• Does more “normal” shoulder motion after arthroplasty improve patient satisfaction?: Correlation of range of motion, patient-reported function,and patient satisfaction following shoulder arthroplasty

      Winsor, Kimberly; The University of Arizona College of Medicine - Phoenix; Tibor, Lisa (The University of Arizona., 2014-04)
      Objective and Hypothesis The goals of this study are to address the following questions regarding shoulder arthroplasty (TSA): (a) Does restoring range of motion (ROM) lead to increased patient satisfaction? (b) How is ability to carry out activities of daily living (ADLs) influenced by ROM? (c) How does ADL performance correlate with patient satisfaction? We hypothesize that more “normal” ROM following TSA leads to increased patient satisfaction and better performance of ADLs. Methods Patients who underwent TSA, reverse TSA, hemiarthroplasty, or humeral head resurfacing were prospectively enrolled in a shoulder arthroplasty registry. 155 patients who had preoperative and 6 month postoperative data for ROM, patient satisfaction, and performance of ADLs were included in the study. Results Of these 155 shoulders, the response rate for patient satisfaction was only 82 (52.9%), with 96.8% reporting they were “satisfied or “very satisfied”. Postoperative ROM was associated with patient satisfaction for forward flexion, adduction, and external rotation. This association demonstrated a “dose;response” relationship, as higher percentage of normal ROM correlated with higher satisfaction. Mean ADL scores were higher for patients who achieved normal ROM in each plane of motion. The greatest improvement in mean ADL score occurred when a patient achieved normal ROM for at least 3 of 5 measurements. There was also a significant association between improved ADL and higher patient satisfaction. Significance Glenohumeral arthrosis causes considerable morbidity, and rates of shoulder arthroplasty are increasing. As the predominant goals of TSA are pain relief and restoration of ROM, it is important to assess postoperative patient satisfaction. While most historic studies have focused on measures of implant performance, interest is increasing in patient-centered outcomes. Both objective and subjective outcomes should be included in future large multicenter registries. Data collected from these registries has the potential to substantially improve success rates and longevity of shoulder arthroplasty.
    • Improving Endoscopic Retrograde Cholangiopancreatography (ERCP) Performance and Complication Rates: A Single Operator Retrospective Review from 2004‐2011

      Choi, Joshua; The University of Arizona College of Medicine - Phoenix; Nadir, Abdul (The University of Arizona., 2014-04)
      Endoscopic retrograde cholangiopancreatography (ERCP) is a technically difficult procedure that requires extensive training to achieve competency. The study was undertaken to assess retrospectively whether advanced ERCP training made a difference in the competency of a physician who was performing ERCPs for eleven years before taking an extra year of advanced training in ERCP. The physician did not get any ERCP experience during the two-year formal fellowship between 1995-97, and learned ERCPs from colleagues post formal GIfellowship for four years after which he was given privileges to independently perform ERCPs. Data were collected on 172 and 213 patients who underwent ERCP before and after the training year respectively. Chi-square test was utilized to analyze the data. Baseline characteristics including height, weight, race and indications for ERCP were similar in the two groups. The results of the study showed that rates of biliary cannulation increased from the Pre-ERCP fellowship rate of 83% to 93% (Chi- Square = 9.06, p = 0.0026) and a reduction in postprocedure pancreatitis from 8.1% to 2.7% (Chi- Square = 4.56, p = 0.0327). Data in this study indicate that extra training in ERCP improves outcomes of ERCP in a single operator’s experience.
    • Modern Techniques of Adjunctive Pain Control Lower Opioid Use, Pain Scores, and Length-of-Stay in Patients Undergoing Posterior Spinal Fusion for Adolescent Idiopathic Scoliosis

