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

Objective and Hypothesis The goals of this study are to address the following questions regarding shoulder arthroplasty (TSA): (a) Does restoring range of motion (ROM) lead to increased patient satisfaction? (b) How is ability to carry out activities of daily living (ADLs) influenced by ROM? (c) How does ADL performance correlate with patient satisfaction? We hypothesize that more “normal” ROM following TSA leads to increased patient satisfaction and better performance of ADLs. Methods Patients who underwent TSA, reverse TSA, hemiarthroplasty, or humeral head resurfacing were prospectively enrolled in a shoulder arthroplasty registry. 155 patients who had preoperative and 6 month postoperative data for ROM, patient satisfaction, and performance of ADLs were included in the study. Results Of these 155 shoulders, the response rate for patient satisfaction was only 82 (52.9%), with 96.8% reporting they were “satisfied or “very satisfied”. Postoperative ROM was associated with patient satisfaction for forward flexion, adduction, and external rotation. This association demonstrated a “dose;response” relationship, as higher percentage of normal ROM correlated with higher satisfaction. Mean ADL scores were higher for patients who achieved normal ROM in each plane of motion. The greatest improvement in mean ADL score occurred when a patient achieved normal ROM for at least 3 of 5 measurements. There was also a significant association between improved ADL and higher patient satisfaction. Significance Glenohumeral arthrosis causes considerable morbidity, and rates of shoulder arthroplasty are increasing. As the predominant goals of TSA are pain relief and restoration of ROM, it is important to assess postoperative patient satisfaction. While most historic studies have focused on measures of implant performance, interest is increasing in patient-centered outcomes. Both objective and subjective outcomes should be included in future large multicenter registries. Data collected from these registries has the potential to substantially improve success rates and longevity of shoulder arthroplasty.

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

Over 121,000 individuals are awaiting renal allograft in the United States.1 This ongoing imbalance of supply and demand has made research aiming to improve renal allograft survival a necessity. Details of the collection, distribution, and outcomes of renal allografts found in the United Network for Organ Sharing (UNOS) database were used in a retrospective study to identify and evaluate differences in allograft survival between American Indians and other heritage groups. In particular, the study aimed to identify whether American Indians have a similar distribution of HLA mismatches between recipient and donor when compared to other populations; and whether this impacts overall kidney allograft survival. Contingency table and Cox Regression analyses were applied and found that the Hazard Ratio was greater than 1 for all mismatches; and furthermore, an increase in mismatches was proportional to an increase in hazard ratio that was statistically significant. Recipients with 4, 5, or 6 mismatches showed a hazard ratio of 1.466 (p<0.0564). The HLA-DR allele has been known historically as the most important locus for transplants.2 Better matching, particularly at the DR locus, results in improved kidney survival time. Additionally, age, gender, and transplant era were used as major covariates in allograft survival using a proportional hazards model. Increasing age of recipient is associated with increased kidney survival time, and female gender is associated with decreased kidney survival time. Transplant era had a very high Chi-Square of 40.22 and an overall 5% increased survival with most recent transplants living longer than older era transplants. These results have implications for potential policy changes regarding organ allocation in addition to identifying an increased need in organ donation within specific heritage groups.

The purpose of this survey was to expand the limited knowledge regarding non-radiologist physician preferences in radiology report styles and content.

Psoriasis is a chronic inflammatory skin disease featuring abnormal keratinocyte proliferation and differentiation. A genetic risk factor for psoriasis (PSORS4) is a deletion of LCE3B and LCE3C genes encoding structural proteins in differentiated keratinocytes. Because analogs of 1,25-dihydroxyvitamin D3 (1,25D) are used in psoriasis treatment, we hypothesized that 1,25D and other VDR ligands act via the vitamin D receptor (VDR) to upregulate expression of LCE 3A/3D/3E genes, potentially mitigating the absence of LCE3B/LCE3C gene products. This hypothesis was pursued using cultured keratinocytes, quantitative real time PCR (qPCR) to assess LCE gene expression, competition binding assays to assess direct ligand binding to VDR, and reporter gene assays to assess the ability of VDR ligands to activate transcription in a VDR- and VDR response element-dependent fashion. qPCR results in a human keratinocyte line, HaCaT, suggested that 1,25D and selected alternate or candidate VDR ligands might upregulate LCE transcripts. Further experiments in primary human keratinocytes confirmed that 1,25D and 10 µM delphinidin do indeed upregulate all five LCE3 genes (LCE3A–E), especially in calcium-differentiated cultures. Further, competition binding assays revealed that delphinidin does in fact bind VDR, but only weakly (IC50 approximately 1 mM). Finally, 20 µM delphinidin was shown to be capable of upregulating a luciferase reporter gene linked to a vitamin D responsive element found near the LCE3 gene cluster. Taken together, these results are consistent with delphinidin (or a metabolite) stimulating LCE3 transcription in a VDR/VDRE-dependent manner. We propose that upregulation of LCE genes may be part of the therapeutic effect of 1,25D to ameliorate psoriasis by providing sufficient LCE proteins, especially in individuals missing the LCE3B and 3C genes. Results with delphinidin further suggest that this compound or its metabolite(s) might offer an alternative to 1,25D in psoriasis therapy.

