• Is a comprehensive methadone program within the jail system effective at lowering rates of recidivism in opiate-dependent pregnant women inmates?

      Koljonen, Jessie; Cartsonis, Jonathan (The University of Arizona., 2020)
      The aim of this study was to demonstrate that a comprehensive methadone program within the jail system, bridged to the community on jail release, is effective at lowering rates of recidivism in opiate-dependent pregnant women. We addressed the gap in the literature evaluating the efficacy of methadone therapy specifically in women prisoners, while focusing on pregnant women prisoners. There have been very few published studies evaluating a comprehensive methadone program (CMP) in the prison setting. A CMP in the prison setting, such as the one in place at Estrella Jail in Maricopa County, Arizona, includes patient-specific dose adjustment, patient education, provider evaluation, and bridging opportunities to community methadone clinics post-discharge from jail. We performed a retrospective chart review of all women who have gone through the comprehensive methadone program in the past four years at Estrella Jail in Phoenix, Arizona. Data was used from the pregnant patients who participated in a CMP at Estrella Jail. Our primary result compared recidivism rates within six months in three groups - those in Years One and Two, Year Three, and Year Four of the program. Demographics including age range, race, booking year, and length of incarceration were also compared among the groups. We hypothesized that women in Year Four of the program, who received comprehensive education and a dose-adjustment of their methadone, would have lower rates of recidivism among all demographics, compared to women in Years One and Two of the program. There were a total of 199 program participants, 28.1% were incarcerated during Years One and Two combined, 37.2% during Year 3, and 34.7% during Year 4. The mean age of these women was 28.3. 76.4% of patients were Caucasian. 22 total women (11.1%) were reincarcerated, 40.9% during Years 1 and 2 combined, 22.7% during Year 3, and 36.4% during Year 4. With this data, we have provided evidence that a comprehensive methadone program can have a far-reaching public health impact. Through this program, we hope to have shed more light on methadone therapy in pregnant prisoners. The impact of this study could significantly impact the decision of other correctional health facilities to begin a methadone program for their prisoners, women prisoners, and/or pregnant prisoners. We hope to bring awareness to this treatment method, which is a promising option for opioid dependent prisoners
    • Epidemiology of surgically correctable gastrointestinal disease among neonates in Cape Town, South Africa

      Hamman, Justin; Lofberg, Katrine; Sayrs, Lois (The University of Arizona., 2020)
      Background/Purpose A large percentage of neonatal surgery involves gastrointestinal (GI) disease with high disability indexes, leaving opportunity for significant disability-adjusted life year (DALY) reduction in lowmiddle income countries (LMICs). We aimed to evaluate the impact individual neonatal GI diagnoses and their procedures have on LMIC health systems. Methods All neonates who presented with a surgical GI condition at 2 pediatric hospitals in Cape Town, South Africa from 2010-2011 were included and statistically analyzed by diagnosis, case numbers, and individual procedures. Results 118 neonates and 236 surgical procedures were analyzed. The most common overall diagnoses were anorectal malformations (ARM) (19.5%), necrotizing enterocolitis (NEC) (15.3%), and gastroschisis (9.3%). These same 3 diagnoses represented > 50% of overall total case load. Diagnoses of intestinal atresia, gastroschisis, and NEC were determined to have significantly higher mean number of procedures per patient (p = 0.002). Further, 35% of all procedures were related to stages of enterostomy/enterectomy and 18% of all procedures were determined minor in nature. Conclusions Our results demonstrate significant burden of congenital conditions with high risk of morbidity and mortality and provide evidence-basis for multi-level interventions. Additionally, our procedural results may improve resource allocation through proper referrals to higher levels of care and the opportunity for task-shifting minor procedures.
    • Real World Experience of Poly (ADP-ribose) Polymerase Inhibitor Use in a Community Oncology Practice

