• Comparison of Autografts vs. Allografts in the Surgical Repair of Pediatric Obstetrical Brachial Plexus Injuries

      Hamant, Laura; The University of Arizona College of Medicine – Phoenix; Adelson, P. David (The University of Arizona., 2019)
      Obstetrical Brachial Plexus Injuries(OBPI) occur during delivery with a global incidence ranging from 0.2- 4% of live births, and generally, prognosis is excellent with spontaneous recovery in up to 95% of patients. For patients with OBPI that do not obtain a functional recovery by 4-6 months of life, treatment is primarily surgical in nature. Surgical treatment involves testing of the nerves to determine whether they remain connected distally and proximaly, removal of scar tissue/ neurolysis, and then bridging the nerve discontinuity or block with a nerve graft. Nerve grafting provide a three-dimensional extracellular matrix that promotes Schwann cell migration and axon regeneration. Historically, nerve graft was autograft using sural nerve. More recently, a decellularized processed cadaveric nerve allograft (Axogen) has been utilized in numerous peripheral nerve injury repairs, mostly in adults, but has not been reportedly used in pediatric OBPI. The aim of this study is to determine if using nerve allografts (Axogen) will have similar functional outcomes as compared to sural nerve autografts in reconstruction of the brachial plexus after OBPI.
    • Comparison of Occipito-atlanto-axial Parameters on Computed Tomography in Pediatric Trauma Patients

      Calhoun, Matthew; The University of Arizona College of Medicine – Phoenix; Connell, Mary (The University of Arizona., 2019)
      Spinal cord injury without radiographic abnormality is a prevalent issue within the pediatric population. Children under the age of 10 are prone to sustaining injury at C1 to C4 because their biomechanical fulcrum exists between C2 and C3. The incidence of spinal cord injury in pediatric population has been estimated to be 4.6 per million per year or 1-2 % of all pediatric trauma cases. There may be subtle findings on computed tomography (CT) that may be able to identify occult cervical spine injury in pediatric trauma patients, which would be evident on magnetic resonance imaging (MRI). This study aims to measure various dimensions of the atlantoaxial and atlantooccipital joints in the pediatric cervical spine in patients with normal spines to detect subtle irregularities on CT scans to warrant further work up with an MRI in trauma patients. Additionally, having an accurate diagnosis will help guide the appropriate type and duration of treatment, which can range from conservative treatment with immobilization to surgery.
    • Comparisons of Emergency Medicine Residency Programs in Their Inclusion of Allopathic and Osteopathic Graduates

      Auerbach, Lauren; The University of Arizona College of Medicine – Phoenix; Stapczynski, J. Stephan (The University of Arizona., 2019)
      Residents entering residency come from two lines of medical education, allopathic (MD) and osteopathic (DO). While schooling is nearly identical, there is a discrepancy between the specialties in which these graduates enter. In 2018, emergency medicine residency programs were made up of three-quarters allopathic graduates and one-quarter osteopathic graduates. This study sought to better understand the diversity of emergency medicine programs as it relates to their location, duration, and credentials of members.
    • Confocal Microscopy Provides a Rapid Intraoperative Histological Assessment of Brain Neoplasms: Experience with 106 Cases

      Carotenuto, Alessandro; The University of Arizona College of Medicine – Phoenix; Preul, Mark C. (The University of Arizona., 2019)
      Frozen section histological analysis is the mainstay for intra-procedural tissue diagnosis during resection of intracranial neoplasms and for evaluating tumor margins. However, frozen sections are time-consuming and sometimes inaccurate. This study describes potential advantages of CSM imaging of fresh human brain tumor tissues labeled various fluorophores within the neurosurgical operating room facility.
    • Deep Interarytenoid Notch in Young Children Managed with Systematic Thickener Wean and Injection Laryngoplasty

      Basharat, Usmaan; The University of Arizona College of Medicine – Phoenix; Williams, Dana (The University of Arizona., 2019)
      A deep interarytenoid notch (DIN) is a normal congenital variation of the larynx where the interarytenoid notch height is below average. It is frequently found in young children and often associated with dysphagia and aspiration. The Aerodigestive Clinic (ADC) at PCH reported that 30% of young patients presenting with dysphagia and aspiration in 2013 were diagnosed with DIN. There exists both functional management with thickeners2 and surgical management with injection laryngoplasty (IL) 3-5. Thickener Wean Protocol (TWP) is a PCH developed 6 month protocol where thickening agents are systematically reduced on a weekly basis while clinical signs of aspiration, respiratory health, and oral motor skills are monitored to ensure safety with the least restrictive diet. An initial modified barium swallow (MBS) score is used in equivalence of thickener level, and patients do not repeat MBS during TWP. A gel (IL) is injected into the interarytenoid notch to close the anatomical gap. Our objective was to evaluate DIN patients who were managed with both thickeners and IL.
    • Determination of the Correlation Between Types of Strabismus and Certain Medical Conditions

