increased thrombosis in
COVID-19 patients, we sought to explain these findings
as they relate to Virchow’s triad. Hypercoagulability and
endothelial injury are directly affected by the coronavirus
due to its usage of spike (S) protein to infiltrate (9). We
reason that stasis is a contributing factor to thrombosis in
COVID-19 patients likely due to prolonged bed rest and
immobility. In this paper, we will explore the pathology
of COVID-19 at the cellular and biochemical level, with
a focus on Virchow’s triad and shed light on possible
treatments for patients.
Hypercoagulability
RESULTS
SARS-CoV-2 belongs to a family of coronaviruses that
infect human host cells. However, these family members
differ in virulence and have unique thrombotic activity.
Based on initial investigations, Gabutti et al. postulate that
the S protein for SARS-CoV-2 has a higher affinity for
human angiotensin converting enzyme 2 transmembrane
receptor (ACE-2R) than the previous SARS-CoV
reported in 2002 (10). Although the specific differences
between SARS-CoV-2 and SARS-CoV S proteins are still
under investigation, it is known that the higher ACE-2R
affinity for the current virus has allowed for lower viral
loads to produce symptoms in the host (10). Despite the
differences between the two strains, SARS-CoV-2 spike
protein shares approximately 75 percent amino acid
sequence homology with the SARS-CoV spike protein
(11).
Similar to its predecessor, SARS-CoV-2 uses a
transmembrane protease, serine 2 (TMPRSS2) enzyme as
a primer for the surface unit of its S protein, which binds
to the ACE-2R and achieves viral entry into host
respiratory epithelium (12). Since SARS-CoV-2 shares a
high degree of amino acid sequence homology with
SARS-CoV, it is logical that there are similarities in
biological pathogenesis (13). SARS-CoV-2 causes tissue
damage and vascular leakage due to cytotoxic T cell and
neutrophil activation, coupled with upregulation of proinflammatory cytokines interleukin 6 (IL-6), tumor
necrosis factor alpha (TNFα), interleukin 1 beta (IL-1β),
and C-C motif chemokine ligand 2 (CCL2) (12).
Furthermore, COVID-19 increases activation of profibrotic genes transforming growth factor beta 1 (TGFβ1),
connective tissue growth factor (CTGF), and platelet
derived growth factor subunit A (PDGFA). The
combination of pro-inflammatory cytokines and profibrotic genes leads to the coagulation cascade cleavage
of prothrombin to thrombin and subsequent
transformation of fibrinogen to fibrin (12). The cytokineinduced cascade of fibrin clot formation generates the
abnormal hypercoagulation associated with COVID-19,
which is similar to chronic (compensated) disseminated
intravascular coagulation (DIC), with rapid consumption
of endogenous coagulation factors promoting blood clots
(14). It is important to note that COVID-19-associated
coagulopathy (CAC) is a preliminary stage, which could
further progress to DIC (15). The primary notable
difference between CAC and sepsis-induced DIC is that
initially, fibrinogen remains elevated in CAC as an acute
phase response. Eventually, as CAC progresses,
METHODS
A literature search was performed to investigate the
effects of COVID-19 on Virchow’s triad. Using PubMed,
we conducted individual searches on the components of
Virchow’s Triad. The inclusion criteria used were as
follows: 1) published within the last year to ensure
relevance, 2) written in English, and 3) full-text must be
available. The primary exclusion criterion was case report
articles, as these were not considered to be adequate
evidence for evaluating widespread effects on Virchow’s
Triad. The search terms “COVID-19” and
“hypercoagulation” resulted in 411 articles. These were
then screened by two of the investigators (JN, AM) based
on their pertinence to elucidating biochemical
mechanisms and/or histopathology. Articles without this
focus were removed from our search. This yielded 9
studies describing the mechanism of action for
hypercoagulability in COVID-19. We repeated this
process with the other two components of Virchow’s
triad, yielding 132 articles involving “endothelial injury”
and 5 articles each involving “cytokine injury” and
“stasis”. However, we chose to expand this search to
“COVID-19” and “stasis” in order to yield greater results.
We had a total of 16 results after expanding the search and
included 7 of these stasis-related studies after applying the
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The third element of Virchow’s triad is venous stasis.
Although current literature does not have a quantitative
measure of the degree to which venous stasis is associated
with COVID-19 infection, behavioral and physical
explanations for a potential association exist. Fatigue is a
common clinical presentation of COVID-19, and it is
hypothesized that this symptom occurs due to an IL-6
cytokine surge, which is known to influence skeletal
muscle fatigability in mice (24). In addition, most patients
experience respiratory difficulties, such as dyspnea,
pleurodynia, cough, and expectoration (25). The
constellation of symptoms (common to most viralinduced respiratory infections) likely occur due to the
viral destruction of lung parenchyma and interstitial
inflammation (25). COVID-19 is known to cause mast
cell degranulation (26). As a result, histamines are
released, increasing vascular permeability of pulmonary
endothelial cells. The subsequent leakage of transudative
fluid in the pulmonary interstitium is associated with
dyspnea from increased work of breathing and discomfort
(26). Pulmonary edema reduces the lung’s ability to
oxygenate blood, resulting in an increased arterialalveolar gradient. Combining this increased respiratory
effort with IL-6-induced systemic fatigue, COVID-19infected persons are less likely to be mobile. With
immobility, venous blood begins to pool due to reduced
velocity and decreased muscle activity, which can
promote higher risks of venous thromboembolism (27). It
has been shown in the past that those who are in a
stationary position for a prolonged time are at a higher risk
of developing blood clots (28). One study by Murugesan
et al. mentions that post-operative deep venous
thrombosis (DVT) in Caucasian populations occurs in 1540% of hospitalized patients (28). While the exact cause
of this is unknown, it can be hypothesized that postsurgical bed rest is a contributing factor, since immobility
is a common cause of thrombosis in obese populations
and video game users (29).
fibrinogen decreases to low levels in DIC (15). The
underlying mechanism of this difference is not yet well
understood. Additionally, platelet aggregation and
abnormal thrombus formation rapidly causes tissue
hypoxia (16). Vascular events predominantly reported in
COVID-19 patients with severe infection include VTE
and pulmonary embolism (PE). Patients have developed
rare complications such as venous gangrene of the
extremities, which can lead to critical limb ischemia, but
the more common and potentially worrisome event of
VTE is a PE presenting with dyspnea, syncope and/or
palpitations (17). Rapid deterioration has been noted and
if left untreated, is fatal (18).
Endothelial Injury
Weibel-Palade bodies (WPB) stored in endothelial cells
contain P-selectin and ultra-large Von Willebrand Factor
(ULVWF) (19). Based on current knowledge of the
mechanisms of COVID-19-induced cytokine storms, IL8 and TNFα have particular importance due to their
impact on endothelial cells. Specifically, their activation
causes the release of P-selectin and ULVWF from WPBs,
thereby accelerating clotting and contributing to the
development of VTE (20). P-selectin plays a vital role in
the leukocyte adhesion cascade by binding to P-selectin
Glycoprotein Ligand-1 (PSGL-1) on neutrophils (21).
With regards to coagulation, ULVWF is known to initiate
clotting by promoting the glycoprotein Ib receptor to bind
to glycoprotein IIa receptors on platelets (22). This step of
clotting is known as platelet aggregation, in which
platelets can connect to one another.
