• Outcomes for the Hybrid Approach to First State Treatment of Hypoplastic Left Heart Syndrome

      Crawford, Daniel; The University of Arizona College of Medicine - Phoenix; Graziano, Joseph (The University of Arizona., 2018-06-05)
      BACKGROUND & SIGNIFICANCE Hypoplastic left heart syndrome (HLHS) is a congenital condition that involves hypoplasia or atresia of left heart structures. Treatment requires three separate interventions, and the “hybrid” procedure is a less invasive alternative to the initial open-heart operation. This approach has become favorable for certain patients in recent years, but there is a need to better understand the outcomes and the factors that influence the outcomes for hybrid Stage 1 palliation of HLHS.

      O'Connor, Devin; The University of Arizona College of Medicine - Phoenix; Brady, Michael (The University of Arizona., 2018-04-10)
      Background This systematic review focuses on discussing the critical shortage of surgeons and access to surgical services in many low income African nations and the difficulties encountered by non-physician clinicians who are trained to increase the surgical workforce by carrying out less severe surgeries and peri-operative care. By critically assessing the literature this review seeks to present the benefits to surgical task shifting and the most commonly encountered problem with this type of healthcare intervention
    • An Unusual Complication of Gastrografin®: Gastric Precipitation

      Bergin, Edward; The University of Arizona College of Medicine - Phoenix; VanSonnenberg, Eric (The University of Arizona., 2018-04-10)
      Gastrografin®, an oral contrast agent, is important for non-operative management of small bowel obstruction and post-operative ileus. However, Gastrografin® can cause complications with its propensity to precipitate in an acidic environment. We describe a case of Gastrografin® precipitation in the stomach that resulted from delayed gastric emptying and increased gastric acid secretion in an elderly woman.
    • Survey Determining Involvement of Certified Athletic Trainers in Return to Activity/Play Decisions and Concussion Education

      Olla, Danielle; The University of Arizona College of Medicine - Phoenix; Handmaker, Hirsch (The University of Arizona., 2018-04-10)
      In the some states a Certified Athletic Trainer (AT) has the ability to determine if a player can return to activity or play (RTP) following a mild Traumatic Brain Injury (mTBI), also known as a concussion. Premature return to activity or RTP and sustaining another concussion can result in further axonal damage, prolonged complications and rarely, death. There currently is no standardized education and certification for ATs regarding concussion management, and no data exists determining how often ATs are involved in return to activity or RTP decisions. The aim of this study was to survey ATs and establish a baseline of their involvement in return to activity and RTP decisions and determine what type and amount concussion education ATs are completing at the present time. A twenty (20) question electronic survey was sent to 2084 randomly selected ATs registered with the National Athletic Trainer Association (NATA). 382 responses were collected in a 38‐day period. The survey was successfully completed by a total of 356 ATs from across the United States.
    • Predicting Postpartum Hemorrhage: A Retrospective Study

      Amaya, Stephanie; The University of Arizona College of Medicine - Phoenix; Gerkin, Richard; Mattox, John (The University of Arizona., 2018-04-10)
    • Geographic correlation between nonmedical exemption rates in Arizona kindergarten classes and rates of community pertussis infection

      Sun, Sophie; The University of Arizona College of Medicine - Phoenix; Villarroel, Lisa (The University of Arizona., 2018-04-09)
      Background: Every state in the US mandates specific vaccinations for all children prior to school entry. However, many states, such as Arizona, are permit nonmedical exemptions (NMEs), and thus, communities with high levels of NMEs are potentially more vulnerable to outbreaks of vaccine preventable diseases. Objective: The objective of this study was to detect spatial clusters of pertussis cases and kindergarten NMEs of DTaP vaccine in Arizona. Methods: Data detailing kindergarten NMEs for each AZ school in the 2012-13 and 2013-14 school years and pertussis cases with report dates during those time periods were obtained from the Arizona Department of Health Services databases. Addresses for each school and pertussis case were geocoded, and the coordinates were obtained for each corresponding census tract. Using a purely spatial analysis with Poisson probability model, areas with high rates of pertussis or NMEs were identified with SaTScan. Clusters for both the number of NMEs and pertussis cases were detected and presented in maps. Extremely large (>50km radius) clusters extending beyond state boundaries were considered irrelevant and removed. Results: Multiple clusters of NMEs and pertussis cases were identified in two school years. While the clusters were generally in highly populated regions, they were not located at the same region in both years. The NME clusters and case clusters did not always overlap. Conclusions: The current analysis does not support an association between kindergarten NME frequency and pertussis outbreaks within these time periods. Clusters of both NMEs and pertussis cases were located in different regions each year. Since kindergarten NMEs vary from year to year, it is possible that these NME rates are not reflective of those in the community. Further studies with larger datasets will be important in elucidating the spatial distribution of pertussis cases and NMEs.
    • Epidemiology of Post-Traumatic Brain Injury-Induced Hypothalamic Pituitary Dysfunction in Arizona AHCCCS Patients

