• Variability in the Interpretation of Elbow Fractures in Children

      Kraynov, Liliya; The University of Arizona College of Medicine - Phoenix; Zebulon, Timothy; Bulloch, Blake (The University of Arizona., 2016-03-25)
      Background and Significance The first physician to encounter a child with an elbow fracture is usually the emergency medicine (EM) physician. Many hospitals may not have access to immediate orthopedic consultation or “real-time” radiology reads, therefore, EM physicians have a great responsibility for an accurate diagnosis. Unfortunately, many EM physicians have little training in pediatric orthopedic injuries. The elbow's anatomy and radiographic features of the growing elbow increase the difficulty in determining an accurate diagnosis and proper treatment. Inaccurate interpretation of elbow fractures in children may lead to unnecessary or improper medical decisions. Accurate interpretation is especially important in rural settings where patients may need transportation to facilities with higher levels of care. Research Question This study aims to survey EM physicians and determine if certain elbow fractures are diagnosed inaccurately more frequently and if some physician characteristics share a relationship with the accuracy of diagnosis of pediatric fractures. The characteristics include area of specialization, annual ED volume, years of experience post residency training, and working in an academic versus non-academic department. Different types of fractures, including type 1 supracondylar, type 2 supracondylar, type 3 supracondylar, medial epicondyle, lateral epicondyle, and olecranon along with uninjured elbows were evaluated to determine if a particular type was misdiagnosed more frequently. Methods A 16-question multiple-choice paper survey was distributed to physicians working in academic and non-academic centers within adult or pediatric emergency departments. Questions included radiographs and asked the physician to determine which fracture existed, if any.Results Lateral epicondyle fractures were the most likely fractures to be misdiagnosed (22.12%), while type 3 supracondylar fractures were the most likely to be accurately diagnosed (95.5%). There was no significant difference in accuracy of diagnosis based on physicians working either in an academic department, non-academic department, or both. Those physicians who were board certified or board eligible in two or more specialties had a higher mean percent correct, as well as those who worked in pediatric emergency medicine. Conclusions While this study served to start clarifying the most frequently misdiagnosed pediatric fractures and whether physicians with particular characteristics were more likely to diagnose fractures accurately, further steady is necessary to draw a definitive conclusion. This study does shed light on which pediatric elbow fractures physicians misdiagnose more frequently. It is important for all emergency medicine physicians to keep in mind the types of fractures that are most commonly misdiagnosed as it can affect medical decision-making. This is an area where additional education about elbow fractures in the developing pediatric elbow may be needed.
    • Visual Findings in Neovascular Macular Degeneration Refractory to Bevacizumab after Intravitreal Aflibercept Therapy

      Moazez, Carmel; The University of Arizona College of Medicine - Phoenix; Reddy, Rahul (The University of Arizona., 2016-03-25)
      Neovascular (wet) age‐related macular degeneration (AMD) is associated with blindness in patient populations above 55 years of age, affecting approximately 2 million Americans. Intravitreal (IV) bevacizumab is widely employed in the treatment of wet AMD. Development of a novel pharmacologic intervention to match bevacizumab’s indications is possible with the advent of aflibercept. This study evaluated the optical coherence tomographic (OCT) findings and intraocular pressure after IV aflibercept therapy in patients with wet AMD refractory to IV bevacizumab therapy. This retrospective review of 29 patient records (30 eyes) demonstrated that 73% of patients did not show an increase in OCT. Furthermore, 83% of patients did not demonstrate an increase in intraocular pressure (IOP) and all patients had an IOP of 20 or less after three months of therapy. This study further explores the mean change per patient in retinal thickness via OCT as well as intraocular pressure. The results of this study demonstrate that aflibercept can improve visual findings in patients refractory to bevacizumab and therefore we recommend that patients be switched to it. Further, it is safe to use in patients with glaucoma as it will not increase the IOP.
    • 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.
    • Diagnosing Ventilator‐Associated Pneumonia in Burn Patients: Endotracheal Aspirates Versus Bronchoalveolar Lavage

