• 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.
    • The Effectiveness of Military Medicine in Counterinsurgency Campaigns

      Ly, Jane; The University of Arizona College of Medicine - Phoenix; Beyda, David (The University of Arizona., 2017-05-10)
      While medical diplomacy has played a large role in US counterinsurgency (COIN) campaigns, few studies have been done to show their effectiveness. This study is a systematic review based on literature published by July 2014, looking at military medicine’s role in Operations Enduring Freedom and Iraqi Freedom (OEF/OIF). Both scientific and military databases were searched and yielded an initial 1,204 papers; however, these were later narrowed down to four articles, mostly restricted by the requirement of structured, scientific methods. These four studies were not well‐powered and focused on such different topics that no real conclusion could be drawn on the topic. In the end, the real value of the study was to show that despite the significant amount of resources poured into these COIN medical operations, very little study has been done to see if they have any effect.
    • Effects of High Vs. Reduced‐Dose Melphalan For Autologous Bone Marrow Transplantation in Multiple Myeloma On Pulmonary Function: A Longitudinal Study

      Nikolich‐Zugich, Tijana; The University of Arizona College of Medicine - Phoenix; Knox, Kenneth (The University of Arizona., 2017-05-12)
      Bone marrow transplants (BMT, also hematopoietic stem cell transplants or HSCT/SCT) are one of the greatest medical achievements of the 20th century. They offer a treatment for a host of malignant and nonmalignant hematopoietic disorders, genetic diseases and solid tumors that could otherwise be fatal. Studies have found that 60% of patients undergoing BMT develop pulmonary complications (PC), and 1/3 of those require intensive care after transplantation. Despite the potential pneumotoxicity of induction agents, to date there have been no longitudinal studies following pulmonary function in this high‐risk patient population. This study reviewed patient who underwent autogeneic bone marrow transplant for multiple myeloma at Banner University Medical Center – Tucson (formerly University of Arizona Health Network) from January 1, 2003 through December 31, 2013. Pretransplant evaluatin and pulmonary function testing data were obtained and stratified between high dose (standard) Melphalan (200 mg/ms2) and reduced dose (140 mg/ms2). Statistically significant differences were present between the 2 groups at baseline for DLCO but disappeared at 6 and 12‐month followup, while a statistically significant difference for FEV1/FVC ratio was seen at baseline and 6 months but disappeared at 12‐month follow‐up. There were no statistically significant differences seen with FEV1 between the two groups. Given there is no difference in mortality and relapse outcomes between the groups, the standard of care dosing for Melphalan is not associated with an increase in pulmonary morbidity.
    • The Efficacy of Maternity Waiting Homes in Decreasing Maternal and Perinatal Mortality in Low-Income Countries – A Systematic Review

      Ekunwe, Akua Boatemaa; The University of Arizona College of Medicine - Phoenix; Coonrod, Dean (The University of Arizona., 2017-05-23)
      Maternal and perinatal mortality remains significantly high in low‐income countries with over 800 deaths per day of women around childbirth. Greater than 90% of such deaths occur in low‐income countries. The concept of maternity waiting homes (MWH) was reintroduced to aid in decreasing maternal and perinatal mortality. Since the previous Cochrane Review in 2012 on maternity waiting homes, there have not been any published randomized controlled studies. Do observational studies on MWHs demonstrate decreased maternal and perinatal mortality in low‐income countries when compared with the standard of care? We searched for primary articles that reported maternal and perinatal deaths as major outcomes in studies who compared MWHs to other methods such as direct hospital admits, we also investigated cesarean delivery rates. Search engines used were: Cochrane Review, Medline and CINAHL. Meta‐analyses and forests plots were formulated using MedCalc Software. Systematic review was drafted using MOOSE guidelines for meta‐analysis and systematic reviews of observation. Seven articles met criteria for this study. The maternal mortality rate for MWH was 105/100,000 and 1,066/100,000 for non‐MWH, Relative Risk (RR) 0.145 (95% Confidence Interval (CI) 0.062 to 0.204). Perinatal mortality rate was 60/1,000 in MWH compared to 65/1,000, RR 0.782 (CI 0.602 to 1.120) in non‐MWH. Stillbirth rate was 18/1,000 in MWH and 184/1,000 in non‐MWH, RR 0.204 (CI 63.88 to 94.08). Neonatal mortality rates were 16/1,000 in MWH and 15/1,000 in non‐MWH, RR 0.862 (CI 0.392 to 1.628). Cesarean deliveries rate was 24/100 for MWH and 18/100 in non‐MWH, RR 1.229 (CI 1.226‐1.555). MHWs statistically decreased maternal death, stillbirths and increased cesarean delivery rates. Overall, the observation nature of the study designs introduces selection biases that may have altered the results of the studies. No randomized trials have been done to date. We suggest cluster‐randomized studies to further evaluate the effect of MWHs.
    • Evaluation of an Opt-Out HIV Screening Program in the Maricopa County Jails

