Osteopathic Medical Schools In Arkansas
Vol.115 No. 11MAY 2019Osteopathic Medical Schools in ArkansasWorking to Lessen Future Shortages, Increase Access to CareNUMBER 11MAY 2019 241
Your job is keepingyour patients healthy.So who’s watching theirhealthinformation?AFMC Security Risk Analysis can help your practice: Comply withHIPAA directives Protect your patients’health information Identify and mitigatesecurity risks/vulnerabilities Develop privacyand securitypolicies/procedures Provide expertiseand guidance forbest practices Relieve staff burdenContact us to learn more.Visit afmc.org/SRA, call 501-212-8733or email SRA@afmc.org.242 THE JOURNAL OF THE ARKANSAS MEDICAL SOCIETYVOLUME 115
by CASEY L. PENNON THE COVER246Medical students Sunbir Gill, Michelle Tedrowe,and Samantha Connor in NYITCOM at ArkansasState’s Osteopathic Manipulative Medicine lab.Also pictured on cover: ARCOM building.PHOTOS COURTESY ARCOM AND NYITCOM.244Tim Paden, MDA Closer Lookat QualityCASE REPORTHydralazine-induced Rheumatologic Disease:Back to the FutureSruthi Kanu ru, MD; Neriman Gokden, MD;Shirin Trisha, MD; Seth Mark Berney, MD252Winner of the ASAE Excellencein Communications AwardSCIENTIFIC ARTICLERelationship Between Visceral Fat and Health-related Quality ofLife in Fifth and Sixth Graders in a Rural Public School in ArkansasRoy Dale Grant Jr., BS; Alicia Landry, PhD, RDN, LDN, SNS;Rachel Schichtl, MS, RDN, CFCS; Nina Roofe, PhD, RDN, LD, FANDVolume 115 Number 11May 2019Established 1890. Owned and edited by the Arkansas MedicalSociety and published under the direction of the Board ofTrustees.Subscription rate: 30.00 annually for domestic; 40.00,foreign. Single issue 3.00.258Laura HaywoodCASE STUDYGood’s Syndrome: It’s Good to Have a Diagnosis260P E O P L E E V E N T S 262The Journal of the Arkansas Medical Society (ISNN 0004-1858)is published monthly by the Arkansas Medical Society:Naga Saranya Addepally, MD#10 Corporate Hill Drive, Suite 300, Little Rock, AR 72205(501) 224-8967Printed by The Ovid Bell Press Inc., Fulton, Missouri 65251.Periodicals postage is paid at Little Rock, AR, and at additionalmailing offices.Articles and advertisements published in The Journal are for theinterest of its readers and do not represent the official positionor endorsement of The Journal or the Arkansas Medical Society.The Journal reserves the right to make the final decision on allcontent and advertisements.Join us to stay updated on health care news in Arkansas. Copyright 2019 by the Arkansas Medical Society.www.ArkMed.orgNUMBER 11254Doctor of theDayAdvertising Information: Penny Henderson, (501) 224-8967or penny@arkmed.org. #10 Corporate Hill Drive, Suite 300,Little Rock, AR 72205.Postmaster: Send address changes to:The Journal of the Arkansas Medical Society,P.O. Box 55088, Little Rock, AR 72215-5088.249Feature cArkMed.orgMAY 2019 243
COMMENTARYTim Paden, MDSTAND UP FOR MEDICINEAs physicians, we set oursights on the professionfor a variety of reasons– interest in medicine, familytradition, a desire to comfort orheal others. In my case, I trace it back tofourth grade when my father, Robert W. Paden,a pharmacist in the small town of Yellville,influenced me the most with his compassionfor others and willingness to help no matterthe time of day or night. We can each identifya few influences in our past that directed us insome way into medicine. When reflecting on thedriving nature and traditions in medicine thatconnect all of us in the profession across theglobe no matter the location of your training nowthat we all practice in Arkansas, we have onething in common – protecting the sanctity of ourprofession.Long before health care became a hot topicin our nation based on expense, access, andhealth management, this profession was one ofthe healing arts. Men and women are drawn tothe elements of protecting life, preserving health,or advancing treatment methods. Consider thesacrifices of our professional ancestors, goingall the way back to Hippocrates. The focus onan individual in order to ascertain a diagnosisand subsequent