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  Evaluating Intimate Partner Violence (IPV) Education in MD and PharmD Training Programs at The University of Arizona: Seeking Improvement

  Strouse, Isabel; The University of Arizona College of Medicine - Phoenix; Handmaker, Hirsch (The University of Arizona., 2024)

  Intimate partner violence (IPV) is a public health crisis, and recognizing IPV in clinical settings can be challenging, requiring a specialized skillset. Gaps in health care professionals’ competency regarding IPV highlight the need for enhanced IPV education. This prospective cohort study assessed the extent and effectiveness of IPV education among medical (MD) and pharmacy (PharmD) students at The University of Arizona (UA), following an initiative through The UA College of Pharmacy that targeted increased IPV screening in rural Arizona pharmacies. After email recruitment, a two-part survey that assessed student perceptions of IPV and objective IPV knowledge was distributed to participants from January to February 2024. Planned comparisons evaluated the extent of IPV education, student readiness, and objective knowledge within and between the student cohorts. 164 students participated (144 MD, 20 PharmD) with no differences in demographics. MD students expressed higher confidence (p = 0.002) and received more education (p = 0.003) related to IPV than PharmD students. For MD students, positive correlations were found between education and confidence (r = 0.49, p < 0.001, 95% CI [0.36, 0.61]), readiness (r = 0.63, p < 0.001, 95% CI [0.52, 0.72]), and objective knowledge (r = 0.27, p < 0.001, 95% CI [0.11, 0.42]). There were no significant correlations in the PharmD cohort. Overall, MD students exhibited greater preparedness in addressing IPV-related concerns compared to PharmD students. MD students also showed a consistent association between extent of IPV education and measures of preparedness. These findings highlight the importance of IPV education and serve to better understand the landscape of IPV curriculum across healthcare training programs, with the ultimate goal of preparing future clinicians to recognize and support IPV survivors across many clinical contexts.
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  A Comparative Analysis of the Risk of Decompression Sickness with respect to Dive Profile and Associated Dive Depth, Ascent Rate, Dive Era, and Inspired Gas Composition

  Jayaraman, Meghna; Irwin, Chase; Lee, Ernest; The University of Arizona College of Medicine - Phoenix; Lee, Ernest (The University of Arizona., 2024)

  To date, no systematic review has been conducted to assess the compounded risk of decompression sickness (DCS) with respect to more nuanced variables such as dive profile (dive depth, ascent rate), dive era, and inspired gas composition. The aim of this study is to determine if the diving profile of deep-sea diving alters the risk of developing DCS in divers. This study is a retrospective cohort study of 6,050 deep sea diving events and the corresponding 331 instances of DCS experienced by the underwater divers. The primary outcome was DCS development between the “saturation” and “repetitive and multi-level” experimental dive profile cohorts, compared to the “single-dive” control dive profile cohort. This was assessed via adjusted risk ratios. Further subgroup/confounding factor analyses were additionally performed to assess secondary outcomes of DCS development as a function of dive depth, ascent rate, dive era, and inspired gas composition. Divers and dives enrolled in this study were obtained from a study by the Naval Medical Research Center titled “The Dive Profiles and Manifestations of Decompression Sickness Cases After Air and Nitrogen-Oxygen Dives.” Dives were performed and recorded from 1940-1997. IRB approval was not required as this study utilized publicly available deidentified data. With marginal DCS events excluded due to reporting discrepancies, this study evaluated a total of 5,861 deep sea dives. Primary outcome evaluated was DCS development between the “saturation”, “repetitive and multi-level”, and “single- dive” control dive profiles evaluated by adjusted risk ratios. Secondary outcomes included DCS development as a function of dive depth, ascent rate, dive era, and inspired gas composition evaluated by adjusted risk ratios. Demographic differences were assessed via Chi-square test for categorical variables and One-way ANOVA for continuous variables. Primary and secondary outcomes were analyzed via adjusted log- binomial regression models. Primary dive profile analysis consisted of (1) “single-dive” square-profile control cohort of 3,817 dives and 189 (4.95%) instances of DCS, (2) a “repetitive and multi-level (R&M)” cohort of 1,584 dives and 67 (4.23%) instances of DCS, and (3) a “saturation” cohort of 649 dives and 75 (11.56%) instances of DCS. Single dive profile subgroups included Air Gas Inspiration: 3,139 dives and 164 (5.22%) instances of DCS and Non-Air Gas Inspiration: 678 dives and 25 (3.69%) instances of DCS. Repetitive and multi-level dive profile subgroups included Air Gas Inspiration: 849 dives and 39 (4.59%) instances of DCS and Non-Air Gas Inspiration: 735 dives and 28 (3.81%) instances of DCS. Mean(SD) dive depths (meters) for the single, R&M, and saturation cohorts were 145.2 (90.8), 91.7 (38.9), 57.2 (32.2), respectively. Mean (SD) ascent rates (meters/min) for the single, R&M, and saturation cohorts were 54.0 (114.5), 18.7 (22.4), 5.5 (12.09), respectively. Conclusions and Relevance: Primary dive profile analysis reflects that divers from the “Saturation” group were 3.65 times (95% CI: 2.63 – 5.05) more likely to experience the event then divers from the “Single: Air Gas” control group. These results were statistically significant. With regards to secondary outcomes, adjusted RRs differences in inspired gas composition do not appear to be statistically significant. Dive era, expectedly, appears to play the most significant role in determining risk of DCS, and for every 10-foot increase in depth, divers were 1.03 times (95% CI: 1.01 – 1.05) more likely to experience the event. These results were statistically significant. Ascent rate analysis was unreliable as the ascent time values in the original data are “more or less useful depending on the dive type (essentially of no use in the repetitive and multi-level dives)”.
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  Evaluation of CYP2C19 Phenotype Impact on Sertraline Treatment of Major Depressive Disorder

