• Assessing Chlamydia Rates and Screening in a Community Health Care Setting

      Keller, Rachel; The University of Arizona College of Medicine - Phoenix; Brite, Kathleen, MD (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.
    • 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, PhD (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.
    • Birth Outcomes of Diabetic Health Start Participants in 2010

      Espinoza, Magdalena; The University of Arizona College of Medicine - Phoenix; Rumann, Sara, MA; Henry, Sarah, MPH (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.
    • 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, MD (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.
    • Cognitive Effects of Music: Working Memory Is Enhanced in Healthy Older Adults After Listening to Music

      Wang, Alan; The University of Arizona College of Medicine - Phoenix; Denburg, Natalie PhD (The University of Arizona., 2013-03)
      Music is ubiquitous in all media, and, in the last decade, has become a potential tool for enhancing cognition. This study aimed to investigate the facilitating effect of music on working memory performance in a healthy older adult cohort. Sixty-three healthy, community-dwelling older adults who had previously undergone comprehensive neuropsychological testing were enrolled in the study. Participants were randomized into one of two groups, and were presented with a series of positive and negative musical clips. Following listening, working memory performance was tested using Wechsler Digit Span and a computerized Spatial Span task. For each task, a total score consisting of number of correct forward and backward sequences was calculated. A significant improvement in Digit Span scores was found after listening to music as compared to Digit Span scores collected ~5 years ago. Contrary to our hypothesis, this facilitative effect of music on working memory held for both positive and negative musical stimuli. It has been shown that negative music can illicit the same pleasurable feelings as positive music, and, given West’s frontal lobe hypothesis, can therefore produce the same effects on working memory as positive music.
    • Comparison of recovery time from uncomplicated sports-related mild traumatic brain injury (mTBI) in intercollegiate athletes: A baseline study

      Wong, Andrew; The University of Arizona College of Medicine - Phoenix; Overlin, Amy, MD (The University of Arizona., 2013-03)
      Sports-related mild traumatic brain injuries (mTBIs) have become an increasingly popular topic. Cognitive and physical rest are the mainstays of management, but effective evidence-based therapies do not exist. Very few studies report mean recovery times from mTBI and even less for intercollegiate athletes. The primary aim is to retrospectively compare the recovery time in athletes from a large Division I University that suffered a sports-related mTBI during 2010 - 2012 to published data for quality assessment and improvement. Since the institution's concussion management follows current guidelines, no significant difference was expected. Secondary aims included comparing recovery times between gender, sport, and league. As reported in current literature, no significant gender differences were expected. 53 athletes with sports-related mTBI (27 male and 26 female) showed a mean recovery time of 10.11 days (95 % confidence interval [CI] = 8.58 - 11.65 days), statistically different than the time reported in 1 study of 7 days, but not in another of 7 - 10 days. Mean recovery time in males and females was 9.74 days (95 % CI = 7.38 - 12.1 days) and 10.5 days (95 % CI = 8.4 - 12.6 days), respectively. Mean recovery time in National Collegiate Athletic Association (NCAA) and non-NCAA (club) athletes was 9.91 days (95 % CI = 8.27 - 11.55) and 11.25 days (95 % CI = 5.87 - 16.63), respectively. A nonparametric Wilcoxon rank-sum test showed no significant variation between genders and between NCAA and non-NCAA athletes. Subgroup statistics of 13 sports were inconclusive due to inadequate power. However, the subgroup of male football athletes showed a mean recovery time of 6.5 days (95 % CI = 4.86 - 8.14 days), which was not significantly different than published rates. Multiple confounding variables were not well controlled for including: sport, gender, concussion severity, multiple concussions, etc. However, this study did highlight areas for quality improvement in the institution's concussion management plan. Further investigation with increased power and confounding variable control is indicated for a more definitive mean time to recovery. This study is the first to detail the mean time to recovery from sports-related mTBI in an intercollegiate athletic program. Similar studies should be done at other institutions for quality assessment and improvement of 4 concussion management. Such data will be useful in establishing a baseline for measure of efficacy in future investigations of therapeutic interventions.
    • Death Certification of ‘‘Suicide by Cop’’

      Neitzel, Amber Rae; The University of Arizona College of Medicine - Phoenix; Gill, James R., M.D. (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
    • Determining variable contagiousness of MRSA by setting

      Routh, Joshua; The University of Arizona College of Medicine - Phoenix; Panchanathan, Sarada, MD, MS (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.
    • Diagnosis and Initial Management of Musculoskeletal Coccidioidomycosis in Children

