• End-of-Life Care in American Indian Populations of the Southwest

      Law, Emily; The University of Arizona College of Medicine - Phoenix; Trujillo, Michael (The University of Arizona., 2015-05-13)
      American Indians and American Native (AI/AN) populations have faced health disparities for a period of time. Although their incidence for some chronic diseases such as cancer, may be lower than the general population, they suffer from the poorest survival rates of any ethnic group. As the AI/AN populations age and live longer with chronic disease as seen with the rest of the general population, the discussion of palliative care is becoming more important. Currently, there is not a lot of literature about palliative care that is specific to the AI/AN population. The paucity of research serves as an impetus to learn and examine the need of available palliative care resources for the AI/AN populations. We present the analysis of twenty interviews with staff members of local hospice organizations and hospitals. The interview questions ask participants about their views and experiences in delivering palliative care. Through these discussions, we investigate the current needs, social and cultural barriers, and the infrastructure of how palliative care is accessed and delivered.

      Wadas, Erica; The University of Arizona College of Medicine - Phoenix; Graziano, Kathleen; Nigro, John (The University of Arizona., 2015-04-14)
      Purpose: Infants born with Heterotaxy Syndrome (HS) often have intestinal malrotation in addition to severe congenital heart disease (CHD). Given the catastrophic risk of midgut volvulus, where the vascular supply to the gut is cut off causing necrotic bowel and possible future short‐gut syndrome following surgery, an elective Ladd procedure is recommended at the first diagnosis of malrotation. In patients with severe CHD, however, the risk of complications from prophylactic surgery is high, especially in infancy prior to stable cardiac palliation. This study sought to determine whether deferring a Ladd procedure during the first six months of life in infants with CHD is safe by focusing on the incidence of volvulus in the HS population, morbidity of volvulus and morbidity of an elective Ladd procedure. Methods: Medical records of patients with HS and intestinal malrotation at Phoenix Children’s Hospital from 2006‐2011 were reviewed. Stage of heart surgery, severity of heart disease, diagnosis of intestinal malrotation, and timing of Ladd procedure if applicable were recorded. Results: 31 patients with HS and intestinal malrotation were identified. Of the 31, 9 had a Ladd procedure prior to six months of age, 2 for volvulus and the other 7 either electively or for less severe GI symptoms that were not suggestive of volvulus. The other 22 did not have a Ladd procedure prior to six months of age. There was one death (1/22) from a non‐gastrointestinal cause in a patient who had not undergone a Ladd procedure. There were no deaths in the 9 patients who underwent a Ladd procedure (0/9). Conclusions: Given the low overall incidence of volvulus in HS, and with continued vigilance for obstructive symptoms, this study suggests that delaying the Ladd procedure in asymptomatic patients with HS and CHD and intestinal malrotation is safe. Watchful waiting may reduce the incidence of cardiac complications during the Ladd procedure by allowing for stabilizing cardiac surgical palliation prior to elective abdominal surgery.

      Sinha, Natasha; The University of Arizona College of Medicine - Phoenix; Beyda, David (The University of Arizona., 2015-04-14)
      End‐of‐life (EOL) care and decision‐making in pediatrics is a challenging and complex aspect of patient care experienced by residents and physician attendings. Previous studies have evaluated determinants that contribute to physicians’ attitudes towards EOL care as well as preparedness of students and residents in EOL decision‐making. However, the determinants contributing to a physician’s ability to make such decisions and feel confident in addressing EOL issues are dynamic. Recognizing that decision‐making changes over time, identifying when these changes occur may demonstrate the need for educational interventions for medical students and residents early in their career to help prepare them for EOL decision‐making. A longitudinal assessment of changes in attitudes and knowledge of EOL discussions and how they impact EOL decision‐making was not previously evaluated. This preliminary study establishes a baseline for medical student, resident, and attendings for EOL decision‐making and those factors that contribute to their decisions. This preliminary data has demonstrated a difference amongst attendings compared to residents and students. Despite low probability of survival, residents and students are more likely to select more aggressive management options when compared to attendings. Data obtained after completion of future surveys will show when decision‐making changes, which factors contribute to these changes and their significance in making decisions, and when participants are comfortable addressing EOL care.

