• Outcomes after massive honeybee envenomation in patients with comorbid conditions during hospital admission: a retrospective review

      Zelic, Maximilian; The University of Arizona College of Medicine – Phoenix; Ruha, Michelle (The University of Arizona., 2019)
      This study’s aim was to discover the outcomes associated with massive honeybee envenomation. Additionally, we wanted to observe what trends might be seen with regard to outcomes in patients with comorbidities and those without. Honeybees belong to the insect family of Hymenoptera, which includes wasps, yellow jackets and hornets. Hymenoptera are responsible for more deaths than any other venomous insects and pose a risk to the public due to the emergence of well-established populations of Africanized honeybees. These honeybees are prevalent in southwestern states such as Arizona. Africanized bees are more aggressive and take less to provoke stings than non-hybridized bees, and mass envenomations can cause fatal accidents. This study was a retrospective review of patient charts based on ICD-9 and ICD-10 records indicating massive honeybee envenomation and screened to include only patients meeting our inclusion criteria of ≥ 50 stings over a 10 year period at Banner – University Medical Center Phoenix. 25 total patients were included and epidemiological, clinical, and therapeutic data were obtained and compared for noticeable trends in the data with regard to demographics and comorbidities. The 25 patients ranged in age from 16 to 82 years old. Total number of stings varied from an estimated 50 stings, to over 1000. The majority of patients were estimated to have been stung by between 100 to 500 bees representing thirteen patients (52%). Four patients (16%) had a history of CAD, fourteen patients had hypertension (56%), nine patients had diabetes (36%), and one patient had asthma. In terms of outcomes, five patients (20%) required intubation for airway management, two patients were dialyzed (8%), and the average length of stay was 84.2 hours over the course of hospital admission. Our results showed that there was no obvious trend in the outcomes of patients with and without CAD, asthma, hypertension, and diabetes. Significant trends were primarily seen in the total number of stings sustained. In patients with a greater number of stings, the total length of stay increased dramatically. Number of stings also seemed to indicate a greater risk of requiring intubation as well. Finally, creatine kinase levels were also significantly elevated in patients with a higher sting count, supporting prior work done regarding the effect of mass envenomations with resulting rhabdomyolysis. This research supports that fact that ultimately the biggest determinant of a patient’s clinical course is the number of stings that they present with. It seems safe to assume that a mass envenomation on the scale of hundreds to thousands of stings will greatly increase the chance that this particular patient is going to have significant rhabdomyolysis, be at greater risk of requiring advanced airway measures such as intubation, and be admitted to the hospital for a longer period. Future work would be enhanced by implementing a multicenter review to increase the power of the study to allow for statistical comparisons to be made, creating an opportunity to delineate potential differences in outcomes based on comorbid conditions.
    • Patient Activation Through Community Paramedicine – Initial Assessment and Future Directions

      Goff, Nathan; The University of Arizona College of Medicine – Phoenix; Clever, M. Todd (The University of Arizona., 2019)
      Community paramedicine (CP) is an evolving concept that promises to expand the role of emergency medical services to support patients beyond the conventional emergency activation. Community paramedics engage in a variety of activities during visits to patient homes including post hospital discharge follow up, medication reconciliation and monitoring of health parameters such as body weight and blood pressure. As CP programs develop, it is important to have a mechanism by which to measure their success. Patient activation is a holistic concept that describes a patient’s ownership of his or her health and healthcare. The survey based Patient Activation Measure (PAM) is a quantitative means to assess a patient’s level of activation. Is it possible that participation in a CP program could increase patient activation, which in turn could act to describe the success of the CP intervention? This study analyzed data derived from a PAM survey used in association with a CP program at Buckeye Fire Department in Buckeye, Arizona. It was expected that patient activation would increase among patients participating in the program. A clear correlation was not found however several insights were gained which hold promise to better define a future study.
    • Pediatric RSV Patients: Radiographic Findings on Admission and Clinical Outcomes

