Virginia Tech Carilion School of Medicine (VTCSOM)

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2021-2025 Strategic Plan, Virginia Tech Carilion School of Medicine
(Virginia Tech Carilion School of Medicine, 2021)
The VTCSOM Strategic Plan will guide our medical school into a vibrant future. In collaboration with our parent university (Virginia Tech), our health system partner (Carilion Clinic) and other community stakeholders, we will understand the challenges and opportunities we face as a medical school and respond with a comprehensive plan to achieve feasible, sustainable and measurable objectives.
A machine-learning approach for differentiating borderline personality disorder from community participants with brain-wide functional connectivity
Lahnakoski, Juha M.; Nolte, Tobias; Solway, Alec; Vilares, Iris; Hula, Andreas; Feigenbaum, Janet; Lohrenz, Terry; Casas, Brooks; Fonagy, Peter; Montague, P. Read; Schilbach, Leonhard (Elsevier, 2024-05-26)
Background: Functional connectivity has garnered interest as a potential biomarker of psychiatric disorders including borderline personality disorder (BPD). However, small sample sizes and lack of within-study replications have led to divergent findings with no clear spatial foci. Aims: Evaluate discriminative performance and generalizability of functional connectivity markers for BPD. Method: Whole-brain fMRI resting state functional connectivity in matched subsamples of 116 BPD and 72 control individuals defined by three grouping strategies. We predicted BPD status using classifiers with repeated cross-validation based on multiscale functional connectivity within and between regions of interest (ROIs) covering the whole brain—global ROI-based network, seed-based ROI-connectivity, functional consistency, and voxel-to-voxel connectivity—and evaluated the generalizability of the classification in the left-out portion of non-matched data. Results: Full-brain connectivity allowed classification (∼70 %) of BPD patients vs. controls in matched inner cross-validation. The classification remained significant when applied to unmatched out-of-sample data (∼61–70 %). Highest seed-based accuracies were in a similar range to global accuracies (∼70–75 %), but spatially more specific. The most discriminative seed regions included midline, temporal and somatomotor regions. Univariate connectivity values were not predictive of BPD after multiple comparison corrections, but weak local effects coincided with the most discriminative seed-ROIs. Highest accuracies were achieved with a full clinical interview while self-report results remained at chance level. Limitations: The accuracies vary considerably between random sub-samples of the population, global signal and covariates limiting the practical applicability. Conclusions: Spatially distributed functional connectivity patterns are moderately predictive of BPD despite heterogeneity of the patient population.
A Novel Outpatient Mental Health Clinic Addressing Patient Access, Teaching, and Team-Based Care
O'Brien, Virginia C.; Kurdila, Laura; Martin, Rachel K.; Nayani, Huma (2024-10-17)
A rare case of ventricular tachycardia caused by an intramyocardial fibroma with successful surgical resection in an adult
Binder, M. Scott; Roby, Matthew; Chancellor, William; Yarboro, Leora; Arnold, Scott; Hodge, Kyle; Kern, John; Sane, David (Springer, 2024-09-05)
Background: Cardiac fibromas are extremely rare in adults. The preferred treatment is surgical resection, but antiarrhythmic medications or heart transplantation have also been used previously. The cardiac imaging, particularly MRI, can be useful to help delineate between primary cardiac tumors, and surgical factors such as the extent/size of the fibroma, involvement of the coronary arteries or mitral apparatus and amount of residual myocardium influence whether surgical resection is feasible. Case presentation: A 42-year-old male presented with a wide-complex tachycardia, unresponsive to amiodarone. An echocardiogram was performed which showed a possible posterior wall mass. A cardiac MRI showed a well circumscribed lateral wall intracardiac fibroma, measuring 5.2 × 5.1 × 3.8 cm with preserved function. Surgical resection was successful, and he was discharged without a defibrillator. Conclusions: Cardiac fibromas are encapsulated tumors which do not infiltrate myocardium and should be surgically resected if possible.
Abuse and Neglect in the Aging Population
Stubbs, Sarah (2023-03-26)
A recorded AAFP presentation as part of their "Dementia: From Differential Diagnosis to End of Life" CME series.
