• 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.
    • 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.
    • 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.
    • 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.
    • First-Word Characteristics of Individuals with Autism Disorder Based On Onset of Language

      McBride, Andrew; The University of Arizona College of Medicine - Phoenix; Panchanathan, Sarada S. (The University of Arizona., 2013-03)
    • Assessing the University of Arizona Medical School Admission Committee Members’ Knowledge of Predictors of Rural Practice for Medical School Applicants

      LeSueur, Philip; The University of Arizona College of Medicine - Phoenix; Galper, Carol (The University of Arizona., 2013-03)
      Objective: There is a disparity in physician to population ratios between rural and urban Arizona. The University of Arizona Medical School has a unique opportunity to increase the supply of physicians serving in rural Arizona through its admissions process. This study is a quality improvement project which examined whether or not the admission committee members at both the Tucson and Phoenix campuses are considering probability of future rural practice when making admission decisions and if they know the evidence based predictors for rural practice. Methods: The admission committee members from the University of Arizona Medical School were asked to fill out a questionnaire regarding their preferences for future rural practitioners and if they knew the two most accurate predictors for rural practice. Results: There were 22 respondents to the survey- 12 out of 13 from Phoenix and 10 out of 14 from Tucson. Fifty-nine percent (n=13) of the total respondents listed likelihood to practice in a rural community as positively affecting their admission decision, 27 percent (n=6) said it does not affect their decision at all, and 13 percent (n=3) said it affects their decision very positively. All 22 respondents correctly identified rural background as one of the two strongest predictors of rural practice while 11 correctly identified stated interest in family practice as the other. Conclusion: The University of Arizona Medical School admissions committees are well positioned to increase the supply of rural physicians in Arizona. Even still, some of the members of the committee could benefit from education regarding accurate predictors of rural practice.
    • Assessing Chlamydia Rates and Screening in a Community Health Care Setting

      Keller, Rachel; The University of Arizona College of Medicine - Phoenix; Brite, Kathleen (The University of Arizona., 2013-03)
      Introduction: Chlamydia trachomatis is the most prevalent treatable sexually transmitted disease, with peak prevalence in young women, resulting in a CDC recommendation for annual screening. A community health center in Phoenix Arizona implemented this recommendation in 2010. Objective: Determine the prevalence of Chlamydia and assess changes in screening based on a protocol for screening at a community health center. Hypothesis: The prevalence of Chlamydia in the center’s population is greater than the national average of 6.8%, and the rate of screening will have increased with a protocol in place. Methods: Data from 2011 were collected by review of 1,074 charts, noting type of visit, if symptomatic for Chlamydia, if Chlamydia screening performed and results. Data from 2008, prior to screening protocol, were obtained via review of 313 charts, recording if the women were screened and result obtained. Results: The 2011 review revealed a Chlamydia rate in the women who were screened of 8.7%: when broken down by age the prevalence ranged up to 12.5% in 16 year olds. The study also demonstrated that in 2011, after the institution of the protocol for screening, 66% of the women in the designated age group were screened for Chlamydia at the visit or in the prior year, an increase of 39 percentage points when compared with 2008. The 2008 screening rate was 27%, with 3.5% of the women having a positive result using point-of-care testing. Discussion: Transition from point-of-care testing to send out NAAT testing may have impacted the detection rate of Chlamydia in the women screened. The 2011 data demonstrate a Chlamydia prevalence of 8.7% (6.7-11.1), which based on the 95% CI is not significantly above the national average of 6.8%. The screening rate in 2011 showed a statistically and clinically significant improvement of 39 percentage points for women utilizing the clinic.
    • 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.
    • Systematic Review on the Relationship Between Marijuana Use

      Janousek, Alyssa; The University of Arizona College of Medicine - Phoenix; Campos-Outcalt, Douglas (The University of Arizona., 2013-03)
      Objective: To develop a systematic review on the association between marijuana use and cyclic vomiting sydrome for the Arizona Department of Health Services. The review attempted to answer the key question of whether there is an association between marijuana use and cyclic vomiting syndrome and if so, whether marijuana use causes cyclic vomiting syndrome. Methods: The databases MEDLINE (PubMed), The Chocrane Library, CINAHL (EBSCO), psycINFO, Web of Science, and Google Scholar were searched for the topics of marijuana use and cyclic vomiting syndrome multiple times from September 2012 – November 2012. The quality of each pertinent study was assessed by two reviewers. Case-control and cohort studies were assessed using the Newcastle-Ottowa Assessment Scale.45 Case series’ were assessed using the criteria laid out in Guise et al.’s systematic review which was adapted from Deeks et al. and Agency for Healthcare Research and Quality.15,11,1 Literature reviews were assessed using the AMSTAR criteria.35 Overall quality of evidence and causation were determined using the GRADE methodology and the Bradford Hill criteria, respectively.16,18 Results: A total of 95 articles were identified and 37 of these were found to address the key question in some way. The study designs of identified articles were 1 case-control study, 3 cohort studies, 4 case series, 24 case reports, and 5 literature reviews. The majority of reviewed studies report an association between marijuana use and cyclic vomiting syndrome or cannabinoid hyperemesis syndrome with marijuana use preceding the onset of vomiting symptoms. However, the overall body of evidence reviewed is of very low quality and does not meet criteria to demonstrate causation. Significance: The majority of reviewed studies suggest an association between marijuana use and cyclic vomiting syndrome or cannabinoid hyperemesis syndrome though no studies suggested any evidence as to whether marijuana use causes cyclic vomiting syndrome or cannabinoid hyperemesis syndrome. The entire body of evidence reviewed, however, is of very low quality and therefore no definitive conclusions can be drawn from this review about the association between marijuana and cyclic vomiting syndrome or whether marijuana use causes cyclic vomiting syndrome.
    • Long-Term Outcome in Occipital Nerve Stimulation Patients

