• 10-Year Epidemiology of Ankle Injuries in Men’s and Women’s Collegiate Soccer Players

      Gulbrandsen, Matt; Chhabra, Anikar (The University of Arizona., 2020)
      Background: Data from the National Collegiate Athletic Associ-ation (NCAA) Injury Surveillance Program (ISP) has indicated that ankle injuries are the most common injuries among NCAA soccer players. Objective:To review 10 years of NCAA-ISP data for soccer players’ ankle injuries to understand how the time period (2004-2005 through 2008-2009 versus 2009-2010 through 2013-2014), anatomical structure injured, and sex of the athlete affected the injury rate, mechanism, and prognoses. Design:Descriptive epidemiology study. Setting: Online injury surveillance. Main Outcome Measure(s): The NCAA-ISP was queriedfor men’s and women’s soccer ankle data from 2004 to 2014. Ankle injury rates were calculated on the basis of injuries per 1000 athlete-exposures. Rate ratios (RRs) were used to compare injury rates. Injury proportion ratios (IPRs) were used to compare injury characteristics. Results: When compared with the 2004-2005 through 2008-2009 seasons, the 2009-2010 through 2013-2014 seasons showed a similar rate of injuries (RR¼0.94, 95% confidence interval [CI]¼0.85, 1.04) but fewer days missed (P,.001) and fewer recurrent injuries (IPR¼0.55, 95% CI¼0.41,0.74). The 4 most common ankle injuries, which accounted for 95% of ankle injuries, were lateral ligament complex tears(65.67%), tibiofibular ligament (high ankle) sprains (10.3%), contusions (10.1%), and medial (deltoid) ligament tears (9.77%). Of these injuries, high ankle sprains were most likely to cause athletes to miss 30þdays (IPR¼1.9, 95% CI¼1.24, 2.90). Men and women had similar injury rates (RR¼1.02, 95% CI¼0.94, 1.11). Men had more contact injuries (IPR¼1.28, 95% CI¼1.16, 1.41) and contusion injuries (IPR¼1.34, CI¼1.03, 1.73) but fewer noncontact injuries (IPR¼0.86, 95% CI¼0.78, 0.95) and lateral ligamentous complex injuries (IPR¼0.92, 95% CI¼0.86, 0.98). Conclusions: Although the rate of ankle injuries did not change between the 2004-2005 through 2008-2009 seasons and the 2009-2010 through 2013-2014 seasons, the prognoses improved. Among the 4 most common ankle injuries, high anklesprains resulted in the worst prognosis. Overall, male and female NCAA soccer players injured their ankles at similar rates; however, men were more likely to sustain contact injuries.
    • 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.
    • Alternative Treatments for Osteoporosis in Postmenopausal Women - A Systematic Review

      McCann, Lelan; Beyda, David (The University of Arizona., 2020)
      Introduction: Many postmenopausal women desire non-pharmaceutical alternatives to bisphosphonates for the treatment of osteoporosis and prevention strategies against osteoporosis. Although highly effective in the treatment of osteoporosis, bisphosphonates have a serious side effect profile. These side effects limit the use and duration of bisphosphonates for the treatment of osteoporosis, thus revealing the need for alternative therapies for osteoporosis. Methods: The systematic review was conducted by searching the electronic database of PubMed/MEDLINE using the MeSH terms “postmenopausal osteoporosis” and “vitamins” from January 1961 to April 2019. The review included randomized controlled trials that studied the effects of vitamin supplementation on bone turnover markers and bone mineral density in postmenopausal women with or without osteoporosis. The articles selected for use in this review were assessed for quality using an assessing instrument developed by Jadad et al (1). Results: Twelve articles were included in the final systematic review. These studies showed that vitamin supplements, soy isoflavones, or probiotics decreased the measured markers of bone turnover in studies with a treatment period ranging from 84 days to 48 months. Discussion: Supplementation with probiotic supplements, folic acid, vitamin K, calcium, and phytochemicals with vitamins D and K are shown to be beneficial to bone health with evidence that bone turnover markers are decreased in these treatment groups, although these findings demonstrate that vitamin or probiotic supplementation are not effective in increasing bone mineral density.
    • An assessment of the prevalence and degree of Post Traumatic Stress Disorder in Syrian refugees in Arizona

