• Antipsychotic Rechallenge After Neuroleptic Malignant Syndrome with Catatonic Features

      Bond, Alicia Giuffrida; The University of Arizona College of Medicine - Phoenix; Cornelius, Christian, MD (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.
    • Cardiovascular Disease Risk Factors and Blood Pressure Control in Ambulatory Care Visits to Physician Offices in the U.S.

      Couch, Christopher; The University of Arizona College of Medicine - Phoenix; Campos-Outcalt, Douglas, MD, MPA (2011-03)
      Background: Cardiovascular disease is the leading cause of mortality in the U.S. Risk factors identified for coronary artery disease, cerebrovascular disease, and kidney disease include uncontrolled blood pressure, diabetes, renal disease, hyperlipidemia, obesity, and tobacco use. The threshold for pharmacologic treatment of hypertension in patients with diabetes or chronic kidney disease is ≥130/80 mmHg. It may be of benefit to extend these criteria to individuals who have other cardiovascular disease risk factors and no diagnosis of hypertension. Blood pressure recommendations in this population have largely been unstudied. This study investigates blood pressure control in this non-hypertensive population. Methods: We analyzed 2006 National Ambulatory Medical Care Survey (NAMCS) data to determine blood pressure control at physician office visits in the U.S. among patients with cardiovascular disease risk factors and no diagnosis of hypertension. Physician office visits with a documented diagnosis of hypertension were excluded from our study. Characteristics of the non-hypertensive population were indentified and were classified by blood pressure above or below 140/90 mmHg. Cardiovascular disease risk factors examined were diabetes, 4 renal disease, hyperlipidemia, obesity, tobacco use, males >55 years, and females >65 years. This population was then divided into two groups, those with blood pressure above or below 130/80 mmHg. Results: We found 22,744 records (77.4% of visits) with no diagnosis of hypertension out of 29,392 total records, with 43.2% of the non-hypertensive population having BP <140/90 mmHg. Males fulfilled criteria for hypertension (≥140/90 mmHg) more frequently than females (63.5% vs. 52.3%, P-value <.001). Patients were mostly younger than 65 years. Males >55 years was the most prevalent CVD risk factor, with 79.2% of these with BP ≥130/80 mmHg. Second most prevalent risk factor was tobacco use at 10.1% of non-hypertensive visits, and BP was ≥130/80 mmHg in 63.6% of these visits. Hyperlipidemia in 5.6% of total visits, with BP ≥130/80 mmHg in 60.5%. Obesity was documented in 5.5% of non-hypertensive population, with BP ≥130/80 mmHg in 60.0%. Visits with one risk factor with BP ≥130/80 mmHg were found in 22.8% of our non-hypertensive study population. Conclusions: 56.8 % of those without a diagnosis of hypertension had elevated blood pressure recorded at their physician visit. BP control rate in our non-hypertensive population was 43.2%, surprisingly
    • Contraception Use Among Women in an Urban Clinic

      Melcher-Post, Jesselyn Rose; The University of Arizona College of Medicine - Phoenix; Molina, John, MD (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.
    • Design, Evaluation, and Feasibility of a Pediatric Mentoring Program

      Chiang, Ruth; The University of Arizona College of Medicine - Phoenix; Robert, Jason, PhD (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.
    • 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, MD (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.
    • 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, MD, MPA (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.
    • 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, MD (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
    • 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, MD (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).
    • Factors Associated with Failure to Diagnose Acute Pulmonary Tuberculosis in a Public Emergency Department

      Geyer, Brian, Ph.D.; The University of Arizona College of Medicine - Phoenix; Moffitt, Maricella, MD (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.
    • 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, MD (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.
    • HIV and Syphilis Co-Infection in Maricopa County