One fifth to one third of hemodialysis patients develop infections from bacterial and viral pathogens over the total course of their treatment, many of which are healthcare acquired, leading to significant morbidity and mortality. Over recent years, significant strides have been made to decrease the rate of healthcare-acquired infections (HAIs) by reducing the risk of transmission of pathogens, including increased compliance to hand-washing of healthcare workers (HCW) and improved quality of environmental cleaning. The goal of the project was to improve the thoroughness of cleaning of a hemodyalysis (HD) suite using objective monitoring and a program of education and feedback. To achieve this goal, the project was broken down into three aims: 1. Determine the baseline thoroughness of cleaning using a novel marker system; 2. Educate and provide feedback to hospital administration and environmental services staff involved in overseeing and in cleaning the HD suite, and; 3. Determine if the program improves the thoroughness of cleaning when compared to baseline. Due to institutional constraints, the third aim of the project was not performed. This investigation demonstrated a baseline thoroughness of cleaning for all high-touch surfaces to be 42% of surfaces cleaned, indicating there are opportunities for improvement in the sanitation practices of the hospital hemodialysis suite. Most individual surface types fell below the internal goal of 90% cleaned. Through presenting the baseline data to hospital administration and environmental services staff, areas of potential improvement in hemodialysis suite sanitation practices were identified, which included the assignment of the cleaning of individual surfaces to specific hospital departments. Though the follow-up testing could not be performed, it is likely that the identification of these areas for process improvement resulted in increased cleaning of overlooked surfaces.

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

OBJECTIVE: To investigate the variability in early recovery after hemiparetic stroke. BACKGROUND: Prior work suggests that most hemiparetic patients recover approximately 70% of their initial impairment by 3-months, but the speed of the recovery is unknown. METHODS: We assessed 30 patients with first-ever hemiparetic stroke using the Fugl-Meyer upper extremity score (max score=66) at 24-72 hours (FMInit), 1-week (FM1wk), and 3-months (FM3mo). Patients who did not demonstrate proportional recovery (0.70 x initial impairment) were excluded from analysis. The distribution of recovery at 7-days among the proportional recoverers was characterized and contrasted with recovery at 90-days using the Shapiro-Wilk test for normality and Sarle’s binomial coefficient. Cluster analysis was then used to assess the distribution of recovery rates at 7-days. Tests of differences and association were performed to assess if the early recovery-rate groups differed significantly in clinical and demographic characteristics. RESULTS: Twenty-six of the 30 initial patients were identified as proportional recovers, the other 4 were non-recoverers at 90-days. Among the proportional recoverers, there was a bimodal distribution of recovery at 7-days. Cluster analysis identified patients who achieved virtually all of their total recovery at 7-days (n=13, percent recovery=0.89±0.19; 95%CI:0.79-1.00) and patients who achieved virtually none their total recovery at 7-days (n=13, percent recovery=-0.23±0.77, 95%CI:-0.65-0.19), but went on to achieve the expected recovery at 90 days. Initial stroke severity was the only characteristic that showed a statistically significant correlation with early recovery group membership. SIGNIFICANCE: Patients who demonstrate proportional recovery over the first 3-months fall into 2 distinct early recovery groups, either achieving approximately 90% of their total recovery by 1-week or making little or no recovery early, and only later achieving their total expected recovery. Implications for treatment planning are profound.

The purpose of this study was to examine health care providers’ experiences regarding the processes of disclosure and assent in pediatric HIV/AIDS patients. The study population included providers who were involved with the care of pediatric HIV/AIDS. A survey was distributed through email and asked questions to explore provider demographics, the average age of assent to treatment and research, the average age of disclosure of HIV, what factors determine the age of disclosure, barriers to disclosure, provider opinions, and provider perceptions of conflict within the disclosure process. While results showed that there are wide variations among individual patients and providers, most providers agree that disclosure should occur in older school age children (between ages 6-10 years), which is also the time that they typically are able to assent to treatment and clinical trials. Providers often agreed that there is a conflict between the ages of disclosure and assent. Parental concerns (fear of stigma, inappropriate disclosure, and personal guilt) were most often the reason for delays in the disclosure process. The disclosure process was felt to be most effective when done in a step-wise manner that includes multiple practitioners and counseling with families.