• 

  Primary Care Attitudes & Culture at the University of Arizona College of Medicine-Phoenix

  Puracan, Jasper; The University of Arizona College of Medicine - Phoenix; Briney, Stephanie (The University of Arizona., 2021)

  Introduction. There has been prior research that indicate perceptions held by medical students regarding the field of primary care in medicine can change over time, whether through direct intervention or naturally as a consequence of a medical school’s curriculum. However, the currently held beliefs of medical students and faculty at the University of Arizona College of Medicine – Phoenix (UACOM-P) is unknown. Methods. A cross-sectional study was performed to assess attitudes and beliefs held by members of the UACOM-P community regarding the field of primary care. A Qualtrics survey instrument was developed and distributed to medical students and faculty at UACOM-P in the summer of 2019, with responses from 75 medical students and 33 faculty members. Results. Analysis indicate that there is a generally positive view held by the study population towards primary care, though the strength of endorsement of certain aspects differed between medical students and faculty. There also appeared to be differences between subgroups under both populations, such as Certificate of Distinction versus dual degree students and physician versus non-physician faculty. Discussion. The UACOM-P community has an overall positive attitude toward the field of primary care, with notable differences in some cases. Follow-up studies that may come after this investigation must capture more of the target population and consider impacts of global events such as the COVID-19 pandemic in order to negate potential confounding factors and biases. Future, well designed longitudinal research that assesses how these beliefs change overtime can shed more light on the primary care culture at UACOM-P and can inform campus leadership on future directions to take to support the mission of the program.
• 

  CT Texture Analysis (CTTA): Developing a Diagnostic Imaging Biomarker for KRAS Mutation in Metastatic Colon Cancer

  Khurana, Sukhdeep; The University of Arizona College of Medicine - Phoenix; Silva, Alvin (The University of Arizona., 2021)

  PURPOSE To evaluate multi-parametric modeling on imaging textures from contrast-enhanced, multiphasic computed tomography (CT) for identification of Kirsten rat sarcoma (KRAS) gene mutations in metastatic colon cancer to the liver. METHOD AND MATERIALS This retrospective study included 99 patients diagnosed histologically with colon cancer: 51 KRAS wild-type and 48 KRAS gene mutation. Matched-size regions of interest (ROIs) were drawn over viable tumor and unaffected background liver on multiphase CT. Paired ROIs were spatially rescaled, intensity-normalized, and then analyzed using 3 Texture Algorithms: GLCM, LBP, and Gabor. Feature selection method was based on KNN classifier and DEFS (Differential Evolution-based Feature Selection). For each of the 30 independent experiments, patients were randomly allocated into training (n = 79) and testing (n = 20) datasets to develop predictive models for KRAS gene mutation. Classification models were generated based on: 1) All features; and 2) Selected features as per DEFS. RESULTS Predictive models utilizing all 56 features (13 GLCM, 26 LBP, and 14 Gabor) resulted in an average accuracy/sensitivity/specificity of 61/54/62%; ranging from a single best model (80/80/90%) to a single worst model (35/20/20%). Predictive models utilizing a DEFS optimized 3-feature subset resulted in average accuracy/sensitivity/specificity of 89/80/84%; ranging from a single best model (95/92/96%) to a single worst model (80/68/68%). Among the three texture algorithms, LBP provided better discriminatory power compared to GLCM and Gabor. CONCLUSION Utilizing advanced analytics with machine learning techniques (CTTA and DEFS selection analysis), multi-textural data obtained from conventional, multiphase CT images has the capability to detect a therapeutically relevant genetic aberration (KRAS mutation) in metastatic colon cancer with high accuracy, sensitivity and specificity.
• 

  A Comprehensive Institutional Overview of Intrathecal Nusinersen Injections for Spinal Muscular Atrophy

  Mousa, Mohammad; The University of Arizona College of Medicine - Phoenix; Towbin, Richard (The University of Arizona., 2021)

  Background: Spinal muscular atrophy (SMA) is an autosomal recessive neuromuscular disorder resulting in progressive muscle weakness. In December 2016, the U.S. Food and Drug Administration approved the first ever treatment for SMA, a drug named nusinersen (Spinraza) which is administered intrathecally. However, many SMA patients have neuromuscular scoliosis and/or spinal instrumentation resulting in challenging intrathecal access. Therefore alternative routes must be considered in these complex patients. Methods: This study was reviewed and approved by our institution’s institutional review board. From March to December 2017, institutional SMA patients were referred for intrathecal nusinersen injections. In select patients with spinal hardware, spinal imaging was requested to facilitate pre-procedure planning. Standard equipment for intrathecal injections was utilized. All patients were followed-up by their referring neurologist. Results: A total of 104 intrathecal nusinersen injections were performed in 26 patients with 100% technical success. 60 procedures were performed without pre-procedural imaging and via standard interspinous technique. The remaining 44 procedures were performed in 11 complex (i.e. neuromuscular scoliosis and/or spinal instrumentation) patients requiring pre-procedural imaging for planning purposes. 19 of 44 complex procedures were performed via standard interspinous technique from L2 to S1. 22 of 44 complex procedures were performed using a neural-foraminal approach from L3 - L5. 3 of 44 complex procedures were performed via cervical puncture technique. There were no immediate or long-term complications but 1 short term complication of meningismus and back pain at the injection site. Conclusion: Although we achieved 100% technical success in intrathecal nusinersen administration, our practice habits evolved during the course of this study. Our early experience has led to the development of an algorithm to assist in promoting safe and effective nusinersen administration in children with Spinal Muscular Atrophy regardless of SMA type, abnormal spinal anatomies and complex spinal instrumentation.
• 