  Kashyap, Eshaan; Rivas, Salvador; Hashemzadeh, Mehrtash; The University of Arizona College of Medicine - Phoenix; Heise, William (The University of Arizona., 2024)

  Treatment for Major Depressive Disorder (MDD) has classically involved selective-serotonin reuptake inhibitors (SSRIs), but the appropriate selection of a specific pharmacologic has remained elusive. Clinical response to an SSRI can be predicted by clinical improvement within weeks of treatment initiation, but for many patients, clinical improvement is never identified. Recent research demonstrates an association between pharmacokinetics of SSRIs and the metabolizer phenotype of their associated cytochromes. In this retrospective chart review, we investigated 94 adult patients who were diagnosed with a depressive disorder and prescribed sertraline. Each patient’s clinical response to sertraline, as determined by clinician judgment, was recorded and evaluated with respect to the patient’s CYP2C19 metabolizer phenotype. We hypothesized that adult patients who are CYP2C19 ultra-rapid metabolizers and rapid metabolizers (UM+RM) did not experience response with sertraline when compared to patients who are CYP2C19 normal metabolizers (NM). We found no significant difference in clinical response between UM+RM and NM patients, and therefore patients may not benefit from preemptive pharmacogenomic testing for their CYP2C19 metabolism phenotype.
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  Examining the relationship between social determinants of health and obesity status at a federally qualified health center

  Alteri, Natalie; The University of Arizona College of Medicine - Phoenix; Saririan, Shahrzad (The University of Arizona., 2024)

  Importance: Specific health outcomes and biomarkers are correlated with many social factors including socioeconomic status (SES) and race, but the correlation with specific social determinants of health (SDH) metrics of food security, housing security, and social integration are not as well understood. Objective: The purpose of this study is to examine the correlation between security status for these social determinants of health and obesity status. Design: Retrospective cross-sectional observational study, 2021 Setting: Federally Qualified Health Center Participants: Patients aged 18 and older who have completed a PRAPARE assessment between January 20, 2021 and August 08, 2021 and have a recorded height and weight (to calculate body mass index (BMI)). Descriptive and comparative statistics were used to characterize the population and explore the relationship between obesity and SDH. Exposures: food insecurity, housing insecurity, social integration insecurity Main outcomes and measures: 1) Mean BMI in patients experiencing insecurity and security for food, housing, and social integration and 2) Proportion of patients experiencing insecurity with obesity and without obesity Results: 721 patients were included in this study with a median BMI of 29.9 (IQR 26.5, 33.7). Of respondents, 57 (9.7%) reported food insecurity, 125 (18.9%) reported housing insecurity, and 97 (14.9%) reported limited social integration. Chi-square analysis revealed that obesity status and SDH security status are independent for these metrics. T-tests revealed that average BMIs were not different for patients experiencing insecurity versus security. Conclusions and relevance: In this single-center study using a convenience sample, there was no correlation between security status and obesity status for selected SDH metrics. More research needs to be done to understand the impact of SDH on health outcomes in different patient populations.
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  Does referral to and follow up with a registered dietitian affect adolescents’ self-reported patterns of dietary intake, physical activity, or nutritional knowledge: a cross-sectional survey study in children ages 11-17 receiving care at a Federally Qualified Health Center

  Mendoza, Elen; The University of Arizona College of Medicine - Phoenix; Abdollahi, Shaghayegh (The University of Arizona., 2024)

