• Primary Care Attitudes & Culture at the University of Arizona College of Medicine-Phoenix

      Puracan, Jasper; The University of Arizona College of Medicine - Phoenix; Briney, Stephanie (The University of Arizona., 2021)
      Introduction. There has been prior research that indicate perceptions held by medical students regarding the field of primary care in medicine can change over time, whether through direct intervention or naturally as a consequence of a medical school’s curriculum. However, the currently held beliefs of medical students and faculty at the University of Arizona College of Medicine – Phoenix (UACOM-P) is unknown. Methods. A cross-sectional study was performed to assess attitudes and beliefs held by members of the UACOM-P community regarding the field of primary care. A Qualtrics survey instrument was developed and distributed to medical students and faculty at UACOM-P in the summer of 2019, with responses from 75 medical students and 33 faculty members. Results. Analysis indicate that there is a generally positive view held by the study population towards primary care, though the strength of endorsement of certain aspects differed between medical students and faculty. There also appeared to be differences between subgroups under both populations, such as Certificate of Distinction versus dual degree students and physician versus non-physician faculty. Discussion. The UACOM-P community has an overall positive attitude toward the field of primary care, with notable differences in some cases. Follow-up studies that may come after this investigation must capture more of the target population and consider impacts of global events such as the COVID-19 pandemic in order to negate potential confounding factors and biases. Future, well designed longitudinal research that assesses how these beliefs change overtime can shed more light on the primary care culture at UACOM-P and can inform campus leadership on future directions to take to support the mission of the program.
    • A race against time: Does Epinephrine compliance by emergency physicians increase ROSC in cardiac arrest patients

      Pho, Karen; The University of Arizona College of Medicine - Phoenix; Stites, Daniel (The University of Arizona., 2021)
      One of the most crucial medicinal intervention during a cardiac arrest is epinephrine. Advanced cardiac life support (ACLS) guidelines lays out the recommendation of delivering epinephrine every 3 – 5 minutes. The purpose of this study is to evaluate if physicians are compliant with delivering epinephrine as recommended, and how does compliance vs. non-compliance affect patient outcomes as measured by attaining return of spontaneous circulation (ROSC). The design of this study is a retrospective chart review with analysis, using Wilcox-Rank sum and Chi-Square fisher exact test to evaluate for statistical significance, which was defined with a P value < 0.05. There were 111 patient charts included in the study, and the results were charted into 3 categories: demographics by non-compliance, any non-compliance and mean non-compliance, and demographics by sinus rhythm. None of the results showed any statistical significance except for the mean number of doses a patient receives to achieve sinus rhythm, which was a mean of 10.3 vs 3.95. Although this study did not achieve statistical significance overall, it highlighted some clinical significance that may be of importance moving forward for all physicians. One clinical aspect that this study highlights further is the health disparity that people of color encounter. Patients who are people of color experienced higher mean number of noncompliance and percentage of any non-compliance. The overall conclusion that this study emphasized is that more studies into the overall quantity of epinephrine given during resuscitation may be worthwhile. Additionally, further emphasis on the importance of physician awareness of health disparity among people of color is needed.
    • Rapid Versus Standard Clozapine Titration Orders in a Psychiatric Acute Inpatient Facility

      Kaur, Bhupinder (Rose); The University of Arizona College of Medicine - Phoenix; Sood, Shabnam (The University of Arizona., 2021)
      Objective: The aim of this study is to evaluate if rapid versus standard clozapine titration is associated with reduced length of stay (LOS) for treatment resistant psychiatric inpatients. Methods: This retrospective chart review study collected socio-demographics and clinical outcomes of psychiatric inpatients with clozapine order sets, including primary diagnosis, order initiation date, discharge readiness and post-discharge placement. An electronic health record report of psychiatric inpatients with clozapine orders between September 2016 and April 2018 yielded 93 separate admissions receiving either rapid titration protocol (RTP) or standard titration (STP) based upon the physician preference. Results: Of the 93 patients who were prescribed clozapine, 37 were started on the RTP and 56 were on the STP. The primary diagnosis of patients in both RTP and STP groups was Schizoaffective disorder at 78.38% and 62.5%, respectively. The median discharge ready (DCR) days were in fact lower for RTP than STP inpatients, although this was not statistically significant. Conclusion: Ultimately, it was determined that the median LOS was similar between patients on rapid and standard titrations.
    • Referral Patterns to Pediatric Pulmonology for Asthma-like Symptoms

