• Pediatricians’ Attitudes and Practices Regarding Patient Immunization in Arizona

      Khan, Soofia; The University of Arizona College of Medicine - Phoenix; Sunenshine, Rebecca (The University of Arizona., 2012-04-30)
      Background: Despite the widespread availability of vaccines, including to the uninsured, significant numbers of both children and adults, remain unvaccinated or undervaccinated. Many reasons, including an increasing financial burden on primary care practices, availability of access to healthcare, and beliefs regarding vaccine safety, have been implicated; however, increasing concern has arisen regarding insurance payments for vaccines to providers [2, 5, 8]. Due to these concerns, we conducted a survey to understand the attitudes, perceptions and practices of Arizona pediatricians regarding vaccines and their reimbursement by insurance companies. Methods: In February 2011, 1407 standardized surveys were emailed, 87 surveys were faxed, and 216 surveys were mailed to AZ pediatricians who were listed in the Arizona Chapter of the American Academy of Pediatrics membership database. Results: From the 138 (9.0% response rate) responses, we identified that about half of all provider respondents refer insured and uninsured 5 patients to public health or other outside clinics for vaccines. The most common reason for outside patient referral for vaccine is inadequate reimbursement by insurance companies, and approximately one-third of providers did not vaccinate a patient due to inadequate reimbursement. Additionally, the vast majority of providers were interested in participating in a buying group run by TAPI. Conclusions: Based on our survey, inadequate reimbursement for vaccines by insurance companies negatively affects Arizona pediatricians’ provision of immunizations. A provider buying group coordinated by a not for profit immunization coalition is one possible solution for this problem.
    • Phase Two Study Examining Magnesium Dependent Tinnitus

      Patel, Alpen; The University of Arizona College of Medicine - Phoenix (The University of Arizona., 2012-05-01)
      Background: Recent studies in noise-induced and idiopathic sensorineural hearing loss have suggested that magnesium supplementation may lessen both hearing loss and the severity of tinnitus in patients. Further epidemiological evidence indicates that all age groups of Americans fall short of the recommended daily allowance for magnesium by 100 mg daily. Purpose: The purpose of this study was to examine any potential benefit in lessening the severity of tinnitus in patients taking supplemental magnesium. Research Design: The study was a single-arm, open-label, before-and-after study of oral magnesium (532 mg per day) in 26 patients for 3 months. Tinnitus severity was evaluated and recorded daily by the patient using the Tinnitus Distress Rating (TDR) scale of 0 (no tinnitus) to 10 (worst possible tinnitus). The Tinnitus Handicap Inventory (THI) was administered before and at the end of the study, and scores were converted to the grades of the 5-item Tinnitus Severity Scale (TSS).As a phase 2 study, the current design could not distinguish the effect of treatment from a placebo effect or regression to the mean. All data were collected at Mayo Clinic in Scottsdale, Arizona. 3 Study Sample: Patients with moderate to very severe tinnitus (TDR score of 3 through 8). Intervention: Daily magnesium supplementation, 532 mg; patient completion of the THI; and daily self-report of TDR. Data Collection and Analysis: The main outcome measures were mean TDR scale scores and THI scores as converted to TSS grades. The primary analysis was done on the basis of intention to treat. Results: Twenty-six patients were enrolled; 19 completed the study. The extent of handicap, as measured by THI/TSS, for subjects with slight or greater impairment was significantly decreased (P=.03). Patients who ranked slight or greater on the THI/TSS before intervention showed a significant decrease in the severity of their tinnitus at post-testing (P=.008). Conclusion: The results suggest that magnesium may have a beneficial effect on perception of tinnitus-related handicap when scored with the THI. Keywords: Magnesium; Tinnitus; Tinnitus Distress Rating; Tinnitus Handicap Inventory; Tinnitus Severity Scale
    • Preference of Health-related Learning Modalities Among Asian Americans in Maricopa County