      Shoshan, Dor; The University of Arizona College of Medicine – Phoenix; Connell, Mary (The University of Arizona., 2019)
      Respiratory Syncytial Virus (RSV) is a common cause of respiratory tract infection in children. This retrospective review attempts to evaluate the association of admission chest radiographs with severity of clinical outcome. Radiographic findings were correlated with ‘severe’ and ’non-severe’ clinical outcomes, whereby a severe outcome was defined as hospitalization > 2 days, PICU admission, or mechanical ventilation during hospitalization. A non-severe outcome was defined as absence of the previous criteria. The most common abnormal chest radiograph findings were: interstitial prominence (n=182 [61.5%]), airspace opacity (n=106 [35.8%]), and hyperinflation (n=78 [26.3%]). The radiographic findings found to be associated with a severe clinical outcome were hyperinflation (p=0.033) and airspace opacity (p<0.001). Clinicians should consider more aggressive treatment and closer monitoring when these findings are present on admission chest radiography.
    • Physical, Emotional/Psychological and Sexual Abuse Analysis based on Victim Characteristics

      Salefsky, Sherilyn; The University of Arizona College of Medicine – Phoenix; Hussaini, Khaleel (The University of Arizona., 2019)
      It is estimated that 25-35% of women and men in Western countries have experienced Intimate Partner Violence (IPV). Research has been performed indicating that there are long term effects of physical and emotional problems including associations with higher rates of mental illness and substance abuse. However, most research has been geared towards females as the victims of abuse. Research looking at the risk factors and long-term outcomes of male abuse victims has been limited. For this reason, this study was designed to determine the associated diagnoses and demographic factors which are associated in victims of physical, emotional/psychological and sexual abuse in both males and females presenting to Emergency Departments in Arizona.
    • Pre-Hospital Factors that Lead to Increased Mortality and Morbidity in Trauma Patients in Developing Countries: A Systematic Review

      Smith, Gabriella; The University of Arizona College of Medicine – Phoenix; Beyda, David (The University of Arizona., 2019)
      Trauma is a growing global concern and the WHO estimates that injuries account for one-sixth of the global adult disease burden. Furthermore, there is a disproportionate number of trauma related deaths that occur lower middle-income countries compared to higher income countries. Studies show that deficiencies in care in preventable related deaths include pre-hospital delays, delays in treatment and inadequate resuscitation. Additionally, most trauma related deaths occur in the prehospital setting and it is in the lower to middle income countries where structured emergency medical services are lacking. This review seeks to identify and categorize the contributing prehospital factors that lead to increased mortality and morbidity in trauma patients in developing countries. A systematic review was performed using primary journal articles (written in English) that report pre-hospital interventions and morbidity and mortality outcomes in trauma patients in developing countries. PubMed/MEDLINE and other literature databases were used to locate these primary journal articles by utilizing combinations of search terms “developing countries (MeSH),” “Emergency Medical Services (MeSH),” “pre-hospital emergency response,” and “third world countries.” Our analysis found that patients who experienced a prehospital delay had an 86% increase in mortality. Regarding prehospital care, which was not a well-defined factor across all three papers, one papers found that patients who did not experience adequate prehospital care had a 226% increase in mortality while the other papers only included frequency rates of interventions and corresponding data on mortality. Regarding intubation, one study showed that prehospital intubation was associated with increased mortality compared to emergency department intubation. This study adds to the scarce literature how a lack of prehospital infrastructure is associated with an increased likelihood of mortality. It also highlights the importance and necessity of an increase in quality primary research conducted in developing countries. Only prehospital delay had enough papers with data and thus was the only factor we were able to perform a meta-analysis. Our analysis found that patients who experienced a prehospital delay had an 86% increase in mortality.
    • Quality of Bowel Preparation does not Influence Adenoma Detection Rate

      Barendrick, Lindsay; The University of Arizona College of Medicine – Phoenix; Guha, Sushovan (The University of Arizona., 2019)
      Adenoma detection rate (ADR) is the gold standard and quality measure for screening colonoscopies, however the impact of bowel preparation quality on ADR is not clearly understood. The aim of our study was to investigate the influence of bowel preparation quality on ADR in screening colonoscopies.
    • Readability of After Visit Summaries: Comparing the Level of Information in After Visit Summaries from Internal Medicine and Family Medicine Residencies