Homeostatic autoregulation of the clotting process is
facilitated by the ADAMTS13 enzyme, which works by
cleaving endothelial-bound ULVWF into smaller
components such that thrombi do not form (22).
Deficiencies in ADAMTS13 can present as thrombotic
thrombocytopenic purpura, which produce microthrombi
dispersed throughout the body (22). In COVID-19
infection, IL-6 generation downregulates ADAMTS13,
thus increasing the propensity for ULVWF to aggregate
and create thrombi (22). Similar to IL-6, activated
neutrophils have adverse effects on ADAMTS13 activity.
Activated neutrophils and neutrophil extracellular traps
(NETs) produce reactive oxygen species (ROS) in the
process of fighting viral infections such as COVID-19.
Increases in ROS levels prevent ADAMTS13 from
cleaving ULVWF along the endothelium (23). The
subsequent cytokine storm propagates endothelial
dysfunction and hypercoagulation, two of the three
components of Virchow’s triad, and serves as a plausible
framework to understanding the presentation of VTEs in
COVID-19 patients.
Stasis is also impacted by hyperviscosity, which is
strongly associated with COVID-19. A study from Emory
University involving a cohort of 15 COVID-19 patients
identified blood viscosities exceeding 95% of the normal
limit (30). One potential explanation for this phenomenon
is the correlation between severity of COVID-19 disease
course and increased plasma fibrinogen levels,
fibrinogen-to-albumin ratio (FAR), and D-dimer levels.
Specifically, one cohort study found that patients with
severe disease were in a hypercoagulable state with
shortened prothrombin time (PT) and activated partial
thromboplastin time (aPTT), which stabilized as patients’
condition improved (31). As a result, there may be a
critical threshold of FAR that can serve as a predictor of
the severity of disease (31).
Treatments
Stasis
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Natarajan, et al
As of January 2021, the American Society of Hematology
and American College of Chest Physicians have provided
guidelines stating that all adult patients admitted to the
hospital for COVID-19 infection should be placed on
prophylactic low molecular weight heparin (LMWH)
over unfractionated heparin (UFH) and direct oral
anticoagulant, unless contraindicated (32,33). Studies in
China have shown clinical benefits of this therapy. In a
cohort of 449 COVID-19 patients in Tongji hospital, 99
patients were placed on a LMWH regimen. In patients
who had a D-dimer score greater than six times the normal
limit, a LMWH regimen for at least 7 days improved the
28-day mortality risk (34).
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We would like to thank our primary investigator, Dr.
Gary Lemmon, for this opportunity. As a retired
vascular surgeon, his commitment and passion for
academia is admirable. We would not have been able
to accomplish this work without his constant
guidance and critiques along the way.
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Tanksley CL, Duncan A. COVID-19-associated
hyperviscosity: a link between inflammation and
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We would like to also thank our parents for the
inspiration behind this work. As frontline fighters,
they have fought the grueling battle against COVID19 in efforts to save patients day in and day out. Their
constant support and love have brought us to where
we are today. Thank you.
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due to COVID-19 based on an analysis of initial
Fibrinogen to Albumin Ratio and Platelet count.
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CONFLICTS OF INTEREST
All authors declare no conflicts of interest.
AUTHOR CONTRIBUTIONS
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COVID-19 and VTE-Anticoagulation - Hematology.
org. Published September 18, 2020. Accessed
October 15, 2020. https://www.hematology.org/
covid-19/covid-19-and-vte-anticoagulation.
Conceptualization: GWL
Methodology: JPN, AKM, GWL
Investigation: JPN, AKM, GWL
Project administration: GWL
Supervision: GWL
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Prevention, Diagnosis, and Treatment of VTE in
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Writing – original draft: JPN, AKM, GWL
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37
Journal of Medical Sciences at NEOMED
Volume 1, Issue 1, August 2022
Efficacy of the Glasgow Coma Scale in Determining the Severity of Traumatic Brain Injury
Vihanga Perera, MD1*, Harris Imam, MD2, Percival Pangilinan, MD3
1.
2.
3.
Northeast Ohio Medical University, College of Medicine, Rootstown, OH, 44272
Parkview Health; Fort Wayne, IN
Michigan Medicine; Ann Arbor, MI
* Corresponding author
ABSTRACT
Mr. D, a 52-year-old male, was in an un-helmeted motorcycle collision with a concrete barrier resulting in
polytrauma and traumatic brain injury. Mr. D was assessed by emergency services to be unresponsive with a
Glasgow Coma Scale (GCS) of 13. He sustained an open skull injury, subdural hematoma, multiple facial
fractures, and traumatic vitreous humor hemorrhage with unresponsive, dilated pupils. He received CT and
X-ray imaging before undergoing multiple surgeries for repair and debridement of injuries. After being
weaned off sedation, he entered a state of post-traumatic amnesia lasting two months. Fifteen days postaccident, he began a regimen of amantadine to stimulate interaction and participation in physical therapy. Mr.
D remained for two months until he progressed with physical therapy and was independent with his mobility.
He was admitted to an inpatient traumatic brain injury facility because he was mentally unable to care for
himself.
Keywords: Traumatic Brain Injury, Glasgow Coma Scale, Physical Medicine & Rehabilitation
further classify TBIs as severe (GCS 3-8), moderate (GCS
9-13), or mild (GCS 14-15). This is meant to be an
objective measure to gauge clinical status and outcome at
the time of injury as well as progression over time. Serial
GCS can be used to follow patients and assess their
improvement or deterioration following a TBI (3).
INTRODUCTION
Traumatic brain injury (TBI) is abnormal brain
functioning resulting from an external injury (1). TBIs are
characterized by three periods – impaired consciousness,
post-traumatic amnesia (PTA), and functional recovery
(2). PTA is defined as a period of time when a person is
unable to retain new information following a TBI (2). It is
an important indicator of long-term outcomes post-TBI
(2). The duration of PTA is closely tied with functional
outcomes with long durations of PTA correlating with
decreased functionality (2). The initial severity of TBI is
evaluated with the Glasgow Coma Scale (GCS) whereas
PTA can be assessed with the Galveston Orientation and
Amnesia Test (GOAT) and the Orientation Log (O-Log).
The GOAT is a 10-item questionnaire measuring the
patient’s orientation to time, place, and person in addition
to assessing PTA and retrograde amnesia. PTA differs
from retrograde amnesia in that PTA describes an
inability to form new memories for a period of time
following the TBI, while retrograde amnesia is the loss of
memories just prior to the accident. The GOAT is scored
out of 100 with scores of less than 75 indicating ongoing
PTA. Emergence from PTA is indicated by two
consecutive scores of greater than 75 on the GOAT (2).
The GCS is composed of three parts – eye opening (scored
1 to 4), verbal response (scored 1 to 5), and motor
response (scored 1 to 6). Lower scores on each part
indicate decreased functioning and, therefore, a more
severe injury. The sum of the three scores is used to
The O-Log is also a 10-item questionnaire that measures
orientation more specifically than the GOAT; the O-Log
assesses orientation to city, kind of place, name of
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hospital, month, date, year, day of week, clock time,
traumatic event/accident, and injury/deficits resulting
from the accident. Each of these measures are scored out
of three for a total of 30 points. The goal of the O-Log is
to follow orientation improvements over time (4). This
case report seeks to highlight the limitations of GCS in
predicting the duration of PTA and prognosis post-TBI
and to consider how the initial GCS can be improved to
better evaluate patients at the scene of trauma.