      Vanhoy,Steven; The University of Arizona College of Medicine - Phoenix; Hopf, Harriet (The University of Arizona., 2015-04-14)
      Objective: To compare findings of emergency echocardiography (rescue echo) in the intra‐ operative period to findings of rescue echo in the ICU setting. Design: We queried a database of perioperative echo for all rescue echo studies done over a two year period. We compared the frequency of left ventricular (LV) and right ventricular (RV) systolic dysfunction, LV diastolic dysfunction, LV segmental wall motion abnormalities, and hypovolemia of the intraoperative and ICU studies. Results: LV and RV systolic dysfunction were more prevalent in ICU rescue echo studies compared to intra‐op rescue studies (22% vs. 10%, and 34% vs. 13%, respectively, p<0.05 for each). LV diastolic dysfunction was more prevalent in ICU rescue echo studies compared to intra‐op rescue studies (60% vs. 48%, p<0.05). Segmental wall motion abnormalities (SWMA) were more prevalent in the ICU compared to intra‐op setting (38% vs. 19%, p<0.05). Conclusion: In an observational study of real‐world rescue echo, the incidence of LV and RV systolic dysfunction, LV diastolic dysfunction, and LV SWMA were all more common in the ICU compared to the intra‐op studies. This could reflect the differences in patient population, differences in reasons clinicians perform rescue echo in the OR and in the ICU, or the hemodynamic effects of anesthesia.

      Parsons, Christine; The University of Arizona College of Medicine - Phoenix; Yaari, Roy; Dougherty, Jan (The University of Arizona., 2015-04-13)
      Memory screening in the community promotes early detection of memory problems, as well as Alzheimer’s disease (AD) and related illnesses, and encourages appropriate intervention. The Montreal Cognitive Assessment (MoCA) is a rapid and sensitive screening tool for cognitive impairment that can be readily employed at the clinical level, but little is known about its utility as a community screening tool. Also, little is known regarding the demographics of the population that presents for a community screen. The research aims to evaluate the demographics of the participants that attended community memory screens in the greater Phoenix metropolitan area and to evaluate the prevalence of screen positives using the MoCA. It is hypothesized that cognitive impairment will be significantly prevalent in the screened population and that age and family history of dementia will correlate with the presence of cognitive impairment. The study methods involve descriptive analysis and application of statistical tests to evaluate for significant relationships between demographic variables and MoCA scores. The population (n=346) had a mean age of 72 (SD =10.7), was primarily female (70%), primarily Caucasian (68%) and 86% had greater than a high school education. A 58% prevalence of cognitive impairment was found in the population as defined by the MoCA. Increased age, male gender, and non‐Caucasian race correlated with lower MoCA scores. Lower education correlated with lower MoCA scores despite the inherent educational correction in the MoCA. Diabetes and a family history of AD were not significant factors. Although the number of true positives following methodical diagnosis is unknown, given the validity of the MoCA in discerning cognitive impairment, the screen was likely worthwhile and supports more routine use of community memory screens. Variables identified that were associated with increased cognitive impairment better describe the population at risk and can be utilized to focus future screening efforts.

      Lukefahr, Ashley Leigh; The University of Arizona College of Medicine - Phoenix; Funk, Janet (The University of Arizona., 2015-04-13)
      Zoledronic acid (ZA), the gold standard treatment for breast cancer‐derived osteolytic bone lesions, induces apoptosis in mature osteoclasts. Curcumin, a plant‐dervied component of turmeric (Curcuma longa), inhibits osteoclast differentiation. This study aimed to determine the in vitro and in vivo effects of ZA and curcuminoids, alone and combined, on osteoclast differentiation and survival, breast cancer cell growth, breast cancer cell‐induced osteolytic bone lesion area, and bone mineral density (BMD). Curcuminoids, but not ZA, inhibited osteoclast formation at doses that did not alter precursor viability, as assessed by osteoclastogenesis assays using murine RAW 264.7 cells. Combined curcuminoids and ZA did not differ from curcuminoids alone in their effects on osteoclast survival/formation. The half maximal inhibitory concentration (IC50) for ZA alone was 4 μM, while the IC50 for curcuminoids plus ZA was 6μM. Curcuminoids and ZA inhibit in vitro cell viability of human breast cancer‐ derived MDA‐MB‐231 cells, as assessed by MTT assays. The IC50 of ZA alone was projected to be 1.0677 x 10^4 μM, while the IC50 for curcuminoids alone (9.1 x 10^1 μM), was close to the IC50 for curcuminoids plus ZA (1.31 x 10^2 μM curcuminoids with 300 μM ZA). In vivo effects of ZA (2 μg/kg/d) and curcuminoids (25 mg/kg/d), alone and combined, on osteolytic bone lesions dervied from innoculation with MDA‐MB‐231 cells were assessed. Radiographically‐evident osteolytic bone lesion area did not differ between treatment groups, with a trend towards decreased osteolytic lesion area in mice treated with ZA. BMD In non‐responders, without bone or pericardiac tumors, assessed by dual energy x‐ray absorptiometry, was increased in mice administered ZA. Thus, for the first time, the combined in vitro effects of ZA and curcuminoids on osteclast formation and survival were demonstrated, as well as the combined effects of ZA and curcuminoids on bresat cancer‐derived osteolytic bone lesions and BMD.

