Electronic Medical Charts Research Articles

Acute low-pressure hydrocephalus in aneurysmal subarachnoid hemorrhage

Acute and chronic hydrocephalus are common pathologies after aneurysmal subarachnoid hemorrhage (SAH). Generally, the presence of acute hydrocephalus is associated with elevated intracranial pressure (ICP) treated with a ventricular drain. Subsequently, however, pronounced hydrocephalus without elevated ICP may develop in some patients with SAH in the postacute phase. This is described as acute low-pressure hydrocephalus (aLPH), and there are very limited data in the literature of this pathology. The aim of this study was to evaluate the rate of and factors associated with aLPH and describe its clinical course. In this retrospective single-center cohort study, the frequency and clinical characteristics of SAH-associated aLPH were investigated. Acute LPH was defined as an increase in ventricular size as measured by the Evans index, ICP within the normal range (< 5 mm Hg) at the time of ventricular enlargement, and timely neurological improvement after indwelling ventricular CSF drainage with negative pressure up to 5 cm H2O below normal level. Demographic and SAH-specific factors in patients with SAH treated using an external ventricular drain were extracted from the electronic medical chart and further analyzed. From November 2010 to May 2020, 15 (3.7.%) of 406 patients with SAH fulfilled the criteria for aLPH. Acute LPH was diagnosed after an average of 13.1 ± 7.7 days. The presence of IVH and its extension were associated with the occurrence of aLPH. After undergoing the transient phase of aLPH, these patients subsequently developed a chronic, typical malresorptive hydrocephalus requiring a ventriculoperitoneal shunt more often (66.7% vs 17.4%, p < 0.001) and stayed longer in the intensive care unit (27 vs 20.5 days, p = 0.043) and in the hospital (36.4 vs 26.3 days, p = 0.004). Acute LPH is a rare pathology in patients with SAH and negatively impacts the clinical course. It should be especially considered in patients with a lack of neurological improvement, an increase in ventricular width, and normal ICP values, so that forced CSF drainage is implemented.

A98 ASSOCIATIONS BETWEEN DISTANCE TO CLINIC AND PATIENT CHARACTERISTICS FOR YOUNG ADULTS WITH IBD AT THE TIME OF PEDIATRIC TO ADULT TRANSFER OF CARE

Abstract Background Patients with inflammatory bowel disease (IBD) in childhood are a vulnerable population. Compared to patients diagnosed in adulthood, they may present more often with extensive disease, delayed growth, and more frequently have perianal disease. Eventually, these patients will transfer care from the pediatric to the adult system, which has been associated with medication nonadherence and increase in health care utilization. Within the literature, travel distance has been cited as a barrier to accessing health care; however, understanding its’ impact on this vulnerable patient population has not been well-established. Purpose The study objective was to characterize differences between patients transferring from pediatric to adult care based on distance from an IBD center. To achieve this, the study aims to measure associations between distance to clinic and smoking status, anxiety and depression, history of surgery, and biologics at the time of first appointment in adult care. Method A retrospective cross-sectional study is ongoing using electronic medical charts for patients who transferred from pediatric to adult care from January 1, 2014 – October 4, 2022. Transfer was defined as the patient’s first appointment in adult care at the University of Alberta’s IBD clinic. Distance was measured by driving distance from the patient’s postal code to the postal code of the IBD clinic. Distance was categorized as being &amp;lt;50km from IBD clinic and &amp;gt;50km. Binary outcome variables collected at time of transfer included reported biologic use, anxiety and depression, smoking status, and history of surgeries. Descriptive and inferential statistics were used to analyze data. Result(s) Of the 185 electronic medical charts were reviewed, 46 (24.9%) patients lived &amp;gt;50km from clinic. The median age at diagnosis for the &amp;gt;50km group was 14.5 (IQR: 15.9-13.6), 41% were female sex, 54% had Crohn disease, 41% had ulcerative colitis (UC), and 26% had completed a fecal calprotectin within the last 6 months. The median age at diagnosis of the 139 patients living &amp;lt;50km from clinic was 14.3 (IQR:15.9-12.5), 45% were female sex, 60% had Crohn disease, 32% had UC, and 59% had completed a fecal calprotectin. Of those who had a fecal calprotectin, in group 1, 26% had a result over &amp;gt;250 ug/g, compared to 60% in the reference group. Univariate analysis (Table 1) showed that those living further than 50 km were more likely than those closer to engage in daily smoking (OR~4.7). Weaker and lack of associations were seen with anxiety and depression (OR~1); being on biologics (OR~0.7); history of surgical intervention (OR~2.2). Image Conclusion(s) When smoking status was reported, patients &amp;gt; 50km away from clinic were 4.7 times more likely to engage in daily smoking at time of transfer compared to those patients within 50km from the clinic. By acknowledging and understanding potential differences and similarities between patients characterized by geographical location, we can use this research to inform personalized care plans. Disclosure of Interest None Declared