      Lish, James; The University of Arizona College of Medicine - Phoenix; Foster, Kevin N. (The University of Arizona., 2016-03-25)
      Introduction: Ventilator‐associated pneumonia (VAP) is associated with increased mortality, ventilator days, intensive care unit days and length of stay, especially in the thermal burn patient. In addition to poorer patient outcomes it is estimated that VAP increases the cost of care, making the prevention of VAP a high priority within healthcare. While no “gold standard” diagnosis for VAP exists, criteria typically include clinical suspicion, radiography and microbiological testing. The purpose of this study was to correlate results of endotracheal tube swabs (ETT), endotracheal aspirates (TA) and broncheoalveolar lavage (BAL) in burn patients with suspected VAP. The goal of this study is to determine if TA sampling is a viable alternative to BAL in the diagnosis of VAP in burn patients. Methods: This was a non‐interventional prospective study of 42 adult burn patients with suspected VAP. Respiratory specimens via ETT, TA, and BAL were collected and cultured. Basic demographics, clinical signs and symptoms and culture results were collected and descriptive statistics were performed. Results: Concurrent cultures were performed on the 42 patients with suspected VAP. Correlations were done between TA, BAL and ETT. TA and BAL correlated 87% of the time while TA and ETT correlated 49% of the time. The correlation between ETT and BAL was 40%. Calculated sensitivities, specificities, positive predictive values (PPV) and negative predictive values (NPV) for TA and BAL were roughly equal, while the values for ETT were much lower. Conclusions: TA is nearly as reliable as BAL in identifying the causative organisms in VAP, and should be considered as an economical and easily obtained initial diagnostic test in burn patients suspected to have VAP.
    • Evaluation of Skin Cancer Screenings in Tucson, Arizona from 2006‐2013

      Romano, Gianna; The University of Arizona College of Medicine - Phoenix; Harris, Robin (The University of Arizona., 2016-03-25)
      Background: One out of every three cancer diagnoses is a skin cancer, and the incidence of both melanoma and non‐melanoma type skin cancers is increasing. Skin cancers, including melanoma, are typically treatable if detected early. However, there is insufficient evidence to support recommendations to establish population based skin cancer screening programs. The specific aims of this study are 1) to evaluate characteristics of participants who attend a community skin cancer screening event and who are referred for follow up due to suspicious lesions, 2) to determine the proportion of participants with suspicious lesions identified at a community skin cancer screening event who complied with a request to visit a dermatologist or primary care physician, and 3) to evaluate attitudes toward sun protection practices, and perceived risk of developing skin cancer among participants who attend a community skin cancer screening and have a suspicious skin lesion. Methods: The Skin Cancer Institute sponsored a series of community skin cancer screening events in Tucson, Arizona from 2006 to 2013. Participants completed an American Academy of Dermatology screening form prior to a skin examination by a dermatologist. Participants with suspicious lesions identified at the examination who agreed to be contacted again received questionnaires 4 months after the initial screening to assess compliance with follow‐up recommendations, and their sun protection practices and risk perceptions. Results: 1979 community members attended the skin cancer screenings. The majority of the participants were Caucasian, females, had blue eyes and brown hair, were college educated, had no prior personal or family history of skin cancer, had health insurance but did not have a regular dermatologist, reported that they had never been to a skin cancer screening before, and stated that without this screening that they would not have their skin examined. 748 (37.8%) of community members were referred and instructed to see a dermatologist for further evaluation of a skin lesion. Of the 441 participants with a suspicious lesion who consented to participate in the follow‐up study, 120 returned a questionnaire; 90 (75%) reported that they followed up with a dermatologist or physician, and 30 (25%) did not. Of the 90 participants who followed up, 53% received a skin biopsy. The self reported diagnoses from the biopsies of the suspicious skin lesions were the following: 1% atypical or dysplastic nevus, 21% actinic keratosis, 16% basal cell carcinoma, 8% squamous cell carcinoma, 2% melanoma, and 38% did not have skin cancer. Conclusions/Impact: This study demonstrated that 38% of community skin cancer screening participants were referred for follow up due to a suspicious skin lesion being identified during a skin cancer screening event. It also appeared that 75% of those who responded to the follow‐up questionnaire complied with the request within four months, although the response rate for the follow‐up questionnaire was low. Therefore, implementing a formal reminder system following the skin cancer screenings may increase the percentage of participants who follow up with a primary care physician or dermatologist after the screening for further evaluation of their suspicious skin lesion.
    • The Utility of Hemoglobin A1c in Detecting Prediabetes in Obese Youth