      Warrington, Nicole; The University of Arizona College of Medicine – Phoenix; Salevitz, Mark (The University of Arizona., 2019)
      There are numerous subtypes of strabismus: esotropia where one eye deviates inward compared to the other, exotropia where one eye deviates outward compared to the other, hypertropia where one eyes is higher than the other, concomitant strabismus where the degree of deviation is the same in each gaze, incomitant strabismus where the degree of deviation varies in different gazes. Adult strabismus can be caused by various conditions including vasculopathic diseases (diabetes, hypertension, and stroke), compressive CNS lesions, myasthenia gravis, sensory strabismus, thyroid ophthalmopathy, multiple sclerosis, trauma, post-surgical strabismus, recurrent childhood strabismus, longstanding adult strabismus without proven cause, syndrome related strabismus, restrictive orbital masses, and congenital fibrosis of the extraocular muscles. It is currently unknown whether any of these underlying conditions correlate with a specific type of strabismus. The purpose of this study is to determine if underlying conditions correlate with a certain misalignment (i.e. esotropia, exotropia, hypertropia, concomitant, or incomitant). If there is a statistically significant correlation between a certain misalignment and systemic disease, this could add to the algorithm that physicians use to diagnose these systemic conditions. This was a retrospective review of 692 patients >=21 years of age who presented to a pediatric ophthalmologist with adult strabismus from September 2008 to September 2015. The inclusion criteria were: (1) an age of 21 years or older, (2) a confirmed diagnosis of new-onset or recurrent childhood strabismus, (3) any severity and type of deviation, and (4) documentation of diplopia in any field of gaze. The variables that were extracted from the files were: the type of misalignment (esotropia, exotropia, hypertropia, concomitant, incomitant) and the underlying disorder (vasculopathic diseases (diabetes, hypertension, and stroke), compressive central nervous system (CNS) lesions, myasthenia gravis, sensory strabismus, thyroid ophthalmopathy, multiple sclerosis, trauma, post-surgical strabismus, recurrent childhood strabismus, longstanding adult strabismus without proven cause, syndrome related strabismus, restrictive orbital mass caused strabismus, and congenital fibrosis). Interpretation of the data consisted of determining if a correlation between type of misalignment and underlying condition exists. The average age of the population is 60.5 years with a standard deviation of 16.9, of which 49.6% were male. Results of this study indicate that multiple conditions that cause strabismus have a proclivity to negatively or positively predict a certain type of strabismus. Specifically, post-surgical patients are more likely to have hypertropia than esotropia or exotropia, sensory strabismus patients are more likely to have exotropia. Adult patients with recurrent childhood strabismus are more likely to have exotropia and concomitancy. Compressive CNS lesions, thyroid ophthalmopathy, and traumatic causes of strabismus are more likely to cause incomitant strabismus. Vasculopathic causes of strabismus do not have a tendency to cause any certain type of strabismus. These findings will assist ophthalmologists in delineating a cause of their patient’s strabismus based on which types of strabismus correlate with certain conditions.
    • Does Animal Assisted Therapy (AAT) have an effect on mood in United States Veterans?

      Baumann, Alysa; The University of Arizona College of Medicine – Phoenix; Nelson, Erin (The University of Arizona., 2019)
      Research has shown benefit for United States veterans with service dogs and emotional support animals. However, the literature is lacking in research on the beneficial effects and impact of therapy animals specifically on the disabled veteran population. This pilot study explored the effects of a single therapy dog on various aspects of mood, including depression and anxiety, in disabled veterans by incorporating five weeks of thirty-minute therapy sessions to a group of eight veterans. Although this was a small sample population, we concluded that five weeks of consecutive animal assisted therapy resulted in a general decrease in anxiety and depression, and an overall positive increase in mood as evidenced by Beck Anxiety Inventory, Beck Depression Inventory, and Trauma Symptom Inventory scores. Further large-scale studies will need to be conducted with a greater number of participants to help support the data in this study.
    • Does Obesity Exist in Developing Countries? Evaluation of a Rural Clinic Population in the Dominican Republic