      Alattar, Zana; Beyda, David (The University of Arizona., 2020)
      Background: In the absence of information on the mental health impact of the Syrian conflict on refugees resettled in the United States, we measured the prevalence of Post Traumatic Stress Disorder (PTSD) among Syrian refugees in Arizona. Methods: 50 participants were surveyed with the Arabic version of the Harvard Trauma Questionnaire (HTQ). Univariate logistic regression was used to ascertain the odds of PTSD score >2.5 relative to survey characteristics. Multivariate linear regression was used to ascertain the mean difference of raw scores relative to survey characteristics. Results: Overall PTSD prevalence among Syrian refugees was 18%, nearly 9 times higher than the 2.3% of Syrian refugees who are referred to behavioral health services upon arrival to Arizona. The odds ratios for patients who experienced trauma and torture were significantly higher than all other questionnaire responses. Discussion: This suggests the need for expansion of behavioral health screening and the use of validated tools to identify PTSD rates among this population
    • An ecological snapshot of Clostridioides difficile: characterizing genetic diversity of C. difficile within Banner-University Medical Center Phoenix

      Brussels, Aaron; Vedantam, Gayatri (The University of Arizona., 2020)
      RATIONALE: The genetic diversity of Clostridioides difficile within hospitals is known to vary geographically: the C. difficile ecology within Banner-University Medical Center Phoenix (BUMCP) is uncharacterized. METHODS: A laboratory-based surveillance study design was used unique to-be-discarded stool samples testing positive for C. difficile infection (CDI) at BUMCP per their existing testing protocol were collected and banked over a 16 month period. Each deidentified sample underwent selection and culture before being prepared for and subjected to capillary PCR in order to determine genetic type (ribotype) of each offending strain of C. difficile. RESULTS: A total of 267 samples met inclusion criteria for this study; 225 were successfully genetically typed, and 83 unique ribotypes were identified. 17 ribotypes (20.5%) are responsible for 60.5% of all typeable cases of CDI during the study period, while 43 strains (51.8%) were each represented by only one case (15.1% of typeable cases) and another 23 strains (27.7%) were represented by two cases (20.4% of typable cases). CONCLUSIONS: There is an uneven distribution of disease burden relative to ribotype. This finding is consistent with similar investigations in other geographies. The highest burdens of disease are attributable to ribotypes 027, 106 and 176 – all well-documented hypervirulent outbreak associated strains.
    • Analysis of the Efficacy of Diabetes Self-Management Education among an Underserved Population

      Hoelscher, Tyler; Lee, Maurice (The University of Arizona., 2020)
      Question: Does the St. Vincent de Paul Diabetes Self-Management Education (DSME) program improve diabetic control among adults who have received care or are currently receiving care at the St. Vincent de Paul free clinic? Background: Diabetes Mellitus is a disease that requires substantial lifestyle modification to control and prevent significant complication. Because of this, Diabetes Self-Management Education (DSME) is an important part of treatment. This study is designed to evaluate diabetic control among patients who have attended the program as compared to those who have not. Methods: Subjects will be recruited from St. Vincent de Paul’s electronic health records (EHR). Patients having completed at least four DSME classes will be placed into the experimental group, and patients having completed fewer than four classes and who are not currently enrolled in a DSME program will be recruited into the control group. A combo of chart review, biometrics and survey will assess thirteen dichotomous variables either on-site or from medical records. A subject will be considered “controlled” with a pass in at least 70% of variables. Results: The primary outcome for diabetic control, meeting the criteria for 70% of the quality metrics, was met in 46% of patients on the treatment group and 19% of those in the control (P=0.052). A1c was ?8% in 54% of the treatment group and 14% of the control (P=0.02) and blood pressure was controlled in 96% of the treatment group and 52% of the control group (P=0.04). Conclusions: There was a nonsignificant improvement in overall diabetic control among patients who attended the DSME course, though A1c and blood pressure were significantly impacted. Though limited by sample size, the study shows that there is promise for future research in DSME.
    • Assessing the Surveillance and Treatment of Perinatal Hepatitis C Transmission among Different Specialties in Arizona

