• PEDIATRIC PAIN ASSESSMENT PRACTICES AND PREFERENCES OF EMS PROVIDERS

      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.
    • PILOT STUDY: A NOVEL APPROACH TO CASE‐BASED INSTRUCTION OF MEDICAL STUDENTS USING SIMULATION EDUCATION

      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.
    • THE POTENTIAL FOR MORAL HAZARD IN AN ALLOPATHIC INTERVIEW SETTING

      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.
    • THE RELATIONSHIP OF PLAQUES, TANGLES, AND LEWY‐TYPE ALPHA‐SYNUCLEINOPATHY TO VISUAL HALLUCINATIONS IN PARKINSON’S DISEASE AND ALZHEIMER’S DISEASE

      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.
    • RESCUE ECHOCARDIOGRAPHIC FINDINGS ARE DIFFERENT BASED ON PATIENT SETTING

      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.
    • THE ROLE OF TURMERIC AS AN ADJUVANT THERAPEUTIC FOR OSTEOLYTIC BREAST CANCER BONE METASTASES

      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.
    • TRENDS IN CHLAMYDIA TRACHOMATIS INFECTION IN MARICOPA COUNTY ADOLESCENTS, 2006‐2010

      Breslauer, Cori Ann; The University of Arizona College of Medicine - Phoenix; Mickey, Tom; Taylor, Melanie (The University of Arizona., 2015-04)
    • THE TWEAK-FN14 LIGAND RECEPTOR AXIS PROMOTES GLIOBLASTOMA CELL INVASION AND SURVIVAL VIA ACTIVATION OF MULTIPLE GEF-RHO GTPASE SIGNALING SYSTEMS

      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.
    • VARIABLES IMPACTING DENGUE SURVEILLANCE IN KEY WEST FLORIDA

      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.
    • WATCHFUL WAITING: DEFERRED LADD PROCEDURE IN PATIENTS WITH CONGENITAL HEART DISEASE, HETEROTAXY SYNDROME, AND KNOWN INTESTINAL MALROTATION

      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.
    • “WATCHING” WHAT WE EAT: WHAT TELEVISION IS MODELING

      Cavallo, Katherine; The University of Arizona College of Medicine - Phoenix; Coles, Sarah (The University of Arizona., 2015-04-09)
      Background: Obesity has transitioned from an individual health concern to being a national problem with almost two‐thirds of the adult population in the United States now overweight or obese1. Television potentially provides a medium in which to model healthy and unhealthy behaviors to millions of viewers each week. Although there is no quick solution to obesity, promoting and normalizing healthy lifestyles in today’s most viewed shows may be one tool to help combat an obesogenic lifestyle. Research Question: To what degree do today’s most popular sitcoms model healthy and unhealthy behaviors? Methods: A scorecard with 11 behaviors (6 healthy and 5 unhealthy) was created using publically published guidelines from the Center for Disease Control (CDC)1,2,3, World Health Organization (WHO)4, and the United States Department of Agriculture (USDA)5,6. The top three sitcoms for the 2013‐2014 season, as determined by TV Guide, were viewed and analyzed by one evaluator. These included The Big Bang Theory, The Millers, and Modern Family7. Results: In total, 898 unhealthy behaviors and 532 healthy behaviors were portrayed. The Big Bang Theory demonstrated the most behaviors overall and had the most favorable ratio of healthy to unhealthy behaviors at 1/1.1, compared to 1/3.8 for The Millers and 1/3.2 for Modern Family. The most common unhealthy behavior viewed was beverage choice with 492 occurrences. One of the least portrayed healthy behaviors was moderate physical activity with only 47 instances. In two of the three shows, there were remarkably few examples of fruit and vegetable consumption. Conclusion: Today’s top three sitcoms expose their viewers to many healthy and unhealthy behaviors during the span of a 22‐minute show. Significantly more unhealthy behaviors were portrayed than healthy behaviors. The most common unhealthy behavior centered on beverage choice. This is a behavior that can easily be adjusted to promote a healthier lifestyle. Additionally, food content could reflect more healthy choices. Television shows reach millions of viewers each week and may prove to be a useful tool in helping to reinforce and normalize healthy lifestyle choices.