An Acoustic Sensor for Airflow in Pediatric Artificial Airways
Gooty, Vasu; Harris, Charles; Muelenaer, Andre A.; Watson, Brian; Safford, Shawn D. (Elsevier, 2015-01-06)
Pulmonary hyalinizing granuloma (PHG) is a rare benign pulmonary nodular lesion of unknown etiology. We present a case of a 5-year-old boy who was found to have a chest mass while being evaluated for abdominal pain. He underwent a CXR and CT scan that showed popcorn calcifications in the right posterior mediastinum and within the hilum of right lung. These lesions were suspicious for benign calcified lymph nodes and follow-up chest CT after 3.5 months showed no interval changes in the calcified mediastinal masses. Extensive testing ruled out infectious diseases and malignancies. Given the unknown etiology of the lesions, he underwent VATS biopsy that demonstrated a nodular lesion characterized by a peripheral rim of fibrous tissue and central zone of necrosis and calcification, findings consistent with hyalinizing granuloma. PHG is extremely rare in pediatric age group. Although diagnosis of this condition is made by radiological and histopathological findings, it is important to rule out other causes of chest masses. Most of the patients usually have good prognosis with this rare disorder.
Acute onset apathy in the context of malignancy: a case report
Samarbafzadeh, Ehsan; Adikey, Archana; Alee Koloukani, Sahar (2021-05-03)
Adenovirus transduction to express human ACE2 causes obesity-specific morbidity in mice, impeding studies on the effect of host nutritional status on SARS-CoV-2 pathogenesis
Rai, Pallavi; Chuong, Christina; LeRoith, Tanya; Smyth, James W.; Panov, Julia; Levi, Moshe; Kehn-Hall, Kylene; Duggal, Nisha K.; Weger-Lucarelli, James (Elsevier, 2021-11-01)
The COVID-19 pandemic has paralyzed the global economy and resulted in millions of deaths globally. People with co-morbidities like obesity, diabetes and hypertension are at an increased risk for severe COVID-19 illness. This is of overwhelming concern because 42% of Americans are obese, 30% are pre-diabetic and 9.4% have clinical diabetes. Here, we investigated the effect of obesity on disease severity following SARS-CoV-2 infection using a well-established mouse model of diet-induced obesity. Diet-induced obese and lean control C57BL/6 N mice, transduced for ACE2 expression using replication-defective adenovirus, were infected with SARS-CoV-2, and monitored for lung pathology, viral titers, and cytokine expression. No significant differences in tissue pathology or viral replication was observed between AdV transduced lean and obese groups, infected with SARS-CoV-2, but certain cytokines were expressed more significantly in infected obese mice compared to the lean ones. Notably, significant weight loss was observed in obese mice treated with the adenovirus vector, independent of SARS-CoV-2 infection, suggesting an obesity-dependent morbidity induced by the vector. These data indicate that the adenovirus-transduced mouse model of SARS-CoV-2 infection, as described here and elsewhere, may be inappropriate for nutrition studies.
The adhesion function of the sodium channel beta subunit (beta 1) contributes to cardiac action potential propagation
Veeraraghavan, Rengasayee; Hoeker, Gregory S.; Alvarez-Laviada, Anita; Hoagland, Daniel T.; Wan, Xiaoping; King, D. Ryan; Sanchez-Alonso, Jose; Chen, Chunling; Jourdan, L. Jane; Isom, Lori L.; Deschenes, Isabelle; Smith, James W.; Gorelik, Julia; Poelzing, Steven; Gourdie, Robert G. (2018-08-14)
Computational modeling indicates that cardiac conduction may involve ephaptic coupling - intercellular communication involving electrochemical signaling across narrow extracellular clefts between cardiomyocytes. We hypothesized that beta 1(SCN1B) - mediated adhesion scaffolds trans-activating Na(V)1.5 (SCN5A) channels within narrow (<30 nm) perinexal clefts adjacent to gap junctions (GJs), facilitating ephaptic coupling. Super-resolution imaging indicated preferential beta 1 localization at the perinexus, where it co-locates with Na(V)1.5. Smart patch clamp (SPC) indicated greater sodium current density (I-Na) at perinexi, relative to non-junctional sites. A novel, rationally designed peptide, beta adp1, potently and selectively inhibited beta 1-mediated adhesion, in electric cell-substrate impedance sensing studies. beta adp1 significantly widened perinexi in guinea pig ventricles, and selectively reduced perinexal I-Na, but not whole cell I-Na, in myocyte monolayers. In optical mapping studies, beta adp1 precipitated arrhythmogenic conduction slowing. In summary, beta 1-mediated adhesion at the perinexus facilitates action potential propagation between cardiomyocytes, and may represent a novel target for anti-arrhythmic therapies.