      Nabar, Sean J.; The University of Arizona College of Medicine - Phoenix; Shrader, M. Wade (The University of Arizona., 2013-04-17)
      Study Design. Retrospective analysis. Objective. To determine if the use of adjunctive pain medications (subcutaneous bupivacaine, dexmedetomidine infusion, and intravenous ketorolac) will reduce the need for opioids, reduce postoperative pain, and shorten length of hospital stay in patients with adolescent idiopathic scoliosis undergoing posterior spinal fusion. Methods. Retrospective review of children 10 to 18 years with adolescent idiopathic scoliosis receiving posterior spinal fusion surgery over the past 10 years at Phoenix Children’s Hospital. Physicians managed the patients’ pain postoperatively with adjunctive medications in addition to intravenous and oral opioids. Variables of interest were local anesthetic bupivacaine delivered subcutaneously via elastomeric pain pump, sedative/analgesic dexmedetomidine infused for up to 24 hours postoperatively, and the NSAID ketorolac delivered intravenously. These three medications were used either alone or in some combination determined by the physician’s clinical judgment. Primary outcomes analyzed were normalized opioid requirement after surgery, VAS pain scores, and length of stay in the hospital. Results. One hundred and ninety-six children were analyzed with no significant differences in demographics. Univariate analysis showed that all three adjunct medications improved outcomes. A multivariate regression model of the outcomes with respect to the three medication variables of interest was developed to analyze the effects of the three medications simultaneously. The regression analysis showed that subcutaneous bupivacaine significantly reduced normalized opioid requirement by 0.98 mg/kg (P = 0.001) and reduced VAS pain scores by 0.67 points (P = 0.004). Dexmedetomidine significantly reduced the average VAS pain scores in the first 24 hours by 0.62 points (P = 0.005). Ketorolac had no effect in the multiple regression analysis. Conclusion. The use of subcutaneous bupivacaine provides good analgesia with low pain scores. A reduction in opioid requirement is beneficial and may be directly related to presence of the bupivacaine pump, although this may be limited by potential treatment bias. The three adjunct medications improve our outcomes favorably and should be studied prospectively.
    • Central neuropathic pain in MS results from distinct upper thoracic spinal cord lesions

      Melmed, Kara R.; The University of Arizona College of Medicine - Phoenix; Okuda, Darin (The University of Arizona., 2013-04-13)
      There is central pain complaint of burning cold pain common to patients with multiple sclerosis. Approximately 30‐40% of patients with multiple sclerosis (MS) suffer from central neuropathic pain, usually focused symmetrically in both feet and legs and often accompanied by cold allodynia and deep hyperesthesia [Osterberg et al 2005]. This condition resembles thalamic central pain, which also presents with dysfunctional pain and temperature sensations; however, thalamic pain is strictly contralateral [Craig 2007]. A distinct explanation for bilateral MS central pain likely involves a spinal lesion, yet a correlation has not been found [Svendson et al 2011]. We hypothesized that ascending projections from lumbosacral lamina I neurons to bilateral midthoracic autonomic nuclei are mirrored by descending projections [Craig 2002]; thus, a midthoracic lesion that damaged bilateral autonomic descending projections to lumbosacral lamina I neurons might underlie bilateral central pain in MS. Sympathetic interneurons in the midthoracic IMM/IML project to the brainstem but not the thalamus, implying they could be involved in homeostatic sensory integration at both brainstem and spinal levels. The lower extremity pain could be due to a lesion in the upper thoracic cord, interrupting the homeostatic integration pathway between the parabrachial nucleus in the brainstem, the (intermediomedial) and intermediolateral (IMM/IML) region of T2‐6 segments of the spinal cord, and lumbar lamina 1. To prove the existence of bilateral propriospinal projections between upper thoracic sympathetic interneurons and lumbosacral sensory (“pain”) neurons, anterograde and retrograde labeling with CTb and fluorescent tracers were performed in three animal species. In parallel, MRI analysis of MS patients with bilateral burning cold pain in the lower extremities tested the theory by examining for spinal lesions in the upper thoracic level. We tested this hypothesis with parallel clinical and neuroanatomical studies and identified a striking correspondence; MS patients with central neuropathic pain are distinguished by the presence of a lesion focused in the center of the mid‐thoracic spinal cord, and in three mammalian species neurons with bilateral descending projections to the lumbosacral superficial dorsal horn are concentrated in the autonomic intermediomedial nucleus surrounding the mid‐thoracic central canal. These findings will allow us to devise future treatments based on the newly understood neuroanatomical mechanisms.
    • Randomized comparison of the portable laparoscopic trainer to a standardized trainer