      Ewongwo, Agnes; Chase, Dana M. (The University of Arizona., 2020)
      Objective: This study aims to describe the real-world experience, including the clinical and financial burden, associated with PARP inhibitors in a large community oncology practice. Methods: Retrospective chart review identified patients prescribed olaparib, niraparib or rucaparib for maintenance therapy or treatment of recurrent ovarian, primary peritoneal or fallopian tube cancer across twelve gynecologic oncologists between December 2016 and November 2018. Demographic, financial and clinical data were extracted. One PARP cycle was defined as a single 28-day period. For patients treated with more than one PARPi, each course was described separately. Results: A total of 47 patients and 506 PARP cycles were identified (122 olaparib, 24%; 89 rucaparib, 18%; 294 niraparib, 58%). Incidence of grade >3 adverse events were similar to previously reported. Toxicity resulted in dose interruption, reduction and discontinuation in 69%, 63% and 29% respectively. Dose interruptions were most frequent for niraparib but resulted in fewer discontinuations (p-value 0.01). Mean duration of use was 7.46 cycles (olaparib 10.52, rucaparib 4.68, niraparib 7.34). Average cost of PARPi therapy was $8,018 per cycle. A total of 711 phone calls were documented (call rate 1.4 calls/cycle) with the highest call volume required for care coordination, lab results and toxicity management. Conclusions: Although the toxicity profile was similar to randomized clinical trials, this realworld experience demonstrated more dose modifications and discontinuations for toxicity management than previously reported. Furthermore, the clinical and financial burden of PARP inhibitors may be significant and future studies should assess the impact on patient outcomes.
    • Retrospective Internal Validation of the HEART Score as an Objective Predictor of a Major Adverse Cardiac Event

      Howarth, Kyle; Guttman, David (The University of Arizona., 2020)
      Background: The goal of the HEART score is to provide emergency physicians with a superior risk stratification tool in the assessment of the acute chest pain patient. It is difficult to determine the severity of the chest pain complaint and many regional emergency physicians have expressed a desire to have a validated, easy, reliable, and quick predictor that will allow them to safely discharge chest pain patients with an acceptably low risk of MACE occurring in the following 6 weeks. Objectives: This retrospective study is an internal validation in the Scottsdale, Arizona region of the HEART score as an objective predictor that a major adverse cardiac event (MACE) has a 1.7% or lower chance of occurring within six weeks in the adult patient population presenting to and discharged from the emergency department with acute chest pain. Methods: This study included 117 patients available for review. 53 could not be contacted for follow-up, yielding 64 patients for analysis. Eligible patients were considered those with an initial chief complaint of “chest pain” upon presentation, who met the “low risk” classification of the HEART score, and who were appropriately discharged (NOT admitted) from any of the Honor Health Scottsdale Hospitals. Results: Less than 1.7% of discharged patients (1/64, 1.57%) who met the HEART score criteria for “lowrisk” patients had a MACE occurrence in the 6 weeks following discharge. Conclusions: The HEART score is internally validated as an objective predictor of no MACE occurring in chest pain patients presenting to these emergency departments.
    • Associated Risk of Head Trauma in Child Maltreatment

      Misra, Shivani; Beyda, David (The University of Arizona., 2020)
      Background- Almost 70% of infant deaths are associated with head trauma, making traumatic brain injury a leading cause of death and disability in infants. Those who survive have lifelong physical, developmental, and emotional sequelae. As such, efforts to characterize and understand the factors that lead to head trauma in infants is critical. Methods- This was a single-institution, retrospective review of suspected AHT patients from 2010-2017. Data were collected on demographics, hospitalization, injury, family characteristics, socio-behavioral characteristics, physical examination, laboratory findings, imaging, discharge, and other follow-up information on fatal and non-fatal head trauma. Statistical analysis involved descriptive statistics, logistic regression, and receiver operating characteristics. Results- Key risks associated with AHT included bruising (OR: 6.1; 95%CI: 3.5-10.5), multiple fractures (OR: 9.5; 95%CI: 4.2-21.5), unknown method of injury (OR: 3.9; 95%CI: 2.2-7.0), self-reported history of substance abuse (OR: 8.8; 95%CI: 3.0-26.0), prior Child Protective Services reports (OR: 2.1; 95%CI: 1.1-3.9), prior police involvement (OR: 5.3; 95%CI: 2.7- 10.4), domestic violence (OR: 1.3; 95%CI: 1.3-5.5), and unknown number of adults in the home (OR: 4.2; 95%CI: 2.4-7.4). The regression model captured 57% of the variance, was 73% sensitive, and was 90% specific using ROC. Conclusions- We propose to broaden the classification of AHT to include inflicted injury and non-inflicted injury, along with a new category called “traumatic injury from an unexplained Event.” An expanded classification system for AHT would capture abuse, neglect, and undetermined patients, making AHT more useful in surveillance, screening, treatment, and prevention of head injury in very young children.
    • Methylene Blue Use in Pediatric Patients in the Cardiovascular Intensive Care Unit

