As of 2019, there are close to 4,000 suicide attempts by United States youth, in grades 9-12, every day. With cases of youth suicide rising, more research should be conducted on risk factors associated with suicidal contemplation specifically sexual violence, sex, gender identity, and race/ethnicity. Sexual violence can impact anyone regardless of gender, sexual orientation, and age. The hypothesis of this study is that youth with a history of sexual violence is associated with increased suicidal contemplation. Unlike previous studies, this study will not focus on subpopulations but will analyze data from individuals across age, race, gender, and sexual orientation groups to be as inclusive and generalizable. Data from the Youth Risk Behavior Surveillance Survey, an ongoing survey conducted in schools nationwide for students grades 9-12, was used for this study. A bivariate chi-squared analysis was completed to evaluate the relationship between suicidal ideation with various covariates. Results demonstrated strong associations between suicidal ideation and alcohol/drug use before sexual activity (2.33, 95%CI 2.56-2.41), feeling sad or hopeless (9.33, 95%CI 9.08-9.60), and forced sexual intercourse (4.64, 95% CI 4.46-4.83). These results demonstrate there is a relationship between suicidal ideation and sexual violence. Additionally, results showed an increased likelihood of suicidal ideation for those who are experiencing homelessness, engaging in physical fights, have a sexual identity other than heterosexual, and have been bullied. These findings support previous studies describing the associations between suicidal ideation and sexual violence.

Norovirus Gastroenteritis Leading to Partial Small Bowel Obstruction David Berry DO, Arthur Cecchini DO, Koushik Sanku MD, Bhavesh Gajjar MD Berrydw@etsu.edu, Cecchini@etsu.edu, Sankuk@etsu.edu, Gajjarb@etsu.edu Department of Internal Medicine, Quillen College of Medicine, East Tennessee State University BACKGROUND Acute gastroenteritis (AGE) is a common problem in both inpatient and outpatient settings. Most cases are viral in origin, with norovirus being the most cited. Typical symptoms include low-grade fever, chills, nausea, vomiting, and abdominal discomfort. The physical examination is usually unremarkable, but abdominal tenderness or signs of volume depletion may be present in severe disease. Most patients have spontaneous remission within a few days and do not require hospitalization or diagnostic evaluation. Laboratory evaluation is often helpful in severe disease, immunocompromised patients, or when bloody or mucoid diarrhea is present. Polymerase chain reaction (PCR) gastrointestinal multiplex testing is often the preferred evaluation as it has a high sensitivity, specificity, and turnaround time when compared to traditional stool studies of enzyme-immunoassay studies. Treatment is often supportive, but specific bacterial and parasitic pathogens should prompt treatment with antimicrobial therapy. CASE PRESENTATION This case presents a 47-year-old male with no known previous medical history or history of intraabdominal surgeries. He presented with four days of progressive nausea, vomiting, diarrhea, and abdominal discomfort. The physical examination revealed a distended and tender abdomen. The metabolic panel did not show any electrolyte derangements. Computed tomography with intravenous contrast revealed partial small bowel obstruction versus less likely ileus. Gastrointestinal pathogen PCR returned positive for norovirus. The patient was given intravenous fluid, nausea control, and pain control, his diet was advanced, and his symptoms subsequently resolved. We believe this case to be unusual, as most cases of viral gastroenteritis are uncomplicated, and this patient presented with radiographic evidence of ileus versus partial small bowel obstruction. PCR testing revealed positivity for norovirus. He had no previous abdominal surgeries or family history of early intestinal malignancies, and the symptoms spontaneously resolved with several days of conservative management, making another etiology much less likely. CONCLUSION AGE is a common diagnosis seen in the primary care clinic, and most patients have an uneventful recovery. However, suspicion of partial obstruction or intestinal ileus should arise when severe abdominal pain and prolonged vomiting are present.