  Increased Risk of Depression in Patients with Crohn’s Disease

  Smith, Savion; The University of Arizona College of Medicine - Phoenix; Alishahi, Yasmin (The University of Arizona., 2021)

  Introduction Individuals with IBD have been shown to be at an increased risk of developing depression and anxiety. Previous work has demonstrated patients with UC were more likely to report depressive symptoms preceding their diagnosis of IBD than the general population. Young patients with CD also have a greater risk for developing anxiety disorders. One study demonstrated mental conditions are often diagnosed within one year prior to UC diagnosis. This signifies that psychiatric disorders may either be a consequence of early symptoms of the undiagnosed gastrointestinal condition or may increase an individual’s susceptibility to develop IBD. Psychological disease may amplify symptom severity, particularly abdominal pain perception in adults with IBD. Previous work has demonstrated that psychological state may influence perception of abdominal pain and patients with depression were more likely to take IBD-related disability. Methods This was a retrospective chart review. We used a subset of Veterans charts from the national VA database. Patient charts were divided into two groups: CD with depression and CD without depression (control). From the CD with depression group, all patients with a diagnosis of Crohn’s disease with depression were used, however, patients with a diagnosis of CD who did not receive treatment at the VA were excluded. Patients were considered in remission if their most recent colonoscopy showed no active disease. Patients were considered to have active disease if their most recent colonoscopy demonstrated signs of inflammation. When reported, depression severity was recorded in charts as mild, moderate or severe. From this we created a depression severity score by converting them to numerical values (mild=1, moderate=2, severe=3). Severity score is recorded as an average of these values. Results A total of 159 patient charts were included in this study, 122 from the Depression group and 37 from the no depression group. The odds of active Crohn’s Disease increased with depression (odds ratio [OR], 2.88; 95% confidence interval [CI], 1.21-6.81; p>0.016). The odds of depression also increased with substance abuse (odds ratio [OR], 3.87; 95% confidence interval [CI], 1.28-11.7; p>0.016) and PTSD (odds ratio [OR], 6.39; 95% confidence interval [CI], 1.85-22.0; p>0.003). Mean depression severity score of remission patients was 2.00 and mean depression severity score for active Crohn’s patients was 2.06. Notably, patients the odds of having more severe depression were higher for tobacco users (users: odds ratio [OR], 2.14; mean [SD], 2.14 [0.38]; 95% confidence interval [CI], 0.35-6.14; p>0.59; non-users: mean [SD], 1.96 [0.77]) and patients with substance abuse (users: odds ratio [OR], 2.37; 95% confidence interval [CI], 0.69-8.20; mean [SD], 2.21 [0.58]; p>0.17; non-users: mean [SD], 1.88 [0.77]) . Discussion These findings provide additional evidence that depression is associated with increased Crohn’s disease activity in the Veteran population. Based on this data, one may consider that treating an individual’s depression may reduce the frequency and severity of Crohn’s disease activity. There may be benefits to holistically treating a patient’s IBD through also evaluating and monitoring his or her psychological health. Other studies have demonstrated the likelihood that psychiatric disorders often co-exist with inflammation, infections, and autoimmune diseases. Furthermore, our data demonstrated strong associations found between substance abuse and the likelihood of depression. Interestingly, our results indicated no association for the measured CRP and calprotectin between the Crohn’s Disease with depression and the Crohn’s disease without depression groups.
• 

  Chest Compression Release Velocity Factors During Out-of-Hospital Cardiac Resuscitation

  Beger, Samuel; The University of Arizona College of Medicine - Phoenix; Bobrow, Bentley (The University of Arizona., 2021)

  Background: Higher chest compression release velocity (CCRV) has been associated with better outcomes after out-of-hospital cardiac arrest (OHCA), and patient factors have been associated with variations in chest wall compliance and compressibility. We evaluated whether patient sex, age, weight, and time in resuscitation were associated with CCRV during pre-hospital resuscitation from OHCA. Methods: Observational study of prospectively collected OHCA quality improvement data in two suburban EMS agencies in Arizona between 10/1/2008 and 12/31/2016. Subject-level mean CCRV during the first 10 minutes of compressions was correlated with categorical variables by the Wilcoxon rank-sum test and with continuous variables by the Spearman’s rank correlation coefficient. Generalized estimating equation and linear mixed-effect models were used to study the trend of CCRV over time. Results: During the study period, 2,535 adult OHCA cases were treated. After exclusion criteria, 1,140 cases remained for analysis. Median duration of recorded compressions was 8.70 minutes during the first 10 minutes of CPR. An overall decline in CCRV was observed even after adjusting for compression depth. The subjectlevel mean CCRV was higher for minutes 0-5 than for minutes 5-10 (mean 347.9 mm/s vs. 339.0 mm/s, 95% CI of the difference -12.4 ~ -5.4, p < 0.0001). Males exhibited a greater mean CCRV compared to females [344.4 mm/s (IQR 307.3-384.6) vs. 331.5 mm/s (IQR 285.3-385.5), p=0.013]. Mean CCRV was negatively correlated with age and positively correlated with patient weight. Conclusion: CCRV declines significantly over the course of resuscitation. Patient characteristics including male sex, younger age, and increased weight were associated with a higher CCRV.
• 