  Importance: Few studies have examined the impact of a pediatric dietitian referral on nutrition-related behaviors and no studies to our knowledge have captured the effects of an RD referral on physical activity, nutritional knowledge (e.g., food label use), stage of change, and other factors affecting dietary intake (food insecurity, self-efficacy, body-image, etc.) Objective: The aim of our study is to assess how a visit with a registered dietitian (RD) not only affects diet and physical activity but also knowledge, and we hope to capture additional variables that may moderate the relationship between RD follow-ups and lifestyle changes such as demographic factors, food insecurity, and body image Design: This study was a cross-sectional survey study with data gathered from March to November 2022 Setting: Participants were recruited from the Laveen Family Health Care and other Valleywise primary care clinics during both well child checks and sick visits Participants: Our volunteer sample included adolescents 11 years of age and older; exclusion criteria included referral to a dietitian for a gastrointestinal or genetic disorder Exposures: We compared the responses of adolescents who were referred to and/or followed up with a dietitian (at least one visits) to a control group who had not been referred to a dietitian Main Outcome(s) and Measure(s): The Bright Future Survey Tool, a 21-item screening tool developed by the American Academy of Pediatrics, was used to assess dietary intake and physical activity. There were 7 food categories including drinks, grains, vegetables, fruit, meat or meat alternatives, and fats or sweets included in the survey. Each of these categories included checklists with more specific foods. For physical activity, the question was a binary yes or no question (“Did you participate in any physical activity in the past week?) with a follow up question (“If yes, how many minutes per day?”) to elicit a numerical response. Additional items included meal skipping, sharing meals with family, food security, body-image, involvement in food preparation or grocery shopping, fast food consumption, and a gauge of adolescent’s desire to lose weight. The Food Label Quiz is a 5-item nutritional knowledge assessment tool developed by the MOVE! Veteran’s Weight Management Program. The questions include correctly interpreting serving size on a food label, correctly understanding percent daily value of a category, and general nutritional knowledge regarding energy density of fats compared to carbohydrates. Results: Participants were on average 13.9 years of age (SD of 2). 41.8 % of surveys were completed in Spanish (58.2% in English), and 56.9% of participants were female (42.5% were male). 72.8% of respondents self-identified as Hispanic or Latinx, 13.2% as non-Hispanic, non-Latinx Black or African American, 6.6% non-Hispanic, non-Latinx White or Caucasian, and 3.3% non-Hispanic, non-Latinx Native American or Alaska Native. Children and adolescents who had been referred to a dietitian had a statistically significant reduction in the odds of eating junk food (fats, sweets, sodas, chips). Participants who had been referred to a dietitian were less likely to indicate having consumed fats, sweets, or chips in the past two weeks, with an odds ratio of 3.78 x10-8 compared to participants who were not referred (95% CI of 1.27x10-8 to 1.12x10-7). Additionally, there was a statistically significant decrease in the odds of eating junk food for those children and adolescents who have visited a dietitian 1-2 times by 95% (95% CI of 0.006 to 0.433). No statistically significant difference or further benefit was found for children and adolescents with additional visits (3 or greater). In contrast to our hypothesis, no statistically significant correlations were found between dietitian referral/follow-up and number of sweetened beverages consumed, vegetable consumption, fruit consumption, minutes of physical activity per day, or nutritional knowledge as captured by the Food Label Quiz. In terms of secondary outcomes, adolescents who have visited a dietitian ≥3 times had a statistically significant increase in the odds of being concerned about their weight by a factor of 27.2 (95% CI 3.27 to 226.23). Visiting a dietitian ≥3 times was also associated with an increase in the odds of being on a diet by a factor of 12.1 (95% CI 2.85 to 51.14). There was no statistically significant difference in weight concerns or dieting for children and adolescents who visited a dietitian less than 3 times or were only referred with no follow-up. Adolescents who had 1-2 visits with a dietitian (compared to 0) had decreased odds of spending 2 + hours of screen time per day by a factor of 0.21 (or 79%) (95% CI 0.047 to 0.913). Interesting, there was no statistically significant difference between children and adolescents with 3 or more dietitian visits compared to those with no visits. Children and adolescents with food insecurity had a massive increase in their odds (6.21) of having disordered eating patterns—such as binging and/or purging (95% CI 5.03 to 1409.67). Food insecure youth on average obtained nearly 30 minutes less physical activity compared to their food secure counterparts (95% CI -56.21 to -2.88). In terms of correlations between various demographic factors and primary and secondary outcomes, being female and being Black/African American was associated with increased odds of eating fast food (95% CI 1.12 to 7.95, 95% CI 1.76 to 30.60 respectively). Female youth were also more likely to report appetite problems and had increased odds of being on a diet by 829% (95% CI 3.69 to 128.70, 95% CI 1.56 to 55.39). Additionally, female participants on average reported more than 20 minutes of less physical activity compared to their male counterparts (95% CI -38.88 to -1.77). There were no other statistically significant correlations between gender or race/ethnicity and patterns of dietary intake, disordered eating, food security, or nutritional knowledge. Conclusions and Relevance: This cross-sectional survey study found that adolescents consulting with a dietitian tended to consume less junk food, with the most significant difference seen in those who had 1-2 dietitian visits. This could be attributed to increased awareness and education provided during these sessions. Notably, there was no significant difference for those with 3 or more visits, possibly due to the small sample size. No other significant correlations were found between dietitian visits and dietary patterns or physical activity, contrary to the initial hypothesis. Regarding secondary outcomes, children with 3 or more dietitian visits were more likely to express weight concerns and be on a diet, possibly linked to education on healthy growth and BMI. Food-insecure participants reported less daily physical activity, possibly influenced by socioeconomic factors such as neighborhood walkability. They were also more likely to report disordered eating patterns, possibly due maladaptive compensatory mechanisms linked to binge eating. In terms of gender, females showed higher odds of appetite problems, dieting, and less physical activity compared to males. Socialization, enrollment in school sports, and societal influences on body image may contribute. The study underscores the importance of clinicians, especially primary care providers, engaging with pediatric patients to address lifestyle choices early and screen for SDOH, food security, and disordered eating.
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  Major Depression Was not Found to be Associated with a Higher Rate of Myocardial Infarction Using a Large Inpatient Database

  Meskal, Sarah; The University of Arizona College of Medicine - Phoenix; Hashemzadeh, Mehrnoosh (The University of Arizona., 2024)

  Importance: In 2014, the American Heart Association issued a statement proposing that depression be recognized as a risk factor for increased mortality from myocardial infarction (MI), but noted further research is needed. However, most studies that concluded this association evaluated depression after the occurrence of heart disease. Objective: To evaluate any association between depression and myocardial infarction using a large inpatient database. Design: Retrospective study using the Nationwide Inpatient Sample (NIS) database in the U.S. from 2005 to 2020. Patients discharged from hospitals using the NIS and ICD-9 and ICD-10 codes consistent with depression and acute MI. IBM SPSS Statistics 25.0 was applied to data. Demographics, clinical details, and hospital features were presented with 95% confidence intervals. Chi-squared and univariate linear regression for trend analysis. Multivariable logistic regression determined odds for binary clinical outcomes considering patient and hospital characteristics, and temporal evolution. Analyses incorporated population discharge weights, with statistical significance set at p ≤ 0.05 Setting: Hospitals that use the NIS database ICD codes. Database is publicly available and is the largest all-payer inpatient care database in the US from the Healthcare Cost and Utilization Project (HCUP). Its data are used to analyze national trends in healthcare utilization, healthcare quality, and patient outcomes. www.hcup-us.ahrq.gov. Participants: Inclusion criteria: adults aged 30 and above (exclusion < 30), discharged from hospitals using the NIS. Included 4,413,113 STEMI (mean age of 67) patients, 224,430 with depression, and 10,421,346 NSTEMI patients (mean age 69), including 437,058 NSTEMI with depression. Exposure: Is depression associated with a higher rate of myocardial infarction (STEMI & Non-STEMI) in adults 30 and over? We hypothesize that there will be a positive correlation between depression and myocardial infarction. Main Outcome and Measure: Primary outcomes: Myocardial Infarction (STEMI and non-STEMI) Results: We did not find any significant association between depression and myocardial infarction. Interestingly MI including STEMI and NSTEMI occurred to a lesser degree in patients with a diagnosis of depression. Our data showed this as a consistent trend over 15 15-year period. For instance, in 2005, within the depression STEMI group, the odds ratio (OR) was 0.12, with a 95% confidence interval (CI) of 0.10-0.15, and a p < 0.001. In 2020, the depression STEMI OR was 0.71, with a 95% CI of 0.69-0.73, and a p < 0.001. A similar pattern was observed within the NSTEMI group. The 2005 NSTEMI depression OR was 0.14, with a 95% CI of 0.13-0.16, p-value < 0.001. In 2020, the NSTEMI depression OR was 0.69, with a 95% CI of 0.68-0.71, p-value < 0.001. Conclusions and Relevance: Our study did not identify an increased association between myocardial infarction and major depression. The results suggest that depression may not independently be a significant risk factor for myocardial infarction. Prospective cohort or intervention studies are necessary to elucidate the cause-and-effect relationships between depression, anxiety, and cardiac events. Future studies should delve into the specifics of depression treatment, including dosages and types of medications, to provide a clearer picture of how these factors influence MI prevalence. The implications are far-reaching, and our findings should serve as a catalyst for a deeper understanding of the complex connections between mental health and heart health.
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  The Prevalence of Abnormal CYP2D6 Phenotypes in those with Treatment Resistant Depression