Earlier this decade, “bath salts” were popularized as legal alternatives to the pyschostimulants cocaine and the amphetamines. These products contained synthetic cathinones including 3,4-methylenedioxypyrovalerone (MDPV), 4-methylmethcathinone (mephedrone), and 3,4-methylenedioxymethcathinone (methylone). Studies indicate that the cathinones have similar pharmacology to controlled psychostimulants, increasing levels of dopamine (DA) in the synaptic cleft. Most preclinical investigations have only assessed the effect of these synthetic cathinones independently; however, case reports and DEA studies indicate that “bath salts” often contain mixtures of these substances. Therefore, in a recent study by our laboratory, we examined effects of individual versus combined exposure to MDPV, mephedrone, and methylone. Interestingly, an enhanced effect on the levels of DA was observed, as well as significant alterations in locomotor activity following co-exposure to the cathinones. In this study, we examine whether the enhanced effects of the drug combination were due to pharmacokinetic (PK) interactions. It is known that many of the same cytochrome P450 (CYP) isoenzymes metabolize each of these three drugs. Therefore, it is probable that the drugs’ PK would differ when administered individually as compared to in combination. We hypothesize that combined exposure to MDPV, mephedrone, and methylone will result in increased drug concentrations and enhanced total drug concentrations when compared to individual administration. The pharmacokinetics of MDPV, mephedrone, and methylone in the brain and plasma were examined following intraperitoneal injection in mice. Briefly, adolescent male Swiss-Webster mice were injected intraperitoneally with either 10 mg/kg MDPV, 10 mg/kg mephedrone, 10 mg/kg methylone, or 10 mg/kg combined MDPV, mephedrone, and methylone. Following injection, brains and plasma were collected at the following time points: 1, 10, 15, 30, 60, and 120 minutes. Samples were then flash-frozen and stored at -70°C until analysis. Drugs were extracted via solid-phase extraction and concentrations were determined using a previously validated and published high pressure-liquid chromatography tandem mass spectrometry (LC-MS/MS) method. Following intraperitoneal administration, all drugs quickly crossed the blood-brain barrier and entered the brain. Peak drug concentrations, time to peak concentration, drug half-lives, and total drug exposure (as measured by area under the curve) are compared when drugs were given individually versus in combination. These data provide insight into the consequences of co-exposure to popular “bath salt” products.

An unprecedented rise in the availability of new synthetic drugs of abuse has been observed in the recent years. One of the most noted cases is that of a popularized designer drug mixture known as ‘bath salts’. Commonly obtained from various shops and on the internet, “bath salts” often contain the synthetic cathinones 3,4 methylenedioxypyrovalerone (MDPV), mephedrone, and methylone in diverse combinations. Individually, the synthetic cathinones are known to have similar pharmacology to controlled psychostimulants such as cocaine and the amphetamines, increasing the levels of dopamine (DA) in the synaptic cleft. DA is an important neurotransmitter that regulates a variety of behaviors and functions; neurons within the mesolimbic DA pathway (ventral tegmental area to nucleus accumbens) are involved in reward and motivation and are activated by these drugs of abuse. Additionally, psychostimulant-induced increases in DA in the nigrostriatal pathway (substantia nigra to corpus striatum) lead to increases in locomotor behavior. However, the majority of preclinical investigations have only assessed the effects of individual bath salt constituents and have provided little information regarding the possibility of significant drug interactions with the co-exposure of MDPV, mephedrone, and methylone. This study sought to evaluate and compare the effects of individual versus combined MDPV, mephedrone, and methylone on dopamine (DA) levels in discrete brain regions as well as motor stimulant responses in mice. Male adolescent Swiss-Webster mice received intraperitoneal injections of saline, MDPV, mephedrone, methylone (1.0 or 10.0 mg/kg), or the cathinone cocktail (MDPV + mephedrone + methylone at 1.0, 3.3, or 10 mg/kg). The effect of each treatment on DA and DA metabolite levels in mesolimbic and nigrostriatal brain tissue was quantified 15 min after a single exposure utilizing high pressure liquid chromatography with electrochemical detection (HPLC-ECD). Additionally, locomotor activity was recorded in mice after acute (day 1) and chronic intermittent (day 7) dosing. The results demonstrate that MDPV, mephedrone, and methylone produce dose-related increases in the mesolimbic and nigrostriatal DA levels that are significantly enhanced following their co-administration. Additionally, a decrease in locomotor activity on day 1 that was exacerbated by day 7 was noted in mice treated with the cathinone cocktail and was not observed with any of the single agents. The decrease in locomotor activity was accompanied by an increase in stereotypic-like behavior including excessive grooming and even self-mutilation. Our findings demonstrate a significantly enhanced effect of MDPV, mephedrone, and methylone on both DA and its metabolites resulting in significant alterations in locomotor activity. This work provides insight into the potential enhanced risk of the use of these combination synthetic cathinone products.