      Srivastava, Sarika; The University of Arizona College of Medicine - Phoenix; McClellan, Donald (The University of Arizona., 2016-03-25)
      Introduction. The incidence and prevalence of Type 2 diabetes mellitus has been steadily increasing over the past ten years, and is currently approximately 4.1 per 1000 12‐19 year olds in the US2. This increase has been linked to obesity and a sedentary lifestyle. Prediabetes, in the pediatric population is defined as having a fasting plasma glucose concentration ≥ 100 to 125 mg/dL or 2‐hour glucose concentration during an oral glucose tolerance test ≥ 140 mg/dL but <200 mg/dL. Aims. The goal of this study is to describe the sensitivity and specificity of hemoglobin A1c at various thresholds to identify prediabetes, as defined by impaired fasting glucose and/or impaired glucose tolerance; the population included in this study consist of obese youth referred to the Division of Endocrinology and Diabetes at Phoenix Children’s Hospital for weight‐related issues. We anticipate describing various levels of sensitivity and specificity of hemoglobin A1c in comparison with gold standard tests, such that it can be used to propel further studies to ultimately reduce the immense patient burden of fasting in the pediatric population. Methods. We conducted a retrospective cross‐sectional chart review and employed receiver operating characteristic (ROC) curve analysis of data including but not limited to hemoglobin A1c, fasting plasma glucose, and 2‐hr post‐prandial plasma glucose. The benefits of this study include the potential of reducing the patient burden of fasting prior to examination. This review will determine, if any, the potential value in being able to use hemoglobin A1c clinically to detect prediabetes in pediatric patients; determining this may provide critical information to improve the monitoring and screening of prediabetes. Conclusions. Compared to the gold standards of fasting plasma glucose and oral glucose tolerance tests, we found that hemoglobin A1c had a low sensitivity and specificity for identifying prediabetes.
    • Comparison of 64‐Slice EKG‐Gated Computed Tomographic Angiography, Transthoracic Echocardiography, and Transesophageal Echocardiography for Detection and Complete Characterization of Anomalous Coronary Arteries in Infants with Comorbid Congenital Cardiac Malformations

      Sridhar, Shravan; The University of Arizona College of Medicine - Phoenix; Richardson, Randy R. (The University of Arizona., 2016-03-25)
      Background and Objective: Computed tomographic angiography (CTA) offers several benefits over echocardiography in the detection of CAAs (coronary artery anomalies). These include higher spatial resolution, operator independency, non‐invasiveness, and the availability of reconstructive techniques to track the entire arterial course.1,4,9 Accordingly, standard clinical practice (per ACC/AHA guidelines for adults with CAAs) for adults with suspected CAAs includes use of CTA as a first‐line imaging modality.6 Currently, there is no evidence favoring either CTA, transthoracic echocardiography (TTE), or transesophageal echocardiography (TEE) for initial imaging of infants with suspected CAAs. Therefore, the aims of this retrospective study include investigating the efficacy of CTA, TTE, and TEE in the detection and complete characterization of CAAs. Methods: Imaging and surgical data for 27 patients who presented for evaluation of congenital heart disease between 2006 and 2011 were evaluated. Patients had a mean age of 2.2 ± 0.7 months at initial evaluation and had undergone EKG‐gated 64‐slice cardiac CTA with 3D reconstruction in addition to multiple TTE and TEE studies. Performance metrics (including sensitivity, specificity, positive predictive value, negative predictive value, and accuracy) of each modality in CAA detection were computed. Concordance between each modality and surgical/conventional angiographic diagnosis in the characterization of anatomy along the origin, course, and termination of anomalous coronary arteries was evaluated. The rate of limitations of each modality in the imaging and interpretation of coronary anatomy was also reported. Results: Using surgical/angiographic diagnosis as the gold standard, CTA produced a sensitivity, specificity, and accuracy of 80%, 50%, and 74%, respectively. TTE produced a sensitivity, specificity, and accuracy of 20%, 50%, and 26%, respectively. TEE produced a sensitivity, specificity, and accuracy of 27%, 100%, and 42%, respectively. CTA outperformed TTE and TEE at characterizing anatomy at the origin and course of an anomalous coronary artery. At characterizing anatomy at the termination of an anomalous coronary artery, CTA outperformed TEE but did not significantly outperform TTE. CTA had a higher rate of documented limitations to imaging/interpretation compared to TTE and TEE but a lower rate when compared to conventional angiography. Conclusion and Impact: CTA is a rapid, non‐invasive, operator‐independent imaging modality that offers high resolution, 3‐dimensional imaging of CAAs in infants. The results of this study indicate that CTA is the most sensitive and accurate modality for detection of CAAs in infants and is optimal for characterizing anatomy along the entire length of an anomalous coronary artery. As such, CTA may be the optimal modality for first‐line coronary artery imaging in infants with suspected anomalous coronary artery anatomy who have a high pretest probability for having a CAA.
    • A Survey to Assess Parent Perspective of the Impact of a Gluten‐Free, Casein‐Free Diet on Their Child’s Symptoms of Autism Spectrum Disorder