Change in glottic view during intubation using a KoMAC videolaryngoscope: A retrospective analysis.

Intubation with videolaryngoscopy has become popular in various clinical settings. However, despite the use of a videolaryngoscope, difficult intubation still exists and intubation failure has been reported. This retrospective study assessed the efficacy of the 2 maneuvers in improving the glottic view during videolaryngoscopic intubation. The medical records of patients who underwent videolaryngoscopic intubation and whose glottal images were stored in electronic medical charts were reviewed. The videolaryngoscopic images were divided into 3 categories according to the applied optimization techniques as follows: conventional method, with the blade tip located in the vallecular; backward-upward-rightward pressure (BURP) maneuver; and epiglottis lifting maneuver. Four independent anesthesiologists scored the visualization of the vocal folds using the percentage of glottic opening (POGO, 0-100%) scoring system. A total of 128 patients with 3 laryngeal images were analyzed. The glottic view was the most improved in the epiglottis lifting maneuver among all the techniques. The median POGO scores were 11.3, 36.9, and 63.1 in the conventional method, BURP, and epiglottis lifting maneuver, respectively (P < .001). There were significant differences in the distribution of POGO grades according to the application of BURP and epiglottis lifting maneuvers. In the POGO grades 3 and 4 subgroups, the epiglottis lifting maneuver was more effective than the BURP maneuver in improving the POGO score Inadequate visualization of the vocal folds occurred even when intubation was performed using a videolaryngoscope. The application of optimization maneuvers, such as BURP and epiglottis lifting by the blade tip, could improve the glottic view.

The Impact of Data Management on the Achievable Dose and Efficiency of Mammography and Radiography During the COVID-19 Era: A Facility-Based Cohort Study.

To evaluate the impact of using computational data management resources and analytical software on radiation doses in mammography and radiography during the COVID-19 pandemic, develop departmental diagnostic reference levels (DRLs), and describe achievable doses (ADs) for mammography and radiography based on measured dose parameters. This ambispective cohort study enrolled 795 and 12,115 patients who underwent mammography and radiography, respectively, at the King Fahd Hospital of the University, Al-Khobar City, Saudi Arabia between May 25 and November 4, 2021. Demographic data were acquired from patients' electronic medical charts. Data on mammographic and radiographic dose determinants were acquired from the data management software. Based on the time when the data management software was operational in the institute, the study was divided into the pre-implementation and post-implementation phases. Continuous and categorical variables were compared between the two phases using an unpaired t-test and the chi-square test. The median accumulated average glandular dose (AGD; a mammographic dose determinant) in the post-implementation phase was three-fold higher than that in the pre-implementation phase. The average mammographic exposure time in the post-implementation phase was 16.3 ms shorter than that in the pre-implementation phase. Furthermore, the median values of the dose area product ([DAP], a radiographic dose determinant) were 9.72 and 19.4 cGycm2 in the pre-implementation and post-implementation phases, respectively. Although the data management software used in this study helped reduce the radiation exposure time by 16.3 ms in mammography, its impact on the mean accumulated AGD was unfavorable. Similarly, radiographic exposure indices, including DAP, tube voltage, tube current, and exposure time, were not significantly different after the data management software was implemented. Close monitoring of patient radiation doses in mammography and radiography, and dose reduction will become possible if imaging facilities use DRLs and ADs via automated systems.

