• The Incidence of Contrast Induced Nephropathy in Trauma Patients.

      Cordeiro, Samuel; The University of Arizona College of Medicine - Phoenix; Petersen, Scott (The University of Arizona., 2014-04)
      PURPOSE: Contrast-induced nephropathy (CIN) has been recognized as a potential adverse outcome in patients receiving contrast dye for CT evaluation for over 50 years. Despite the time and resources dedicated to better identifying at-risk patients and implementing preventative measures, contrast induced nephropathy continues to be a significant cause of hospital acquired renal insufficiency. This study was aimed to evaluate the incidence and factors associated with contrast-induced nephropathy in the trauma patient population. MATERIALS AND METHODS: A retrospective institutional review of 563 patients admitted to the trauma service at St. Joseph’s Hospital and Medical Center were evaluated. Data were recorded for each patient including demographics, injury severity score (ISS), clinical prediction score (CPS), laboratory values on admission, 24, 48 and 72 hours including hematocrit, blood urea nitrogen, creatinine and eGFR, IV fluid volume given, contrast volume given, systolic blood pressure (SBP), urine output (UOP), intensive care unit length of stay (ICU LoS) and total hospital length of stay (tot LoS). Contrast induced nephropathy was considered to be present if the patient received contrast material for CT scan and 24-48 hour creatinine increased by an absolute value of 0.5mg/dl or if there was a 25% increase in 24-48 hour creatinine when compared to admission creatinine. Contrast volumes given to each patient before CT scan were determined by the Department of Radiology. RESULTS: As seen in table 1 results of univariate analysis demonstrate the following significant data: CIN vs age (p 0.004), CIN vs ISS (p <0.000), CIN vs CPS (p <0.000), CIN vs ICU length of stay (p 0.006), CIN vs total length of stay (p 0.002), CIN vs SBP (p <0.000), CIN vs IVF volume given in the 2nd 24 hours (p <0.000) and CIN vs IVF volume given in the first 48hrs (p <0.000). Data from multivariate analysis demonstrate the following significant data: CIN vs CPS (p <0.000, CI 1.92E-2 – 3.93E-2), CIN vs SBP (p 0.003 CI 8.61E-4 – 4.41E-3) and CIN vs IVF vol 2nd 24 hours (p 0.001, CI 1.47E-5 – 5.91E-5). The mean data for patients who did and did not develop CIN respectively were CPS: 9.09 and 3.12, SBP 84mmHg and 99mmHg, and IVF vol 2nd 24 hrs 2504ml and 5931ml CONCLUSION: Contrast induced nephropathy continues to be a significant problem in many hospital populations including trauma patients. Certain patient groups including those with higher CPS, hypotension or receiving decreased IV fluids may benefit from aggressive mindfulness of the risk of contrast induced kidney injury and continued investigation is needed to better identify trauma patients at increased risk.
    • Interpregnancy Interval and Neonatal Outcomes

      Hefley, Erin; The University of Arizona College of Medicine - Phoenix; Coonrod, Dean (The University of Arizona., 2014-04)
      Objectives: Interpregnancy interval (IPI), the time period between the end of one pregnancy and the conception of the next, can have a significant impact on maternal and infant outcomes. This study examines the relationship between interpregnancy interval and neonatal outcomes of low birth weight, preterm birth, and specific neonatal morbidities. Study Design: Retrospective cohort study comparing neonatal outcomes across 6 categories of IPI using data on 202,600 cases identified from Arizona birth certificates and the Newborn Intensive Care Program data. Comparisons between groups were made using odds ratios and 95% confidence intervals, and multivariable logisitic regression analysis. Results: Interpregnancy intervals of < 12 months and ≥ 60 months were associated with low birth weight, preterm birth, and small for gestational age births. The shortest and longest IPI categories were also associated with specific neonatal morbidities, including periventricular leukomalacia, bronchopulmonary dysplasia, intraventricular hemorrhage, apnea bradycardia, respiratory distress syndrome, transient tachypnea of the newborn, and suspected sepsis. Relationships between interpregnancy interval and specific neonatal morbidities did not remain significant when adjusted for birth weight and gestational age. Conclusions: Significant differences in neonatal outcomes (preterm birth, low birth weight, and small for gestational age) were observed between IPI categories. Consistent with previous research, interpregnancy intervals < 12 months and ≥ 60 months appear to be associated with increased risk of poor neonatal outcomes. Any difference in specific neonatal morbidities between IPI groups appears to be mediated through increased risk of low birth weight and preterm birth by IPI.
    • Intravenous Immunoglobulin Use in the Treatment of Toxic Epidermal Necrolysis and Stevens-Johnson Syndrome: A 10-year Retrospective Analysis of Patients of a Single Burn Center