      Fox, Joe; The University of Arizona College of Medicine - Phoenix; Castle, Erik (The University of Arizona., 2013-04-12)
      PURPOSE: To evaluate the effectiveness of the portable laparoscopic trainer in improving skills in novice subjects. MATERIALS AND METHODS: Twenty-nine medical students with no prior surgical experience were recruited and given a pretest of three tasks on a standardized laparoscopic trainer. Subjects were evaluated objectively and subjectively. Fifteen subjects were randomized to receive a portable laparoscopic trainer and 14 subjects were assigned to the standardized laparoscopic trainers at our facility. The portable trainer group was advised but not required to complete at least 3 hours of training. The group at the facility had a proctored 1-hour session each week for 3 weeks. Each subject was then retested and evaluated with the same pretest tasks. Objective and subjective improvements between the groups were compared. HYPOTHESIS: Both the portable and standardized trainer groups were expected to improve comparably based on objective and subjective measures. The portable group had a theoretical objective advantage due to unlimited practice time and the standardized group had the advantage of proctored training sessions, thought to increase subjective performance. RESULTS: Baseline demographics and pretest scores were similar between both groups. All students in the facility group completed the three 1-hour proctored sessions. The portable trainer group reported an average 204 minutes of practice. Objectively, the facility group did better on the post-test in overall time, and in two exercises. Subjectively, the facility group had a significant improvement compared with the portable trainer group (4.6 versus 2.4 point average increase, P=0.03). CONCLUSIONS: Both groups showed objective and subjective improvement after a 3-week period of training. The portable trainer group did report longer average practice time, but this made no significant difference in subjective or objective improvement. The portable laparoscopic trainer is an effective method for improvement of basic inferior compared to proctored sessions on a standard trainer.
    • Postpartum Depression Tool in Burmese Women

      Belmonte, Chari; The University of Arizona College of Medicine - Phoenix; Veres, Sharry (The University of Arizona., 2013-04-12)
      Background: In the United States, the prevalence of postpartum depression is 10-15%. There is limited study on the appropriate postpartum screening tool for Burmese refugees in the United States. Hypothesis: The Burmese and Karenni versions of Edinburgh Postnatal Depression Scale (EPDS) are appropriate to use as a tool for screening postpartum depression in Burmese refugees. Aims: This study examines the views of Burmese refugees on the questions of Edinburgh Postnatal Depression Scale as a routine screening for postnatal depression and their opinion and experiences on postpartum depression. Methods: A qualitative approach was chosen to complete this study. A medical student and a Burmese interpreter participated in a one-on-one interview with 30 Burmese women sharing their views and opinions on translated EPDS and postpartum depression. Results: Thirty Burmese women were interviewed in the Phoenix area. The qualitative analysis indicate that the EPDS screening turned out to be a useful and culturally appropriate tool for the Burmese refugees to screen postpartum depression in this specific population. Conclusions: Without consistent and culturally appropriate screening for Burmese women, it would be hard to treat Burmese women for postpartum depression. Our study shows that acceptability for routine screening with a translated EPDS amongst health visitors is possible to achieve. Using the Edinburgh Postnatal Depression Scale in Burmese and Karenni language should be considered when seeing Burmese refugees in the clinic.
    • Pain Scales in the ED: Can They Predict Admission for Abdominal Pain?

