• 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.
    • 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.
    • Human Plant Exposures Reported to a Regional (Southwestern) Poison Control Center over Eight Years

      Enfield, David; The University of Arizona College of Medicine - Phoenix; Brooks, Daniel (The University of Arizona., 2018-02-26)
    • Impact of a Smartphone-delivered Sedentary Behavior Intervention on Glucose Metabolism in Prediabetic Adults

      Hicks, Meghan; The University of Arizona College of Medicine - Phoenix; Buman, Matthew (The University of Arizona., 2018-02-26)
      This study investigates whether an 8-week lifestyle-based, smartphone-delivered intervention targeting reduction in sedentary behavior (i.e., sitting) significantly reduces objectively measured time spent sitting and improves fasting glucose and insulin. The incidence of type II diabetes has continued to increase in the United States and increases in sedentary behavior along with reductions in physical activity throughout the day have contributed to the increase of disease. There were 31 participants in the study and they started with a 3-week run-in period where a basic self- monitoring component was installed on their smartphone. After this run-in period, participants were randomly assigned to one of the eight experimental conditions. All participants received a basic self-monitoring with feedback component where they self-reported sleep, sedentary, and more active behaviors. Sitting time was measured with the activPAL3c, which is a device that they wore 24/7. Study visits occurred at week 0 (immediately after the 3-week run-in period), week 4, and week 8. Fasting glucose and insulin were measured at each of these visits. Participants logged approximately 60% of their sleep, sedentary, and exercise behaviors, which took 3– 4 min/day to complete. The impact of the intervention was not significant, such that decreases in sedentary time in those assigned to the sedentary component did not significantly differ from those not assigned to the sedentary component at 8 weeks (beta (SE) = -1.19 (.32), p>0.05); however, the effect size was moderate (Cohen’s d = 0.29). There was no significant impact on fasting glucose or insulin.
    • Is Fever a Marker of Infection or Side Effect of Misoprostol?

      Edinoff, Amber; The University of Arizona College of Medicine - Phoenix; Coonrod, Dean (The University of Arizona., 2018-02-26)
      Introduction: Endometritis, a polymicrobial infection resulting from ascending cervicovaginal bacteria into the uterus, complicates 6-27% of cesarean deliveries. A recent meta-analysis showed a reduction in endometritis in women who received 30 seconds of vaginal cleansing (4.5% vs 8.8%). Our study will look at the rates of endometritis from two time periods – prior to and after the implementation of vaginal cleansing at time of cesarean delivery. We will also investigate the influence of misoprostol on the clinical diagnosis of post-cesarean endometritis.
    • Lestaurtinib (CEP-701) Potentiates the Anticonvulsant Effect of Phenobarbital against Kainic Acid-induced Status Epilepticus

      Kuk, Raafat; The University of Arizona College of Medicine - Phoenix; Obeid, Makram (The University of Arizona., 2018-02-26)
      Status epileptics (SE) can be refractory to standard anti-seizure medications in up to 20% of patients. The timely abortion of SE is key to preventing harmful consequences. Prolonged SE is molecularly characterized by acute alterations in certain ion channels including a decrease in the inhibitory properties and internalization of the γ-Aminobutyric acid type A receptors (GABARs). This increases excitability and weakens the effectiveness of many standard medications such as phenobarbital; the anticonvulsant effect of which is mediated via the modulation of such channels. We have recently shown that blockade of tropomyosin-related kinase B receptor (TrkB) with the investigational new drug, lestaurtinib (CEP-701), attenuates SE-induced hyperexcitability 1. Since TrkB is a regulator of GABARs 2, and its blockade might potentially prevent SE-induced changes in these receptors, we hypothesized that TrkB blockade with CEP-701 will potentiate the anticonvulsant effect of phenobarbital against kainic acid (KA)-induced SE. Seizures were induced in periadolescent postnatal day 35-40 (P35-P40) Sprague Dawley rats by injecting 0.5 μg of KA into the basolateral amygdala. Status epilepticus was confirmed using epidural cortical electroencephalography (EEG). Fifteen minutes after SE onset, rats received either 25 mg/kg of CEP (KA-CEP) or its vehicle (KA-V) intraperitoneally (i.p.). Six hours after SE onset, rats were given 100 mg/kg of phenobarbital i.p., supplemented every 15 minutes with an additional 25 mg/kg until cessation of clinical and electrographic seizures was achieved. All the rats that received KA developed electroclinical SE within 30 minutes to 1 hour after KA injections. The average cumulative dose of phenobarbital required to achieve seizure cessation in the KA-CEP group (107.5 ± 4.5 mg/kg, n=14) was significantly lower than in the KA-V group (125.0 ± 5.4 mg/kg, n=15, t-test, p=0.015). Moreover, recurrence of SE occurred 5-10 hours after abortive therapy in 4 of the KA-V rats, and only in 2 of the KA-CEP rats. Given its known clinical safety profile in children, CEP-701 is a clinically promising adjuvant drug that can be potentially used with standard anticonvulsant medications to abort SE.
    • Low Field-Of-View CT in the Evaluation of Acute Appendicitis in the Pediatric Population