      Nelson, Erin Da‐Hye; The University of Arizona College of Medicine - Phoenix; Taylor, Melanie; Mullany, Charles (The University of Arizona., 2017-05-12)
      Since inmates are a population disproportionately affected by HIV, correctional settings are important sites for delivering HIV services. The Maricopa county (Phoenix Area) jail system is the 4th largest in the nation. In 2011, the Maricopa County Correctional Health Service implemented an opt‐out HIV screening program for individuals booked into the Maricopa County Jails (MCJ). The aims of this study were to determine for the years 2012‐2014: • The number of inmates screened for HIV • The HIV positivity rate • The number of newly diagnosed patients • The clinical characteristics of the newly diagnosed HIV positive patients Five to seven days after booking, inmates are offered HIV screening. These laboratory records were used to determine the number of inmates tested and positivity. Prior history of previous HIV diagnosis was obtained from Maricopa public health records. Retrospective chart review of the MCJ health and case management records, including Ryan White forms, was performed to gather gender, age, race/ethnicity, sexual orientation, drug use, homelessness and co‐morbidities of newly HIV‐infected persons, such as Hepatitis C and prior STDs. Categorical factors were compared between groups with the Chi‐square test. Means were compared using a standard t test. P values ≤0.05 were considered significant. A total of 319,575 persons were booked and 46,346 were screened (14.5%) for HIV during the study period. The majority of booked inmates were male (76.9%) and Caucasian (50.8%). The mean age of inmates was 36 years. There were 70 newly HIV‐diagnosed patients. Chi squared and t tests comparing newly diagnosed individuals to the general jail population revealed statistical significance for male gender (p=0.02), African American race (p=0.04), and age (p=0.003). Undiagnosed HIV, including AIDS (CD4 counts <200), is an important issue among individuals booked into the MCJ. Compared to the general jail population, HIV is more likely to be diagnosed in males rather than females, younger patients, and African‐American patients. Additionally, IV drug use, polysubstance abuse, other STDs (particularly syphilis), high risk sexual activity, Hepatitis C and homelessness were common among HIV positive patients. Surveillance should be continued and include more patient education on the importance of screening. Furthermore, targeting high‐risk populations may result in even greater numbers of individuals being diagnosed and treated. Within the next year, all patients at the MCJ will also be offered screening for Hepatitis C, chlamydia, gonorrhea and syphilis. This may also result in more patients agreeing to be screened, and subsequently diagnosed with HIV.
    • Evaluation of Educational Intervention on Concussion Knowledge and Behavior in Student Athletes