      Ho, Aaron K.; The University of Arizona College of Medicine - Phoenix; Shrader, M. Wade, MD (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.
    • 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 MD (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.
    • Dysphagia in Encephalopathic Neonates Treated with Hypothermia

      Collins, Michael; The University of Arizona College of Medicine - Phoenix; Miller, Jeffrey, MD (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.
    • Effect of Carpal Tunnel Syndrome on Trial-to-Trial Adaptation to Object Mass-Sensorimotor Integration for Multi-Digit Grasping

      Sanniec, Kyle; The University of Arizona College of Medicine - Phoenix; Smith, Anthony, MD (The University of Arizona., 2013-01)
      Introduction/Objective: Somatosensory feedback from the fingertips is integrated with voluntary control of hand muscles in order to successfully grip objects. This integration can be disrupted in Carpal Tunnel Syndrome (CTS) and lead to dropping objects. This raises the question of how the central nervous system (CNS) integrates sensory information from CTS-affected and non-affected digits. The primary objective was to use CTS as a model to understand mechanisms underlying sensorimotor integration responsible for whole-hand griping of objects with a changing mass. CTS patients should be able to modulate digit forces to object weight, however, as different grip types involve the exclusive use of CTS-affected digits or a combination of CTS-affected and non-affected digits, we hypothesize sensorimotor deficits to be larger for grips involving the coordination of CTS-affected and non-affected digits. Methods: Sixteen CTS patients (3 males, 13 females) and age- and gender-matched controls participated in the study. Subjects were instructed to use one of four grip types: two digits, three digits, four digits, or all five digits to grasp, lift, hold level and release a grip device for 7 consecutive lifts. Object mass was changed across blocks of trials by inserting either a “light mass” (445g) or a “heavy mass” (745g) underneath the grip device. Force and torque exerted by each digit were measured. Results: CTS patients learned multi-digit force modulation to object weight regardless of grip type. Although controls exerted the same total grip force across all grip types, patients exerted significantly larger grip force than controls but only for manipulations with four and five digits. Importantly, this effect was due to CTS patients’ inability to change the finger force distribution when adding the ring and little fingers. Significance: These findings indicate CTS primarily challenges sensorimotor integration processes underlying the coordination of CTS-affected and non-affected digits.
    • Effectiveness of Pharmacological Treatments in Imploding vs. Exploding Headaches

      Hunt, Megan; The University of Arizona College of Medicine - Phoenix; Files, Julia, MD (The University of Arizona., 2013-03)
      Recent research shows variability in the effectiveness of botulinum toxin A among patients who experience their headaches as imploding compared with those who experience exploding headache sensations. Further research has not yet examined whether such variability exists among other pharmacological treatments. This study examines the effectiveness of acute and preventative medications in imploding vs. exploding headaches. 201 patients were recruited in the Women’s Health Internal Medicine Program at Mayo Clinic. These patients were given surveys to determine their physician identified headache type (imploding, exploding, or ocular), as well as patient-reported information about the effectiveness of prophylactic medications or triptans. This data was analyzed to determine whether a significant difference existed between medications that were effective for imploding, exploding, or ocular headaches. The study found that no such difference existed. The data was also used to analyze the correlation between physician-identified headache type and the patient-identified headache type. There appears to be only a weak correlation between these assignments, suggesting some room for improvement in the way headache directionality is explored by physician and understood by patients. In the future, research will hopefully uncover additional factors which are useful as predictors for migraine pharmacology.
    • Elucidation of the Molecular Actions of 1,25 Dihydroxyvitamin D3 and Docosahexaenoic Acid that may Mediate Cardiovascular Health