Providers’ Perspectives on Treating Patients for Substance Use Disorder in Northeast Tennessee Stefan Pienkowski MA, Abbey Mann PhD Department of Family Medicine, Quillen College of Medicine, East Tennessee State University, Johnson CIty, TN ABSTRACT Previous research has shown that people who identify as lesbian, gay, bisexual, transgender, and/or queer/questioning (LGTBQ+) have higher rates of substance use disorder (SUD) compared to the general population.1,2 Additionally, gender and sexual minorities have shown less treatment-seeking intentions than their heterosexual cis-gender counterparts.3 Given these circumstances, increasing approachability to SUD treatment options for people who identify as LGBTQ+ may significantly reduce this health disparity. Through this action research study, we set out to identify barriers to SUD treatment in northeast Tennessee as well as identify SUD treatment providers that make special accommodations for people who identify as LGBTQ+. Through purposive sampling, we identified nine providers of SUD treatment in Washington, Carter, and Sullivan counties. Providers included three physicians, three certified peer support specialists, a licensed counselor, and two facility directors. Providers each participated in a one-on-one semi-structured interview that lasted approximately 45 minutes and was audio recorded without the use of identifying information. Interview data were reviewed, and preliminary analysis was performed in order to identify themes. Themes included barriers to care, general resources, and stigma. LGBTQ+ specific findings revealed that none of the interviewed providers had received formal LGBTQ+ cultural competency training, but most providers expressed interest in receiving LGBTQ+ cultural competency training. Additionally, many providers did not believe that LGBTQ+ patients have specific needs concerning SUD treatment. Only three of the providers interviewed made special accommodations for their LGBTQ+ patients. In addition to identifying themes in the interview data, the results of this project were used to create a LGBTQ+ friendly SUD treatment resource guide for northeast Tennessee. Next steps for this action research project include 1) interviewing people who have experience with SUD treatment in northeast Tennessee and identify as LGBTQ+, 2) developing a community-based LGBTQ+ cultural competency training module informed by those interviews, 3) implementing and evaluating that module with SUD treatment providers in northeast Tennessee. 1. Medley, Grace, et al. “Sexual Orientation and Estimates of Adult Substance Use and Mental Health: Results from the 2015 National Survey on Drug Use and Health.” Substance Abuse and Mental Health Services Administration, Oct. 2016, www.samhsa.gov/data/sites/default/files/NSDUH-SexualOrientation-2015/NSDUH-SexualOrientation-2015/NSDUH-SexualOrientation-2015.htm. 2. Mereish, Ethan H, and Judith B Bradford. “Intersecting Identities and Substance Use Problems: Sexual Orientation, Gender, Race, and Lifetime Substance Use Problems.” Journal of Studies on Alcohol and Drugs, Rutgers University, Jan. 2014, www.ncbi.nlm.nih.gov/pubmed/24411810.` 3. Benz, Madeline. “Stigma and Help-Seeking: The Interplay of Substance Use and Gender and Sexual Minority Identity.” Addictive Behaviors, Pergamon, 23 May 2019, www.sciencedirect.com/science/article/abs/pii/S0306460318311316.

