• Security and Privacy in Radiology

      Workie, Betre; The University of Arizona College of Medicine - Phoenix; Krupinski, Elizabeth (The University of Arizona., 2011-10-28)
      Radiology is one of the most high-tech fields of medicine. The digitization of medical information including radiographic data has led to improved efficiency and productivity but it has also presented new challenges in the area of privacy and security. In this study we have tried to answer some questions regarding how secure the current electronic radiology systems are and what individual and systemic factors affect the security and privacy of confidential patient data. A total of 77 radiologists and radiology residents participated in an online survey which included questions on physical security, computer systems security, and training and prevention. Since there was no objective way to measure overall security, we have used the overall security grade given by survey takers as our outcome, the dependent variable. Multiple regression analysis and ANOVA (Analysis of Variance) analyses were conducted. The regression analysis, with few exceptions, showed that only two variables contributed significantly to the final security grade. One of them was about unauthorized persons gaining access to the radiology facility, and the second one was about locking computer screens when temporarily away from a work station. A separate analysis was done using data for physical security, 4 computer systems security, training and prevention, and other security/privacy questions. Security threat level to current radiology systems is very low; however, the preparedness of these facilities to protect their infrastructure from future attacks is not adequate and there is room for improvement. As far as keeping confidential patient information private, most institutions seem to be doing a good job.
    • The effects of acupuncture on in vitro fertilization outcomes: a systematic review of the literature and an update to the Cochrane Collaboration review

      Drake, Melissa; The University of Arizona College of Medicine - Phoenix; Campos-Outcalt, Douglas (The University of Arizona., 2011-10)
      Background Infertility, or impaired fecundity, affects 11.8% of women between the ages of 15 and 44, which translates to 7.3 million women. The use of assisted reproductive techniques has doubled over the past decade, with 148,055 cycles performed during 2008 resulting in 46,326 live births and the delivery of 61,426 infants. Acupuncture has been used in China to treat numerous and disparate medical conditions for thousands of years. Many anecdotal reports and non-randomized studies have claimed that acupuncture improves fertility, but the number of high-quality randomized controlled clinical trials and cohorts is much thinner. Objectives To determine whether the use of acupuncture results in higher pregnancy rates in patients undergoing in vitro fertilization compared with placebo acupuncture or no treatment. Search strategy All randomized controlled trials and prospective cohort reports of acupuncture and assisted reproductive technology were obtained through a systematic search of Medline and the MeSH database (1996 to February 2011). Selection criteria Prospective, randomized controlled trials comparing acupuncture treatment versus no treatment, placebo acupuncture, sham acupuncture at non-acupoints, and sham acupuncture at non-fertility-related acupoints during IVF treatment with or without intracytoplasmic sperm injection (ICSI). Inclusion criteria: - primary or secondary subfertility - undergoing IVF with or without ICSI - timing of acupuncture for before and after embryo transfer Exclusion criteria: - frozen embryo transfer - acupuncture used as adjunct to analgesia - electroacupuncture - donor oocytes - non-randomized trials, case-controls, case studies - studies included in the 2009 Cochrane review Data collection and analysis Thirteen randomized controlled trials were identified that involved acupuncture and in vitro fertilization with embryo transfer. Trials were analyzed for the following methodological details and quality criteria: study characteristics (randomization, blinding, power analysis, intention-to-treat analysis), patient characteristics (demographics, inclusion and exclusion criteria), interventions (IVF stimulation protocols, timing of acupuncture or control, acupoints chosen), and outcomes (ongoing pregnancy rates, live birth rates). Main results Only one of the trials demonstrated a result that achieved statistical significance. So 2009 showed that placebo acupuncture resulted in significantly higher overall birth rate when compared to true acupuncture. Even with adequate power, none of the other trials showed a difference that achieved statistical significance in pregnancy rate or live birth rates between acupuncture and control groups. Conclusions Acupuncture does not improve IVF outcomes and should not be offered routinely as an adjunct to fertility treatment. The evidence from the current literature suggests a positive effect of sham and placebo acupuncture on IVF outcomes, and therefore merits further study with adequately powered RCTs.
    • Antipsychotic Rechallenge After Neuroleptic Malignant Syndrome with Catatonic Features