DISCUSSION
Mr. D is a 52-year-old male who sustained a TBI and
polytrauma after an un-helmeted high-speed motorcycle
collision with a concrete barrier. His TBI was initially
judged to likely be mild at the time of presentation, though
his GCS of 13 indicated a moderate TBI. His hospital
course was prolonged with PTA and agitation lasting two
months, an indication of severe TBI and a poor prognosis
of decreased functional recovery.
CASE DESCRIPTION
There are several factors of TBI that make assessment of
injury and treatment difficult. Patients are often assessed
with the GCS soon after traumatic injuries, which also
gives a rough estimate of the severity of TBI (3). The
patient’s initial GCS was scored at 13, indicating a
moderate TBI. His recovery in the hospital was
prolonged, and his orientation was assessed every few
days with the O-Log and GOAT to determine the duration
and severity of PTA. He remained in PTA for just over
two months, suggesting that the TBI he incurred was
severe. This can be assumed because patients with severe
TBI often have PTA, the length of which can be used as a
prognostic indicator of long-term outcomes post-TBI (2).
The length of time the patient remained in PTA, just over
two months, suggests that he will have less functional
outcomes and goals and is unlikely to ever be able to
return to work or recover fully from this accident.
Mr. D, a 52-year-old male, was an un-helmeted
motorcycle driver who presented to the Emergency
Department following a high-speed collision with a
concrete barrier. His initial GCS was 13, and he tested
positive for alcohol, amphetamines, cocaine, and opiates.
He had sustained a frontal open-skull injury, bilateral
frontal subdural hematomas with small contusions, minor
brain contusion, multiple facial fractures, proximal ulnar
and humeral medial epicondylar fractures of the left
elbow, and traumatic vitreous humor hemorrhage with
dilated pupils unresponsive to light. He underwent several
surgeries to clean wounds, beginning a lengthy treatment
process. Surgeries included tracheostomy, facial fracture
repair, maxillomandibular fixation to wire his jaw shut,
washout of the left elbow fracture with external fixation,
irrigation and debridement of left elbow open fracture,
and partial extensor tendon repair to left middle finger.
The disconnect between the patient’s GCS and resulting
estimated prognosis was found to be highly inaccurate
compared to the reality of his prolonged hospital stay and
duration of PTA. The GCS is commonly used to assess
TBI in emergent situations because it is easily
administered. However, the inconsistency of the initial
GCS and the patient’s outcomes in this case has raised
concerns about whether GCS is the best scale for initial
assessment of TBI. A highly inaccurate prognosis given
too early to patient families can cause distress when
patients do not recover as quickly or as completely as
estimated. The GCS will need modification to improve its
accuracy in determining TBI severity. GCS needs to give
a more accurate representation of severity of TBI and
better estimation of functional recovery. O-Log and
GOAT both include measures of orientation whereas GCS
only assesses body functions – do the eyes open? are they
responsive to light? – which fail to account for mental
functioning and orientation. In the initial patient
assessment with GCS, it would be helpful to include parts
of the GOAT or O-Log to create a more accurate modified
GCS and allow for a better assessment of patients
following trauma.
An initial assessment by the Physical Medicine &
Rehabilitation (PM&R) physician predicted a mild TBI
with short-lived, if any, agitation. This proved to be an
inaccurate prediction. The patient remained sedated for
three days after his accident. After being weaned off
sedation, he continued to be somnolent and difficult to
arouse. During his hospital stay, the patient required nonviolent restraints at several points. He was in a state of
PTA and had difficulty paying attention and following
commands. After being in the hospital for 15 days, the
patient was given 100-mg Amantadine twice a day to help
stimulate interaction and his participation in therapies. He
remained in a PTA state for approximately two months.
He was not qualified for admission into inpatient
rehabilitation because adequate supervision after
discharge is required at the time of admission, so he
remained in the acute care surgery unit for the entirety of
his hospital stay. He progressed with therapies during his
hospitalization to the point where he became independent
with his mobility and no longer had any physical therapy
goals necessitating an inpatient rehabilitation admission.
The PM&R physician recommended that Mr. D be
transferred to an inpatient TBI facility for further care.
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CONCLUSIONS
CONFLICTS OF INTEREST
The length and severity of PTA is a good indicator of
long-term functional outcomes following a TBI. The GCS
is quick and easily administered, though it is not always
adequate in determining the severity of a TBI and is not
always accurate in estimating prognosis. In the future,
research should evaluate whether the GOAT or the O-Log
are better measures for determining severity and length of
PTA and which allows for better monitoring over time.
More precise protocols are needed for the treatment of
patients with severe TBI, and future controlled studies
should work to improve the efficacy of the assessments as
well as the treatments used.
All authors declare no conflicts of interest.
AUTHOR CONTRIBUTIONS
Conceptualization: VP, PP
Methodology: VP, PP
Investigation: PP, HI, VP
Visualization: VP
Funding acquisition: VP
Project administration: PP, HI
REFERENCES
1.
Supervision: PP
Writing – original draft: VP
Watts L, Jaramillo CA, Eapen BC. The
Pathophysiology of Traumatic Brain Injury. In: Mitra
R. eds. Principles of Rehabilitation Medicine.
McGraw-Hill; 2019. Accessed March 08, 2021.
https://accessmedicine-mhmedical-com.neomed.
idm.oclc.org/content.aspx?bookid=2550§ionid=
206760227.
2.
Amorapanth PX, Im BS. Rehabilitation Outcomes,
Systemic Manifestations, and Problems in Traumatic
Brain Injury. In: Mitra R. eds. Principles of
Rehabilitation Medicine. McGraw-Hill; 2019.
Accessed March 08, 2021. https://accessmedicinemhmedical-com.neomed.idm.oclc.org/content.aspx?
bookid=2550§ionid=206760495.
3.
Wright DW, Merck LH. Head Trauma. In: Tintinalli
JE, Ma O, Yealy DM, Meckler GD, Stapczynski J,
Cline DM, Thomas SH. eds. Tintinalli's Emergency
Medicine: A Comprehensive Study Guide, 9e.
McGraw-Hill; Accessed March 08, 2021.
https://accessmedicine-mhmedical-com.neomed.
idm.oclc.org/content.aspx?bookid=2353§ionid=
221181086.
4.
Jackson WT, Novack TA, Dowler RN. Effective
serial measurement of cognitive orientation in
rehabilitation: the Orientation Log. Arch Phys Med
Rehabil. June 1998;79(6):718-720. doi:10.1016/
s0003-9993(98)90051-x.
Writing – review & editing: VP, HI, PP
FUNDING
Academy of American Physiatrists Medical Student
Summer Clinical Experience (VP)
40
Journal of Medical Sciences at NEOMED
Volume 1, Issue 1, August 2022
Robotic Assisted Laparoscopic Prostatectomy Post-Prostatic Urethral Lift Implants
Matthew R. DeSanto, MD1,2* and Daniel J. Ricchiuti, MD1
1.
2.