      Tay, Kimberly; The University of Arizona College of Medicine – Phoenix; Barcellona, Dawn (The University of Arizona., 2019)
      There is a growing obesity prevalence in developed and developing countries. According to the WHO, in 2014, more than 1.9 billion adults were overweight and 600 million of them were obese while 41 million children under the age of 5 were overweight or obese. Therefore, we are also seeing an increased prevalence of obesity related comorbidities like diabetes and hypertension. This study aims to determine the obesity rate in the bateys in the Dominican Republic (DR), compare it to the US obesity rates US, and determine necessary interventions to prevent further complications from the growing obesity epidemic. Patients were evaluated in mobile clinics in the bateys in the DR during medical service trips in 2016 by UACOMP Global Health teams. A retrospective chart review was performed to collect patients’ age, sex, height, and weight. The BMI was calculated for each patient. Pediatric (<18 y) patients’ BMI was recorded as a percentile based on age. Compared to the US pediatric population, there was a difference of 3.6% in overweight children and 4.4% in obese children among the clinic patients in the bateyes. Approximately 55% of the bateyes’ adult population was overweight (BMI>25-30) versus 31% in the US. About 23%of the bateyes’ adult patients was obese (BMI≥30) compared to 36% in the US. These results indicate a growing obesity epidemic in the rural farming villages in the DR that is like the trend in the US. We hope to implement public health interventions by educating this population about the dangers of obesity and its associated comorbidities, including coronary artery disease and diabetes.
    • Does triptolide alter c-Myc expression through regulation of its associated transcriptional factors and coactivators?

      Cao, Thanh; The University of Arizona College of Medicine – Phoenix; Han, Haiyong (The University of Arizona., 2019)
      In this study we investigated whether triptolide regulates c-Myc expression by inhibiting FBP1 protein expression at the transcription and/or protein level. We performed an RNA sequence to determine global regulation of transcriptome in response to triptolide treatment. In addition, we determined the effects of triptolide on c-Myc, FBP1 and FIR protein expression. We found that 100nM of triptolide inhibited gene expression of c-Myc, FBP1, FIR and XBP. This finding is consistent with a decrease in protein expression of c-Myc and FIR. These finding suggest that triptolide may inhibit FBP1 ability to bind with XBP.
    • Effect of Donor Demographics on Transfusion Recipient Outcomes

      Asprer, Jeanine Elaine; The University of Arizona College of Medicine – Phoenix; Lifshitz, Jonathan (The University of Arizona., 2019)
      Over 21M units of blood are transfused every year, making blood transfusion one of the most common medical interventions in the US. It can be lifesaving, but like many medical interventions, it is not without risks. Thus, most of transfusion research has focused on making the process safer and more accessible. Recent developments in stem cell science – where the transfusion of young blood was shown to reverse stem cell aging and improve physiological function in older mice and conversely, the transfusion of old blood was shown to accelerate stem cell aging and worsen physiological function in younger mice – raise important questions regarding the content of blood being transfused and its associated risks and/or benefits. The purpose of this study is to determine if donor demographics such as age and sex affect patient outcomes. Our hypothesis is that patients receiving blood from younger donors of the same sex have better over-all survival and shorter hospital and ICU stays.
    • Egr3-­/-­ Mice, a Mouse-Model of Schizophrenia, Show Decreased Levels of Htr2a mRNA in the Anterior Frontal Cortex after Sleep Deprivation Compared to WT Mice