      Bond, Alicia Giuffrida; The University of Arizona College of Medicine - Phoenix; Cornelius, Christian (The University of Arizona., 2011-03)
      Neuroleptic malignant syndrome (NMS) is a life-threatening condition that can occur in patients who require long-term antipsychotic therapy, and who therefore must be rechallenged with antipsychotics after their NMS episode. Current guidelines are based on limited data and recommend that rechallenge be undertaken by titrating from low doses of low-potency antipsychotics, after a period of two weeks following resolution of symptoms. We present the case of a patient with an NMS course complicated by residual catatonia course and a literature review with analysis to determine whether time to rechallenge, potency of rechallenge drug, and dose of rechallenge drug are independent predictors of NMS recurrence in patients. One hundred thirteen instances of neuroleptic rechallenge in non-catatonic NMS cases and 29 cases of rechallenge in NMS with catatonic features were identified through broad Medline and PsycInfo database searches and were analyzed by a single reviewer for rechallenge data. Fifty-five cases involved female patients, and 87 male patients; patients ranged in age from 12 to 86, with a mean of 37. There was no statistically significant relationship found between rate of NMS recurrence and time elapsed before rechallenge, either for all cases or by subgroup. Although the recurrence rate for patients rechallenged with highest-potency antipsychotics was found to be higher than those rechallenged with lowest-potency drugs,the relationship was not significant. The maximum antipsychotic dose reached during rechallenge was significantly lower among patients with recurrence of NMS than those who did not recur, likely due to recurrences early in dose titration. There was no statistically significant relationship between starting dose and recurrence. Based on our analysis, time between resolution of symptoms and rechallenge may have no bearing on risk of recurrence, in contrast to current recommendations. Dose of rechallenge drug is also unlikely to be an independent predictor of recurrence. Several studies, including ours, have shown a statistically insignificant but consistent positive relationship between potency of rechallenge drug and risk of recurrence.
    • Evaluation of Outcomes of a Newly Implemented Sexually Transmitted Infection Rapid Testing System

      Sein, Vicki; The University of Arizona College of Medicine - Phoenix; Khurana, Renuka (The University of Arizona., 2011-03)
      Objectives: To evaluate the outcomes of a newly implemented express testing system for sexually transmitted infections at the Maricopa County Public Health Department. Methods: This study reviewed data that was collected by the Maricopa County Public Health Department. There are two avenues for sexually transmitted infection (STI) testing at the department. Individuals are given a questionnaire at the time of check-in to assess their possible exposure to others who might have sexually transmitted infections and their symptoms at the time of presentation. Those who are asymptomatic and deemed to be at low risk for infection are sent to the express testing system, while individuals who are determined to be at higher risk for infection or are actively symptomatic, are seen by a provider for a comprehensive visit. Testing that is offered to patients, regardless of visit type is; urine nucleic acid amplification for Chlamydia trachomatis (CT) and Neisseria gonorrhea (GC), and blood tests for syphilis and HIV. Results were evaluated from September 2008 to March 2010. Data were evaluated for difference in positivity of the express testing patients as opposed to those who saw a provider, as 5 well as the demographic differences between the two groups. Also evaluated, was the treatment obtained by individuals in the express testing group, and the time to return for treatment. Results: Between September 01, 2008 and March 31, 2010, there were 33294 visits made to the clinic for STI testing. Of these, 4232 (12.7%) were express testing visits. During this time, a total of 3268 cases of CT and 1030 cases of GC were diagnosed. Express testing had a lower incidence of CT and GC, with 204 and 24 cases respectively. Compared the provider visits, the incidence of CT and GC were lower in express testing with CT being 4.8% (vs 10.5% in provider visits), and GC 0.6% (vs 6.5% in provider visits). Of the express testing CT cases, 90.2% returned for treatment, with an average return time of 16.9 days, as compared to 92.6% treatment with an average return time of 13.8 days in the provider visit group (66% were treated the same day). Of the express testing GC cases, 87.5% returned for treatment, with an average return time of 9.8 days, as compared to 88.5% return for treatment and average return time of 13.7 days in the provider visit group (70.2% were treated the same day).
    • The Efficacy and Safety of Ultrasound Guided Peripheral Nerve Blockade A Qualitative Systematic Review