Evaluation of lymphopenia as a predictor of postoperative mortality and major complications in patients undergoing surgery for metastatic spine tumors.

Lymphopenia is often seen in advanced metastatic disease and has been associated with poor postoperative outcomes. Limited research has been done to validate this metric in patients with spinal metastases. The objective of this study was to evaluate the capability of preoperative lymphopenia to predict 30-day mortality, overall survival (OS), and major complications in patients undergoing surgery for metastatic spine tumors. A total of 153 patients who underwent surgery for metastatic spine tumor between 2012 and 2022 and met the inclusion criteria were examined. Electronic medical record chart review was conducted to obtain patient demographics, comorbidities, preoperative laboratory values, survival time, and postoperative complications. Preoperative lymphopenia was defined as < 1.0 K/μL based on the institution's laboratory cutoff value and within 30 days prior to surgery. The primary outcome was 30-day mortality. Secondary outcomes were OS up to 2 years and 30-day postoperative major complications. Outcomes were assessed with logistic regression. Survival analyses were done using the Kaplan-Meier method with log-rank test and Cox regression. Receiver operating characteristic curves were plotted to classify the predictive ability of lymphocyte count as a continuous variable on outcome measures. Lymphopenia was identified in 47% of patients (72 of 153). The overall 30-day mortality rate was 9% (13 of 153). In logistic regression analysis, lymphopenia was not associated with 30-day mortality (OR 1.35, 95% CI 0.43-4.21; p = 0.609). The mean OS in this sample was 15.6 months (95% CI 13.9-17.3 months), with no significant difference between patients with lymphopenia and those with no lymphopenia (p = 0.157). Cox regression analysis did not show an association between lymphopenia and survival (HR 1.44, 95% CI 0.87-2.39; p = 0.161). The major complication rate was 26% (39 of 153). In univariable logistic regression analysis, lymphopenia was not associated with the development of a major complication (OR 1.44, 95% CI 0.70-3.00; p = 0.326). Finally, receiver operating characteristic curves generated poor discrimination between lymphocyte count and all outcomes, including 30-day mortality (area under the curve 0.600, p = 0.232). This study does not support prior research that had shown an independent association between low preoperative lymphocyte level and poor postoperative outcomes following surgery for metastatic spine tumors. Although lymphopenia may be used to predict outcomes in other tumor-related surgeries, this metric may not hold a similar predictive capability in the population undergoing surgery for metastatic spine tumors. Further research into reliable prognostic tools is needed.

Clinical outcomes for Clostridioides difficile associated diarrhea in inflammatory bowel disease patients versus non-IBD population: A retrospective cohort study.

Patients with inflammatory bowel disease (IBD) have a higher incidence of Clostridioides difficile infection (CDI). Previous studies have demonstrated negative clinical outcomes in IBD patients with CDI compared to patients without CDI. The clinical presentation of CDI is indistinguishable from IBD exacerbation, thus posing a frequent clinical dilemma on the role of Clostridioides infection in the testing, diagnosis, and treatment of these patients. To compare clinical outcomes of CDI in patients with IBD to those without IBD. Retrospective cohort of adult patients admitted to Rabin Medical Center Israel between the years 2014 and 2020 with a concurrent diagnosis of IBD and CDI. Matching 1:2 was performed between the IBD patients and the non-IBD population with respect to age and sex. Sixty-seven patients with IBD and 134 patients without IBD were included in the study. The groups' median age was 40.6 (interquartile range [IQR] of 29.8-68.9), with 45.8% male and 54.2% female. The non-IBD group had a higher Charlson score with 2 (IQR 0; 5) versus 0 (IQR 0; 4) in the IBD group (P value <.01). Patients with IBD had more exposure to systemic antibiotics, 71.1% versus 26.3% (P value <.01). In a multivariable analysis we found no difference in 90-day mortality and rate of relapse between the 2 study groups with an odds ratio of 1.709 (95% confidence interval 0.321-9.905) and odds ratio of 0.209 (95% confidence interval 0.055-1.513) respectively. In our cohort patients with IBD who present with diarrhea and concomitant CDI have similar rates of relapse and mortality compared with patients without IBD.