      Raza, Ali; The University of Arizona College of Medicine - Phoenix; Ernst, Kacey (The University of Arizona., 2015-04-13)
      Background: Dengue fever is the most common mosquito borne viral disease in the world. Its symptoms can be fairly nonspecific and most commonly include fever, rash, headache, and eye pain. Passive surveillance is currently the most prevalent method used to detect dengue cases in the United States. Identification of positive cases can be limited by the public’s awareness of the disease’s symptoms, barriers to healthcare seeking behavior, and by physician approval of laboratory testing. Objective: This study sought to evaluate barriers to dengue reporting, as well as the patient‐ level factors that may limit the efficacy of passive surveillance of dengue in Key West, Florida. Methods: Cross‐sectional surveys were administered across Key West, FL. Subjects were asked if they had a recent fever, additional dengue symptoms, and whether they sought medical care for these symptoms. Also the hypothetical question was posed: would you seek medical care for a fever greater than 102 F? Responses were stratified according to patient characteristics and demographics. Results: In Key West, patient‐level factors that influenced the decision to seek medical care for a high fever were: having a specific doctor call when sick (p<0.006), health insurance status (p<0.037), and ethnicity (p<0.005). Additionally, barriers to dengue reporting were identified. The most impactful were the decision to seek medical care for symptoms consistent with dengue fever, and the doctor’s decision to administer confirmatory dengue laboratory tests. Only one person with a recent fever plus one additional classic dengue symptom received laboratory testing, and this was done outside of the United States. There were four individuals who met the current WHO clinical case definition for dengue, yet none were offered laboratory testing or were diagnosed with the disease. Conclusion: This study shows that both patients and doctors in Key West, Florida underestimate the potential for dengue when there are symptoms consistent with the disease. As such, it is certainly possible that there have been unreported cases in the country.

      Parrish, Ashley; The University of Arizona College of Medicine - Phoenix; Bulloch, Blake (The University of Arizona., 2015-04-13)
      Background: Pain scales developed for children were noted not to be useful or practical in an ambulance, and EMS providers have been found to use non‐standardized measures of pain severity in children. A recently published evidence‐based guideline recommends using pictorial scales (PS) for patients aged 4‐12 years, and observational‐behavioral scales (OBS) for younger patients. Objectives were to assess EMS providers’ baseline knowledge, self‐reported practices, self‐efficacy for treating pain in children, and preference for pediatric pain scales. Methods: A survey and education module were administered to a convenience sample of EMS providers from four agencies within a large metropolitan area. Providers answered 20 Likert scale items, received a 15‐minute didactic on pain assessment in children, and then answered four additional survey items. Results: There were 397 surveys returned (80% of providers receiving didactic). Six‐tenths of providers had practiced >10 years, 99% were EMT‐P, and 91% were male. 88% reported feeling “Very‐Extremely” comfortable measuring pain severity in adults; 38% reported the same in children. 57% reported having been trained on the use of pain scales in children; 46% were at least “Moderately” familiar with any PS and 24% with any OBS. While 44% assessed their current practice as “Sometimes‐Always” using pediatric scales, <25% of providers reported carrying paper or electronic copies of pain scales. 75% reported using their own observation to assess pain “Most of the Time‐Always.” Self‐efficacy results for utilizing pain protocols and measuring pain scores for 8‐year and 36‐month patients revealed 68% and 48% were at least “Mostly” certain they could perform correctly. After education about pediatric pain scales, 41% and 31% reported they would be more than “Somewhat” likely to use PS or OBS, respectively. Conclusion: A sample of EMS providers reported a high level of discomfort assessing pain in children, a moderate prevalence of training, and a low familiarity with existing pediatric pain scales. Most use general impression to assess pain instead of pain scales. After education, the minority of providers reported likelihood of incorporating these tools into their practice. This is an important barrier to adoption of the evidence‐based guideline for management of acute traumatic pain.

