• Identifying an Oxygenation Index Threshold for Increased Mortality in Acute Respiratory Failure

      Hammond, Brandon; The University of Arizona College of Medicine - Phoenix; Dalton, Heidi; Willis, Brigham (The University of Arizona., 2016-03-25)
      Objectives: To examine current oxygenation index (OI) data and outcomes using EMR data to identify a specific OI values associated with outcome. Methods: Retrospective review of electronic medical record (EMR) data for patients age 1 month ‐ 20 years mechanically ventilated for >24 hours in the PICU. Serial, average and maximum OI values were calculated. Length of mechanical ventilation, hospital stay and outcome were assessed. Results: OI was calculated on 65 patients from EMR data, of which 6 died (9.2%). The median maximum OI was 10 for all patients, 17 for non‐survivors (NS), and 8 for survivors (S), (p=0.14 via Wilcoxon rank‐sum test). Odds ratios (OR) indicated 2.1 times increase odds of death (p=.08), 95% confidence interval (0.89–5.03) for each one‐percent increase in maximum OI. Average OI OR also revealed 2.1 times increase in odds of death (p=.14), 95% confidence interval (0.77–5.48). ROC analysis indicated a higher discriminate ability for max OI (AUC = 0.68) than average OI (AUC = .58). OI cut points for mortality were established. Mortality was unchanged until max OI >17, for which mortality nearly tripled at a value of 18% versus 6‐7% for range 0‐17. Conclusions: Serial assessment of OI values may allow creation of alert values for increased mortality risk and aid in development of clinical decision rules. Consideration for escalation of therapies for respiratory failure such as high frequency ventilation or ECMO at lower levels of OI than historically reported may be warranted. This study also helps to validate prior reports that OI is useful as a severity score for clinical research and outcome prediction.
    • Implementation of a Pediatric Stroke Team: Outcomes and Resource Utilization

      Esque, Jacquelin; The University of Arizona College of Medicine - Phoenix; Buttram, Sandra (The University of Arizona., 2016-04)
      Background and Significance: Pediatric stroke is associated with significant morbidity and mortality. In an effort to improve diagnosis and patient management, we established a Pediatric Stroke Team (PST) available 24/7 in January 2012. Outcomes of patients before and after PST implementation are reported. Methods: Retrospective review of pediatric stroke patients (Jan 2009 ‐Dec 2012) at Phoenix Children’s Hospital in Phoenix, Arizona. Primary outcomes assessed were Glasgow Outcome Scale‐Extended Pediatric Revision (GOS‐E Peds) and discharge disposition. Hospital length of stay, time to neuroimaging, stroke therapies, and adherence to neuroprotective strategies (sodium, glucose, temperature) were also evaluated. Data were analyzed by Wilcoxon rank sum, Fisher’s exact, and chi‐square. Results: There were 64 patients pre‐PST and 30 post‐PST. Overall, GOS‐E Peds was improved post‐PST 2 [1, 3] vs. pre‐PST 3 [2, 6] (p = 0.004) with no change if deaths were excluded (post‐PST (2 [1, 2]) vs. pre‐PST (2 [1, 6]) (p = 0.030)). Discharge to home was more common in the post‐PST group (p = 0.018). Definitive neuroimaging tended to occur more quickly post‐PST 2h [1, 2.6] compared to pre‐PST 4.7h [1.3, 16.5] (p =0.16). Post‐PST patients appropriately received heparin (23%) more often than pre‐PST (6%) (p = 0.034) and had fewer episodes of hyperglycemia (3%) compared to pre‐PST (20%) (p = 0.033). There were no differences in episodes of fever, hyponatremia or hypoglycemia. Conclusions: Availability of a PST improved patient care and outcomes. Time to definitive neuroimaging was decreased, appropriate therapies were administered and adverse events (hyperglycemia) were decreased with PST management. We continue to strive for improved care of pediatric stroke patients.
    • Improving Colorectal Cancer Screening Rates in an Urban Community Health Center

      Seelbaugh, Joseph; The University of Arizona College of Medicine - Phoenix; Brite, Kathleen (The University of Arizona., 2016-03-25)
      Colorectal cancer (CRC) is a leading cause of cancer‐related deaths. Although screening has been shown to significantly reduce mortality associated with the disease, CRC screening rates remain low, especially among many minority groups. The purpose of this study was to determine whether an organized screening regimen improves screening in a community clinic serving patients with low baseline CRC screening rates. The study was conducted at the Wesley Health Center, a Federally Qualified Health Clinic (FQHC) that serves a predominantly uninsured patient population. Participants were patients aged 50 – 75 years who visited the clinic for routine primary care. A team of clinicians and support staff at the Wesley Health Center developed a systematic CRC screening protocol with interventions tailored for the clinic. Following the implementation of the screening regimen, screening rates among the targeted population were examined over a one‐year period and compared to a recent one‐year period previous to protocol implementation. The primary outcome was the change in CRC screening rates in the intervention group compared to screening rates prior to implementation of the protocol. Results of the study showed CRC screening rates of 45.6% over the trial period, as compared to 13.7% prior to screening interventions, a statistically significant difference (p < 0.001). The investigation provides valuable information regarding the use of practical strategies to increase CRC screening in community health care settings.
    • Inferior Vena Cava Filter Fracture and Migration to the Heart: A Review of the Literature and Case Report