      Patel, Sarah; Willis, Brigham C. (The University of Arizona., 2020)
      Objective: 1) Compare trends in mean arterial blood pressures and vasoactive-inotropic scores of pediatric patients after treatment of hypotension with methylene blue compared to controls; 2) Describe the dose administered and the pathologies of hypotension cited for methylene blue use; 3) Compare the morbidity and mortality of pediatric patients treated with methylene blue versus controls. Design: A retrospective chart review. Setting: Cardiac ICU in a quaternary care free-standing children’s hospital. Patients: Thirty-two patients with congenital heart disease who received methylene blue as treatment for hypotension, fifty patients with congenital heart disease identified as controls. Interventions: None. Measurements and Main Results: Demographic and vital sign data was collected for all pediatric patients treated with methylene blue during a three year period. Linear regression models examined trends in mean arterial blood pressures twelve hours post methylene blue treatment and vasoactive-inotropic scores for twenty-four hours post treatment. Methylene blue treatment correlated with an increase in mean arterial blood pressure of 10.8mm Hg over a twelve hour period (p< 0.001). Mean arterial blood pressure trends of patients older than one year did not differ significantly from controls (p=0.79), but patients less than or equal to one year of age had increasing mean arterial blood pressures that trended toward significance compared to controls (p=0.07). Similarly, a statistically significant decrease in vasoactive-inotropic scores was observed over a twenty-four hour period (?= -0.62, p< 0.001, ECMO ?= -6.07, p= 0.029). This difference remained significant compared to controls (p=0.001). Survival estimates did not detect survival differences between the groups (p=0.5). Conclusion: Methylene blue may be associated with a decreased need for vasoactive-inotropic support and may correlate with an increase in mean arterial blood pressure in patients who are less than or equal to one year of age.
    • Does exposure to chronic stress in rodents alter the level of SIRT1 in the nucleus accumbens?

      Peoples, Sandy; Ferguson, Deveroux (The University of Arizona., 2020)
      In this study we show that chronic social defeat stress, an ethologically validated model of depression in mice, stably induces SIRT1 levels in the nucleus accumbens, an area of the brain that is associated with motivation and reward. We exposed rodents to chronic social defeat stress for a period of ten days and then assessed the rodents on a social interaction test to determine stress response. Rodents were then classified as susceptible or resilient to chronic stress. SIRT1 mRNA and protein levels were then measured in the nucleus accumbens. Results showed that SIRT1 mRNA and protein levels were increased in susceptible rodents but not control or resilient rodents. This supports our hypothesis that SIRT1 levels are associated with depression and anxiety-like behaviors induced by chronic stress and may identify a novel signaling pathway for the treatment of major depressive disorders.
    • Optimization of a Novel Hepatobiliary Scintigraphy Protocol

      Peterson, Juliana; Singer Pressman, Melissa (The University of Arizona., 2020)
      Strategic use of medical imaging can improve healthcare quality and reinforce the practice of precision medicine by providing specific, individualized diagnostic information. Unfortunately, excessive radiologic scan duration times limit imaging center efficiency, leading to decreased patient satisfaction and heightened facility costs. A novel hepatobiliary scintigraphy protocol outlined by Verma et al. can be utilized with equivalent diagnostic ability to maximize scanner operation. The current study demonstrated multiple ways in which the new scintigraphy protocol can be optimized to increase imaging facility productivity. The models presented allow for customization based on facility preference and capability in order to decrease costs and generate revenue, while improving patient satisfaction.
    • Effects of a workplace sedentary behavior intervention on sleep in office workers with sleep complaints: Results from the Stand and Move at Work Trial