      Wendt, Rebecca; The University of Arizona College of Medicine - Phoenix; Melmed, Raun; Savi, Christine (The University of Arizona., 2016-03-25)
      With the prevalence of Autism Spectrum Disorder (ASD) rising (approximately 1 in 45)1 treatment for the disorder becomes even more important. Families turn to both traditional and alternative medicinal sources for help. The Gluten‐Free, Casein‐Free (GFCF) diet is an example of an alternative therapeutic approach. Study Aims: Our aims were to design and begin initial validation of a survey to evaluate the use and efficacy of the GFCF diet in children with ASD with concurrent gastrointestinal (GI) symptomatology. We also aimed to assess feasibility of the survey in the target population through piloting the survey. This is the first step in determining association of the GFCF diet in children with ASD. Methods: A survey was developed with expert review, meant for completion by parents and primary caregivers of children with ASD. The survey content included demographics, treatments used, GI symptoms (as measured by a modified Rome III parent report form), food allergies and intolerances, and frequency of aberrant behaviors (as measured by the Aberrant Behavior Checklist). Questions regarding diet use (specifically gluten‐free diet, casein‐free diet, or GFCF) were included in the treatment modalities and as well as questions regarding compliance and length of time used. The survey was advertised to our target population and 38 completed responses were obtained for a pilot study. Results: The pilot study revealed questions which were not clear to the target population and required modifications. Data from the responses revealed 14/38 participants who attempted the GFCF diet or its variants with their child, 11 for 3 months or greater. Number of food intolerances was heightened among those who used the diet or its variants. Heightened ABC irritability subscores were noted among those with GI symptoms. Conclusions: The pilot survey developed for this project suggests that the use of the GFCF diet in children with ASD is not only common but also might be a useful therapeutic agent. The need for further validation of the tool is paramount.
    • Expedited Partner Therapy, Addressing Increased STD Infection Rates in Arizona