      Immel, Shanan; Kim, Elizabeth (The University of Arizona., 2020)
      Hepatitis C is the most common chronic bloodborne infection in the United States as well as a leading cause of chronic liver disease. Recently, there has been increasing infections in younger people and women of childbearing age due mostly to the opioid epidemic. Among the many diseases that can pass vertically during pregnancy, hepatitis C is able to establish perinatal infections in approximately 5% of HCV-positive mothers. There is increasing evidence that many of these infections go undiagnosed and are lost to follow-up, putting children at risk of complications of hepatitis C at a young age. This study was designed to examine the knowledge, attitudes, and practices (KAP) of Arizona providers surrounding perinatal HCV infections through a Qualtrics survey. A difference was found between specialty guidelines, knowledge, and practices as it related to perinatal HCV. 6/30 (20%) FM providers, 5/10 (50%) Pediatric providers, and 14/23 (61%) OB/GYN providers correctly stated the vertical transmission rate of HCV. For antibody-based testing FM scored 4/30 correct, Pediatrics scored 8/10 correct, and Pediatric Infectious Disease scored 1/2 correct. 73.2% support universal prenatal screening for HCV as opposed to risk-based screening. 31% said they rarely or never ask about these risk factors for HCV. For OB/GYN providers 45% always counsel HCV-positive women about postpartum follow up for their child, 32% said they rarely or never do. In conclusion this survey showed a statewide deficiency in knowledge of screening and transmission of perinatal hepatitis C among certain specialties as well as a majority of respondents in favor of routine screening prenatally.
    • 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.
    • Cefazolin Monotherapy Versus Cefazolin Plus Aminoglycoside for Antimicrobial Prophylaxis of Type III Open Fractures

      Meshay, Ian; Culver, Mark (The University of Arizona., 2020)
      Background: There are conflicting recommendations between organizations regarding aminoglycoside use for the prophylaxis of type III open fractures. Study Question: To compare cefazolin monotherapy versus cefazolin plus aminoglycoside therapy for prophylaxis of type III open fractures in trauma patients. Study Design: This was a multicenter retrospective cohort study conducted in three academic medical centers in the United States. Consecutive adult trauma patients with type III open fractures between January 2014 and September 2016 were included. Patients were divided into two groups: 1) cefazolin monotherapy versus 2) cefazolin plus aminoglycoside. Measures and Outcomes: The primary outcome measure was occurrence of infection at the open fracture site. The secondary outcome measure was occurrence of acute kidney injury. Results: There were 134 patients included in the study cohort. Of these, 39 received cefazolin monotherapy and 95 received cefazolin plus aminoglycoside. Overall, the mean age was 39 ± 15 years, 105 (78%) were male, and the most common fracture location was tibia/fibula (n=74, 56%). Infection at the open fracture site occurred in 6/39 (15%) in the cefazolin monotherapy group and 15/95 (16%) in the cefazolin plus aminoglycoside group (p=1.000). Acute kidney injury occurred in 0/39 (0%) in the cefazolin monotherapy group and 1/95 (1%) in the cefazolin plus aminoglycoside group (p=1.000). Conclusion: Cefazolin monotherapy may be appropriate for antimicrobial prophylaxis of type III open fractures in trauma patients.
    • 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.
    • Current Trends in Creatine Use Rates Among the Adolescent Athletic Population