      Parisian, David Lynn; The University of Arizona College of Medicine - Phoenix; Rosenfeld, David (The University of Arizona., 2011-03)
      The clinical application of regional anesthesia has grown dramatically in recent years in part due to the increasing adoption of ultrasound imaging for peripheral block placement. Ultrasound technology enables real-time visualization of nerves, surrounding structures and local anesthetic spread and therefore offers theoretical advantages over existing methods of nerve localization. This systematic analysis was conducted to assess the current state of evidence for improved block efficacy, safety and other patient related outcomes with ultrasound guided peripheral nerve blockade (UGPNB). A search of the PubMed database was conducted for all randomized controlled trials comparing UGPNB to peripheral blocks performed at the same anatomic site by an alternative method of nerve localization. Forty-four studies, 39 adult and 5 pediatric, were identified for analysis and the results presented in Appendix 1,2,3,4,5. There is increasing Level Ib Grade A evidence that UGPNB, when applied by clinicians with the appropriate skill set, can be performed faster than alternative techniques yielding blocks that are more effective, with quicker onset and longer duration, requiring less local anesthetic, and causing less vascular puncture and greater patient comfort. Improved safety with UGPNB remains largely theoretical due to the low complication rate of all techniques of peripheral nerve block, but there is Level III Grade
    • The Test Tube Baby: Out of Reach or Out of Luck? A Retrospective Look at the Impact of Basal FSH and Age on In Vitro Fertilization Success in a Clinic Operating Without Laboratory Value Thresholds or Age Limits?

      Padrnos, Leslie; The University of Arizona College of Medicine - Phoenix; McGaughey, Robert (The University of Arizona., 2011-03)
      Objective: To assess the impact of age and FSH on IVF outcomes in an assisted reproductive technology clinic that does not have treatment thresholds based on age or laboratory FSH values. Design: Retrospective cohort study Setting: The Arizona Center For Fertility Studies in Phoenix, AZ Patient(s): Women who sought fertility treatment (with the exclusion of patients using donor or frozen oocytes) ages 18-50, representing a total of 1388 IVF cycles Intervention(s): IVF using nondonor embryos Main Outcome Measure(s): Live-birth rate per cycle started Result(s): A total of 1388 IVF cycles with autologous oocytes were analyzed to determine the impact of basal FSH and age on therapy outcomes. The pregnancy rates for individuals 18-34 years old were not significantly different and ranged from 41.1% to 34%. Pregnancy rates for individuals aged 35-39 years old exhibited a reduced pregnancy rate that ranged from 24.7% to 19.8%. For the eldest patients, a significant reduction in pregnancy rates was demonstrated with patients over the age of 40 having a pregnancy rate of 14.3%, and for those 41 years old and 42 and older having pregnancy rates of 7% and 6% respectively. The live birth rate also mirrored this trend with the youngest age group having a live birth rate of 38.9% and the eldest group of individuals aged 42-50 years having a live birth rate of 3.4%. While increasing FSH levels were associated with reduced numbers of oocytes retrieved and transferred during the IVF procedures, there was no statistically significant reduction in pregnancy rate or live birth rate in those with elevated basal FSH levels. Conclusion: The data analysis revealed that increasing age in this population does correlate with decreasing successful outcomes in IVF. At ages 36 and 40 years, there are significant reductions in pregnancy rate. At ages 38 and 40, there are significant reductions in live birth rate. Interestingly, there were no significant differences in pregnancy rate or live birth rate based on basal FSH level.
    • Physician Personal Characteristics and Obesity Treatment Plan Study

      Schottelkorb, Marisa Jo; The University of Arizona College of Medicine - Phoenix; Appelhans, Brad (The University of Arizona., 2011-03)
      Obesity is a very common finding in the primary care physician's office; however, physicians do not always treat obese patients according to guidelines. This investigation examined the possible relationships between a physician's personal weight history, anti-obesity bias, and the proposed treatment plan for an obese, hypertensive patient. Fifty-five Family Medicine, twenty-one Internal Medicine, and five “Other” Family or Internal Medicine Subspecialty physician participants viewed a video featuring either a hypothetical female or male patient with stage I hypertension and obesity (with a BMI of 32.) Of the total 81 physician participants, only 33 completed the entire study. Of these, 79.4% had attempted weight loss in their lifetime, with 55.9% having attempted weight loss in the past year. Median physician BMI was 25, with a small standard deviation of 2.7. Mean obesity bias score was 50.6 (out of possible 117, the maximum value reflecting the most anti-obese attitudes,) with a standard deviation of 19.7. Among all 81 participants, weight loss was in the three highest-ranked treatment recommendations in 90.9% of physician participants. Only 21.2% recommended all four JNC- 6 recommended components of lifestyle change. 93.9% recommended the initiation of a drug during this diagnostic visit. Statistical significance was not achieved in relating physician personal characteristics such as weight history to treatment recommendations due to the low number of participants completing all study measures.
    • Parental Attitudes Regarding HPV Vaccination of Pre-Adolescent and Adolescent Females in Arizona