Adult Intestinal Intussusception Caused by the Gastrojejunostomy Tube: An Endoscopically Treatable Phenomenon
Zhang, Kermit S.; Bansal, Jash; Bansal, Anmol; Chitnavis, Vikas (Hindawi, 2021-06-11)
Adult duodenoduodenal intussusception is extremely rare due to the retroperitoneal fixation of the second, third, and fourth parts of the duodenum. A majority of clinically significant intussusception with identifiable etiologies is typically neoplastic with more rare causes including retained food and indwelling enteral tubes, specifically with gastrojejunostomy (GJ) tubes. Herein, we discuss the case of a 23-year-old male who developed duodenoduodenal intussusception upon a PEGJ placement with associated gastroduodenal dilation and telescope phenomenon. To the best of our knowledge, there are no reports of intussusception found to be caused by GJ tubes in the adult population. The reported patient was found to have a 4-cm enteroenteric intussusception without obstruction or ischemia with bowel thickening proximal to the pathology. Although adult intussusception cases are typically managed surgically, we were able to reduce the intussusception via endoscopy due to rapid diagnosis upon presentation and intervention before the bowel wall could be compromised.
Advanced Care Planning for People Living with Dementia
Stubbs, Sarah (2023-03-26)
A recorded AAFP presentation as part of their "Dementia: From Differential Diagnosis to End of Life" CME series.
Aesthetic Outcomes of the Adipofascial Turnover Flap for Nasal Defects
Canzoneri, Christina N.; Capito, Anthony E. (Wolters Kluwer Health, 2023)
Background: The single-stage adipofascial turnover (AFT) flap with full-thickness skin grafting is a novel technique that has been demonstrated as a safe, reliable, and cost-effective alternative to forehead flaps for nasal tip reconstruction. The purpose of this study was to compare aesthetic outcomes of these reconstructive techniques. Methods: A retrospective review was conducted of patients who underwent either a forehead flap or an AFT flap for nasal reconstruction between January 2016 and January 2021. Aesthetic outcomes were compared via patient surveys and photographic analysis by plastic surgeons. All photographs were standardized and masked to conceal which reconstructive technique was utilized. Wilcoxon ranksum tests and t-tests were performed to determine significance. Results: Ten forehead flaps and 22 AFT flaps were performed between January 2016 and January 2021. Seven forehead flap patients and 18 AFT flap patients participated in the aesthetic outcome survey. Seven forehead flap postoperative photographs and 20 AFT flap postoperative photographs were available for analysis. Patients who underwent forehead flap reconstruction reported higher satisfaction for color match of the reconstruction to the surrounding nasal skin (P = 0.005). Otherwise, there was no statistical significance between the two patient groups. There was no statistical difference in the photographic analysis of the two groups. Conclusion: The single-stage AFT flap with full thickness skin grafting provides similar aesthetic outcomes compared with the two-stage forehead flap when reconstructing large defects of the nasal tip, which is supported by both patient-reported outcome measures and standardized photographic analysis by a panel of plastic surgeons.
Air hunger: A primal sensation and a primary element of dyspnea
Banzett, Robert B.; Lansing, Robert W.; Binks, Andrew P. (Wiley, 2021-04)
The sensation that develops as a long breath hold continues is what this article is about. We term this sensation of an urge to breathe “air hunger.” Air hunger, a primal sensation, alerts us to a failure to meet an urgent homeostatic need maintaining gas exchange. Anxiety, frustration, and fear evoked by air hunger motivate behavioral actions to address the failure. The unpleasantness and emotional consequences of air hunger make it the most debilitating component of clinical dyspnea, a symptom associated with respiratory, cardiovascular, and metabolic diseases. In most clinical populations studied, air hunger is the predominant form of dyspnea (colloqui-ally, shortness of breath). Most experimental subjects can reliably quantify air hunger using rating scales, that is, there is a consistent relationship between stimulus and rating. Stimuli that increase air hunger include hypercapnia, hypoxia, exercise, and acidosis; tidal expansion of the lungs reduces air hunger. Thus, the defining experimental paradigm to evoke air hunger is to elevate the drive to breathe while mechanically restricting ventilation. Functional brain imaging studies have shown that air hunger activates the insular cortex (an integration center for perceptions related to homeostasis, including pain, food hunger, and thirst), as well as limbic structures involved with anxiety and fear. Although much has been learned about air hunger in the past few decades, much remains to be discovered, such as an accepted method to quantify air hunger in nonhuman animals, fundamental questions about neural mechanisms, and adequate and safe methods to mitigate air hunger in clinical situations
The Airway Alert: A Multi-Disciplinary Approach to Management of The Difficult Airway
Lee, Maxine (Virginia Society of Anesthesiologists, 2021-03-01)
The Airway Alert: Optimizing Management of the Difficult Airway
Lee, Maxine (2022-01-14)
Alanyl-glutamine Supplementation for Clostridioides difficile Infection Treatment (ACT): A double-blind randomized controlled trial