      Chan, Nam; The University of Arizona College of Medicine - Phoenix; Hirano, Doug (The University of Arizona., 2012-04-30)
      Asian Americans are the fastest growing racial/ethnic group in the United States, with more than 60% of its members being foreign born, and 30% of limited English proficiency. Often perceived as the healthy and wealthy “Model Minority,” Asian Americans in fact suffer disproportionately in a number of areas of health, such as liver cancer and diabetes. There is a paucity of evidence-based interventions specifically adapted for and tested among Asian American to address these health disparities. We therefore aimed to investigate the preferred learning modalities in this population. We utilized a brief questionnaire to investigate how Asian Americans residing in Maricopa County prefer to learn and build skills related to health improvement. The results suggest that there is no dominant preference for learning modalities among Asian Americans; therefore, modalities in both individual and group learning should be offered. The only group that shows a statistically significant preference for individual learning is the respondents with postsecondary education. Consequently, in addition to group interventions such as the Diabetes Prevention Program, researchers should consider developing self-guided training on-line and through printed materials. This initial 4 research will help guide future efforts to educate the Asian American populations on diabetes prevention and other health conditions.
    • Prophylactic Dosing of Myofascial Release in a Human Fibroblast Model of Wound Closure

      Powell, Travis Joseph; The University of Arizona College of Medicine - Phoenix; Standley, Paul (The University of Arizona., 2012-05-01)
      Myofascial release (MFR) allows clinicians to directly stretch and palpate soft tissue restrictions, improving tissue elasticity, and maximizing range of motion. Research has focused on MFR following repetitive motion strain (RMS), however there is no known application of prophylactic MFR. Utilizing in vitro strain models we will investigate the role of prophylactic MFR in regulating fibroblast wound healing. We hypothesize that MFR treatments will have greater efficacy when used prior to the repetitive motion strain, increasing the rate of wound healing. Human fibroblasts were seeded onto 6-well collagen-I bioflex plates, strained with the Flexcell vacuum compression system. Sub-confluent cell constructs were wounded using sterile 1ml pipette tips to create an area devoid of cells. Spatial wound edge changes were monitored to determine closure rate at 0, 12, 24, 36 and 48 hours. Pooled data for 36 hours demonstrated that RMS closed 32% faster than the combined RMS+MFR and 30.5% faster than the non-strain control, p<0.05. This meant the data did not support the hypothesis, but prophylactic stretching has been shown to prevent and reduce injury in 5 other models. Prophylactic MFR requires additional studies to expand our model to include multiple dosed treatments with a stronger emphasis on prevention vs. healing.
    • Relationship Between Maternal Expectations of Perinatal Care and Postpartum Depression

      Williams, Danielle; The University of Arizona College of Medicine - Phoenix; Mattox, John (The University of Arizona., 2012-05-01)
      The incidence of postpartum depression (PPD) is estimated at 13-19%, with effects reaching far beyond the affected mother. However, its precise cause is still unknown. In this double-blinded study, a 30-question Maternal Expectations Survey (MES) was developed to explore the notion that unmet maternal expectations for labor, delivery, and the immediate postpartum period impose risk factors for PPD. The MES was administered to postpartum women at Banner Good Samaritan Medical Center; and scores were compared to those on the Edinburgh Postnatal Depression Scale (EPDS), administered 6 weeks postpartum to the same women in the outpatient setting of the clinic of their attending physician. Results of this interim analysis, using Poisson regression models, indicated that there is no significant correlation between total MES score and EPDS score. Two MES queries (relating to spontaneous onset of labor and coping mechanisms during labor) are independently predictive of an increased EPDS score. With attainment of adequate power, other components of the MES may emerge as genuine risk factors for PPD and help identify women who would benefit from earlier-than-usual, pre-emptive postpartum counseling. This study also served to buttress the validity of 5 considering the presence of neonatal health complications as a risk factor for PPD; and, conversely, it identified obstetric complications, neonatal health complications and a recent stressful life event as significant predictors of an increased MES score. Additionally, the presence of a written birth plan is also a significant predictor of increased
    • Renal Cell Carcinoma in Arizona American Indians/Alaska Natives