      Morris, Stephanie M.; The University of Arizona College of Medicine - Phoenix; Taylor, Melanie (The University of Arizona., 2011-03)
      Background – HPV (human papillomavirus) is considered to be the most pervasive sexually transmitted disease among sexually active young adults in the U.S. and is responsible for approximately 90% of cervical cancers worldwide. In 2006, the FDA (Federal Drug Administration) licensed the first HPV vaccine for use in girls aged 9 to 26; however, evidence shows that vaccine uptake rates among adolescent females remains to be low throughout the country. Objective – To assess parental attitudes and beliefs regarding HPV and HPV vaccination of pre-adolescent and adolescent females in order to identify factors that affect intent to vaccinate. Methods – A questionnaire instrument was distributed to parent members of the AZPTA (Arizona Parent-Teacher Association) and the general internet population in Arizona from March 2010 to August 2010. Results – Of the eligible respondents, 61.1% expressed intent to vaccinate their daughter(s) with the HPV vaccine. Approximately 92% of parents who did not intend to vaccinate their daughter(s) had completed some or all of a post-secondary education. Parents who believed that the HPV vaccine promotes earlier sexual debut (33.3% vs. 68.8%), unsafe sexual behavior (40.0% vs. 73.5%) and sexual promiscuity (25.0% vs. 74.0%) showed significantly less intent to vaccinate with the HPV vaccine than parents who did not believe that the HPV vaccine promotes high-risk sexual activity. 75% of parents were aware that HPV causes cervical cancer and is transmitted by sexual contact; however, 75% of parents answered incorrectly to other HPV knowledge questions. Parents who believed that vaccinations, in general, are unsafe universally did not intend to vaccinate with the HPV vaccine. Conclusions – Barriers to HPV vaccination included parental aversion to vaccinations, miseducation or lack of education about human papillomavirus infection, belief that vaccination will encourage risky sexual behavior among teenagers and concerns regarding efficacy and safety of the HPV vaccine. Efforts to educate parents regarding
    • Informed Consent with Homeless Patients

      Whitley, Sarah Marie; The University of Arizona College of Medicine - Phoenix; Robert, Jason (The University of Arizona., 2011-03)
      Access to healthcare for homeless persons is a significant problem within the United States. However, as barriers are lessened through federally funded or philanthropic organizations, attention must be paid to ensuring quality healthcare. The homeless population has disproportionately high rates of substance abuse, mental health disorders, and traumatic brain injuries. This places these patients at greater risk for lacking capacity to consent. This study was designed to examine the informed consent practices of healthcare practitioners in the primary care setting of clinics having received the federal Healthcare for the Homeless grant. Due to the poor response rate, no data of statistical significance were obtained and the study was treated as a pilot study. Patient demographics closely mirrored national statistics of homelessness excepting ethnicity. Likewise, patients seen in these clinics experience high rates of substance abuse and mental health disease. Providers reported only low rates of traumatic brain injuries in their population, contrary to national statistics demonstrating high rates of this disorder. Despite the high prevalence of risk factors for incapacity to consent, providers rarely questioned their patients’ decisional capacity. Practices involving informed consent varied widely. Further studies need to be conducted to evaluate informed consent practices though it is apparent that studies of this nature may be impractical and unethical, if not impossible.
    • Specificity of Enzyme Immunoassay for Serologic Coccidioidomycosis Diagnosis Compared to Immunodiffusion