      Bowles, Brad; The University of Arizona College of Medicine - Phoenix; Shennib, Hani (The University of Arizona., 2016-04-01)
      Background and Significance: The utilization of IVC filters for pulmonary embolism prevention has increased significantly over the past decade as the indications continue to expand. Although the risks associated with IVC filters are small, a well‐known complication is filter fracture and subsequent embolization of the fragment. Case reports have been published on the devastating effects of fragment migration to the heart, causing intense chest pain, pericardial effusion, cardiac tamponade and death. Research Question: There is a paucity of experience and guidelines for treating patients with a metallic foreign object lodged within the heart. Is there a consensus on the proper management of these cases? How do these patients present and what are the outcomes of treatment? Some clinicians have chosen to observe and monitor, while others have gone to the operating room for open‐heart surgery and retrieval of the fragment. Methods: In an attempt to answer these questions, a systematic review of the published literature was conducted between 1985 and 2015. Only articles related to IVC filter fracture and subsequent fragment migration to the heart were included. The clinical presentation, workup, management, treatment and outcomes were collected as available. Results: A total of 23 articles were published consisting of a prospective study, retrospective series and case reports. There were 37 migrated fragment to the heart reported in 29 patients. The most common clinical presentations were chest pain (69.0%) and no symptoms (27.6%). Regarding treatment, ten patients underwent observation, three had successful endovascular retrieval, 12 went to the operating room for open‐heart surgery and four cases were unreported. Of the 12 patients with reported pericardial effusion, 11 (91.7%) underwent open surgical repair. Of the eight asymptomatic patients, seven (87.5%) were ultimately in observation and the management of the other was unreported. Conclusions: There appears to be a consensus in the literature that observation and close follow up are appropriate options for asymptomatic patients. Symptomatic patients with pericardial effusion may benefit from open‐heart surgery. Cardiovascular compromise such as cardiac tamponade should be managed with open surgery. Based upon these findings and other details in the cases, we have proposed a management algorithm.
    • Initial Generalist Versus Subspecialist Provider for Fertility Treatment, Use of In Vitro Fertiliation, and Time to Pregnancy

      Boltz, Mandy; The University of Arizona College of Medicine - Phoenix; Stanford, Joseph B. (The University of Arizona., 2016-03-23)
      Background and Significance: Infertility is a common problem in the United States. Infertility is recognized as a disease by the World Health Organization (WHO) and is identified as an emerging public health priority by the Centers for Disease Control (CDC). It is also associated with numerous effects on women’s physical and emotional health, and involves treatment methods that are medically invasive and associated with health implications for the resulting children. A better understanding of the role of generalist providers in the management of infertility may lead to opportunities to promote a balanced approach to infertility. Research Questions: 1) With what types of providers do most women initiate infertility care? 2) How do women who enter care with a generalist provider differ from those who enter care with a fertility subspecialist? 3) Are different outcomes associated with presenting first to a generalist provider versus a fertility subspecialist? Methods: We analyzed mixed-mode questionnaire data from 279 Utah women with primary infertility enrolled through population-based sampling. We compared women presenting first to generalist providers with women presenting first to fertility subspecialists, with the main outcomes of receiving in vitro fertilization (IVF), time to pregnancy, and live birth. Results: The first point of contact for most women (84%) with infertility was a generalist provider. Only 5% of women sought care initially from a fertility subspecialist, and these women were more likely to have higher incomes, be older, and have been trying to conceive for longer periods of time before seeking care. Women who presented first to a generalist provider were less likely to receive IVF (aOR 0.17; 95% CI: 0.05, 0.57), were equally likely to achieve a pregnancy, and had similar times to pregnancy (aHR 0.80; 95% CI: 0.38, 1.69) as women who presented first to a subspecialist, after controlling for age, time attempting to conceive before seeking care, and income. Conclusion: In this population-based sample of women with primary infertility, presenting first to a generalist was associated with a decreased likelihood of receiving IVF and a similar time to pregnancy. Generalist providers are frequently the first point of care for women with difficulty conceiving and are uniquely positioned to promote a balanced management of infertility.
    • Injections of Bone Marrow Aspirate Concentrate as Treatment for Discogenic Pain