      Wade, Laura; The University of Arizona College of Medicine - Phoenix; Manriquez, Maria (The University of Arizona., 2016-03-25)
      Introduction: Chlamydia and gonorrhea are the two most reported sexually transmitted diseases (STDs) in Maricopa County.1 Effective treatment of the sex partner(s) of patients diagnosed with these STDs is an important step in preventing repeated infections. Expedited partner therapy (EPT) is the practice of prescribing antibiotics to the sex partner(s) of a patient diagnosed with a STD. EPT is recommended by the CDC in cases of uncomplicated chlamydia or gonorrhea infection.2 On September 26, 2008, Arizona statue was revised to allow for the use of EPT.3 Our study seeks to determine whether the use of EPT results in fewer repeat infections of chlamydia or gonorrhea within six months of initial diagnosis. Methods: We performed a retrospective chart review of 200 female patients diagnosed with chlamydia or gonorrhea between 2010 and 2013. We recorded how partner treatment was addressed, whether or not the patient had a repeat infection within six months, provider specialty and additional demographic information. Data was analyzed using One‐Way ANOVA or Wilcoxon Rank‐Sum for continuous variables and Chi‐Squared or Fisher’s Exact was used for categorical variables. Results: Overall documented percent repeat infection of 14.7% (n=20) out of 136 patients with follow up testing within 6 months. Loss to follow up of 32% (n=64). Percent repeat infection in EPT 0.0% (n=0), partner referral 16.1% (n=9), partner notification 20.9% (n=9) and not documented 16.7% (n=2). When comparing percent repeat infection in EPT (0.0%) to all other treatments combined (14.7%) the difference is statistically significant with p=0.025. Conclusions: The use of EPT results in fewer repeat infections in patients diagnosed with chlamydia. Limitations include loss to follow up and incomplete documentation in the electronic health record. Further investigation into the barriers to EPT is warranted to increase utilization of this strategy for partner 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.
    • 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.
    • The Effects of Stigma Toward Mental Illness on Family Physicians

      Sipe, Michelle; The University of Arizona College of Medicine - Phoenix; Goto, Kristine (The University of Arizona., 2016-03-25)
      Many individuals utilize primary care as their main source of mental health care, as in many areas of the US access to specialized psychiatric care does not meet the demand. Prior research has showed that many healthcare practitioners, including those working in generalist fields, carry stigmatized views about individuals with mental illness. Such stigmatized views can result in misattribution of symptoms to mental illness and a decline in proper diagnosis and treatment. Our study aims to examine if stigmatized views about mental illness relate to family medicine physicians’ comfort levels with treating mental illness, patterns of referral to psychiatrists, or amount of continuing medical education on psychiatric issues. Our hypothesis is that family medicine physicians who carry less stigmatized views will be more comfortable and up to date with psychiatric care practices and less likely to refer mental health issues to specialized mental health services. Methods: We administered an email survey to family medicine physicians via the Arizona Academy of Family Physicians monthly electronic newsletter. The survey contained demographic questions, a short (5‐question) validated stigma questionnaire (Attitudes to Mental Illness Questionnaire or AMIQ), and questions regarding self‐stated comfort level with mental illness, amount of recent mental‐health CME, and likelihood of referral for various mental illnesses. Results: AMIQ stigma ratings and referral rates for anxiety were significantly related (p=.012), as were AMIQ stigma ratings and amount of mental health CME (p=.001). Other trends were discovered, but were not significant. Impact: These results further demonstrate the need for increased emphasis on psychosocial and psychiatric issues, particularly stigma reduction, in family medicine residency training and CME. If family medicine physicians with high levels of stigma are less likely to treat mentally ill patients or seek further education regarding psychiatric issues, it could disrupt their patients’ quality, cost, and continuity of care.
    • Building a Medical App: Approach, Infrastructure, and Challenges of Developing a Congenital Heart Defects App for Educational Purposes

      Stoker, Alexander; The University of Arizona College of Medicine - Phoenix; Richardson, Randy (The University of Arizona., 2016-03-25)
      Mobile software application (apps) have exploded in popularity since 2008, when Apple’s App Store opened and have become increasingly present in medical education and medical practice. As evidence of educators realizing the potential apps have for educating students, the University of Arizona has created a department called the Office of Instruction and Assessment (OIA), which has a programming team that is committed to assisting faculty in the design, development and implementation of apps for University of Arizona Students. Congenital heart defects are the most common type of birth defect in the United States, affecting nearly 1% of, or about 40,000, births per year. There are complex three‐dimensional relationships involved in many of the congenital heart defects that may be difficult for students to fully understand through the traditional method of reading and looking at two‐dimensional diagrams. The principle goal of this project was to participate in the design and development of an educational mobile app that allows the user to interactively rotate digital 3D models of hearts with congenital heart defects. Multiple approaches to developing an educational medical app were explored including utilizing basic app‐building programs that do not require computer coding or programming, paying a for‐profit company to develop an app, and collaborating with a larger educational institution that has the resources available for developing an app and has a potential use for the app. This thesis aims to describe the resources available to develop an educational app, the major factors that determine the best approach for app development and the challenges associated with each approach. Through the case example of developing “Heart Defects” with the Office of Instruction and Assessment at the University of Arizona and publishing the app on the Apple App Store it was determined that the major factors guiding the approach to app development are complexity of the app, computer programming experience of the individual planning to develop an app, and having access to a larger institution with the ability to develop apps and the institution having a perceived benefit from developing the app.
    • 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.
    • 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.
    • The Characteristics of Physicians Elected and Serving in State Legislatures and the United States Congress