      Petein, Nathalie; The University of Arizona College of Medicine - Phoenix (The University of Arizona., 2011-03)
      BACKGROUND: Serologic testing for coccidioidomycosis challenges clinicians due to conflicting small studies regarding the sensitivity and specificity of newer enzyme immunoassay (EIA) tests and the lack of a true gold standard diagnostic test for comparison. METHODS: We analyzed all Lab Corp coccidioidomycosis serological test results from February 2008 through February 2009 and calculated the sensitivity, specificity, and positive/negative predictive values of EIA immunoglobulin (Ig)M and IgG. Immunodiffusion IgM and IgG (ID), complement fixation titers (CF), and tissue/culture diagnosis were used as tests for comparison. The comparison test (CT) was considered positive if any comparison test was positive the day of EIA collection or if tissue/culture diagnosis occurred during the time period. Cases required EIA IgM and IgG and ≥ 2 comparison tests performed the same day for inclusion. Medical records associated with positive EIA and negative comparison test results were reviewed for coccidioidomycosis symptoms, physician diagnosis, and subsequent positive comparison test results. Sensitivity, specificity, and predictive values were calculated, including those with subsequent positive comparison test results. RESULTS: A total of 1445 laboratory test sets were identified. EIA sensitivity and specificity were 83.8% and 92.6%, respectively. Positive and negative predictive values were 61.5% and 97.6%, respectively. Of 94 “false positive” EIA results, 92 (97.9%) were associated with documented coccidioidomycosis symptoms and 81% with coccidioidomycosis physician diagnosis. CONCLUSION: Based on the largest study of sensitivity and specificity calculated from laboratory surveillance data, EIA sensitivity and specificity for coccidioidomycosis diagnosis are lower than previously reported using only coccidioidomycosis laboratory tests as a comparison. However, association of “false positive” EIA results with coccidioidomycosis symptoms and physician diagnosis suggests that ID and CF laboratory tests alone are not a sufficient confirmation test for diagnosis.
    • Development of a Database for Storage and Analysis of Factors Affecting Treatment of Hepatocellular Carcinoma

      Mitropanopoulos, Meg; The University of Arizona College of Medicine - Phoenix; Wood, David (The University of Arizona., 2011-03)
      Hepatocellular carcinoma (HCC) is the fifth most common solid tumor worldwide. There are 626,000 new cases per year of primary liver cancer worldwide, most of which are HCC. Over 1,000,000 people die of HCC per year, making HCC the third most frequent cause of cancer deaths worldwide1. Major etiologic factors associated with HCC include chronic HBV and HCV infection, chronic alcoholism, non-alcoholic steatohepatitis, and aflatoxin exposure. The standard treatment for HCC is surgical resection, however on presentation many patients have progressed to the point where such treatment is not an option, and are placed on liver transplant lists. Palliative treatment modalities are often used in the interim, including trans-arterial chemoembolization (TACE), radiofrequency ablation (RFA), or systemic chemotherapy. In this study over 200 patients who received either Therasphere or Sirsphere (TACE methods), or RFA treatment for unresectable HCC were catalogued in a relational database allowing for analysis of treatment outcomes and treatment comparisons. A Microsoft Access database was created to store data such as patient demographics, disease details, adverse events, patient lab values, treatment details, and pre- and post-lesion measurements. This database is currently in use by the department of Interventional Radiology at Banner Good Samaritan Medical Center.
    • Impact of the Integrative Medicine Elective on Medical Students

      Wright, Courtney A.; The University of Arizona College of Medicine - Phoenix; Maizes, Victoria (The University of Arizona., 2011-03)
      Background: Integrative Medicine offers an approach to medical practice which addresses the public’s increasing use of complementary and alternative medicine (CAM), personal, professional, and federal calls for more patient-centered care, and medical professionals’ deficiencies in self-care and reflection. Though the need for exposure to IM in medical school has been well articulated and many schools offer exposure to the field, the impact of such experiences is largely unknown. The University of Arizona’s Center for Integrative Medicine (AxCIM) re-designed its month-long elective in 2004 to better introduce students to the discipline. This paper reports the preliminary findings of a study examining changes in medical students’ attitudes about IM after participation in this elective. Methods: The Integrative Medicine Attitudes Questionnaire (IMAQ) was administered to medical students participating in the AzCIM’s bi-annual, month long IM elective at the beginning of the elective, at the end, 6 months after completion and 1 year after the elective. Results: 66 complete IMAQ scores were collected at baseline, 36 six months post-elective and 23 1 year after. Post-elective scores were significantly higher than at baseline. No difference from baseline was found in scores 6 months and 12 months post-elective. Conclusions: The preliminary results are encouraging regarding the elective’s improving attitudes toward IM immediately after its completion. This study serves as a resource and encouragement for IM education assessment and evaluation.
    • Personal Reflection: A Prescription for Medical Education