      Widener, Tim; The University of Arizona College of Medicine - Phoenix; Jurutka, Peter, PhD; Haussler, Mark, PhD (The University of Arizona., 2013-03)
      Omega 3 polyunsaturated fatty acids (PUFAs), composed of eicosapentaenoic acid (EPA) and docosahexaenoic acid (DHA), have been demonstrated to be beneficial in primary and secondary cardiovascular disease (CVD) prevention. The mechanism of action of PUFAs is not yet fully understood. Vitamin D, via its active form, 1,25-dihydroxyvitamin D3 (1,25 D3), functions through the vitamin D receptor (VDR), regulating serum calcium and phosphorus, and ultimately bone health. There is now evidence that 1,25 D3 may be cardioprotective as well, but the mechanism is also not fully understood. Evidence supports DHA as a weak VDR agonist, therefore there may be crosstalk between the two ligands and their known and yet to be discovered receptors. In the present research, we probed six genes as potential VDR targets, identified both through literature searches as well as their logical association with proposed 1,25 D3 and DHA cardioprotective mechanisms. Treating human embryonic kidney cells (HEK293) with 1,25 D3 and DHA independently, and in combination, we demonstrate changes of expression of three genes through quantitative real time polymerase chain reaction analysis (qRT-PCR). Nitric oxide synthase (NOS2), involved in the immune system nitric oxide burst, was significantly repressed by 1,25 D3 (fold effect 0.84, p value 0.04), DHA (fold effect 0.85, p value <0.01), with the greatest repression in the 1,25 D3 and DHA combination (fold effect 0.74, p value 0.01). Serpin peptidase inhibitor (SERPINE1), for which expression results in increased thrombus formation through tissue plasminogen activator inhibition, was repressed in the 1,25 D3 treatment group (fold effect 0.78, p value <0.01). Thrombomodulin (THBD), which indirectly activates protein C and increases thrombolysis, was repressed in the DHA (fold effect 0.69, p value <0.01) and combination 1,25 D3 and DHA groups (fold effect 0.75, p value 0.04). SERPINE1 and NOS2 repression is consistent with cardioprotective decreases in thrombus formation and immunomodulation, but THBD repression is not consistent with this hypothesis.
    • Evaluation of CHK1 and WEE1 as Candidate Sensitizers to Cisplatin and Paclitaxel

      Huber, Bryan; The University of Arizona College of Medicine - Phoenix; Cunliffe, Heather, PhD; Azorsa, David, PhD (The University of Arizona., 2013-03)
      Ovarian cancer is the foremost cause of death from gynecologic malignancies in the developed world. The American Cancer Society estimated 22,280 new cases in 2012 and 15,500 deaths. The majority of patients with advanced ovarian cancer relapse from primary treatment and develop drug-resistant disease. The mechanisms underlying drug-resistance are poorly understood. Inhibition of CHK1, a cell cycle G2/M checkpoint kinase has previously been shown to have a synergistic effect with cisplatin in reducing ovarian cancer cell viability. Additional mediators of the G2/M checkpoint have also been found to potentiate the effect of cisplatin and paclitaxel. We chose to evaluate the role of G2/M checkpoint kinases Chk1 and Wee1 and hypothesized that blockade of these kinases would increase the efficacy of cisplatin and paclitaxel either synergistically or additively in the A2780 ovarian cancer cell line model. We determined whether inhibition of CHK1 or WEE1 resulted in an additive or synergistic cytotoxicity in A2780 cells using siRNA technology and specific inhibition using pharmacologic agents. siRNA silencing of CHK1 or WEE1 resulted in an additive effect with Cisplatin and a synergistic effect with Paclitaxel. The response of A2780 cells to Paclitaxel was potentiated in the presence of Chk1 inhibitor PD407824, but not by Wee1 inhibitor MK1775. Our data demonstrates both CHK1 and WEE1 play a role in mediating resistance of A2780 cells to cisplatin and paclitaxel and suggests inclusion of targeted agents against Chk1 or Wee1 may be effective in the treatment of drug-resistant ovarian cancer.
    • 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., MD, MS (The University of Arizona., 2013-03)
    • 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 MD (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.
    • Informational Book for Patients Newly Diagnosed With Systemic Lupus Erythematosus

      Tahan, Yarden; The University of Arizona College of Medicine - Phoenix; Finch, William R, MD; Feuerstein, Burt G., MD, PhD (The University of Arizona., 2013-03)
      Objectives/Hypothesis To provide a useful resource for patients newly diagnosed with SLE (Sys-temic Lupus Erythematosus). Methods Surveys were distributed to patients currently living with SLE via three rheumatology offices. All surveys were completed anonymously. Survey responses were combined with per-sonal patient anecdotes as well as medically focused questions and answers to create a com-plete educational piece under the genre of narrative medicine. Results Patient survey responses provide a variety of information for patients and clinicians. Low response rate encouraged the addition of supplemental sections in the final product in or-der to create a piece with a significant amount of patient-centered information. The format therefore changed with the addition of Doctor in Training sections, highlighting answers to commonly asked patient-centered questions on SLE as well as personal anecdotes building on the narrative medicine format. Significance The combination of patient survey responses, personal anecdotes, and ques-tion/answer sections unite to provide valuable information in a unique format to patients newly diagnosed with SLE. Specifically, the survey responses give future patients a variety of view-points and tips on how to handle living with lupus while the narrative
    • Long-Term Outcome in Occipital Nerve Stimulation Patients

      Brewer, Ann Chang; The University of Arizona College of Medicine - Phoenix; Trentman, Terrence, MD (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.
    • 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, MD (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.