      Elizalde-Rodriguez, Diana; The University of Arizona College of Medicine – Phoenix; Gallitano-Medel, Amelia (The University of Arizona., 2019)
      In the U.S., 1 in 25 adults experience serious mental illness each year. Despite ongoing research efforts, the pathogenesis of schizophrenia remains unknown. The aim of this study is to answer the question “Do Egr3-­/-­ mice, a mouse-­model of schizophrenia, show decreased levels of Htr2a mRNA in the prefrontal cortex (PFC) region of the brain after sleep deprivation (SD) compared to wild type (WT) mice?” Data resulting from the study will shed light on the pathogenesis of such a disabling mental disorder. Our study investigates the interaction between two of the genes linked to increased risk of schizophrenia, the early growth response (Egr) 3 gene and Htr2a, which encodes the serotonin 2a receptor (5HT2AR) in response to SD, a form of stress. We used a cohort of age-­matched pairs of C57BL/6 Egr3-­/-­ and WT male mice. Half of these underwent a SD protocol, while the other half served as a control group. Htr2a mRNA was quantified in four different brain regions via densitometry after it was visualized using in-­situ hybridization. Our findings that Egr3-­/-­ mice show statistically significant decreased expression levels of Htr2a mRNA in the PFC support our proposed biological pathway for schizophrenia risk.
    • Evaluation of Rural Pediatric Patients with Intractable Epilepsy for Vagal Nerve Stimulation: A Telehealth Education Based Model

      Hussain, Omar; The University of Arizona College of Medicine – Phoenix; Adelson, P. David (The University of Arizona., 2019)
      Vagal Nerve Stimulation (VNS) has turned into the treatment of choice for pediatric patients with medically refractory epilepsy. It is non-invasive, has few complications, and has a significant impact on the frequency, severity, and duration of seizures. This project sought to answer three main questions. What are the epidemiologic factors that are significant (if any) for pediatric medically refractory epilepsy? What are the best outcome predictors for VNS implantation? And finally, is there a way to improve rural physicians’ decision making abilities when referring patients for evaluation of VNS implantation?
    • Evaluation of the Effects of the MOVE+ vs STAND+ Interventions in the Workplace on Snacking

      Cook, Arianna; The University of Arizona College of Medicine – Phoenix; Buman, Matthew (The University of Arizona., 2019)
      Snacking has been identified as a dietary pattern that could contribute to the prevalence of overweight and obesity. Snacking patterns can be influenced by the environment such as the workplace. The purpose of this study is to determine the effect of workplace sedentary interventions on diet, more specifically snacking, and to give more information on the nutritional value of snacking.
    • Examining the Safety and Cost of Risk-Reducing Salpingectomies as Prophylactic Treatment for Women Seeking Sterilization Who Are at Low to Moderate Risk for Ovarian Cancer

      Samareh-Jahani, Farmin; The University of Arizona College of Medicine – Phoenix; Kaufmann, Bruce (The University of Arizona., 2019)
      Ovarian cancer ranks fifth among the most common cause of cancer deaths in women. There is evidence that the site of origin for the majority of the most serious form of ovarian cancers is the fallopian tube. There is growing consensus for risk-reducing salpingectomies (RRS) to be performed for women who are at moderate risk for developing ovarian cancer especially at a time of patient desired sterilization. A retrospective chart review to determine the safety and cost of risk-reducing salpingectomies in comparison to tubal ligations was performed using the Healthcare Cost and Utilization Project inpatient database from 2008-2012. Results showed no significant difference between each procedure for length of stay in days (95%CI -0.19, 0.79 p: 0.24) or intraoperative complications (OR 4.84 (95%CI 0.38, 60.9 p: 0.22)). There was a significant difference between the total charges associated with each procedure with tubal ligation having a mean cost of $2,227.21 (95%CI $403.2, $4051.10) and the bilateral salpingectomy procedure having a mean cost of $11,189.80 (95%CI $6,582.70, $15,796.80 p<0.001). The cost difference between the two procedures should shift the conversation towards the question of whether hospital billing and insurance coverage for bilateral salpingectomy without oophorectomy should be examined more closely in order to provide RRS as a prophylactic treatment for women at moderate risk for developing ovarian cancer seeking sterilization.
    • Healthcare Charges Incurred from Scorpion Envenomation Treated with Centruroides F(ab’)2 Antivenom