Northeast Ohio Medical University, College of Medicine, Rootstown, OH, 44272
Department of Urology, Charleston Area Medical Center, Charleston, WV, 25304
* Corresponding author
ABSTRACT
Prostate cancer is the second most commonly diagnosed form of cancer in men. While there are several
treatment options for prostate cancer, robotic assisted laparoscopic prostatectomy is a customary option in
the treatment of clinically localized disease. It entails prostate removal using the Intuitive da Vinci surgical
system. Another very prominent urologic condition affecting older males is benign prostatic hyperplasia
(BPH); BPH has an increased lifetime prevalence reaching 80% of men by the 9th decade of life. It is
characterized by lower urinary tract symptoms due to prostatic enlargement. These conditions often develop
concomitantly in males given the high prevalence of each. Surgical advancements such as the prostatic
urethral lift (PUL) system are becoming more commonly utilized. However, patients with benign prostatic
hyperplasia who independently develop clinically significant prostate cancer may necessitate definitive
management, namely prostatectomy. In this case report, we discuss a 67-year-old male presenting with
Gleason group 2 (3+4=7) prostate cancer with previous PUL implants, who then underwent robotic assisted
laparoscopic radical prostatectomy. Prostatectomy following prior PUL implantation has never been fully
discussed in the literature, and there are no intraoperative or postoperative complications from prostatectomy
to report thus far.
Keywords: Prostatectomy, Prostate Cancer, Benign Prostatic Hyperplasia, Prostatic Urethral Lift
4+3=7, Grade 4 is 4+4=8, and Grade 5 is any score
equating to 9 or 10 total. Gleason scoring, prostatespecific antigen, patient history, and physical exam are all
essential for the diagnosis and treatment plan of prostate
cancer.
INTRODUCTION
Prostate cancer is one of the most pervasive oncologic and
urologic conditions that males endure. It is the second
most commonly diagnosed cancer in males, second only
to lung cancer (1). Depending on patient presentation and
prostate cancer grading, options such as prostatectomy or
radiation therapy may be pursued. There are many factors
for clinicians to consider in the course of prostate cancer
workup, and grading methods such as the Gleason grade
and score remain the gold standard. Gleason grading is
comprised of two Gleason scores. The Gleason system is
a scoring system from 1-5, where 1 most histologically
represents normal prostate cells and 5 is most resemblant
of high-grade cancerous cells (2). The first number is the
most predominant type of cell from the biopsy, and the
second number is the second most predominant. Grade 1
is a scoring of 3+3=6, Grade 2 is 3+4=7, Grade 3 is
BPH is another frequently diagnosed urologic condition.
As the name suggests, BPH is a proliferation of smooth
muscle and epithelial cells within the prostatic transition
zone typically due to increased levels of androgens (3).
Due to this enlargement, outflow from the bladder to the
proximal urethra can be greatly diminished. Men may
experience more lower urinary tract symptoms (LUTS) as
the prostate tissue grows. LUTS constitutes symptoms of
urinary urgency, frequency, straining, nocturia, and
intermittency of urinary stream (4). The prostatic urethral
lift system is a novel therapy intended for the treatment of
BPH.
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DeSanto & Ricchiuiti
The PUL system was first studied in 2011 and since then
has obtained FDA approval in the United States and the
United Kingdom as a minimally invasive therapy for BPH
(5). The PUL procedure is unique in comparison to other
endoscopic treatments for BPH in that the technology is
mechanical rather than cavitating or ablative, such as
transurethral resection of the prostate (TURP) (6,7).
TURP has historically been the “gold standard” surgical
procedure for relief of BPH. As mentioned, TURP is an
ablative procedure that entails highly charged
electroresection to remove prostate tissue (8). With PUL,
non-absorbable implants are placed transurethrally to lift
and hold enlarged prostate tissue in order to increase the
urethra’s lumen and decrease outflow obstruction (Fig. 1).
This system has become increasingly more popular as an
alternative to TURP and other surgical BPH treatment
options, given the lower incidence of side effects coupled
with favorable sexual, urinary, and functional outcomes
(9). Now, if patients have a large median prostatic lobe or
if total prostate volume is greater than 80 grams, patients
are not candidates for PUL. Regardless, PUL has become
increasingly more utilized.
standard recommendations of 4-6 implants. The patient
continued to experience LUTS such as hesitancy,
nocturia, and weak urinary stream. Three supplementary
PUL implants were placed in 2020 in response to his
persistent symptomology.
Given the concerning MRI findings, the patient was rebiopsied for evaluation of prostate cancer approximately
three months after the additional implants. The repeat
biopsy revealed Gleason grade 2 (3+4=7) prostate cancer.
Furthermore, Decipher testing, which is a genomic test to
help further stratify biopsied prostate cancer and guide
treatment management, indicated the cancer was
clinically significant high-risk disease (13). The results of
this test further ascertained the need for definitive prostate
cancer treatment.
We discussed with the patient how our literature search
showed minimal information regarding prostatectomy
following PUL implants. The patient was scheduled for
robotic assisted laparoscopic radical prostatectomy at the
end of 2020. Emphasis was made to identify the PUL
implants when dissecting the prostate. In total, seven PUL
implants were identified. There was little difficulty
identifying the urethral end piece and the capsular tab of
each prostatic urethral lift device. The urethral end piece
is considered the inner portion of the device while the
capsular tab is the outer metallic clip. Care was taken to
minimize cautery usage around the clip as this resulted in
arcing. There were no abnormal fibrotic tissue changes
surrounding the implants; dissection and extraction of the
implants were not problematic. The capsular tabs were
disconnected from the suture and were individually
removed. The urethral end pieces and sutures from the
seven PUL implants were left with the prostate specimen.
The remainder of the operation and dissection was
uneventful for robotic prostatectomy. Vesicourethral
anastomosis was achieved without any unexpected
difficulties. There was no other evidence of inflammation
or adherence surrounding the prostate in the surgical field
of view. There was no additional challenge encountered
to nerve-sparing technique.
The TURP procedure, and now PUL, aim to relieve LUTS
secondary to BPH. However, patients undergoing these
procedures may still develop prostate cancer
concomitantly that is unrelated to their BPH. Typical
management options for prostate cancer, such as active
surveillance, prostatectomy and radiation therapy, are
logical to consider for these patients. Specifically, robotic
assisted laparoscopic prostatectomy has become
increasingly employed compared to open prostatectomy.
Robotic prostatectomy offers many benefits such as
improved surgical view, reduced blood loss, and lower
incidence of urinary incontinence and erectile dysfunction
when compared to open technique (10). While the L.I.F.T
study briefly mentions two instances of prostatectomy
after PUL at 2 and 5 year follow-ups, this is not discussed
in depth (11,12). There are currently no case reports in the
literature detailing the full course of prostatectomy after
the placement of PUL devices.
CASE REPORT
DISCUSSION
This case report details a 67-year-old otherwise healthy
male who was in active surveillance for low risk prostate
cancer. He was diagnosed with low volume Gleason grade
3 prostate cancer in 2013, and elected to be managed with
active surveillance. Surveillance magnetic resonance
imaging (MRI) of the prostate seven years later revealed
a 47-gram prostate with a new nodular mass measuring
11mm.
Findings recorded in this case report are significant
because there was an absence of difficulties, and radical
prostatectomy performed as usual despite the prior
placement of PUL implants. It was theorized that there
may be increased adhesions surrounding the prostate
given the presence of foreign bodies, making dissection
more difficult. Moreover, we were unsure how the
implants would affect our ability to use electrocautery for
extraction. This patient also had three additional implants
due to continual LUTS.