      Winegard, Billie; The University of Arizona College of Medicine - Phoenix; Flood, Timothy (The University of Arizona., 2012-05-02)
      OBJECTIVE – This study assesses trends in the incidence of cancers of the kidney and renal pelvis (K&RP) with focus on renal cell carcinoma (RCC) from 1995-2009 among American Indian/Alaska Natives (AI/AN) residing in Arizona. RESEARCH DESIGN AND METHODS – Using the Arizona Cancer Registry (ACR), we obtained the total number of new cases of cancers of the K&RP from 1995 through 2009. The incidence rates of these cancers, as well as the sub-group of RCC, were age-adjusted to the 2000 U.S. population for comparison between populations. Comparisons between demographic and tumor characteristics were also completed between AI/AN and non-Hispanic white cases. RESULTS – Between 1995 and 2009, 502 cases of K&RP were diagnosed in AI/AN in Arizona, with a majority of these cases (463, 92.23% of cases) being RCC of the kidney parenchyma. Over the study period, the age-adjusted incidence per 100,000 population was 19.18 for all tumors of the K&RP and 17.65 for RCC. Comparing the average age-adjusted rate over the first third (1995-1999) of the study period versus the last third (2005-2009), the rate of RCC among AI/AN increased 12.30% from 16.55 to 18.58 per 100,000 population. When this rate was stratified by sex, AI/AN males showed the most striking increase - 54.56% (19.22 to 29.70 cases of RCC per 100,000 population). While AI/AN females showed a decrease in the rate of 28.24% (14.20 to 10.19 cases per 100,000 population). CONCLUSIONS – The incidence rate of RCC has increased dramatically in Arizona AI/AN males. Research looking at this disease in this group is needed to determine which risk factors may be associated and to determine if any steps can be taken toward prevention or if there is a need for screening in this population.
    • A Role for Estrogen Receptor β in the Inhibition of Prostate Cancer Cell Growth

      Ibragimov, Angela; The University of Arizona College of Medicine - Phoenix; Handa, Robert (The University of Arizona., 2012-04-30)
      Prostate cancer (PC) and benign prostatic hypertrophy (BPH) are highly prevalent neoplasms. Studies have demonstrated the androgen-dependent nature of benign and pathologic growth of prostate cells. Although Androgen Receptors (AR) have strong proliferative activity in the prostate, recent studies have implicated an anti-proliferative role for Estrogen Receptor Beta (ERβ). This study investigates the effects of ERβ stimulation on normal prostate growth in vivo as well as on PC cell growth in vitro to better elucidate a mechanism for the proposed anti-proliferative actions of ERβ. We also study the interplay between concurrent androgen and ERβ stimulation on PC cell proliferation in vitro. Our hypothesis is that ERβ activation will decrease cell growth and increase cell death in PC cells. Three different ERβ-simulating compounds were analyzed; the selective ERβ agonist diarylpropionitrile (DPN), the dihydrotestosterone (DHT) metabolite 5 alpha androstane-3 β 17b diol (3β-diol), and the isoflavone metabolite, equol, a daidzein-derived compound with phytoestrogen properties. DPN (2mg/Kg) treatment of adult male EZC3 mice for 21 days caused a significant decrease in dorsolateral lobe weight as 4 compared to control (P=.0002). Equol has the same effect on the dorsolateral lobe weight of Sprague-Dawley rats. Furthermore, DPN treatment of human Lymph Node Carcinoma of the Prostate cells (LNCaP) decreased cell proliferation, an effect that was overcome by concurrent treatment with DHT. Interestingly, equol also showed an anti-proliferative effect in cells when used alone as well as in the presence of DHT. 3β-diol, however, did not alter cell growth. Prostate specific antigen (PSA) levels measured from treated LNCaP cells as a measure of androgen stimulation demonstrated that DPN does not interfere with the ability of DHT to stimulate the AR. Furthermore, in vitro data strongly suggest an antagonistic action of equol on the effects of DHT not seen by DPN or 3β-diol. Our data suggest an anti-proliferative role of some ERβ agonists, notably DPN and equol. Although these agonists are ligands of the same receptor, it appears that they activate different molecular pathways and have varying effects on androgen stimulation by DHT. The effects of ERβ agonists are of paramount importance in modulating hormone-induced PC cell proliferation and may have future clinical implication in this widely-prevalent disease condition.
    • The Role of Access: Acute Asthma Care Utilization in a 2008 Arizona Medicaid Population

