Brooklyn Hospital Center Research Articles

Abstract PO4-02-11: Optimizing Taxane-based Chemotherapy in Breast Cancer: Retrospective study comparing 4 cycles of TC to 6 cycles of TC

Abstract Breast cancer remains one of the most prevalent cancers among women worldwide. First-line chemotherapy options include anthracycline (AC-T) and Taxane (TC) based regimens. While anthracycline-based chemotherapy is most commonly used, the use of anthracycline-sparing regimens is also approved. The US Oncology 9735 trial conducted in the mid 2000s showed that four cycles of docetaxel and cyclophosphamide (TC4) were superior to four cycles of Doxorubicin and cyclophosphamide (AC). The follow-up ABC trials compared six cycles of TC(TC6) to AC-T. This trial showed that while AC-T was superior to TC, the difference was modest. AC-T has remained the standard of care, but TC is an acceptable option. One retrospective analysis involving 143 patients showed TC4 was non-inferior to TC6, and suggested that TC4 had fewer adverse events; however, statistical significance was not reached. The question remains whether six cycles of TC is required, or if four cycles is adequate. Methods: Patient information was retrieved from the EMR of a large private oncology group. The EMR was screened for all breast cancer patients who began treatment with TC between 1/1/2011 and 12/31/2021. Patients were required to have continuous follow-up, documented up to at least 6/30/2022. Only patients receiving TC as the first-line setting were included, while patients with metastatic disease were excluded. Adjusted Kaplan Meier curves for overall survival (OS) and disease-free survival (DFS) were generated. A log-rank test was used to determine the statistical difference between the two curves. OS was defined from the date of the last chemotherapy given to death. DFS is defined from the date of the last chemotherapy given to disease recurrence. The Chi-square analysis test of homogeneity was conducted to evaluate the differences in reported symptoms. Statistical analysis was completed with IBM SPSS version 29. Ethical approval was obtained from The Brooklyn Hospital Center Institutional Review Board. Results: A total of 376 charts were reviewed, out of which 224 met the criteria for inclusion. Of these 191 patients received TC4 and 33 received TC6. TC4 patients were noted to be older than TC6 patients. There were a higher percentage of hormone-positive cancers in the TC4 group while the TC6 group had a larger proportion of triple-negative breast cancers. There was a larger proportion of stage III patients that received TC6 than in TC4. TC6 patients were also noted to receive neo-adjuvant chemotherapy at a substantially higher rate. A greater proportion of patients in the TC4 group received breast-conserving surgery, with radiation than the TC6 group. TC6 had a completion rate of 76 % (Table 1). There was a significant difference in DFS noted between TC4 and TC6 (p = 0.016) with TC6 patients having a higher rate of relapse. No difference was noted in the overall survival. No differences were seen in side effects between TC4 and TC6, however, there was a trend toward high rates of neutropenia, anemia, and neuropathy seen in the TC6 group (Table 2). Conclusions: This real-world retrospective study reviewed patients who received TC in a large community oncology practice. The study reaffirms conclusions seen in previous retrospective studies conducted in the academic setting that there is no difference in overall survival when using six cycles of TC compared to four cycles of TC. Slight detriment was seen in the DFS setting when using TC6 however the small sample size along with the larger proportion of patients with stage III disease make it challenging to interpret this finding. There was a trend towards higher toxicities with TC6 that did not reach significance. Until a prospective randomized study comparing four vs six cycles of TC is conducted no definitive conclusions can be drawn, however, this study contributes to the current body of evidence that four cycles of TC is adequate and could potentially improve the quality of life of patients with early breast cancer. Table. Patient characteristics Patient characteristics including age, hormone status, stage, type of surgery, radiation, and treatment setting. Table. Adverse effects Adverse effect information obtained from physician documentation, and CBC reports documented at time of treatment with TC. Citation Format: Amith Ahluwalia, Michelle Koifman, Jaspreet Nannar, Bhavya Vachhani, Kanwal Ashraf, Maxim Shulimovich. Optimizing Taxane-based Chemotherapy in Breast Cancer: Retrospective study comparing 4 cycles of TC to 6 cycles of TC [abstract]. In: Proceedings of the 2023 San Antonio Breast Cancer Symposium; 2023 Dec 5-9; San Antonio, TX. Philadelphia (PA): AACR; Cancer Res 2024;84(9 Suppl):Abstract nr PO4-02-11.

Glycemic Control in Patients Living With HIV Initiated on Integrase Inhibitor-Based Three-Drug Antiretroviral Therapy.

