• Does Adjunctive Pain Control with Dexmedetomidine Improve Outcomes in Patients with Adolescent Idiopathic Scoliosis?

      Spaulding, Kole; The University of Arizona College of Medicine - Phoenix; Shrader, M. Wade (The University of Arizona., 2017-05-19)
      Adolescent Idiopathic Scoliosis (AIS) is typically treated surgically by Posterior Spinal Fusion (PSF) surgery. Intravenous analgesics and oral opioids are commonly used for pain management. Several adjunct therapies are used in addition to the standard treatments. One of these therapies is the use of dexmedetomidine (dex). Though dex has been found to be an effective sedative for post‐operative patients, there are also several adverse effects that are associated with its use. The purpose of this study was to investigate the effectiveness and overall benefit of using dex for pain control for patients undergoing PSF for AIS. IRB approval was obtained. A group of 43 patients with AIS undergoing PSF and using Dex for adjunctive pain control were matched with 43 patients who did not use Dex. The groups were matched based on gender, age, height, weight, and level of spinal fusion. During the patients’ post‐operative hospital stay, the total opioid use and clinical pain scores were compared between the two groups using t‐tests, with significance set at p<0.05. Total opiate use was 239.6 morphine equivalent doses in the non‐Dex (control) group and 246.2 in the group that received Dex (p=0.72). The average pain score in the control group was 2.3, and the group that received Dex was 2.6 (p =0.43). There were no differences in the complication rate between the two groups, specifically the oversedation rates and pulmonary complications. Lastly, the average length of stay for the control group was 4.8 days compared to the dex group, which was 5.0 days (p=0.35). Although adjunctive pain modalities may be very useful in the treatment of postoperative pain after PSF in patients with AIS, the use of Dex in this cohort did not improve pain scores, lower opioid use, or lower the LOS. Based on these results, we do not recommend the routine use of dexmedetomidine as an adjunctive pain control modality. Adjunctive modalities are important in pain control in patients with AIS undergoing PSF, but the use of dexmedotomidine was not effective in improving pain control.
    • The Effect of Two Attending Surgeons on Patients with Large Curve Adolescent Idiopathic Scoliosis Undergoing Posterior Spinal Fusion

      Bosch, Liam Christian; The University of Arizona College of Medicine - Phoenix; Shrader, Wade (The University of Arizona., 2017-06-01)
      Surgical correction of Adolescent Idiopathic Scoliosis (AIS) carries a substantial risk of complication. The literature supports improved perioperative outcomes through the two surgeon strategy in other complex orthopedic procedures. Does the presence of 2 versus 1 attending surgeons affect the perioperative morbidity of posterior spinal fusion (PSF) in patients with AIS curves greater than 70°? We reviewed the database from a large regional children’s hospital of all patients with AIS curves greater than 70° who underwent PSF from 2009‐2014 and divided the cohort into single versus 2‐surgeon groups (28 vs. 19 cases, respectively). We analyzed cases for length of surgery, estimated blood loss, and length of stay. The groups were identical when comparing age, gender, spinal levels fused, and average ASA score. However, the average Cobb angle in the single surgeon group was significantly less than in the 2 surgeon group at 78.4 vs 84.0 degrees, respectively (p=0.049). Mean operative time for single versus 2 surgeons was 238 (SD 48) vs 212 (SD 46) minutes (p=0.078). Mean percent estimated blood loss was 26% (SD 14.1) for single surgeon vs 31% (SD 14.9) for 2 surgeons (p=0.236), and mean estimated blood loss for single surgeon vs 2 surgeons was 830ml (SD 361) vs 1045ml (SD 346) (p=0.052). Mean length of stay was significantly decreased in the 2 surgeon group at 5.16 days (SD 1.7) versus the single surgeon group at 6.82 days (SD 6.82) (p=0.002). The use of 2 surgeons in AIS deformity correction at an experienced regional children’s hospital did not improve clinical outcomes. The average length of stay was reduced in the two‐surgeon group, but there was no significant impact on blood loss or operative time. However, this study does not rule out the potential for positive impact with a two‐surgeon strategy, and given previous supportive data in the literature, this approach should further evaluated to determine its effect on improving perioperative outcomes.
    • Feasibility of Pre-Operative Neurovascular Examination in Pediatric Elbow Fractures