      Ortiz, Zachary; The University of Arizona College of Medicine - Phoenix; Petitti, Diana (The University of Arizona., 2012-05-01)
      Prior research shows racial disparities in patient (IP) and emergency department (ED) use for children with asthma. It has been difficult to disentangle the effects of race/ethnicity from the effect of socioeconomic status on IP and ED use. To better understand the relationship between race/ethnicity and care in these settings, data from a cohort of 3490 school-age children with asthma enrolled in the AHCCCS (Medicaid) program in Maricopa County, Arizona in 2008 were analyzed. For children with asthma, odds ratios were estimated by comparing ‘any visit’ (ED or IP) to ‘no visits’ according to race/ethnicity. Among children with asthma, junior high and high school individuals were more likely to experience a visit compared to elementary school age individuals. African-Americans were about twice as likely to have at least one ED or IP visit compared with White, non-Hispanics. Odds ratios for having any ED or IP visit were also increased in Hispanics and Native-Americans compared with White, non-Hispanics but the increases were not statistically significant. Although the generalizability of the study is limited, the data suggest that differences in socioeconomic status do not fully explain racial disparities in use of the ED and IP settings for asthma care. Attempts 5 to further understand any causal relationship between race/ethnicity and asthma should be coupled with targeted interventions to minimize known disparities.
    • Segmental Glomerulosclerosis in Pima Indians with Type 2 Diabetes

      Seidel, Ruthanna; The University of Arizona College of Medicine - Phoenix; Weil, E. Jennifer (The University of Arizona., 2012-05-01)
      Diabetes mellitus is widespread in the United States, and diabetic kidney disease is one of the most common complications. There is increasing evidence that podocyte injury is the initial pathologic change in diabetic nephropathy, and podocytopathy often manifests on renal biopsy as segmental sclerosis in other kidney diseases. The purpose of this study was to determine if segmental sclerosis is widespread in diabetic kidney disease. This study examined 1142 glomeruli from 61 Pima Indians who had diabetes for at least ten years. 24 patients were normoalbuminuric, 20 were microalbuminuric, and 17 were macroalbuminuric. The presence of segmental sclerosis was noted, as was global sclerosis. Segmental sclerosis was present in less than 2% of glomeruli. All glomeruli showed evidence of diabetic nephropathy including mesangial hypercellularity and invasion of mesangium into capillary loops. These data suggest that segmental sclerosis is not present in significant amounts in diabetic kidney disease. Rather, pathologic changes in the glomeruli of diabetic patients occur in a more diffuse pattern.
    • Suppression of Lipopolysaccharide-induced Inflammatory Responses in RAW 264.7 Macrophages by Aqueous Extract of Clinopodium vulgare L. (Lamiaceae)

      Burk, David; The University of Arizona College of Medicine - Phoenix; Daskalova, Sasha (The University of Arizona., 2012-04-30)
      ETHNOPHARMACOLOGICAL RELEVANCE: The wild basil Clinopodium vulgare L. is commonly used in Bulgarian folk medicine for treatment of irritated skin, mastitis- and prostatitis-related swelling, as well as for some disorders accompanied with significant degree of inflammation (e.g. gastric ulcers, diabetes, and cancer). AIM OF STUDY: To determine the effect of aqueous extract of Clinopodium vulgare L. on LPS-induced inflammatory responses of murine RAW 264.7 macrophages. MATERIALS AND METHODS: Cell cytotoxicity was evaluated by MTT assay. Protein expression levels were monitored by Western blot analysis. Production of NO and PGE(2) was measured by the Griess colorimetric method and enzyme immunoassay, respectively. Activation of MMP-9 was visualized by gelatin zymography. Cytokine levels were determined by BioPlex assay. Intracellular ROS and free radical scavenging potential were measured by DCFH-DA and DPPH method, respectively. Xanthine oxidase activity was evaluated spectrophotometrically.
    • Sustainability of a Culturally Informed Community-Based Diabetes Prevention Program for Obese Latino Youth