      Roberts, Alexa; The University of Arizona College of Medicine – Phoenix; O'Connor, Ayrn (The University of Arizona., 2019)
      Centruroides F(ab’)2 antivenom (AV) is a safe and effective treatment for bark scorpion envenomation; however, concern exists regarding the substantial charges associated with this therapy and resulting unexpected costs of treatment. This retrospective review seeks to quantitate patient charges associated with antivenom use to better understand its impact on patient and healthcare economics. This is a retrospective review of 527 patients presenting to a hospital system with severe scorpion envenomation between April 2013 and May 2015. Included patients had Centruroides scorpion envenomation and received AV. They were excluded if they were not a grade III or IV envenomation, did not receive antivenom or their clinical records were not available. Patient charges and hospital costs were acquired from institutional financial records and were included if total costs were accurate as defined by costs > $2500. Clinical manifestations, length of stay (LOS), method and amount of AV administration were abstracted. Continuous data were reported as medians with interquartile range and linear regression was utilized to determine predictors of outcomes. All patients had a grade 3 or 4 envenomation and received AV. The total number of vials received were 1 (18.2%) to a maximum of 7 (0.4%) with most patients receiving three vials (46.7%). Most patients received three vials of antivenom initially (52.6%) as compared to one vial (43.6%) and only few receiving two vials (3.8%). Median total charges were $28,060 ($18,805 - $33,742). Linear regression showed that total charges were predicted by total number of vials administered and LOS (adjusted R2 of 0.75). Charges of care were found to increase by $7901.59 per vial of AV and by $415.48 for each hour of LOS. The only predictors of total charges were age, number of vials and total length of stay. Correlation between total charges and costs was poor. Despite established safety and efficacy, anticipated patient charges appear to influence the manner in which bark scorpion antivenom is administered by healthcare providers.
    • Hepatitis C Virus Knowledge, Attitudes, and Practices among Arizona Providers

      Appleton, Leslie; The University of Arizona College of Medicine – Phoenix; Villarroel, Lisa (The University of Arizona., 2019)
      Hepatitis C virus (HCV) is the most common chronic blood borne infection in the U.S. and it is estimated that there are 80,000 Arizonans infected with HCV (ADHS). HCV is the leading cause of liver cancer and transplants (Ly et al., 2012). Research shows vast variation in the availability and uptake of HCV testing, screening, and treatment (Jones et. al, 2013), in part because HCV literacy is low among healthcare professionals (Bruggman, Grebely, 2014). A Knowledge, Attitudes, and Practices (KAP) survey elicits quantitative and qualitative information that can reveal misunderstandings or misconceptions regarding a certain topic (USAID, 2011). Through this, we aimed to better understand the extent to which Arizona providers serve as a barrier to care for HCV patients.
    • Implicit Bias Toward Cervical Cancer: Provider and Training Differences

      Liang, Juliana; The University of Arizona College of Medicine – Phoenix; Chase, Dana (The University of Arizona., 2019)
      Implicit prejudice and stereotyping may exist in health care providers automatically without their awareness. These biases often correlate with outcomes that are consequential for the patient. This study examined gynecologic oncology care providers' implicit prejudice and stereotyping toward cervical cancer. Members of professional gynecologic oncology organizations were asked to complete two Implicit Association Tests (IAT) to determine if they implicitly associate cervical cancer with feelings of anger (prejudice) or beliefs about culpability for the disease (stereotypes), compared to ovarian cancer. Linear regression models and Student t-tests examined average levels of implicit bias and moderators of the implicit bias effects. One-hundred seventy-six (132 female, 43 male, 1 nonresponse; mean age = 39.18 years, SD age = 10.58 years) providers were recruited and the final sample included 151 participants (93 physicians and 58 nurses, mean age=38.93, SD age=10.59). Gynecologic oncology providers showed significant levels of implicit prejudice, X = 0.17, SD = 0.47, 95% CI: (0.10, 0.25), toward cervical cancer patients. They also showed significant levels of implicit stereotyping of cervical cancer patients, X=0.15, SD=0.42, 95% CI: (0.08, 0.21). Whereas physicians did not demonstrate significant levels of implicit bias, nurses demonstrated greater levels of implicit prejudice and implicit stereotyping. Providers without cultural competency training or implicit bias training demonstrated greater implicit bias than those who had completed such training (p < .05). This study provides the first evidence that gynecologic oncology providers hold implicit biases related to cervical cancer. Interventions designed to target specific groups in gynecologic oncology may help improve interactions with patients.
    • Increasing Rates of Screening for Food Insecurity in a General Pediatrics Teaching Practice