      Petterson, Matthew; The University of Arizona College of Medicine - Phoenix; Derksen, Daniel (The University of Arizona., 2016-03-25)
      Physician participation in United States governance has a long and honorable history, dating to the nation’s inception. At a time of unprecedented change in health policy ‐ to control the growth of health care costs, to cover the uninsured through Affordable Care Act (ACA) provisions, to improve quality, to meet the demand for health services as the population grows and ages ‐ the need for physician leadership to guide policy interventions has never been greater. Yet physician‐legislator participation has declined. There is little data about physicians involved in shaping health policy in state or federal legislative branches. This study examines the characteristics of physician‐legislators at the federal and state levels, and compares them to U.S. physicians in general. Using rosters fixed on March 13, 2014, the study reviewed biographic and demographic information on physician‐legislators. The study’s four hypotheses were that physician‐legislators were more likely to be (1) men than women, (2) members of the Republican Party than the Democratic Party, (3) a non‐primary care physician than a primary care physician, and (4) elected in the states where they completed graduate medical education than where they attended college. Ninety‐five physician‐legislators were identified in 51 legislative bodies in 2014. Physician‐legislators were more likely to be male than female, to be Republican than Democrat, and to be practicing in a non‐primary care than in a primary care specialty. Physician‐legislators were less likely to be elected in the state where they completed graduate medical education training than where they attended college. No personal factor was identified that linked the majority of physician‐legislators to the state in which they were elected.
    • Effectiveness and Student Perception of Simulated Case Based Learning in a Pre Clinical Medical Education

      Weed, Michael; The University of Arizona College of Medicine - Phoenix; Savi, Christine (The University of Arizona., 2016-03-25)
      Over the past decade, patient simulation has become an important teaching tool in allopathic medical education. Initially, medical simulation was used exclusively in the clinical years of medical training, but implementation into pre‐clinical curriculum is becoming increasingly common. Because simulated teaching experiences are a relatively new practice in pre‐clinical medical education, little is known about their value in this setting. We hypothesize that high‐fidelity patient simulation is an effective method of teaching basic medical sciences during the pre‐clinical years and that it will be viewed favorably by students when compared to other established teaching modalities. The purpose of our study is to: (1) test for an effect of teaching method on test score performance by comparing the results of relevant test items given to two student groups: a simulation group and a traditional case‐based instruction group; (2) determine student perception of simulation as a learning method for basic medical sciences. Methods: A one tier, mixed methods design was used to sequence this study. Test item scores were obtained from the classes of 2015 and 2016 at the University of Arizona College of Medicine ‐ Phoenix and results were analyzed using descriptive statistics to compare means and item difficulty. A Fisher’s exact test was conducted to compare test item performance between students who did and did not use simulation in their case‐based instruction group. Presimulation and post‐simulation surveys were also administered and thematic extraction used to triangulate results to quantitative findings. Results: There was no significant difference between performance of the simulation (n=48) and non‐simulation (n=79) group on the three test items. Survey results from this particular study indicate that students do enjoy learning in the simulated case‐based environment and that they find it to be intellectually stimulating. They also believe simulation will be useful in their careers. They do not, however, believe that it is as effective at teaching basic medical sciences when compared to the traditional lecture hall setting. Students also find simulation learning to be more stressful than small group learning. Conclusion: Our findings suggest that students who learn material through simulated case instruction perform as well as their counterparts who learn the material in traditional small group non‐simulated settings. However, our survey data suggests that while student perception of simulation is positive overall, there are instances in which simulation is viewed less favorably than both small group and traditional lecture environments. When analyzed together, the test item performance and survey findings show that while simulation can be an effective teaching tool in pre‐clinical medical education, there was not a significant difference when compared to lecture hall and non‐ simulated small group learning settings.
    • Complex Transcriptional Regulation of the Fibroblast Growth Factor‐23 Gene by 1,25‐Dihydroxyvitamin D3: Evidence for Primary and Secondary Mechanisms