      Johal, Ovninder; The University of Arizona College of Medicine - Phoenix; Shrader, M. Wade (The University of Arizona., 2017-05-09)
      A detailed pre‐operative examination of a child’s neurovascular status following pediatric elbow fractures is critical to the assessment of these injuries. Without proper documentation of the preoperative exam, apparent postoperative changes in the neurovascular examination may be difficult to determine, and may dictate different treatment strategies. The reported incidence of neurologic (11.3%) and vascular (0.3‐4.6%) injury associated with supracondylar fractures underscores the importance of the preoperative exam. The purpose of this prospective study was to determine how frequently a complete neurovascular exam could be completed in children with elbow fractures. A detailed, specific elbow fracture History and Physical form was developed for prospective use on all pediatric elbow fractures in a tertiary care pediatric trauma hospital from 2013 through 2014. Specific neurovascular exam criteria were documented in an easily used checklist form. Demographic data collected included age, BMI, mechanism of injury, fracture type, comorbidities, pre‐operative pain management, and the operative procedure performed. There were 163 patients meeting the inclusion criteria. Attempted neurovascular (NV) exam was documented in 146 of these patients (89.6%). A clinically reliable, complete NV exam was possible in 104 patients (71.2%). In the remainder of the children, the clinician could not determine at least one aspect of the neurovascular exam. A significant correlation was found between age of the subject and ability to obtain a complete exam, with younger children less than age 5 being more likely to have incomplete information on the NV exam (p<0.000001). Gender, BMI, fracture type, pre‐assessment pain control, and potential language barriers had no effect on whether or not the exam was complete. Although a complete and detailed neurovascular examination is considered necessary when evaluating pediatric elbow fractures, over a fourth of our patients (29%) were unable to reliably participate in a full preoperative neurovascular exam. Younger children (less than 5 years of age) were less likely to participate in a complete neurovascular assessment. Neurovascular examinations in the setting of elbow fractures in children less than five years of age were unreliable and incomplete.
    • The Healthy Eating Active Living Total Health (HEALTH) Model Improves the Quality of Pediatric Obesity Prevention

      Fah, Megan; The University of Arizona College of Medicine - Phoenix; Samaddar, Kristen (The University of Arizona., 2017-05-08)
      BACKGROUND: The prevalence of childhood obesity has tripled in the past 30 years. There are many published recommendations to address pediatric obesity, yet countless physicians are challenged by the time and resources required to provide obesity screening and counseling in a busy practice. OBJECTIVE: To determine the effects of a motivational interviewing (MI) program and an electronic health record (EHR) reminder system to improve physician performance in identifying and counseling patients about obesity prevention and management. METHODS: Baseline and two post‐intervention cohorts were created with patients, ages 5‐18 years, from 100 consecutive well child visits at an academic teaching practice in Feb 2014, Feb 2015, and Aug 2015. The HEALTH model was created to improve care by providing in‐room family education tools, provider training in MI, an evidence‐based pathway to standardize care, and family coaching between visits. The model was implemented using quality improvement methodology. A second intervention added an alert in the EHR to notify providers if a patient’s body mass index (BMI) was > 85%ile. Outcome measurements included documentation of BMI percentiles, identification of overweight/obesity in the problem list, quantity and quality of healthy lifestyle counseling, and recommending follow up for BMI monitoring per prevention guidelines. P‐values were calculated using Chi‐Squared or Fisher’s Exact tests. RESULTS: Post HEALTH implementation, physicians improved their identification of patients with elevated BMI, improved the quantity and quality of healthy lifestyle counseling, and increased compliance with prevention plus recommendations for follow up. Providers increased their rates of identifying and counseling patients with obesity from a baseline of 50% to 76% (HEALTH) to 85% (EHR alerts). Post HEALTH intervention, physicians increased counseling about screen time and sleep (p<0.001) while maintaining high rates of counseling about nutrition, exercise and minimizing sugary beverages. Providers increased documentation of a specific, individualized action plan from 33% of the time at baseline to 59% post HEALTH intervention (p<0.001). Physicians increased recommendations for patients with elevations in BMI post intervention (p<0.005). CONCLUSIONS: After implementation of the HEALTH model and electronic reminders, physicians significantly improved their performance in identifying and counseling patients with elevated BMI. They also increased performance in counseling abouthealthy lifestyle behaviors for patients of all BMI categories. The HEALTH quality improvement model combined with electronic alerts provides a means to implement evidence‐based obesity prevention guidelines into clinical practice.
    • HPV Vaccination Acceptability Among Immigrant and Ethnic Minorities in the United States: Systematic Review