Additionally, four PUL implants were placed for BPH
relief at an outside institution in 2019, aligning with
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JMS, August 2022 – Volume 1, Issue 1
DeSanto & Ricchiuiti
Figure 1. Benign prostatic hyperplasia before prostatic urethral lift implantation (a) and following four prostatic urethral lift implants
(b). (A) Diagram showing an enlarged prostate that significantly obstructs urinary tract outflow from the bladder through the urethra. (B) Placement
of four prostatic urethral lift implants to unobstruct urinary flow.
surgical setting. Prostatectomy was performed for this
patient without deviation from standard operative
technique. Furthermore, there are no intraoperative or
postoperative complications to report following
prostatectomy thus far. This case report will aid urologists
in their decision-making when similar clinical scenarios
arise. Our case shows that prostatectomy in the setting of
prior PUL implantation is feasible and, in this case, added
no additional challenge to robotic prostatectomy.
Usually patients do not require additional PUL implants,
so this did add some consideration in regard to more
adhesions. However, the number of implants did not
greatly impact the decision to pursue prostatectomy as
this was necessary to treat the patient’s prostate cancer.
Ultimately, the patient tolerated the procedure well and
has been seen in the postoperative period. He is currently
without clinical evidence of prostate cancer recurrence.
The patient has had minimal LUTS and incontinence
post-surgery. He has not reported significant worsening of
sexual function following prostatectomy.
REFERENCES
The absence of unexpected events is encouraging as the
prostatectomy was performed safely and efficiently
without compromising surgical technique. Prostate cancer
and BPH are both highly prevalent urologic conditions. It
is common for both pathologies to develop
concomitantly. Therefore, as the PUL procedure becomes
more widely adopted for BPH relief, it is reasonable for
urologists to expect to encounter patients with PUL
implants that have later developed prostate cancer.
It would be advantageous to see additional case reports of
prostatectomy in patients with BPH who received PUL
implants. Specifically, seeing how different Gleason
grades affected the ability to extract the implants during
prostatectomy, if at all, would be beneficial.
1.
American Cancer Society. Key Statistics for Prostate
Cancer. Published January, 12, 2021. Accessed June
25, 2021. https://www.cancer.org/cancer/prostatecancer/about/key-statistics.html
2.
Epstein JI, Egevad L, Amin MB, Delahunt B, Srigley
JR, Humphrey PA. The 2014 International Society of
Urological Pathology (ISUP) Consensus Conference
on Gleason Grading of Prostatic Carcinoma:
Definition of Grading Patterns and Proposal for a
New Grading System. Am J Surg Pathol. Feb
2016;40(2):244-52. doi:10.1097/pas.000000000000
0530
3.
Wein, AJ, Kavoussi, LR, Campbell, MF. CampbellWalsh Urology. 12th ed. Philadelphia, PA: Elsevier
Saunders. 2020.
4.
Parsons JK. Benign Prostatic Hyperplasia and Male
Lower Urinary Tract Symptoms: Epidemiology and
Risk Factors. Curr Bladder Dysfunct Rep. Dec
2010;5(4):212-218. doi:10.1007/s11884-010-0067-2
CONCLUSION
This is the first known case report of radical
prostatectomy in a patient with PUL implants in place.
Without other significant literature, it was uncertain what
complications or challenges would be faced in the
43
JMS, August 2022 – Volume 1, Issue 1
DeSanto & Ricchiuiti
5.
6.
7.
Jones P, Rai BP, Aboumarzouk O, Somani BK.
UroLift: a new minimally-invasive treatment for
benign prostatic hyperplasia. Therapeutic advances
in urology. 2016;8(6):372-376. doi:10.1177/17562
87216671497
CONFLICTS OF INTEREST
All authors declare no conflicts of interest.
AUTHOR CONTRIBUTIONS
Garcia C, Chin P, Rashid P, Woo HH. Prostatic
urethral lift: A minimally invasive treatment for
benign prostatic hyperplasia. Prostate international.
2015;3(1):1-5. doi:10.1016/j.prnil.2015.02.002
Conceptualization: MRD, DJR
Bozkurt A, Karabakan M, Keskin E, Hirik E, Balci
MB, Nuhoglu B. Prostatic Urethral Lift: A New
Minimally Invasive Treatment for Lower Urinary
Tract Symptoms Secondary to Benign Prostatic
Hyperplasia. Urol Int. 2016;96(2):202-6. doi:10.
1159/000441850
Visualization: MRD, DJR
8.
Teo JS, Lee YM, Ho HSS. An update on transurethral
surgery for benign prostatic obstruction. Asian
journal of urology. 2017;4(3):195-198. doi:10.1016/
j.ajur.2017.06.006
9.
Perera M, Roberts MJ, Doi SA, Bolton D. Prostatic
urethral lift improves urinary symptoms and flow
while preserving sexual function for men with benign
prostatic hyperplasia: a systematic review and metaanalysis. Eur Urol. Apr 2015;67(4):704-13. doi:10.
1016/j.eururo.2014.10.031
Methodology: MRD, DJR
Investigation: MRD, DJR
Project administration: MRD, DJR
Supervision: DJR
Writing – original draft: MRD
Writing – review & editing: MRD, DJR
10. Finkelstein J, Eckersberger E, Sadri H, Taneja SS,
Lepor H, Djavan B. Open Versus Laparoscopic
Versus Robot-Assisted Laparoscopic Prostatectomy:
The European and US Experience. Reviews in
Urology. 2010;12(1):35-43.
11. Roehrborn CG, Gange SN, Shore ND, et al.
Durability of the Prostatic Urethral Lift: 2-Year
Results of the L.I.F.T. Study. Urology Practice.
2015;2(1):26-32. doi:doi:10.1016/j.urpr.2014.08.001
12. Roehrborn CG, Barkin J, Gange SN, et al. Five year
results of the prospective randomized controlled
prostatic urethral L.I.F.T. study. Can J Urol. Jun
2017;24(3):8802-8813.
13. Dalela D, Löppenberg B, Sood A, Sammon J,
Abdollah F. Contemporary Role of the Decipher®
Test in Prostate Cancer Management: Current
Practice and Future Perspectives. Reviews in urology.
2016;18(1):1-9.
44
Journal of Medical Sciences at NEOMED
Volume 1, Issue 1, August 2022
Improving Community Health by Encouraging Remote Office Visits
Rachel Krevh, BS1*, Eliot Mostow, MD, MPH2
1.
2.
Northeast Ohio Medical University, College of Medicine, Rootstown, OH, 44272
Akron Dermatology; 566 White Pond Dr, Akron, OH, 44320, USA
* Corresponding author
ABSTRACT
The COVID-19 pandemic has affected patient access to healthcare in the field of dermatology. Due to efforts
to minimize in-person healthcare visits, wait times for dermatology visits have increased, negatively affecting
patients’ finances and furthering concerns about their skin conditions. This commentary highlights how the
pandemic will potentially change the future of dermatology by promoting the use of telemedicine to reduce
office wait times during the pandemic and beyond.