  Resolution of Diabetes Mellitus with Laparoscopic Sleeve Gastrectomy

  Daas, Eshaan; The University of Arizona College of Medicine - Phoenix; Soto, Flavia (The University of Arizona., 2021)

  Background: Laparoscopic sleeve gastrectomy (LSG) is a proven intervention to induce weight loss. Its applications as a surgical procedure may extend beyond body weight control to the realm of metabolic therapy in chronic conditions such as diabetes mellitus (DM), which results from the dysregulation of blood glucose levels. Objective: The aim of this study is to evaluate the improvement and resolution of diabetes following sleeve gastrectomy at our facilities. Setting: Two affiliated non-profit surgery centers, United States Methods: Eighty-two adult diabetic patients were treated with sleeve gastrectomy. We conducted a single point analysis of our existing longitudinal data for that calendar year through a retrospective chart review. Statistical outcomes were determined for anthropometric data unique to patients with DM including prescribed medications, Hemoglobin A1C, excessive weight loss (EWL), and body mass index (BMI). Results: Time was a significant predictor of diabetic resolution after six months post-op in patients who originally presented with Type 1 DM and change in hemoglobin A1C values held a significant association to improvement of Type 1 diabetes. BMI and EWL displayed a positive correlation to resolution at all time points of interest. Conclusions: There are differences between the post-operative improvements in diabetic status following sleeve gastrectomy depending on the initial diagnosis of insulin-dependent or insulinindependent DM. Pathophysiological mechanism of a patient’s diabetic condition, specifically auto-immune destruction of pancreatic beta cells, may contribute to the variable metabolic response following sleeve gastrectomy.
• 

  Validation of PI-RADS v2 Scores at Various Non-University Radiology Practices

  Austin, Evan; The University of Arizona College of Medicine - Phoenix; Chang, John (The University of Arizona., 2021)

  Purpose: Validate the second version of the Prostate Imaging Reporting and Data System (PIRADSv2) scores in predicting positive in-bore MRI guided targeted prostate biopsy results across different non-university related institutions. Materials and Methods: This was a retrospective review of 147 patients who underwent multiparametric magnetic resonance imaging followed by in-bore MRI guided targeted prostate biopsy from 2014-2018. Lesions were rated according to PI-RADS v2 criteria. Scores were compared to MR-guided biopsy results and pre-biopsy PSA values. Results: Prostate Cancer (PCa) was detected in 54% (80/147) of patients, with more prostate cancer being detected with each increase in PI-RADS scores. Biopsy results with PI-RADS 3, 4, and 5 lesions resulted in PCa in 25.6% (10/39), 58.1% (33/55), and 86.0% (37/43) respectively. Clinically significant PCa (Gleason score ≥7) was detected in 17.9% (7/39), 52.7% (29/55), and 72% (31/43) of cases for PI-RADS 3, 4, and 5 lesions respectively. When PI-RADS scoring/biopsy results were compared across different institutions, there was no difference in the PI-RADS scoring or in positive biopsy rates.. The sensitivity, specificity, PPV, and NPV for PIRADS 3-4 were not statistically different across the institutions for detecting Gleason 7 or greater lesions. Conclusion: Our results agree with prior studies that higher PI-RADS scores are associated with clinically significant PCa and suggest lesions with PI-RADS 3-5 have sufficient evidence to warrant biopsy. Comparison of PI-RADS across different types of non-university practices revealed no difference in scoring/biopsy outcome, suggesting that PI-RADS v2 can be easily applied outside of the university medical center setting.
• 

  Interprofessional Escape Room: Evaluating Teamwork among Healthcare Profession Students

  Hearn, Jaimie; The University of Arizona College of Medicine - Phoenix; Denny, Lee Anne (The University of Arizona., 2021)