      Schaeffler, Kelby; Buman, Matthew (The University of Arizona., 2020)
      Background: Chronic inadequate sleep is associated with increased risk for cardiovascular disease, hypertension, obesity, immunosuppression and overall mortality. There is an abundance of research on the effects of exercise on sleep, but there is currently no data on the impact of sedentary interventions in the workplace on acute and long-term sleep quality/quantity. Purpose: The purpose of this study is to determine if increased standing and/or light-intensity physical activity (LPA) at work will improve sleep quality and duration in sedentary office-workers with mild to moderate sleep complaints. Methods: For this group randomized trial, 51 participants with mild-to-moderate sleep complaints were selected from the Stand and Move at Work Trial. Participants were randomized into two groups: MOVE+ (a multilevel individual, social, environmental, and organizational intervention targeting increases in LPA in the workplace) and STAND+ (MOVE+ intervention with the addition of the installation of sit-stand workstations). Sedentary behavior/LPA and sleep were measured objectively at baseline, 3 and 12 months with the activPAL3 micro accelerometer (PAL Technologies, Glasgow, United Kingdom) and the GeneActiv (GeneActiv, Activinsight, Wimbolton, UK) wrist-worn actigraphy sensor. Results: The sit-stand workstation intervention was effective, with the STAND+ participants sitting on average 70 minutes/day less than the MOVE+ participants at 12 months (p<0.05). There were no statistically significant differences between intervention groups in objectively or subjectively measured time in bed, total sleep time, sleep onset latency, wake after sleep onset, or sleep efficiency at the 3 or 12-month timepoints. On the individual level, adjusting for group assignment, there was no correlation between change in sedentary behavior and sleep measures, objective or subjective. Conclusion: This study found no correlation between a decrease in sedentary behavior at work and changes in objective or subjective measures of sleep. Limitations of this study include underpowering due to small sample size, potential significance of difference in baseline demographics and sleep/sedentary behavior between in groups, and the nature of the intervention being low-dose.
    • Pediatric Primary Headache Sensitivity to Weather Variables

      Sabb, Dylan; Hickman, Carolyn (The University of Arizona., 2020)
      Objective: To determine the relationship between weather patterns and pediatric Emergency Department visits for primary headache. Methods: A retrospective descriptive correlational design was used. Chart reviews were done on 351 medical records of children less than 18 years of age. Study setting was visits to an Emergency Department at an academic pediatric hospital in the Southwest region of the United States. One calendar year of assessments of weather variables to include temperature, relative humidity, precipitation, and barometric pressure were obtained at multiple time points prior to presentation to identify weather-sensitive subsets. In addition, assessments of demographic (date of birth, sex, race, zip code) and clinical variables (chief complaint, diagnoses codes, imaging, medication, and disposition) were collected. Results: Findings indicate that there is a correlation between weather variables and Emergency Department visits in pediatric patients, especially in forecasts of two to five days. Conclusion: A subset of pediatric patients with primary headaches are sensitive to temperature changes within the 5 days preceding the presentation of the headache.
    • 3D Volumetric Measurement of Normal Pediatric Livers: Creating a Reference Database and Predictive Model