      Sukhina, Alona; The University of Arizona College of Medicine - Phoenix; Lifshitz, Jonathan (The University of Arizona., 2018-04-09)
      Introduction: Traumatic brain injury (TBI) in children can result in cognitive, emotional and somatic neurological impairments. In adults, post-traumatic hypopituitarism can extend or exacerbate these impairments, likely due to mechanical damage to the pituitary and hypothalamus. The pituitary in the pediatric brain likely suffers similar mechanical damage, inducing endocrinopathies as in adults, but injury-induced endocrinopathies are infrequently reported in children. Unrecognized hypopituitarism may lead to elevated risks of metabolic syndrome, diabetes, delayed or absent puberty, short stature, and other endocrinopathies. However, screening for endocrine deficiencies in susceptible patients and initiating appropriate hormone replacement therapy may prevent these sequelae and improve the prospects for recovery. Results: We determined that TBI victims were 3.18-times higher risk of developing a central endocrinopathy compared with the general population (CI=0.264), pediatric AHCCCS patients with a central endocrinopathy had a 3.2-fold higher odds of a history with TBI than those without a central endocrinopathy (CI=0.266), of the central endocrinopathy in TBI victims is attributable to the TBI, and the number of patients who need to be exposed to a TBI for 1 patient to develop an endocrinopathy was 154.2 (CI=7.11). We also determined that more males than females presented with central endocrinopathies after TBI compared with the general population of TBI victims.
    • Novel Approach to Determine the Effect of Sub-Optimal Semen Analysis Parameters on Obtaining Euploid Blastocysts after Intracytoplasmic Sperm Injection

      Savage, Narry; The University of Arizona College of Medicine - Phoenix; Lipskind, Shane (The University of Arizona., 2018-04-09)
      Preimplantation genetic screening (PGS) is a method of screening a blastocyst for chromosomal abnormalities during in vitro fertilization (IVF) by performing a karyotype on a single cell from the blastocyst. PGS was previously offered to couples with advanced maternal age, recurrent pregnancy loss, repeated implantation failure, or severe male factor infertility. Now PGS is common practice for all IVF cycles to improve outcomes by selecting chromosomally normal (euploid) embryos for transfer. This investigation aims to study the effect of male semen parameters on the likelihood of obtaining chromosomally normal embryos using ICSI. A unique approach was taken by comparing the outcomes between multiple “paired couples” who have utilized donor eggs obtained from the same donor in the same cycle. This model was adopted to minimize oocyte variation as a confounding variable. Using retrospective record review and data analysis, the relationship between optimal vs suboptimal sperm parameters and the resultant percentage of euploid embryos obtained after ICSI was evaluated.
    • "El viaje al otro lado: Relationship between Depression Onset in Latinas and Immigration Experience Coming to the United States”