      Greenwood-Ericksen, Margaret; The University of Arizona College of Medicine - Phoenix; Shaibi, Gabriel (The University of Arizona., 2012-04-30)
      Latino youth are disproportionately impacted by obesity and type 2 diabetes; however, few lifestyle interventions have targeted this population. Therefore, the purpose of this study was to assess the impact of a culturally informed lifestyle education pilot program on nutrition and physical activity behaviors among obese Latino youth. A retrospective chart review of 67 youths was conducted with self-reported nutrition and physical activity assessed both immediately following the program and after long-term follow-up. Body mass index (BMI) was evaluated to determine the impact of behavior changes on adiposity. Healthy nutrition and physical activity changes were reported by 20%-59% of youths immediately following the program. However, most of these changes were attenuated over the 261 ± 49 day follow-up with reported walking (25.4%) and sports participation (34.3%) sustained to a greater extent than dietary changes (3.4–14.9%). Nonetheless, children who continued walking at follow-up exhibited significantly larger reductions in BMI compared with those who did not (-1.63 ± 0.56 vs. 0.44 ± 0.30 kg/m2, P < .05). Based on our pilot study, we conclude that community-based lifestyle education programs can support behavior modification and weight management 5 in obese Latino youth. Ongoing support may be necessary to encourage
    • Three Cases in Pediatric Neuroradiology: Athabascan Brainstem Dysgenesis Syndrome, Aicardi Goutières Syndrome, and Aplasia of the Parotid Glands

      Higley, Meghan; The University of Arizona College of Medicine - Phoenix; Towbin, Richard (The University of Arizona., 2012-04-30)
      Summary: The human HOXA1 mutation syndromes commonly present with abnormalities of the inner ear and internal carotid arteries. Previous cases describe varying degrees of hypoplasia or aplasia of the affected structures, often with asymmetrical involvement. We present imaging findings documenting complete absence of the internal carotid arteries bilaterally with bilateral Michel aplasia of the inner ear, which, to our knowledge, has not been previously reported. Based on the number of cases identified and birth rates within studied populations, we estimated the incidence of ABDS at 0.5-1:1000 live births on the White River Apache Reservation and 1:3000 live births in the Navajo population. If accurate, this suggests a carrier frequency similar to that for cystic fibrosis in Caucasian populations. ABDS may represent a significantly underrecognized disorder among Athabaskan Native Americans, raising questions of the possible benefit of genetic counseling for affected families. However, cultural considerations in this population bring into question the possible conflict between counseling based on gene theory and traditional beliefs.
    • Trends In Unintentional Drug Overdose-related Deaths

      Sharer, Rustan; The University of Arizona College of Medicine - Phoenix; Petitti, Diana (The University of Arizona., 2012-05-01)
      Since undergoing a radical paradigm shift in prescribing trends in the late 80s/early 90s, the therapeutic use and non-therapeutic abuse of controlled prescription drugs (specifically opioids) has reached prolific levels in the US. Despite seemingly widespread awareness of such trends and associated dangers, mortality and morbidity associated with such medications continues to escalate in the face of rapidly increasing prescribing patterns. This investigation attempts to further characterize time trends of accidental deaths secondary to overdoses of various drugs (primarily comparing Arizona to national trends with respect to various demographic identifiers). Utilizing publicly available data sources, a statistical analysis was performed on yearly mortality rates for selected drug-overdose related causes of death between 1999 and 2007. Arizona consistently exhibited higher death rates--with Pinal County claiming the highest among all urbanizations--(but lower annual rates of increase) than the national trends. Men were also shown to have much higher death rates than women (although women’s rates are increasing much faster than men). Furthermore, Hispanics demonstrated significantly lower death rates than non-Hispanics (whose death rates were shown to be increasing three times faster than Hispanics). Rapidly increasing death rates pose a significant concern at both the state and national levels.
    • TRP1 Peptide Requires Internalization and is Partially Dependent on GILT for Efficient Presentation on MHC Class II