Background: The increased risk of cardio-metabolic disorders associated with people living with human immunodeficiency virus (HIV) is of growing importance. Given the broad adoption of integrase strand-transfer inhibitor (INSTI)-based antiretroviral therapy (ART) as first-line therapy for HIV, additional data are needed regarding the metabolic effects of these regimens. Objective: The purpose of this study is to assess glycemic control in patients started on INSTI-based 3-drug regimens over a 2-year period. Methods: A retrospective study was conducted on patients seen in the Brooklyn Hospital Center. Men and nonpregnant, nonlactating women aged 18 years or older with a diagnosis of HIV who were initiated on or switched to an ART consisting of 2 nucleoside reverse transcriptase inhibitors (NRTIs) plus an INSTI were included in the analysis. The primary endpoint is change in A1C from baseline (pre-INSTI initiation) to 2 years after initiation. Results: Two hundred fifty-one patients were eligible based on specified inclusion and exclusion criteria. Overall, a statistically significant increase in A1C was seen in all patients started on INSTI-based regimen (95% CI, 0.10-0.36; P < 0.001). Primarily patients on both elvitegravir-based and bictegravir-based regimens saw the most significant increase in A1C: 0.16% (95% CI, 0.04-0.27; P = 0.006) and 0.39% (95% CI, 0.02-0.76; P = 0.038), respectively. Conclusion and Relevance: Integrase strand-transfer inhibitor-based 3-drug ART was associated with a small but statistically significant increase in A1C over a 2-year period, requiring additional monitoring by clinicians.

S1222 Appropriate Use of Ascitic Fluid Studies Among Inpatients With Ascites: A Quality Improvement Project

Introduction: Ascites is the most common decompensating event in cirrhosis. Paracentesis is recommended in all patients with new-onset ascites, all patients admitted with ascites and all patients with ascites and signs or symptoms of infection. Standard of care tests from ascitic fluid include cell count with differential, total protein, albumin, and culture. In a limited number of patients, glucose, lactate dehydrogenase, cytology, amylase, pH, and bilirubin will be helpful. However, in clinical practice, a battery of ascitic fluid studies are commonly ordered. Many of these tests have no clinical impact and do not help guide management. Our initiative was to educate the residents enrolled in the internal medicine training program at The Brooklyn Hospital Center on appropriateness of ascitic fluid testing in patients admitted with ascites and improve the testing practices. Methods: We provided an educational session focused on most recent guidelines on ascitic fluid tests to the residents enrolled in the internal medicine training program at The Brooklyn Hospital Center. Participants included residents first through third year of residency training. The educational session focused on appropriate use of ascitic fluid testing based on the most recent American Association for the Study of Liver Diseases (AASLD) guidelines. All participants completed a questionnaire testing the participant’s knowledge on appropriate use of ascitic fluid tests before and after the educational session. Results: Our results portray a significant improvement in the participants' understanding of the appropriate use of ascitic fluid tests after the educational session (Figure). In the questionnaire completed before the educational session, post-graduate year 3 (PGY-3) participants scored the highest followed by PGY-2 and PGY-1 participants. After the educational session, there was increase in scores from all three category of participants with the highest improvement in the PGY-1 class (38.52%), followed by PGY-2 (29.32%) and PGY-3 participants (26.47%) (Table). Conclusion: Ordering physician’s knowledge and education plays a key role in relevant use of ascitic fluid testing. Our study has demonstrated improved understanding of the appropriate use of ascitic fluid tests after our educational session. As a follow up, we plan on performing a retrospective chart review and post-intervention (post-educational session) chart review to monitor for improvement in the appropriate use of ascitic fluid testing.Figure 1.: Results of Pre-Didactic and Post-Didactic Tests of all Classes Table 1. - Results of Pre-Didactic and Post-Didactic Tests of all Classes Class Pre-Didactic Test Result Average Post-Didactic Test Result Average PGY-1 52.08% 90.60% PGY-2 58.33% 87.65% PGY-3 64.44% 90.91%

Narcotic use and pain control after cesarean section

Opioid use and dependence have markedly increased in recent years which has led to an opioid epidemic. Various factors that have contributed to this crisis, one being the over prescription of opioid medication to post-surgery patients. In the United States cesarean section deliveries accounted for 31.8% of all births in 2020. Therefore, it is necessary to evaluate pain control and narcotic use in the postpartum period. Most studies on postpartum pain control focus primarily on the immediate inpatient postoperative period. This study investigates pain control and Percocet use in the 3-day post-discharge period of women who underwent Cesarean delivery at The Brooklyn Hospital Center (TBHC) from January to June 2021. This study evaluated 100 women; the data shows that patients took on average 4 out of 36 Percocet pills; only 11% of the total prescribed dose. Additional factors were taken into consideration including pain scale up to 3 days post-discharge, pain management alternatives, home childcare, family size, and prior opioid use. This study concludes that post cesarean delivery patients were overprescribed narcotics upon discharge from the hospital. Considerations should be made for smaller doses, spaced-out hourly doses, and shorter interval of days. Patients should be advised that if additional pain medication is required to contact their provider and be educated on the importance of properly disposing unused opioid medications.