      Amundsen, Tyson; The University of Arizona College of Medicine – Phoenix; Coles, Sarah (The University of Arizona., 2019)
      Written advice can improve compliance with medical instructions. The Centers for Medicaid and Medicare Services expect physicians to provide a summarized report following at least most patient encounters. We analyzed 400 after visit summaries (AVS) provided to patients at Internal Medicine and Family Medicine residency clinics. The Flesch-Kincaid Grade Level Test and the Flesch Reading Ease Score were used to evaluate readability. We demonstrated that AVS are usually written at a level that is too high to be helpful to patients. We conclude that patient visit summaries are not written to the appropriate recommended grade levels of <-8th grade for the average patient population. Further studies are needed to show if appropriate grade level summaries will improve quality of care.
    • Retention Rates of Sex trafficked and At-risk Youth in a Rehabilitation Center

      Khan, Aliya; The University of Arizona College of Medicine – Phoenix; Roe-Sepowitz, Dominique; Calvin, Samantha (The University of Arizona., 2019)
      Sex trafficking is a prevalent criminal enterprise in the world. The United States has the second largest sex trafficking market in the world. There are rehabilitation facilities and interventions that exist for children and young people who experience commercial sexual exploitation (CSEC). However, there remains limited information on the most effective interventions for these young people. The study aims to report on the at-risk and sex trafficked youth in a facility in Arizona, retention, as well as risk factors that differentiate these two cohorts. By comparing 69 sex trafficked youth to 70 at-risk youth, we can further delineate how prior sexual abuse, emotional abuse and substance abuse affects rates of retention. Findings indicate that CSEC girls were more likely to run away. There was a statistically significant difference between the CSEC and non-CSEC girls with regards to substance abuse and sexual abuse. The two groups did not differ significantly in terms of emotional abuse.
    • Retrospective Study Comparing the Efficacy of Epidural Analgesia to Perineural Nerve Catheter Analgesia for Postoperative Pain Management in Pediatric Patients Following a Unilateral Lower Limb Surgery

      Trif, Daniel; The University of Arizona College of Medicine – Phoenix; Belthur, Mohan (The University of Arizona., 2019)
      The primary aim of this study was to determine if peripheral nerve catheterization offers a better analgesic alternative than an epidural catheter in pediatric patients who undergo a unilateral lower limb surgery. Postoperative pain management is not only important in promoting comfort to patients in pain but can also promote rehabilitation and optimal healing. Multimodal analgesia is the use of multiple modalities to treat patients’ pain; two of these methods include epidural and peripheral catheters. Epidural catheter infusions offer global analgesia from the waist to both of the lower extremities. Epidurals do pose side effect risks that include infection, urinary retention, hypotension, pruritus, nausea/vomiting, headaches, backaches, and respiratory depression. Peripheral nerve infusions can act more locally at a targeted area and deliver carefully dosed anesthetics to nerve fibers that can hinder the sensory function of nerves while preserving the motor function, allowing for earlier rehabilitation. The use of multimodal analgesia as a postoperative pain management plan can still vary greatly from clinician to clinician, so it would be of benefit to determine which subset of patients may benefit from having a catheter infusion as part of their treatment regimen and whether a peripheral infusion is superior to an epidural infusion. This was a retrospective study that looked at 65 pediatric patients, ages 5-15, that received either an epidural infusion (n = 53) or a peripheral nerve block infusion (n = 12) for a unilateral lower limb operation. Their charts were analyzed to determine pain scores, PCA usage, PRN morphine equivalents, total morphine equivalents, adverse events, length of catheter use, and length of hospital stay, amongst other things. The epidural group was used as the control for the study and the data analysis revealed that the patients that received a peripheral infusion had 43% higher (p = 0.35) pain scores, received 98% less (p = 0.001) continuous morphine equivalents in their infusions, required 31% less (p = 0.34) PRN morphine equivalents, had 68% less (p = 0.049) PCA usage rates, received 32% less (p = 0.39) total morphine equivalents, had 30% less (p = 0.45) adverse effects, and left the hospital 0.54 days earlier (p = 0.13) on average when compared to patients that received continuous epidural infusions. The data indicates that although the pains scores were higher for the peripheral infusion patients, these patients required less opioid exposure, which indicates relatively acceptable pain management for the patient and healthcare team while also allowing for the opportunity to engage in rehabilitation and avoid the global effects of epidural infusions and the associated increased profile risk. The conclusion of this study suggests that continuous peripheral infusions are a valid alternative to epidural infusions for pediatric patients that undergo a unilateral lower limb surgery and that a randomized control trial would be warranted to offer more definitive insight.
    • Salvage Hyperthermic Gemcitabine and Docetaxel Combination Chemotherapy After BCG Failure in Non-Muscle Invasive Bladder Cancer Patients