      Johnson, Annelyssa; The University of Arizona College of Medicine - Phoenix; Sarko, John; Smith, Ed (The University of Arizona., 2013-03)
      OBJECTIVES and HYPOTHESIS: The purpose of this project was to assess whether pain scales have an association with the disposition of adult emergency department patients with abdominal pain. It is hypothesized that higher pain scores are associated with a greater likelihood of admission. METHODS: One hundred forty-nine patients (63 admitted and 86 discharged) 18 years and older who were evaluated for abdominal pain in the emergency department (ED) at Maricopa Medical Center were identified retrospectively through a case-control chart review. Demographic variables were compared to assess pain in different groups. Receiver operating characteristics curves (ROC) were created for initial, final, and change in pain scores. Logistic regression was performed to assess the interaction of the prespecified variables initial pain, presence of comorbidities, duration of pain, patient temperature, white blood cell count, and age. RESULTS: In an unadjusted analysis, patients with a higher initial pain score were admitted more often. There was no difference in final or change in pain score and disposition. Men had higher initial pain scores but women were more often admitted. No difference was found between races in pain scores. Patients with surgical diagnoses were admitted more often, and those with nonspecific or OB/GYN-related diagnoses were more often discharged. Patients were less likely to be admitted if imaging was not done. In an adjusted analysis, age was the only variable associated with an increased chance of admission, with an odds ratio of 1.048 (95% confidence interval 1.016-1.082) for each one-year increase. The initial pain score was not associated with admission in the adjusted analysis (odds ratio 1.095 (95% confidence interval 0.943-1.272)).
    • Organization and role of international collaboration in research production

      Hsieh, David; The University of Arizona College of Medicine - Phoenix; Whitfield, G. Kerr (The University of Arizona., 2013-03)
      The prevalence of multi-national and cross-disciplinary collaborative in the production of knowledge defines modern science as a social enterprise that extends beyond political, social, and geographic boundaries. The purpose of this study was to assess global trends in the composition and impact of multinational research teams. By examining the bibliometric data of 3.7 million primary research articles published from 1975 to 2005, it was ascertained that the frequency and scale of international collaborations has increased globally. Of note, the publications of many countries associated with lower research output were more often consistently affiliated with other nations across the time frame studied. By analyzing the number of times a publication is cited, it was discovered that multinational research studies have a greater research impact than research without an international presence, although the number of affiliated nations does not strictly correlate with citations. Taken together, this study provides insight into the dynamics of research teams which may better inform us how scientific partnerships between countries may be fostered and which collaborations may be advantageous.
    • TDP-43 Deposition in Prospectively Followed, Cognitively Normal Elderly Individuals: A Correlative Study

      Arnold, Stacy J.; The University of Arizona College of Medicine - Phoenix; Beach, Thomas; Dugger, Brittany (The University of Arizona., 2013-03)
      TAR DNA-binding protein 43 (TDP-43) has been heavily researched in recent years due to its involvement in amyotrophic lateral sclerosis (ALS) and frontotemporal lobar degeneration (FTLD). Numerous studies have also sought to investigate the frequency of TDP-43 deposition in other neurodegenerative diseases such as Alzheimer’s and Parkinson’s diseases, with very few studies focusing on the relationship of TDP-43 to pathological and clinical parameters within cognitively normal subjects. We sought to explore the deposition of TDP-43 and its relation to pathological and clinical parameters in a series of prospectively followed, cognitively normal, elderly individuals whom have come to autopsy. We screened thick, coronal sections of mesial temporal lobe; containing hippocampus and/or amygdalar regions from a series of 110 cognitively normal subjects (age range 71-100 years) using immunohistochemical methods for phosphorylated TDP-43. Consistent with previous results, we found a 36.4% incidence of pathologic TDP-43. Deposition was detected in the form of dendritic neurites, intranuclear inclusions, and perikaryal cytoplasmic neuronal inclusions. With respect to other concomitant pathologies commonly found in elderly individuals, cases with TDP-43 had a greater proportion of cases with argyrophilic grains (ARG) (40% vs. 18.6%). There was not greater prevalence or densities of other concomitant pathologies, including cerebral white matter rarefaction, incidental Lewy bodies, neurofibrillary tangles or amyloid plaques in TDP-43 positive cases. These results indicate deposition of TDP-43 occurs in a substantial subset of cognitively normal elderly subjects and is more common in those with argyrophilic grains.
    • Survey of Primary Care Offices: Triage of Poisoning Calls