      Solem, Casey; The University of Arizona College of Medicine - Phoenix; Robert, Jason (The University of Arizona., 2011-03)
      Since the time of the Second World War, patients have taken a more active role in their medical decision-making processes (Thomasma 1983). This has led to an increased expectation of professionalism, empathy, and respect from their physicians. The act of personal reflection by physicians is proposed as a means to help physicians meet these growing expectations from patients. The study of literature throughout the process of medical education has been established as a means to promote this type of personal reflection (Charon 2006). An exploration of the historical elements of this process provides a framework for the role that personal reflection plays in the practice of medicine and in the process of medical education. An analysis of key components of educating future physicians is provided, with an emphasis placed on methodologies that have been previously implemented. A review of personal reflection seminars that have been available in various medical education settings provides an understanding of factors that lead to the success and failure of such curricula, and provides the framework for a set of recommendations, a prescription, which may assist additional medical educators as they produce similar programs. Examples of personal reflection by the author are provided in order to emphasize the salient themes identified by the literature.
    • Design, Evaluation, and Feasibility of a Pediatric Mentoring Program

      Chiang, Ruth; The University of Arizona College of Medicine - Phoenix; Robert, Jason (The University of Arizona., 2011-03)
      A chronic illness can have a significant impact on a child’s psychological and social wellbeing. Although children and their families show great ability to adapt to chronic health conditions, epidemiologic studies show that these same children display twice the prevalence of psychological symptoms when compared to children without a chronic condition. One intervention that may improve a child’s psychosocial wellbeing is a “buddy program” involving one-on-one mentorships between medical students and children diagnosed with a chronic illness. One-on-one mentoring has been shown to be successful in promoting better social, academic, and behavioral outcomes, with some follow-up studies showing these benefits to extend a year or more beyond the end of a youth’s participation in a mentoring program. The purpose of this study is to design and evaluate the feasibility of a buddy program between pediatric chronically ill patients at Phoenix Children’s Hospital and medical students at the University of Arizona College of Medicine – Phoenix Campus.
    • Nutrition in Phoenix Metropolitan Area Homeless Youth

      Burnett, Greg; The University of Arizona College of Medicine - Phoenix; Appelhans, Brad (The University of Arizona., 2011-03)
      Homeless youth are a large, poorly characterized population of the United States [1, 2]. Though over seven percent of American youth aged twelve to seventeen years experienced homelessness last year, there is a paucity of data regarding their general condition and health status. This study was undertaken to describe the adequacy of nutritional intake of homeless youth in the Phoenix metropolitan area. Interviews were conducted with 71 homeless youth aged 16 to 21 years (44 male, 27 female) who were recruited from homeless youth drop-in centers and outdoor public areas. A standardized 24 hour dietary recall was utilized during the interview to gather nutritional data, which was analyzed against Dietary Reference Intakes (DRI). Overall results demonstrated a slight excess of caloric and macronutrient intakes; though intakes of several micronutrients were deficient. Over one third of participants consumed less than 50% of the DRI for folate, calcium and zinc; 42% consumed under 50% of the DRI for vitamin C, and 63% consumed under 50% of the DRI for vitamin A. Upon further analysis, statistically significant difference in iron intake was found between male and female participants. Statistically significant difference in fat, iron, and zinc intake was also found between participants recruited from differing locations. In comparison to 2007-2008 data reported in the WWEIA/ NHANES study, participants in this study consumed more calories, protein, carbohydrates, and fat [3]. Participants from both studies consumed insufficient vitamin A quantities; female participants from both studies consumed insufficient calcium. Interstingly, mean iron intake was low for female WWEIA/ NHANES data, but at DRI for study participants. Further surveys of a larger number of participants may be warranted, especially considering the significant skew and non-normal distribution of the nutritional intake data from this study. This study does find inadequate micronutrient intake in homeless despite the fact that they are consuming more than enough macronutrients (calories, protein, carbohydrates, fat). These inadequacies could potentially contribute to poorer health in these youth.
    • Factors Associated with Failure to Diagnose Acute Pulmonary Tuberculosis in a Public Emergency Department