  Purpose: The aim of this study is to evaluate interprofessional teamwork amongst health professions students in an escape room and compare the evaluation of teamwork to the time it takes to “escape the room.” Methods: 42 interprofessional student teams of MD, PA, PT, and OT students participated in an escape room and 40 teams were included in the final data analysis. Each team was evaluated using a modified version of the Jefferson Teamwork Observation Guide (JTOG). Primary outcomes: total JTOG score, overall impression of teamwork score, and escape room time. Secondary outcomes: IPEC theme scores (themes represented in the JTOG) of leadership, communication, roles and responsibilities, and values and ethics. Results: Total JTOG scores had little correlation to escape room time (correlation coefficient = 0.084). Teams with higher overall impression scores tended to escape faster; for every 1-point increase in score, escape room time decreased by 4.78 minutes (95% CI - 7.01, -2.55; p<0.001). For every 1-point increase in the leadership theme, teams took 1.07 minutes longer to escape (95% CI 0.11, 2.04; p=0.031). For every 1-point increase in the teamwork theme, teams took 15.2 minutes longer to escape (95% CI 6.61, 23.7; p=0.001). For every 1-point increase in the communication theme, teams escaped 2.55 minutes faster (95% CI -5.33, 0.23; p=0.07). Conclusion: Teams that escaped the room the fastest had higher overall impression scores of teamwork and higher communication theme scores. Overall, greater team functioning and communication clinically translates to teams being faster and more efficient at problem-solving and moving through tasks.
• 

  First-year Medical Student Clinical Confidence on Global Health Immersion Trip

  Taylor, Kristin; The University of Arizona College of Medicine - Phoenix; Ross, Robin (The University of Arizona., 2021)

  Introduction There are few reports demonstrating the clinical benefits of global health trips specifically for first-year medical students. The aim of this study was to determine whether first-year medical student confidence in clinical diagnosis improved over their week-long global health immersion trip and to determine what kinds of diagnoses medical students felt confident in making in a global health setting after their first year of medical school education. Methods This study was a survey involving confidence ratings in diagnoses provided by University of Arizona College of Medicine- Phoenix first year medical students who participated in a weeklong medical trip to bateyes (rural communities of sugar cane workers) surrounding Santo Domingo, Dominican Republic in 2019. This study received IRB approval. Confidence in diagnosis was determined by a five-point Likert scale. Diagnoses were separated into categories by body system. Results There were no significant differences in student confidence ratings over time when including all time points. There was a statistically significant increase in confidence from 5/28 and beyond (p=0.001). There were no significant differences in student confidence ratings amongst category of diagnosis. Discussion The results demonstrated that overall, students reported similar confidence throughout the trip. There was a large decrease in confidence level from the first to the second time point and this is likely attributable to being redirected by attending supervision. Confidence then gradually increased throughout the trip. Unfortunately, weaknesses in certain subject areas were not able to be elicited as students reported similar confidence for all categories
• 

  Current Trends of Clostridioides difficile infections (CDI) in the United States: Results from the National Inpatient Sample Database

  Zamarripa, Alec; The University of Arizona College of Medicine - Phoenix; Kannadath, Bijun (The University of Arizona., 2021)

  Background Clostridioides difficile infection (CDI) is a cause of significant hospital morbidity and mortality in the United States. Objective Our aim was to analyze the current trends of CDI burden using the National Inpatient Sample (NIS) database, which tracks all hospital discharges in the United States. Methods Using the NIS, all adult discharges (age ≥ 18 years) between 2012 and 2017 were evaluated. Discharges with CDI were identified based on the appropriate ICD9 (00845) and ICD10 (A047, A0471, A0472) codes. All data was analyzed after applying recommended weights using Stata Statistical Software: Release 16. (College Station, TX) and pandas statistical package in Python. Main Measures The overall CDI trends, including incidence, mortality, age, and length of stay were analyzed. The incidence and mortality rates were also analyzed with respect to race, sex, comorbidity (diabetes, hypertension, hyperlipidemia), and hospital location, size, and ownership. Key Results Records representing 181,132,460 adult discharges in the United States over 6 years (2012 – 2017) were included in the analysis; of these, 2,088,825 (1.15%) discharges had CDI. Overall incidence increased until peaking in 2015 at 1.21%, before declining to 1.06% in 2017. Despite the fluctuation in incidence rate, the mortality rate exhibited a steady decrease from 7.32% in 2012 to 6.25% in 2017. Also, the average length of stay decreased from 10.6 days to 9.9 days, along with average age of CDI patients dropping from 67.9 years to 66.2 years. Incidence and mortality rates were consistently higher in males compared to females. Incidence was typically higher in White Americans; however, Asians/Pacific Islanders regularly demonstrated the highest mortality rates during the study period. Finally, incidence and mortality rates were highest in large-bedded, urban teaching hospitals. Conclusion Improvement in overall mortality rate (Δ -1.07%) outpaced improvement in the incidence rate (Δ -0.09%), which may be indicative of improved diagnosis and management of CDI. Specifically, the adoption of oral vancomycin and fidaxomicin as standard treatments may be a key reason for our findings. However, primary prevention efforts are still struggling to effectively control the spread of CDI, especially in large-bedded, urban teaching hospitals – this may be due in part to a higher acuity patient population. Despite limitations, these findings suggest a lessening of overall burden of CDI in the United States.
• 

  The impact of medical student research as a discussion topic during the residency interview process

  Daus, Kelly; The University of Arizona College of Medicine - Phoenix; McEchron, Matthew (The University of Arizona., 2021)