P157 Serial daily recording of patient-reported outcomes (PRO2) might predict treatment change in the patients with Ulcerative Colitis.

Abstract Background Patient-reported outcome (PRO2) score composed solely of the stool frequency and bleeding components from partial Mayo (pMayo) score are used for the evaluation of clinical symptom in the patients with Ulcerative Colitis (UC). Although pMayo and PRO2 score also perform as well as the full Mayo score to identify the disease activity and clinical response, it is unclear whether serial daily PRO2 score are relevant in clinical practice. Moreover, its clinical significance for long-term outcome has not been established. The aim of this study istherefore to clarify the relationship between daily PRO2 records using a smart device application and prognosis. Methods This study was approved by the ethics committee in Tokyo Medical and Dental University (TMDU). The application was originally developed by the cooperation with TMDU and Hitachi ltd. Patients with UC input their symptoms by themselves in accordance with PRO2 once a day using the application on their smart device. The alert for their symptom exacerbation is set according to our logic. Patient's condition including alert status is confirmed by the doctor once a week using doctor’s PC. Medical information such as therapeutics and blood examination, was extracted from the electronic medical chart in the hospital. The application data was combined with medical information on a daily basis. We defined a start or change of the treatment with prednisone or biologics as treatment change for the outcome of this study. The difference of PRO2 score before the date of treatment change is calculated for each patient and the odds ratio (OR) and AUC of the ROC curve are estimated by univariate logistic regression analysis. Results From July 2020 to March 2022, 183 UC patients participated in this study. Mean age was 46.6 years. Male to female ratio was 81:102. Mean observation period was 346 days. The number of the patients with alert of symptom exacerbation averaged 5.79/week. There were 27 patients with treatment change during the period. PRO2 score in the patients with treatment change was significantly increased compared with the patients with no change in treatment. The OR [95%CI] of the PRO2 change from 90 days to 5 days before treatment change was 7.708 [2.713-21.902], the AUC [95%CI] was 0.872 [0.772-0.973], the OR [95%CI] of the PRO2 change from 10 days to 5 days was 3.309 [1.601-6. 841] and AUC [95%CI] was 0.679 [0.569-0.789]. Conclusion PRO2 variation over 90 days was highly reliable for predicting treatment change. Further analysis will clarify the clinical significance of serial daily PRO2 score recording.

Factors affecting dialysis duration in children with Shiga toxin-producing Escherichia coli-associated hemolytic uremic syndrome.

Predicting disease severity can be informative for management of HUS. Dialysis requirement, volume depletion, elevated white blood cell counts, very young age, and use of antimotility agents are known factors associated with severe HUS. A retrospective cohort analysis was performed to identify factors associated with dialysis duration using electronic medical record and chart review of 76 children ≤ 18years of age at presentation with STEC-HUS identified through billing data from July 2008 to April 2020 at James Whitcomb Riley Hospital for Children, Indiana University, Indiana. Novel findings associated with prolongeddialysis duration were age ≥ 6years old at presentation (p = 0.041) and lack of drop in platelets below 60,000/mm3 anytime during the illness (p = 0.015). In addition, children with NSAID exposure trended longer on dialysis: 15days with vs. 10days without (p = 0.117). Known risk factors for severe disease including elevated peak white blood cell (WBC) count and higher hematocrit at presentation were also associated with longer dialysis duration: children with peak WBC > 20,000/mm3 were on dialysis for 15 vs. 9.5days (p = 0.002) and in children on dialysis ≥ 14days hematocrit at presentation was 29.6% vs. 24.2% (p = 0.03). Children requiring dialysis for 20days or longer were more likely to be on anti-hypertensive medications (p = 0.025) and have chronic kidney disease at 12-month follow up (p = 0.044). Age ≥ 6, elevated WBC count > 20,000/mm3, higher hematocrit at presentation, lack of drop in platelets to < 60,000/mm3, and possibly NSAID exposure during illness are associated with longer dialysis duration in STEC-HUS. A higher resolution version of the Graphical abstract is available as Supplementary information.