      Shillington, Jon Mark; The University of Arizona College of Medicine - Phoenix; Wolff, Michael (The University of Arizona., 2016-04-20)
      Low back pain (LBP) is one of the most common musculoskeletal pain complaints, affecting up to 84% of the U.S. adult population. In the United States, the highest rate of incidence is between the ages of 45 and 64 years. The causes for LBP are complex and of multiple origins, but one of the primary causes is mechanical low back pain that is discogenic in etiology. This can be secondary to either internal disc disruption (IDD) and/or degeneration of the intervertebral disc (IVD), also known as degenerative disc disease (DDD) [10,11]. Combined physical and medical therapies are successful in relieving pain in approximately 90% of cases of low back pain. However, the remaining 10% become chronic and generate a serious public health problem, known as chronic low--‐back pain (CLBP). CLBP decreases both the quality of life and the labor capacity of the patient. As specific diagnostic procedures for LBP have improved, discogenic pain has been identified as the primary cause of CLBP amongst adults. Within the classification of discogenic pain, the most common specific cause of pain – up to 42% of LBP complaints – is internal disc disruption (IDD), with other distinguishable causes including disc herniation, degenerative disc disease (DDD), and instability of the lumbar segment [10]. Effective treatment for discogenic LBP – and therefore for CLBP – would provide significant relief for individuals as well as for the overall health care system and the employers affected by the patients’ condition. One promising treatment option involves the use of Mesenchymal Stem Cells (MSC), which may allow for regeneration of the disc itself. Treatment with MSCs via injections derived from autologous concentrated Bone Marrow Aspirate (cBMA) would capitalize on the regenerative potential of MSCs while reducing the risk of infection or rejection, both significant risks of treatment from a heterologous source. This project analyzed data collected from 33 patients with confirmed discogenic LBP, who were treated with intradiscal injections of autologous concentrated Bone Marrow Aspirate. After initial treatment, patients were monitored through follow up visits and questionnaires (VAS, Oswestry, SF--‐36) to determine the efficacy of treatment. The areas of interest for this study were intentionally narrow. This study sought to identify specifically the patients’ self--‐reported pain and functioning levels from 2 weeks post--‐treatment to 12 months post--‐treatment. Those reports were gathered using the aforementioned instruments and synthesized to show overall trends and statistically significant changes in the patients’ self--‐ assessment. The patients were also asked to give an overall impression of whether or not their back pain had improved post treatment. While admittedly limited in authority compared to a double--‐blind, randomized, controlled trial, the information was gathered from the patients with the hopes of augmenting ongoing research related to innovative treatments for discogenic LBP and of identifying new areas for further, future research.
    • The Interaction of β-catenin, Vitamin D, Resveratrol, and Two Common VDR Polymorphic Variants in Colorectal Carcinogenesis

      Van Pelt, Chad; The University of Arizona College of Medicine - Phoenix; Jurutka, Peter (The University of Arizona., 2016-04-20)
      Vitamin D and resveratrol have been widely researched in recent years, especially their apparent abilities to impact a host of physiological processes. Resveratrol, a phytoalexin found in various berries, peanuts, and other vegetables, is purported to possess anti-aging, anti-inflammatory, antioxidant, anticancer, neuroprotective, and antiarthritic properties, while the classical endocrine functions of vitamin D are the control of calcium and phosphate homeostasis. The biologically active metabolite of vitamin D, 1,25-dihydroxyvitamin D (1,25D), is typically synthesized in the kidney, bound to vitamin D binding protein, and shuttled to cellular target sites. Mounting data on the effect of locally synthesized 1,25D in immune, epithelial, neural, and other tissues have led to an increased awareness of the myriad functions of vitamin D, including detoxification, cellular aging and its modulation, immune regulation, neurotransmitter activity, and metabolic control. Both endocrine and intracrine actions of vitamin D are mediated by the vitamin D receptor (VDR), a nuclear receptor that controls vitamin D-directed transcription of target genes. Importantly, the VDR has numerous polymorphisms, one of which results in two phenotypically distinct isoforms, designated M1 and M4. VDR M4 is postulated to be more active than M1 in vitamin D-dependent transactivation. Variable binding affinities between the two isoforms and VDR interacting proteins such as TFIIB and RXR have also been observed. Another protein known to interact with VDR is β-catenin, the mediator of the Wnt/β-catenin signaling pathway that can drive colorectal carcinogenesis. The goal of this study was to investigate the ability of vitamin D and resveratrol to regulate the Wnt/β-catenin system via stimulation of β-catenin-VDR (both M1 and M4) interaction and subsequent inhibition of β-catenin-mediated transcription. The current data reported herein support and extend previous work by demonstrating that VDR binds directly to β-catenin and that both vitamin D and resveratrol appear to enhance this interaction. We also present data that 1,25D-stimulated VDR is capable of inhibiting β-catenin transcriptional activity. Significantly, we have shown that the two common VDR polymorphisms M1 and M4, are functionally variable, both in their induction of vitamin D-dependent genes and in their inhibition of β-catenin-mediated transcription. VDR M4 exhibits both elevated transactivation and amplified capacity for β-catenin suppression compared to M1, and studies employing site-directed mutagenesis of VDR implicate the glutamic acid at position 2 as being responsible for the reduced activity of the M1 variant. Both polymorphic VDR variants display 1,25D-mediated enhancement of -catenin association, with the M1 SNP possessing a lower basal (-1,25D) binding to this protein partner but a higher fold stimulation in -catenin interaction in the presence of 1,25D. Taken together, these data support the notions that VDR influences pathways important for colorectal carcinoma (CRC) development, and that supplementation with vitamin D and resveratrol may reduce colon cancer risk in the general population, especially in individuals with the less active M1 VDR polymorphism. A comprehensive understanding of 1,25D and resveratrol action in VDR signaling may allow for a more personalized approach toward treating vitamin D–related disorders and evaluating risk for carcinogenesis.
    • Investigating the Effects of a Pre‐ and Post‐Discharge Intervention on Access to Care and 30‐Day Readmission Rates of CHF Patients at the Phoenix VA Medical Center