      Cooper, Ryan; The University of Arizona College of Medicine - Phoenix; Pressman, Melissa; Foster, Kevin (The University of Arizona., 2014-04)
      Stevens - Johnson syndrome and Toxic Epidermal Necrolysis Syndrome are rare, but serious conditions affecting skin and mucous membranes that are primarily treated with supportive care. Other more specific therapies have limited evidence to support the benefit of their use; one such treatment is intravenous immunoglobulin (IVIG). The use of IVIG in the treatment of these syndromes remain controversial due to mixed results demonstrated in the literature, and at present is not considered a component of the standard of care. This study seeks to provide additional data regarding the efficacy of IVIG treatment on mortality in a small cohort of patients presenting with these syndromes at a regional burn center over a 10-year period; data was retrospectively collected from patient medical records. On analysis of this data, IVIG use showed a potential, but not significant. improvement on mortality in comparison to the non-treatment group. Compared with the non-treatment group, odds ratios for death were 0.81 (95% CI 0.3-2.0) for IVIG. There is ultimately no new evidence that the benefit of IVIG in the treatment of Stevens - Johnson syndrome and Toxic Epidermal Necrolysis Syndrome is anything more than potential. Further investigation should include a rigorous analysis and comparison of different dosing regimens.
    • Key Attributes in Obtaining Better Outcomes and Reduced Costs in the Healthcare System

      Cowdell, Colt; The University of Arizona College of Medicine - Phoenix; Cortese, Denis (The University of Arizona., 2014-04)
      Objective/Hypothesis: The United States does not universally produce optimal levels of healthcare delivery, however, there are pockets throughout the country where organizations have utilized innovative strategies to produce high-value healthcare (better outcomes at lower costs). Our project aimed to identify factors that result in, or impede, the delivery of high-value healthcare. We hypothesized that there are common factors assisting or inhibiting organizations from producing high-value healthcare. Methods: We performed an analysis of innovative delivery models utilized at 10 different healthcare organizations throughout the country. The analysis included a literature search pertinent to each innovation we selected, a telephone interview with executives at the organization, integration of information we obtained into a pre-established template, a follow-up questionnaire, and finally an integration of new data from the questionnaire. Results: 10 different enablers were found to be common among the organizations. These included: shared vision, provider leadership, front-line empowerment, defined population, patient centeredness, co-creation with customer, information technology, culture of learning, presence of a willing payer, and a clear business case. The organizations ranked provider leadership and shared vision to be the two most important enablers. Three common barriers to success were found among the organizations and included government regulations, provider culture, and reimbursement. Provider culture was assessed as the most important barrier to overcome in the follow up questionnaire. Significance: The United States spends more overall and more per capita than any other country on healthcare, yet we are ranked 37th in the world for healthcare performance on average.1 Moreover, there is significant variability in mortality rates, access, safety, and patient satisfaction throughout the country.2 The information from this study provides a better understanding of how effective organizations are producing higher value healthcare and may act as a roadmap for organizations actively looking to produce better outcomes while lowering their costs.
    • Medical Marijuana Certification, a CME Educational Module, and the Correlation between the two on “high volume” Certifiers in Arizona.