      Austin, Travis; The University of Arizona College of Medicine - Phoenix; Brooks, Daniel (The University of Arizona., 2013-03)
      Poison control centers hold great potential for saving health care resources particularly by preventing unnecessary medical utilization. We developed a four-question survey with three poisoning-related scenarios, based on common calls to our poison center, and one question regarding after-hours calls. We identified primary care provider offices in our poison center's region from an internet search. We contacted these offices via telephone and asked to speak to an office manager or someone responsible for triaging patient phone queries. Using a scripted form, trained investigators questioned 100 consecutive primary care provider offices on how they would handle these poisoning-related calls if there was no poison center available for patient referral. It was hypothesized that a substantial proportion of these poisoning-related calls would be triaged to 911 or an emergency department. Results of our survey suggest that 82.5% of poisoning-related calls to primary care offices would be referred to 911 or an emergency department if there was no poison center. These results further support the role that poison centers play in patient care and health care utilization.
    • Birth Outcomes of Diabetic Health Start Participants in 2010

      Espinoza, Magdalena; The University of Arizona College of Medicine - Phoenix; Rumann, Sara; Henry, Sarah (The University of Arizona., 2013-03)
      In Arizona, the Health Start program, a home visiting program, aims to identify at risk (for Low-birth-weight-for-gestational-age babies) women, and educate them about maternal, child, and fetal health, and refer them to medical care throughout their pregnancy and two years post-partum. The goals of the program are to reduce low birth weight infants, reduce the number of infants and young children affected by childhood disease, and increase the number of pregnant women receiving prenatal care. During the years 2009-2010, 2,168 pregnant women received a visit from in the Health Start (HS) program. After matching and exclusions, 808 pregnant women who gave birth in Arizona in 2010 were included. Of the 808 matched HS clients, 3% (n=23) of women were identified as having diabetes (gestational, type I or type II); this group of women was examined for birth outcomes and compared to a matched 2:1 control group of non-HS Arizona women who gave birth in 2010. Known diabetic complications were compared between the groups using chi square tests. Additional birth outcomes that were measured in both groups were congenital abnormalities. The hypothesis was that women with diabetes in the HS program would have better birth outcomes as compared to the control group. The results comparing the groups were not statistically different.
    • Patient Attitudes Regarding Medical Student Involvement in a Primary Care Setting

      Kaser, Scott; The University of Arizona College of Medicine - Phoenix; Carroll, Andrew (The University of Arizona., 2013-03)
      Previous studies on patient comfort with medical student involvement have consistently reported positive or neutral results within multiple specialties. The objective of this study was to examine patient attitudes toward medical students in a private family practice setting. This study also looked to examine whether recent medical student interaction alters patient attitude and if patient attitude can be improved with the prospect of providing feedback. It was hypothesized that there would be a positive pre-to-post test change in patient attitudes and that patients would respond positively to the prospect of providing feedback. Ninety-nine consecutive consenting adult patients completed a self-administered questionnaire before and after their office visit, which included a medical student interaction. Patient demographics (age, gender, race, prior student exposure, # years with doctor) as well as their attitudes toward the involvement of medical students were recorded. Data were collected for 10 months at Renaissance Medical Group, a private family practice with one physician provider. Data were compiled in Excel and analyzed with STATA12. Paired two-tailed T-tests and ANOVA were used to determine statistical significance. The results demonstrated that, prior to medical student interaction on 8 of 9 measures, patients have positive attitudes toward medical students. After medical student interaction, on 7 of 9 measures, respondents changed their response to a more positive position (P<=0.05). In addition, patients demonstrated a willingness to provide feedback to the medical student, but providing this feedback would not significantly alter their patient care experience. There were also statistically significant demographic differences on specific measures. This study provides evidence that patients respond positively to medical student interaction in the private Family Medicine setting. This study also demonstrates areas in which the patient care experience can be improved and provides the basis for further study on the patient - medical student interaction.
    • Success Rates for Reduction of Pediatric Distal Radius and Ulna Fractures by ED Physicians

