• Analysis of Risk Factors Associated with Fatal Motor Vehicle Collisions in Arizona

      Liu, Margaret; The University of Arizona College of Medicine – Phoenix; Fischione, Mark; Skinner, Ruby (The University of Arizona., 2019)
      In 2014, Arizona had 109,554 motor vehicle collisions (MVCs), 708 of which were fatal. The objective of this study was to analyze behavioral patterns in drivers which resulted in fatal MVCs. This was a retrospective chart review of MVCs in 13 Arizona counties from 2007 to 2015. Results showed a high incidence of high-risk behaviors due to substance use and lack of safe driving practices, including 26% of subjects with an ethanol content above the legal limit, 10% with THC in their system at the time of the collision, 9% with amphetamines or cocaine, 8.5% with benzodiazepines, and 5% with opiates. More than 50% had a combination of substances. Other notable characteristics were the lack of seatbelt use in 30% of subjects, and lack of motorcycle helmet use in 69% of motorcycle drivers. More data is needed on distracted driving behaviors, particularly related to cellular phone use, in order to optimally target future legislation and prevention.
    • Associations of Chest Compression Release Velocity and Age, Weight, and Gender during Cardiac Resuscitation

      Sutter, John; The University of Arizona College of Medicine – Phoenix; Bobrow, Bentley J. (The University of Arizona., 2019)
      Higher chest compression release velocity (CCRV) has been associated with better outcomes after out-of-hospital cardiac arrest (OHCA), and patient factors have been associated with variations in chest wall compliance and compressibility. We evaluated whether patient sex, age, weight, and time in resuscitation were associated with CCRV during pre-hospital resuscitation from OHCA. This observational study of prospectively collected OHCA quality improvement data in two suburban EMS agencies in Arizona between 10/1/2008 and 12/31/2016. Subject-level mean CCRV during the first 10 minutes of compressions was correlated with categorical variables by the Wilcoxon rank-sum test and with continuous variables by the Spearman’s rank correlation coefficient. Generalized estimating equation and linear mixed-effect models were used to study the trend of CCRV over time. During the study period, 2,535 adult OHCA cases were treated. After exclusion criteria, 1,140 cases remained for analysis. Median duration of recorded compressions was 8.70 minutes during the first 10 minutes of CPR. An overall decline in CCRV was observed even after adjusting for compression depth. The subject-level mean CCRV was higher for minutes 0-5 than for minutes 5-10 (mean 347.9 mm/s vs. 339.0 mm/s, 95% CI of the difference -12.4 ~ -5.4, p < 0.0001). Males exhibited a greater mean CCRV compared to females [344.4 mm/s (IQR 307.3-384.6) vs. 331.5 mm/s (IQR 285.3-385.5), p=0.013]. Mean CCRV was negatively correlated with age and positively correlated with patient weight. CCRV declines significantly over the course of resuscitation. Patient characteristics including male sex, younger age, and increased weight were associated with a higher CCRV.
    • C-Terminally Truncated Apolipoprotein A1 Glutamate Residue 243 Is a Biomarker for Oxidative Stress in Coronary Artery Disease and Chronic Kidney Disease

      Wilson, Zachary; The University of Arizona College of Medicine – Phoenix; Breberda, Christian S. (The University of Arizona., 2019)
      High density lipoprotein (HDL) oxidation is a potential biomarker for coronary artery disease (CAD) severity. Methionine sulfoxidation, tyrosine chlorination and C-terminal truncation are Apo A- I modifications that inactivate HDL and lead to pro-oxidant action. We hypothesize that C-terminal truncation of apolipoprotein A1 glutamate residue 243 (Apo A-I Des-Q243) is a byproduct of a protease, such as a matrix metalloprotease (MMP), and it is associated with the presence and severity of coronary artery disease and chronic kidney disease (CKD). We enrolled 103 patients presenting for evaluation of chest pain in this cross-sectional study at Maricopa Medical Center. Plasma and serum samples were collected, processed, and transferred to Arizona State University (ASU) Biodesign Institute for high pressure liquid chromatography-mass spectrometry (HPLC-MS). A statistical analysis was conducted with a spearman’s coefficient, two-tailed linear regression and multivariate analysis of the relative fractional abundance (RFA) of Apo A-I Des-Q243 and clinical variables. Multivariate analysis revealed significantly reduced levels of Apo A-I Des-Q243 in the presence of male gender (-1.5%, P=0.035), atrial fibrillation (-2.8%, P=0.04), and ACEi/ARB use (-2.4%, P=0.001). Additionally, a diagnosis of CKD (2.3%, P=0.037) and the presence of four (9.6%, P=0.005) or five (4.7%, P=0.045) coronary stents, regardless of vessel location, were associated with significantly increased levels of Apo A-I Des-Q243. American Indian/Alaskan race as compared to Caucasian race (Plasma -5.8%, 95% CI -9.9- -1.8%, P=0.005; Serum -4.6%, 95% CI -8.5- -0.8%, P=0.02), and the eGFR (Plasma ρ=-0.024, P=0.014, Serum ρ=-0.291, P=0.003) only reached significance in the linear regression and spearman’s correlation analysis respectively. Apo A-I Des-Q243 is elevated in patients with multiple coronary stents, and thus may be contributing to vascular inflammation and plaque formation. Furthermore, Apo A-I Des-Q243 is elevated in CKD and is directly correlated with its severity as determined by eGFR. These findings highlight the renin-aldosterone system’s (RAS) role in HDL oxidation and the anti-oxidant action of ACEi/ARBs. Apo A-I Des-Q243 appears to be an important link between CAD and CKD and is a promising biomarker that warrants further study.
    • Changes in Body Fat Phenotype After Four-Month Walking Interventions