      Romo, Ryan; The University of Arizona College of Medicine – Phoenix; Samaddar, Kristen (The University of Arizona., 2019)
      Food insecurity is a widespread and complex problem that affects approximately 21% of the nation’s children. Demographic and socioeconomic data alone are not indicative of all families that are unable to access enough food to fully meet basic nutritional needs because of insufficient means. Screening for food insecurity is essential to identify these families so that they can be set up with resources to increase their access to resources. This study assesses if the implementation of a two-question food insecurity screen at well child checks improves screening rates through prospectively looking at patients in PCH’s General Pediatric Clinic. The validated screen includes the questions, “In the past 12 months, did you ever worry whether the food for you and your family would run out before you had enough money to buy more?” and “In the past 12 months were there times when the food for you and your family just did not last and there was no money to get more?” (Hagar et al. 2010). A family who answered positively to either of these questions was identified as food insecure and set up with resources. Three stages of data were analyzed for identification of food insecurity. These included: 1) previous practices, 2) following provider education, and 3) following integration of the validated screening tool in the EMR. 60 well child visits, 20 from each age group (<1yr, 1-4yr, and 5-11yr), were randomly selected and reviewed for each stage. The integration of the screening tool into the EMR showed statistically significant improvement of screening rates and consequently more families were able to be identified as food insecure. This increase in identification improved overall quality of care by allowing providers to then share resources with families to gain access to food. The screen also has the potential to lower the cost of care through prevention of poor/fair health, hospitalizations, and developmental risks that are associated with FI in children. The next steps include identifying more resources to provide the families, improve follow up to see if the resources are actually being accessed, and encourage the use of the screen in other clinical settings seeing how not everyone presents for primary care.
    • Investigating the Role of p53 in Herpes Simplex Virus - 1 Replication

      McMahon, Savanah; The University of Arizona College of Medicine – Phoenix; Boehmer, Paul E. (The University of Arizona., 2019)
      Herpes simplex virus 1 (HSV-1) is a common human virus that can cause a variety of pathologies, including oral lesions and invariably fatal encephalitis. As there is currently no cure for HSV-1 infection, worldwide morbidity and mortality rates remain high. HSV-1 replication is under intricate control by both viral and cellular factors that dictate whether the virus undergoes productive lytic replication or enters a state of latency during which there is decreased viral gene expression and virus production. The intricate mechanisms that determine the fate of the virus are not completely understood. p53, the well-known tumor suppressor gene, is involved in various cellular responses to stress, such as viral infection. We hypothesized that p53 plays a role in the establishment of HSV-1 latency by negatively regulating HSV-1 replication through repression of viral gene expression via the ATM/ATR damage response pathway leading to expression of p53 and regulation of gene expression via p53 response elements (RE). Viral yields were determined for HSV-1 strain KOS grown on HCT116 wild-type (p53 +/+) and HCT116 p53-deficient (p53 -/-) cells at a multiplicity of infection (MOI) of 1 and at 72 hours post-infection, with the prediction that the viral titer would be higher for the virus derived from the HCT116 p53-deficient cells. Our results demonstrate that there is no significant difference in HSV-1 titer between p53-deficient cells and wildtype cells under these conditions. This suggests that p53 does not play a vital role in promoting HSV-1 latency overall; rather, p53 may exert both positive and negative effects on HSV-1 replication at varying points in time without favoring one cycle over another. Future research, such as determining viral yield harvested from cells in which the levels of p53 have been increased by both overexpression and the use of pharmacological agents to stabilize endogenous p53, should be conducted to further elucidate these complexities.
    • Is Ketamine an Effective Sedative in the Acutely Agitated Patient in the Prehospital Setting?

      Hawk, Katie; The University of Arizona College of Medicine – Phoenix; Gallagher, John (The University of Arizona., 2019)
      Excited Delirium Syndrome: disorder characterized by hallucinations, aggressive and peculiar behaviors, a catecholaminergic surge and secondary risk for sudden cardiac death (Gerold, 2015). The development of sedatives and antipsychotics lead to a decreased incidence until the 1980s. With increasing use of stimulants such as cocaine and methamphetamines, the rates of “undetermined cause of death” has increased in patients exhibiting acute agitated delirium who were in police custody. Patients in this state may be in danger of avoidable death. Emergent medical treatment may prevent death in these patients as suggested by a retrospective review of deceased patients; indicating a need for sedation that minimizes the use of physical restraint and sedates the patient chemically. Ketamine, which functions as a noncompetitive antagonist to NMDA receptors and releases of glutamate, is an option for chemical sedation. The safety profile is ideal as it has a wide therapeutic index and does not act on opioid or GABA receptors. This study asks if Phoenix Fire Department paramedics assessments indicate that IV/IM ketamine administration to patients with Excited Delirium Syndrome is more effective at sedation than Midazolam alone for prehospital transport to an acute care facility?