      Bedard, Julia; The University of Arizona College of Medicine - Phoenix; Wilson, Kristina (The University of Arizona., 2017-04-20)
      Background and Significance: The purpose of this study was to evaluate the effectiveness of the Barrow Brainbook (BBB) concussion education program as a tool to increase concussion knowledge among Arizona high school athletes and to modify attitudes and behaviors regarding concussion. Methods: This was a cross sectional study of Arizona high school athletes utilizing a 31 question multiple‐choice de‐identified survey. Attitude, knowledge, and behavior questions, as well as sport and level of participation were analyzed using the Wilcoxon Rank Sum test. Means between groups were analyzed using a two‐way ANOVA. Linear regression was used to determine if there was a relationship between number of years since completing BBB and concussion knowledge. Results: Surveys were distributed to 382 student athletes with 363 of those being completed. 224 students participated in BBB (62%). Knowledge and behaviors regarding concussion were not statistically significant when comparing students who had and had not participated in BBB. Those who participated in BBB scored more poorly on questions regarding attitudes about concussion than those who had not (p=0.033). Subsequent two‐way ANOVA testing showed that students who sustained a concussion scored worse (p<0.01) while completing BBB did not significantly affect attitude (p=0.399) when history of a concussion was brought in to the analysis. 90 students (25%) reported sustaining a concussion. Football and varsity level participation were significant for a higher mean number of concussions (p<0.05, p<0.05). There was no relationship between time since taking BBB and concussion knowledge (R2 was 0.007). Conclusions: In this study, there was no evidence to show that participating in the BBB program improved concussion knowledge, attitudes, or behaviors. Number of years since taking BBB was not a good predictor of concussion knowledge. Students who played football and participated at a varsity level were significantly more likely to sustain a concussion. Sustaining a concussion was associated with a higher attitude risk sum score. This is an evaluation of an educational tool specifically designed for adolescents that demonstrated no statistically significant change in increasing knowledge or modifying attitudes and behaviors in a population of high school athletes in Arizona.
    • Extracellular Matrix Biomarkers are Time Dependent and Regional Specific in Experimental Diffuse Brain Injury

      Jenkins, Taylor; The University of Arizona College of Medicine - Phoenix; Lifshitz, Jonathan (The University of Arizona., 2017-05-09)
      The extracellular matrix (ECM) provides structural support for neuronal, glial and vascular components of the brain, and regulates intercellular signaling required for cellular morphogenesis, differentiation and homeostasis through constant remodeling. We hypothesize that the ECM is susceptible to degradation and accumulation of glycoproteins, which serve as biomarkers specific to diffuse brain injury severity and region. Experimental TBI was induced in male Sprague Dawley rats (325‐375g) by midline fluid percussion injury (FPI) at sham (n=6), mild (1.4 atm, n=16) and moderate (2.0 atm, n=16) severity. Tissue from the cortex, hippocampus and thalamus was collected at 15 minutes, 1, 2, 6 and 18 hours post‐injury as well as 1, 3, 7 and 14 days post‐injury. All samples were quantified by western blot for glycoproteins: reelin, fibronectin, laminin, and tenascin‐c. Band intensities were normalized to sham and relative to β‐actin. In the cortex fibronectin decreased significantly at 15 minutes, 1 hour and 2 hours postinjury, while tenacin‐C decreased significantly at 7 and 14 days post‐injury. In the thalamus, reelin decreased significantly at 2 hours, 3 and 14 days post‐injury. In the hippocampus, tenacin‐C increased significantly at 15 minutes and 7 days post‐injury. Changes in levels of these glycoproteins at acute time points suggest that they may be useful diagnostic biomarkers in an emergency room setting. Further investigation into breakdown products and penetrance into blood is needed. The specificity and sensitivity of these biomarkers remain to be validated as clinically useful tools.
    • Fat Bone Ratio: A New Measurement of Obesity