      Reeder, David; The University of Arizona College of Medicine - Phoenix; Beyda, David (The University of Arizona., 2015-04-13)
      The value of an allopathic medical school interview lies in its inherent ability to produce something of value that is unobtainable by other means: a rough assessment of the non‐ cognitive components of a viable candidate. Many allopathic institutions rely on the interview when determining applicant viability for both professional standards and institutional fit. However, applicants can distort the truth or train themselves to appear to exude any one of a number of admirable qualities for a brief period of time. Responses that reflect socially acceptable answers, rather than the true nature of an applicant’s character, represent forms of dishonesty. It is our belief that the high‐stakes setting of a conventional allopathic interview creates a moral hazard for prospective matriculates, such that applicants’ genuine responses are confounded with social desirability bias. Social desirability is often simplified for the research world to refer to the articulation of both self‐deceptive enhancement and impression management (IM). We sought to establish the presence of impression management and/or self‐deceptive enhancement tactics among interviewing allopathic medical school applicants. The presence of the aforementioned was determined using the 6th version of the Balanced Inventory of Desirable Responding (BIDR), a validated inventory that relies on 40 self‐responses on a Likert scale to common situations. We offered the BIDR interview to all interviewing applicants to the University of Arizona College of Medicine ‐ Phoenix on three of the six interview days. This inventory was administered during a 10 minute break period offered directly after the completion of the university’s multiple mini interviews, so as to assess the presence or absence of social desirability as close to the high stakes setting as possible. We received 104 responses, 12 of which were not included in the dichotomous scoring because they were not completed in their entirety. Our findings from 92 allopathic medical school applicant respondents indicated that our average interviewing medical school applicant was engaging in impression management tactics above and beyond the oft‐referenced BIDR cutoff values, with an average of 7.543/20; however, they were not engaging in self‐deceptive enhancement tactics beyond their BIDR reference peers with an average of 6.27/20. Both self‐ deception and impression management exist on a spectrum; however the arbitrary cutoffs of honest impression management established by Paulhaus’ 6th version of the BIDR were exceeded. Our results indicate that the context of allopathic interviews is associated with increased levels of impression management tactics; conversely, it is not associated with increased self‐deceptive enhancement tactics.

      Scotch, Allison; The University of Arizona College of Medicine - Phoenix; Henry, Michael (The University of Arizona., 2015-04-13)
      Background. Rates of childhood obesity in the United States have risen dramatically in recent decades, with more than 31% of children currently classified as overweight or obese. This raises concerns about the effects of weight on outcomes for pediatric illness, including cancer. There is some evidence of poorer outcomes for pediatric leukemia patients who are overweight or obese, and studies in adults have suggested negative impacts of obesity in numerous cancer types. To date, there are no studies investigating outcomes in overweight and obese children with Hodgkin lymphoma (HL). Our hypothesis was that higher body mass index (BMI) at diagnosis is associated with increased risk for HL relapse. Methods. We conducted a retrospective cohort study of 101 pediatric HL patients treated between 1980 and 2010 at Phoenix Children’s Hospital, a large pediatric oncology referral center in the Southwestern United States. Data was abstracted from electronic and paper medical charts as well as survival clinic follow‐up records. We performed logistic regression and conducted a survival analysis to test whether body mass index (BMI) at diagnosis was associated with time to disease relapse. For this pilot study, we conducted a primary analysis as well as several exploratory secondary analyses with the goal of generating hypotheses to be tested in future large studies of this population. Results. In the primary analysis comparing underweight and normal children to overweight and obese children, none of the patient characteristics – sex, race, age, clinical risk level, or radiation status – were significantly associated with BMI group. In the univariate analysis of HL relapse, children in the overweight/obese group had an increased unadjusted odds ratio of 1.58 (95% CI: 0.50‐5.28), but this was not statistically significant. Exploratory analyses categorizing BMI groups in various ways also suggested an association between increased BMI and risk for HL relapse, though this failed to reach statistical significance. No potential confounders were associated with HL relapse except radiation status (p=0.004), although we were unable to calculate an odds ratio due to a lack of patients in some subgroups. In the survival analysis, radiation was the only variable significantly associated with time to HL relapse. Kaplan‐Meier curves of relapse‐free survival time did not show a significant difference between BMI groups in the primary analysis, but secondary analyses suggested a nonsignificant trend toward decreased long‐term disease‐free survival in patients with higher BMI. Discussion. The relatively small sample size for this pilot study precluded demonstration of statistically significant differences in HL relapse risk or time to relapse between BMI groups. However, exploratory analyses suggested a trend toward increased risk for relapse and shorter disease‐free survival in patients with higher BMI, and these results merit further investigation in larger studies. Multi‐center collaborative studies will be required to attain sufficient sample sizes to accurately assess clinical prognosis in this patient population. Improving our understanding of how BMI affects pediatric cancer outcomes is an important step toward identifying patients at increased risk and determining how best to individualize treatment and monitoring plans for overweight and obese children.