      Zahedi, Bita; The University of Arizona College of Medicine - Phoenix; Johnson‐Agbakwu, Crista (The University of Arizona., 2017-05-22)
      To systematically review all studies examining HPV vaccination acceptability among immigrant and ethnic minority parents and eligible individuals for cervical cancer prevention in the Unites states. MEDLINE/PubMed, Cumulative Index to Nursing and Allied Health Literature, EMBASE, and Cochrane database searches were conducted searching for English language, US‐based studies to examine immigrant and ethnic minority population’s acceptability of HPV vaccination. Thirteen of more than 3,098 potentially relevant articles were included in the final analysis. Results. Latinos were statistically more likely to accept vaccination for both their daughters and sons. Foreign‐born adult Latinas were more accepting of the vaccine than U.S.‐born Latinas after controlling for other variables. Overall African American and Asian American parents were less likely to accept HPV vaccination for their daughters than Hispanic and White parents. Of the African American parents who intended to vaccinate their children the majority were significantly non‐Baptist and had higher levels of education. The majority of Haitian immigrants intended to vaccinate daughters and the rest agreed that they would most likely have their daughters vaccinated if their daughters’ physicians recommended it. More research is needed, particularly in the context of health care provider HPV vaccination recommendation to immigrant and ethnic‐minority populations. Acceptance figures so far suggest that the vaccine is generally well received among Hispanic/Latin and Haitian immigrants, but details of ethnic variations among these groups and a qualitative understanding of lower rates of acceptability among African American and Asian American communities are still being awaited. Despite advances in cervical cancer screening rates in the US, cervical cancer remains disproportionately high among low‐income immigrant and minority women, making this subgroup particularly vulnerable to disparities in screening and its detection. The purpose of this study is to examine the qualitative aspects of institutional and community level interventions of Cervical Intraepithelial Neoplasia (CIN) within the immigrant and refugee populations and the use of HPV vaccination as a prevention method. Combinations of the following keywords/phrases will be used: CIN‐ Cervical Intraepithelial Neoplasia, Cervical diseases, Cervical dysplasia, Refugees, Pap smear, Cervical Cancer Screening, HPV‐ Human Papillomavirus, HPV vaccination, Ethnic minorities, Immigrants. Independent reviews of each article will be conducted to assess the study quality and confirm the accuracy, completeness, and consistency of the abstracted data.
    • Qualitative Assessment of Activated Microglia and Astrocytes in Focal Cortical Dysplasia: Case Series of Pediatric Patients

      Yee, Nicole; The University of Arizona College of Medicine - Phoenix; Lifshitz, Jonathan; Adelson, P. David (The University of Arizona., 2017-05-22)
      Epilepsy is the most common neurologic condition seen in children. Focal cortical dysplasia (FCD), a seizure disorder characterized by abnormal cortical laminar development, comprises approximately 75% of medically intractable epilepsies in the pediatric population. A greater appreciation of the pathology and intrinsic properties of the epileptogenic zone may help in understanding why FCD lesions are drug‐resistant, and could potentially lead to more effective treatments in the pediatric population. Neuronal support cells such as microglia and astrocytes have shown to have a role in FCD pathology. These cells are also activated during aging and traumatic brain injury as evidence by morphological change. This study aims to characterize the spatial distribution of microglia and astrocytes using immunohistochemistry in dysplastic tissue of eight male pediatric patients diagnosed with FCD. Cortical specimens from patients who underwent surgical resection of focally dysplastic cortex at Phoenix Children’s Hospital between 2008 and 2014 were examined using immunohistochemistry. Primary antibodies against GFAP and Iba1, as well as structural staining using hematoxylin and eosin (H&E), were incubated on sections and further analyzed using bright‐field microscopy. A pattern of perivascular activated microglia was observed in five patients around at least one blood vessel, while a pattern of non‐localized ramified microglia was observed in the other three patients. No identifiable pattern of astrocytic distribution was found. Thus, distinct patterns of microglia, rather than astrocytes, suggest dual underlying mechanisms of epileptogenesis.
    • The Seasonality of Eosinophilic Esophagitis Flares in Children and Adolescents in Arizona