      Brown, Bryant; The University of Arizona College of Medicine - Phoenix; Roh, Albert; August, David (The University of Arizona., 2017-04-24)
      Importance: This study proposed a new radiographic measure of obesity that is a better predictive indicator of obesity‐related risk: Fat/Bone Ratio. Primary Objective: Does the Fat/Bone Ratio correlate with obesity. Secondary Objective: Does the Fat/Bone Ratio correlate more closely with the comorbidities of obesity as compared to BMI. Design: Retrospective review of 2703 upright posterior‐anterior (PA) and lateral chest radiographs obtained from June 2013 through May 2014. The soft tissue height overlying the acromioclavicular joint was calculated and divided by the mid‐clavicle width to determine the Fat/Bone Ratio. Comorbidities of obesity were determined through chart review. Setting: Adult community emergency department. Participants: All adults (age greater than 18). Main Outcomes and Measures: BMI, Fat/Bone Ratio, comorbidities: hypertension, obstructive sleep apnea, osteoarthritis, hyperlipidemia, atherosclerosis, coronary artery disease, cerebrovascular accident, and myocardial infarction. Results: Fat‐to‐Bone ratio and BMI were both significantly associated with hypertension, diabetes, hyperlipidemia, obstructive sleep apnea, and osteoarthritis (P < .05). However, only Fat/Bone Ratio is associated with atherosclerosis (p = 0.02), coronary artery disease (p = 0.001), myocardial infarction (p = 0.002), and peripheral vascular disease (p = 0.01); BMI is not associated with these comorbidities (p = 0.90, 0.42, 0.25, and 0.50, respectively). Conclusions and Relevance: Findings suggest that Fat/Bone Ratio is an improved measure of obesity as compared to BMI.
    • 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.
    • Follow-Up Instrument Development and Results from a Trial Cohort for Graduates of the Integrative Medicine in Residency Certificate Program

      Perkins, Jaime; The University of Arizona College of Medicine - Phoenix; McClafferty, Hilary; Brooks, Audrey (The University of Arizona., 2017-05-18)
      Integrative medicine (IM) is a unique clinical paradigm that may be applied across numerous healthcare professions and diverse settings. With its focus on whole person health and lifestyle medicine, it advocates utilizing complementary and alternative medicine in addition to traditional treatments in order to achieve an individual’s optimal wellness. Literature supports how significantly this distinctive, promising field of practice can help reduce overall healthcare costs, alleviate the heavy burden of chronic disease, bolster efforts focused on preventive measures, and improve both patient outcomes along with practitioner wellbeing. In order to meet a growing demand for easily accessible, ongoing professional education in IM, the Arizona Center for Integrative Medicine launched an innovative curriculum called the Integrative Medicine in Residency (IMR). This online, two hundred hour, integrative course premiered with eight Family Medicine Residencies across the United States. The purpose behind this study was to aid in developing an appropriate compilation of instruments for a long-term follow‐up questionnaire for IMR graduates, distribute the survey to a trial cohort, and present a summary of the pilot survey results. The instrument was developed in order to: provide feedback on the course, aid in future program modification, determine how graduates implement what they learned through IMR, identify barriers to care, and help distinguish areas where physicians may need additional support to better incorporate IM into practice. The final forty‐four‐question survey, with quantitative and qualitative measures, was distributed in 2015 over three months to residents that graduated between 2011‐2014 via their program directors. All candidates were sent an email with an embedded link to Survey Monkey. Through this series of online, self‐reported responses, the questionnaire was filled out in real time and results were auto‐populated into a secure excel file for further statistical analysis. Our trial cohort attained valuable responses from thirty‐one graduates. Results demonstrated that students were largely satisfied with their education and pleased with the personal and professional impacts following their IMR training; however, barriers to care most notably reported were time, cost, and patient receptivity. This study emphasizes the importance of providing easy access to ongoing IM education for physicians, while also highlighting the equal importance of future research into how to better support healthcare providers seeking to provide the comprehensive IM therapy all patients deserve.
    • 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.
    • Histologic Comparison of Pressure and Autoimmune Wounds

      Nanda, Alisha; The University of Arizona College of Medicine - Phoenix; Gottlieb, Marc (The University of Arizona., 2017-05-12)
      The cell make‐up and architecture of a wound is generally not explored before treatment is started. This pilot study will potentially be able to differentiate the histologic makeup of different wound etiologies and therefore start to elucidate a more targeted therapy to treat a wound with the hypothesis that etiology of wound is associated with a set of histologic characteristics. 12 samples of pressure wounds and 13 samples of autoimmune connective tissue wounds were examined and characterized under microscopy. Types of cells, necrosis, granulation, and inflammation, among other characteristics were studied. The autoimmune wounds displayed a statistically significant increase in lymphocytes, chronic inflammation, and fibrosis than in the pressure wounds. There are apparent differences in histology and morphology of wounds of different etiologies, as hypothesized. This suggests the possibility of requiring specific treatments for the varying wound types.
    • Hospital Admissions After Standard Versus Positive Pressure Nebulization in Patients with Bronchiolitis