      Ahmad, Shahjehan; The University of Arizona College of Medicine - Phoenix; Urbine, Terry; Dev, Sandesh (The University of Arizona., 2016-03-23)
      Significance: Cardiovascular disease represents the single most costly and common cause of hospitalizations in the US. More alarmingly, congestive heart failure (CHF) represents the largest cause of preventable hospitalizations. The 30‐day readmission rate after a hospitalization for CHF is an increasingly important measure of quality in the management of this chronic condition. Interventions targeted at CHF patients after discharge should address access to care and early follow‐up, and should be investigated as a means of decreasing 30‐day readmissions and improving patient outcomes. The Phoenix VAMC created a new early‐follow up clinic in 2011, and this study was the first investigation of outcomes from the intervention. Methods: Patients were selected who were admitted to the Phoenix VAMC with a primary diagnosis of heart failure (ICD‐9: 428.x). Patients referred to the early follow‐up clinic by their primary medicine team were our cohort of interest; patients which underwent standard care and served as our controls. A retrospective chart review was done to assess health status, compliance with the intervention, and 30‐day outcomes, the patient level outcomes. We also compared patients in two time periods, before and after the intervention was implemented, the hospital level outcome. Statistical analysis of this cohort study was done by identifying the relative risk of readmission and death. The RE‐AIM framework was used to determine the hospital‐level impact of the intervention. Results: 275 patients were divided into 116 control patients and 159 intervention patients. The RR of readmission in those referred to the clinic was 1.57 (p=0.09), and mortality was 0.78 (p=0.05). In those patients who were discharged in the post‐intervention time period, the RR of readmission was 0.57 (p=0.036) and 30d mortality was 0.72 (p=0.015). Time to follow‐up was reduced from 15 to 9 days (p<0.01) from the early time period to the late one. Conclusions: The use of care transition interventions have the potential to address issues of rehospitalization, especially in chronic diseases. Establishing a model which improves patient outcomes will have many long‐term benefits for our healthcare system. This intervention decreased mortality and increased readmissions on a patient level, while decreasing both mortality and readmissions on a hospital level, though other factors may be involved.
    • “It’s About Heart”: A Qualitative Study of Rural Family Physician Training Needs.

      Varner, Samantha; The University of Arizona College of Medicine - Phoenix; Brown, Steven (The University of Arizona., 2016-04)
      Efforts to reduce a chronic physician shortage and meet the needs of rural communities face long standing challenges such as physician recruitment and retention. While these topics have been researched at length, issues surrounding the contribution of training specifically geared toward the needs of the Southwest’s rural communities are not well understood. The goal of this investigation is to discuss with rural family physicians the realities of rural practice and to determine what, if any, skills and competencies are specific to rural family practice and that, if addressed in training, would increase the number of students and residents pursuing rural family medicine and increase the number of physicians in rural areas. Methods: Physicians throughout rural areas in the Southwest meeting the role of thought leader were interviewed. Chain sampling was used to generate diversity of ideas. Interviews were conducted in person or by phone using a semi‐structured format and a topic guide. Participants were asked to discuss what skills they feel are important to a successful practice in a rural community, the degree to which the competencies were covered in their residency training, and how having or not having these skills might affect job satisfaction and retention. Interviews were recorded and transcribed. Transcripts were analyzed by a two person committee for repeating themes. Results: Seven major repeating themes were evident in the data. Of these residency training type, individual resilience, comfort with lack of resources, community were some of the most common and important to participants. Conclusion: This study has shown that the challenges to recruitment and retention of family physicians in rural areas are many and complex. These results combined with the extensive literature studying successful recruitment and retention programs demonstrates the enormous potential that exists in a multifactorial approach to rural recruitment and retention to meet the tremendous need for more family physicians in rural areas.
    • Label‐free Microscopic Assessment of Glioblastoma Biopsy Specimens Prior to Biobanking

      Zehri, Aqib; The University of Arizona College of Medicine - Phoenix; Preul, Mark (The University of Arizona., 2016-04)
      Introduction: Glioblastoma is the most common primary brain tumor with a median 12‐ to 15‐ month patient survival. Improving patient survival involves better understanding the biological mechanisms of glioblastoma tumorigenesis and seeking targeted molecular therapies. Central to furthering these advances is the collection and storage of surgical biopsies (biobanking) for research. We addressed an imaging modality, confocal reflectance microscopy (CRM), for safely screening glioblastoma biopsy samples prior to biobanking to increase the quality of tissue provided for research and clinical trials. We hypothesize that CRM is a safe and effective method for screening specimens prior to biobanking. Methods: Intracranial implantation of human glioma cells was performed to create glioblastoma xenografts. Rodents xenografts were anesthetized to collect whole brain specimens, which were sectioned into tumor containing slices. One set of slices were incubated with DAPI and imaged. A coefficient of determination analysis was then used to compare cells identified with CRM to cells labeled with DAPI. The other set of slices were imaged using CRM at various time points and subsequently frozen for later analysis of DNA, RNA, and protein integrity. We subsequently imaged human glioma biopsies with CRM to determine cellularity and necrosis. Results: CRM provides definitive contrast between cell nuclei, cytoplasm, and extracellular tissue to help identify tumor regions, margins, and acellular regions of animal glioblastoma specimens without altering DNA, RNA, or protein expression of imaged tissue. When imaging fresh human biopsy samples, CRM can differentiate a cellular glioblastoma biopsy from a necrotic biopsy. Conclusion: These data illustrate CRM’s potential for rapidly and safely screening clinical biopsy samples prior to biobanking, which demonstrates its potential as an effective screening technique that can improve the quality of tissue biobanked for patients with glioblastoma.
    • Management of Rhinosinusitis During Pregnancy: Systematic Review and Expert Panel Recommendations

