• 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.
    • 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.
    • 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.