      Kim, Jeffrey; The University of Arizona College of Medicine - Phoenix; Chidi, Arati (The University of Arizona., 2017-05-26)
      In the United States, bronchiolitis has consistently been the most common diagnosis leading to hospitalization in infants under one year of age, representing over 90,000 cases a year and a significant financial burden on the healthcare system. A condition with such widespread incidence should have an established algorithm for treatment of respiratory symptoms, but studies on the efficacy of certain therapies have been inconclusive. Some reports suggest that the use of positive pressure nebulization may be of benefit in treating bronchiolitis, but it has not yet been studied systematically. 1) To determine whether positive pressure nebulization (PPN) is more effective than standard nebulization (SN) in reducing admission rate in infants with bronchiolitis 2) To determine whether the use of positive pressure nebulization causes a change in Bronchiolitis Score, Pediatric Intensive Care Unit (PICU) admission rate, length of stay (LOS), and unscheduled returns to the pediatric emergency department (PED). The project is a retrospective study conducted at a single‐center tertiary care children's hospital. Participants included in the study were infants 2‐24 months of age with moderate to severe bronchiolitis, who were evaluated by trained respiratory therapists using an objective scoring tool and treatment algorithm that included suctioning, albuterol, and racemic epinephrine. Infants received the above nebulization therapies by either a standard or a positive pressure nebulization delivery device. The two treatment groups were compared to see if one approach was superior as measured by outcomes such as hospital and PICU admission rate, length of stay, and returns to the emergency department. Initial survey of the 2012‐2013 winter season at Phoenix Children's Hospital yielded 2,095 patients who were diagnosed with bronchiolitis. As the majority of patients were excluded due to age, comorbidities, or poor documentation of treatment, our study examined 19 patients who received positive pressure nebulization, which were matched in a 1:3 ratio (PPN:SN), for a total of 57 patients who received standard nebulization. In measuring the primary markers of outcome, we found that 12 of the 19 PPN patients (63%) were admitted to the regular pediatric ward, and 4 of the 19 (21%) were admitted to the PICU. 35 of the 57 SN patients (63%) were admitted to the regular pediatric ward, and 5 of the 57 (8%) were admitted to the PICU. Statistical analysis showed that the estimated minimum 'n' required in each treatment group was 252 patients, but our study was only able to obtain a sample size of 19 patients in the PPN group, which was not enough for statistical significance. An association between hospital admission rate with positive pressure nebulization or standard nebulization was not able to be determined.
    • 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.
    • Identification of Apnea Events Using a Chest‐Worn Physical Activity Monitor

      Salazar, Eduardo; The University of Arizona College of Medicine - Phoenix; Buman, Matthew (The University of Arizona., 2017-05-25)
      Obstructive sleep apnea (OSA) is a condition characterized by upper airway obstruction during sleep causing intermittent hypoxia and nighttime awakening. It is a common condition in the United States that is often undiagnosed. It is a significant risk factor for decreased daytime productivity, quality of life, cardiovascular disease, and death. The current gold standard for diagnosis of OSA is laboratory‐based polysomnography (PSG). While PSG is necessary for the diagnosis and monitoring of OSA, many patients have limited access to PSG due to wait times at PSG laboratories or economic or geographic limitations. Portable sleep monitoring has been studied as a possible solution for patients who do not have access to timely PSG. This study aimed to use the Zephyr BioHarness 3, a chest‐worn physical activity monitor that records movement and physiologic data in real‐time, to detect apnea events in patients with suspected OSA undergoing single‐night laboratory PSG. Twenty patients underwent single‐night laboratory‐based PSG while simultaneously wearing the Zephyr BioHarness 3. The Zephyr BioHarness 3 data was analyzed using three methods. First, apnea events were identified in 10‐second windows of Zephyr data via support vector machine, logistic regression, and neural network (sensitivity = 76.0 ± 0.3%, specificity = 62.7 ± 0.2%, accuracy = 63.7 ± 0.1%). Second, apnea events were identified using the mean, median, and variance of the 10‐second windows (sensitivity = 72.3 ± 0.3%, specificity = 69.4 ± 0.1%), accuracy 69.6 ± 0.1%). Third, apnea events were identified using phase‐space transformation of the Zephyr BioHarness 3 data (sensitivity = 76.9 ± 0.3%, specificity = 77.9 ± 0.1 %, accuracy = 77.9 ± 0.1%). The Zephyr BioHarness shows initial promise as a possible OSA screening tool for patients suspected of OSA but who lack access to timely laboratory‐based PSG.
    • Identifying Barriers to Enrollment of Diverse Populations in Arizona Following the Initial Open Enrollment Period of the Affordable Care Act