1042. Inflammatory Representation of COVID-19 at the Time of Hospitalization: An Insight into the Mild, Moderate, Severe and Critical COVID-19 Disease

Abstract Background The ongoing state of the COVID-19 pandemic necessitates the characterization of the biological basis of disease severity. We aimed to correlate the clinical severity of illness upon hospitalization with inflammatory sero-biomarker levels. Methods A single-center prospective cohort study was conducted at a 776-bed tertiary care urban academic medical center in Detroit, Michigan. Adults with confirmed reverse-transcriptase-polymerase-chain-reaction assay for COVID-19 were recruited in equal numbers into four disease severity categories, as defined by the WHO, upon hospital admission from January 8th, 2021 to September 1st, 2021. Electronic medical charts were reviewed. In addition to clinical markers, cytokines and chemokines were assessed to gain detailed understanding of COVID-19 pathology. Results We included 200 patients with 50 patients each in the mild, moderate, severe and critical illness. The mean age of the cohort was 58.6.±15.9 yrs, 104 (52%) were males, and 135(67.5%) were blacks. The common comorbidities were hypertension (67.5%), diabetes (37%) and chronic lung diseases (26.5%). At the time of admission, oxygen therapy was needed in 49.5% but intubation in only 0.5%. Conclusion We noted COVID-19 severity dependent changes in the clinical representation as well as the biomarker profiles. Clinical markers such as CRP, LDH, D-dimer and Ferritin were relatable to COVID-19 severity. Inflammatory cytokines and chemokines such as CCL-2, CXCL-10, IL-1ra, IL-6 and TNF-alpha also varied with the severity of disease. Our results provide a system level insight into the inflammatory state of COVID-19 at the time of hospital representation. Disclosures All Authors: No reported disclosures.

474. Differences In Clinical Manifestation, Prognostic Factors, and Outcomes Between Patients With Community-onset And Nosocomial Candidemia

Abstract Background Candidemia is an invasive and deadly infectious disease. The associated risk factors of candidemia include immunosuppression, broad-spectrum antibiotics, catheters, glucocorticoids, critical illness, surgery, neonates, previous candida colonization, and illicit drug use. In previous studies, the characteristic of community-onset candidemia was distinct from nosocomial candidemia. Methods We selected patients who were admitted for equal or more than two days in Taichung Veterans General Hospital of Taiwan from 2015 to 2018 with electronic medical charts. The diagnosis of candidemia was defined as Candida species identified in blood cultures by commercial identification systems. We applied Kaplan-Meier survival curves with a log-rank test and built multivariate Cox proportional-hazards models for risk factors associated with in-hospital mortality. The purpose of this study is to investigate the difference in the characteristics, outcomes, and associated risks of death between community-onset and nosocomial candidemia. Results A total of 339 patients were included for analysis. The incidence was 1.50 per 1000 admission person-years. 64.60% of patients were male, and the mean age was 64.24-year-old. The characteristics of patients were similar in both groups except for the status of port-A, glucocorticoid usage, and diabetes mellitus. In the community-onset group, a higher proportion of C. glabrata and C. parapsilosis, but fewer C. albicans and C. tropicalis were identified than in the nosocomial group. The all-cause mortality rate was 55.75%. Multivariate Cox proportional-hazards model showed that nosocomial (hazard ratio; HR, 1.96; 95CI, 1.291 - 2.97 ; p =0.002), glucocorticoids within seven days before candidemia (HR, 1.68; 95CI, 1.21 -2.32, p = 0.002), and septic shock (HR, 1.85; 95CI, 1.292 - 2.641, p &amp;lt; 0.001) were associated with poor outcome whereas treatment with an echinocandin within two days after candidemia was a protective factor (HR, 0.65; 95CI, 0.466 - 0.911, p = 0.012). Survival curves analysis between community-onset candidemia and nosocomial candidemia A log-rank test was applied to assess the statistical significance, and a p-value less than 0.05 was considered statistically significant. Conclusion In conclusion, candidemia is a lethal disease with a better outcome noted in those with community-onset candidemia. Species diversity existed in both groups, and Early initiation of echinocandin therapy within two days could reduce 35% mortality. Disclosures All Authors: No reported disclosures.