      Rubin, Arielle; The University of Arizona College of Medicine - Phoenix; Moreno, Francisco (The University of Arizona., 2018-04-06)
      Background: Few studies investigate unique psychosocial hardships and trauma during immigration by mode of travel. This retrospective pilot study explores the trauma and hardship during different types of immigration travel among Latina women and explores its relationship to psychiatric diagnosis in Latina immigrant women with and without psychiatric diagnosis history. Conclusion: In this small pilot study, “coyote” travel significantly correlated with trauma exposure. There was a numerical suggestion that coyote travel is more often associated with depression than non-coyote travel. With only 14 individuals this pilot study had limited power to detect effects. The lack of difference in depressive symptomatology one year after arrival between the group of people previously diagnosed and community volunteers suggest a multifactorial high-risk adjustment period warranting a high-degree of clinical suspicion and screening in all newly immigrated patients.
    • Calculating Ventilatory Threshold in Patients After Stroke

      Quezon, Irvin; The University of Arizona College of Medicine - Phoenix; Bosch, Pamela (The University of Arizona., 2018-04-06)
      BACKGROUND: Aerobic training intensity is commonly determined from heart rate reserve (HRR) or a percentage of maximal heart rate measured during a graded exercise stress test. This method has limitations in people after stroke, who may not reach maximal heart rate. Ventilatory Threshold (VT) is an alternate method of establishing aerobic training intensity. VT indicates the exercise intensity above which ventilation increases disproportionately compared to whole-body oxygen uptake, theoretically representing the optimal intensity for sustaining aerobic exercise. CONCLUSION: Ventilatory Threshold in stroke patients undergoing treadmill testing can be effectively calculated from gas exchange data using the Venilation Curve and the V-slope methods. More research is needed to assess other factors that may affect VT measurements, such as medications or diseases impacting respiratory and cardiac function in patients with stroke to determine the most optimal and effective means of establishing training intensity after stroke.
    • Predicting Diameter of ACL Quadrupled Hamstring Autograft in a Pediatric Population

      Rohrback, Mitchell; The University of Arizona College of Medicine - Phoenix; Vaughn, Jeffrey (The University of Arizona., 2018-04-06)
      Background: The incidence of anterior cruciate ligament tears and subsequent reconstructions in the pediatric population has significantly increased over the last twenty years.2 Hamstring autograft reconstruction is a common approach to ACL reconstruction in the pediatric population because of their open physes and the reduced risk of re-tear with the use of autograft as opposed to allograft tissue.4 In recent publications, the size of the autograft has also been shown to be a significant factor influencing the risk of re-tear after ACL reconstruction with autograft.10 We attempted to determine patient specific factors that would allow us to estimate the patient’s probable quadrupled hamstring graft diameter preoperatively. Characteristics that we evaluated included age, sex, height, weight, BMI, and graft diameter determined intraoperatively. Conclusions: ACL hamstring autograft diameter in a pediatric population can most accurately be predicted using the patient’s height. These results are valuable in determining the treatment plan for children undergoing ACL reconstruction, and provide useful insight for counseling families prior to ACL reconstruction.
    • Exertional Syncope: A 10 year Retrospective Review

      Pitt, Taylor; The University of Arizona College of Medicine - Phoenix; Cohen, Mitchell (The University of Arizona., 2018-04-06)
      Although the usual faint is common, syncope may be an indication of a more serious underlying condition. Exertional syncope has loosely been defined as syncope occurring during or immediately after activity. The evaluation of exertional syncope is often extensive in order to rule-out a potentially life-threatening conditions. This was a retrospective review of all children presenting to the ambulatory clinics at Phoenix Children’s Hospital over the last 10 years with a syncopal event. This study sought to analyze the most consistent diagnosis for a primary complaint of exertional syncope and the most effective diagnostic tests to rule out serious conditions. Major findings include 1) 25% of patients presenting with exertional syncope were diagnosed with cardiac disease and 2) the association between heart disease and abnormal ECG and heart disease and abnormal electrophysiology (EP) study were both statistically significant with increased Odds Ratios (ORs). Consistent with prior studies, ECG and EP study are appropriate initial tests.
    • Rapid PCR TB Testing Results in 68.5% Reduction in Unnecessary Isolation Days in Smear Positive Patients.