      Brewer, Ann Chang; The University of Arizona College of Medicine - Phoenix; Trentman, Terrence (The University of Arizona., 2013-03)
      Objectives and Hypothesis: Occipital nerve stimulation (ONS) may provide relief for refractory headache disorders. However, scant data exist regarding long-term ONS outcomes. We sought to provide long-term data on ONS efficacy in refractory headache disorder. Methods: The methods used were retrospective review of the medical records of all (non-industry study) patients who were trialed and implanted with occipital nerve stimulator systems at our institution, followed by a phone interview. Up to three attempts were made to contact each patient, and those who were contacted were given the opportunity to participate in a brief phone interview regarding their ONS experience. Data for analysis were gleaned from both the phone interview and the patient’s medical records. Results: Twenty-nine patients underwent a trial of ONS during the 8.5-year study period. Three patients did not go on to permanent implant, 12 could not be contacted, and 14 participated in the phone interview. Based upon the phone interview (if the Patient was contacted) or chart review, ONS was deemed successful in five of the 12 migraine, four of the five cluster headache, and five of the eight miscellaneous headache patients, and therapy was documented as long as 102 months. In one of the 26 patients, success of ONS could not be determined. Among patients deemed to have successful outcomes, headache frequency decreased by 18%, severity by 27%, and migraine disability score by 50%. Fifty-eight percent of patients required at least one lead revision. Significance: These results, although limited by their retrospective nature, suggest that ONS can be effective long term despite technical challenges. The number of patients within each headache subtype was insufficient to draw conclusions regarding the differential effect of ONS. Randomized controlled long-term studies in specific, intractable, primary headache disorders are indicated.
    • Dysphagia in Encephalopathic Neonates Treated with Hypothermia

      Collins, Michael; The University of Arizona College of Medicine - Phoenix; Miller, Jeffrey (The University of Arizona., 2013-03)
      Objective: The purpose of this study is to determine the rate of dysphagia in neonates treated with targeted body temperature reduction as compared to neonates who have not been exposed to hypothermia. Methods: We performed a retrospective study of encephalopathic neonates who were treated with hypothermia and who underwent a modified barium swallow (MBS). For comparison, a group of neonates who had been evaluated with MBS but did not receive hypothermic therapy was identified. This group consisted of non-encephalopathic patients. MBS results were qualified as either normal or abnormal. Results: There was no statistically significant difference in the percentage of abnormal MBS results between the hypothermic and control groups (Fisher’s exact; P = 0.78). The odds ratio for abnormal MBS results in the hypothermia group relative to the control group was 1.2, with 95% confidence interval of 0.42 to 3.8. Significance: These data indicate that hypothermia does not seem to increase short term risk of dysphagia compared to the control group. There is no apparent association between hypothermia and dysphagia. This supports previous findings that hypothermia is a safe treatment for neural injuries in NICU patients.
    • Neurodevelopmental effects of synthetic glucocorticoid at different time point on stress and metabolism gene expression in the developing hypothalamus