      Kaye, Bryan; The University of Arizona College of Medicine - Phoenix; Bulloch, Blake (The University of Arizona., 2013-03)
      Objective: To determine the success rates for reduction of pediatric distal radius and/or ulna fractures by emergency department (ED) physicians. Methods: We conducted a retrospective study of children <18 years of age who presented to a large, urban free standing children’s hospital between January 1, 2009 and December 31, 2010 with a fracture of the radius and/or ulna. Patients were excluded if they had an open fracture, were taken directly to the operating room without attempted ED manipulation, or had additional fractures besides isolated radius/ulna fractures. The primary endpoint was the proportion of successful reductions of closed forearm fractures in the ED, as defined by first orthopedic follow up visit. Results: All reductions were performed by Board certified/eligible Pediatric Emergency Medicine (PEM) physician or PEM fellow. There were a total of 15 different PEM faculty and 10 PEM fellows that were involved in the fracture reductions during the study period. There were 295 forearm fractures reduced in the ED during the study period. The mean age was 8.27 years (median 8 years; range 1 to 16) and males comprised 69.2% (n=204) of the study group. A total of 225 (76.3%) fractures were of the distal forearm and 70 involved the midshaft (23.7%). All but 67 (22.7%) patients returned for their orthopedic follow up exam. A total of 33 (14.5%) of all patients required re-manipulation at follow up; 24 in the distal forearm fracture group (22 were closed reductions and 2 open reduction with internal fixation [ORIF]), versus 9 in the midshaft group (7 closed reductions and 2 ORIF). Conclusion: The literature reveals that between 7% and 39% of children who have fracture reductions in the ED by orthopedics will require re-manipulation. Our rate of 14.5% is consistent within that range. With training, pediatric ED physicians have similar success rates as orthopedists in the reduction of forearm fractures.
    • Naloxone Utilization in a Tertiary Care Medical Center

      Shah, Ruby; The University of Arizona College of Medicine - Phoenix; Rosenfeld, David (The University of Arizona., 2013-03)
      The purpose of this research project was to review the use of naloxone for oversedation events from 2008-2011 at the Mayo Clinic Hospital in Phoenix, Arizona. Opiates are generally an accepted form of acute and chronic pain management. Opiate analgesic use has increased in past decades due to several factors including cultural and healthcare ideas on the importance of pain management, as well as the availability, cost, and marketing of the drugs. Concomitant with the increased use of opiates has been a rise in addiction, diversion, and abuse. In addition, opiate overdose is a potentially lethal consequence. Balancing the use of opiates for effective pain control and the possible risks of opiates is a constant effort for healthcare professionals. Monitoring the use of naloxone has arisen as an effective metric to examine the safety and outcomes of opiate utilization in a hospital setting. Reviewing every dose of naloxone delivered over the years 2008-2011 has allowed us to recognize trends that have led to improvements in patient safety. 154 cases of naloxone use for sedation events were reviewed in a retrospective case controlled unmatched chart review. We were able to determine that patient risk for oversedation is greatest within our surgical practices, especially general and orthopedic, and that the overall risk is greatest within the first 24 hours in all surgical patients. In addition, we were able to determine statistically significant increase in risk with elevated creatinine level, American Society of Anesthesiology (ASA) Class, and patient controlled analgesia (PCA) use compared to our unmatched control group. The significance of these findings is that it identifies certain risk groups and factors that carry increased risk for sedation events, and therefore can lead to improvements in quality and education across the institution.
    • Determining variable contagiousness of MRSA by setting