      Sandoval, Amber; Bardo, Dianna M. E. (The University of Arizona., 2020)
      Background: Accurate and reproducible measurements of pediatric organs are necessary for defining normal organ volume, size, growth rates, and patterns of development, which aids in determining pathological variants. Currently, no modern reliable database exists for normal liver volume (LV) in children, and although predictive equations have been proposed, many are based on adult data, ethnically homogenous populations, or are derived from smaller samples and have not utilized advanced imaging technology in determining LV in vivo. Objective: To establish normal LV measurements in children, using a three-dimensional (3D) volumetric approach, with additional consideration for height, weight, body surface area (BSA), and body mass index (BMI), and to develop a predictive model using these parameters. Materials and methods: A retrospective review of normal contrast enhanced abdomen and pelvis CT images of 184 patients from 1 month to 18 years, identified within the Phoenix Children’s Hospital picture archive communications system (PACS) was performed. Gender, age, height and weight were recorded for each patient; BSA and BMI were calculated. LV measurements were obtained using segmentation images software (IntelliSpace, Phillips Healthcare, Haifa, Israel). Results: Univariate analysis of LV was most strongly correlated with and predicted by BSA (R2 = 0.90, p < 0.0001), which could be defined by: LV = -115.5 + 941.7*BSA. In multivariate analysis, BSA (p < 0.0001), gender (p = 0.01), and height (p = 0.001) were the covariates that best predicted LV with an adjusted R2 value of 0.90. 3 Stratifying the model by age did not modify the predictive capabilities of the covariates. Further stratifying by gender revealed inconsistent effect modification in some age groups. Conclusion: Univariate analysis of LV was most strongly correlated with and predicted by BSA, which can be defined by: LV = -115.5 + 941.7*BSA.
    • Lesion Size as a Predictor of Non-Operative Therapy Failure in Juvenile Osteochondritis Dissecans of the Knee

      Roehr, Mark; Kelly, Brian (The University of Arizona., 2020)
      Background: The primary challenge in juvenile osteochondritis dissecans of the knee management lies in the lack of definitive non-operative treatment criteria. The purpose of this study was to evaluate the predictive nature of the lesion size and to determine a lesion size cutoff point beyond which a patient’s likelihood of successful 3 month non-operative therapy significantly declines. Methods: 36 knees were retrospectively identified that met the inclusion criteria of stable JOCD lesions that received a 3 month non-operative therapy treatment consisting of either unloader bracing and/or activity restriction. The primary outcome of interest was improved clinical status at three months with accompanying MRI evidence of reossification. Continuous and categorical variables including lesion size were analyzed using logistic regression to ascertain the likelihood of a surgical intervention following a non-operative treatment regimen. Results: Following three months of non-operative treatment, 23 of the 36 knees (64%) had progression toward healing. The mean starting age of the patients with lesions that progressed toward healing was 10.4 years +/- 2.10 years and the mean age that required surgical referral was 12.4 years +/- 1.18 years (p = 0.002). The mean surface area of the lesions that demonstrated progression toward healing was 185.0mm2 +/- 103.7mm2, and the mean surface area of the lesions that did not progress toward healing and were referred for surgical management was 266.6mm2 +/- 95.5mm2 (p = 0.01). The mean lesion surface area cut point >250mm2 contained 13 knees. Of these 13 knees, 4 progressed toward healing (17.4% of the healing group), while 9 required surgical referral (69.2% of the surgery group) (OR = 6.84, 95% CI [1.17,39.8], p = 0.032). Conclusion: Increased lesion size and increased age were the strongest predictors of JOCD non-operative therapy failure. Stable lesions with a mean surface area that is > 250mm2 are at an increased risk for non-opperative failure and should be considered for direct surgical referral on a case by case basis.
    • Evaluating Narrative Operative Reports for Endoscopic Sinus Surgery in a Residency Training Program

      Wheeler, Shannon; Lal, Devyani (The University of Arizona., 2020)
      Methods: The quality of NRs for endoscopic sinus surgery (ESS) was evaluated by studying 90 NRs for ESS written between 2014-2017. Thirty-three elements that the attending surgeon regards as “critical” variables, or quality indicators (QIs), that should be documented in the NR, were studied to evaluate quality. “NR efficiency” (average percent of QIs dictated / total word count) was studied. Subgroup analysis by the level of training was additionally performed. Results: Surgical indications, procedural steps and immediate postoperative findings were accurately documented in 71%, 84%, and 82% of patients, respectively. The attending surgeon had the highest quality (proportion of included key elements) of NR (89% +/- 6.2%) followed by junior residents (87% +/- 5.7%) and then senior residents (80% +/- 14%) [p=0.008]. The attending surgeon also demonstrated the highest degree of “NR efficiency”, followed by senior and then junior residents (p<0.0001). Conclusions: The quality of NRs was found to be high overall, but not “perfect” for either the attending or trainee surgeon. NR efficiency amongst residents was expectedly lower than the attending surgeon. We propose that a synoptic reporting system that ensures inclusion of key elements may be helpful in training residents (and attendings) in creating comprehensive and efficient NRs.
    • Clinical and demographic features of burn patients at Arizona Burn Center Emergency Department