      Prynn, Tory; The University of Arizona College of Medicine - Phoenix; Drewek, Rupali (The University of Arizona., 2021)
      Objective: This study aimed to characterize referrals for asthma-like symptoms to a pediatric pulmonology clinic, evaluate consult interventions, and identify opportunities for improving access. Methods: A retrospective chart review examined patients ages 5-18 years, referred to the pulmonology clinic at Phoenix Children’s Hospital between July 2016 and July 2019. Descriptive statistics summarized demographics, prior asthma diagnosis, ICS use and compliance, reason for referral and intervention during consult. An appropriate referral was defined as prior asthma and ICS Step 3. Results: The total 171 study subjects had mean (standard deviation) age of 9.4 (3.8) years, with 100 (58%) males, and prior asthma diagnosis in 105 (61%). The most common reason for pulmonology referral was asthma in 90 (53%) patients, of which 70 (78% of 90) had prior asthma. Among 105 patients with asthma, 79 (76%) had a history of ICS, with 33 (42% of 79) patients reporting spacer compliance issues. The rate of appropriate referrals was 0.11 (95% confidence interval: 0.06-0.16). During the pulmonology consult, nearly half 10 (53%) of 19 patients appropriately referred received an ICS step up. Among 151 inappropriate referrals, ICS was initiated for 91 (60%) and increased for 45 (30%). Education was provided to all patients during pulmonology consult. Conclusions: Mild-to-moderate asthma can be effectively treated by primary care providers (PCPs) with implementation of ICS, thus prioritizing healthcare resource utilization by enabling the pulmonologist to see higher acuity patients sooner. Further study is warranted to identify strategies and tools for PCPs to optimize asthma management.
    • Resolution of Diabetes Mellitus with Laparoscopic Sleeve Gastrectomy

      Daas, Eshaan; The University of Arizona College of Medicine - Phoenix; Soto, Flavia (The University of Arizona., 2021)
      Background: Laparoscopic sleeve gastrectomy (LSG) is a proven intervention to induce weight loss. Its applications as a surgical procedure may extend beyond body weight control to the realm of metabolic therapy in chronic conditions such as diabetes mellitus (DM), which results from the dysregulation of blood glucose levels. Objective: The aim of this study is to evaluate the improvement and resolution of diabetes following sleeve gastrectomy at our facilities. Setting: Two affiliated non-profit surgery centers, United States Methods: Eighty-two adult diabetic patients were treated with sleeve gastrectomy. We conducted a single point analysis of our existing longitudinal data for that calendar year through a retrospective chart review. Statistical outcomes were determined for anthropometric data unique to patients with DM including prescribed medications, Hemoglobin A1C, excessive weight loss (EWL), and body mass index (BMI). Results: Time was a significant predictor of diabetic resolution after six months post-op in patients who originally presented with Type 1 DM and change in hemoglobin A1C values held a significant association to improvement of Type 1 diabetes. BMI and EWL displayed a positive correlation to resolution at all time points of interest. Conclusions: There are differences between the post-operative improvements in diabetic status following sleeve gastrectomy depending on the initial diagnosis of insulin-dependent or insulinindependent DM. Pathophysiological mechanism of a patient’s diabetic condition, specifically auto-immune destruction of pancreatic beta cells, may contribute to the variable metabolic response following sleeve gastrectomy.
    • REVAMP: A prospective study on the impact of virtual medicine on CPAP compliance and satisfaction of care

      Lee, David; The University of Arizona College of Medicine - Phoenix; Pineda, Lilibeth (The University of Arizona., 2021)
      Although continuous positive airway pressure (CPAP) is the gold standard treatment for the chronic sleep disorder, obstructive sleep apnea (OSA), compliance with the CPAP machine among patients continues to be a challenge. REVAMP (Remote Veterans Apnea Management Platform) is a personalized, interactive web platform and mobile app that enables veterans to be evaluated for their OSA and better optimize their management of OSA. REVAMP aims to improve transparency and access to healthcare, reduce patient burdens of traveling and wait times, and establishes better communication with patients and their healthcare team. The purpose of this project was to assess whether the utilization of REVAMP improves the compliance of CPAP for rural Arizona veterans diagnosed with OSA compared to veterans who do not use any additional aide or intervention for their CPAP machine. From 2016 to 2020 for patients from the Phoenix VA Health Care System, 50 patients were randomly selected for a control population and 51 patients were randomly selected from the population enrolled in REVAMP with CPAP compliance as the primary outcome measured. CPAP compliance is defined as 30 nights of CPAP usage for >=4 hours per night at least 70% of nights used. CPAP compliance data came from each patient’s CPAP machine that has its data collected via a wireless modem and stored onto the REVAMP or Resmed Airview platforms that are accessed by a secure VA account. The REVAMP population presented an overall 60.8% compliance rate compared to the 24.0% overall CPAP compliance rate for the control population. The REVAMP mean CPAP usage (%) was found to be 75.2 +/- 33.0 compared to the control population with mean CPAP usage (%) 45.1 +/- 40.4 (p < 0.0001) and a mean CPAP usage >=4 hours per night (%) as 62.5 +/- 37.1 compared to the control population of mean CPAP usage >=4 hours per night (%) as 32.6 +/- 37.4 (p < 0.0001). Based on these findings, there is strong evidence to suggest that interventions like REVAMP that increase education, transparency, and communication with a patient’s healthcare team increase compliance rates for treatments like CPAP. It is also possible that patients who enroll in REVAMP are a self-selecting population who are more motivated to seek out interventions to improve their condition, and further studies should investigate such manners.
    • Shielding Anatomy Outside of the Direct Radiation Beam: Appropriate Practice or More Harm than Good?