      Chong, David; The University of Arizona College of Medicine - Phoenix; Handa, Robert (The University of Arizona., 2013-03)
      The clinical use of synthetic glucocorticoids (sGC) to improve acute respiratory status in newborns with bronchopulmonary dysplasia, have been shown to have the undesired effects of increasing the risk of developing metabolic and neuropsychiatric disease in adulthood. Current data indicate that critical periods of sensitivity exist in fetal development during which exposures, such as sGC use, are more likely to result in long-term disease. In this study, we hypothesize that exposure to the sGC dexamethasone (DEX) at different time points during early development will result in unique expression profiles of hypothalamic genes in the adult rats. Sprague Dawley rat pups were treated with 0.2 mg/kg DEX beginning on postnatal day (PND) 4-6. Brain tissue from offspring was harvested at PND 7, 21, 90 and quantitative real-time PCR (RT-qPCR) was performed to measure the mRNA level of hypothalamic genes involved in metabolic and behavioral regulation. Results were also compared to a previous study in which pregnant Sprague Dawley dams were treated prenatally with DEX (gestational day 18-21). Of the genes we measured, thyrotropin releasing hormone (Trh) expression was decreased in the adult animals when DEX was administered either prenatally or postnatally. Subsequent examination of brain sections by immunohistochemistry (IHC) showed decreases in fiber and neuron counts that were only seen in the offspring treated with DEX prenatally. Further evidence suggesting a critical window of exposure include observations that mRNA coding for somatostatin and oxytocin, and plasma levels of the protein IGF-1 decreased only in the animals treated with DEX postnatally. Collectively, these data demonstrate that permanent effects of sGCs on hypothalamic gene expression are dependent upon the timing of the exposure
    • Prevalence of Imploding, Exploding and Ocular Headache Types in a Women’s Health Outpatient Practice

      Patel, Salma; The University of Arizona College of Medicine - Phoenix; Files, Julia (The University of Arizona., 2013-03)
      Objectives: (i) Determine the prevalence of imploding, exploding and/or ocular headaches in women with migraine in a primary care practice of women (ii) Investigate the concordance of physician diagnosis with patient self-diagnosis of pain directionality (iii) Assess correlation between the type of headache and severity of migraines, reproductive stage, and response to acute and prophylactic treatments Background: botulinum toxin A is a drug made from the toxin produced by Clostridium botulinum that works by weakening or paralyzing certain muscles or by blocking certain nerves.17 Recent migraine trials evaluating the efficacy of botulinum toxin A therapy noted differences in the efficacy of botulinum toxin A therapy based on directionality of pain ((imploding exploding and ocular). 5,6,7 However, the prevalence of these migraine types and their responses to conventional migraine prevention therapies has not yet been assessed. Methods: 201 patients participated in structured clinician-administered interviews and completed written questionnaires. Directionality of migraines were determined by both patients and physicians. Descriptive statistics, kappa coefficients and Kruskal-Wallis tests were used to assess migraine prevalence, physician-patient diagnosis concordance and association of migraine to severity, treatment and reproductive stage respectively. Results: 201 patients were enrolled with average age of 46. All patients reported directionality of their migraine and prevalence varied depending upon the method used to assign directionality and were: 33%-42% imploding headaches with or without ocular pain, 18%-44% exploding headaches with or without ocular pain, 7%-39% had ocular pain only, and 8%-13% had imploding and exploding headaches with or without ocular pain. The concordance between physician diagnosis of headache directionality with patient written response, between physician diagnosis and patient diagnosis via selection of representative picture, and between patient diagnosis via written question and via selection of representative pictures were week to moderate using Kappa coefficient. No correlation between the type of headache and severity of migraines, reproductive stage, and response to acute and prophylactic treatments was found (p>0.05). Conclusion: Improved methods of determining pain directionality and target therapy are needed.
    • Myocardial Protection Strategy Utilizing Retrograde Cardioplegia

      Karbasi, Michael; The University of Arizona College of Medicine - Phoenix; Willis, Brigham (The University of Arizona., 2013-03)
      Introduction: Myocardial protection strategies are a central component of neonatal arterial switch operations. Traditionally antegrade cardioplegia through the aortic root has been the method of delivery, but use of retrograde cardioplegia via the coronary sinus has become the standard of practice by many in the field. Methods: After obtaining IRB approval and informed consent, a retrospective chart review was done to assess outcomes between 48 patients receiving antegrade (n= 5) and retrograde (n= 43) cardioplegia during neonatal switch operations. Preoperative demographics and postoperative outcomes were compared between the two groups. Results: Patients from the retrograde cardioplegia group demonstrated a trend towards shorter postoperative ventilation days (6.67 +/- 8.57 vs. 10.2 +/- 10.1) and hospital length of stay (18.3 +/- 15.3 vs. 24.8 +/- 11.8) which were not statistically significant. Patients receiving retrograde cardioplegia demonstrated a trend towards an increased incidence of postoperative arrhythmias which was not statistically significant. The retrograde group also demonstrated an increased cardiopulmonary bypass (CPB) time (95.6 +/- 36.59 vs. 146.74 +/- 44.26) and a trend towards an increased aortic cross clamp (ACC) time (74.4 +/- 24.42 vs. 101.30 +/- 29.56) which was not statistically significant. All patients survived to discharge in both groups. With results trending towards shorter hospital length of stays, postoperative ventilation days and zero mortality in patients receiving retrograde cardioplegia, it can be utilized as a safe and efficacious strategy for myocardial protection during neonatal switch operations.
    • 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.