Serological response with Heplisav-B® in prior Hepatitis B vaccine non-responders living with HIV

BackgroundAs people living with HIV (PLWH) are at risk for contracting Hepatitis B Virus (HBV), they should be screened for HBV and vaccinated if not immune. Seroconversion rates in PLWH receiving traditional recombinant HBV vaccines (Engerix-B® and Recombivax-HB®) have historically been low with at most 70% achieving immunity. In 2017, a recombinant, adjuvanted HBV vaccine (Heplisav-B®) was approved for use in HIV-negative patients.Heplisav-B® has shown superior seroprotection in this population compared to Engerix-B® and Recombivax-HB®, as well as interim analysis showing higher seropositivity rates in patients undergoing dialysis. However, its efficacy in PLWH is currently unknown. This study evaluates the rate of seroconversion following Heplisav-B® administration in PLWH with previous HBV vaccination failure. MethodsRetrospective, cross-sectional study at The Brooklyn Hospital Center’s HIV primary care clinic in Brooklyn, NY. HIV-positive adults who received at least two doses of Heplisav-B® and had previously failed to seroconvert after vaccination with Engerix-B® or Recombivax-HB® were included. The primary outcome is the percentage of PLWH who became seropositive following Heplisav-B®. ResultsA total of 67 patients met the inclusion criteria. Twenty-five (37.3%) PLWH had failed at least 2 courses of recombinant vaccines. Fifty-eight (86.6%) PLWH became seropositive (Anti-HBs > 10 mIU/mL) at least two months after completing Heplisav-B®. For the 9 (13.4%) patients that did not develop immunity, 3 (33%) had a detectable HIV RNA and 3 (33%) had a CD4 count < 200 cells/uL3. ConclusionsHeplisav-B® was highly effective in achieving immunity to HBV in PLWH who failed non-adjuvanted recombinant vaccines.

Studies Detail Heart Risks for Firefighters

Studies Detail Heart Risks for Firefighters

The Psychological Impact of COVID-19 on Hospital Trainees in a New York City Hospital

PurposeOn January 7, 2020, China reported a group of cases of pneumonia caused by the novel coronavirus 2019 (COVID-19). This novel virus spread rapidly to other countries. As of August 2020, there are close to 6 million diagnosed cases in the United States and 460,000 diagnosed cases in New York State. The purpose of this article is to examine the psychological impact of the COVID-19 outbreak on trainees in a New York City hospital. To achieve this goal, trainees of the Brooklyn Hospital Center were sent a questionnaire via e-mail. The questionnaire asked about the residents’ demographic characteristics, health information, and self-report questions regarding anxiety, depression, and PTSD (posttraumatic stress disorder).MethodsParticipants were trainees at the Brooklyn Hospital Center from the OMFS (oral and maxillofacial surgery), general dentistry, and other medical departments. A 3-part survey including demographic information, a PHQ-9 (Patient Health Questionnaire-9), and an impact of events score revised (IES-R) questionnaire was obtained. Descriptive analysis assessed participant demographic characteristics and mean scores on questionnaires. Additionally, independent samples t-test was used to determine statistical difference in mean scores on PHQ-9 and IES-R questionnaires between dental (OMFS and general dentistry) and medical specialties. Bivariate correlation was used to assess the relationship between scores on the PHQ-9 and IES-R questionnaires. Level of significance was accepted at .05.ResultsThe mean score on the PHQ-9 questionnaire was significantly higher for dental compared to medical specialties (18.9 vs 7.24, P < .001). Likewise, for the IES-R questionnaire, the dental group scored significantly higher than the medical group (61.9 vs 30.36, P < .001). Furthermore, depression severity was much worse for the dental group: 7 (33.3% vs 8.9% medical, P < .001) were classified as severe and 12 (57.1% vs 8.9% medical, P = .013) were moderately severe.ConclusionCurrently, trainees are facing enormous isolation, burnout, and fear of contracting and transmitting COVID-19.1 Trainees are also facing concerns about inadequate training (clinical and didactic). Previous literature has demonstrated that one's physical location and holding an intermediate title during a pandemic were associated with severe depression, distress, and anxiety.2-4 The participants of our study were trainees from the oral and maxillofacial surgery, general dentistry, and other medical specialty departments. The trainees from the dental department scored significantly higher on the IES-R and PHQ-9 questionnaires. Many participants had graduated from dental school less than a year ago. Additionally, this study was conducted in New York, which was the epicenter to the pandemic for a period of time. Being aware of the impact of the coronavirus on health care workers is an important step in providing intervention. This intervention may prevent the anxiety, depression, and PTSD seen after previous pandemics.

Outpatient management of chronic warfarin therapy at a pharmacist-run anticoagulation clinic during the COVID-19 pandemic.