Late diagnosis of autism spectrum disorder-Journey, parents' concerns, and sex influences.

Despite increasing awareness for diagnosing autism spectrum disorder (ASD) and initiating treatments early in life, many children and adolescents continue to be diagnosed at a relatively older age. Focusing on children who first received an ASD diagnosis at age six or older, this study aimed to describe the symptoms that parents reported when ASD was diagnosed, follow the patients' clinical trajectory prior to receiving the diagnosis, and describe differences in symptoms and prior diagnoses between males and females cases. We included 258 children (205 males and 53 females) who were first diagnosed with autism at age 6-18 in 2017-2018. We retrieved demographic information, neurologic and developmental symptoms, diagnoses, and medications dispensing history from the children's electronic medical charts. The data indicated that prior diagnoses of language delays and attention deficit hyperactivity disorder were common among children with a late ASD diagnosis. Two thirds of the children were prescribed one or more medications to treat psychosocial and behavioral conditions before receiving a late ASD diagnosis. Difficulties in social relationships with peers were the leading reported symptoms by parents at the time of ASD diagnosis. Across these different domains, some differences were found between males and females, including a somewhat higher cognitive level in males, who were also more likely to present aggressive behavior.

Clinical Features and Management of Small Bowel Masses Detected During Device-Assisted Enteroscopy: A Multi-Center Experience.

Small bowel mass lesions (SBMLs) are rare, span a range of different histologies and phenotypes, and our understanding of them is limited. Some lesions occur in patients with recognized polyposis syndromes and others arise sporadically. The current literature regarding SBMLs is limited to small retrospective studies, case reports, and small case series. This large multi-center study aims to understand the various clinical presentations, histologies and management options for SBMLs. After obtaining Institutional Review Board (IRB) approval, electronic records were used to identify all device-assisted enteroscopy (DAE) performed for luminal small bowel evaluation in adult patients at three US referral centers (Duke, LSU and UMass) from January 1, 2014, to October 1, 2020. We identified all patients within this cohort in whom a SBML was detected. Using a focused electronic medical record chart review, we collected patient, procedure, and lesion-related data and used descriptive statistics to explore relationships between these data and outcomes. A total of 218 patients (49 at Duke, 148 at LSU, and 21 at UMass) in this cohort had at least one SBML found on DAE. The most common presenting symptoms were iron-deficiency anemia/bleeding (73.3%) and abnormal imaging (33.6%). Thirty-five percent of patients had symptoms for more than a year prior to their diagnosis. Most patients (71.6%) underwent video capsule endoscopy (VCE) prior to DAE and 84% of these exams showed the lesion. The lesion was seen less frequently (48.9%) on computed tomography (CT) scan performed prior to DAE. The majority of lesions were found on antegrade (56%) or retrograde (29.8%) double-balloon enteroscopy (DBE). The most common lesion phenotypes were submucosal (41.3%) and pedunculated (33%) with a much smaller number being sessile (14.7%) or obstructing/invasive (11%). They were found equally as commonly in the jejunum (46.3%) and ileum (49.5%). Most lesions were 10 - 20 mm in size (47%) but 22.1% were larger than 20 mm. The most common histologies were neuroendocrine tumors (NETs, 20.6%) and hamartomas (20.6%). Primary adenocarcinoma of the small bowel was rare, constituting only 5% of lesions. The majority of polyps (78.4%) were sporadic, compared to 21.7% associated with a polyposis or hereditary cancer syndrome, most commonly Peutz-Jeghers syndrome (18.3%). After DAE, 37.6% were advised to undergo surgical resection and 48% were advised to undergo endoscopic surveillance or no further management because of benign histology or successful endoscopic resection. In this multi-center retrospective study we found that SBMLs are more likely to be sporadic than syndromic, medium in size and either pedunculated or submucosal. NETs and hamartomas predominated and symptoms, most commonly anemia, can be present for more than a year prior to diagnosis. Close to one half of lesions required either no further intervention or only endoscopic surveillance.