Keywords: Telemedicine, Teledermatology, COVID-19, Dermatology, Remote, Wait Times
like atopic dermatitis, psoriasis, and impetigo can lead to
morbidity and mortality if not detected in a timely fashion
(2). Long wait times for in-person dermatology
appointments were problematic even before COVID-19
and have further worsened for patients whose conditions
are deemed ‘non-emergent’ amid office-visit restrictions
brought upon by the pandemic (1). The extended wait
times have led to quality-of-life issues and financial
burdens such as paying for over-the-counter medications
to maintain the conditions (2). However, the pandemic
has shown that telemedicine is an effective resource to
relieve the burdens experienced by patients and follow-up
with them over time to see treatment progress (2).
INTRODUCTION
The COVID-19 pandemic has affected all aspects of the
healthcare field, particularly in dermatology. Conditions
presented in the field of dermatology may generally be
considered non-emergent during a pandemic.
Furthermore, patients with non-acute conditions such as
alopecia and acne have had their visits and procedures
postponed to maintain social distancing (1). The long wait
times for appointments are problematic due to financial
burdens for patients to self-maintain their skin conditions
while waiting for appointments. There is also added fear
and anxiety when waiting and concerns that skin
conditions will worsen. The pandemic has proven that
dermatology visits can proceed via telemedicine, and
patients can have their skin conditions resolved with
expedience through approved online platforms (2). The
ability for telemedicine to present socially distanced skin
findings in real time can be a way to resolve the long-wait
times even after the pandemic (Fig. 1).
Temporary policy changes in the United States have been
implemented to allow physicians and patients to remain
connected via telemedicine during the pandemic (3).
These changes allow communication without violating
HIPAA, provided that the encounters adhere to certain
regulations. For example, dermatologists may
communicate with patients over “non-public facing”
applications such as FaceTime, Zoom, and iMessage (4).
It is suggested for patients to establish telemedicine visits
with in-state medical practices to allow for easier access
to appointments after the pandemic (5).
DISCUSSION
In dermatology, there is a continued need to screen,
monitor, and treat skin conditions that may affect the
future health of a patient. Skin cancers (melanoma and
non-melanoma types) and other progressive skin diseases
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JMS, August 2022 – Volume 1, Issue 1
Krevh & Mostow
Within the private media platforms that allow for
telemedicine, there are several ways for the patient to
present their skin condition to the dermatologist. One is
through the exchange of pictures that target the lesion, and
another is through video visits. This depends on the
request of the dermatologist (6). Although dermatologists
cannot physically examine skin lesions through a screen,
being able to visualize the patient’s general appearance
and extent of disease is helpful in monitoring disease
progression and guiding treatment.
allow a broader range of telemedicine services and
provide appropriate physician compensation is currently
being discussed to address these issues and allow for a
more effective dermatological practice.
Before the pandemic, there were barriers to telemedicine
that prevented its widespread adoption. For example,
physicians invested in costly HIPAA-compliant platforms
to complete the telemedicine visits. Furthermore, the
physician and patient were required to have previously
established care before the telemedicine visit (7). The
temporary cessation of regulations for telemedicine have
shown that visits can still be effective for patient health
and resolve the long wait-time issues for dermatology
visits.
There are efforts to make long-lasting changes to
regulations with telemedicine, which can change the
future of dermatology visits and their long wait times (8).
These efforts include expanding broadband networks,
allowing insurers to provide reimbursement for remote
visits, and increasing digital literacy (8). Insurance
programs and healthcare providers have also supported
the transition to telemedicine during the pandemic. They
offer waivers, flexibility, and reimbursements state-bystate. It is imperative to view state guidelines for
telehealth before beginning telemedicine visits. Also, it is
important to be cognizant of patients’ levels of comfort
with technology. Low income and less educated
populations may need resources to understand and utilize
telemedicine. Hospitals can partner with public libraries
and colleges to design educational programs and
technology classes. These programs should be in multiple
languages and offer 24/7 online help for those who may
not know how to use these resources (9).
CONCLUSION
Although the COVID-19 pandemic has brought along
many uncertainties, it has addressed a long-standing issue
with dermatology visits: a solution to the long wait times
that patients experience when getting their skin conditions
checked. This pandemic has shown that telemedicine is a
valuable resource that should be adopted throughout the
rest of the pandemic and beyond. With the ability to
conduct virtual physical exams, observe skin lesions
through video, and send pictures of skin conditions
through online modalities, these visits can be effective
and address patient concerns. Future legislative action to
Figure 1. Access to dermatology care during COVID-19
REFERENCES
46
JMS, August 2022 – Volume 1, Issue 1
Krevh & Mostow
9.
REFERENCES
1.
Bhargava S, Negbenebor N, Sadoughifar R, Ahmad
S, Kroumpouzos G. Global impact on dermatology
practice due to the COVID-19 pandemic. Clin
Dermatol. 2021;39(3):479-487. https://doi.org/10.
1016/ j.clindermatol.2021.01.017.
2.
Greater Access for Patients Partnership. Patients Are
Waiting: America’s Dermatology Appointment Wait
Times Crisis. Greater Access for Patients
Partnership. Accessed Aug 26, 2020. https://cdn.
ymaws.com/www.dermpa.org/resource/resmgr/GAP
P_Wait_Time_Report_final.pdf.
3.
National Center for Immunization and Respiratory
Diseases (NCIRD), Division of Viral Diseases. Using
Telehealth Services. Centers for Disease Control and
Prevention. Updated Jun 10, 2020. Accessed Aug 26,
2020. https://www.cdc.gov/coronavirus/2019-ncov/
hcp/telehealth.html.
Eruchalu C, Pichardo M, Bharadwaj, M, et al. The
Expanding Digital Divide: Digital Health Access
Inequities during the COVID-19 Pandemic in New
York City. Journal of Urban Health. 2021; 98
(2):183-186. doi:10.1007/s11524-020-00508-9
ACKNOWLEDGMENTS
We would like to acknowledge Northeast Ohio
Medical University for providing physician
mentoring resources, which allowed the medical
student and physician to be introduced and work on
this research project together.
CONFLICTS OF INTEREST
4.
All authors declare no conflicts of interest.
AUTHOR CONTRIBUTIONS
Conceptualization: RK, EM
Formal analysis: RK, EM
Health Resources and Services Administration, U.S.
Department of Health and Human Services. Policy
changes during COVID-19. Health Resources &
Services Administration. Accessed Aug 26, 2020.
https://telehealth.hhs.gov/providers/policy-changesduring-the-covid-19-public-health-emergency/.
Investigation: RK
Methodology: EM
Project administration: RK, EM
Resources: RK
5.
American Academy of Dermatology Association.
COVID-19: Teledermatology. Updated 2021.
Accessed Aug 26, 2020. https://www.aad.org/
member/practice/coronavirus/teledermatology.
Validation: EM
6.
Hanes, E. Dermatologist Visits During the COVID19 Pandemic. healthgrades. Updated Apr 21, 2020.
Accessed Aug 26, 2020. https://www.healthgrades.
com/right-care/coronavirus/dermatologist-visitsduring-the-covid-19-pandemic.
Writing – review & editing: RK, EM
7.
Caravan Health. Is Telehealth Here to Stay? What
you need to know about Medicare’s new virtual care
flexibilities. Caravan Health. Updated Jun 18, 2020.
Accessed May 28, 2021. https://caravanhealth.com/
thought-leadership/articles/is-telehealth-here-tostay-what-you-need-to-know-about-medicares-newvirtual-care-flexibilities/.