As a result of infection control regulations during the coronavirus disease 2019 (COVID-19) pandemic, anticoagulation clinics have been required to adjust their practices in order to continue providing safe and effective services for their patients. In accordance with a guidance document issued by the Anticoagulation Forum, The Brooklyn Hospital Center (TBHC) anticoagulation clinic in Brooklyn, New York implemented measures including telemedicine follow-ups instead of in-person clinic visits, extending the interval of INR testing, and reviewing eligible candidates for transition from warfarin to direct oral anticoagulants. This study describes the outcomes of one hospital-based clinic location in the 3 months before and after COVID-19 became a significant concern in the New York City area. The primary outcome of time-in-therapeutic range (TTR) for patients receiving warfarin was 60.6 % and 65.8 % in the pre-COVID and post-COVID groups, respectively (p = 0.21). For secondary outcomes, there was no difference in percent of therapeutic INRs (51.5 % pre-COVID v. 44.8 % post-COVID, p = 0.75) or percent of INRs ≥ 4.5 (2.3 % pre-COVID v. 4 % post-COVID, p = 0.27). Based on the data reported in this study, the short-term changes implemented at TBHC’s anticoagulation clinic did not appear to cause reductions in safety and efficacy of chronic warfarin therapy management.

Risk factors for mortality in COVID-19 patients in a community teaching hospital.

As of December 2020, there were over 450,000 confirmed coronavirus disease 2019 (COVID‐19) cases in New York City (NYC) with approximately 25,000 deaths. Previous literature identified advanced age, higher severity of illness, elevated inflammatory biomarkers, acute organ dysfunction, comorbidities, and presentation from long‐term care facility as risk factors for mortality in patients from Wuhan, China, and the United States. Additional studies conducted in NYC are warranted to confirm these findings. The objective of this study was to assess the risk factors for in‐hospital mortality in patients with confirmed COVID‐19 infections. This was a retrospective case‐control study at The Brooklyn Hospital Center, a 464‐bed community teaching hospital. Adult patients with a confirmed COVID‐19 infection and who received at least 24 h of COVID‐19 therapy were included. Univariate and multivariate logistic regression analyses were conducted to identify the risk factors for in‐hospital mortality. Two‐hundred and eighty four patients were included, of whom 95 (33.5%) were nonsurvivors and 189 (66.5%) patients were survivors. Multivariate analysis showed higher in‐hospital mortality with advanced age (odds ratio [OR] 6.476; 95% confidence interval [CI], 1.827–22.953), presentation from long‐term care facility (OR 4.259; 95% CI 1.481–12.250), elevated total bilirubin (OR 4.947; 95% CI 1.048–23.350), vasopressor initiation (OR 36.262; 95% CI 5.319–247.216), and development of renal failure (OR 36.261; 95% CI 2.667–493.046). Risk factors associated with mortality for patients with COVID‐19 in a community teaching hospital included advanced age, vasopressor initiation, development of renal failure, elevated total bilirubin, and presentation from long‐term care facility.

399. Risk Factors for Mortality in COVID-19 Patients in a Community Teaching Hospital

BackgroundAs of May 2020, there were over 190,000 confirmed COVID-19 cases in New York City (NYC) with approximately 13,000 deaths. Previously published literature identified risk factors (advanced age, higher severity of illness and elevated d-dimer) for mortality in a cohort of patients from Wuhan, China and mechanical ventilation in a case series from NYC. Another case series from NYC evaluated clinical outcomes only. There are limited published studies assessing clinical characteristics, outcomes and risk factors for mortality in COVID-19 patients in NYC. The objective of this study was to assess the risk factors for mortality in patients with confirmed COVID-19 infections.MethodsThis study was a single center retrospective case-control at The Brooklyn Hospital Center, a 464-bed community teaching hospital. Adult patients with confirmed COVID-19 infection, who received at least 24 hours of COVID-19 therapy were included. Endpoints assessed were risk factors for mortality in COVID-19 patients, increase in QTc, renal failure or renal replacement therapy, ventricular fibrillation or ventricular tachycardia. Baseline characteristics between survivor and non-survivors were analyzed utilizing Mann-Whitney U test/two-tailed t-tests for continuous data and Chi-square/Fisher’s exact test for categorical data. Univariable and multivariable logistic regression analyses were conducted to identify the risk factors for in-hospital mortality.ResultsTwo-hundred and eighty six patients were included in this analysis, of whom 97 (33.9%) were non-survivors and 189 (66.1%) patients were survivors. Diabetes and coronary artery disease were more common in non-survivors compared to survivors (p = 0.003 and p < 0.001, respectively). Multivariable logistic regression showed higher in-hospital mortality in patients with advanced age (odds ratio 5.779, 95 % confidence interval 1.369–24.407), vasopressor initiation (OR 28.301, 95 % CI 3.307–242.176), and development of renal failure (OR 30.927, 95 % CI 1.871–511.201).ConclusionRisk factors associated with mortality for COVID-19 patients in a community teaching hospital include advanced age, vasopressor therapy, and development of renal failure.Disclosures All Authors: No reported disclosures

AHA telemetry guidelines improve telemetry utilization in the inpatient setting.