  Background: Students with a greater number of research experiences are more successful in the National Residency Match Program (NRMP.) As a result, approximately two-thirds of allopathic medical schools have implemented a scholarly research project (SP) as a part of their curriculum. While inclusion of a SP in the medical school curriculum increases research productivity, literature to date has not investigated its ability to provide students with a means to communicate their scholarly strengths to residency programs during interview discussions. Methods: 123 students from the graduating class of 2019 and 2020 at the University of Arizona College of Medicine Phoenix (UACOMP) completed a 17-question survey examining the student’s SP and whether they completed additional research. Survey participants were asked to quantify how many residency interviewers asked about their SP or additional research during the interview process. Results: 27% of interviewers (SD 27.0) asked students about their SP and 41% of interviewers (SD 32.0) asked students about additional non-SP research. 40% of interviewers asked about research overall to include SP and/or non-SP research. A greater percentage of interviewers (50%, SD 26.2) asked students about their SP if they had undertaken additional research compared to interviewers of students who did not undertake additional research (29%, SD 28.4, p = 0.0237). A greater percentage of interviewers at academic institutions (31%, SD 27.9) asked students about their SP, compared with a smaller percentage of interviewers at predominantly non-academic programs (22%, SD 25.5, p = 0.0054). There were no significant differences in the proportion of interviewers asking about the SP based on the type of specialty, competitiveness of specialty, topic relatedness of project, and publication/presentation status of project. Conclusion: Student research experiences may serve as a meaningful discussion topic during the residency interview. Approximately one-third of interviewers ask about the SP regardless of specialty, research topic, and publication/presentation status of the project. Students with additional research experiences beyond their SP may experience a higher percentage of interviewers asking about their SP. Also, students applying to predominantly academic programs may experience a higher proportion of interview questions about research compared to peers interviewing at non-academic programs.
• 

  Shift in electrocorticography electrode locations after surgical implantation in children

  Munter, Bryce; The University of Arizona College of Medicine - Phoenix; Foldes, Stephen (The University of Arizona., 2021)

  Interpreting electrocorticography (ECoG) in the context of neuroimaging requires that multimodal information be integrated accurately. However, the implantation of ECoG electrodes can shift the brain impacting the spatial interpretation of electrode locations in the context of pre-implant imaging. We characterized the amount of shift in ECoG electrode locations immediately after implant in a pediatric population. Electrode-shift was quantified as the difference in the electrode locations immediately after surgery (via post-operation CT) compared to the brain surface before the operation (preimplant T1 MRI). A total of 1140 ECoG contracts were assessed across 18 patients ranging from 3 to 19 (12.1 ± 4.8) years of age who underwent intracranial monitoring in preparation for epilepsy resection surgery. Patients had an average of 63 channels assessed with an average of 5.64 ± 3.27 mm shift from the pre-implant brain surface within 24 h of implant. This shift significantly increased with estimated intracranial volume, but not age. Shift also varied significantly depending of the lobe the contact was over; where contacts on the temporal and frontal lobe had less shift than the parietal. Furthermore, contacts on strips had significantly less shift than those on grids. The shift in the brain surface due to ECoG implantation could lead to a misinterpretation of contact location particularly in patients with larger intracranial volume and for grid contacts over the parietal lobes.
• 

  Shielding Anatomy Outside of the Direct Radiation Beam: Appropriate Practice or More Harm than Good?

  Sitton, Zach; The University of Arizona College of Medicine - Phoenix; Gridley, Daniel (The University of Arizona., 2021)

  Introduction/Background: Lead shields have been used for decades to reassure patients and clinicians that radiosensitive areas (e.g., gonads, thyroid) are protected during radiography. Despite this common practice, supporting data have been limited and conflicting. Further examination of this practice is warranted to improve patient safety. The purpose of this study was to measure the effect of a pelvic lead shield on radiation dose during a chest radiograph. Methods: For 50 consecutive pediatric chest radiographs, 2 nanoDot™ dosimeters were affixed to either side of the pelvic lead shield, which was placed according to existing protocols. After the exam, dosimeters were labeled with the position (in front of or behind the shield) and a patient identifier. Radiation doses from the dosimeters were measured and recorded along with the patient’s age, gender, weight, exam type (anteroposterior or posteroanterior), and technologist identifier. For a small subset of the exams, the mA and kVp were recorded. Results: The median radiation dose measured in the front of the shield was 33.7 mrad, while the median radiation dose measured behind the shield was 33.4 mrad. The median absolute dose reduction demonstrated a statistically significant decrease of 1.01 mrad (p=0.02) behind the shield, with an interquartile range of -0.93 to 2.79 mrad. The trend did not significantly vary by technologist. There were no statistically significant trends based on patient age, weight, weight percentile for age, exam type, mA, or kVp. Discussion/Conclusion: Using a pelvic shield results in a statistically significant reduction in radiation dose behind the shield during chest radiography. However, the median dose reduction of 1.01 mrad was 3% of the total median dose and is equivalent to 1 day of natural background radiation exposure. Therefore, the difference in radiation dose in front of and behind the lead shield may be statistically but not clinically significant. Additionally, the variation between exams was large, with approximately 1/3 of the exams recording an increased dose behind the lead shield. The long-held assumption that lead shielding provides marked radiation dose reduction should be reconsidered, as the effective dose difference may be negligible and not clinically
• 