  Lovell, Kielan; Heise, C. William; Agarwal, Sumit; Hashemzadeh, Mehrtash; The University of Arizona College of Medicine - Phoenix; Heise, C. William (The University of Arizona., 2024)

  Treatment-resistant depression (TRD) affects approximately 30% of patients with depression, and genetic variations in drug-metabolizing enzymes have been implicated in treatment failure. However, the role of abnormal CYP2D6 gene variants in TRD remains unclear. In this retrospective analysis of 356 patients from a large southwestern US hospital system, we investigated the difference in abnormal CYP2D6 variants between those with TRD and those with other depression. The TRD group was defined as patients who had undergone adequate trials of two different antidepressants and whose symptoms persisted beyond the treatment window, required augmentation, or resulted in a suicide attempt. Other Depression was defined as those who had been diagnosed with a depressive disorder, were treated with antidepressants, but did not meet the definition of TRD as reported in their psychiatric treatment record. Our analysis found a significantly greater prevalence of abnormal CYP2D6 variants in those with TRD (47.12%) compared to those with Other Depression (31.51%) (p=.04). These findings suggest that abnormal CYP2D6 variants play a role in anti-depressant failure, increasing the risk of TRD in affected patients. Our study provides further evidence of the complex genetic factors that influence treatment response in depression. Prospective studies are needed to confirm these findings and to explore the clinical implications for patients with TRD. Such studies could include a more specific definition of categories, such as surveys to determine the extent of TRD and confirm depression remission. Ultimately, a better understanding of the genetic basis of TRD could lead to more personalized treatment approaches and improved outcomes for patients with this challenging condition.
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  Etiologies of Iron Deficiency Anemia Secondary to Blood Loss in Children Presenting to a Tertiary Care Setting

  Everly, Cassandra; The University of Arizona College of Medicine - Phoenix; Shah, Sanjay (The University of Arizona., 2024)

  Background: Iron deficiency anemia (IDA) is the most common type of anemia worldwide, affecting more than 6 million individuals. In children, IDA can impair psychomotor and cognitive development. Objective: To highlight trends and unique findings related to the etiologies of iron deficiency anemia secondary to blood loss in children presenting to a tertiary care facility. Method: This was a retrospective chart review study with 91 subjects. Patients were identified using the ICD 10 code D50.0 (iron deficiency anemia secondary to blood loss), and the inclusion criteria were ferritin <15 micrograms/L and hemoglobin <11 g/dL for children 6 months to <5 years and hemoglobin <11.5 g/dL for children 5 to 18 years. Demographic data, baseline and follow up data were collected, and each subject was classified by etiology. Qualitative data were described using frequencies and quantitative data were analyzed using t-tests. Results: HMB was the most common etiology in 53 (58.3%) subjects, followed by bleeding disorders in 21 (23.1%) subjects, IBD in 8 (8.8%) subjects, H. pylori in 5 (5.5%) subjects, non-IBD GI bleeding in 3 (3.3%) subjects, dietary in 2 (2.2%) subjects, other bleeding in 1 (1.1%) subject and unknown in 4 (4.4%) subjects. There was significant improvement with treatment in follow-up labs, including hemoglobin (p<0.001), MVC (p<0.001), ferritin (p<0.001), serum iron (p=0.005) and transferrin saturation (p<0.001), compared to baseline labs. In patients with heavy menstrual bleeding (HMB) with underlying bleeding disorder had statistically inferior improvement in serum iron (p=0.02) and transferrin saturation (p=0.40). 13.2% of the patients with HMB were diagnosed with a bleeding disorder. 33% of patients had an underlying systemic chronic illness such as IBD or a bleeding disorder. Conclusions: Pediatric patients presenting to a tertiary care facility with IDA secondary to blood loss receive effective treatment to address the IDA. Bleeding disorders are likely to be under-diagnosed in patients with HMB. It is important to identify bleeding disorders in patients with HMB, because it less likely for IDA to be resolved with treatment.
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  Menstrual Attitudes and Practices in the Rural Dominican Republic

  Sadhu, Monica; The University of Arizona College of Medicine - Phoenix; Ross, Robin (The University of Arizona., 2022)