      Jategaonkar, Ameya; The University of Arizona College of Medicine - Phoenix; Lal, Devyani (The University of Arizona., 2016-04)
      Background: Rhinosinusitis, both acute and chronic, represents a common disease. Approximately 29.6 million adults in the United States suffer from sinusitis with 11 million suffering from CRS1. The multicenter GA2LEN study showed that amongst lifetime nonsmokers, women were at a greater risk of being affected by chronic rhinosinusitis than men2. Various other rhinologic manifestations of pregnancy have also been described. Nevertheless, management of rhinosinusitis during pregnancy is poorly described in the literature. Objectives: 1. Conduct a systematic review of the literature for the management of acute and chronic rhinosinusitis (CRS) during pregnancy. 2. Make evidence based recommendations on the management of acute and chronic rhinosinusitis during pregnancy. Methods: A systematic review of the literature was conducted using MEDLINE and EMBASE databases. Search terms included “rhinitis” OR “sinusitis” OR “rhinosinusitis” AND “pregnant” OR “women” OR “gender”. Title, abstract, and full manuscript review was conducted. Full manuscripts including citations and references were reviewed if the abstract noted any gender specific outcomes. A multispecialty panel of experts in the fields of rhinology, allergyimmunology, and obstetrics‐gynecology was invited to review the systematic review. Recommendations were sought on the use of the following for the management of CRS during pregnancy: oral corticosteroids, antibiotics, leukotriene antagonists, topical corticosteroid sprays/irrigations/drops, aspirin desensitization, elective surgery for CRS, and vaginal birth vs. planned cesarean delivery for patients with history of skull base erosions or CSF rhinorrhea. Results: 3052 abstracts were screened, and 88 manuscripts were reviewed. No relevant level 1, 2 or 3 studies were found. Expert panel recommendations were synthesized. Conclusions: Several recommendations were made. These include continuing all modern topical corticosteroids for CRS maintenance, using pregnancy safe antibiotics for acute rhinosinusitis and CRS exacerbations, and discontinuing aspiring therapy for desensitization in patients with aspirin exacerbated respiratory disease.
    • Marijuana Smoking and the Risk of Developing COPD, Lung Cancer, And/or Chronic Respiratory Symptoms: A Systematic Review

      Byers, Chris; The University of Arizona College of Medicine - Phoenix; Campos-Outcalt, Douglas (The University of Arizona., 2017-06-01)
      The aim of this study is to conduct a systematic review of the existing evidence on marijuana use and its association, or the absence of an association, with an increased risk of developing chronic obstructive pulmonary disease (COPD), lung cancer, and/or chronic respiratory symptoms. We hypothesize that a systematic review will not demonstrate sufficient evidence to determine that marijuana use increases the risk of developing COPD, lung cancer, and/or chronic respiratory symptoms. The term “chronic respiratory symptoms” encompasses the following: cough, sputum production, wheeze, shortness of breath, acute bronchitis, and chest tightness. The following databases were searched for the topics of marijuana smoking, COPD, lung cancer, and chronic respiratory symptoms: MEDLINE (PubMed/OvidSP), the Cochrane Controlled Trials Register, the Cochrane Database of Systematic Reviews, PsycINFO, the Database of Abstracts of Reviews of Effects, and Google Scholar. The search ended September 7th, 2016. Studies were initially limited only by the requirement that they were based upon human research and published in English. Studies were included if they were systematic reviews, randomized controlled trials (RCTs), prospective or retrospective cohort studies, case control studies, or cross‐sectional studies. A total of 739 articles were screened for eligibility, 17 unique studies met the inclusion criteria and underwent qualitative analysis1‐17. The quality of systematic reviews was evaluated using the AMSTAR criteria18; cohort, case‐control, and cross sectional studies were evaluated based upon the Newcastle‐Ottawa Quality Assessment Scale (NOS) 19. No RCTs were identified. The overall quality of the evidence for each outcome was determined by utilizing the GRADE methodology20‐21. Studies were primarily assessed by a single reviewer, with random validation of assessments on a limited number of studies by a second reviewer. Overall, there is very low quality evidence that assesses for an association between marijuana smoking and an increased risk of developing lung cancer, COPD, and/or chronic respiratory symptoms. There was no conclusive finding for lung cancer and COPD. However, seven of eight studies concluded that there was an association between marijuana use and chronic respiratory symptoms. The totality of evidence describing any associations between marijuana smoking and the risk of developing lung cancer, COPD, and/or chronic respiratory symptoms is not strong enough to confidently state that marijuana use is associated with any of these chronic pulmonary conditions. Of all the evidence examined in this systematic review, the most convincing appears to be that relating to a potential positive association between marijuana smoking and the risk of developing chronic respiratory symptoms. Unfortunately, the overall quality of evidence was very low due to significant methodological weaknesses within the studies. Thus, there is insufficient evidence in the current literature to make a definitive statement regarding this possible association.
    • Marijuana Use and the Risk of Depression: A Systematic Review and Meta‐Analysis