Overuse of telemetry among hospitalized patients results in poor patient care and wasted health care dollars. Guidelines addressing telemetry use have been developed by the American Heart Association (AHA) and are effective when applied to specific clinical practices and high-value care. The purpose of our intervention was to facilitate more effective utilization of telemetry in our hospital. We aimed to reduce patient days on telemetry through use of AHA guideline criteria for telemetry. We used Plan-Do-Study-Act cycles with chart review for pre- and postintervention measurement collection. We included patients hospitalized at The Brooklyn Hospital Center on inpatient general medical wards from January 1, 2017, through July 31, 2018. The intervention consisted of a standard process of reviewing patients on telemetry based on AHA guidelines, educating teams on the guidelines, and changes to telemetry order sets. The primary outcome measured was the total number of days that patients remained on telemetry. Secondary measures included the daily number of telemetry downgrades and total number of patients on telemetry. Diagnosis-related group and case mix index were also noted. Patient average days on telemetry changed from 7.20 days preintervention to 3.51 days post intervention (P < .0001). The number of patients on telemetry with a diagnosis meeting AHA guidelines for telemetry increased. The stated intervention resulted in more effective use of telemetry, evidenced by fewer patient days on telemetry and increased numbers of patients on telemetry meeting AHA guidelines for telemetry.

Characterization of Critically Ill COVID-19 Patients at a Brooklyn Safety-Net Hospital.

BackgroundThe novel coronavirus disease 2019 (COVID-19) pandemic continues to spread across the country with over 3 million cases and 150,000 deaths in the United States as of July 2020. Outcomes have been poor, with reported admission rates to the intensive care team of 5% in China and mortality among critically ill patients of 50% in Seattle. Here we explore the disease characteristics in a Brooklyn safety-net hospital affected by the severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2) pandemic.MethodsA retrospective chart review of COVID-19 positive patients at The Brooklyn Hospital Center who were treated by the intensive care team prior to April 20, 2020. Data was extracted from the electronic health record, analyzed and correlated for outcome.ResultsImpact of various clinical treatments was assessed, showing no change in median overall survival (OS) of both hydroxychloroquine with azithromycin or vitamin C with zinc. Supplemental therapies were used in selected patients, and some were shown to increase median OS and patients requiring vasopressor support or invasive mechanical ventilation showed decreased OS. There was no statistically significant difference in overall survival based on ethnicity, healthcare status, or individual medical comorbidities, although a negative trend exists for diabetes. Despite this, there is a trend towards increasingly poor prognosis based on the number of comorbidities and Class 3 obesity. ConclusionsDespite the fact that we show no significant differences in mortality based on ethnicity, insurance status, or individual medical comorbidities, we show a high overall mortality. There is also a trend towards increased overall mortality in Class 3 obesity, which should be further investigated. We suggest that these findings may be attributed to both socioeconomic factors and an increased incidence of total medical comorbidities in our patient population.

Can We Use Non Invasive Prenatal Testing to Determine Adverse Obstetrics Outcomes? [07K

INTRODUCTION: The purpose of this study was to determine if an increased fetal fraction of cell free DNA (cfDNA) in maternal plasma collected during first and second trimester aneuploidy screening is predictive of adverse obstetric complications related to placental dysfunction including preeclampsia, IUGR, preterm birth, PIH and GDM. Therefore possibly implementing early interventions which may reduce the mortality and morbidity associated. METHODS: Retrospective study on women with singleton pregnancies who underwent first/second trimester noninvasive Prenatal Testing between 2017 and 2019 at Brooklyn Hospital Center. The fetal fraction of each sample, gestational age and maternal weight was obtained. EMR was used to obtain maternal characteristics/obstetric records such as age, BMI, ethnicity, parity, significant past medical history, social history, antepartum course and gestational age at delivery. Obstetric complications, if any, were identified. Data was transcribed to Microsoft Excel, eliminating any definitive patient identifiers to maintain confidentiality during analysis. Statistical analysis utilized descriptive statistics, the Students t-test for equality of means and linear regression. Probability outcomes &lt;0.05, were statistically significant. RESULTS: Patients with preeclampsia had a mean CfDNA fetal fraction of 8.86% +3% which was statistically significant (P=.040) as compared to 11.61% + 5% for the non-preeclampsia group. The BHCG from sequential part 1 was higher in the preeclampsia group (P&lt;.05). CONCLUSION: Our results indicated fetal fraction and BHCG (from Sequential Part 1) are predictive of preeclampsia. No other obstetric complications correlated to fetal fraction CfDNA. However there was a narrow sample size of obstetric complications and complete serum marker profiles for sequential screens.