  Background: Studies show that negative taboos and ideologies surrounding menstruation are a serious hindrance to managing menstrual hygiene. A 2016 study conducted by Russel et al. in the rural Dominican Republic identified menstruation as a top concern of adolescents, reiterating the need for further research on this topic. Objectives: As leader of UACOM’s Global Health Trip, I designed a menstrual needs assessment survey to improve women’s health care by assessing our patients’ menstrual hygiene practices and access to menstrual resources. Methods: This was a cross-sectional study conducted in the Dominican Republic from 05/25/2019-06/01/2019 using an English/Spanish survey of 15 questions. Data was analyzed through logistic regressions via STATA. Results: 73 participants responded. 80% of participants indicated that they replaced their hygiene products regularly, and 60.3% of participants reported access to affordable products. 40% of participants reported missing school due to their period, and 67.1% of participants reported taking medication for menstrual pain. Participants with access to affordable products were 2.19 times more likely to replace their menstrual products, and participants who had access to clean water were 3.77 times more likely to replace their products. Conclusion: The findings agreed with the current literature that stigma may prevent adolescents from seeking advice about menstruation from parents or teachers, who may also prefer to stay at home rather than be uncomfortable at schools which lack menstrual hygiene facilities. The results were clinically significant and can be used as a needs assessment to guide women’s health care for future medical trips.
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  Hear my Voice: Understanding how community health workers in the Peruvian Amazon expanded their roles to mitigate the impact of the COVID-19 pandemic through Community-Based Participatory Action Research

  Samsamshariat, Tina; Madhivanan, Purnima; Moya, Eva; Meza-Sánchez, Graciela; Reinders, Stefan; Blas, Magaly; The University of Arizona College of Medicine - Phoenix; Madhivanan, Purnima; Blas, Magaly (The University of Arizona., 2023)

  Introduction: The COVID-19 pandemic led to the collapse of the Peruvian health system, which disrupted healthcare access for indigenous communities in the Amazon. We aimed to understand how the COVID-19 pandemic transformed the responsibilities of community health workers (CHWs) from indigenous communities in the Peruvian Amazon so policymakers can support indigenous health efforts. Methods: Fourteen CHWs from Loreto, Peru participated in a community-based Participatory Action Research (CBPR) project using Photovoice, a technique that encourages vulnerable groups to take photos and develop stories illustrating their lived experiences. Participants were recruited from Mamás del Río, a local university-based program, through purposive sampling. CHWs were trained in Photovoice and asked to photograph how the pandemic affected their lives and work. Participants met four times over five months to share photos and develop action items. Data were organized into key themes using a general inductive method. Final photos and action items were shared with policymakers during galleries in Iquitos and Lima. Results: CHWs took a total of 36 photos with 33 accompanying texts highlighting their roles during the pandemic. Four core themes emerged: (1) the collapse of social infrastructure, (2) the use of medicinal plants versus pharmaceuticals, (3) the community adaptations and struggles, and (4) the importance of CHWs. CHWs expanded their responsibilities or leveraged their leadership across these themes to support COVID-19 patients, vaccination, and mandates without training or resources from the government. CHWs asked policymakers for formal integration into the health system, standardization of CHW training, and better management of community pharmacies. Conclusion: CHWs, who work on a voluntary basis, took on additional roles during the pandemic with little to no training from the government. CHWs demonstrated how their roles could be better supported by the government to ameliorate future health catastrophes in the Peruvian Amazon.
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  Rapid and Specific Diagnosis of Astrocytomas with Fluorescent Aptamers

  Farhadi, Dara; The University of Arizona College of Medicine - Phoenix; Nakaji, Peter (The University of Arizona., 2023)

  Introduction Neurosurgical tumor resections are routinely assisted by intraoperative histological assessment of biopsies. However, it is difficult to differentiate, via gross appearance or frozen section analysis, high-grade gliomas from non-operative lesions, such as primary central nervous system lymphoma (PCNSL). Aptamers are an emerging class of polynucleotides that function as “chemical antibodies” with high binding affinity to specific cellular targets. They can identify samples in minutes compared to the typical 24-to-48-hour timeframe via immunohistochemistry (IHC). We have previously developed a PCNSL-specific aptamer and aim to develop a fluorescent aptamer targeting glial fibrillary acid protein (GFAP), a common IHC target for gliomas. Hypothesis: GFAP aptamers can accurately identify glioma cell lines in twenty minutes, a timeframe that can support intraoperative decision-making for best treatment practices. Objective: Develop a GFAP aptamer to utilize as an intraoperative assay to diagnose glioma tumors. Methods Our data was obtained from human glioma cells (U251) and human PCNSL (Ramos) cell lines. We demonstrate a CD20-specific aptamer labeling protocol to rapidly identify Ramos cells and preliminary data which demonstrates a GFAP aptamer’s ability to label U251 cells. Cell lines were cultured with their appropriate mediums and grown at 37C at 5% CO2. Aptamers had AF488 and Cy5 fluorophores for the CD20 (TD05) and GFAP aptamers, respectively. Annealed aptamers were incubated on ice for 20 min, treated with fixation/permeabilization, and tested at different concentrations. For comparison, we ran positive and negative control validation experiments for each aptamer individually and a mixed aptamer assay with analysis of fluorescence via flowcytometry. Results We found a concentration of 400nM or higher of both the TD05 and the GFAP aptamers were highly sensitive and appropriate for labeling Ramos and U251 cells, respectively. When gating baseline fluorescence of non-stained cells, 100% of cells at all aptamer concentrations greater than 400nM showed AF488 fluorescence for Ramos cells stained with TD05 aptamer and Cy5 fluorescence for U251 cells stained with the GFAP aptamer. We unexpectedly found Cy5 fluorescence with 100% of Ramos stained with GFAP aptamers, AF488 fluorescence with 37.3% of U251 stained with TD05 aptamers. With a mixed aptamer assay, we found Cy5 fluorescence in 99.8% of U251 stained with GFAP aptamers and AF488 fluorescence in 97.6% of Ramos stained with TD05 aptamers. We found Cy5 fluorescence in 78.7% of Ramos stained with GFAP aptamers and AF488 fluorescence in 96.7% of U251 stained with TD05 aptamers. Discussion/Conclusion Our current aptamer protocol to label Ramos and U251 cells are highly sensitive in labeling the appropriate cells. However, we found cells which should not be labeled with an aptamer are displaying fluorescence. Such results should not have occurred as CD20 is a surface receptor expressed only on lymphoma cells and GFAP is an intracellular protein only expressed in glioma cells. This could be due to non-specific binding. Thus, future refinement of our staining protocol, and testing different concentrations may reduce false positives. Our results could also potentially be explained by a known phenomenon that Cy5 fluorophore can be taken up in mitochondria. Acknowledgment of Support We would like to acknowledge the Valley Research Partnership for their funding support via a 2021-2022 round 6 grant.
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  The Effect of Language Concordance on Health Care Relationship Trust Scores