treatment based on the currentknowledge and treatment methods of the timeto restore health or limit the damage, is stillthe underlying theme. Now, with the evolutionof health care to this point – with the coststrategies, population management, and accessand scope-of-care issues – what are we to do?We are to stand up for health care. If you’rein direct patient care with full office schedulesand call, then take good care of your patients.Stand up for health care. If you’re involved inadministrative duties, organizational activities,or management positions, stand up for healthcare. If you’re on the Arkansas Medical SocietyBoard of Trustees and following legislation or inteaching positions of the university system, standup for health care. Two years ago, I joined AMSafter 28 years of practice in a small town. Onereason for joining was because I felt that someof us need to stand up for health care. We mustdo this to keep the profession solid, honorable,and intact despite the direction of control or thedemands of the “system.” It is and always willbe about the patient.If it’s a prescription the patient needs, thenfight for it. If it’s a position you hold on a hospitalcommittee, fight for it. If you teach students,fight for it. On all ground and all places and allcircumstances, we must fight for our profession.Delegate others to help you. Inspire theyouth to seek medicine and share why youwent into medicine. Some say the Golden Age ofMedicine is over. I say it is just beginning. Neverbefore has our art form been needed more than itis today. So, stand up for health care and fight forit – not just for the income or for control, but forthe sake of the profession itself. Our ancestorsgave us a noble, honorable profession, so let’sgive the same to our offspring.David WrotenExecutive Vice PresidentPenny HendersonExecutive AssistantJournal AdvertisingNicole RichardsManaging EditorJeremy HendersonArt DirectorEDITORIAL BOARDAppathurai Balamurugan, MD, DrPH, MPHFamily Medicine/Public HealthTim Paden, MDFamily MedicineSandra Johnson, MDDermatologyIssam Makhoul, MDOncologyNaveen Patil, MD, MHSA, MA, FIDSAInternal Medicine/Infectious DiseaseBenjamin Tharian, MD, MRCP, FACP, FRACPGastroenterologist/HepatologistRobert Zimmerman, MDUrologyTobias Vancil, MDInternal MedicineDarrell Over, MDFamily MedicineEDITOR EMERITUSAlfred Kahn Jr., MD (1916-2013)ARKANSAS MEDICAL SOCIETY2018-2019 OFFICERSLee Archer, MD, Little RockPresidentAmy Cahill, MD, Pine BluffImmediate Past PresidentDennis Yelvington, MD, StuttgartPresident ElectChad Rodgers, MD, Little RockVice PresidentGeorge Conner, MD, Forrest CitySecretaryStand up for health care and fight for it, not justfor the income or for control but for the sake ofthe profession itself.244 THE JOURNAL OF THE ARKANSAS MEDICAL SOCIETYBradley Bibb, MD, JonesboroTreasurerDanny Wilkerson, MD, Little RockChairman of the Board of TrusteesVOLUME 115
NUMBER 11MAY 2019 245
by CASEY L. PENNOsteopathic Medical Schools in ArkansasWorking to Lessen Future Shortages, Increase Access to CareUntil 2016, Arkansas had onlyone medical school. Foundedin 1879 and still the only traditional (allopathic) medical school in thestate, the UAMS College of Medicine isa comprehensive academic medicalcenter that plays a vital role in educating Arkansas physicians. Today, however, Arkansas is also home to two more medicalschools, both osteopathic in nature. This month,we bring you an update on the state’s osteopathicmedical schools, New York Institute of TechnologyCollege of Osteopathic Medicine at Arkansas StateUniversity in Jonesboro and Arkansas College ofOsteopathic Medicine in Fort Smith.Osteopathic and allopathic schools both offer a means to become a licensed physician inthis nation.NYITCOM at Arkansas State medical students Matt Gorecki, Mirsha Stevens,Katherine Byrd, and Jay Patel.In addition, osteopathic medical schools tendto produce more primary care physicians.* “DOscan – and do – enter any specialty from neurosurgery to radiation/oncology,” said Dr. Speights.