      Wang, Jeffrey; Kelly, Brian (The University of Arizona., 2020)
      The primary purpose of this study was to obtain the current creatine usage rates among the adolescent athletic population and compare the usage rates between different demographics including sex, age, and sport of participation. We conducted a survey of student athletes in grades 7-12 investigating current trends in creatine use within this population. Of the total participants, 16.3% reported knowing someone who takes creatine; 8.7% have thought about taking creatine themselves; 3.8% admitted to currently using creatine supplements, with the majority of those taking creatine comprising of upper classmen and football athletes. Most students have not researched how creatine or other supplements would affect their health, and 71.2% reported not knowing what creatine was. Only 6.5% believed that creatine use was safe to use as a supplement. The demographics of those using creatine remained consistent since the early 2000s, but the usage rate appears to have dropped. It appears that lack of knowledge on the subject and lack of research could be contributing to the low usage rates seen in this survey. A greater number of students also felt that creatine use was unsafe, and the general consensus seems to be trending away from creatine use in this population.
    • 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).
    • 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.
    • 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.
    • 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.
    • Effects of Fascial Stretch Therapy on Pain Index and Activities of Daily Living in Patients with Chronic Non-specific Low Back Pain

      Ayotunde, Oluwatosin; Standley, Paul; Frederick, Chris; Frederick, Ann (The University of Arizona., 2020)
      Numerous fascia-focused therapies are used to treat pain, most relying on direct manipulation and or tool-mediated techniques. FascialStretchTherapy,on the other hand,uses distally applied techniques to yield both local and global desired tissue outcomes and subjective pain improvement, including those related to LBP(Figure1). We hypothesize that subjects receiving FST will have reduced nonspecific LBP and enhanced activities of daily living (ADL) scores. Using healthy adults between the ages of 18 to 55, this prospective study was used to determineifa two week, four session FST program will lead to reduced pain, reduced use of pain medications, improved ADL and quality of life scores, increased sleep, and increase range of motion in individuals with CNSLBP.
    • Emergency Telemedicine Supported by Onsite Emergency Responder Technicians Reduces EMS Transports, Hospitalizations, and Total Patient Costs from Skilled Nursing Facility

      Hasecic, Elzada; Fisher, Jonathan (The University of Arizona., 2020)
      Background: Skilled nursing facility (SNF) residents tend to be older adults and have increased medical complexity and acuity, making them more likely to access the emergency department (ED) and get hospitalized. Several programs have been created with the intention to increase treatment of medical problems on-site and decrease rates of transfer from SNFs to acute hospitals. An Emergency Telemedicine Service (ETS) is designed through interprofessional collaboration with remote emergency medicine physicians and on-site emergency technicians. This framework allows for multi-provider evaluation, navigation, and treatment of patients within SNFs with potential avoidance of transfer to an ED. Objective: To examine the efficacy of an Emergency Telemedicine Service in reducing unplanned EMS to ED transports from skilled nursing facilities (SNFs) and hospitalizations. Secondarily, we aimed to determine which chief complaints were most commonly to be transferred to the ED compared with those more likely to be treated on-site. Methods : A before and after study design was used to examine the implementation of ETS at a single 202 bed SNF. A six month pre-implementation period from July 1, 2015 to December 31st, 2015 was compared to July 1, 2016 to December 31st, 2016. Data regarding the number of ED transfers, hospital admissions, and cost for patients in the SNF were collected from medicare databases. Medical record demographics including patient age, gender, chief complaint, and disposition, were examined for patients who utilized the ETS. Results: The rate of ED transport per patient was 1.10 before implementation compared to 0.97 after implementation; a decrease of 11.69% (95% CI 8.32 - 15.0). ED costs decreased by 33.6% ($2,708, p=0.016) per patient visit. The rate of hospital admission per patient was 0.77 before implementation compared to 0.65 after implementation; a decrease of 15.37% (95% CI 11.6 - 19.1). Inpatient admission costs decreased by 9% ($2,175, p=0.392) per patient. Additionally, the overall monthly cost per patient at the SNF also decreased by 4.42% ($6,345.51 vs $6,064.83) regardless of whether they required the use of the ETS. The average age of patients who utilized the telemedicine service was 80.78 (SD=11.86). 56.44% (n=57) of patients were female and 43.56% (n=44) were male. The most common chief complaint category was respiratory, with musculoskeletal and general complaints also being frequent. Musculoskeletal related complaints required the most transfer, along with cardiovascular/lymph and respiratory complaints. In contrast, all male reproductive, and most digestive, and mental health-related complaints were successfully managed with on-site resources. Conclusions: Through the use of an advanced Emergency Telemedicine Service in a single SNF, there was a reduction in ED transfers and a significant decrease in the cost for SNF residents transferred to the ED. Keywords: Skilled Nursing Facility, Geriatrics, Emergency Medical Services, ET3, Telemedicine
    • Endoscopically Assisted Targeted Keyhole Retrosigmoid Approaches for Microvascular Decompression: Quantitative Anatomic Study