  Daggett, Alexandria; Abdollahi, Shaghayegh; Hashemzadeh, Mehrtash; The University of Arizona College of Medicine - Phoenix; Abdollahi, Shaghayegh (The University of Arizona., 2023)

  Objective: To determine if Spanish-speaking patients who receive health care from language concordant providers report higher Health Care Relationship (HCR) Trust scores when compared to professional or ad hoc interpreters. Methods: Prospective survey in Family and Internal Medicine clinics in Phoenix, Arizona administered between October 2020 and February 2021. 214 participants were recruited with 176 surveys completed. The primary outcome was total mean HCR trust score compared among language concordant, professional interpreter, and ad hoc interpreter groups. Results: The mean score (48.73) for the language concordant group was significantly higher than the ad hoc interpreter group (mean 45.53, p = 0.009). The professional interpreter group (mean 48.27) also had higher scores than the ad hoc interpreter group (p = 0.01). Individual questions varied. Conclusions: Patients with language concordant care or professional interpreters demonstrated higher trust in their physician than those who used ad hoc interpreters.
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  Disparities in Regional Anesthesia Application during Inpatient Surgery

  Carlson, Tyler; The University of Arizona College of Medicine - Phoenix; Heise, C. William (The University of Arizona., 2023)

  Abstract: Introduction: The purpose of this study was to determine if there are any factors that affect the utilization rates of regional anesthesia techniques with regards to the inpatient procedures; knee arthroplasty as inpatient, mastectomy, colectomy, and coronary artery bypass graft. Methods: Utilizing the HCUP database for inpatient procedures and hospitalizations, data from 2020 that including ICD10 codes specific for these four procedures as well as those indicative for regional anesthesia were compared against those who did not receive regional anesthesia for the same surgical procedure codes. Data compared patients with a population size of 32,355,827. Data compared between groups included controlling for age, gender, income quartile, and insurance payor. Demographic information included age, gender, race, income quartile (fourth quartile being highest at $86,000+ and first quartile the lowest at $49,999 and below), and payor. Multivariable logistic regression was performed to determine odds of binary clinical outcomes relative to patient and hospital characteristics. All p-values 2-sided and p<0.05 were considered statistically significant. Results: Race based comparisons showed no statistically significant p-value regarding group-to-group odds ratios. There were significant differences for self-pay and private insurance groups when compared to Medicare groups for individuals undergoing colectomy, OR 7.7, 6 (95% CI 1.4-42 and 1.2-29.8 respectively). For mastectomy a similar result was seen with statistically significant OR of 1.4 (95% CI 1.1-1.8). for increased utilization of regional anesthesia for private insurance as compared to Medicare. Additionally in the mastectomy group a significant OR 1.6 was seen for the fourth quartile income zip code individuals as compared to first quartile (95% CI 1.2-2.2). There was also a trend toward significance of decreased regional anesthesia in mastectomy use with the Medicaid group OR 0.7 (95% CI 0.5-1). CABG group comparisons as broken down by zip code income quartile also showed fourth quartile OR of 2.1 (95% CI 1.2-3.8). There was also statistical significance seen in the CABG and mastectomy groups when comparing age with those receiving regional anesthesia being younger; for CABG no regional mean age of 68 as compared to regional mean age 65.7(OR .98 95% CI .97-.99) and mastectomy no regional mean age 70.2 as compared to regional mean age 65 (OR .98 95% CI .97-.99). Conclusion: There is a strong possibility that healthcare is improving equity in treatment across racial groups, but more work needs to be done to continue to investigate other socio-economic disparities and related care applications. This study indicates that those with a higher income quartile and private insurance were more likely to receive regional anesthesia, which often results in faster recovery and return to activity.
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  The Correlation Between Food Insecurity and Type 2 Diabetes Management at a Federally Qualified Health Center

  Yang, Deborah; The University of Arizona College of Medicine - Phoenix; Marvasti, Farshad Fani (The University of Arizona., 2023)

  Type 2 diabetes is a complex, chronic disease that impacts over 34 million Americans. Effective long-term management through medications and lifestyle modifications can be complicated by social determinants of health. Food insecurity is correlated with poor diabetes management and is more prevalent in populations of low socioeconomic backgrounds. The Wesley Community and Health Centers (“Wesley”) is an FQHC that serves many diabetic patients but has not conducted any systematic food insecurity screenings before this year. In response to the COVID-19 pandemic, Wesley implemented a clinic-wide social determinants of health screening of their patients, including a validated 2-item food insecurity screening tool, the Hunger VitalSign™. This project was a retrospective chart review of diabetic patients at Wesley who were screened for food insecurity to determine if there are any correlations between food insecurity status, measured by the Hunger VitalSign™ responses, and glycemic control, measured by A1c levels. Correlation was analyzed by linear regression. The results demonstrated that this population had a similar prevalence of food insecurity as the population of Arizona. The linear regression analysis did not demonstrate any correlations between food insecurity status and A1c in this population, primarily because the final sample size did not reach sufficient statistical power. However, the results cannot rule out the possibility of any correlations, therefore further research is recommended to better characterize the true levels and impacts of food insecurity at Wesley.
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  Understanding the Experiences and Barriers to Care Affecting Families of Children with Autism Spectrum Disorder (ASD)