      Rao, Mounica; The University of Arizona College of Medicine – Phoenix; Lamm, Donald L. (The University of Arizona., 2019)
      In patients with non-muscle invasive bladder cancer (NMIBC), intravesical BCG has been shown to reduce the rate of disease recurrence and disease progression, as well as improve disease-specific survival. While Bacillus Calmette-Guerin (BCG) has become the gold-standard therapy for NMIBC, there are still patients who fail this therapy or are not good candidates for it. Although a radical cystectomy is recommended when BCG is failed, some patients either desire bladder preservation or are not surgical candidates. Thus, further exploration into salvage chemo therapy treatments should be done to provide these patients with an alternative treatment option. The purpose of this study is to analyze if combination Gemcitabine and Docetaxel chemotherapy (GEM/DOCE) is a successful salvage option in adults who have failed or cannot tolerate BCG therapy for NMIBC, and are poor surgical candidates for a radical cystectomy (RC) or desire bladder preservation. In this retrospective study, 60 patients were included. Overall treatment success was 83% (50/60) at first surveillance, 69% at 1-year, and 55% at 2-years after induction of GEM/DOCE in the entire cohort, and 90%(53/51) at first surveillance, 74% at 1-year, and 56% at 2-years in the BCG-failure patients. These success rates are quite favorable and warrant further investigation in a prospective manner to further optimize this salvage protocol for patients who remain a challenge to treat.
    • Surgery Night Float Team: Should Medical Students Have a Spot on the Roster?

      Richter, Madeline; The University of Arizona College of Medicine – Phoenix; Keric, Natasha (The University of Arizona., 2019)
      Following the trend of residency programs, more medical schools are offering night float (NF) schedules for clerkships and sub-internship rotations. The efficacy of this structure to educate students and prepare them for residency was evaluated. This study investigates the question: Is a night float surgical rotation an effective educational experience for 4th year medical students to prepare for internship in that it matches or exceeds day-shift rotations in operative and procedural opportunities, autonomy, and instructive interactions with attending physicians and residents? Twenty individuals were surveyed after a month-long 4th year NF rotation in Trauma and Emergency Surgery. Thirteen participants responded (65%), reporting more bedside procedures (84.7%) and one-on-one teaching with residents (84.7%), when compared to daytime shifts. All participants (100%) reported: increased autonomy; that this elective better prepared them for their surgical residencies; and that they would recommend this type of program to other students considering a career in surgery. Overall the NF surgical sub-internship effective and well-received, with increased autonomy, more frequent procedures, and added resident-led education, when compared to a traditional daytime surgical clerkship/sub-internship. A NF schedule can be a valuable learning experience that prepares medical students for surgical residency.
    • Systematic Review of Quality of Life for Family Members of Children with Autism Spectrum Disorder in Asia and Mindfulness Based Interventions for Children with Autism Spectrum Disorder and Their Parents: Mechanism, Evidence, and Feasibility