      Routh, Joshua; The University of Arizona College of Medicine - Phoenix; Panchanathan, Sarada (The University of Arizona., 2013-03)
      Objective and Hypothesis Methicillin resistant Staphylococcus aureus (MRSA) is currently a major cause of skin and soft tissue infections (SSTI) in the United States. In order to characterize the spread of MRSA in the pediatric population we built a probabilistic, discrete-event, individual-based simulation. Specifically, our model looked at the spread of MRSA in households and at schools to determine if there was a difference in communicability between the two settings. Methods We developed a probabilistic, discrete-event, individual-based model. This model was validated using insurance billing data for skin and soft tissue infections. The first validation trained the model for two years of data, and validated it with the next two years of data. The second method trained the model in one region and validated it in another. Following the validation, the Poisson-bootstrap resampling method was used to find specific values for a contagiousness factor(CF) in households and schools. Results Both methods of validation supported the model with no statistically significant difference. The bootstrap resulted in a CFhousehold of 30.69 (95% CI [29.09, 32.29]) and a CFschool of 0.55 (95% CI [0.46 to 0.64]). Effective reproduction number for the school setting was found to be 0.0015 and 0.06 to 3.04 for households of different size. Conclusion In this study we characterize a marked difference in communicability in the household and at school, which has not previously been shown. The identification of colonization clusters in households can be used to design strategies reduce the disease burden. The model can be used to simulate and predict responses to different interventions.
    • Death Certification of ‘‘Suicide by Cop’’

      Neitzel, Amber Rae; The University of Arizona College of Medicine - Phoenix; Gill, James R. (The University of Arizona., 2013-03)
      Death certification of ‘‘suicide by cop’’ is controversial among some medical examiners and coroners. We present five such deaths that were certified as suicides and discuss the medico-legal issues involved with these certifications. To certify such a death as a suicide, certain criteria should be met. Suicide by cop is a circumstance that involves competing intentional acts that may result in dichotomous determinations of the manner of death. Despite the absence of direct self-infliction, there is overwhelming evidence that these five individuals intended to end their own lives. Their use of an unusual method to accomplish this goal may inappropriately result in a reflexive certification of homicide. All of the decedents possessed weapons or a facsimile of a weapon. We present five instances of suicide by cop and contend that these types of deaths are best certified as suicides. KEYWORDS: forensic science, forensic pathology, suicide, police, gunshot wounds, manner of death
    • Monoacylglycerol lipase exerts dual control over endocannabinoid and fatty acid pathways to support prostate cancer

      Ward, Anna; The University of Arizona College of Medicine - Phoenix; Nomura, Daniel (The University of Arizona., 2013-03)
      Cancer cells couple heightened lipogenesis with lipolysis to produce fatty acid networks that support malignancy. Monoacylglycerol lipase (MAGL) plays a principal role in this process by converting monoglycerides, including the endocannabinoid 2-arachidonoylglycerol (2-AG), to free fatty acids. Here, we show that MAGL is elevated in androgen-independent versus androgen-dependent human prostate cancer cell lines, and that pharmacological or RNA-interference disruption of this enzyme impairs prostate cancer aggressiveness. These effects were partially reversed by treatment with fatty acids or a cannabinoid receptor-1 (CB1) antagonist, and fully reversed by co-treatment with both agents. We further show that MAGL is part of a gene signature correlated with epithelial-to-mesenchymal transition and the stem-like properties of cancer cells, supporting a role for this enzyme in pro-tumorigenic metabolism that, for prostate cancer, involves the dual control of endocannabinoid and fatty acid pathways.
    • What’s in your sample closet? A cross-sectional study to quantify the number of expired samples and to evaluate novelty and usefulness of sample closet medications

      Evans, Kari; The University of Arizona College of Medicine - Phoenix; Brown, Steven (The University of Arizona., 2013-03)
      Background Many physicians dispense drug samples in their offices. In general, evidence suggests that drug samples provide minimal benefit to patients. Objective and Hypothesis To quantify the number of expired sample closet medications and to analyze the medications most commonly found for their novelty and usefulness. We hypothesized that the medications found in local sample closets will often be expired and will not be novel or useful. Methods We inventoried ten sample closets in primary care clinics. We quantified the number of expired medications and analyzed the 23 medications found in seven or more closets. To assess novelty, we determined if the sample medication: had a new mechanism of action, had a generic on market with same mechanism of action, and had a generic medication on market for the same indication. To assess usefulness, we determined if the sample medication had improved patient oriented outcomes, safety, and tolerability. We noted the cost of a one-month supply for the typical starting dose of each sample medication. Results Of the 12,581 drug packages and boxes we inventoried, 14% of were expired. Ninety-six percent (n=22) of sample closet medications had a generic medication on the market for the same indication and 74% (n=17) had a generic medication on the market with the same mechanism. Only 3 medications (13%) had evidence of superior patient oriented outcomes when compared to other medications for the same indication. Six medications (26%) demonstrated superior safety and tolerability. Only one medication (4%) was recommended as first line therapy in an evidence-based guideline. The mean cost for a one month supply of a typical starting dose was 178 dollars. Significance and Conclusions. Sample closet medications are often expired, have limited novelty and usefulness, and are expensive. The widespread use of sample medications should be re-examined.
    • Diagnosis and Initial Management of Musculoskeletal Coccidioidomycosis in Children