  Solorio, Abigail; The University of Arizona College of Medicine - Phoenix; Nadesan, Majia (The University of Arizona., 2023)

  The national prevalence of ASD has shown a rising trend in recent years, specifically with a rise in cases diagnosed at younger ages in patients who identify as white, which may be due to progress in detection and increased surveillance in populations. Not all children are benefitting from this optimistic increase in early detection and intervention as ethnic disparities remain and certain minority groups continue to be disproportionately diagnosed at a later age despite similar clinical presentations to age-matched patients from other cultural backgrounds. Early therapeutic interventions are crucial for children to develop appropriate social, emotional and communicative behaviors. Consequently, children who are diagnosed later in life and face greater challenges in accessing treatment may have undesirable developmental outcomes. The purpose of this project is to identify potential sociocultural factors that may contribute to the disparities that exist. Although the factors influencing disparities may be multifactorial, this study focuses specifically on the level of acculturation and social determinants of health as quantitative measures. While also considering perspectives of the diagnostic process from the families of children with ASD reported as qualitative findings. Participants completed a mixed-mode online survey instrument, available in English and Spanish, that investigated potentially problematic barriers influencing delays in diagnosis and limited access to treatment. The goal of this study is to better understand the experiences that families encounter and identify important predictors that a child with ASD will have difficulty in obtaining adequate care.
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  Mobile Application Enhanced Care in Pregnant Women with Opioid Use Disorder

  Oleksak, Mackenzie; The University of Arizona College of Medicine - Phoenix; Manriquez, Maria (The University of Arizona., 2023)

  Abstract: Project title: Mobile Application Enhanced Care in Pregnant Women with Opioid Use Disorder Author names: Maria Manriquez, MD; Mackenzie Oleksak, MS4 Clinical Importance: Opioid using women and prospective children are part of a national crisis of chronic and complex health challenges requiring transdisciplinary skills and coordination. Objective: Evaluate the effectiveness of mobile application to improve treatment engagement and neonatal outcomes. Design: Prospective cohort feasibility study occurring June 2019-March 2020. Setting: BUMCP Women's Institute & MIHS Women's Care Clinic Participant & Control Groups: 33 patients approached by PI or Nurse OUD Care Coordinator on inclusion criteria of age 18-50, pregnant, and receiving treatment for opioid use disorder. Population-based sample of 23 participated. Historical controls via secondary anonymous data on 23 similar patients from a period 180-120 days prior selected via same inclusion criteria after participant data was collected. Intervention: Mobile Application Platform for Pregnant Women with OUD connects participants with their care team via secure messaging, video, and phone modalities. Emphasizes a personalized care plan and educational activities. Main Outcomes and Measures: Formulated prior to data collection. Increased maternal engagement in treatment, measured by OBGYN & MAT appointment attendance rates and decreased relapse occurrences. Improved neonatal outcomes, measured by decreased NOWS occurrences and length of NICU stays. Results: Total 46 patients pregnant receiving treatment for opioid use disorder, 23 control and 23 interventions. No participants withdrawn. Average total number appointments in intervention (16.65, SD 6.09) statistically significantly higher than control (11.13, SD 6.56), p<0.05. Average appointments attended in intervention (15.78, SD 6.19) statistically significantly higher than control (7.65, SD 5.19), p<0.05. Median missed appointments in intervention (0, range 0.00-1.00) statistically significantly lower than control (3, range 1.00-6.00), p<0.05. Significant association (p=0.028) between control/participant and no neonatal withdrawal, participant (82.61%) vs control (52.17%). Conclusions and Relevance: Increased intervention attendance rates show application correlated with positive maternal outcomes regarding increased participant engagement in OBGYN & OUD care. No difference in relapse rates, so cannot conclude association with intervention and mothers maintaining sobriety. Decrease in neonatal withdrawal syndrome but no difference between NICU stay lengths. This pilot study demonstrates the utility of a technology-based care coordination system for pregnant women with OUD and justifies the need for further investigation within more robust experimental and clinical settings.
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  Does the type of medical insurance influence outcome after hip or knee total joint replacement?

  Popescu, Cornel; The University of Arizona College of Medicine - Phoenix; Davidson, James (The University of Arizona., 2022)