      Sitton, Zach; The University of Arizona College of Medicine - Phoenix; Gridley, Daniel (The University of Arizona., 2021)
      Introduction/Background: Lead shields have been used for decades to reassure patients and clinicians that radiosensitive areas (e.g., gonads, thyroid) are protected during radiography. Despite this common practice, supporting data have been limited and conflicting. Further examination of this practice is warranted to improve patient safety. The purpose of this study was to measure the effect of a pelvic lead shield on radiation dose during a chest radiograph. Methods: For 50 consecutive pediatric chest radiographs, 2 nanoDot™ dosimeters were affixed to either side of the pelvic lead shield, which was placed according to existing protocols. After the exam, dosimeters were labeled with the position (in front of or behind the shield) and a patient identifier. Radiation doses from the dosimeters were measured and recorded along with the patient’s age, gender, weight, exam type (anteroposterior or posteroanterior), and technologist identifier. For a small subset of the exams, the mA and kVp were recorded. Results: The median radiation dose measured in the front of the shield was 33.7 mrad, while the median radiation dose measured behind the shield was 33.4 mrad. The median absolute dose reduction demonstrated a statistically significant decrease of 1.01 mrad (p=0.02) behind the shield, with an interquartile range of -0.93 to 2.79 mrad. The trend did not significantly vary by technologist. There were no statistically significant trends based on patient age, weight, weight percentile for age, exam type, mA, or kVp. Discussion/Conclusion: Using a pelvic shield results in a statistically significant reduction in radiation dose behind the shield during chest radiography. However, the median dose reduction of 1.01 mrad was 3% of the total median dose and is equivalent to 1 day of natural background radiation exposure. Therefore, the difference in radiation dose in front of and behind the lead shield may be statistically but not clinically significant. Additionally, the variation between exams was large, with approximately 1/3 of the exams recording an increased dose behind the lead shield. The long-held assumption that lead shielding provides marked radiation dose reduction should be reconsidered, as the effective dose difference may be negligible and not clinically
    • Shift in electrocorticography electrode locations after surgical implantation in children

      Munter, Bryce; The University of Arizona College of Medicine - Phoenix; Foldes, Stephen (The University of Arizona., 2021)
      Interpreting electrocorticography (ECoG) in the context of neuroimaging requires that multimodal information be integrated accurately. However, the implantation of ECoG electrodes can shift the brain impacting the spatial interpretation of electrode locations in the context of pre-implant imaging. We characterized the amount of shift in ECoG electrode locations immediately after implant in a pediatric population. Electrode-shift was quantified as the difference in the electrode locations immediately after surgery (via post-operation CT) compared to the brain surface before the operation (preimplant T1 MRI). A total of 1140 ECoG contracts were assessed across 18 patients ranging from 3 to 19 (12.1 ± 4.8) years of age who underwent intracranial monitoring in preparation for epilepsy resection surgery. Patients had an average of 63 channels assessed with an average of 5.64 ± 3.27 mm shift from the pre-implant brain surface within 24 h of implant. This shift significantly increased with estimated intracranial volume, but not age. Shift also varied significantly depending of the lobe the contact was over; where contacts on the temporal and frontal lobe had less shift than the parietal. Furthermore, contacts on strips had significantly less shift than those on grids. The shift in the brain surface due to ECoG implantation could lead to a misinterpretation of contact location particularly in patients with larger intracranial volume and for grid contacts over the parietal lobes.
    • Should Gastrojejunostomy Tubes be Changed Every Three Months? A Two-Year Single Institution Retrospective Analysis of Unscheduled Gastrojejunostomy Tube Changes