8.
Health Resources and Services Administration, U.S.
Department of Health and Human Services.
Telehealth during the COVID-19 emergency. HHS.
Accessed Mar 24, 2021.https://telehealth.hhs.gov/
patients/telehealth-during-the-covid-19-emergency/.
Visualization: RK
Writing – original draft: RK
47
Journal of Medical Sciences at NEOMED
Volume 1, Issue 1, August 2022
Enhancing Diversity in Medical Education Representation of Cutaneous Disease: VisualDx
Skin-of-Color Atlas
Arjun Pandya, MD, MBA1*, Jay Patel, MD1, Sarah Eley, BS1, Rachel Krevh, BS1, Kishan Pandya,
BS1, Rahul Mal, MD1, Kelly Kimball, BS1, Eliot Mostow, MD, MPH1,2
1.
2.
Northeast Ohio Medical University, College of Medicine, Rootstown, OH, 44272
Akron Dermatology; 566 White Pond Dr, Akron, OH 44320, USA
* Corresponding author
Keywords: Perspective, Bias, Dermatology, Medical Education
published in the Journal of the American Academy of
Dermatology. This prompted Adelekun et al. to launch an
investigation on how severely underrepresented SoC truly
is. According to their study published in April 2020, only
4.5% of images in general medicine textbooks illustrate
dermatologic diseases in dark skin (6). It is clear that the
underrepresentation of SoC in medicine is not a new
issue, and physicians worldwide are starting to notice the
injustice.
DISCUSSION
Cutaneous presentations of dermatologic and systemic
disease may vary widely based on a patient’s skin tone
(1). Recent studies have demonstrated that medical
education
resources
display
a
significant
underrepresentation of pathology in individuals with skin
of color (SoC). For example, only 24% of dermatologic
images in common medical school board materials
(Pathoma, Uworld, First Aid) represent pathology in SoC
(2). Another study showed that medical students are more
likely to misdiagnose conditions on images with SoC,
including squamous cell carcinoma, urticaria, and atopic
dermatitis (3). The differences in presentation based on
skin tone can be seen in Figures 1 and 2: two potentially
life-threatening infectious diseases with diagnosis
necessary in a timely manner. Accurately diagnosing
these conditions without proper exposure during medical
training can pose a major challenge. With an expanding
population of approximately 40% of United States
citizens being of SoC, it is crucial that medical students
receive proper training in identifying conditions on
patients of all skin tones (4).
VisualDx is an award-winning diagnostic clinical
decision support system that has taken steps to combat
this healthcare inequality. It is an innovative tool that has
nearly 29% of its leading medical image library
representing presentations in SoC (1). This virtual
platform has a leading SoC atlas with a user-friendly
interface that allows for rapid diagnosis in real-time. By
listing the chief complaint, location of the finding,
symptoms/signs, or other notable findings, VisualDx can
identify differential diagnoses and visual depictions that
match the listings. The SoC atlas allows skin conditions
to be identifiable across several races. The company has
also launched Project IMPACT, a global effort to address
implicit bias in medicine. Project IMPACT hosts monthly
webinars that educate healthcare professionals and
students on cultural awareness in medical practice,
identifying diseases on SoC and new advancements for
treating skin conditions.
The COVID-19 pandemic has recently brought to light
the gross underrepresentation of cutaneous pathology in
SoC. In early 2020, dermatologists created an
international registry to compile cases of dermatological
manifestaions of COVID-19, to gather clues to the disease
and aid diagnosis. Out of the 700 submissions to the
registry, there were only 34 Hispanic patients and 13
black patients represented (5). Despite the pandemic
starting in March, it took until July of 2020 for the first
pictures of "Covid toes" in nonwhite patients to be
At Northeast Ohio Medical University (NEOMED), we
also seek to use innovation to foster diversity and fight
racial disparities in medicine. With the help of a generous
donation and support from the Dermatology Interest
Group (DIG), NEOMED was able to purchase a one-year
subscription to VisualDx for all students in the College of
Medicine. We believe this software can be helpful to
48
JMS, August 2022 – Volume 1, Issue 1
Pandya, et al
students in all stages of medical training. Preclinical
students can benefit by supplementing course material
with VisualDx and applying it toward relevant clinical
content. Meanwhile, students in their clinical years can
use the tool on rotations in an effort to reduce diagnostic
errors by augmenting a clinician’s point of view. We plan
to incorporate VisualDx into both preclinical and clinical
lectures to highlight the variance of skin pathology
presentation in SoC. We will aim to do this by
incorporating images of dermatopathological conditions
in SoC from VisualDx into the M1 and M2 NEOMED
lectures covering infectious disease and dermatology
topics. Currently, only several lectures explicitly
highlight disease presentations on SoC. We hope that by
bringing awareness to VisualDx as a resource of diversity
and inclusion, lecturers will have an easy way to locate
and incorporate images of SoC reflecting any cutaneous
disease they discuss in their lectures. Additionally, many
medical schools across the country have started
incorporating diversity, equity, and inclusion (DEI)
statements into their lectures and grand round
presentations to foster a more inclusive learning
environment. With the promotion of VisualDx, we hope
all NEOEMD associated faculty will gradually begin to
incorporate these DEIs into their curriculum and utilize
the images from VisualDx to practice inclusivity in
medicine. Ultimately, we hope to expand further
VisualDx access to the College of Pharmacy and
NEOMED postgraduate students to continue our goal of
enhancing diversity and improving healthcare outcomes.
Our research into the present substantial issue of
inequality in medicine has motivated us to make a
difference in the NEOMED community. In a year with a
global pandemic, our system has further shown its cracks
with the COVID-19 morbidity and mortality rate
disproportionately affecting black Americans (7).
However, maybe this enormous flaw in the healthcare
system is what it takes to start the conversation, to create
a movement. This step in improving the gap in medical
education is our small step, a step in the direction of
positive change, a step in the direction of equality in
healthcare.
Figure 1. Acute Meningococcemia in a patient with skin-of-color (SoC) (left) and in white skin (right). Note
difference in the optics of color- presentation of red rash on a dark background (presents as dark brown) versus
a white background. Image reproduced with permission from VisualDx (8).
Figure 2. Rocky Mountain Spotted Fever on patient with SoC (left) and white skin (right). Once again, note
subtle differences again with optics of color- presentation of a red rash on a dark REFERENCES
background versus a white
background. Image reproduced with permission from VisualDx (9).
49
JMS, August 2022 – Volume 1, Issue 1
Pandya, et al
Rochester NY: VisualDx 2021. Accessed April 8th,
2021. https://www.visualdx.com/visualdx/diagnosis/
rocky+mountain+spotted+fever?diagnosisId=52279
&moduleId=101
REFERENCES
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3.
Alvarado SM, Feng H. Representation of dark skin
images of common dermatologic conditions in
educational resources: a cross-sectional analysis. J
Am Acad Dermatol. 2021;84(5):1427-1431..
doi:10.1016/j.jaad.2020.06.041
ACKNOWLEDGMENTS
We sincerely thank Mr. Simon Robins, Dr. Erica
Stovsky, Dr. Eliot Mostow, the Dermatology Interest
Group, and the generous anonymous donors for their
contributions in acquiring and implementing
VisualDx to the NEOMED College of Medicine.