  A race against time: Does Epinephrine compliance by emergency physicians increase ROSC in cardiac arrest patients

  Pho, Karen; The University of Arizona College of Medicine - Phoenix; Stites, Daniel (The University of Arizona., 2021)

  One of the most crucial medicinal intervention during a cardiac arrest is epinephrine. Advanced cardiac life support (ACLS) guidelines lays out the recommendation of delivering epinephrine every 3 – 5 minutes. The purpose of this study is to evaluate if physicians are compliant with delivering epinephrine as recommended, and how does compliance vs. non-compliance affect patient outcomes as measured by attaining return of spontaneous circulation (ROSC). The design of this study is a retrospective chart review with analysis, using Wilcox-Rank sum and Chi-Square fisher exact test to evaluate for statistical significance, which was defined with a P value < 0.05. There were 111 patient charts included in the study, and the results were charted into 3 categories: demographics by non-compliance, any non-compliance and mean non-compliance, and demographics by sinus rhythm. None of the results showed any statistical significance except for the mean number of doses a patient receives to achieve sinus rhythm, which was a mean of 10.3 vs 3.95. Although this study did not achieve statistical significance overall, it highlighted some clinical significance that may be of importance moving forward for all physicians. One clinical aspect that this study highlights further is the health disparity that people of color encounter. Patients who are people of color experienced higher mean number of noncompliance and percentage of any non-compliance. The overall conclusion that this study emphasized is that more studies into the overall quantity of epinephrine given during resuscitation may be worthwhile. Additionally, further emphasis on the importance of physician awareness of health disparity among people of color is needed.
• 

  Should Gastrojejunostomy Tubes be Changed Every Three Months? A Two-Year Single Institution Retrospective Analysis of Unscheduled Gastrojejunostomy Tube Changes

  Kaur, Manroop; The University of Arizona College of Medicine - Phoenix; Wong, Kevin (The University of Arizona., 2021)

  Background: To date there is a significant lack of data on the best practices for maintaining gastrojejunostomy tubes (GJ) in pediatric medicine. Purpose: To determine the average longevity of a GJ tube, the reasons for GJ tube change, and the cumulative radiation dose associated changes. Methods: A single institution retrospective chart review of patient data over a two-year period was performed utilizing an MPower database to identify GJ exchanges/replacements. An exchange was defined as a correctly positioned GJ tube and replacement as a mispositioned GJ tube. The patients’ age, fluoroscopy time, time between change, brand of tube, and reason for replacement were recorded and statistical analysis performed. Results: 143 patients were identified, with a total of 534 GJ changes performed. There were 331 exchanges and 203 replacements. The average length between procedures was 140.6 days with an average fluoroscopy time of 1.76 minutes. Cumulative fluoroscopy time annually was significantly higher if a patient needed a replacement (11.4 minutes) versus an exchange (0.92 minutes). G-JET® brand was more likely to malfunction (8.9%) due to a valve issues compared to MIC-KEY® (3.3%), p = 0.03. MIC-KEY® was three times more likely (OR = 3.01) to be replaced for malposition or leaking, p= 0.009. Conclusion: Current guidelines set by manufacturers can be extended from 3 months to nearly 5 months. Tube replacements result in significantly higher radiation exposure compared to exchanges. Further studies are needed to ascertain whether scheduling has a lower rate of exchanges vs not scheduling.
• 

  Impact of Prenatal Visit Utilization on Pregnancy Outcomes within Differing Risk Populations

  Young, Rebecca; The University of Arizona College of Medicine - Phoenix; Erickson, Laurie (The University of Arizona., 2021)

  Objectives: To investigate the association between number and timing of prenatal visits (PNV) and pregnancy outcomes within differing maternal risk populations [non-high-risk (“non-HR”) and high-risk (“HR”)]. Methods: Retrospective study of mothers who delivered at Banner University Medical Center Phoenix during the 2017 calendar year. Inclusion criteria included maternal documentation at time of delivery of either: complete absence of PNV or complete PNV records. Maternal groups were either classified as “non-HR” or “HR” if received any of the following diagnoses: advanced maternal age (AMA), obesity, diabetic (DM) disorders, hypertensive (HTN) disorders, or asthma. Data collection included total PNV quantity per pregnancy and trimester. Pregnancy outcomes included labor interventions, labor complications, delivery complications, and adverse neonatal outcomes. Result: Of 503 mothers in the cohort, 324 met inclusion criteria and were evenly split between non-HR (159, 49.07%) and HR mothers (165, 50.93%). Pregnancy outcomes were then compared within same risk group depending on total pregnancy PNV utilization category [low (≤8 PNV), mid (9-11 PNV), and (≥12 PNV] and frequency of PNV per trimester (“T1,” “T2,” or “T3”). Non-HR mothers with a higher total PNV category were more likely to have labor interventions (odds ratio [OR] 4.02; 95% confidence interval [CI] 1.26-12.9, p = 0.019). Non-HR mothers with higher quantities of PNV in T3 were less likely to have labor interventions (OR 0.69; 95% CI 0.48-0.98, p = 0.039). HR mothers with higher PNV quantities in T1 and T2 were less likely to have labor interventions (T1: OR 0.34; 95% CI 0.13-0.91, p = 0.032) (T2: OR 0.42; 95% CI 0.21- 0.84, p = 0.015). HR mothers with higher quantities of PNV in T2 were less likely to have labor complications (OR 0.70; 95% CI 0.51-0.98, p = 0.043). Conclusions for Practice: Labor interventions were less likely found by non-HR mothers with higher quantities of PNV in T3 and by HR mothers with higher quantities of PNV in T1 and T2. Labor interventions were more likely found by non-HR mothers with a higher total PNV category. Labor complications were less likely found by HR mothers with higher quantities of PNV in T2. Limitations include small sample size and study would therefore benefit from further investigation. Anticipated clinical benefits could include contributing to the development of tailored PNV recommendations dependent on maternal health history ultimately resulting in increased cost savings, decreased unnecessary interventions, and decreased poor outcomes.
• 