“However, about 60% of DOs, nationally, migrateto generalist specialties (family medicine, internalmedicine, pediatrics, general surgery, OB/GYN,emergency medicine). When we talk about theneeds of the state, shortages in those general areasreally stand out.”They educate through many of the samecourses – gross anatomy, biochemistry, pharmacology, pathophysiology, etc. In addition, they sharesimilar degree paths consisting of two years inthe classroom and two more in rotation, followedby three-plus years of residency. The osteopathicdifference is indicated by the term itself, as NYITCOM Dean Shane Speights, DO,A Medical School with aexplained. The term osteopathicHeart for the Deltadenotes an emphasis on the strucNYITCOM at A-State operture and function of the humanates through a public-private partbody coupled with manipulativenership between Arkansas Statemedicine. “On the osteopathic side,University and NYIT College ofwe embrace the whole body,” heOsteopathic Medicine in Old Westsaid. “In my opinion, this can alsobury, New York. The A-State camoccur in allopathic schools; it’s justpus is accredited for 115 studentsthat we put that at the forefront. Wehave an osteopathic manipulativeper class, and by the fall of 2019,medicine lab and a common beliefwill reach full capacity at 460 toShane Speights, DOthat the body has the innate abilitytal students. The applicant pool isto heal itself if given the chance. That’s not to say quite large, while the acceptance rate is tiny, justthat DOs don’t prescribe medications (antibiotics, 6.1%. About 80% of students come from within thechemotherapies, etc.) or perform surgery. They do.” school’s target market, which encompasses Arkan-246 THE JOURNAL OF THE ARKANSAS MEDICAL SOCIETYsas and surrounding states. The student populationis roughly 50% male and 50% female, with underrepresented minorities at about 14%.NYITCOM’s mission is to create and retainmore physicians who stay and practice here in Arkansas, particularly in underserved areas aroundthe state. “It isn’t a job that one institution cansolve,” said Dr. Speights. “It takes a collaborativeeffort amongst many institutions, hospitals, medicalschools, residency training programs, and communities. To truly see results, you must have enoughphysicians graduating from a medical school in thestate that can then flow into residency programs inthe state to try to increase the number that will stayin the state. We know that of medical students thatgraduate from a medical school in Arkansas and attend a residency program in Arkansas and graduatefrom that program, 80% of those graduates (basedon current data), will remain in the state or region.**That’s a statistic we need to capitalize on.”NYITCOM at A-State cares for all Arkansans,but is particularly committed to improving thequality of life in the Mississippi Delta region. “It’salways been our focus to make a positive impact inthis, one of the poorest, most underserved regionsVOLUME 115
in the nation,” said Dr. Speights. “The challengesare great, and we’re not naïve to think we can goin there with a couple of outreach programs andtruly turn things around. But we have to start somewhere, and we have to start today.”Some of NYITCOM’s work in the Delta happensthrough rotation and residency programs. Short ofrunning residency programs of its own, the schoolsupplies resources that support programs in itsvicinity. “Through our partnership with ArkansasState University and our parent institution, we’reable to provide resources like access to onlinemedical libraries, a full simulation lab, faculty development, graduate programs, and the capacity tohost speakers and events related to specific residency programs. We also support them by partnering with them on grants, scholarly activities, andresearch programs that align with our mission,”said Dr. Speights. Indeed, through a USDA researchgrant, NYITCOM partners with St. Bernard’s Internal Medicine Residency Program, Arkansas StateUniversity School of Health Professions, and UAMSFamily Medicine Residency Program in northeastArkansas to deliver health screenings and healtheducation to rural areas through NYITCOM’s DeltaCare-a-van.