      Morshed, Trisha; The University of Arizona College of Medicine - Phoenix; Jacobson, Sandra (The University of Arizona., 2015-04-13)
      Objective: Formed visual hallucinations are a common phenomenon in neurodegenerative disorders such as Parkinson’s Disease (PD), Alzheimer’s disease (AD) and Dementia with Lewy bodies (DLB). While Lewy‐type alpha‐synucleinopathy (LTSis the hallmark neuropathological finding in PD and DLB, amyloid plaques and neurofibrillary tangles are the pathological finding in AD. Previous research has linked complex or formed visual hallucinations (VH) to LTS in neocortical and limbic areas in patients with PD and DLB. As VH also occur in Alzheimer’s disease, and AD pathology often co‐occurs with LTS, we questioned whether this pathology might also be linked to VH. Methods: We performed a semi‐quantitative neuropathological study across brainstem, limbic, and cortical structures in subjects with a documented clinical history of VH and a clinicopathological diagnosis of Parkinson’s disease (PD), Alzheimer’s disease (AD), or dementia with Lewy bodies (DLB). 173 subjects – including 50 with VH and 123 without VH – were selected from the Arizona Study of Aging and Neurodegenerative Disorders. Clinical variables examined included the Mini‐mental State Exam, Hoehn & Yahr stage, and total dopaminergic medication dose. Neuropathological variables examined included total and regional LTS and plaque and tangle densities. Results: A significant relationship was found between the density of LTS and the presence of VH in all diagnostic groups. Plaque and tangle densities also were associated with VH in PD (p=.003 for plaque and p=.004 for tangles), but not in AD, where densities were high regardless of the presence of hallucinations.. Conclusion: Plaques and tangles as well as LTS may contribute to the pathogenesis of VH. Incident VH may be a clinical indicator of underlying pathological events: the development of plaques and tangles in patients with PD, and LTS in patients with AD.

      OShea, Michele; The University of Arizona College of Medicine - Phoenix; Tang, Jennifer (The University of Arizona., 2015-04-13)
      Background and Significance: Both HIV and unintended pregnancies have been associated with adverse maternal, perinatal, and infant outcomes. Malawi is a country with both high HIV prevalence and rates of unintended pregnancy, where 13% of women aged 15‐49 years have HIV, and 41% of pregnancies are unintended. Research Question: The objectives of this study were to describe the most recent pregnancy intentions and family planning preferences of HIV‐infected and HIV‐uninfected postpartum Malawian women, and to assess whether HIV status is associated with fertility desire and knowledge of intrauterine contraception (IUC) and the subdermal contraceptive implant. Methods: We conducted a cross‐sectional analysis of the baseline characteristics of Malawian women enrolled in a prospective cohort study assessing postpartum contraceptive uptake and continuation. Women at a government hospital completed a baseline survey assessing reproductive history, family planning preferences, and knowledge of IUC and the implant. We used Pearson’s chi‐square tests to compare these parameters between HIV‐infected and HIV‐uninfected women. Modified Poisson regression was performed to assess the association between HIV status and fertility desire and knowledge about IUC and the implant. Results: Of 634 postpartum women surveyed, HIV‐infected women were more likely to report their most recent pregnancy was unintended (49% versus 37%, p=0.004). Nearly all women (97%) did not want a child in the next two years but HIV‐infected women were more likely to desire no more children (adjusted PR: 1.59; 95% CI: 1.33, 1.89). HIV‐ infected women were also less likely to know that IUC (adjusted PR 0.72; 95% CI: 0.61, 0.84) and the implant (adjusted PR 0.83; 95% CI: 0.75, 0.92) are safe during breastfeeding. Conclusion: Postpartum women strongly desire family spacing and many HIV‐infected postpartum women desire no more children, suggesting an important role for these long‐acting methods. Education about the efficacy and safety of IUC and the implant particularly during breastfeeding may facilitate postpartum use.