  A Case Study: The Effect of Hormone Therapy on Vascular Function in a Male-to-Female Transgender Endurance Athlete

  Statham, Sally; The University of Arizona College of Medicine - Phoenix; Angadi, Siddhartha (The University of Arizona., 2021)

  The aim of this case study was to assess vascular function in a 27-year-old male-to-female transgender endurance athlete before hormone therapy and during treatment with gender affirming hormone therapy (GAHT) in an effort to better understand the effects of estrogen therapy and testosterone blockade on male vascular physiology. Testing occurred at 4-8 week intervals for 19 months. At each visit, testing included measurement of blood hormone levels including free testosterone, total testosterone and estradiol, resting heart rate and blood pressure, non-invasive central blood pressure measurements, pulse wave velocity (PWV), ultrasound quantified arterial flow mediated dilation (FMD), and dual-energy x-ray absorptiometry (DEXA) scans. These data were analyzed over time to observe gross trends and then analyzed for correlation. Visceral body fat measured remained unchanged from baseline after 15 months gender affirming hormone therapy. Systolic and diastolic blood pressures increased throughout treatment and systolic pressures were positively correlated with time. PWV showed signs of decreasing arterial stiffness after initiation of GAHT, but returned to baseline by the end of the study. FMD trended downwards initially with GAHT, indicating reduced vascular reactivity, but returned towards baseline following sustained treatment with GAHT. More research is needed to examine the long-term effects of gender affirming hormone therapy on vascular function, blood pressure, and vascular stiffness.
• 

  Assessing Middle Cerebral Artery Blood Flow Velocities and Outcomes in Pediatric Severe Traumatic Brain Injury using Transcranial Doppler Ultrasound

  Maykowski, Philip; The University of Arizona College of Medicine - Phoenix; Adelson, P. David (The University of Arizona., 2021)

  Objective: To assess the impact cerebrovascular flow velocities of pediatric traumatic brain injury (TBI) patients using transcranial doppler (TCD) and to assess for acute and long-term clinical correlations. Methods: This is a retrospective study of pediatric patients who suffered a severe TBI defined as Glasgow Coma Scale < 8. A total of 47 patients were treated between January 2014 and August 2018 and all patients received TCD assessments for cerebral blood flow velocity for a total of 210 measurements. The primary outcome measure was the correlation between middle cerebral artery (MCA) mean flow velocities (MFVs) and clinical characteristics. MCA velocities were identified as high flow or low flow states using age-adjusted standardized velocities. Persistent low flow states were defined as >50% of TCD recordings per patient displaying the specified flow state without resolution to a flow state within 2 standard deviations of age-sex defined normal. Secondary outcomes included mortality and the global function using Pediatric Glasgow Outcome Scale-Extended (GOS-E Peds) at 3, 6 and 12 month and the association of the TCD findings to other physiologic variables at the time of scanning. Results: Of the 47 patients, the mean age was 8.24 years (+ 5.82) and there were 33 (70%) males and 24 (51%) Hispanic. At least 1 low flow velocity (>2 SDs below agenormalized mean) was identified in 20 (43%) patients and at least one high flow (>2 SDs above age-normalized mean) in 10 (21%) patients. There were no associations between demographics and single episodes of low or high flow velocity, however, patients aged >5 and <10 and non-Hispanic patients were more likely to have persistent low flow states. Persistent low flow states were significantly associated with mortality (p=0.014). Conclusions: TCD can be used to assess cerebrovascular function following pediatric TBI and may be used to for earlier identification of abnormal flow velocities.
• 

  How does HIV knowledge, attitudes and behaviors of young adults in Arizona compare to those of China and Taiwan?