      Kaur, Manroop; The University of Arizona College of Medicine - Phoenix; Wong, Kevin (The University of Arizona., 2021)
      Background: To date there is a significant lack of data on the best practices for maintaining gastrojejunostomy tubes (GJ) in pediatric medicine. Purpose: To determine the average longevity of a GJ tube, the reasons for GJ tube change, and the cumulative radiation dose associated changes. Methods: A single institution retrospective chart review of patient data over a two-year period was performed utilizing an MPower database to identify GJ exchanges/replacements. An exchange was defined as a correctly positioned GJ tube and replacement as a mispositioned GJ tube. The patients’ age, fluoroscopy time, time between change, brand of tube, and reason for replacement were recorded and statistical analysis performed. Results: 143 patients were identified, with a total of 534 GJ changes performed. There were 331 exchanges and 203 replacements. The average length between procedures was 140.6 days with an average fluoroscopy time of 1.76 minutes. Cumulative fluoroscopy time annually was significantly higher if a patient needed a replacement (11.4 minutes) versus an exchange (0.92 minutes). G-JET® brand was more likely to malfunction (8.9%) due to a valve issues compared to MIC-KEY® (3.3%), p = 0.03. MIC-KEY® was three times more likely (OR = 3.01) to be replaced for malposition or leaking, p= 0.009. Conclusion: Current guidelines set by manufacturers can be extended from 3 months to nearly 5 months. Tube replacements result in significantly higher radiation exposure compared to exchanges. Further studies are needed to ascertain whether scheduling has a lower rate of exchanges vs not scheduling.
    • Validation of PI-RADS v2 Scores at Various Non-University Radiology Practices

      Austin, Evan; The University of Arizona College of Medicine - Phoenix; Chang, John (The University of Arizona., 2021)
      Purpose: Validate the second version of the Prostate Imaging Reporting and Data System (PIRADSv2) scores in predicting positive in-bore MRI guided targeted prostate biopsy results across different non-university related institutions. Materials and Methods: This was a retrospective review of 147 patients who underwent multiparametric magnetic resonance imaging followed by in-bore MRI guided targeted prostate biopsy from 2014-2018. Lesions were rated according to PI-RADS v2 criteria. Scores were compared to MR-guided biopsy results and pre-biopsy PSA values. Results: Prostate Cancer (PCa) was detected in 54% (80/147) of patients, with more prostate cancer being detected with each increase in PI-RADS scores. Biopsy results with PI-RADS 3, 4, and 5 lesions resulted in PCa in 25.6% (10/39), 58.1% (33/55), and 86.0% (37/43) respectively. Clinically significant PCa (Gleason score ≥7) was detected in 17.9% (7/39), 52.7% (29/55), and 72% (31/43) of cases for PI-RADS 3, 4, and 5 lesions respectively. When PI-RADS scoring/biopsy results were compared across different institutions, there was no difference in the PI-RADS scoring or in positive biopsy rates.. The sensitivity, specificity, PPV, and NPV for PIRADS 3-4 were not statistically different across the institutions for detecting Gleason 7 or greater lesions. Conclusion: Our results agree with prior studies that higher PI-RADS scores are associated with clinically significant PCa and suggest lesions with PI-RADS 3-5 have sufficient evidence to warrant biopsy. Comparison of PI-RADS across different types of non-university practices revealed no difference in scoring/biopsy outcome, suggesting that PI-RADS v2 can be easily applied outside of the university medical center setting.
    • What do individuals experiencing homelessness want for their care?: A needs assessment survey

      Zeien, Justin; The University of Arizona College of Medicine - Phoenix; Hartmark-Hill, Jennifer (The University of Arizona., 2021)
      The homeless population is growing across the United States, particularly in urban areas. Homelessness has a detrimental impact on health and quality of life, especially among the unsheltered homeless population. Oftentimes, there is a disconnect between existing community services and actual needs of individuals experiencing homelessness. The purpose of this study was to identify prioritized needs in an urban unsheltered homeless population and measure associations with self-reported health. We conducted a needs assessment from April-June 2018 of 144 unsheltered homeless individuals in metro Phoenix, Arizona. The 16-question survey investigated perceptions of priority needs, sources of medical care, health literacy, and health status. Survey results were analyzed using Wilcoxon Rank Sum Test, Chi-squared analysis, and multivariable logistic regression. Most respondents (91.6%) identified food as a top need. The majority (64.1%) utilized emergency departments (EDs) as their primary source of care, and 40.1% reported suboptimal health. Suboptimal health was more likely to be reported in those who expressed transportation (OR 3.03, 95% CI: 1.30-7.07) or medical care (OR 2.47, 95% CI: 0.99-6.14) as a top priority need. Health illiteracy (OR 3.68, 95% CI: 0.76-17.9) was associated with suboptimal health, as was obtaining care at an ED (OR 2.05, 95% CI: 0.81-5.25). The data demonstrate that food security was the top priority need of this urban unsheltered population. Interventions improving accessibility to transportation, high-quality medical care, and health education should be implemented to improve the health of this population. Such interventions may also decrease care sought in ED settings. These conclusions are likely generalizable to other unsheltered homeless populations in large urban cities; however, regional and cultural differences exist. Our needs assessment may serve as a template for future needs assessments of other urban unsheltered homeless populations.