      Little, Colin; The University of Arizona College of Medicine - Phoenix; Sarko, John (The University of Arizona., 2015-04-10)
      Background and Significance: The i‐STAT point of care blood analyzer is a handheld device used for a variety of laboratory analyses in medical settings. Much research has been performed to evaluate its validity, but it has not been exhaustively tested in real‐world emergency department settings, despite its increasingly popular use in such settings. Methods: We retrospectively examined medical records at the Maricopa Integrated Health Systems Emergency Department to find 100 instances between February 2014 and September 2014 in which a patient had electrolyte testing performed on both the i‐STAT and in the central laboratory within a 60 minute timeframe. These data were examined using variance of means and Bland‐Altman graphing for equivalency. Results: We set the clinical equivalence threshold for each lab to be 5% of the mean normal value. That is, if the i‐STAT differed from central lab by less than 5% of the middle of the normal range (137‐145 for sodium, 5% of which is 7) then we consider them to be clinically equivalent. At this level we were unable to show clinical equivalence. In additional, all electrolytes tested showed small but significant bias between the i‐STAT and the central laboratory. Re‐examination of the data excluding all measurements more than 15 minutes apart showed similar findings. Conclusions: At this time we cannot show equivalency between the i‐STAT device and the central laboratory when used under real‐life emergency department conditions. More research is needed is to support or refute these findings.

      Fortin Ensign, Shannon Patricia; The University of Arizona College of Medicine - Phoenix; Tran, Nhan (The University of Arizona., 2015-04-10)
      Glioblastoma (GB) is the highest grade and most common form of primary adult brain tumors, characterized by a highly invasive cell population. GB tumors develop treatment resistance and ultimately recur; the median survival is nearly fifteen months and importantly, the invading cell population is attributed with having a decreased sensitivity to therapeutics. Thus, there remains a necessity to identify the genetic and signaling mechanisms that promote tumor spread and therapeutic resistance in order to develop new targeted treatment strategies to combat this rapidly progressive disease. TWEAK-Fn14 ligand-receptor signaling is one mechanism in GB that promotes cell invasiveness and survival, and is dependent upon the activity of multiple Rho GTPases including Rac1. Here, we show that Cdc42 is essential in Fn14-mediated Rac1 activation. We identified two guanine nucleotide exchange factors (GEFs), Ect2 and Trio, involved in the TWEAK-induced activation of Cdc42 and Rac1, respectively, as well as in the subsequent TWEAK-Fn14 directed glioma cell migration and invasion. In addition, we characterized the role of SGEF in promoting Fn14-induced Rac1 activation. SGEF, a RhoG-specific GEF, is overexpressed in GB tumors and promotes TWEAK- Fn14-mediated glioma invasion. Moreover, we characterized the correlation between SGEF expression and TMZ resistance, and defined a role for SGEF in promoting the survival of glioma cells. SGEF mRNA and protein expression are regulated by the TWEAK-Fn14 signaling axis in an NF-B dependent manner and inhibition of SGEF expression sensitizes glioma cells to TMZ treatment. Lastly, gene expression analysis of SGEF depleted GB cells revealed altered expression of a network of DNA repair and survival genes. Thus TWEAK-Fn14 signaling through the GEF-Rho GTPase systems which include the Ect2, Trio, and SGEF activation of Cdc42 and/or Rac1 presents a pathway of attractive drug targets in glioma therapy, and SGEF signaling represents a novel target in the setting of TMZ refractory, invasive GB cells.

      Dulude, Alexandra; The University of Arizona College of Medicine - Phoenix; Ramanathan, Ramesh (The University of Arizona., 2015-04-10)
      Introduction: Thousands of people die from influenza or its complications each year despite the fact that it is one of the few vaccine preventable diseases. Immunocompromised cancer patients are among the most vulnerable to this infection and flu‐related complications, and therefore vaccination is highly recommended in these patients; however, current vaccination rates and attitudes towards vaccination remain unknown. We hypothesize that immunization rates are lower than the 100% recommendation rate, and hope to understand the reasoning behind the discrepancy. The purpose of this study is to assess cancer patient attitudes towards influenza vaccination in an effort to minimize barriers to vaccination and eventually increase vaccination rates in this immunocompromised population. Methods: Cancer patients enrolled in phase I clinical oncology trials at the Virginia G Piper Cancer Center at Scottsdale Healthcare were invited to participate in a voluntary survey. The 15‐item survey consisted of demographic information, knowledge regarding the flu vaccine, vaccination status after cancer diagnosis and while on treatment, and general attitudes towards vaccination. A total of 84 cancer patients completed the survey. Results were stratified by age, gender, education level, and vaccination status. As this was a descriptive study, no statistical analyses were performed. Results: A total of 84 (n=84) advanced cancer patients enrolled in phase I clinical oncology trials completed the survey. Results indicate that although 71% of patients received the vaccine prior to cancer diagnosis, only 58% of patients have received the vaccine since their cancer diagnosis, and only 48% have been vaccinated while on cancer treatment. Of those vaccinated since cancer diagnosis, 94% reported doctor recommendation of the vaccine and most vaccinate to protect themselves from the virus. Of those not vaccinated since cancer diagnosis, only 37% report their doctor recommends the vaccine and the majority avoid vaccination because they believe the vaccine can cause the flu, they do not feel at risk of infection, and they do not believe the vaccine is effective. Conclusion: Our findings suggest that although the CDC strongly recommends influenza vaccination in cancer patients due to the risk of secondary complications and even death in these immunocompromised individuals, vaccination rates remain low. Our data demonstrates that patients who receive a doctor recommendation for the vaccine are more likely to be vaccinated, but not all doctors recommend the vaccine. Furthermore, false information regarding the vaccine, its efficacy, and its ability to cause infection continues to deter patients from vaccination. Together, this information offers profound insight into the cancer patient population and suggests the need for increased physician and patient education regarding the benefits of annual influenza vaccination to improve vaccination rates and decrease influenza infection and complications in the future.