      Sjursen, Anne Marie; The University of Arizona College of Medicine - Phoenix; Hastings, Karen (The University of Arizona., 2012-05-01)
      Tyrosinase-related protein 1 (TRP1) is a melanosomal integral membrane protein and melanocyte differentiation antigen that contributes to the synthesis of melanin in melanocytes. Present in both benign and malignant melanocytes, it has been implicated in the autoimmune development of vitiligo and melanoma antitumor immunity. Since a naturally occurring MHC class II-restricted TRP1 epitope contains cysteine residues, we hypothesized that this epitope will require internalization and reduction by gamma-interferon-inducible lysosomal thiol reductase (GILT) for presentation on class II. GILT is known to catalyze the reduction of protein disulfide bonds in the endocytic pathway and contribute to antigen processing and presentation of certain MHC class I and class II epitopes. We have previously shown that GILT is required for efficient class II-restricted presentation of TRP1. Here, we found that TRP1 peptide presentation is partially dependent on GILT and that TRP1 peptide requires internalization for efficient presentation on class II. We also determined that antigen presentation increased with increasing peptide dose and increasing APC:T cell ratio. Compared to other TRP1-specific T cells, primary TRP1-specific T cells from TRP1BwRAG-/- 5 TRP1tg mice produce maximal IL-2 in response to presentation of TRP1. These results further illustrate the importance of GILT in the processing and presentation of TRP1. Thus, GILT may play a role in both the development of autoimmune vitiligo and anti-melanoma immune responses.
    • Validation of the Confusion Assessment Method in the Intensive Care Unit in the Post-Anesthesia Care Unit

      Townsend, Nichole L.; The University of Arizona College of Medicine - Phoenix; Murray, Michael (The University of Arizona., 2012-05-02)
      Introduction: Patients who develop delirium while hospitalized are increasingly recognized as at risk for the development of long term cognitive impairment. We became interested in the contribution of delirium to the development of post-operative cognitive dysfunction (POCD) when we found that patients at Mayo Clinic in Arizona, compared to patients at the Mayo facilities in Rochester, MN, were 17 times more likely to receive the drug physostigmine (Antilirium®) for the treatment of delirium in the Post Anesthesia Care Unit (PACU). However, before we could examine the relationship between delirium and POCD we needed to validate a tool we could use to quickly assess the presence of delirium in patients emerging from anesthesia in the PACU. Hypothesis: The Confusion Assessment Method in the Intensive Care Unit (CAM-ICU) can be used in the PACU to identify patients with delirium. Methods: Patients 65 years of age or greater who were going to have a standardized general anesthetic for a surgical procedure were identified on the day of surgery and consent to participate in the study was obtained. The CAM-ICU was used preoperatively to determine study eligibility (patients who scored less than 7 [scale of 1-10], indicating delirium, on the test were not followed further) and postoperatively, one hour after the patient was admitted to the PACU, to assess for delirium. The CAM-ICU was administered after we asked the patient’s nurse whether or not he or she had determined that the patient was delirious. Results: 168 patients, mean age 75 ± 7 (SD) with the majority of participants having urologic or orthopedic procedures were assessed pre- and post-operatively with the CAM-ICU, and post-operatively by a nursing assessment for delirium. The CAM-ICU took little time to administer and was easy for patients to understand and use. The nurse at the bedside identified 5 of 168 patients as delirious (prevalence of 2.98%). The CAM-ICU was positive for delirium in 11 of 168 (6.55%). The CAM-ICU had a sensitivity of 60% (3/5) and a specificity of 95% (155/163). Conclusion: In this investigation, the CAM-ICU was easy to use and had a high specificity for identifying post-operative delirium.