      Onaka, Naomi; Preul, Mark C. (The University of Arizona., 2020)
      OBJECTIVE: We describe and quantitatively assess minimally invasive keyhole retrosigmoid approaches targeted to the upper, middle, and lower cranial nerve (CN) complexes of the cerebellopontine angle (CPA). METHODS: Anatomic dissections were performed on 10 sides of 5 fixed, silicone-injected cadaver heads. Surgical views through various trajectories were assessed in endoscopic videos and 3-dimensional (3D) interactive virtual reality microscope views. Surgical freedom and angles of attack to the proximal and distal areas of CN complexes of the CPA were compared among upper and lower keyholes and conventional retrosigmoid craniotomy using neuronavigation. RESULTS: Compared with keyholes, the conventional approach had superior surgical freedom to most areas except for the distal CN V, the root of CN VII, and the root of CN IX, where differences were not significant. The conventional retrosigmoid approach provided a larger horizontal angle of attack than either the upper or lower keyholes for all selected areas; however, the vertical angles of attack were not different. Splitting the petrosal fissure resulted in a significant increase in the vertical angle of attack to the root zones of CNs V and VII but not to the distal areas of these nerves or CN IX. Illustrative cases of endoscope-assisted keyhole retrosigmoid approaches for the treatment of trigeminal neuralgia, hemifacial spasm, and glossopharyngeal neuralgia are presented. - CONCLUSIONS: Targeted keyhole retrosigmoid approaches require detailed understanding of the 3D anatomy of the CPA to create appropriate locations of corridors, including skin incisions and keyholes. Endoscope assistance complements the standard microsurgical technique by maximizing the visualization and identification of the delicate neurovascular structures.
    • 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.
    • Ethical Guidelines for Human Subjects Research in Least Developed Countries: How do they compare to the Council for International Organizations of Medical Sciences International Ethical Guidelines?

      Reed, Melissa; Beyda, David (The University of Arizona., 2020)
      Background: The most vulnerable populations for human subjects research are those living in the most resource poor settings. As technology has progressed to support convenient long-distance travel, international communication, and data sharing via the internet, international research has become a more manageable task. While some dismiss the ethical guidelines for human subjects research as necessary only for the most barbaric researchers, history demonstrates the need for ethical guidelines as well as oversight of adherence to such guidelines. Methods: Forty-eight countries designated as least developed countries (LDCs) were identified and selected for analysis. An internet search was utilized to identify research guidelines for LDCs available online or primary research studies conducted in such countries to determine to what extent authors noted ethical considerations. Council for the International Organizations of Medical Sciences (CIOMS) guidelines were distilled into keywords by the authors and compared to guidelines for LDCs. Frequencies and percentages of comparison to CIOMS guidelines were tabulated across the 48 LDCs. Findings: Of the 48 LDCs identified, 22 did not have published research guidelines or mention of a Research Ethics Committee (REC). An additional 10 countries had documentation of some sort of REC, 3 countries had at least one ethical guideline in addition to a REC, and 13 countries had no mention of a REC but did have established ethical guidelines available online. Overall, the average number of guidelines per country was 5 with a SD of 4.11. Conclusion: Over half of countries had online documentation of limited ethics oversight for research, indicating a clear lack of thoroughness in the available guidelines as compared to the international gold standard guidelines from CIOMS. The majority of primary research articles reviewed showed no mention of ethical considerations despite some of the articles using chart review or engaging in patient care interventions. Based on the findings of this study, authors recommend the adoption of existing ethical guidelines by countries still lacking individualized guidelines, as well as a movement toward journals requiring documentation of ethical approval or ethical considerations as a requirement prior to approving articles for publication.