      Saini, Rimpi; The University of Arizona College of Medicine - Phoenix; Haussler, Mark R. (The University of Arizona., 2016-03-25)
      Fibroblast growth factor 23 (FGF23) is a circulating phosphaturic hormone synthesized in osteocytes and osteoblasts that corrects hyperphosphatemic states by inhibiting renal phosphate reabsorption via the fibroblast growth factor receptor‐1 and its klotho coreceptor. In a closed endocrine loop, 1,25‐dihydroxyvitamin D3 (1,25D) induces FGF23 expression in bone, with the phosphaturic peptide in turn acting at the kidney to feedback repress CYP27B1 to suppress production of 1,25D. FGF23‐null mice cannot correct the severe hyperphosphatemia and ectopic calcification that results from the 1,25D‐stimulated calcium and phosphate intestinal absorption and renal reabsorption. Furthermore, abnormal concentrations of FGF23 have been linked to several potentially fatal pathologies, including chronic kidney disease and cardiovascular events. FGF23 synthesis is induced by the 1,25D‐bound vitamin D receptor (VDR), resulting in FGF23‐signaled suppression of the phosphate transporters NaPi‐IIa and NaPi‐ IIc, decreasing renal phosphate reabsorption and resulting in urinary phosphate excretion. Previous reports document upregulation of FGF23 mRNA by 1,25D; however the exact molecular mechanism(s) for this phenomenon remain unknown. In preliminary research, we identified five functional vitamin D responsive elements (VDREs) in the human FGF23 gene region remote to the promoter that may directly control FGF23 gene transcription. However, these VDREs displayed only modest induction activity, implying that a secondary mechanism for transactivation by 1,25D must exist to explain the observed high magnitude induction of FGF23 mRNA and protein by vitamin D, in vivo, and in cultured osteoblasts. In the present study, we disprove our hypothesis that membrane and extracellular matrix proteins, namely klotho and/or osteopontin, induced by 1,25D‐liganded VDR, secondarily generate a signaling cascade to increase FGF23 production. Instead, by truncation and point mutagenesis, we characterized a novel cis‐regulatory module in the proximal promoter of mouse FGF23, located between ‐400 and ‐200 bp from the transcriptional start site. A ‐0.6 kb construct of the murine FGF23 promoter demonstrates a 4‐fold induction in response to 1,25D when transfected into human leukemia (K562) cells. Mutation of one of the ETS1 sites at ‐346 bp within this construct, or an adjacent VDRE/Nurr1 site, reduces the transcriptional response to 1,25D to that of a minimal ‐0.06 kb promoter construct. Thus, the composite ETS‐VDRE/Nurr1 cis‐element identified herein may function in 1,25D‐elicited induction of FGF23 in a primary mechanistic manner via a novel VDRE located at ‐334 bp in the murine FGF23 promoter, and/or in a secondary fashion through 1,25D‐primary transcriptional activation of ETS1 and Nurr1. Also, we demonstrate a significant 1.7‐ to 2.0‐fold increase in transcription of a ‐1.0 kb murine FGF23 promoter construct in response to high calcium exposure of MC3T3 mouse osteoblastic cells. Thus, the FGF23 proximal promoter harbors cis‐elements that drive responsiveness to 1,25D and calcium, agents that induce FGF23 to curtail the pathologic consequences of their excess. Our results contribute to the understanding of the complex transcriptional regulation of FGF23 by providing evidence for cis‐regulatory elements within the FGF23 proximal promoter that are responsive to primary and secondary actions of 1,25D and calcium. Such findings may influence future therapeutic modalities in the treatment of FGF23‐related pathologies.
    • Chronic Pain in Noonan Syndrome: A Previously Unreported but Common Symptom