  Cox, Analissa; The University of Arizona College of Medicine - Phoenix; Cevallos, Manuel (The University of Arizona., 2021)

  INTRODUCTION: The Centers for Disease Control (CDC) 2018 HIV Surveillance Report indicates that 13.6 per 100,000 people were diagnosed with HIV in the United States2. In Arizona specifically, this value was 12.7 per 100,000 in 20182. According to the Arizona Department of Health, groups most susceptible to contracting HIV in Arizona are African Americans, men, men having sex with men (MSM), and those ages 20-293. These data can be compared to countries, like China and Taiwan, that studied their college students using the International AIDS Questionnaire – English (IAQ-E). METHODS: The IAQ-E is a knowledge, attitudes, and behaviors (KAB) assessment that tells us the respondents’ level of understanding given different facts, myths, risks, and attitudes. We sought to assess the KAB of young Arizonans by presenting them with the IAQ-E and assessing respondents’ level of agreement using a Likert scale (strongly disagree =1 to strongly agree = 5). HYPOTHESIS: Based on Arizona’s sexual education curriculum and overall cultural stigma, we hypothesized that the results would show relatively moderate knowledge and negative attitudes and understanding of behaviors related to HIV/AIDS. RESULTS: The IAQ-E and demographic survey was distributed to college students in Arizona using Qualtrics, totaling 591 participants. The average age range was between 21-22, 77.2% biologically female, 19.9% biologically male and almost 3% non-binary/other or transgender, 2.2 % African American, and 22.84% identified with the LGBTQ community. Overall, students in Arizona have higher knowledge of HIV/AIDS compared to both China and Taiwan, and their attitudes were more positive than China, yet more negative than Taiwan. The behaviors showed positive understanding in all three groups, despite culture differences. Arizona participants exhibited increasing levels of understanding with increasing age (p <0.0001), increasing GPA (p <0.0001), and being married (p 0.002). CONCLUSION: The purpose of this project was to better understand the general knowledge, attitudes and behaviors regarding HIV/AIDS in young Arizonans and compare that to other countries. Understanding these differences can help design targeted public health interventions to decrease future transmission within the state and beyond.
• 

  Did the Millennium Development Goal Target 7c (to halve between 1990 and 2015 the proportion of the global population without sustainable access to safe drinking water) Reduce the Prevalence of Diarrheal Illness in the Dominican Republic

  Frazier, Weston; The University of Arizona College of Medicine - Phoenix; Beyda, David (The University of Arizona., 2021)

  Background: Waterborne diseases are caused by a variety of microorganisms, biotoxins, and toxic contaminants, which lead to devastating illnesses. According to the World Health Organization, diarrheal illnesses are the ninth leading cause of death worldwide. Developing countries are at especially high risk due to the lack of quality infrastructure and the Dominican Republic is no exception. Access to a quality public water supply has been shown to significantly reduce the incidence of diarrheal illnesses worldwide and in 2012, the Dominican government celebrated as achieved the completion of the Millennium Development Goal Target 7c (to halve between 1990 and 2015 the proportion of the global population without sustainable access to safe drinking water). Our aim was to determine whether the initiative was successful at reducing the prevalence of diarrheal illnesses across the country. Methods: This is a cross-sectional study that obtained data using the Demographic and Health Surveys Database. Census data from the Dominican Republic was obtained from 2002, 2007 and 2013 Since the Millennium Development Goal Target 7c was celebrated as complete in 2012, data from 2002 and 2007 censuses were used to compare the change in prevalence of diarrheal illness in the 2013 census data. Odds ratio values and 95% confidence intervals were then calculated to evaluate various demographics and outcomes. Findings: Census data from the Dominican Republic including the years 2002, 2007, and 2013 actually revealed a steadily increasing prevalence when participants were asked if they had, “Diarrhea within the last 2 weeks (2002: 15.6%, 2007: 16.5%, and 2013: 17.7%; p=0.03).” This increase was observed throughout the course of the Millennium Development Goal Target 7c, which began in 1990 and was celebrated as accomplished in 2012. Before 2012, a total of 16.1% of participants reported that they had, “Diarrhea within the last 2 weeks”, while after 2012, 17.7% of participants reported that they had (p=<0.0001). This resulted in an odds ratio of 1.23 (p=<0.0001) with the current water supply. Other data that supports the poor state of the current water supply is the increased odds of having diarrhea when water is piped into the dwelling or brought in by a tanker, with odds ratios of 1.24 (p=<0.0001) and 1.11 (p= 0.043) when compared to a bottled water source respectively. Higher education decreased the odds of contracting diarrheal illness with an odds ratio of 0.77 (p=0.003). Secondary and higher education also decreased the risk of blood in the stool with odds ratios of 0.44 (p=0.01) and 0.45 (p=0.03) respectively. Interpretation: It appears the Millennium Development Goal Target 7c (to halve between 1990 and 2015 the proportion of the global population without sustainable access to safe drinking water), was ineffective at reducing the prevalence of diarrhea in the Dominican Republic. In fact, the prevalence has increased throughout the course of the initiative. The increase was especially notable in populations that used water piped into dwellings and tanker truck water sources. This is precisely the water supply that the initiative set out to improve. Using diarrhea as a single factor to determine the water quality in the Dominican Republic, it appears that the state of the country’s water is significantly worse than before.

View more