***The medical school feels a responsibility toprovide vital health education and problem-solvingsupport to K-12 and undergraduate programs andcommunity and civic organizations. Toward thisend, students are routinely sent into the community(classrooms, Lions Clubs, Rotary, etc.) to educate ontopics like the importance of vaccines, hand washing, physical activity, and the spread of disease.“We believe this is just one way that our studentscan start changing health outcomes long beforethey graduate,” said Dr. Speights.Now that NYITCOM’s inaugural class has entered rotations, students are experiencing firsthandthe disparities of the Delta region and some arealready committed to serving the region. Rotationsare possible through relationships with roughly 150hospitals, clinics, and individual physicians whoprovide training in the real world – a valuable stepthat helps students like Clayton Preston choose apath. “I did my undergrad in Jonesboro and established some roots there, so I had my heart set onstaying there for my rotations,” said the third-yearstudent. However, things changed during Preston’srotation in his home town of Pine Bluff. At JeffersonRegional Medical Center, where he was born andhad worked his first job in the hospital cafeteria,Preston felt a call to serve there as a pediatrician.“I’ve been exposed to so many cases that have provided unique learning opportunities, and I’ve had aNUMBER 11During a recent Interview Day in Jonesboro, medical students Megan Patel andColton Eubanks explain how NYITCOM at A-State uses fully-functioning mannequinsin their training.great experience in Pine Bluff. Things work out theway they’re supposed to.”Nothing can replace training that comes fromrotations, Dr. Speights indicated. “Physicians – particularly those in underserved areas – are truly onthe front lines of health care – treating the sick,maintaining the well, and making a difference inthe lives of patients and their families. Our studentsappreciate the education they receive by witnessing that care that’s being provided. We make aconcerted effort to rotate our students into areaslike Arkadelphia, Gravette, Pocahontas, Mena, Monticello, Crossett, and many others.”A New and Fast-GrowingMedical SchoolAffiliated with Arkansas Colleges of Health Education, ARCOM is housed on 228 acres at ChaffeeCrossing in Fort Smith. Founded in 2014, the schoolwelcomed its inaugural class in August 2017 andis currently educating its second class. Each classsize is 150 students, from a large-and-growing applicant pool.Students are excelling thus far, with averageMCAT scores of over 500 and an average GPA ofmore than 3.5. The student population is roughly50% male and 50% female, with 15% underrepresented minorities. Around 65% of enrolled studentscome from within the school’s service area of Arkansas, Kansas, Kentucky, Louisiana, Mississippi,Missouri, Oklahoma, Tennessee, and Texas.Frazier Edwards, MPA, is the executive director of ARCOM Clinical Resources and ContinuingMedical Education. He is excited to share that ARCOM has the fastest growing applicant pool of anymedical school in the country. As for reasons why,Edwards points to the school’s “shiny and new”state-of-the-art facilities, faculty, and helical teambased curriculum.ARCOM’s mission, according to Edwards, isto “serve the underserved” and help solve publichealth issues facing Arkansas – specifically, physician shortages. Authors of a 2018 guest editorialpublished by the Arkansas Foundation for MedicalCare touched on such shortages, particularly inrural areas of the state. “Several trends are driving this shortage,” wrote authors Ray Hanley, AFMCpresident and CEO, and AFMC Board Chair StacyC. Zimmerman, MD, FACP, FAAP. “An increasednumber of Arkansans have access to health carethrough the Medicaid-expansion program, Arkansas Works. Our population is aging, and the olderwe get the more medical services we use another reason is more than a third of all active physicians will