      Cora Kopnina, Yanet; Foster, Kevin (The University of Arizona., 2020)
      Background: Burns are a common cause of injury worldwide that can lead to death, physical disability, psychological trauma and financial burden. Incidence of burn injuries, mortality and emergency department admission rates vary by race, age, gender and socioeconomic status. In addition to patient demographic characteristics, clinical features of their burns influence patient outcomes and management strategies. In addition, clinical features of burns influence patient outcomes and management strategies. Despite having a nationally verified adult and pediatric tertiary burn center, Arizona-specific data regarding clinical features and patient demographics for non-fatal burns is not available in the literature. With this study, we aim to provide state-specific clinical and demographic characteristics of burn patients over a 3-month period. Additionally, we aim to identify differences in burn etiology between adult and pediatric patients. Methods: A retrospective chart review of all adult and pediatric patients who presented to the Arizona Burn Center emergency department at Valleywise Health from June through August of 2016 was performed. Demographic and clinical characteristics were reported as means and standard deviation for continuous variables, while frequencies and percentages were used for categorical variables. The Wilcoxon Rank Sum was used to compared continuous variables while Chi-Squared/Fisher’s Exact test was used to compare categorical variables. Multivariate logistic regression was used to associate variables and all regression models were controlled for age, gender, race, income, total body surface area (TBSA), and the total number of comorbidities. Exploratory descriptive analysis was used to ascertain frequencies and percentages of burn type and mechanism of burn in pediatric and adult groups. The one sample Z-test of proportions was used to assess percentage differences between each mechanism of burn and burn type respectively. Results: Of 651 patients, 240 (36.9%) were female, ages ranged between 0-93 years and the average of age was 31.3 ± 22.3 years. Adults accounted for 69.4% and the 18-29 years old group was affected more than other ages (19.1%). Children under 5 were affected more frequently (55.3%) within the pediatric population. White/Caucasian patients were affected more frequently (533, 81.9%), and 221 patients (33.9%) identified as Hispanic. Medicaid/other government insurance was the most common payment method (204, 31.3%) without including Medicare, followed by self pay/uninsured (154, 23.7%). Most common body part affected was upper extremities (372, 57.1%) and mean TBSA burned was 3.67 ± 8.31%. Admission was required in 163 (25%) of patients, and their LOS averaged 14.7 ± 22.2 days. Tobacco use was seen at higher frequency (20.9%). Most common burn type among all patients was scalding (253, 38.9%) and most burn injuries occurred at home (279, 42.9%). Scalding (41.2%) and contact burn (38.2%) affected children more often than adults, but there was no difference in incidence between these two etiologies among children (p=0.38). Adults were affected by flame burn more often than children (13.3% vs 5.53%, p=0.02). Within the adult group, scalding (37.8 %) was the most common cause of burn (p <0.001). Tar/asphalt was the most common mechanism of contact burns (61.5%, p<0.001) in adults. Conclusions: Demographic and clinical features vary among burn patients seen at the Arizona Burn Center ED. Scalding is the most common cause of burn in adults while scalding and contact equally affect children. Tar/asphalt is the most common cause of contact burns. The sample period was during the summer, so contact burns from hot asphalt are likely overrepresented, while burns from fires (fireplaces, furnaces, and heaters) are likely under-represented compared to an analysis of an entire year.
    • Guns and Kids: Treatment of Pediatric Firearm and Air Gun Missile Injuries in the Emergency Department