SEPTIC SHOCK OUTCOMES IN ELDERLY CRITICALLY ILL PATIENTS

SESSION TITLE: Tuesday Abstract Posters SESSION TYPE: Original Investigation Posters PRESENTED ON: 10/22/2019 01:00 PM - 02:00 PM PURPOSE: Sepsis is a common cause of admission to the ICU and is considered a major cause of morbidity and mortality. Among all ICU admissions, elderly patients contribute a high percentage of admissions. Very few studies have explored outcomes and mortality rates among the elderly population with sepsis. This study is designed to answer the question if age is an independent risk factor for mortality, ICU and hospital length of stay(LOS), use and duration of mechanical ventilation(MV), and discharge outcome in critically ill, elderly patients that present to the ICU. METHODS: A retrospective, observational chart review of all patients ≥65 years admitted to the ICU from 01/01/2017 to 12/31/2017 at The Brooklyn Hospital Center was conducted. We collected demographics, BMI, admission diagnosis, comorbidities, vasopressor use, steroid use, and APACHE II score at the time of ICU presentation. Patients with non-septic shock diagnosis were excluded from the study. In-hospital mortality was the primary outcome. ICU and hospital LOS, need and duration of MV, vasopressor requirement and discharge outcomes were secondary outcomes of the study. RESULTS: Out of 595 elderly ICU admissions, 173 presented with septic shock. The average age for septic patients was 79.40 years and average BMI was 25.9 kg/m2. The mean APACHE II score was 26, average ICU LOS and hospital LOS was 7.25 and 15.26 days respectively. Out of 173 patients, 50.29 % developed acute respiratory failure with 30.06% requiring MV for average of 8.1 days, 68.79% required Vasopressors, overall mortality rate was 30.64%. Logistic regression showed that age was not a significant independent risk factor for mortality (OR, 1.029; 95% CI, 0.988-1.071) in septic patients admitted to the ICU. Age was also not a significant risk factor for ICU and hospital LOS, MV use and duration, and vasopressor requirement. Among all survivors, 23.97% were discharged home, 41.32% to Nursing home, 22.31 % were placed in hospice and 12.4% had tracheostomy/PEG tube placement. Logistic regression also showed that age was a significant factor in discharge outcome in that older patients were less likely to be discharged home (OR, 1.059; 95% CI, 1.003-1.120). CONCLUSIONS: Our study showed that among elderly septic survivors, less than 24% were discharged home with a worsening trend as pts get older. This study demonstrated that advanced age among critically ill patients with septic shock is not a risk factor for mortality, need for MV and vasopressor requirement but is a significant contributor to morbidity. CLINICAL IMPLICATIONS: Advanced age among critically ill patients with septic shock contributes to increased morbidity and poorer discharge outcome. DISCLOSURES: No relevant relationships by Mona Alipour, source=Web Response No relevant relationships by Khoi Paul Dang-Ho, source=Web Response No relevant relationships by Louis Gerolemou, source=Web Response No relevant relationships by Nabil Mesiha, source=Web Response

2840 The Association of Polish Ethnicity and Polyp Risk on Screening Colonoscopy in a Local Brooklyn Population

INTRODUCTION: The Brooklyn Hospital Center (TBHC) serves an ethnically diverse community with a large Polish immigrant population. There was a perceived increased quantity of polyps in our Polish patients. Multiple adenomas, larger sized adenomas, and adenomas with advanced histology on index colonoscopy are associated with increased risk for colorectal cancer (CRC). Studies in African Americans demonstrated higher incidence of CRC and mortality compared to whites suggesting different ethnic groups may be at increased risk for CRC. The goal of our study is to see if the Polish population is at increased risk for adenomatous polyps, large polyps(≥1 cm), multiple adenomas(≥3), or advanced adenomas(tubulovillous, villous, or high grade dysplasia) when compared to the non-Polish white population. METHODS: A retrospective chart review was performed from 1/2012 to 10/2018. Inclusion criteria were patients ≥50 years of age undergoing screening colonoscopy. Exclusion criteria consisted of an incomplete exam, personal or family history of CRC, or indication other than screening. Polish and non-Polish whites were identified by demographic data. 121 Polish patients were matched to 121 non-Polish white patients by gender and age. High-risk patients were those having large, multiple or advanced adenomas. Statistical analysis utilized student’s 2 sample t-test for P-values, with an alpha level of 0.05, and odds ratios (OR) with 95% confidence intervals (CI). RESULTS: Each arm consisted of 56 men (46%) and 65 women (54%) with an average age of 64.3 years in both. There was a statistically significant difference between the number of high-risk Polish vs. non-Polish white patients (OR 1.95, 95% CI: 1.07-3.53; P = 0.026). Although not statistically significant, Polish patients had an increased prevalence of total polyps (OR 1.22, 95% CI: 0.73-2.0; P = 0.23), large polyps (OR 1.69, 95% CI:0.88-3.22; P = 0.10), adenomas (OR 1.38, 95% CI: 0.81-2.32; P = 0.23), multiple adenomas (OR 1.63, 95% CI: 0.60-4.35; P = 0.33), and advanced adenomas (OR 1.85, 95% CI: 0.74-4.58; P = 0.18). We also found 2 cases of CRC in the Polish group and no cases in the non-Polish group (P = 0.15). CONCLUSION: These results show a statistically significant difference in the number of high-risk Polish vs. non-Polish white patients with an increase rate of CRC in the Polish group although not statistically significant. These findings warrant larger population based studies to further investigate the benefit of earlier screening for these patients similar to African Americans.