be age 65 or older during the next 10years, and many will retire.”Working toward solutions, ARCOM focuses onproducing primary care physicians. “There’s a cliffcoming,” said Edwards. “That’s why we’re here. Wemust start now to plan for 10 to 15 years from now.A student will go through medical school followedby residency. That’s a minimum of seven years andoftentimes more depending on the specialty. Doingthis now will help lessen the cliff and ensure thatwe won’t go through dips in access or quality ofcare. In our curriculum, we try to ensure that students are aware of the need in these areas.”ARCOM’s third-and-fourth-year rotations allow students to discover and learn from systemsalready in place. “We’ll send them to a large hos-MAY 2019 247
teopathic medical school do have a uniqueness totheir practice. They’re able to perform osteopathicmanipulative therapy, and some of that languageis unique. So, having that unique voice that represents the profession is important. However, it’s alsoimportant to make sure that voice is heard on multiple levels. The AOMA and the AMS have enjoyeda good working relationship already and continueto look forward to working together for the benefitof all medical students, physicians in the state, andultimately, for the overall health of the state.”From left to right: ARCOM students Joseph Kordsmeier, Trent DeLong, MichaelPage, Kelley Harris, and Dania Abu Jubara; Frazier Edwards, MPA.pital for typical third-year core rotation training, butthey’re also required to do a community hospitalrotation – usually a critical-access hospital in arural area – and a rural family practice rotation,”said Edwards. “Because these locations are shortstaffed, students are right in there with the staffworking it’s a ‘roll-up-your-sleeve, let’s get towork’ approach.”Magnolia-native Michael Page is aiming toward just such a diverse, hard-at-work medicalpractice – in his home town, no less. Page is partof ARCOM’s inaugural class and is among thosecurrently gearing up for post-second-year exams.Upon passing, he will move on to rotations. Setto graduate in May 2021, Page plans to pursueresidency in family medicine. He hopes to, eventually, be back in Magnolia to open his own familypractice. “My interests in family medicine centeraround the broad training I can receive that willallow me to provide inpatient and outpatient services, perform procedures, deliver babies, and fulfill my desire to be useful to the rural populationof patients I intend to serve,” said Page. “Growingup, I had the opportunity to spend time at the local family doctor’s office in Magnolia where mymother was the office manager. After seeing thefamily doctor serve many roles as a pillar in thecommunity, I was strongly influenced.”Having more physicians is a win, particularlywhen those physicians remain in Arkansas to practice in underserved areas. ARCOM recently receivedaccreditation to provide residency and fellowshipeducation to its graduating students.**** In line withits goal of producing more Arkansas primary carephysicians, the school is at work now to developnew residency programs in the areas where thosestudents are needed. ARCOM has the capacity toassist area institutions in various roles. “We can beadaptive,” said Edwards, who recently announceda residency partnership with Unity Health. “At UnityHealth, we’re going to be an academic partner. Inother instances, we will be the sponsoring institution.“We have several programs that are in the application process. CHI St. Vincent in Hot Springs isone example of a partnership that will benefit thecommunity. They’re a core rotation site for ourthird- and fourth-year students. Now, they’re developing residency programs in internal medicine andfamily medicine to start with. So, the hope is to havethose programs ready by the time those studentsgraduate. Statistics show that students tend to staywhere they train, and we want to develop as manyprograms as we can that work with that statistic.We want to start by recruiting them from our servicearea. If we can then train