      Thomas, Sarah; The University of Arizona College of Medicine - Phoenix; Khurana, Renuka, MD; Campos-Outcalt, Douglas, MD, MPA; Mickey, Tom (2011-02)
      BACKGROUND: The past decade has seen a resurgence of Syphilis infections on the global, national and local levels, and Arizona has been no exception. After having fallen to record lows nationally in 1999, rates of Primary and Secondary (P&S) syphilis increased incrementally each year from 2001-2008 [5] [16]. Overall increases in rates between 2001 and 2008 were observed primarily among men [5]. Concurrently, the estimated proportion of all P&S syphilis cases occurring in men nationally who have sex with men (MSM) increased dramatically from 5% in 2000 to 62% in 2004 [15]. This trend has been described in epidemiologic research from coast to coast in Washington State’s King County, Southern California and New York City [9] [10] [11]. These national trends are mirrored locally in Arizona. In Arizona early syphilis (primary, secondary and early latent) has increased from 2004-2008 [19]. The majority of these cases have occurred in Maricopa County. Also noted has been an apparent increase in patients who are concurrently infected with HIV, by self report and testing. OBJECTIVES: This study aims to evaluate these trends in syphilis rates, HIV rates and co-infection rates in Maricopa County over an 11 year period. METHODS: The study enrolled all individuals diagnosed with of Primary, Secondary and Early Latent Syphilis identified in Maricopa County between the years 1998-2008. At time of diagnosis all individuals with a syphilis diagnosis were interviewed for demographic and risk factor variables by the Maricopa County Public Health Investigators. This data was then matched and merged with the Arizona State HIV database to identify individuals with confirmed HIV positive status and early syphilis diagnosis. All personal identifiers were removed once the data was merged. Co-morbidity was defined as any individual with any known diagnosis of HIV and early syphilis regardless of the order of the diagnoses. Co-infection was defined as individuals with a diagnosis of early syphilis 3 or more months after the diagnosis of HIV. This information was then analyzed using SAS statistical software. Logistic regression analysis evaluated for significant risk factors within individuals co-infected HIV and Syphilis, as compared to individuals with early Syphilis diagnosis without HIV positive status. The study examined demographics including gender, age, and race as well as behavioral risk factors; men 5 who have sex with men, meeting sex partners on the internet, having anonymous sex partners, number of sexual partners in the past year, citizenship status, drug use, receiving money or drugs for sex, giving money or drugs for sex, and incarceration within the past year. RESULTS: Initial evaluation using Chi Squared analysis revealed that among all factors examined, MSM behavior was most strongly associated with HIV co-infection (Chi Squared Odds Ratio 42.242, 95% CI 29.736 – 60.008). Subsequent analysis was stratified and Non-MSM and MSM populations were considered separately. Early syphilis and HIV co-infection in the non-MSM population (including men that do not have sex with men, women, and transgendered individuals) is associated with several expected STD risk factors; receiving money or drugs for sex (adjusted OR 2.714, 95% CI (1.229 – 5.992)), more than 5 sexual partners (adjusted OR 5.256, 95% CI (1.207 – 5.283)), more than 10 sexual partners (adjusted OR 2.784, 95% CI (1.201 – 6.451)), and having been in jail in the last 12 months (adjusted OR 3.096, 95% CI (1.260 – 7.608), while showing no differences among racial groups when using White/non-Hispanic as a reference group. However, among MSM individuals none of the behavioral risk factors examined were statistically associated with co-infection. The only factor with which an association was demonstrated was citizenship of the United States (adjusted OR 1.925, 95% CI (1.052 – 3.525)) while Hispanic race was negatively associated with co-infection risk among MSM (OR 0.400, 95% CI (0.288 – 0.555)). No other association with co-infection among racial groups was found when using White/non-Hispanic as a reference group. CONCLUSIONS: It is clear that in Maricopa County the population affected by syphilis from 1998-2008 is characterized by increased rates of HIV co-infection. The population affected by early syphilis and HIV co-infection is largely dimorphic between MSM and non-MSM affected, with distinct risk factors and demographic attributes. Clearly there is a need for public health interventions and awareness campaigns regarding the risk of HIV and syphilis co-infection and morbidity, as well as the increasing incidence of syphilis within the community of men who have sex with men, are needed in Maricopa County.
    • Hyperbilirubinemia and Gallbladder Complications in Pediatric Hematopoietic Stem Cell Transplant Patients