      Anand, Keshav; The University of Arizona College of Medicine - Phoenix; Foote, Janet (The University of Arizona., 2014-04)
      In 2010, the Arizona Medical Marijuana Act was passed which required the Arizona Department of Health Services (AZDHS) to establish a medical marijuana program. Since the institution of the program, AZDHS has monitored the “top 24” frequent certifiers for medicinal marijuana who in 2012 accounted for 75% of the total number of marijuana certifications in the state. ADHS contracted with the University Of Arizona College Of Public Health to create a CME module to educate physicians about the medical marijuana act and their responsibilities. Objective: To determine the composition of physicians completing the CME module, to assess the number of certifications written by these physicians, and to understand the trend that has occurred. Results: Among those individuals completing the training module, 25 physicians were identified by ADHS as having certified patients both before and after the module completion. Those 25 physicians account for 8782 certifications prior to the module and 28131 certifications after the institution of the module, a significant increase (p <0.0001). The results are surprising as we expected this number to decrease on the assumption that physicians are over certifying and not cross referencing the Board of Controlled Substances and taking the CME module would educate them on these topics. Hence this study demonstrates that further research is necessary in analyzing physician behavior with regards to medical marijuana certifications, with education of physicians playing a critical role.
    • Non‐invasive testing to determine cardiac or non‐cardiac etiology of dyspnea in the ED

      Morris, Jason; The University of Arizona College of Medicine - Phoenix; Wu, Teresa (The University of Arizona., 2014-04)
      Objectives: There were two main objectives of this study. The first was to determine the diagnostic threshold of hemodynamic values derived from impedance cardiography (ICG) and whether these thresholds are sex specific in determining the etiology of shortness of breath (dyspnea) in patients presenting to the emergency department (ED). The second was to compare ICG hemodynamic values with the results of bedside cardiothoracic ultrasonography and B-type natriuretic peptide (BNP) levels in patients with dyspnea in the ED. Methods: A prospective cohort of 50 adult patients presenting to the Maricopa Medical Center ED with dyspnea were evaluated using ICG, bedside cardiothoracic ultrasound, and BNP to determine the etiology of their complaint. The final etiology was determined through review of the treating practitioner’s final diagnosis and evaluation of the data available from the patient’s ED visit. Cardiac and non-cardiac groups were then compared to determine the accuracy, sensitivity, and specificity of ICG, bedside cardiothoracic ultrasound and BNP in identifying the etiology of their complaint. Results: BNP at a threshold of 164 pg/mL proved to be the most accurate with a sensitivity of 84.21%, a specificity of 79.17% and an area under the curve (AUC) of 0.8684 when plotted on a receiver operating characteristics (ROC) curve. Right ventricle diameter during systole was the most accurate bedside ultrasound parameter; at a threshold of 1.71 cm it showed a sensitivity of 77.78%, a specificity of 60.00% and an AUC of 0.7489. Heather index (HI) was the most accurate ICG parameter; at a threshold of 9.2 Ohm/sec2 it showed a sensitivity of 72.41%, a specificity of 85.00%, and an AUC of 0.8405. Only HI showed a significant difference between male and female patients. HI in females at a threshold of 10.4 Ohm/sec2 was 87.50% sensitive and 87.50% specific with an AUC of 0.9297. In males a HI threshold of 6.9 Ohm/sec2 was 69.23% sensitive and 66.67% specific with an AUC of 0.7564. Conclusion: Bedside cardiac ultrasound was technically challenging and the least accurate modality. ICG demonstrated some sex specific thresholds and while an easy to use modality, it was slightly less accurate than BNP which proved to be a simple and accurate modality for determining a cardiac or non-cardiac etiology of dyspnea.
    • Pediatric Out‐of‐Hospital Cardiac Arrest in the State of Arizona

      Tully, Jeffrey; The University of Arizona College of Medicine - Phoenix; Buttram, Sandra (The University of Arizona., 2014-04)
      Comprehensive databases which collect data on out of hospital cardiac arrests have been useful in identifying markers of outcome in adults, but this data is limited in children. The Arizona Department of Health Services’ Save Hearts in Arizona Registry and Education (SHARE) database contains data on pediatric cardiac arrests in the field and offers a unique opportunity to examine outcome measures and pre-hospital care. We retrospectively analyzed 312 children (1-215 months) from the SHARE database between 2004-2010. Variables assessed included: bystander cardiopulmonary resuscitation (CPR) administration, transport times and impact of Pediatric Intensive Care Unit (PICU) availability on outcome to hospital discharge. Data were analyzed by t-test and Fisher’s exact test. Of 312 children with out of hospital cardiac arrest, 11 (3.6%) survived to hospital discharge. The low survival rates in this review make statistical comparisons difficult, though potential trends were noted that, with additional numbers to increase power, may provide insight into factors affecting survival from pediatric OHCA that have not been assessed on a wide scale in this vulnerable population.
    • A RCT: Is intraoperative acupuncture at acupuncture‐point P6 plus antiemetics more effective than antiemetic therapy alone in preventing postoperative nausea and vomiting in pediatric patients following tonsillectomy with or without adenoidectomy?