Jones VA, Clark KA, Shobajo MT, Cordova A,
Tsoukas MM. Skin of Color Representation in
Medical Education: An Analysis of Popular
Preparatory Materials Used for United States
Medical Licensing Examinations. J Am Acad
Dermatol. 2021;85(3):773-775.. doi:10.1016/j.jaad.
2020.07.112
CONFLICTS OF INTEREST
All authors declare no conflicts of interest.
Fenton A, Elliott E, Shahbandi A, et al. Medical
students' ability to diagnose common dermatologic
conditions in skin of color. J Am Acad Dermatol.
2020;83(3):957-958. doi:10.1016/j.jaad.2019.12.078
4.
Ghosh I. Visualizing the U.S. Population by Race.
Visual Capitalist. 2020. Accessed February 24th,
2021. https://www.visualcapitalist.com/visualizingu-s-population-by-race/
5.
Rabin RC. Dermatology has a problem with Skin
color. The New York Times. https://www.nytimes.
com/2020/08/30/health/skin-diseases-blackhispanic.html. Published August 30, 2020. Accessed
April 12, 2022.
6.
Adelekun A, Onyekaba G, Lipoff J. Skin color in
dermatology textbooks: An updated evaluation and
analysis. J Am Acad Dermatol. 2021;84(1):194-196.
doi:10.1016/j.jaad.2020.04.084
7.
Freeman EE, McMahon DE, Lipoff JB, et al. The
spectrum of COVID-19-associated dermatologic
manifestations: An international registry of 716
patients from 31 countries. J Am Acad Dermatol.
2020;83(4):1118-1129. doi:10.1016/j.jaad.2020.06.
1016
8.
Song P, Burgin S. Acute meningococcemia In:
Goldsmith LA, ed. VisualDx. Rochester NY:
VisualDx 2021. Accessed April 8th, 2021.
https://www.visualdx.com/visualdx/diagnosis/acute
+meningococcemia?diagnosisId=51948&moduleId
=101#:~:text=The%20clinical%20picture%20of%2
0acute,preceding%20upper%20respiratory%20tract
%20infection
9.
Burgin S, Lederman E, Craft N. Rocky Mountain
Spotted Fever. In: Goldsmith LA, ed. VisualDx.
AUTHOR CONTRIBUTIONS
Conceptualization: AP, JP, SE, EM
Writing – original draft: AP, JP, SE, RK, EM
Writing – review & editing: KK, KP, RM
50
Journal of Medical Sciences at NEOMED
Volume 1, Issue 1, August 2022
Human Connection Through Wi-Fi: Is it possible?
Sanaa Mansoor, MS, MD1*
1.
Northeast Ohio Medical University, College of Medicine, Rootstown, OH, 44272
* Corresponding author
LETTER TO THE EDITOR
Due to the COVID-19 pandemic, all medical student assessments at Northeast Ohio Medical University (NEOMED)
were redesigned to be performed virtually. This included my final standardized patient encounter. As nerve-wracking as
it may feel to perform any aspect of the physical examination, it serves as a rite of passage for medical students
transitioning into clinical rotations all around the country. My biggest concern was that my practice sessions and other
standardized patient encounters had always occurred in person over the course of my first two years of medical school.
Would I be able to successfully examine a patient virtually? Would I be able to connect with my patient to gather the
sometimes personal, yet pertinent, details of medical history through a virtual platform? Knowing specific questions to
review each organ system was not enough, and I knew I needed to identify more strategies to connect with patients.
Empathizing and connecting with my patient through a virtual platform proved to be much harder than I expected. I no
longer had the privilege or security of directly facing my patients. Human connection and empathy were the original
foundation of my history-taking and physical examination skills. Staring at my laptop screen, I practiced. I practiced
using my eyes to gaze with compassion. I practiced keeping my lips sealed to motivate my patient to overcome their
hesitations. I practiced using my hands to encourage my patient to open up and trust me with their problems. I practiced
nodding my head to affirm my patient’s feelings. Every part of my physical nature served to complement my purpose.
This was not so that my encounter would feel scripted. Rather, I did not want my screen to numb my non-verbal
communication skills just because I could hide behind it. On test day, I was able to virtually empathize with my patients
by making eye contact, listening to their problems, and trying to absorb each part of the conversation and guide it in the
direction the patient wanted. In the words of my standardized patient, “I felt you were truly listening and concerned
about me as your patient. When you consistently looked at the screen [maintaining eye contact] … I felt very important
and that I had your 100% attention throughout the encounter.”
During these unprecedented times, this feedback is promising. Although this encounter was different, I am grateful for
the unexpected exposure to telemedicine—a service that most medical students are not typically exposed to. This
experience has prepared me, as a future physician, to engage with patients via telemedicine as human connection is very
much possible with an online platform. For patients who are unable to travel, the elderly, or those whose needs can be
met via telemedicine, this is a great opportunity to receive the undivided attention and care of a physician. To start
honing my skills during my medical school education has been invaluable as the use of telemedicine will only continue
to grow in the field of medicine.
51
Journal of Medical Sciences at NEOMED
Volume 1, Issue 1, August 2022
Cardiac Metabolism in the Disease of Acute Myocardial Infarction
Nikhil Datla, MD1*, Chwen-Lih Chen, PhD1, Patrick Kang, PhD1, Yeong-Renn Chen, PhD1, Takhar
Kasumov, PhD1, Serguei Ilchenko, PhD1
1.
Northeast Ohio Medical University, College of Medicine, Rootstown, OH, 44272
* Corresponding author
ABSTRACT
Overproduced reactive oxygen species (ROS) with decreased oxidative phosphorylation is a hallmark of the
post-ischemic heart, which results in reperfusion-induced oxidative injury of the citric acid cycle (CAC).
During ischemia, hypoxic conditions slow down the CAC resulting in succinate accumulation. Succinate is
then rapidly oxidized during reperfusion, fueling ROS overproduction and contributing to ischemiareperfusion (I/R) injury. We test the hypotheses that 1) reperfusion re-accelerates the CAC to correct succinate
accumulation and 2) a vicious cycle caused by excess ROS can impair and downregulate the CAC plus other
metabolic pathways in the post-ischemic heart. Nine–ten-week-old Sprague-Dawley rats (n=15) were subject
to coronary ligation for 30-min followed by 24-h reperfusion. This process allowed us to closely mimic acute
myocardial infarction (MI) and I/R injury. The non-ischemic and risk-regions of myocardium were excised,
and the mitochondria were isolated. Dimethyl labeling was used to illuminate key metabolic pathways.
Previous studies showed data that I/R impairs ADP-dependent O2 consumption rate and ATP generation via
downregulating CAC and fatty acid β-oxidation. However, a major finding in our study was that I/R
dramatically upregulated the Phosphocreatine (PCr)/Creatine (Cr) shuttle (p<0.05) via upregulation of
mitochondrial S-type creatine kinase (Ckmt2). The increased PCr formed in the mitochondria is transferred
to the cytosol for ATP regeneration in-situ, which therefore increases the bioenergetic support of the postischemic myocardium. Therefore, we conclude that upregulating the PCr/Cr shuttle via increased Ckmt2
serves as feedback regulation of I/R, which can be useful for therapeutic intervention by increasing
oxygenation and bioenergetics of the ischemic heart.
52