      Manley, Kelsi; The University of Arizona College of Medicine - Phoenix; Williams, Dana (The University of Arizona., 2017-05-11)
      Aeroallergens are implicated in the pathogenesis of eosinophilic esophagitis, which has a recurrent or relapsing nature. We aim to determine the incidence of seasonal disease recurrence, referred to as flares, of eosinophilic esophagitis in patients in Arizona with eosinophilic esophagitis in remission, and to characterize the presence of allergy and other disease co‐morbidities in patients that experience disease flare. A retrospective study was performed by analyzing data from visits of patients aged 5 to 18 years coded for eosinophilic esophagitis in remission seen by the Phoenix Children’s Hospital Pediatric Gastroenterology Department between June 2010 and June 2011. The data included 148 patients and 326 clinical visits. Data identified demographic information, allergy, and other disease co‐morbidities. Arizona seasons were defined as: spring from February 15 to June 15, and fall from September 1 to November 30, according to the typical pattern of allergen pollination. To analyze incidence and season of flares, statistical methods used included the Chi‐square tests and logistic regressions. Ninety‐four of 148 patients (63.5%) flared during the study period. An increased incidence of flares in the fall compared with other seasons was statistically significant (p = 0.041). Flares in the spring also had an increased incidence. Of the 94 patients that flared, 70 patients (74.5%) had environmental allergy, 83 (88.3%) had food allergy, and 66 (70.2%) had both environmental and food allergy. Our findings suggest a role for seasonal environmental allergens in the pathogenesis of eosinophilic esophagitis and disease flares in children in Arizona, particularly those with food allergy, environmental allergy, or both.
    • The Use of Pulmonary Dead Space Fraction to Identify Risk of Prolonged Mechanical Ventilation in Children after Cardiac Surgery

      Siddiqui, Muniza; The University of Arizona College of Medicine - Phoenix; Willis, Brigham (The University of Arizona., 2017-05-18)
      Children with prolonged mechanical ventilation after cardiac surgery have a higher risk for poor outcome due to a variety of ventilator‐associated morbidities. It therefore becomes essential to identify these children at higher risk of prolonged mechanical ventilation as well as find methods to identify children ready to be extubated as early as possible to avoid these complications. One physiological variable, the pulmonary dead space fraction (VD/VT), has been suggested as a possible indicator of prolonged mechanical ventilation. VD/VT essentially measures the amount of ventilated air that is unable to participate in gas exchange. Can VD/VT be used successfully in children undergoing cardiac surgery to identify those at risk for prolonged mechanical ventilation and identify those ready for extubation? Retrospective chart review of 461 patients at Phoenix Children’s Hospital in the Pediatric Cardiac Intensive Care Unit since the initiation of standard application of the Philips NM3 monitors in October 2013 through December 2014. From the 461 patients screened, only 99 patients met all the inclusion criteria. These 99 patients consisted of 29 patients with balanced single ventricle physiology and 61 patients with two ventricle physiology. Initial postoperative and pre‐extubation VD/VT values correlated with length of mechanical ventilation for patients with two ventricle physiology but not for patients with single ventricle physiology. Additionally, pre‐extubation VD/VT values of greater than 0.5 indicated higher rates of extubation failure in two ventricle patients. Conclusion: For children with two ventricle physiology undergoing cardiac surgery, VD/VT should be used clinically to estimate the length of mechanical ventilation for these children. VD/VT should also be checked in these patients before attempting to extubate. If VD/VT is found to be higher than 0.5, extubation should not be attempted since the patient is at a much higher risk for extubation failure.