      Moseley, Joseph; The University of Arizona College of Medicine - Phoenix; VanPelt, Kim (The University of Arizona., 2017-06-06)
      While it is known that over 266,000 Arizonans enrolled in health coverage through the federal Marketplace and Medicaid from October 2013 through May 2014, little analysis has been performed to examine whether enrollment by diverse racial and ethnic groups sufficiently reduced disparities in coverage. We obtained publicly available data from the Census Bureau comparing rates of uninsured by race/ethnicity from 2013 to 2014 in Arizona from the American Community Survey. The uninsured rate in Arizona for the total civilian no institutionalized population dropped from 17% in 2013 to 13.6% in 2014. The uninsured rate in Arizona for whites declined from 15.7% to 12.2%, for African Americans declined from 17.4% to 11.1%, for American Indian/Alaskan Natives declined from 26.9% to 24.1%, for Asian Americans declined from 15.1% to 11.0% and for Hispanic/Latino declined from 27.5% to 22.2%. We conducted interviews with nine community organizations in order to identify barriers that must be addressed moving forward to lessen insurance coverage disparities among various minority groups. Technological literacy and functionality, lack of funding, lack of personnel, physical vastness of many populations, language, and cultural differences were commonly identified as barriers to enrollment. Mistrust of government and confusion regarding the specific provisions within the ACA pertaining to Native individuals were also cited.
    • Identifying Genetic Pleiotropy through a Literature-wide Association Study (LitWAS) and a Phenotype Association Study (PheWAS) in the Age-related Eye Disease Study 2 (AREDS2)

      Simmons, Michael; The University of Arizona College of Medicine - Phoenix; Lu, Zhiyong (The University of Arizona., 2017-05-26)
      Genetic association studies simplify genotype‐phenotype relationship investigation by considering only the presence of a given polymorphism and the presence or absence of a given downstream phenotype. Although such associations do not indicate causation, collections of phenotypes sharing association with a single genetic polymorphism may provide valuable mechanistic insights. In this thesis we explore such genetic pleiotropy with Deep Phenotype Association Studies (DeePAS) using data from the Age‐Related Eye Study 2 (AREDS2). We also employ a novel text mining approach to extract pleiotropic associations from the published literature as a hypothesis generation mechanism. Is it possible to identify pleiotropic genetic associations across multiple published abstracts and validate these in data from AREDS2? Data from the AREDS2 trial includes 123 phenotypes including AMD features, other ocular conditions, cognitive function and cardiovascular, neurological, gastrointestinal and endocrine disease. A previously validated relationship extraction algorithm was used to isolate descriptions of genetic associations with these phenotypes in MEDLINE abstracts. Results were filtered to exclude negated findings and normalize variant mentions. Genotype data was available for 1826 AREDS2 participants. A DeePAS was performed by evaluating the association between selected SNPs and all available phenotypes. Associations that remained significant after Bonferroni‐correction were replicated in AREDS. LitWAS analysis identified 9372 SNPs with literature support for at least two distinct phenotypes, with an average of 3.1 phenotypes/SNP. PheWAS analyses revealed that two variants of the ARMS2‐HTRA1 locus at 10q26, rs10490924 and rs3750846, were significantly associated with sub‐retinal hemorrhage in AMD (rs3750846 OR 1.79 (1.41‐2.27), p=1.17*10‐7). This associated remained significant even in populations of participants with neovascular AMD. Furthermore, odds ratios for the development of sub‐retinal hemorrhage in the presence of the rs3750846 SNP were similar between incident and prevalent AREDS2 sub‐populations (OR: 1.94 vs 1.75). This association was also replicated in data from the AREDS trial. No literature‐defined pleiotropic associations tested remained significant after multiple‐testing correction. The rs3750846 variant of the ARMS2‐HTRA1 locus is associated with sub‐retinal hemorrhage. Automatic literature mining, when paired with clinical data, is a promising method for exploring genotype‐phenotype relationships.
    • Imaging for Chest Pain Assessment: An Algorithmic Approach Using Noninvasive Modalities to Define Medical vs. Interventional Treatment