      Gentry, James; The University of Arizona College of Medicine - Phoenix; Campos-Outcalt, Douglas (The University of Arizona., 2016-03-25)
      Objective: To conduct a systematic review of the evidence pertinent to the relationship between marijuana use and depression and perform a meta‐analysis on the data in order to inform evidenced‐based practice. The question of interest is: Is marijuana use associated with increased risk of developing depression? Methods: The databases MEDLINE (PubMed), The Cochrane Library, CINAHL (EBSCO), psycINFO, and Google Scholar were searched for the topics of marijuana use and depression through October of 2013. Studies were included if they were systematic reviews, randomized controlled trials, prospective or retrospective cohort studies, or case‐control studies. No randomized controlled trials were discovered. Quality of cohort and case‐control studies was evaluated using the Newcastle‐Ottawa Quality Assessment Scale 1. Overall quality of evidence was determined using the GRADE methodology 2,3. The Bradford‐Hill criteria 4 were used to assess for causation. Studies were assessed by two reviewers. 173 articles were screened for eligibility. Of these fourteen articles were considered to fit the inclusion criteria. Nine homogeneous studies were included in the meta‐analysis. Results: The quality of the evidence reviewed is low to very low. It does not meet Bradford‐Hill criteria for causation. There is a slight positive correlation between marijuana use and onset of depression. However, those studies included in the meta‐analysis demonstrated a low overall pooled odds ratio (OR = 1.17; 95% CI = 1.06—1.29). Conclusion: The evidence suggests a slight positive correlation between marijuana use and depression but is not sufficient to draw a conclusion. This evidence is generally of very low quality. It does not demonstrate a dose response, and is without a significant magnitude of effect.
    • A Model for Improvement: Perinatal Depression Screening

      Hoidal, Kelsey; The University of Arizona College of Medicine - Phoenix; Brite, Kathleen (The University of Arizona., 2016-03-25)
      It is estimated that postpartum depression (PPD) occurs in 10‐20% of women, but fewer than half of cases are recognized.1 CDC survey data form 2004‐2008 utilizing the Pregnancy Risk Assessment Monitoring System (PRAMS) found that young mothers who identify with minority groups have the highest prevalence of PPD.3 Routine screening for PPD with a validated instrument, the Edinburgh Postnatal Depression Scale (EPDS), increased the rate of diagnosis of PPD nearly three times, according to one study.10 PPD screening can detect and mitigate depressive behavior and positively impact the lives of mothers and their children.7,8 In fact, the USPSTF recently published an evidence report which illustrated that screening pregnant and postpartum women for depression may reduce depressive symptoms in women with depression and reduce the prevalence of depression in a given population, especially with additional treatment supports.11 It is a B recommendation to screen the general adult population, including pregnant and postpartum women, for depression. The Wesley Health Center, a busy, urban family medicine FQHC in downtown Phoenix, Arizona has a thorough prenatal care program that includes a postpartum visit. Numbers from 2011 indicate about 25% of the women who participated in the program returned to Wesley for their postpartum care. The postpartum visit includes a PPD screening using the EPDS, which is also well‐established for use prior to birth.10 It is hypothesized that increased patient education about PPD, increased vigilance about postpartum visit scheduling, and routine depression screening using the EPDS at 28 weeks gestational age and at the postpartum visit will improve PPD detection and treatment at Wesley. An intervention was performed in January 2013. It consisted of staff education about PPD and the EPDS, a new policy that all prenatal care patients receive the EPDS around 28 weeks gestation in addition to the postpartum visit, and an EMR checkbox indicating postpartum depression screening was performed and whether or not the patient is experiencing PPD. Screening rates between years were compared using chi‐squared testing. Patients were assigned to groups based on whether they received only prenatal care, only postpartum care, or both prenatal and postpartum care. Between the three data years, 2012 is the control year, 2013 is the year immediately after intervention, and 2014 is assessed for sustainability. There was a statistically significant difference in EPDS screening prior to birth in women who received both prenatal and postpartum care at WHC. For ante‐partum screening, 26.5 percent of women had the EPDS in 2012 versus 79.2 percent and 100 percent in 2013 and 2014, respectively. Postpartum screening was also found to be statistically significant between the years—26.5 percent, 66.7 percent, and 55.2 percent for 2012, 2013, and 2014, respectively. Although not statistically significant, there was a small increase in number of patients identified with depression in the group of women who received the EPDS prior to giving birth—an increase from 1 to 5 and 4 cases identified in 2012 versus 2013 and 2014, respectively. It was clear that increased staff education, a formalized screening system, and ante‐partum depression screening aid a busy, urban FQHC in addressing perinatal depression by identifying women at risk and offering treatment.
    • Outcomes for Epithelial Ovarian Cancers Diagnosed with Concomitant Venous Thromboembolism