Prognosis of NF1 Mutations in Acute Myeloid Leukemia

Background: As molecular testing becomes more widely available, the prognostic and therapeutic implications of specific genetic mutations in acute myeloid leukemia (AML) continue to evolve. Mutations in the Neurofibromin 1 (NF1) gene are not well studied in AML. A limited number of studies have evaluated the presence and potential role of NF1 in AML (Eisfeld et al., 2018; Telfah et al., 2019). NF1 mutations were found in about 5% of AML patients and may carry a worse prognosis. In this IRB-approved retrospective case-control study, we analyzed specific clinical outcomes for AML patients with any NF1 mutation compared to patients with a wild-type NF1 gene, including complete remission (CR) rate and overall survival (OS). Methods: We reviewed electronic medical charts of newly diagnosed AML patients who had next-generation-sequencing (NGS) from bone marrow aspirates at diagnosis at our institution between 2017-2021. We identified patients with any pathogenic or likely pathogenic NF1 mutation. Control patients with a wild-type NF1 gene were matched to the NF1 positive group based on age, sex, race, and AML risk per 2017 ELN criteria. The primary outcome was overall survival; secondary outcomes included the rate of achieving a complete remission (CR), complete remission with incomplete hematologic recovery (CRi) at bone marrow evaluation after chemotherapy induction, allogeneic hematopoietic stem cell transplant rate for those who achieved CR, and finally overall survival (OS). CR, CRi, and transplant rates were compared using a Fisher's exact test and by calculating odds ratios (OR). OS was estimated by the Kaplan-Meier method and compared by using a log-rank test. Significance was defined by a P value <0.05. Results: We identified 34 AML patients with an NF1 mutation on NGS from initial diagnostic bone marrow aspiration between 2017-2021. We compared the outcomes with a matched control group (n=130) as described in the methods. The median age was 63 (27-84) and 64.5 (23-86) in the NF1 mutated and wild-type groups, respectively. There were no differences in sex or race between the two groups (Table 1). There were 20 patients (63%) with high-risk disease in the NF1 mutated group, similar to 74 patients (57%) in the control group. The co-occurring mutations varied between the two groups; RUNX1 mutations were more common in the NF1 mutated group, while DNMT3A and FLT3 were less common (Table 1). NF1 mutated patients were less likely to achieve CR/CRi at 44% compared to 65% of NF1 wild-type patients (OR 0.40; P 0.03; figure 1A). Rates of subsequent allogeneic transplant for patients who achieved CR/CRi were similar in NF1 mutated and wild-type patients (66% and 60%, respectively). The median OS for NF1 mutated patients was 474 days compared to 688 days for wild-type NF1 patients (hazard ratio (HR) for death, 1.45; 95% CI, 0.88 to 2.49; P 0.15; figure 1B). There was no significant difference in median OS between patients who received allogeneic transplants, but NF1 mutated patients who did not receive a transplant had a significantly worse median OS compared to the NF1 wild type patients (HR 1.63, P 0.03; figure 1C). Discussion: Somatic NF1 mutations are not well studied in AML. Prior limited studies are suggestive of worse outcomes, and we have observed similar results in this study. Patients with NF1 mutations were significantly less likely to achieve CR/CRi compared to patients with a wild-type NF1 gene, either with intensive or non-intensive therapies. OS was worse for NF1 mutated patients but did not reach statistical significance except for patients that did not receive an allogeneic transplant, who had significantly worse median OS. While the patients' characteristics, including the risk of AML, were similar between the NF1 mutated and wild-type groups, we observed differences in co-occurring mutations. The common DNMT3a and FLT3 mutations were significantly less common in NF1 mutated patients, while there were more RUNX1 mutations in this group. This distinctive co-occurring mutation pattern may suggest a role for NF-1 in leukemogenesis with a specific leukemia development pathway and provides an opportunity for personalized targeting. This retrospective study has a relatively small sample size. Nonetheless, it provides further evidence for the potentially adverse prognosis of NF1 mutations in AML, which can guide conversations between treating physicians and patients about individualized prognostic risks. Figure 1View largeDownload PPTFigure 1View largeDownload PPT Close modal