      Vincent, Kathleen; The University of Arizona College of Medicine – Phoenix; Melmed, Raun (The University of Arizona., 2019)
      Autism Spectrum Disorder (ASD) is a lifetime neurodevelopmental disorder with presence of symptoms early in development. About 1 in 68 children have been identified with ASD globally. Parents of children with ASD face diverse hurdles that can have a significant impact on their quality of life (QOL), and interventions may be able to improve these outcomes. A systematic review was conducted to assess the QOL for family members of children with ASD in Asia and to elucidate interventions that can impact QOL outcome measures. This study sought to synthesize QOL outcomes for parents of children with ASD across Asia by drawing from currently available primary research. It also sought to examine interventions that have been used in this population to investigate their impact on QOL outcomes in order to unveil the most efficacious interventions for impacting a given outcome. A total of 34 studies were included for review; 17 were used for quantitative analysis and 17 used for qualitative review. Parents of children with ASD in Asia were found to have lower QOL in the areas of general health, role physical, social, vitality, mental health, stress, and overall well-being than parents of typically developing (TD) children. High sense of coherence was shown to be associated with higher parental QOL and lower parental stress. Certain factors were found to be associated with higher sense of coherence including: male gender, parent age greater than 45, and child age greater than seven. Mothers were broadly found to have lower QOL than fathers. Mothers had a lower sense of coherence, lower health-related QOL, poorer overall well-being, and higher stress levels. Coping strategies that parents of children with ASD were found to use most often were religion and a focus on positive growth to create meaning. Not all interventions resulted in positive outcomes. A Mindfulness Based Intervention in Jordan positively impacted QOL outcomes. A Multidisciplinary Parent Education program in China had a significant positive impact on family functioning, while a Cognitive Behavioral Therapy (CBT) intervention for children with ASD decreased parental stress. Additionally, parents having and maintaining contact with parents in a similar situation helped improve well-being, parental stress and family functioning, following an intervention. This preliminary work investigating QOL for family members of children with ASD emphasizes the importance of discovering QOL outcome targets and pairing these with efficacious interventions that are specific to the needs of the population.
    • Systematic Review of Stigmas Present against Disabled Children Globally and How These Stigmas Vary across Regions and Population and Comprehensive Review of the Perceptions and Attitudes that Disabled Children Face Globally

      Pusapati, Nithin; The University of Arizona College of Medicine – Phoenix; Beyda, David (The University of Arizona., 2019)
      Current literature shows that disabled individuals are vulnerable compared to their abled body counterparts in a variety of measures, disability varies across regions and cultures and that attitudes toward these disabilities may also vary globally. Literature searches using keyword searches were done based on search strings of “childhood disability” with other phrases. Outcome variables included region, population studied, a general description of the attitudes, a broader category into which the type of attitude falls and whether or not there were persistent negative attitudes toward disability. Meta analyses were done for outcomes. An initial 114 articles were screened to be relevant to the topic. 15 articles had data extracted. Descriptive results demonstrated that cultural and religious norms are associated with negative attitudes toward disability. Meta analyses did not demonstrate any statistical significance between the cultural, religious or regional factors in the likelihood of having negative attitudes toward disability. The association between religion, culture and region and the likelihood of having negative attitudes was not statistically significant. The presence of negative attitudes on the basis of culturally or religiously held beliefs, globally, does appear to exist on review of the literature.
    • The Effect of Radiated vs Non-Irradiated Blood Transfusions on Extracellular Potassium Levels in Infants Undergoing Craniosynostosis Repair

      Dunn, Tyler; The University of Arizona College of Medicine – Phoenix; Singhal, Raj (The University of Arizona., 2019)
      Transfusion Associated Graft Versus Host Disease (TA-GVHD), a risk of blood transfusions, has a mortality rate > 90%. This results when viable donor T-lymphocytes within the transfused product proliferate and attack host tissue. The risk is reduced with irradiation of blood prior to transfusion. The downside to irradiating cellular blood products is that irradiation also affects other cellular components in the blood product causing the level of extracellular potassium to rise due to hemolysis of the red blood cells. The rapid infusion of high potassium blood products has been associated with fatal cardiac arrhythmias. This study evaluated the effect of irradiated versus non-irradiated blood transfusions on extracellular potassium levels if washing irradiated blood prior to transfusion results in less of a change in extracellular potassium.
    • The Long Term Efficacy of a Behavioral Based Diabetes Prevention Program for High Risk Hispanic Youth

      Wright, Mia; The University of Arizona College of Medicine – Phoenix; Lee, Maurice (The University of Arizona., 2019)
      There is little known about the long term efficacy of diabetes prevention programs in adolescents targeting high risk youth. In this study a chart review was performed to recruit 21 adolescents from the intervention arm and 9 from the control. The HbA1c, BMI% and BP were measured and they all took a health behavior questionnaire. The results varied but the data suggest that there is not an overall decrease in diabetes risk as there was no statistically significant difference in the A1c or BMI.
    • Tumor Infiltrating Lymphocytes as a Predictive Biomarker for Response to CTLA-4 and PDL-1 Therapies