      Panchanathan, Roshan; The University of Arizona College of Medicine – Phoenix; Angadi, Siddharta (The University of Arizona., 2019)
      Walking is an excellent health-promoting activity for obese, sedentary individuals. Visceral fat is linked to cardiovascular disease and mortality. We hypothesized that walking (steps/day) would decrease visceral adiposity and improve laboratory markers of cardiometabolic health in a dose-dependent manner. In the primary study, 79 sedentary, overweight subjects (77% female, 65% Caucasian) were enrolled in a 2x2 factorial randomized controlled walking intervention, with steps measured using a wearable Fitbit fitness tracking device. Participants underwent dual x-ray energy absorptiometry and basic cardiometabolic laboratory measurements (glucose, insulin, total cholesterol, HDL, LDL, triglycerides) before and after the intervention. Lean mass increased from 49.9 ± 9.5 to 50.3 ± 9.4 (p=0.05). No significant changes were observed in any of the cardiometabolic outcomes or localization of fat. The change in steps had no correlation with weight, visceral fat, lean mass, and VO2 peak, refuting the original hypothesis. When analyzing common laboratory markers and demographic characteristics, there were no significant predictors for visceral or total fat mass change, with significant heterogeneity of change in the group. Our study supports the likely contribution of genetic and environmental factors to the physical and laboratory changes seen following a walking intervention in sedentary and insufficiently active overweight people.
    • Comparative Assessment of Severe Pediatric TBI Management between Developed and Developing Country Institutions: A Study Comparing Phoenix, Arizona to Neiva, Columbia

      George, Laeth; The University of Arizona College of Medicine – Phoenix; Adelson, P. David (The University of Arizona., 2019)
      Traumatic Brain Injury (TBI) is an etiologically heterogeneous condition that represents a global public health issue with major socioeconomic impact. Evidence-based guidelines for pediatric TBI management exist, and were last updated by the Brain Trauma Foundation in 2012. There are, however, limitations and barriers to their implementation; one such are the differences in resource utilization and availability in developed versus developing countries. In this study, we performed a retrospective review of pediatric patients with severe TBI in two tertiary, pediatric hospitals in the United States and Colombia, comparing characteristics, management and outcomes.
    • Comparing the Effects of Narrative Nonfiction and Literary Fiction on Empathy Retention in Medical Students

      Shi, Aishan; The University of Arizona College of Medicine – Phoenix; Hartmark-Hill, Jennifer (The University of Arizona., 2019)
      Integration of medical humanities into medical student curricula has been shown to improve medical student empathy and resilience. The purpose of this study is to determine if narrative nonfiction pieces help students retain equal or more empathy skills compared to reading literary fiction. Previous studies show that interventions that utilize medical humanities can vary in medium and genre, and face the challenge of small sample size and confirmation bias due to a lack of randomized trials. In contrast, this study compares the reading of Narrative Nonfiction and Literary Fiction in building empathy in second year medical students randomized to each genre. Participants were asked to read selections from their assigned genre during the intervention period. Baseline, pre-intervention, and post-intervention assessments were measured by the Reading the Mind in the Eyes –Revised. Results demonstrated a statistically significant decrease in empathy across the overall study period, and there was no empathy retention difference between genres. Additionally, female gender identity and increased engagement in the arts and humanities prior to medical school were correlated with higher empathy scores across time. These findings indicate the need for longitudinal and personalised learning in medical humanities for more thorough studies and maximised benefits on empathy retention.
    • 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.