An evidence-based clinical practice guideline was developed to prevent and manage constipation in the long-term care (LTC) resident. Constipation is a prevalent condition in the LTC resident. Guidelines do not address this vulnerable population. Constipation may result in poor nutritional status, quality of life along with increased health care costs and hospitalizations. A literature review was completed and evidence was evaluated and included into the initial draft recommendations. The guideline was reviewed for content validity using a Delphi Committee of clinical experts in gastroenterology, geriatrics, and pharmacy. The updated guidelines were presented to an interdisciplinary team of long-term care residents. Participants were asked to review and complete a survey regarding clinical applicability of the guideline. Thirty-one interdisciplinary members participated in the education session and 30 surveys were received. Overall, the interdisciplinary team members agreed or strongly agreed the guideline was clinically applicable. Finally, the guideline was evaluated by a group of doctoral prepared practicing nurse practitioners using the AGREE II instrument. The scores were >80% in every domain, with an overall score of 91%, indicating the guideline is high in quality. Development of this guideline signifies an initial step in the management and prevention of constipation in the LTC resident.

Introduction: Inferior vena cava (IVC) malformations are extremely rare. Their impact with additional risk factors has not been well studied. Here, we present a case of a young female with absent IVC. She presented with an extensive left lower extremity (LLE) deep venous thrombosis (DVT) after starting oral contraceptives. Case: A 21-year-old female with no past medical history presented with progressively worsening back pain and LLE edema. Her only medication was combined oral contraceptive (OCP) which was started 4 months ago. Physical exam was significant for blue discoloration of her LLE extending from foot to thigh. The ultrasound showed multiple thrombi within the left common and deep femoral veins, left popliteal vein and left peroneal vein. The abdominal computerized tomography revealed the absence of an infrarenal IVC with collateral azygous, hemiazygous and prominent left gonadal veins. Occlusion by the thrombi extended from the left femoral vein to the left iliac vein. Some extension was noted into the right common iliac vein. She was treated with a catheter directed tissue plasminogen activator (tPA) infusion into the left iliac vein followed by continuous heparin infusion. Hypercoagulable testing was negative. While on heparin, she developed asymptomatic gross hematuria. CT urogram showed a significant dilation of the left gonadal vein, a large vein along the left psoas muscle draining into the left renal vein, and a mild enlargement of right gonadal vein. The urine analysis was negative for bacterial infection; but it contained a numerous amount of red blood cells and protein. Once the hematuria had resolved, she was discharged on apixaban. Her OCP was discontinued. Discussion: There have been several case reports describing IVC abnormalities associated with DVT. In our case, DVT was likely provoked by usage of OCP. Current guidelines would require provoked DVTs to be treat for at least 3-12 months with anticoagulation therapy. Case reports of IVC malformations illustrated that these patients are at high risk for DVT at baseline. Hence the underlying abnormality still poses a lifetime risk. Also, with abnormal venous vasculature, gross hematuria, proteinuria and the lack of other causes, we suspect underlying Nutcracker syndrome (NS). Her pelvic abdominal pain can also be attributed to pelvic congestion syndrome, which is commonly associated with NS. Conclusion: There are several questions that arise from this case including: selecting a type of contraceptive method; safety of direct thrombin inhibitors in patients with NS; indefinite direct thrombin inhibitors in young patients. Unfortunately, due to the rarity of this condition, no set guidelines are available on how to manage these individuals.