      Mousa, Abeer; The University of Arizona College of Medicine – Phoenix; Chang, John (The University of Arizona., 2019)
      Recently approved immunotherapies capitalize on antitumor mechanisms of the patient’s immune system by inhibiting CTLA-4 and PD-1 pathways. Studies have shown better overall survival with increased tumor infiltrating lymphocyte (TIL) across multiple cancer. Recent trials with anti-PDL-1 has shown better response with high PDL-1 expression. However, studies have not evaluated whether TIL level would correlate with anti-PDL-1 or anti-CTLA-4 responses. The aim of this study is to determine if the level of TIL in metastatic melanoma and lung cancer correlates with patient response to modern immunotherapies. We identified 10 patients with melanoma or lung cancer treated with an immune checkpoint inhibitor. The biopsy samples were stratified according to level of TIL. The TIL categories ranged from 0 to 3, with 0 indicating no TIL detected and 3 indicating 67-100% TIL infiltration. Survival analysis was achieved with Kaplan-Meier curve, and tumor size change was evaluated with linear mixed model analysis. Overall survival was significantly longer in patients who had TIL (TIL0-0.3 yr; TIL1-2-2.4 yr; TIL3-1.6 yr, p=0.024). Tumor size also dramatically decreased at first follow up based on TIL level (TIL 1-2: 371% greater decrease than TIL 0, p < 0.01; TIL 3: 406%; p<0.01). Decrease in tumor size for TIL0 was 0.12cm2 at first follow-up. Baseline tumor size for TIL0 was 41.9cm2; TIL1-2 0.4 cm2; TIL3 1.4cm2. Our study shows that TIL level may serve as a biomarker to predict tumor response to immunotherapy, without specific histochemical staining. This study is limited by the low number; a larger review is currently taking place.
    • Use of Uterine Electromyography (EMG) for Estimation of Uterine Contractility and Cervical Dilation During the 1st Stage Labor in Pregnant Women

      Ford, Brandon; The University of Arizona College of Medicine – Phoenix; Garfield, Robert (The University of Arizona., 2019)
      Labor and delivery in pregnant women occurs in three stages: The 1st stage begins with the onset of uterine contractility and progressive cervical dilation. The onset and development of labor are commonly monitored with crude and inaccurate instruments and methods: a force transducer (tocodynamometer or TOCO) strapped to the abdominal surface to measure uterine contractility and digital exams to estimate effacement and cervical dilation. Electrical activity is the underlying basis for uterine contractility as it is in all muscles including the heart, skeletal and smooth muscles and electrical activity can be accurately estimated with electromyography (EMG, electrophysiological methods). In the uterus, electrical activity consists of bursts of spikes and the characteristics of the bursts are responsible for the frequency, duration and force of contractions. The goals of this study were to assess: 1) The potential for measuring uterine electrical activity during the 1st stage of labor as the basis for contractility of the uterus; 2) The causal relationship of contractility to and changes in cervical effacement and dilation in pregnant patients , and 3) Define how predicted values of cervical dilation can be obtained from electrical signals and how predicted values of electrical signal characteristics can be obtained from cervical dilation.
    • What are the physical characteristics of the distal tibiofibular syndesmotic joint in uninjured patients?

      Rahman, Qasim; The University of Arizona College of Medicine – Phoenix; Gridley, Daniel G. (The University of Arizona., 2019)
      The syndesmosis is a crucial component for the ankle joint as any injury to it can immobilize a person. The ultimate goal of treatment is to restore the syndesmosis and ankle joint to their respective pre-injury, anatomic alignments. Few studies have attempted to characterize normal syndesmotic joints. Many of these studies have had certain limitations: small population size, minimal diversity in subject demographics, and very few raters taking part in data collection. The purpose of this study is to review a normal distal tibiofibular syndesmosis and characterize the parameters of an uninjured joint using both computed tomography (CT) and magnetic resonance imaging (MRI).
    • Willingness to Receive HPV Vaccine from Community Pharmacists: Exploring the Perspectives of Rural Caregivers of HPV Vaccine Age Eligible Children

      Dominick, Lauren; The University of Arizona College of Medicine – Phoenix; Koskan, Alexis (The University of Arizona., 2019)
      This study explores the perspectives of caregivers of HPV vaccine age-eligible children living in rural Arizona – in terms of having their child vaccinated by a community retail pharmacist.