      Pierson, Kasey; The University of Arizona College of Medicine - Phoenix; Kendrick, Angela (The University of Arizona., 2014-04)
      Purpose: Acupuncture at point P6 has proven efficacious in alleviating postoperative nausea and vomiting (PONV). Evidence supporting its use in pediatric patients is not nearly as conclusive. Furthermore, acupuncture’s effects when combined with antiemetics needs to be further elucidated. We conducted a double-blinded, randomized controlled trial to investigate the effects of P6 acupuncture combined with antiemetics on pediatric patients undergoing tonsillectomy. Methods: A total of 109 patients between the ages of 3 – 9 years old were randomly assigned to one of two treatment groups prior to surgery. Each group received standard antiemetic medications while only one group received acupuncture intraoperatively. PONV was assessed via usual protocol while the patients remained at the post-anesthesia care unit (PACU) and Day Stay Unit. A follow-up phone call 24 hours following surgery was conducted to assess for overnight symptoms. Results: 106 patients completed the study with 58 randomly assigned to the Treatment Group, whom receive acupuncture and antiemetic therapy, and 48 to the Control Group, receiving only antiemetic therapy. When comparing baseline characteristics and possible confounding factors for each group, no statistical differences between the groups could be found. For primary outcomes, the only significant difference between the two groups occurred with the incidence of nausea in the PACU following the surgery (P = 0.02), but nausea in the Day Stay Unit trended toward significance (P = 0.06). Retching and vomiting incidence did not occur frequently enough in the hospital to be analyzed. No differences between the Treatment Group and Control group were seen in the 24 hours after the patients were discharged from the hospital. Discussion: With no adverse events from its use and with statistically significant efficacy, P6 acupuncture embodies a useful prophylactic treatment for postoperative nausea in children.
    • SIRT3: Molecular Signaling in Insulin Resistance

      Barber, Collin; The University of Arizona College of Medicine - Phoenix; Mandarino, Lawrence (The University of Arizona., 2014-04)
      Post-translational modification of intracellular proteins through acetylation is recognized as an important regulatory mechanism of cellular energy homeostasis. Specific proteins called sirtuins deacetylate other mitochondrial proteins involved in glucose and lipid metabolism, activating them in metabolic processes. SIRT3 is a sirtuin of particular interest as it is found exclusively in mitochondria and has been shown to affect a variety of cellular metabolic processes. The activity of this enzyme is related to cellular insulin sensitivity. This study attempted to identify the relationship between insulin sensitivity and change in amount of SIRT3 following a bout of exercise in non-diabetic individuals. We find a moderate inverse correlation between insulin sensitivity and increase in SIRT3 abundance following exercise. This suggests that this protein may not be involved directly in cells’ ability to regulate energy homeostasis or that it may act through another mechanism not investigated in this study.
    • Specific memory complaints and the identification of preclinical Alzheimer's disease years before conversion to Mild Cognitive Impairment.