      Hurtt, Callie; The University of Arizona College of Medicine - Phoenix; Bakkum‐Gamez, Jamie N. (The University of Arizona., 2016-03-25)
      Background and Significance Most large studies on venous thromboembolism (VTE) incidence in gynecologic cancer focus on prevention and management of postoperative VTE. Treatment for preexisting VTE at the time of diagnosis of epithelial ovarian cancer (EOC) includes careful risk assessments, weighing the benefits of debulking and risks of anticoagulation in the setting of a new VTE and new EOC diagnosis, respectively. We aimed to describe perioperative and cancer survival outcomes associated with concomitant diagnoses. Research Question To describe short‐term perioperative outcomes and overall survival (OS) among women who present with VTE at initial EOC diagnosis. Methods Women presenting with VTE within 30 days prior to EOC diagnosis between 1/2/2003 and 12/30/2011 who had primary debulking surgery (PDS) or chemotherapy (CT) alone were included. Descriptive statistics and the Kaplan‐Meier method were used to estimate OS from time of EOC diagnosis, with patient characteristics and process‐of‐care variables retrospectively abstracted. Results Of the 36 women with VTE within 30 days prior to EOC diagnosis, 28 (77.8%; mean age 64.2 years) underwent PDS and 8 (22.2%; mean age 61.4 years) received CT alone. Eastern Cooperative Oncology Group (ECOG) performance status (PS) was ≤2 in 85.7% (n=24) of PDS patients compared to 62.5% (n=5) of CT patients. Advanced stage (III/IV) disease was diagnosed in 71.4% (n=20) of PDS group; all CT patients were advanced stage. Among those who underwent PDS, 26 (92.9%) had a preoperative IVC filter placed; 1 (12.5%) in the CT group received an IVC filter. Perioperative bleeding complications were 7.2% in the PDS group. Within the PDS group, median OS was 25.6 months while the CT group had median OS of 4.5 months.ConclusionsPreoperative VTE in EOC patients can be safely managed with low rates of bleeding complications. Poor OS in CT group may reflect worse overall health or more aggressive cancer. Median OS was notably shorter than previously published; IVC filter utilization on oncologicoutcomes in EOC warrants further investigation.
    • Perception of Access to Prenatal Care of Women Presenting to the Emergency Department During the First Trimester of Pregnancy

      Deason, Brandon; The University of Arizona College of Medicine - Phoenix; Bayless, Patricia (The University of Arizona., 2016-03-23)
      Background: Despite the large amount of research regarding prenatal care (PNC) in physicians’ offices, hospital outpatient clinics, and community health centers, there is a great paucity of information regarding the role the Emergency Department plays in PNC. Objective: To understand the factors associated with pregnant women’s choice to seek prenatal care in the Emergency Department. Methods: This study is an investigative examination of the attitudes towards and perceived barriers to PNC of women in the first trimester of pregnancy presenting to the Emergency Department at an urban level 1 trauma center. Survey questions examined demographic information and patient factors, such as how they found out about the pregnancy, if they had seen a doctor for this pregnancy, use of PNC in prior pregnancies, and whether they would utilize first trimester PNC in the future. Additionally, the survey contained a series of statements about the importance of PNC and factors affecting their utilization as rated on a 5 point Likert scale. All data was abstracted and coded into Excel. Descriptive statistics and 95% confidence intervals were calculated. Logistic regression was used to predict future PNC use. Results: A total of 74 patients who met the inclusion criteria were surveyed. Ninety‐three percent (CI 84‐97%) knew they were pregnant prior to presenting to the ED. Thirty‐seven percent (CI 27‐50%) had a prenatal visit prior to the index ED visit. Twelve percent (CI 6‐22%) reported they were at the ED for PNC, 70% (CI 59‐80%) for another OB/GYN issue, and 18% (CI 10‐28%) for a reason unrelated to pregnancy. However, 22% strongly agreed and 8% agreed that if they had PNC they would not have come to the ED that day. Predictors of future PNC use included knowledge of pregnancy prior to ED visit, number of pregnancies, belief that PNC is important for the mother’s health, knowledge of where to receive PNC, and belief that taking prenatal vitamins during pregnancy can help the baby. Conclusions: For the population of pregnant females presenting to an urban level 1 trauma emergency department during the first trimester of pregnancy, a large proportion (30%) reported they would not have come to the ED if they received PNC. This would represent a significant reduction in ED visits per year if these women received appropriate services. Future research would need to further delineate the perceived barriers to PNC in this population.
    • The Proportion of Adolescents Complaining of Anterior Knee Pain with Osteochondritis Dissecans and the Utility of Screening Radiographs in its Diagnosis.