      Patel, Ravikumar; The University of Arizona College of Medicine - Phoenix; Saubolle, Michael (The University of Arizona., 2018-04-05)
      Acid-fast stain (AFS) of sputum smear is the standard initial test used to evaluate a patient with suspected tuberculosis (TB). Patients with positive AFS smears are normally started on TB medications and placed on TB airborne precautions during their hospital stay until the culture results are released (which can take 2-5 weeks) or patient is discharged. However, not all AFS positive smears indicate the presence of TB. Other acid fast microorganisms, especially the Non- Tuberculous Mycobacteria (NTM) can also result in AFS positive smear hence, there is a high preponderance of false-positivity for TB in smear tests. Infection with the NTM do not require medications specific for TB or airborne isolation precautions. However, due to the lack of a quick definitive TB test most AFS smear positive patients are started on TB meds and placed in airborne isolation leading to inappropriate management of patients including unnecessary isolation, possible extension of hospital stay and increased cost. This is a prospective quality improvement study. Between Nov 2016 and August 2017 a Cepheid PCR test was performed on all AFS sputum smear positive patients from the initial sputum specimen collected on hospital admission. Background data between 2014 and 2016 was also collected for comparison prior to introduction of PCR testing. Data was used to evaluate unnecessary isolation for Smear positive patients.
    • Barriers to Medication Adherence in Homeless Populations in Phoenix, AZ.

      Morgosh, Kelsey; The University of Arizona College of Medicine - Phoenix; Panchanathan, Sarada; Hartmark-Hill, Jennifer (The University of Arizona., 2018-04-05)
      Medication adherence describes the degree to which patients take medications as prescribed. Adhering to medication is a complex issue that has a significant impact on individual patients as well as on the effectiveness and financial burden of the health care system. Several factors emerge as common barriers to medication adherence in the general population including homelessness and its associated risk factors: low functional health literacy, psychiatric conditions, financial hardship, and transient lifestyle. Little research exists exploring what specific barriers prevent medication adherence in the United States homeless population and how these can be addressed. This descriptive retrospective study seeks to answer which, if any, specific barriers exist as obstacles to medication adherence within the Phoenix area homeless population >=18 years of age. Data was collected via retrospective chart review from the web-based EMR, Practice Fusion, at the interdisciplinary Student Health Outreach for Wellness (SHOW) Clinic which included health literacy and medication adherence surveys administered by staff during patient triage.
    • Self-Reported Depression, Anxiety, and Adverse Educational Experiences in Youth Ages 7-18.

      Molina, Cris Jacob; The University of Arizona College of Medicine - Phoenix; Weller, Jennifer (The University of Arizona., 2018-04-05)
      Psychiatric symptoms of depression and anxiety can have profound and lasting effects on a growing child. Children spend much of their time in school, where significant anxiety and depressive disorders may impair children’s ability to learn, socialize, and thrive. It is already known that depression and anxiety can compromise memory and other cognitive functions.1 The Children’s Depression Inventory (CDI) and the Revised Children’s Manifest Anxiety Scale (RCMAS), self-report measures of depression and anxiety in youth, were used to assess symptoms of depression and anxiety in an outpatient clinical sample. Scores on these instruments were correlated with parent report of children’s significant educational events (e.g., evaluation for eligibility for special education services, enrollment in special education services, and repeating a grade). The goal of the study was to investigate the relationship between self-reported depression and anxiety and adverse educational experiences. The hypothesis was that children with higher depression and anxiety scores would have greater occurrence of adverse educational events compared to those with lower scores. Results of multiple logistic regression analyses were mixed. Future studies using larger sample sizes may have the potential to identify youth at risk of adverse educational experiences due to anxiety and depressive symptoms.
    • A Systematic Review of the Risk of HIV Transmission with Concurrent Schistosomiasis Infection

      Lee, Anne; The University of Arizona College of Medicine - Phoenix; Beyda, David (The University of Arizona., 2018-04-05)
      Schistosomiasis and HIV are both significant causes of morbidity in low resource settings worldwide, particularly in Sub-Saharan Africa. Research has indicated that there may be a link between the two infections--specifically that schistosomiasis infection may be a risk factor for HIV transmission. After a comprehensive review was performed to understand current knowledge in the field, a systematic review with meta-analysis exploring the interaction of the two infections was conducted to analyze this relationship. An exhaustive search in PUBMED and Google Scholar of was conducted with search terms related to schistosomiasis and HIV, and studies that were published within the past 30 years in English were included. In
    • A Comparison of How Adolescent Patients and Their Parents Rate Communication by Pediatric Resident Physicians.