      Burnham, Matt; Lee, Justin (The University of Arizona., 2020)
      Background: A recent inpatient data analysis found 16 US children are hospitalized with firearm-related injuries each day. We hypothesized a higher number children are treated in the ED. Therefore, we sought to examine incidence and outcomes of pediatric firearm injuries treated in the ED. Methods: All pediatric (age, 0-18 years) firearm-related injuries were identified from the most recent available 2013 Nationwide Emergency Department Sample database. Results: A total of 16,917 firearm injury cases were identified, estimating 46 cases per day. 11,586 (68.5%) were accidental injuries, 4,090 (24.2%) were assault injuries, and 385 (2.3%) were suicidal injuries. Overall mortality was 575 (3.4%), with 366 (2.2%) deaths in the ED and 209 (1.2%) deaths after hospitalization. Using multivariable logistic regression age less than 2 years, self-pay payer status, multiple injuries, and assault injury were found to be independent predictors for mortality. The highest odds ratio for mortality was found in patients less than 2 years (OR 16.521, CI 10.789-25.300, p<0.001). Mean total charges for ED services were $3,258.70 ($3,076.1, $3,441.3, p<0.001). Conclusion: Approximately 46 children are treated in the ED every day for firearm-related injuries. This is significantly higher than previously reported hospitalization estimates of 16 per day. We also found that children younger than 2 years of age are high risk population for mortality. Future studies including firearm access, safe storage laws, and socioeconomic risk factors are paramount in decreasing pediatric firearm related injuries
    • Managing Challenging Behaviors in Persons with Dementia: A Retrospective Chart Review and Descriptive Analysis of a Unique Hospice Palliative Care Unit Specializing in Dementia Care

      Bean, Christopher; Hamilton, Gillian (The University of Arizona., 2020)
      Patients with behaviors arising from dementia are often rejected for hospice admission because hospices are not equipped to manage these acute symptoms. In addition, patients with dementia on home teams are discharged to geropsychiatric units due to behaviors. These symptoms are often most distressing for family members and the staff that care for them. Despite this, there are no FDA approved medications or interventions for the management of these behavioral symptoms. In 2013, Hospice of the Valley decided to change a standard inpatient unit into a unit devoted to managing persons with dementia to meet this need. A convenience sample of 102 charts of Generalized Inpatient (GIP) admissions of patients with dementia admitted over 5 years for behaviors of hitting, screaming, paranoia/delusions/hallucinations, insomnia, pain, or agitation were reviewed. Pharmacologic and non-pharmacologic interventions, length of stay, oral intake, ambulation, and time to death or discharge were recorded and analyzed. Behaviors leading to admission were agitation (62), pain (53), hitting (37), screaming (35), paranoia/hallucinations (34), and insomnia (20). Psychoactive medications used were antipsychotics (76%), benzodiazepines (36%), morphine (86%), trazodone (42%), and antidepressants (33%), with no clear patterns of use with different behaviors. Nonpharmacologic interventions were documented for 77% of admissions. 51% of patients died within 2 weeks of admission, with pain and screaming most lethal (66% of each). In conclusion, pharmacologic interventions showed no specific patterns, and non-pharmacologic interventions were not documented for 23% of patients despite 100% actual usage per staff. In addition, the availability of the unit enabled direct admission or retention of challenging hospice patients. To our knowledge this is the only hospice inpatient unit in the country focusing on persons with dementia. We believe this research will be beneficial to other hospices, and will contribute to knowledge regarding managing behaviors in patients with dementia at end of life.
    • Determination of Tobramycin and Vancomycin Exposure Required to Eradicate Biofilms on Muscle and Bone Tissue In Vitro