them through rotations inthe area, and then if they can enter a residency program in the area, there’s a good opportunity for acommunity to retain them in the area.”Support for All Medical Studentsand Physicians / AMS and AOMAWith more medical students in the state, thereis much interest from professional societies to worktogether to provide support to future physicians. Inaddition to his role at ARCOM, Edwards is the executive director of the Arkansas Osteopathic MedicineAssociation. He advises students to take advantageof the support offered through medical specialtyorganizations. “There’s an ongoing effort throughthe Winthrop Rockefeller Institute to find ways inwhich all medical schools and societies can cometogether to better serve the needs of the state. Asfor the AMS and AOMA, we have always workedclosely together on difficult issues, whether it’s atthe capitol or in outreach efforts to try and get theprofession engaged.“We encourage students to join both the AMSand the AOMA. Students that graduate from an os-248 THE JOURNAL OF THE ARKANSAS MEDICAL SOCIETYThe AMS is pleased to shine a light on thestate’s osteopathic programs and their impact onthe medical profession and the health of Arkansans. AMS Executive Vice President David Wrotenencourages students to reap the benefits of society participation. “Medical students are the futureleaders of their profession. We recognize that andwant not only to be supportive but also to help students attain the skills and knowledge necessary toassume those leadership roles,” said Wroten. “Thefirst thing the new students will learn about AMS isthat the organization makes a strong commitmentfor the entire length of their medical training. Fromthe first year of medical school through their finalyear as a medical resident, membership in the AMSis available at no cost to the student.“However, that’s just the beginning of the Society’s support. As part of our commitment to involving all students in our organization, AMS hasamended its bylaws to pave the way for osteopathic students to create AMS student chapters.”To learn more about the state’s osteopathicmedical schools, visit nyit.edu/arkansas andacheedu.org/arcom.*For more statistics on osteopathic studentsand practicing physicians (U.S.), download thelatest Osteopathic Medical Profession Report he Association of American MedicalColleges provides Arkansas physician retentiondata and related statistics. profile.pdf***Learn more about NYITCOM’s DeltaCar-a-van. https://www.nyit.edu/box/Features/medicine on the go**** The following articles offer a moredetailed look at ARCOM’s work on the residencyside. -fellowshipprograms/VOLUME 115
CASE REPORTHydralazine-induced RheumatologicDisease: Back to the FutureSruthi Kanu ru, MD;1 Neriman Gokden, MD;2 Shirin Trisha, MD;3 Seth Mark Berney, MD41Assistant Professor of Medicine, Central Arkansas Veterans Healthcare System, UAMS2Professor of Pathology and Urology, Director of Anatomic Pathology, Vice-Chair for Faculty Affairs, UAMS3 rd3 year Medicine-Pediatrics Resident, UAMS4Professor of Medicine, Chief, Division of Rheumatology, Director, Rheumatology Fellowship Program, UAMSABSTRACTWe present a patient who developed both drug-induced lupusand vasculitis after taking hy-dralazine. Additionally, we review the literatureabout these disorders. An 81-year-old hypertensivefemale developed serositis, leukopenia, thrombocytopenia, positive ANA (Antinuclear antibody) andantihistone antibodies, hypocomplementemia, apauci immune glomerulonephritis, and positiveANCA (Anti-Neutrophilic Cytoplasmic Autoantibody)after six months of hydralazine. Although lupus andvasculitis are known side effects of hydralazine,their frequency decreased significantly 25 yearsago, as angiotensin-converting enzyme inhibitorsreplaced hydralazine. However, use of hydralazineincreased recently after heart-failure patient survival improved with the combination of hydralazineand nitrates. It is important to recognize the autoimmune complications of hydralazine, especially inthe setting of its