Hypercoagulable workup in a community hospital setting: to test or not to test; that is the question

ABSTRACTBackground: Thrombophilia tests are often ordered unnecessarily and/or inappropriately, with significant impact on healthcare costs, hospital resources, time, and potential harm to the patient.Objective: To identify the incidence of unnecessary and inappropriate thrombophilia testing in a community hospital setting.Methods: We retrospectively reviewed electronic medical records for patients who underwent inpatient thrombophilia testing at The Brooklyn Hospital Center from 1/1/2018 to 12/31/2018. The indications, and details of the tests, and associated costs were recorded.Results: A total of 62 patients were included (mean age 45.8, 67.7% female). In 57/62 (91.9%) patients, tests were ordered in the acute phase of thrombosis. At the time the tests were ordered, 29/62 (46.8%) patients were on anticoagulation. Positive results were found in 21/62 (53.2%) patients, but was repeated in only 1/21 (4.7%) patient. Results for 51/62 (82%) patients were obtained after discharge. The hematology-oncology service was consulted in 5/62 (8.1%) cases and recommended testing in only 1 (1.6%) patient. Only 1 (1.6%) patient had both an appropriate indication and appropriate testing. Costs for the 273 total tests were $26,400.Conclusion: Thrombophilia tests were often ordered inappropriately and unnecessarily. We recommend testing only for patients with inpatient status under recommendation from the hematology-oncology service.

32. IMPROVING EFFICIENCY OF AUTISM SCREENING

Background Autism is a neurodevelopmental disability appearing before age 3. Children with autism have difficulties in verbal and non-verbal communication, social interaction and play activities. M-CHAT is a 20-question parental survey about a child's social, verbal and emotional development. It is easy to use and validated in primary care settings with 85% sensitivity and 93% specificity. The AAP recommends that all children be screened for autism at ages 18 and 24 months, along with regular developmental surveillance. In Children's Health Center of The Brooklyn Hospital Center, we use Office Practicum with an automated scoring system of M-CHAT. Residents ask 20 questions during the encounter and document answers in the EMR as routine practice at 18 and 24 months visits. We propose a different approach using an M-CHAT paper form to be filled out by the parent before the encounter to improve efficiency of autism screening in a busy primary care clinic. Aim To decrease M-CHAT screening time by 50% and achieve a 100% completion rate at 18 and 24 months visits by May 2018 Interventions PDSA cycle I: Residents ask parent to fill out M-CHAT before the encounter of 18 and 24 months visits. Residents review the answers and input them into the EMR with automated scoring system. Residents address any concerns parent might have. PDSA cycle II: M-CHAT handout is available in front desk with multiple language versions. Educate the front desk staff to distribute M-CHAT to parent at 18 or 24 months well child visit after registration. Measures Autism screen time using M-CHAT-R; Completion rate of documented M-CHAT in EMR at 18 and 24 months visit Results During PDSA cycle I, a significant reduction of autism screen time was noted, with the median time being 1 minute compared to 4.5 minutes without intervention. There were 2 patients with a positive screen result and the screen times were 5 and 10 minutes respectively, which we excluded from data. The average time spent in M-CHAT assessment with negative screen result continued to be 1 minute in PDSA cycle II. In the pre-intervention study from October to December 2017, the documented M-CHAT completion rate was 80% at 18 months visits and 78% at 24 months visits. In January 2018 (PDSA cycle I), the M-CHAT completion rate increased to 100% at 18 months visits and 94.7% at 24 months visits. In PDSA cycle II, the M-CHAT completion rate was 94.6% at 18 months visits and 90% at 24 months visits. Yet, the rate of M-CHAT distribution by front desk staff was 64.5%. Conclusions and Next Steps This quality improvement study demonstrated significant reduction of autism screening time and improvement of workflow, and positive changes in completion of the M-CHAT documented on 18 and 24 months well child visits. Our intervention process excluded child with positive screens due to additional discussion regarding proper follow-up and referral. Use of the M-CHAT handout before the encounter markedly increased efficiency of autism screening, yet adaption to this practice among clinic staff likely contributed to the incompletion rate in quality metrics. Overall, we found the use of M-CHAT paper forms before the encounter helped residents incorporate information faster and assess the risk for autism more efficiently. As a result of this study, the practice leadership decided to continue using the processes introduced in this intervention.

Trends in Epidemiology: Analysis of Risk Factors and Outcomes of Infective Endocarditis: A Retrospective Study (2009-2015).