      Feller, Fionna; The University of Arizona College of Medicine - Phoenix; Roh, Albert; Connell, Mary (The University of Arizona., 2018-03-30)
      CT abdomen and pelvis is a widely-used imaging modality used in the evaluation of appendicitis but it carries risks of radiation. A recent retrospective review localizes all appendices (both normal and abnormal) below the level of the L1 vertebral body, obviating the need to scan superior to that level. This study is a retrospective review of prospectively-collected data from 171 consecutive pediatric patients presenting with clinical suspicion of acute appendicitis and undergoing “low FOV CT.” The low FOV CT uses the L1 vertebral body as the superior aspect of the exam instead of the of the dome of the diaphragm as in standard CT.
    • 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.
    • Misoprostol for the Prevention of Postpartum Hemorrhage and Reduction of Maternal Mortality During Home Birth Deliveries in Developing Countries

      Townley, Kateland; The University of Arizona College of Medicine - Phoenix; Beyda, David (The University of Arizona., 2018-02-28)
      Research conducted in low resource environments suggests misoprostol is effective in reducing the incidence of postpartum hemorrhage (PPH), but larger studies in skilled healthcare facilities suggests misoprostol does not positively impact maternal mortality. There are no systematic reviews specifically examining the effect of misoprostol vs. placebo on PPH in environments where oxytocin is simply not available.
    • Non-Communicable Disease (NCD) Rates in Urbanized versus Rural Populations in Developing Countries.

      Alam, Now Behar; The University of Arizona College of Medicine - Phoenix; Conklin, Cody (The University of Arizona., 2018-03-28)
      Background: Studies estimating the current prevalence rates and future demographics of being overweight or obese and non-communicable diseases initially demonstrated Western countries had the highest rates of obesity. Now, obesity is more prevalent in urban populations of Africa, Central and South America, Asia, and Caribbean and Pacific Islands. Objective: Determine if any differences exist with the NCD rates in urbanized versus rural populations in developing countries. Methods: Using PubMed, a thorough review of the literature was conducted using various search terms related to the research topic. Results: To assess for differences between the urban and rural populations, the effect size using Cohen’s d was utilized to measure the size of associations or differences. Conclusion: Cross-sectional and observational studies comparing BMI values, blood pressure levels, cholesterol levels, and blood glucose levels have addressed if living in urban versus rural areas increases the prevalence of NCDs related to these variables. Urban populations and living a sedentary lifestyle does increase the likelihood of being overweight or obese, hypertension, hypercholesterolemia, but not diabetes.
    • 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.
    • Outcome of Cervical Cerclage in Twin Pregnancies for Treatment of Ultrasound Detected Short Cervix

      Hermann, Catherine; The University of Arizona College of Medicine - Phoenix; Elliott, John (The University of Arizona., 2018-02-26)
      Introduction: The use of cervical cerclage in twin pregnancies is a controversial topic in Obstetrics and Gynecology. It’s use is currently not recommended due to no perceived benefit and potential harm, however recent studies indicate that cerclage may be beneficial.Conclusion: The use of cerclage in twin pregnancies complicated by a TVUS cervical length of 2.0 cm or less prolonged the latency period between diagnosis of short cervix and delivery by 31 days. This data is consistent with other retrospective reviews and indicates the need for a multicenter, prospective randomized control trial.
    • 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.
    • 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.
    • 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)
    • Prevalence of and Differences in Salad Bar Implementation in Rural Versus Urban Arizona Schools

      Blumenschine, Michelle; The University of Arizona College of Medicine - Phoenix; Bruening, Meg (The University of Arizona., 2018-03-28)
      Purpose: To compare the prevalence of school-lunch salad bars in Arizona and differences in implementation by rural vs. urban setting. Background•Individuals in rural settings are increasingly at risk for health disparities and experience a disproportionate burden of chronic conditions. •Fruit and vegetable (F&V) is linked with lower risk for chronic diseases like diabetes, heart disease, and obesity. •Young people do not meet the recommended servings of F&V. •Salad bars are a recommended method to increase F&V intake, however there is limited evidence of their effectiveness. No studies exist that examine implementation of salad bars in urban versus rural environments.
    • Prospective Comparison of Methods for Assessment of Headache Directionality

      Hoffman, Carmen; The University of Arizona College of Medicine - Phoenix; Files, Julia (The University of Arizona., 2018-03-30)
      Response to prophylactic treatment of migraine with Onabotulinumtoxin A (BTX-A) has been noted to be significantly correlated to the perceived direction of headache pain, namely imploding vs. exploding subtype. This study analyzed 3 methods of assessing migraine directionality in comparison to a 30-day headache log; pictorial representation, written description, and physician assessment. Each of these assessment types was shown to have poor agreement with the headache log at the initial visit. However, all 3 assessments displayed excellent agreement at the return visit, as well as significantly improved confidence in patient ability to determine headache directionality.
    • 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.
    • 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.
    • Rattlesnake Envenomations Treated Without Antivenom

      Chang, Phoebe; The University of Arizona College of Medicine - Phoenix; Curry, Steven (The University of Arizona., 2018-03-28)
      The standard treatment for rattlesnake envenomation (RSE) is antivenom. The clinical course of patients treated with antivenom is well described. Prior to 2000, only a whole IgG AV (IgGAV) associated with high rates of hypersensitivity reactions (HSS) was available to treat RSE. Since 2000, Crotalidae Polyvalent Immune Fab (FabAV), which has a better safety profile than IgGAV, has been primarily used. Patients with RSE may not be treated with AV for a variety of reasons including history or perceived risk of HSS, patient refusal, drug shortage, or clinical impression that AV is not indicated. Research Question: What outcomes are associated with moderate to severe RSEs treated without antivenom?