      Ho, Aaron K.; The University of Arizona College of Medicine - Phoenix; Shrader, M. Wade (The University of Arizona., 2013-03)
      Coccidioidomycosis is an invasive fungal infection caused by the inhalation of aerosolized spores of Coccidioides spp., which reside in the arid soil of the southwestern United States and northern Mexico. Dissemination of coccidioidomycosis is rare, and can lead to extrapulmonic diseases including meningitis, osteomyelitis, and skin and soft-tissue involvement. The purpose of this study is to report our experience with musculoskeletal coccidioidomycosis in children. We retrospectively reviewed the charts of patients with musculoskeletal infection with Coccidioides spp. at our institution from 1997 to 2010. Demographic and clinical data were collected from medical records, including the age of the patient, gender, white blood cell count, immunocompetence, length of stay, location of involvement, and initial treatment. In total, we identified 20 children with musculoskeletal coccidioidomycosis. The mean age was 12.3 years (range: 2 to 17) at time of diagnosis. Diagnostic criteria included positive imaging tests (usually MRI), serological positive titers, and/or biopsy with positive cultures. The most common presenting symptom was bone pain (100%) and just 3 (15%) patients had accompanying signs/symptoms of pulmonary infection. Only 2 (5%) patients had a white blood cell count > 15×109/L (5%). Locations of infection included the foot (24%), knee (14%), spine (19%), forearm (10%), lower leg (7%) and other sites (26%). Fluconazole was the most common antifungal agent used (75%). Surgical intervention was required in 12 (60%) of patients. This is the first series that has described musculoskeletal coccidioidomycosis exclusively in children. This study suggests that the initial presentation of this disease can be nonspecific and difficult to recognize in children. Clinicians should consider this diagnosis when faced with a musculoskeletal infection in children from the southwestern United States and northern Mexico.
    • Valproic Acid-Induced Gait Disturbance and Cognitive Impairment that was Reversible

      Evans, Matt; The University of Arizona College of Medicine - Phoenix; Yaari, Roy (The University of Arizona., 2013-03)
      Clinicians should be aware that treating patients with Valproic Acid (VPA) can cause cognitive and neurological decline in a small percentage of patients. A 67-year-old female with urinary incontinence, who had taken VPA without major complaints for 15 years to control her seizures, presented with abnormal gait and cognitive impairment that was significantly impacting her day-to-day level of functioning. Initially normal pressure hydrocephalus was suspected, but large volume LP did not show significant improvements in gait or cognition. Discontinuation of VPA reversed her symptoms over the next two months. The hypothesis of this project was that clinical judgment combined with objective criteria could be used to support the argument that this patient’s symptoms were likely an adverse drug reaction to VPA. The Naranjo adverse drug reaction scale was used as an objective measure and indicated that this patient’s likelihood of an adverse drug reaction to VPA was “probable”. Imaging findings consistent with the literature demonstrated reversible cortical pseudoatrophy and enlargement of the lateral ventricles, although changes in ventricular size did not reach statistical significance by two-tailed t-test. This case exemplifies the adverse effects of VPA, which can cause reversible neurological symptoms even in long-term treated patients and can present as parkinsonism or other dementia syndromes such as normal pressure hydrocephalus.