  Introduction: The purpose of this study was to determine if Medicaid, Medicare and private patients undergoing primary total knee and hip arthroplasty reported different outcome scores. Methods: From 2014-2016, 1076 patients that underwent a total hip arthroplasty and 1936 patients that underwent a total knee arthroplasty and completed a series KOOS/HOOS patient reported outcomes surveys. Available demographic information included gender, age, BMI and payer status. Baseline (pre-surgery) , 3-month and 1-year post-surgery survey responses were collected utilizing a web-based data collection system and reporting platform. Parametric and non-parametric methods of comparing central tendency measures for the captured responses between the insurance types (Medicare, Medicaid, BCBS, Private) were utilized to determine if significant differences exist. The difference between the baseline (pre-op) of the HOOS and KOOS score was calculated as delta, the difference between baseline and 3 months, baseline and 12 months and 3 months to 12 months. Results: The average overall KOOS and HOOS score at base line (pre-op) was 42.8 (KOOS) and 36.9 (HOOS). The average score at 3 months for KOOS and HOOS was 73.8 and 81.7 respectively. At one year the average score for the KOOS and HOOS was 81.2 and 86.5 respectively. The delta changes for the HOOS score in patients with Medicare at baseline to 3 months, baseline to 12 months and 3 months to 12 months were 45.1, 49.3 and 4.45 respectively. The delta changes for the HOOS score in patients with Medicaid at baseline to 3 months, baseline to 12 months and 3 months to 12 months were 47.7, 42.6 and -0.25 respectively. The delta changes for the HOOS score in patients with BCBS/Manage at baseline to 3 months, baseline to 12 months and 3 months to 12 months were 44.1, 49 and 4.88 respectively. The delta changes for the HOOS score in patients labeled as other/private at baseline to 3 months, baseline to 12 months and 3 months to 12 months were 44.4, 49.7 and 4.81 respectively. The delta changes for the KOOS score in patients with Medicare at baseline to 3 months, baseline to 12 months and 3 months to 12 months were 30.7, 36.7 and 6.03 respectively. The delta changes for the KOOS score in patients with Medicaid at baseline to 3 months, baseline to 12 months and 3 months to 12 months were 26.4, 32.6 and 9.25 respectively. The delta changes for the KOOS score in patients with BCBS/Manage at baseline to 3 months, baseline to 12 months and 3 months to 12 months were 32, 39.4 and 7.79 respectively. The delta changes for the KOOS score in patients with other/private at baseline to 3 months, baseline to 12 months and 3 months to 12 months were 31.3, 39.3 and 7.19 respectively. Conclusion: Overall, the best reported outcome for the HOOS and HOOS was at 1 year, with minimal improvement between the 3 months follow up and 12 month follow up. At one year, there was no significant difference in KOOS/HOOS score for all three payer types. Medicaid and private insurance patients were significantly younger than Medicare patients (p<0.001). There was no significant difference in gender or BMI characteristics. Medicaid payer status was associated with lower improvement in KOOS and HOOS scores at one year post total knee arthroplasty or hip arthroplasty, compared to patients having Medicare or private health insurance. The difference at 3 month or, 3 to 12 months post-surgery was minimal. The data supports performing total knee replacements or hip arthroplasty in the Medicaid population. Additional investigation may shed light on why Medicaid patients demonstrate a slower recovery on patient reported outcome surveys.
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  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.
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  CT Texture Analysis (CTTA): Developing a Diagnostic Imaging Biomarker for KRAS Mutation in Metastatic Colon Cancer

  Khurana, Sukhdeep; The University of Arizona College of Medicine - Phoenix; Silva, Alvin (The University of Arizona., 2021)

  PURPOSE To evaluate multi-parametric modeling on imaging textures from contrast-enhanced, multiphasic computed tomography (CT) for identification of Kirsten rat sarcoma (KRAS) gene mutations in metastatic colon cancer to the liver. METHOD AND MATERIALS This retrospective study included 99 patients diagnosed histologically with colon cancer: 51 KRAS wild-type and 48 KRAS gene mutation. Matched-size regions of interest (ROIs) were drawn over viable tumor and unaffected background liver on multiphase CT. Paired ROIs were spatially rescaled, intensity-normalized, and then analyzed using 3 Texture Algorithms: GLCM, LBP, and Gabor. Feature selection method was based on KNN classifier and DEFS (Differential Evolution-based Feature Selection). For each of the 30 independent experiments, patients were randomly allocated into training (n = 79) and testing (n = 20) datasets to develop predictive models for KRAS gene mutation. Classification models were generated based on: 1) All features; and 2) Selected features as per DEFS. RESULTS Predictive models utilizing all 56 features (13 GLCM, 26 LBP, and 14 Gabor) resulted in an average accuracy/sensitivity/specificity of 61/54/62%; ranging from a single best model (80/80/90%) to a single worst model (35/20/20%). Predictive models utilizing a DEFS optimized 3-feature subset resulted in average accuracy/sensitivity/specificity of 89/80/84%; ranging from a single best model (95/92/96%) to a single worst model (80/68/68%). Among the three texture algorithms, LBP provided better discriminatory power compared to GLCM and Gabor. CONCLUSION Utilizing advanced analytics with machine learning techniques (CTTA and DEFS selection analysis), multi-textural data obtained from conventional, multiphase CT images has the capability to detect a therapeutically relevant genetic aberration (KRAS mutation) in metastatic colon cancer with high accuracy, sensitivity and specificity.
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  A Comprehensive Institutional Overview of Intrathecal Nusinersen Injections for Spinal Muscular Atrophy

  Mousa, Mohammad; The University of Arizona College of Medicine - Phoenix; Towbin, Richard (The University of Arizona., 2021)

  Background: Spinal muscular atrophy (SMA) is an autosomal recessive neuromuscular disorder resulting in progressive muscle weakness. In December 2016, the U.S. Food and Drug Administration approved the first ever treatment for SMA, a drug named nusinersen (Spinraza) which is administered intrathecally. However, many SMA patients have neuromuscular scoliosis and/or spinal instrumentation resulting in challenging intrathecal access. Therefore alternative routes must be considered in these complex patients. Methods: This study was reviewed and approved by our institution’s institutional review board. From March to December 2017, institutional SMA patients were referred for intrathecal nusinersen injections. In select patients with spinal hardware, spinal imaging was requested to facilitate pre-procedure planning. Standard equipment for intrathecal injections was utilized. All patients were followed-up by their referring neurologist. Results: A total of 104 intrathecal nusinersen injections were performed in 26 patients with 100% technical success. 60 procedures were performed without pre-procedural imaging and via standard interspinous technique. The remaining 44 procedures were performed in 11 complex (i.e. neuromuscular scoliosis and/or spinal instrumentation) patients requiring pre-procedural imaging for planning purposes. 19 of 44 complex procedures were performed via standard interspinous technique from L2 to S1. 22 of 44 complex procedures were performed using a neural-foraminal approach from L3 - L5. 3 of 44 complex procedures were performed via cervical puncture technique. There were no immediate or long-term complications but 1 short term complication of meningismus and back pain at the injection site. Conclusion: Although we achieved 100% technical success in intrathecal nusinersen administration, our practice habits evolved during the course of this study. Our early experience has led to the development of an algorithm to assist in promoting safe and effective nusinersen administration in children with Spinal Muscular Atrophy regardless of SMA type, abnormal spinal anatomies and complex spinal instrumentation.

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