      Ewbank, Clifton; The University of Arizona College of Medicine - Phoenix; Dougherty, Jan; Lomay, Vicky (The University of Arizona., 2015-04-10)
      Purpose: compare the Southwestern Indigenous Cognitive Assessment (SWICA), a novel tool for screening AI older adults in Arizona, with The Montreal Cognitive Assessment (MoCA), a commonly used memory screening tool, for comparison of cultural bias. Methods: Cultural bias was assessed by retrospectively comparing coded participant responses to 16 questions about their cultural context. Intrasample variation on MoCA and SWICA tests was controlled by using the participants as their own controls. Data were analyzed using a multiple regression general linear model on SPSS software. Results: Scores on the SWICA test were independently associated with English use in the home (Beta = .396, p = .026), years of education (Beta = 335, p = .027), and ease of learning (Beta = .361, p = .029), but not age (Beta = .366, p = .054). Scores on the MoCA test were independently associated with age (Beta = ‐.491, p = .001), English use in the home (Beta = ‐.320, p = .039) , and years of education (Beta = ‐.284. p = .030), but not ease of learning (Beta = ‐.267, p = .067). Conclusions: Scores were similar on both tests (t=3.934, p=.001), and were independently associated with English use in the home and years of education. SWICA was uniquely associated with ease of learning and MoCA was uniquely associated with age. This preliminary comparison demonstrates the usefulness of SWICA, and validation of this tool is recommended.

      Dahl, Aaron; The University of Arizona College of Medicine - Phoenix; Sinha, Madhumita (The University of Arizona., 2015-04-10)
      Objective: Effective physician‐patient communication is critical to the clinical decision making process. The informed consent process for any intervention can be one of the most important moments for effective physician‐patient communication in regards to outcome and liability. We studied parental recall of information provided during an informed consent discussion process prior to performance of emergency medical procedures in a pediatric emergency department of an inner city hospital with a large bi‐lingual population. Methods: Parent/child dyads undergoing emergency medical procedures were surveyed prospectively in English/Spanish, post‐procedure for recall of informed consent information. Logistic regression analysis was used; outcome variables were the ability to name a risk, a benefit, and an alternative to the procedure and predictors were language, education, and acculturation. Results: Fifty‐five parent/child dyads completed the survey. Logistic regression analysis showed that respondents with less than high school education were approximately 80% less likely to be able to name a risk or a benefit, while respondents with a high school education were approximately 24 times more likely to be able to name an alternative procedure. Conclusion: A gap in communication exists between physicians and patients during the consent taking; it is significantly impacted by socio‐demographic factors like education level, language and acculturation.

      Hintzen, Calliandra; The University of Arizona College of Medicine - Phoenix; Quan, Dan (The University of Arizona., 2015-04-10)
      Renal stones (or “calculi”) are a relatively common condition, affecting up to 12 percent of people during their lifetime. Typical presentation of renal calculi is acute, intermittent flank pain, termed “renal colic”, which may radiate to the groin. Pain may be accompanied by hematuria, nausea, or vomiting.1 Acute renal colic is a common cause for presentation to the Emergency Department, accounting for an estimated 1 million emergency room visits annually in the United States.2 The severe pain associated with renal calculi requires immediate analgesia, and effective analgesia is associated with improved functional capacity after drug administration.3 In this trial, we compare the efficacy of IV ketorolac vs. IV ibuprofen for pain control in patients with renal colic in a three‐armed double‐blind prospective trial. Patients were randomized to one of three treatment groups, receiving parenteral infusions of either IV ibuprofen + morphine, IV ketorolac + morphine, or morphine monotherapy. Outcome of drug administration was measured by patients’ self‐assessment of pain on a verbal scale at 15 mins, 30 mins, 60 min, and 120 min after drug administration. We hypothesized that IV ibuprofen would provide effective, non‐opioid pain relief in the emergency setting and might have a lower incidence of adverse effects than ketorolac. Need for rescue analgesia (with 4 mg morphine) was observed as an indirect measure of analgesic efficacy. A total of 11 patients completed the study. There was no significant difference in area under the curve of pain score in any of the three treatment arms (p>0.4). The ibuprofen group demonstrated consistent improvement in pain over the course of 120 min of study, with 100% of the patients in that arm demonstrating downtrending pain scores. Though the sample size was too small to identify a statistically significant difference in need for rescue medication, there was a trend toward increased opioid in the ibuprofen group, with 50% of those participants receiving rescue analgesia with morphine. The sample size of this pilot study is inadequate to fully assess the analgesic efficacy of IV ibuprofen for renal colic. A trend toward improved pain control in the ibuprofen group was observed, with 100% of the patients in the ibuprofen arm reporting decreased pain after 120 minutes (as compared to 66% in the ketorolac arm and 75% in the placebo arm). Further study of efficacy and need for rescue analgesia is warranted.