Rhabdomyosarcomas (RMS) are the most common type of soft tissue neoplasm in children. They typically arise from primitive skeletal muscle and are usually observed in either the head and neck or the genitourinary region. We report a rare case of an embryonal rhabdomyosarcoma lung malignancy and a formulated histopathological process to differentiate these lesions from its main differentials. We aim to bring attention to this case in an effort to assist physicians in making the correct diagnosis, should they be presented with a similar case. Here we present a case of a 56-year-old female with a past medical history of COPD and a 30-pack-year smoking history who was referred to a Regional Cancer Center clinic due to newly diagnosed lung cancer. The patient presented with anorexia, weight loss, cough, dyspnea for two months, and a 30-pound weight loss over the last month. CTA of the chest on 7/26/2021 revealed a 14 cm confluent mass extending throughout the mediastinum and the left hilum with associated narrowing of the left-sided pulmonary arteries and bronchi consistent with neoplasia. Several cavitary nodules in the left lung are present, consistent with metastatic disease. CT-guided biopsy on 8/2/2021 revealed a high-grade neoplasm with neuroendocrine features, and frequent mitotic figures, and tumor necrosis. Immunohistochemical staining was positive for synaptophysin, and CD56. Negative stains include cytokeratin TTF-1, AE1/AE3, CAM 5.2, CK 34 beta E12, CK5/6, CK7, CK20, p40, mart 1, SOX10 and CD45. The patient was then diagnosed with pulmonary embryonal rhabdomyosarcoma. In this case report the patient was diagnosed with pulmonary embryonal rhabdomyosarcoma, which characteristically has cells that show variable degrees of skeletal muscle differentiation with spindled morphology and differentiated rhabdomyoblasts. Desmin, myoD1, and myogenin are the key immunohistochemical stains that should be utilized to confirm the suspected diagnosis of a RMS. The staining pattern varies between different RMS subtypes, as the pulmonary subtype staining pattern is more focal compared to the others which tend to stain diffusely. CD56 staining can also be used to identify an alveolar RMS, however, is nonspecific. In this patient's case, CD56 was positive but the FISH analysis confirmed embryonal RMS as the final diagnosis. Previous studies have indicated that RMS can metastasize to the lung, thus this strain can prove to be a useful tool in rare cases such as this one, where the etiology of the cancer is unclear but has progressed to the lung. This unique case report highlights the diagnostic approach and aims to provide a differential diagnosis for a pulmonary embryonal rhabdomyosarcoma as well as an effective workup. Future research into the origin of the pulmonary embryonal rhabdomyosarcoma is indicated to provide comprehensive treatment for the patient and further understand the pathophysiology of the disease discussed.

Acute Myeloid Leukemia (AML) is a potentially fatal disease, more common in an elderly population. The American Cancer Society estimates 21,450 new cases of AML and 10,920 deaths from AML in the United States in 2019. This malignancy originating in the Bone Marrow (BM), usually presents with peripheral blood (PB) abnormalities. Rarely, AML, particularly monoblastic variants can present with extramedullary disease. Here we describe a case of AML presenting with diffuse lymphadenopathy and a biopsy revealing myeloid sarcoma. A 53 years old male developed diffuse lymphadenopathy. Failure of outpatient empiric antibiotic treatment prompted right cervical lymph node biopsy. Lymph node architecture was distorted by the presence of malignant monocytic myeloid cells. Both the peripheral blood and bone marrow were involved by AML with monocytic features. The monoblasts count was 14% in PB and 24% in BM and the promonocyte count was 12% in PB and 26% in BM. Complete Blood Count showed total white blood cell count of 31,700, hemoglobin 11.8, monocytes 22.5% and platelets 122,000. Flow cytometry of the bone marrow demonstrated a blast population with positive expression of cMPO, CD33, CD13, CD11b, HLA-DR, CD64, CD14 and CD4; and negative for CD34, CD117, nTdT, cCD3, cCD79a. Fluorescence in situ hybridization study was positive for MLL gene rearrangement. Molecular study was positive for IDH1 mutation, and negative for IDH2, RUNX1, FLT3 mutations. Further laboratory analysis was significant for lactate dehydrogenase 346, uric acid 8.6, prothrombin time 13.6, INR 1.2, partial thromboplastin time 33.5 and fibrinogen 293. Computed tomography of chest, abdomen, pelvis with contrast revealed extensive adenopathy with enlarged bilateral supraclavicular, bilateral axillary, mediastinal, bilateral hilar, upper abdominal, periaortic retroperitoneal, pelvic and inguinal lymph nodes. Hepatosplenomegaly was also reported. The term Myeloid Sarcoma (MS) is used when leukemic cells are present outside the bone marrow and peripheral blood. MS tends to oocur more commonly in middle aged males (male-to-female ratio, 2:1, median age, 56 years). The Mayo Clinic Experience of 96 cases demonstrated 27% of patients had no bone marrow involvement, and 69% of patients had primary bone marrow disease. Extramedullary involvement can occur prior to, simultaneously, or after bone marrow involvement. Just as in our case this is an important feature for clinicians to remember so that they may recognize this rare entity early.