increased clinical use.INTRODUCTIONHydralazine is an arterial vasodilator to treathypertension and heart failure since 1953.1 Although lupus and vasculitis are well describedside effects of hydralazine,2 their frequency hasdecreased significantly because angiotensinconverting enzyme inhibitors replaced hydralazine,resulting in several generations of physicians whoare unfamiliar with its complications. In 2004, therecognition that heart-failure patients treated withhydralazine and nitrates survive longer has causedincreased use of hydralazine and the possibility ofa resurgence of its adverse effects.We present a patient with hypertension whodeveloped both lupus and ANCA positive pauciimmune glomerulonephritis after six months ofhydralazine therapy.NUMBER 11CASE PRESENTATIONAn 81-year-old female with renal insufficiency(baseline creatinine 1.5 mg/dl), hypertension(treated with hydralazine for the prior six months),hypothyroidism, and hyperlipidemia was admitted toan outside hospital with four months of intermittent,subjective fever; malaise; fatigue; weakness; nausea; diarrhea; vomiting; 40 pounds of unintentionalweight loss; and two weeks of decreased urinationand leg swelling.Her physical exam and diagnostic laboratorytest results on admission to the outside hospital:Temp: 98.1; BP: 137/71; HR: 75; RR: 20Skin: morbilliform eruption of the neck and upperchest, arms and forearms bilaterallyLung exam: rales at left lower baseHeart sounds: normalMuscle strength: 4/5 in proximal upper and lowerextremitiesWBC: 1000/mm3 (nl 3-12,000)Hemoglobin: 9.1 g/dL (nl 11.5-16)Platelet: 76000/mm3 (nl 150,000-500,000)Potassium: 6.6 mmol/L (nl 3.5-5.1)Bun: 44 mg/dl (nl 6-20)Cr: 2.6 mg/dl (nl 0.4-1.0)UA: 40-50 RBCs/hpf (nl 0-2/)LDH: 986 IU/L (nl 100-248)Blood and urine cultures: steriledaily, megestrol acetate 400 mg daily, calcium/vitamin D 600mg/400 IU daily, simvastatin 40 mgnightly.Her physical exam and diagnostic laboratorytest results on arrival:Vitals: Temp 98.2; RR 14; BP 135/75; P 75General: patient appeared sick but in no acutedistressLungs: clear to auscultation bilaterallySkin: morbilliform eruption of the neck, upper chestand bilateral upper extremities, sparing thehands; Ecchymoses on her forearmsCardiac: regular rate of S1 S2 without S3, S4, murmurs.Abdomen: bowel sounds present, soft, nontender,without hepatosplenomegalyExtremities: diffuse 4 pitting edemaNeurologic: 3/5 proximal muscle strength; 4 /5distal muscle strengthWBC 8840/mm3 (nl 3-12,000)Hemoglobin 9.3 mg/dL (nl 11.5-16 g)Platelet count 37000/mm3 (nl 150,000-500,000)Peripheral smear: rare schistocytesHaptoglobin: 165 mg/dl (nl 30-200)Sodium 134 mmol/L (nl 135-145)Potassium 6.6 mmol/L (nl 3.5- 5.1)She underwent dialysis to treat her hyperkalemia, received filgrastim for the leukopenia withimprovement (5000/mm3) but a worsened thrombocytopenia (35000/mm3). Because of her acutekidney injury, thrombocytopenia, and elevated LDH,her doctors transferred her to our hospital to undergoplasmapheresis for atypical hemolytic uremic syndrome (HUS).Her medications on transfer included: aspirin 81mg daily, levothyroxine 75 mcg daily, hydralazine 25mg TID, triamterene/hydrochlorothiazide 75/50 mgFigure 1. Partial-cellular crescent present ina normocellular glomerulus, PAS stain, 400X Continued on page 250.MAY 2019 249
Figure 2. Mesangial C1q positivity (1 ) by direct IF staining, FITC, 400X.Bicarbonate 12 mmol/L (nl 22-32)BUN 92 mg/dl (nl 6-20)Creatinine 6.2 mg/dl (nl 0.4-1.0)Calcium 7.8 mg/dl (nl 8.6-10.2)Phosphorus 6.3 mg/dl (nl 2.5-4.5)Magnesium 1.8 mg/dl (nl 1.6-2.6)AST 32 IU/L (nl 15-41)ALT 7 IU/L (nl 5-45)LDH 469 IU/L (nl 100-248)TSH: 2.07 IU (nl 0.34-5.6)CK 38 IU/L (nl 38-234)Aldolase: 18.8 U/L (nl 1.5-8.1)Myoglobin 402.3 ng/ml (nl 3-70)UA: Blood large; RBC 100 (nl 0-2); WBC 0-2 (nl 0-2); Dysmorphic RBCs present; Urine protein/creatinine: 1840 mg/24 hoursImmunologyANA-positive (no titer was performed)Anti histone antibody: 8.0 units (nl 0.9)Anti ds DNA antibody: 14 IU/ml (nl 9),Anti smith antibody: negative.C3- 33.1 mg/dl (nl 90-180)C4- 10.0 mg/dl (nl 15-45)ANCA 1:5120 (nl 1:20)Anti MPO 137 AU/ml (nl 19)Anti PR3 40 AU/ml (nl 19)Cryoglobulin: negativeFigure 3. Electron microscopy showing small mesangial densities (Arrow).rophy. Additionally, her biopsy indicated a low-grademesangiopathic glomerulonephritis with immunofluorescence showing full-house staining (Figure 2)and electron microscopy showing mesangial small,electron-dense deposits (Figure 3), favoring autoimmune etiology (such as lupus).Because she began hydralazine six monthsprior to developing serositis, leukopenia, thrombocytopenia, positive ANA, positive antihistone antibody, hypocomplementemia (indicative of activelupus), and features of an ANCA-associated renalvasculitis (a strongly positive ANCA in a perinuclearstaining pattern, anti MPO antibody and a pauci immune crescentic glomerulonephritis), we diagnosedthis patient with simultaneous hydralazine-inducedANCA-positive glomerulonephritis and hydralazineinduced lupus.DISCUSSIONBecause neither denovo lupus nor denovoANCA-associated pauci immune glomerulonephritisare likely in this 81-year-old patient and she took adrug known to cause these
Today, how-ever, Arkansas is also home to two more medical schools, both osteopathic in nature. This month, we bring you an update on the state’s osteopathic medical schools,New York Institute of Technology College of Osteopathic Medicine at Arkansas State University in Jonesboro an
1 The Osteopathic GME Match Report, for the 2011 Match Introduction . The American Association of Colleges of Osteopathic Medicine (AACOM), in cooperation with the American Osteopathic Association (AOA) and the National Board of Osteopathic Medical Examiners, Inc. (NBOME), compiled The Osteopathic GME Matc
the role of the Osteopathic International Alliance 6 the World health Organization and osteopathic practice 7 structure of this report 7 Chapter 1: The concept, history and spread of 8 osteopathic healthcare What is osteopathic healthcare? 9 The range of manual techniques 10 the origins and dissemination of osteopathic practice 11
Burrell College of Osteopathic Medicine (BCOM), New Mexico Campbell University Jerry M. Wallace School of Osteopathic Medicine (CUSOM), North Carolina Chicago College of Osteopathic Medicine of Midwestern University (CCOM/MWU), Illinois Des Moines University - College of Osteopathic Medicine (DMU-COM), Iowa
The American Osteopathic Board of Radiology will not require a written attestation as a requirement for examination or certification. No. 11 In the osteopathic profession, the American Osteopathic Board of Radiology reviews and approves the eligibility of candidates whose training has been reviewed and approved by the American Osteopathic College of Radiology (AOCR). In 1982, the AOCR training .
College of Osteopathic Medicine College of Osteopathic Medicine New York Institute of Technology College of Osteopathic Medicine Catalog 2017 - 2018 Hannah and Charles Serota Academic Center Room 203 Northern Boulevard P.O. Box 8000 Old Westbury, NY 11568-8000 516.686.3747 nyit.edu/medicine NYITCOM at Arkansas State University P.O. Box 119
Phyllis Ragland Arkansas Richard Ramsey Arkansas Diana Ramsey Arkansas Rachel Rayl Arkansas Dustin Rhodes Arkansas Kaleem Sayyed Arkansas Beth Schooley Arkansas . Annie Buerhaus California Timothy Burg California Gregory Burns California
Buried in family cemetery near Searcy, White Co.; Chapter: Little Red River *Eno, Clara, Revolutionary Soldiers Buried in Arkansas, p 53-62. Arkansas History . Arkansas, DAR AR State Historian File. Cousott, Francois Buried Arkansas Co. at or near Arkansas Post; Chapters: Arkansas Post, Grand Prairie Plaque honoring 26 Rev.
Youth During the American Revolution Overview In this series of activities, students will explore the experiences of children and teenagers during the American Revolution. Through an examination of primary sources such as newspaper articles, broadsides, diaries, letters, and poetry, students will discover how children, who lived during the Revolutionary War period, processed, witnessed, and .