      Graber, Taylor; The University of Arizona College of Medicine - Phoenix; Hamburg, Robert (The University of Arizona., 2017-05-09)
      To analyze the roles of CCTA, MPI, and CC to formulate a sequential clinical algorithm to use in patients with chest pain, risk factors for CAD, and an abnormal EKG. The goals of the study are to streamline and refine workup, to decrease radiation exposure to patients, and to contain costs. 39 patients underwent CCTA, MPI, and CC within 30 months of each other. CCTA was used to categorize mild, moderate, or severe CAD. MPI used SSS, SDS, TID, and formal reading to define mild, moderate, or severe physiologic ischemia. CC and coronary intervention cine films were analyzed to define and treat anatomical CAD medically or by intervention. Results: There was strong correlation between CCTA, CC, and treatment type (p<0.0001). CCTA was able to stratify all patients with mild or severe ischemia to appropriate treatment groups, and to reduce the need for MPI. With moderate ischemia from CCTA, the additional use of MPI could have reduced the need for 16/18 (89%) patients who underwent CC to undergo further testing. No patients with mild or moderate CAD by CCTA, followed by mild to moderate physiologic ischemia by MPI, needed CC or intervention. 37/39 patients (95%) could have avoided one or more tests using our algorithm. CCTA followed by MPI may be used in symptomatic patients with risk factors for CAD and an abnormal EKG to stratify mild and moderate CAD, and to thereby avoid cardiac catheterization. Our algorithm could lead to savings in healthcare expenditures, save patients from unnecessary invasive procedures, decrease radiation exposure, and total cost.
    • The Impact of Short-Term Medical Missions on Health Care Sustainability in Low-Income and Developing Communities: A Systematic Review

      Lansky, Charlotte; The University of Arizona College of Medicine - Phoenix; Conklin‐Aguilera, Cody (The University of Arizona., 2017-05-10)
      Short‐term surgical missions (STSMs) provide an opportunity for the global health care community to address the surgical needs of developing communities worldwide. Conditions that require a one‐time intervention, such as cleft lip and palate, clearly demonstrate the positive impact these short‐term missions can have on the individual patient. However, the long‐term impact on the local health care system, economy, and community is less clear. Many in the global health care community believe that STSMs should seek to have a long‐term impact by establishing sustainable health care programs. Information regarding the impact of STSMs is scarce, however, due to limited regulation, research, and data from short‐term missions. This study investigates how short‐term international missions impact health care sustainability in low‐income and developing communities. This study uses a systematic review to investigate the impact of STSMs on health care sustainability. Additional outcomes included education and skills‐transfer, cost‐effectiveness, and cultural awareness. 15 articles were included in the study. The following outcomes were found: sustainability in 9 studies, education and skills‐transfer in 5, cost‐effectiveness in 4, and cultural awareness in 3. STSMs can successfully establish sustainable programs abroad. Factors that contribute to this success include education and training of host providers, cost‐effective services, and cultural awareness. Understanding the complex dynamic between STSMs and developing communities is key to developing effective and sustainable programs that offer long‐term benefits to those communities.