      Makinde, Ambimbolu S.; The University of Arizona College of Medicine - Phoenix; Notrica, David, MD (2011-03)
      3 Abstract Background: Hyperbilirubinemia in pediatric hematopoietic stem cell transplant (HSCT) patients presents a diagnostic and therapeutic dilemma. This study was designed to determine the frequency of known causes of hyperbilirubinemia, correlate its effect on survival, review the effects of gallbladder procedural interventions on outcomes, and to define parameters to guide patient care. Methods: 60 Pediatric HSCT patients transplanted between August 2003 and March 2010 were stratified according to bilirubin levels, presence of Veno-occlusive Disease (VOD), also known as Sinusoidal Occlusive Syndrome (SOS), gallbladder involvement, and surgical intervention. Subgroups were analyzed for peak liver enzyme levels, Intensive care unit (PICU)/hospital length of stay (LOS), and mortality. Results: Fifty-five per cent of patients developed hyperbilirubinemia. Survival was 55% in that group versus 85% in the normo-bilirubin patients. 79% of the hyperbilirubinemia patients exhibited gallbladder involvement and 31% of those underwent surgical intervention. Survival was 60% in the patients with gallbladder involvement without SOS who underwent surgery versus 50% in the non-surgical. In patients with both SOS and gallbladder involvement, survival was 33% in the intervention group versus 50% in the non-intervention group. Overall survival in the SOS alone, SOS with gallbladder involvement, and gallbladder involvement only patients was 50%, 4 44%, and 53% respectively. Hepatic enzymes were increased in patients who received intervention compared to the non-intervention groups, but no individual lab or combination of labs predicted intervention or mortality. Intervention patients spent more days in the hospital post bilirubin peak. Conclusions: Pediatric HSCT patients with elevated bilirubin levels and SOS are at increased risk for gallbladder complications and death. Patients receiving gallbladder procedures are more likely to require longer hospital stays than patients who do not. Surgical intervention may decrease mortality in patients with gallbladder involvement that do not have SOS, but no conclusion regarding a positive impact of gallbladder intervention on patients with coexisting SOS can be made on other patients based on this data set. Keywords: Bilirubin, Hyperbilirubinemia, Hematopoietic stem cell transplant, Cholecystectomy, Cholecystostomy, Veno-occlusive disease, Sinusoidal obstructive syndrome
    • Impact of the Integrative Medicine Elective on Medical Students

      Wright, Courtney A.; The University of Arizona College of Medicine - Phoenix; Maizes, Victoria, MD (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.
    • Informed Consent with Homeless Patients

      Whitley, Sarah Marie; The University of Arizona College of Medicine - Phoenix; Robert, Jason, PhD (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.
    • 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, MD (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
    • Nutrition in Phoenix Metropolitan Area Homeless Youth

      Burnett, Greg; The University of Arizona College of Medicine - Phoenix; Appelhans, Brad, PhD (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.
    • An Objective Methodology to Quantify Motor Skills in Basic Orthopaedic and Gynecologic Surgical Tasks

      Sharer, Sarah Kennedy; The University of Arizona College of Medicine - Phoenix; Kahol, Kanav, PhD (2011-02)
      This study is the initial step in the development of a basic skills simulator for surgical residents, intended to serve as a cross-platform objective motor skills training system. A robust system was developed to measure motor skills of orthopaedic surgeons and gynecologic surgeons. The orthopaedic study focused on three basic skills: drill, tap, and screw insertion. Each of the participants repeated the sequential task of drill, tap, screw insertion ten times in cadaveric femoral diaphyseal bone. The gynecologic study focused on placement of sutures across ten incisions in synthetic skin. Real time wrist, hand, and finger position was recorded bilaterally using Immersion CyberGloves® and the Ascension Liberty Tracker®. Four metrics were evaluated: task duration, gesture proficiency, hand movement smoothness (replaced by subjective rating in Gyn study), and number of errors, in order to differentiate between groups with different skill levels: No Skills, Limited Skills, Advanced Skills, and Expert Skills. The results demonstrated a significant difference between the Expert Skills group and the less skilled groups. In both studies the Expert Skills group completed the tasks the fastest, with the greatest proficiency, smoothness and accuracy. These results establish the 5 capability of our present skill quantification system and will assist in future improvement of the analysis algorithm.
    • 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, MD (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
    • Personal Reflection: A Prescription for Medical Education

      Solem, Casey; The University of Arizona College of Medicine - Phoenix; Robert, Jason, PhD (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.
    • 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, PhD (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.