      Vegunta, Sravanthi; The University of Arizona College of Medicine - Phoenix; Grebe, Theresa A. (The University of Arizona., 2016-03-25)
      Background and Significance: Noonan syndrome (NS) is a multiple malformation syndrome characterized by pulmonic stenosis, cardiomyopathy, short stature, lymphatic dysplasia, craniofacial anomalies, cryptorchidism, clotting disorders, and learning disabilities. Eight genes in the RAS/MAPK signaling pathway are implicated in NS. Chronic pain is an uncommon feature. Research question and Methods: To investigate the prevalence of pain in NS, we distributed a two‐part questionnaire about pain among NS individuals at the Third International Meeting on Genetic Syndromes of the Ras/MAPK Pathway. The first part of the questionnaire queried demographic information among all NS participants. The second part was completed by individuals with chronic pain. Questions included musculoskeletal problems and clinical features of pain. Results: Forty‐five questionnaires were analyzed; 53% of subjects were female. Mean age was 17 (2–48) years; 47% had a PTPN11 mutation. Sixty‐two percent (28/45) of individuals with NS experienced chronic pain. There was a significant relationship between prevalence of pain and residing in a cold climate (P = 0.004). Pain occurred commonly in extremities/joints and head/trunk, but more commonly in extremities/joints (P = 0.066). Subjects with hypermobile joints were more likely to have pain (P = 0.052). Human growth hormone treatment was not statistically significant among subjects without chronic pain (P = 0.607). We conclude that pain is a frequent and under‐recognized clinical feature of NS. Conclusion: Chronic pain may be associated with joint hypermobility and aggravated by colder climate. Our study is a preliminary investigation that should raise awareness about pain as a common symptom in children and adults with NS.
    • Coccidioidomycosis as a Cause of Sarcoid in Arizona

      Yourison, Isaac; The University of Arizona College of Medicine - Phoenix; Kuberski, Tim (The University of Arizona., 2016-03-25)
      BACKGROUND AND SIGNIFICANCE: Sarcoidosis is a granulomatous disease of unknown etiology. Coccidioidomycosis is a granulomatous fungal infection due to Coccidioides immitis and Coccidioides Posadasii endemic to the Southwestern United States and the majority of the cases are reported from Arizona. The cause of sarcoidosis has been studied for over a hundred years without establishing an etiology. Establishing the cause of sarcoid would be a significant contribution to the understanding of an important multisystem disease. RESEARCH QUESTIONS: Based on clinical observations a group of patients with two granulomatous diseases – sarcoidosis and coccidioidomycosis led to the hypothesis for this Scholarly Project – can sarcoidosis be caused by the fungus Coccidioides? METHODS: A literature review was performed which resulted in 5 patient case reports, a medical record review was conducted of patients with sarcoidosis between 2004‐2014 at Maricopa Medical Center with a case‐control comparison to 68 matched patients, and PCR analysis of 34 sarcoid biopsy specimens from the 68 sarcoid patients identified from the medical record. Also, two main patients with sarcoidosis were studied, one prospectively and the other retrospectively, both patients had their diagnosis of sarcoidosis made in Arizona and both develop sarcoidosis. There was no evidence of an etiology for their sarcoidosis at the time of diagnosis, specifically no evidence of coccidioidomycosis. The prospective patient was followed for eight years before he developed coccidioidomycosis. Predicting correctly that a patient diagnosed with sarcoid in Arizona would eventually develop coccidioidomycosis provides strong evidence for an etiologic relationship between Coccidioides and sarcoidosis. INCOMPLETE STUDIES: There is one major study for this Project that has not been completed: 1. Genetic studies on patients with both sarcoidosis and coccidioidomycosis to determine if there is a genetic predisposition to disseminated coccidioidomycosis