      Ohmart, Connor; The University of Arizona College of Medicine - Phoenix; Bhavaraju, Vasudha (The University of Arizona., 2018-04-05)
      There are unique challenges in caring for the adolescent population, including communication in a way that is effective for both the adolescents and their parents or caregivers. While we assume that both are seeking similar qualities in their resident doctor, we sought to determine if a difference exists between adolescents and their parents in the judgment of adequate physician communication. This may offer insight into what each population values most in the skill set of their provider and may guide future pediatric resident education.
    • The Mild Cognitive Impairment of Primary Progressive Aphasia: A Case Series

      Lendrum, James; The University of Arizona College of Medicine - Phoenix; Sabbagh, Marwan (The University of Arizona., 2018-04-05)
      The early and mild phases, termed mild cognitive impairment (MCI), of primary progressive aphasia (PPA) have been poorly described. This cross-sectional care series was conducted via retrospective chart review in order to further delineate the MCI stage during progression to PPA. Nine cases of PPA with a secondary diagnosis of MCI were found, all of which had language as the primary domain affected. The most common deficits found were word finding difficulty (8 of 9 cases) and sentence repetition impairments (8 of 8 cases). Our results showed that there is an MCI stage of PPA, characterized by word finding difficulty on observation and sentence repetition on neurocognitive testing. Early mild cognitive impairment for PPA will have language as the primary domain affected either with or without an amnestic component.
    • Analyzing Unspecified Chest Pain Diagnoses and the Impact of Physician Staffing at the PVAHCS ED

      Lodgek, Erica; The University of Arizona College of Medicine - Phoenix; Abbaszadegan, Hamed (The University of Arizona., 2018-04-05)
      Emergency department overcrowding is a reality that exists within the healthcare system. To standardize monitoring performance, the VHA Directive establishes ED performance metric goals (targets) and minimum standards (thresholds) on a fiscal year basis. In line with these pre-determined metrics, the outcomes examined within this study include the number of patients diagnosed with unspecified chest pain and the respective Door to Doc, Admission Decision, Admission Delay, ED LOS, and Inpatient LOS times. The reasoning behind specifically examining patients with unspecified chest pain was because it was one of the top 10 diagnoses made at the PVAHCS ED for the year of 2016 and is an acuity level only assigned to physician providers. The reason for this study is to determine the impact increased physician staffing has on the flow of the Phoenix VA ED with regard to the described outcome measures. Therefore, examining if unspecified chest pain patients solely seen by physicians have improved flow within the ED.
    • Rapidity of Coccidioidomycosis Diagnosis and Its Effect on Healthcare Utilization

      Mohty, Ralph; The University of Arizona College of Medicine - Phoenix; Bollmann, KeriLyn (The University of Arizona., 2018-04-05)
      Background: Coccidioidomycosis is an infection caused by the fungal Coccidioides species common to Central and South America, and the southwestern United States, with Arizona claiming the vast majority of U.S.-based cases. Recognizing and diagnosing coccidioidomycosis is often difficult, with the wide range of symptoms being commonly misdiagnosed as a bacterial community-acquired pneumonia. Misdiagnosis and a delay in true diagnosis leads to ineffective, costly, and burdensome ramifications. Data investigating the diagnostic delay of Coccidioidomycosis could provide means for future changes in clinical practice. Methods: This is a two-phase study: phase one assessed disease markers and symptomatology, and phase two analyzing healthcare utilization based on electronic medical record data extraction of 139 patients. Results: The mean and median for 0-30 days of delay was $6,273 and $770 respectively; this increased at 151-183 days of diagnostic delay to $57,724 and $8,917 respectively. Small final population size precluded meaningful statistical analysis. Conclusion: Demonstrating diagnostic delay characteristics for patients with coccidioidomycosis is possible, however due to small final population size and difficulties encountered due to the innate properties of the electronic medical record, future investigation and optimization will be necessary for more powerful analysis.