      Donovan, Derek; The University of Arizona College of Medicine - Phoenix; Winkelman, Tyler; McEchron, Matthew (The University of Arizona., 2015-04-10)
      Since the Affordable Care Act (ACA) was signed into law in March of 2010, there have been multiple large survey studies focusing on physicians’ thoughts towards health care policy issues. 1‐6 Unfortunately, there has not been adequate attention paid to medical students’ feelings on reform in the literature. Today’s medical students will enter their practice at a vital time in the ACA’s implementation and will play an integral role in health care reform throughout their careers.7,8 This study is a national project that used a survey tool to demonstrate how well medical students know the details of the ACA and what their feelings are on the legislation. The survey was sent to eight different medical institutions across the country with ten total medical school campuses, using SurveyMonkey to collect results. The institutions were chosen based on their geographic location, mix between private and public institutions, and available investigators at each institution. The survey tool was developed by Tyler Winkelman, MD, from the University of Minnesota after a comprehensive literature review, adaptation of items from his previous survey of medical students in Minnesota performed in 2012, and consultation with physicians and policy experts.9 The survey focuses on student’s opinion of the ACA, knowledge of nine key provisions in the ACA, level of support of key health care policies, feelings towards health care policy education in medical schools, and socio‐demographic information, including political ideology, debt amount and intended specialty. Data analysis was performed using Pearson’s Chi‐square tests and multiple logistic regression models at The University of Minnesota to test for associations between students’ opinion of the ACA and five key predictors: debt, medical school year, political ideology, ACA knowledge, and intended specialty. A total of 2,761 out of 5,340 medical students (52%) responded to the survey, with 63% of students indicating support for the ACA, 75% agreeing that they understand the key ACA provisions, and 56% indicating professional obligation to assist in implementation of the ACA. Students intending to enter surgery or a surgical subspecialty and students who identified themselves as conservative were found to have less support and professional obligation of the ACA when compared to students entering primary care (Internal medicine, family medicine, pediatrics, internal medicine/pediatrics, or emergency medicine) or identifying themselves as liberal or moderate. Students that were most knowledgeable of the ACA were found to more likely support the ACA and indicate professional obligation towards the legislation. In conclusion, our study found that the majority of medical students indicate support for the ACA and feel they have a professional obligation in assisting implementation. The views of the ACA differ based on student’s political ideology, anticipated specialty, and knowledge of key ACA provisions, but overall, there is optimism that this high level of support can lead to advocacy and successful health care reform down the road.

      Jugler, Tanner; The University of Arizona College of Medicine - Phoenix; Hartmark-Hill, Jennifer (The University of Arizona., 2015-04-10)
      This pilot project explores medical student preference regarding simulation education in case based instruction (CBI) compared with the traditional Power Point lecture CBI. The study population consisted of volunteer first, second, third, and fourth year medical students. The subjects were randomized into control (traditional CBI) and intervention (simulation CBI) groups and preference data was collected via pre‐ and post‐survey administered before and after the activity. Preference was limited to enjoyment of learning activity and opinion of benefit on exams of the learning activity. T‐tests were applied to the data in order to determine statistical significance. Enjoyment of the simulation activity was determined to be higher post‐simulation activity in the intervention group compared to the control group. While opinion that simulation CBI may be beneficial in regard to exam scores and knowledge retention was above neutral for the two groups, this study did not determine a significance in opinion between the control and intervention groups. The study results suggest that students who have experienced a simulation CBI enjoy them more compared to the traditional CBI and are more in favor of changing the current model of case‐based instruction.