      Geyer, Brian; The University of Arizona College of Medicine - Phoenix; Moffitt, Maricella (The University of Arizona., 2011-03)
      4 Abstract Objective: Emergency department presentation of active pulmonary tuberculosis (TB) can be highly variable and atypical. Appropriate patient stratification may require the assessment of non-clinical criteria. The aim of this study was to determine unique presentation, risk factors and outcomes in the population of TB patients that present to a public emergency department (PED), as well as to identify those factors associated with ED discharge without a diagnosis of TB during a potentially contagious visit. Methods: Epidemiological characteristics were determined for every patient diagnosed with TB in Arizona for 2000-2008. From these, the 1501 presenting in Maricopa County, Arizona for 2000-2008 were selected for further analysis. Presentation at the only PED in the county was determined by retrospective chart review. Potentially contagious TB patients presenting at the PED were analyzed on the basis of the absence or presence of a TB diagnosis during a potentially contagious visit. Results: Of the study population, 150 (12.0% of pulmonary TB patients) presented to the PED within one month of a verified diagnosis of active pulmonary TB. Patients presenting to the public emergency department were more likely to be male, Hispanic, homeless, HIV-positive, current resident of a correctional facility or a long-term care facility, or to have a recent history of substance abuse. Furthermore, PED patients were more likely to have multidrug resistant TB and to die before completion of treatment. Patients reported a median distance of 4.6 miles from their residence to the PED, with only 10.8% reporting a distance of greater than 15 miles. Comparison of potentially contagious TB patient visits demonstrated that patients were significantly less likely to receive a diagnosis of TB when presenting with a traumatic or orthopedic chief complaint, denying cough, hemoptysis, dyspnea, fever or chills, having a normal pulmonary exam and/or chest x-ray, being unresponsive during questioning, or reporting a recent history of both homelessness and excess alcohol use. Baseline sensitivity for the diagnosis of TB during a potentially contagious visit was 78.2%. Modeling revealed an increase in sensitivity to 97.9% if patients were assessed for altered mental status, pulmonary or infectious chief complaint, abnormal vital signs, or history of substance abuse or foreign birthplace. Conclusions: In this study, TB patients presenting to the public 5 emergency department were significantly more likely to have many of the known risk factors for TB, be diagnosed with MDR-TB and die before completion of therapy. Patients with a history of alcohol abuse and homelessness, or lack of signs and symptoms classical for TB were less likely to be diagnosed with TB during a potentially contagious visit. This study adds evidence to the belief that public emergency departments disproportionally care for TB patients and that these patients have a more precarious health status and greater risk for mortality than those who are diagnosed by other facilities.
    • Contraception Use Among Women in an Urban Clinic

      Melcher-Post, Jesselyn Rose; The University of Arizona College of Medicine - Phoenix; Molina, John (The University of Arizona., 2011-03)
      4 Abstract Ninety-nine percent of all sexually active women recently surveyed in the United States had at some point used at least one form of contraception (Mosher and Jones 2010). A great variety of contraceptive methods are available, and many factors, including side effects, reversibility, medical advice, lifestyle, culture, religion, and partner preference, play a role in each individual’s method of choice. While each woman chooses a method for her own reasons, trends often emerge within particular groups of women. Despite the wide usage and availability of contraception in the US, approximately 50% of pregnancies are unplanned. Some populations are at a higher risk of unintended pregnancies, including those with low income, less education, ethnic minorities and women at either end of the reproductive spectrum. Although data from the United States Centers for Disease Control indicates that women of all ethnicities use contraception at a relatively equal rate, socioeconomic disparities impede successful contraceptive use among some women. The purpose of this study is to understand how female patients at a community health clinic in central Phoenix manage their reproductive health. The majority of patients served by this clinic have a low income and are Hispanic. One objective of the study is to determine what contraceptive methods these patients are currently using. A second is to ascertain what factors are important to these women when choosing contraception. The overarching purpose of the study is to allow health care providers to better understand how these individuals make choices related to contraception and what influences their decisions. A total of 204 women between the ages of 18 and 45 who had scheduled appointments at the Wesley Health Center were given a self -administered survey. Surveys were completed during April of 2010, and contained questions regarding demographic information, number of pregnancies and live births, past and present use of contraception and contraceptive preferences. One hundred and ninety-seven of the 204 surveys were analyzed. Seventy four point six percent of all of the women were using at least one method to prevent pregnancy. Women used contraception at a relatively equal rate between age groups, but the 5 type of contraception a women was most likely to be using varied based on age. Reliability, comfort and ease of use were the factors that women identified as most important to them in determining which method to use. Although most women who were not currently trying to become pregnant were using contraception, it is unknown whether they are using the methods effectively. Additionally, the way in which many surveys were filled out indicated lack of understanding regarding contraceptive options in general. It is important that health care providers take time to educate each woman individually about options that are available to her, and ensure understanding regarding proper use of her method of choice.
    • Perspectives for the Primary-Care Physician on the Strengths and Shortcomings in the Healthcare-Oriented Research of Child and Adult Literacy