BackgroundDespite advanced diagnosis and treatment, infective endocarditis (IE) is a potentially life-threatening condition. Although recent studies have provided evidence of changing trends in IE epidemiology, few studies examine patterns within urban minority populations. Here we present the epidemiology, risk factors, and outcomes of IE among an underserved African American population in Brooklyn, New York, compared to the general population.MethodsThis is a retrospective study which included 67 patients with IE diagnosed at The Brooklyn Hospital Center from 2009 to 2015. Patients were selected according to the modified Duke Criteria for definite IE. Various epidemiological parameters were examined via chi-square and Fisher’s exact test using SPSS 24 software (IBM Corp., Armonk, NY).ResultsThe mean age of the 67 patients was 63 years and 46.3% of the patients were men. The majority of patients (70.1%) were African American while Hispanics and Caucasians were 17.9% and 7.5%, respectively. Healthcare-associated IE (58.2%, n=39) outnumbered community-acquired IE (41.8%, n=28). The sites of vegetation were the mitral valve (62.7%, n=42), tricuspid valve (22.4%, n=15), aortic valve (11.9%, n=8), and intravenous catheter (3%, n=2). In valves, 13.4% of the cases were found in prosthetic valves while the majority occurred in native valves. The most common pathogens of IE were the Staphylococcus (50.8%, n=34) species, followed by Streptococcus species (32.8%, n=22). Overall, the in-hospital mortality was 38.8% (n=26) with higher mortality observed for healthcare-associated IE than community-acquired IE (P = .049). Embolic complications were associated with significant mortality (P < .001).ConclusionOur study demonstrated that the common causative pathogens for IE among African Americans trends towards Staphylococcus species followed by Streptococcus species, similar to the contemporary epidemiology of IE. Healthcare-associated IE outnumbered community-acquired IE and was associated with higher mortality. Embolic complications were significantly associated with high mortality. Therefore, efforts made to control healthcare-associated infections are expected to decrease the trend of IE.

Prescriber Attitudes Toward Implementation of Pharmacogenomic Testing in a Family Medicine Residency Program.

Few qualitative studies have explored the attitude of prescribers towards the implementation of pharmacogenomic testing in the family medicine (FM) setting, and none among FM residents. The purpose of this study was to describe the level of engagement and interest in the implementation of pharmacogenomic education and testing in an FM clinic within a residency program. A qualitative study utilizing semistructured interviews was conducted among prescribers within the FM clinic at The Brooklyn Hospital Center (TBHC). Voluntary prescribers included FM residents and attendings. No prescribers were excluded. Prior to the interview, informational sheets about pharmacogenomics were provided to standardize participant knowledge base. The research team created an interview guide of specific open-ended questions. Interviews were audio recorded and transcribed until a point of saturation was achieved. Transcripts of interviews served as data for analysis. Coding and analysis were performed to develop a hypothesis. No formal statistical analysis was required. Of the total 28 providers eligible for participation, 15 were recruited and interviewed (53% response rate). Based on analysis of interview data, four key conceptual concerns emerged regarding benefits and risks of testing, feasibility, accessibility, and modification of FM residency training curricula. Positive attitudes and perceptions provide support for pharmacogenomic education and testing to be incorporated into FM residency curricula. Addressing practical barriers, such as curricular education and training, will allow for expansion of such initiatives in the future.

Hepatocellular Carcinoma Screening in Patients Co-Infected With Human Immunodeficiency Virus and Hepatitis B: A Phase 1 Quality Assessment Report

Introduction: In the US, about 5% to 10% of people diagnosed with HIV also have chronic HBV infection. Patients coinfected with HIV and HBV have a higher rate of progressing to liver cirrhosis, endstage liver disease, or hepatocellular carcinoma compared to individuals mono-infected. Furthermore, coinfected patients are also at higher risk for morbidity and mortality [1]. Given our current therapeutic armamentarium, neither can fully be eradicated. This is particularly due to the development of antiviral drug resistance after patients have received treatment for some time and followed by the loss of clinical efficacy. Coinfection by these two viruses leads to poor clinical outcomes and intensifies their negative effects. The goal of this study is to determine whether or not patients at The Brooklyn Hospital Center who are coinfected with HIV and HBV are being adequately screened for hepatocellular carcinoma. Determining the screening status of our patients will enable us to tailor intervention programs to improve screening and management practices of patients coinfected with these two viruses. Methods: A total of 43 patients were identified in a retrospective charts review from 2015 to 2018 who were co-infected with HIV and HBV and fit the inclusion criteria of our study. The screening criteria for adequate screening was abdominal ultrasound every 6 months from the time of diagnoses of HIV and HBV. Descriptive statistics were used to compare contiguous and categorical variables. Results: Out of the 43 patients included in our chart review, about 70% (n=30) of patients identified were male. Average basic metabolic index was 31.5. The majority (n=31) were Black, followed by Caucasian (n=8) and Hispanic (n=3). Median age was 50.5 ± 12 years. All patients did not have a family history of hepatocellular carcinoma. The average CD4 count was 498.9 Units. 3 patients were diagnosed with liver cirrhosis. The majority of patients (79%, n=34) were never screened for hepatocellular carcinoma via ultrasound or were only screened once after initial diagnosis. Conclusion: Phase 1 of our quality assessment has revealed that co-infected with HIV and HBV are not being adequately screened for hepatocellular carcinoma. Phase 2 will focus on implementing educational interventions aimed at increasing physician awareness of screening guidelines.