      MacKenzie, James; The University of Arizona College of Medicine - Phoenix; Vaughn, Jeffrey M.; Shrader, M. Wade (The University of Arizona., 2016-04-01)
      Osteochondritis dissecans is a rare condition which can cause disabling knee pain in adolescents. Treatment and prognosis hinges upon the stage of the lesion and early detection is paramount 1‐3. Until recently, epidemiologic information regarding OCD in adolescents was unavailable. However in 2013 Kessler et al. demonstrated an incidence of 9.5/100,000 in the general adolescent population 4. Chief complains from patients with OCD usually localize pain to the knee joint line, but less commonly, patients may complain of anterior knee pain. This retrospective chart review looked at the amount of OCD diagnoses in adolescents specifically complaining of anterior knee pain without causative trauma in the years 2009 and 2010 at a major children’s hospital. It was noted that 7.5% of children with this presentation had a diagnosis of OCD. This number was over three orders of magnitude higher than the incidence seen in the general adolescent population as established by Kessler and may support the use of screening radiographs in this subset of patients to detect OCD in its early stages.
    • Racial/Ethnic Disparities in HIV Survival Among People Diagnosed with HIV in Arizona, 1998‐2012

      Mun, Elijah; The University of Arizona College of Medicine - Phoenix; Gonzalez, Jonathan (The University of Arizona., 2016-03-25)
      Objectives. We described the racial/ethnic disparities in survival among people diagnosed with HIV in Arizona from 1998 to 2012. We determined whether these disparities widened when adjusting for AIDS diagnosis, age at diagnosis, year of diagnosis, and gender. Methods. We compared survival from all causes between Whites and Blacks, Hispanics, Native Americans, Asians, and Multiple/Other races via Kaplan‐Meier survival curves and Cox proportional hazard models controlling for various clinical factors. Results. Multiple/Other races (1.85), Native Americans (1.28), and Blacks (1.19) have statistically significant higher hazard ratios in all‐cause mortality than Whites. When adjusting for AIDS diagnosis, these disparities widened and also showed Hispanics to have greater mortality [Multiple/Other races (2.53), Native Americans (1.44), Blacks (1.43), and Hispanics (1.22)]. Conclusions. Racial/ethnic minorities with HIV, specifically Black, Native Americans, and Multiple races, have significantly decreased overall survival. These disparities widen when considering the AIDS population. Further studies and resources could help identify the cause of these disparities and help generate a solution to diminish the survival gap.
    • A Randomized Controlled Trial Comparing Preemptive Versus On Demand Administration of Analgesics After Mohs Surgery and Cutaneous Reconstruction

      Crow, Lauren; The University of Arizona College of Medicine - Phoenix; Brodland, David (The University of Arizona., 2016-03-23)
      BACKGROUND: Mohs Micrographic Surgery (MMS) affords a high cure rate for cutaneous carcinoma. OBJECTIVE: This study was designed to characterize the pain patients experience after MMS and reconstruction of the head and neck, and to determine if preemptive dosing of analgesics was superior to patient‐initiated dosing on an "as needed" basis. METHODS: A controlled trial of 200 subjects undergoing MMS and reconstruction of skin cancers on the head and neck were randomized to either receive acetaminophen at the time of discharge or to take it on an "as needed" basis. The two groups were evaluated for differences in peak pain, satisfaction with pain management, and the need for narcotic analgesic "rescue" postoperatively. RESULTS: Peak pain levels after surgery were surprisingly low and rated, on average, 2/10 using an analog pain scale. Peak pain occurred at four hours postoperatively for both subgroups and patients were satisfied with pain control 72.5% of the time. There was no significant difference in any of the parameters between the two dosing regimens. CONCLUSIONS: Mohs surgery peak pain typically occurs four hours postoperatively. Patient satisfaction with pain management was high with acetaminophen regardless of the dosing regimen. Preemptive analgesia with acetaminophen does not appear to be superior to "asneeded" regimens.
    • The Role of Injection Laryngoplasty (IL) in Treating Deep Interarytenoid Notch (DIN) Associated Dysphagia in Young Children

      Frantz, Garrett; The University of Arizona College of Medicine - Phoenix; Williams, Dana (The University of Arizona., 2016-04)
      BACKGROUND Deep Interarytenoid Notch (DIN) is the mildest form of laryngotracheoesophageal cleft defect and is frequently found in young children with dysphagia and aspiration. Treatment guidelines are not defined. Injection laryngoplasty (IL) is a surgical procedure injecting polymer gel into the issue around the defect. Our objective was to evaluate the efficacy of IL in pediatric populations with severe dysphagia and aspiration. METHODS We conducted a pilot retrospective chart review of DIN patients under 36 months who underwent IL at PCH. Severity of dysphagia before and after IL was measured using modified barium swallows (MBS) (scale 0‐10) and documented symptoms. Statistical analysis was done using paired two sample t‐test with a p value of 5 percent. RESULTS Patients with initial MBS above double honey (7) improved an average of 2.6 ±1.38 points while those with initial scores below 7 did not see a statistical change in MBS. At the end of the study period, the final MBS scores for both groups were statistically similar.CONCLUSIONS IL treatment for DIN associated dysphagia results in improvement of MBS scores and symptoms in toddlers with severe aspiration. Careful timing of IL impacts morbidity. Future prospective controlled studies are necessary to evaluate the role of IL and medical interventions in thickener wean and clinical improvement.