      Brimhall, Darrell M.; The University of Arizona College of Medicine - Phoenix; Brady, Sharon (The University of Arizona., 2011-03)
      The acquisition of literacy is a skill that cannot be understated. A wide variety of distinct academic fields have long studied this issue and have found strong evidence that proficiency in literacy affect many aspects of the individual including socioeconomic status, health, and behaviors. In the last two decades, literacy in healthcare has been intently investigated not only as it relates to the health status of the individual, but also how one functions in the health system. Health literacy is a subset of the much broader concept of general literacy and physicians will gain a greater ability to understand and assist patients by incorporating this paradigm into their practice. While the literature has made important headway in understanding the impact of literacy, gaps and inconsistencies appear frequently within the literature. The intent of this study was to examine the wide variety of literacy research and summarize the strengths and weaknesses through the perspective of primary-care clinicians.
    • Meningiomas Assessed with In Vivo 3D 1H-Magnetic Resonance Spectroscopy Integrated Into a Standard Neurosurgical Image Guidance System: Determining Biochemical Markers of Clinically Aggressive Behavior and Providing a Resection Advantage

      Moore, Nina Zobenica; The University of Arizona College of Medicine - Phoenix; Preul, Mark (The University of Arizona., 2011-03)
      15 usable patients with recurrent or newly diagnosed meningiomas using a 3T GE Signa scanner. Quantified spectral metabolite peaks were used to select voxels that had high or low alanine for tissue sampling. 3D 1H-MRSI was integrated into a standard image guided surgery (IGS) system; a mask of the voxel was loaded onto the IGS system allowing surgeons to precisely extract tissue intraoperatively according to biochemical mapping. Ex vivo NMR and conventional histological grading were performed on the extracted tissue. Results: Tumor spectra showed biochemically heterogeneous regions, especially for choline, lactate and alanine. Mean alanine concentrations were lower in more aggressive--histologically and immunohistochemically--regions of the meningiomas in the study. In addition, lower grade meningiomas showed high alanine at the tumor periphery with decreased central alanine. Ex vivo NMR was well-correlated with in vivo 3D 1H-MRSI. Conclusions: Non-invasive detection of various intratumoral biochemical markers using 3D 1H-MRSI can distinguish areas within meningiomas that express more aggressive features. There is regional heterogeneity in the concentrations of these markers within individual tumors. Furthermore, 3D 1H-MRSI may be able to exploit these regional differences to separate more aggressive from less aggressive areas within a given meningioma. Such knowledge may be useful to 5 the neurosurgeon faced with the task of meningioma resection, and in the planning adjuvant therapy for residual meningioma
    • Frequency of Alzheimer’s Disease Pathology at Autopsy in Patients with Clinical Normal Pressure Hydrocephalus

      Cabral, Danielle; The University of Arizona College of Medicine - Phoenix; Sabbagh, Marwan (The University of Arizona., 2011-03)
      Background: Normal pressure hydrocephalus (NPH) is considered potentially treatable with the placement of a cerebrospinal fluid (CSF) shunt. Yet, the procedure has had variable success, particularly with respect to improving the cognitive impairment in NPH. The presence of neurologic co-morbidities, particularly Alzheimer’s Disease (AD), may contribute to shunt responsiveness. Uncovering the extent to which AD and NPH co-occur has implications for diagnosis and treatment of NPH. Autopsy studies of patients with NPH during life would elucidate the frequency of such co-morbidities. Methods: We conducted a search of the Sun Health Research Institute Brain Donation Program database between 1/1/1997 and 4/1/09 to identify all cases with neuropathologic evidence of dementia as well as those cases of clinically diagnosed NPH. We reviewed the medical records and brain findings of each NPH case. Results: Of the 761 cases autopsied over the study interval, 563 cases were found to have neuropathological evidence meeting criteria for a dementing illness. AD was found exclusively in 313/563 (56%) cases with 94/563 cases having a secondary diagnosis of dementia. We identified 9/761 cases with a clinical diagnosis of NPH, all nine cases were among the 563 cases with neuropathology of dementing illness at autopsy, representing 1.6% (9/563). Upon review of brain autopsy reports, 8/9 (89%) cases were found to have AD and 1/9 (11%) had progressive supranuclear palsy. Review of the medical records of the nine NPH cases revealed the following clinical co-morbidities: 5/9 with AD; 1/9 with Parkinson’s Disease (PD); 1/9 with Mild Cognitive Impairment (MCI); 1/9 with seizure disorder. Conclusions: Given the findings of our study, we support the AD-NPH theory and posit that AD is a common pathological co-morbidity in the setting of NPH and may preclude cognitive improvement post-shunt placement. This may have influence on selection of cases for shunting in the future.