      Castaneda, Paulo; McLaren, Alex (The University of Arizona., 2020)
      Background: Bacterial biofilms cause chronic orthopaedic infections. Surgical debridement to remove biofilm can be ineffective without adjuvant local antimicrobials because undetected biofilm fragments may remain in the wound and reestablish the infection if untreated. However, the concentrations and duration of antimicrobial exposure necessary to eradicate bacteria from clinical biofilms remain largely undefined. In this study, we determined the minimum biofilm eradication concentration (MBEC) of tobramycin and vancomycin for bacterial biofilms grown on bone and muscle in vitro. Methods: Biofilms of pathogens found in musculoskeletal infections (S. aureus, S. epidermidis, E. faecalis, P. aeruginosa, and E. coli) were established for 72 hr on rabbit muscle and bone specimens in vitro and characterized by SEM imaging and CFU counts. Biofilm-covered tissue specimens were exposed to serial log2 dilutions (4000-31.25 ?g/mL) of tobramycin, vancomycin, or a 1:1 combination of both drugs for 6, 24, or 72 hr. Tissues were subcultured following antimicrobial exposure to determine bacterial survival. The breakpoint concentration with no surviving bacteria was defined as the MBEC for each pathogen-antimicrobial-exposure time combination. Results: All tested pathogens formed biofilm on tissue. Tobramycin/vancomycin (1:1) was the most effective antimicrobial regimen with MBEC on muscle (10/10 pathogens) or bone (7/10 pathogens) generally in the range of 100-750 ?g/mL with 24 or 72 hr exposure. MBEC decreased with exposure time for 53.3% of biofilms between 6 and 24 hr, 53.3% of biofilms between 24 and 72 hr, and for 76.7% of biofilms between 6 and 72 hr. MBECs on bone were significantly higher than corresponding MBECs on muscle tissue (p < 0.05). In most cases, tissue MBECs were lower compared to previously published MBECs for the same pathogens on polystyrene tissue-culture plates. Conclusions: The majority of MBECs for orthopaedic infections on bone and muscle are on the order of 100-750 ?g/mL of vancomycin+tobramycin when sustained for at least 24 hr, which may be clinically achievable using high-dose antimicrobial-loaded bone cement (ALBC).
    • Trends in Surgical Management of Congenital Lung Malformations in the United States

      DeWitt, Jason; Lee, Justin (The University of Arizona., 2020)
      We sought to analyze trends surgical management of congenital lung malformations (CLM) including rate of surgical intervention, thoracoscopic approach, and timing of intervention.
    • Disaster Medicine Curriculum: Determining a Need

      de Tranaltes, Kaylee; Burnett, LB (The University of Arizona., 2020)
      Purpose: Recent terrorist attacks, natural disasters, and mass casualty incidents have made clear the need for properly trained healthcare personnel. Whether or not medical schools require their students to participate in any disaster medicine curriculum, and whether it is beneficial, is currently under review in the medical curriculum. The purpose of this study is to evaluate if fourth year medical students in the state of Arizona have experience in disaster medicine and to determine if they think it should be a part of the medical school curriculum. Design: We created a digital questionnaire assessed the background of the medical student answering the questions and the comfort level of the medical student with disaster medicine, using a 5-point Likert response scale. Results: We found that 51% of students who took the survey felt inadequate to some degree with their disaster medicine training so far and that 69% of respondents think there should be more training within the medical school curriculum. There was no significant difference in confidence to triage and treat disaster medicine patients between students who had received training as premedical students versus those who had not. There was a significant difference in confidence to triage and treat disaster medicine patients between students who had received training in medical school and those who had not. Conclusion: The majority of students in this survey did not feel adequately prepared for disaster medicine and thought that it should be included within the medical school curriculum. Students who had already been exposed to disaster medicine in medical school felt more confident in their ability to triage and treat patients than those who had not.
    • Response to biliary sphincterotomy in patients with RUQ abdominal pain following cholecystectomy

      Kapadia, Chirag; Pitea, Teador (The University of Arizona., 2020)
      Functional abdominal pain in post-cholecystectomy patients is often related to visceral hypersensitivity (VH) and can have a lasting impact on a patient’s wellbeing. Numerous factors may lead to persistent or recurrent abdominal pain in post-cholecystectomy patients, one such factor may be Sphincter of Oddi Dysfunction (SOD) or papillary stenosis. Many patients undergo biliary sphincterotomies to achieve symptomatic resolution. This study observed 49 patients stratified by demographic information (age, gender, race, BMI, and inpatient status). It was determined that patients complaining of biliary pain post-cholecystectomy with failure to respond to medical management papillary stenosis and SOD should be considered. For these patients, symptom improvement was observed in 93%. An association was also seen with symptomatic resolution stratified for demographic data exemplifying that male patients, non- Caucasian patients and patients with in-patient status were more likely to achieve symptomatic improvement and resolution. Although a statistical significance was not observed for symptomatic resolution, it can be said that certain people will be more likely to experience resolution with a sphincterotomy than others.