• 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)).
    • Safety and efficacy of lung recruitment maneuvers in post-­‐operative pediatric cardiac surgical patients

      Morandi, Tiffany; The University of Arizona College of Medicine - Phoenix; Willis, Brigham C. (The University of Arizona., 2013-03)
      OBJECTIVE: To demonstrate the safety of lung recruitment maneuvers in post-operative pediatric cardiac surgical patients. To assess the ability of lung recruitment maneuvers to improve lung function. HYPOTHESIS: We hypothesize that ventilator recruitment strategies be well-­tolerated in cardiac patients, and that they may benefit such patients by improving physiologic variables such as lung function and oxygenation. METHODS: Sixty‐two pediatric post-operative cardiac surgical patients were randomly selected to include in this retrospective chart review. Study subjects were selected from all patients who met inclusion criteria in the year immediately following implementation of a lung recruitment protocol in a local free‐standing pediatric hospital. Physiologic variables before, during, and after lung recruitment were recorded as well as patient demographics, diagnoses, morbidities and mortality. RESULTS: A statistically significant increase in dynamic compliance of the lungs and renal non-invasive regional oximetry was noted immediately after each recruitment maneuver. There was no statistically significant change in blood pressure, heart rate or oxygen saturation during the maneuvers. There was a transient increase in central venous pressure during the maneuvers (average increase < 1 mmHg). Of the 62 patients, there were 7 cases of pneumonia and 5 cases of small pneumothorax, often resolving without intervention. Significance: Demonstrating recruitment maneuvers are safe in pediatric patients with cardiac disease will allow practitioners to confidently utilize them when caring for ventilated patients. Such patients may benefit from potential improvements in lung function and decreased ventilator-associated morbidities.
    • 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.
    • 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.
    • Serum Uric Acid and Type 2 Diabetes

      Dille, Renee; The University of Arizona College of Medicine - Phoenix; Weil, E. Jennifer (The University of Arizona., 2013-03)
      Objectives: In recent years, serum uric acid has emerged as a possible risk factor for type 2 diabetes mellitus (T2DM). It remains unclear if this is independent of other well-known risk factors related to the metabolic syndrome. This retrospective epidemiologic study attempts to clarify the relationship between uric acid and T2DM, as well as to assess uric acid as a predictor for future diabetes development. Methods: Data was collected by the NIDDK biennial study from Pima Indians in Arizona over several decades. A cross sectional analysis using multivariate logistic regression and a survival analysis using a Cox proportional hazards model were created. Sex and body mass index (BMI) were hypothesized to create significant interactions with other variables. Interactions were confirmed by log likelihood tests, so the data was analyzed stratifying by sex. An interaction term between body mass index and uric acid was also included in analyses performed in women, as it was found to be significant in women only. Results: The cross sectional analysis showed that men with diabetes are significantly more likely to be older (OR=1.033, p<0.0001), have a higher BMI (OR=1.117, p<0.0001), mean arterial pressure (MAP) (OR=1.020, p=0.0024), cholesterol (OR=1.003, p=0.003), and lower uric acid (OR=0.625, p<0.0001) than men without diabetes. Uric acid levels did not correlate with diabetes status in women, but an interaction between uric acid and BMI was significant (p=0.0094). A goodness of fit test of the models comparing predicted to observed outcomes were significant with an R-squared value of almost 0.90 in both sexes. The survival analysis in women demonstrated that BMI (p=<0.0002) and uric acid (p=0.0209) both confer risk for diabetes development, and a significant interaction between BMI and uric acid exists with a negative parameter estimate. A nested analysis of the effect of uric acid assessed in BMI quartiles demonstrated an increased risk in normal to moderately overweight individuals, and a hazard ratio under 1 in more obese individuals. Results in men demonstrated no significance of uric acid (p=0.6571). Conclusion: The relationship between serum uric acid and diabetes varies significantly by sex, and BMI appears to have a confounding relationship with uric acid, especially in women. Uric acid is lower in men with current diabetes, confirming previous studies, which may be due to renal hyperfiltration or induction of uric acid as an antioxidant response to diabetes. In women, elevated uric acid confers higher risk of future development of T2DM. Why this was not shown in men is unclear. Utilizing uric acid in clinical practice as a screening tool is limited by interactions between uric acid and other metabolic risk factors, specifically BMI, as well as variations influenced by diet and renal function.
    • Targeting Invasive Glioblastoma via the TROY-JAK1 Signaling Pathway

      Kahn, Allon; The University of Arizona College of Medicine - Phoenix; Tran, Nhan (The University of Arizona., 2013-03)
      Objective and Hypothesis: Glioblastoma multiforme, the most common and lethal primary brain neoplasm in adults, has been historically difficult to treat, as its invasion into contiguous brain tissue mitigates the benefit of surgical resection. Furthermore, its unique ability to evade apoptosis and selectively induce proliferation promotes chemotherapeutic resistance and explains the lack of substantial survival improvement despite decades of research. The orphan transmembrane receptor, TROY, has been shown to influence glioma cell migration and survival. While TROY downstream signaling presents a potential therapeutic target, the detailed pathway has yet to be fully elucidated. We identified the non-receptor tyrosine kinase, JAK1,as a candidate binding partner and hypothesized that JAK1 is a downstream mediator of TROY-induced glioma invasion, ultimately seeking to validate the potential therapeutic potential of this interaction. Methods: TROY-JAK1 binding was assessed by co-immunoprecipitation of JAK1 with immunoblotting for TROY. The mechanism of this JAK1-TROY interaction was assessed by western blottingfor phosphorylated JAK1 and STAT3 in wild type vs. TROY-overexpressing glioma cells. Finally, an in-vitro radial migration assay was performed under siRNA depletion of JAK1 to assess functional validation. Results: JAK1 was confirmedas a TROY binding partner by co-immunoprecipitation, with immunoblotting demonstrating that TROY-overexpression induces JAK1 phosphorylation. siRNA-mediated depletion of JAK1 also resulted in decreasedphosphorylated STAT3 level. Finally, a radial migration assay performed on wild-type and TROY-overexpressing T98G cells with and without JAK1 depletion demonstrated statistically significant reductions in migration rate in both JAK1-depleted groups compared to controls. Significance: This study identified and confirmed JAK1 as a downstream mediator of TROY signaling and demonstrated that JAK1 depletion results in mitigation of the pro-migratory effect of TROY overexpression. Thus, JAK1 provides a potential novel therapeutic target for disruption of glioblastoma TROY signaling in vivo andmay contribute to the development of more efficacious chemotherapeutic agents.
    • Effectiveness of Pharmacological Treatments in Imploding vs. Exploding Headaches

      Hunt, Megan; The University of Arizona College of Medicine - Phoenix; Files, Julia (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.
    • Evaluation of CHK1 and WEE1 as Candidate Sensitizers to Cisplatin and Paclitaxel

      Huber, Bryan; The University of Arizona College of Medicine - Phoenix; Cunliffe, Heather; Azorsa, David (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.
    • Informational Book for Patients Newly Diagnosed With Systemic Lupus Erythematosus

      Tahan, Yarden; The University of Arizona College of Medicine - Phoenix; Finch, William R.; Feuerstein, Burt G. (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
    • 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.
    • 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 (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.
    • 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.
    • 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.
    • 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; Haussler, Mark (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.
    • 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 (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.
    • 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
    • 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 (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.