Warren, Cirle A.; Shin, Jae Hyun; Bansal, Ekta N.; Costa, Deiziane V. D. S.; Wang, Xin Qun; Wu, Martin; Swann, Jonathan R.; Behm, Brian W.; Targonski, Paul V.; Archbald-Pannone, Laurie (BMJ Journals, 2023-07-19)
Introduction: Clostridioides difficile is the leading cause of healthcare-associated infections in the USA, with an estimated 1 billion dollars in excess cost to the healthcare system annually. C. difficile infection (CDI) has high recurrence rate, up to 25% after first episode and up to 60% for succeeding episodes. Preliminary in vitro and in vivo studies indicate that alanyl-glutamine (AQ) may be beneficial in treating CDI by its effect on restoring intestinal integrity in the epithelial barrier, ameliorating inflammation and decreasing relapse. Methods and analysis: This study is a randomised, placebo-controlled, double-blind, phase II clinical trial. The trial is designed to determine optimal dose and safety of oral AQ at 4, 24 and 44 g doses administered daily for 10 days concurrent with standard treatment of non-severe or severe uncomplicated CDI in persons age 18 and older. The primary outcome of interest is CDI recurrence during 60 days post-treatment follow-up, with the secondary outcome of mortality during 60 days post-treatment follow-up. Exploratory analysis will be done to determine the impact of AQ supplementation on intestinal and systemic inflammation, as well as intestinal microbial and metabolic profiles. Ethics and dissemination: The study has received University of Virginia Institutional Review Board approval (HSR200046, Protocol v9, April 2023). Findings will be disseminated via conference presentations, lectures and peer-reviewed publications. Trial registration number NCT04305769.
An Alarming Mimicry of Intra-Abdominal Infections: Acute Appendiceal Diverticulitis
Kim, Youseung; Kesar, Varun; Grider, Douglas J.; Chitnavis, Maithili V. (Hindawi, 2021-11-12)
A 65-year-old woman presented with three days of colicky abdominal pain. Abdominal imaging illustrated small bowel enteritis, ascites in both paracolic gutters, and incidental hepatic steatosis. Although ascites fluid demonstrated high neutrophil count consistent with peritonitis and the patient received adequate antibiotics, she clinically deteriorated. Subsequent exploratory laparotomy revealed necrotic appendix and multiple intra-abdominal abscesses. Histopathology showed acute suppurative appendicitis with multiple other intact small diverticula, indicating likely perforation of inflamed appendiceal diverticula with subsequent abscess formation and abdominal peritonitis. This case highlights the importance of ascites fluid analysis and continued clinical correlation, especially in cases of rare entities with atypical presentations.
Alice in Wonderland Syndrome: The Case of the Elongating Straws
Stavig, Alissa; O'Brien, Virginia C. (2019-10-18)
Accurately interpreting visual stimuli requires a complicated interplay between the eye, visual pathways and cortical pathways. The temporal lobe is responsible for object recognition and the parietal lobe is responsible for motion. Vision requires the integration of information from all cortical areas (temporal, parietal, occipital). Alice in Wonderland Syndrome (AIWS) describes a set of visual and somatosensory symptoms characterized by a distortion in perception of the environment, time or self in contrast to hallucinations or illusions.
The alleged existence of partially oxidized Mg[Pt(CN)4]Cl0.28.7H2O and the attempted preparation of the analogous beryllium(2+) and barium(2+) derivatives. A caveat
Koch, Timothy R.; Gebert, E.; Williams, Jack M. (American Chemical Society, 1976-06)
Almost Everything We Need to Better Serve Children of the Opioid Crisis We Learned in the 80s and 90s
Horn, Kimberly A.; Pack, Robert P.; Trestman, Robert L.; Lawson, Gerard F. (Frontiers, 2018-10-16)
Opioid use disorder impedes dependent parents' abilities to care for their children. In turn, children may languish in unpredictability and persistent chaos. Societal responses to these children are often guided by a belief that unless the drug dependent parent receives treatment, there is little help for the child. While a preponderance of the drug dependence research is adult-centric, a significant body of research demonstrates the importance of not only addressing the immediate well being of the children of drug dependent caregivers but preventing the continuing cycle of drug dependence. The present commentary demonstrates through a brief review of the US history of drug dependence crises and research from the 1980s and 1990s, a range of "tried and true" family, school, and community interventions centered on children. We already know that these children are at high risk of maladjustment and early onset of drug dependence; early intervention is critical; multiple risk factors are likely to occur simultaneously; comprehensive strategies are optimal; and multiple risk-focused strategies are most protective. Where we need now to turn our efforts is on how to effectively implement and disseminate best practices, many of which we learned in the 1980s and 1990s. The greatest opportunity in both changing the nature of the opioid epidemic at scale and influencing rapid translation of existing research findings into policy and practice is not in asking what to do, but in asking how to do the right things well, and quickly.

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