      Adler, Claudia; The University of Arizona College of Medicine - Phoenix; Baxter, Leslie (The University of Arizona., 2014-04)
      Early detection of cognitive decline will become increasingly important as preventative therapies for Alzheimer’s disease (AD) become available. While new imaging techniques and biomarkers have shown evidence of neuropathology in the preclinical stages of AD, most clinicians must rely on the subjective report of symptoms to identify the onset of cognitive decline. Patients often present to primary care physicians with complaints from self or family members about confusion, memory loss or personality changes. However, discriminating complaints associated with normal from abnormal aging is difficult. The identification of patient-generated specific complaints indicating prodromal or Mild Cognitive Impairment (MCI) could lead to more prompt and effective intervention strategies for future dementia patients, and could improve prognosis. This study investigated how specific subjective complaints may be related to subsequent conversion to MCI in a cohort of cognitively normal elderly subjects who have a familial and/or genetic risk for AD. Subjects included cognitively intact participants and their informants (spouse, sibling, adult child) from a large longitudinal study of cognition in individuals with a family history of AD. Participants were further characterized by their APOE ε4 allele status. Both subjects and their informants were administered the Multidimensional Assessment of Neurodegenerative Symptoms (MANS), a questionnaire that assesses subjective changes in memory, personality, motor, vision, and speech. Of 85 subjects who were cognitively normal at the initial MANS administration, 12 converted to MCI within 25-167 months. The participants who later converted to MCI had greater memory complaints at baseline compared to nonconverters (2 = 5.65, p <0.05). There were no significant differences in other MANS domains. In regards to specific memory complaints, converters were significantly more likely to endorse symptoms of “losing or misplacing things” (2 = 13.99, p<0.001), having an “inability to keep events or tasks in right order,” (2 =12.06, p<0.001), "forgetting names of familiar people" (2 = 4.59, p < 0.05), and "forgetting things or events from long ago," (2 = 6.62, p < 0.05). Nonconverters also endorsed some memory complaints, but no complaint or group of complaints was endorsed more than others. The APOE ε4 allele was observed in 83% of the participants who converted to MCI compared to 52% of those who remained cognitively intact over the course of the assessment period. In cognitively normal subjects with a family history of AD, specific memory complaints about losing or misplacing items, forgetting the order of tasks or events, forgetting names of familiar people and forgetting things or events from long ago may be useful clinical tools for identifying Preclinical AD up to eight years before conversion to MCI.
    • A Standardized Template for Measuring and Reporting Telephone Cardiopulmonary Resuscitation

      Dameff, Christian; The University of Arizona College of Medicine - Phoenix; Bobrow, Bentley (The University of Arizona., 2014-04)
      Abstract Background: Bystander cardiopulmonary resuscitation (CPR) improves out-of-hospital cardiac arrest (OHCA) survival. Telephone CPR (TCPR) comprises CPR instruction given by emergency dispatchers to bystanders responding to OHCA and the CPR performed as a result. TCPR instructions improve bystander CPR rates, but the quality of the instructions varies widely. No standardized system exists to critically evaluate the TCPR intervention. Methods: Investigators developed a novel, standardized system to analyze audio recordings of suspected OHCA calls from a large regional 9-1-1 dispatch center. As the initial step of a TCPR quality improvement initiative, baseline data were obtained from October 2010 to November 2011. Dispatcher recognition of CPR need, delivery of TCPR instructions, and bystander CPR performance were documented. Results: A total of 590 calls were analyzed. CPR was indicated in 317 calls and already in progress in 94. Dispatchers recognized the need for TCPR in 176 of the 223 (79%) remaining calls. CPR instructions were started in 65/223 (29%) and bystander CPR resulting from TCPR instructions was started in 31/223 (14%). Median time intervals were: recognition of CPR need [69s (IQR: 44, 104.5)], initiation of CPR instructions [175s (IQR: 139, 207)], and first chest compression [251s (IQR: 189, 306)]. Conclusion: It is feasible to employ a simple data collection and reporting system for critical evaluation of the TCPR intervention. A standardized methodology for measuring TCPR is necessary to perform on-going quality improvement, to establish performance standards, and for future research on how to optimize bystander CPR rates and OHCA survival.
    • Standardizing Radiological Findings for Non‐Accidental Trauma in the Pediatric Population

      Sultani, Masoud; The University of Arizona College of Medicine - Phoenix; Richardson, Randy; Valencia, Elizabeth (The University of Arizona., 2014-04-17)
      The objective of this project was to review skeletal survey reports and examine the differences in reporting of non-accidental trauma in patients with similar radiological findings. The overall purpose of this project is to develop a standardized reporting system for radiological findings suspicious for non-accidental trauma. Ten years’ worth of skeletal survey reports were obtained on over 1,500 pediatric patients. These reports were individually reviewed and their findings were categorized in a table separating findings suspicious for non-accidental trauma. After data collection, analysis was completed to inspect the consistency of reports amongst studies with similar fractures specifying non-accidental trauma. The comparison was made between reports containing long bone fractures, metaphyseal corner fractures, rib fractures, or any combination of these. It was concluded that there are inconsistencies in reporting of non-accidental trauma in reports with similar patterns of these fractures. We propose a Skeletal Survey – Reporting and Data System (SS-RADS) score which will help radiologist standardize their reporting methods for more consistent interpretations and clinical outcomes.