Clinical Features and Survival Analysis of Patients after Mechanical Heart Valve Replacement, with an Emphasis on Prosthetic Valve Thrombosis.

Valvular heart diseases are highly prevalent in the world, and surgical valve replacement has improved patients' survival. To describe clinical and laboratory data of patients undergoing mechanical valve replacement, and to determine the incidence of prosthetic valve thrombosis (PVT). Retrospective cohort study with a follow-up of up to nine years. The study variables were collected from conventional and electronic medical charts. Statistical calculations were performed using the Jamovi software version 1.2.2.; a p<0.05 was considered statistically significant. Kaplan Meier curves were constructed, and Cox regression analysis was performed for analysis of factors related to mortality. A total of 473 patients were included, mean age of 46.9 ±11.3 years. Rheumatic disease was the most common etiology. In a mean follow-up period of 4.43 years, mortality rate was 16.1%. Patients with aortic prosthesis showed higher survival than patients with double implant (mitral and aortic) (p=0.026). Of the factors adjusted for mortality, only functional class and chronic renal failure showed statistically significant association. The incidence of PVT was 0.24/100 patients/year, and the first event occurred more than 1000 days after the implant. Smoking and pannus formation were significantly associated with PVT. No differences were found in INR variability between patients with and without thrombosis by prosthetic position, but significant differences were found in INR before thrombosis as compared with patients without thrombosis (INR= 2.20 [1.80-2.20] vs. 2.80 [2.20-3.40]; p= 0.040). The incidence of stroke and bleeding was 4.4% and 5.2% respectively. The study population was young, and rheumatic valve disease was common in this group. The prevalence of PVT was similar to that described in the literature, despite the low income and low educational level of our sample.

Improving Documentation of Postdischarge Issue Mitigation during Postdischarge Phone Calls

An interdisciplinary quality improvement team used the Model for Improvement to perform planned sequential interventions over 16 months. The outcome measure was documentation of postdischarge issue mitigation. Process measures included PDPC template use and completion and postdischarge issue identification. Balancing measures included call attempts and caller perceptions of ease of documentation. Interventions included creating a flowsheet note template, creating caller template training sessions, and sharing team data and feedback. We gathered data via reports generated from the electronic medical record, chart review, and survey. Data were analyzed using statistical process control charts and established rules for detecting special cause variation. The postdischarge issue mitigation documentation increased from 65% to 91% over 16 months. Template use and completion increased from 0% to 100% and 98%, respectively. The number of postdischarge issues identified remained unchanged. Call attempts increased from 40% to 59%. Caller perceptions remained unchanged. Documentation of postdischarge issues and issue mitigation promotes adequate communication with the patient's care providers, improving the quality and safety of care. Data sharing to promote team engagement was the key factor in improving documentation of postdischarge issue mitigation.

Continuous Ropivacaine Peroneal Nerve Infiltration for Fibula Free Flap in Cervicofacial Cancer Surgery: A Randomized Controlled Study.

Introduction: Pain after cervicofacial cancer surgery with free flap reconstruction is both underestimated and undertreated. There is a rational for regional anesthesia at the flap harvest site, but few studies describe it. We assessed the influence of common peroneal nerve infiltration on pain and opioid consumption in patients having oropharyngeal cancer surgery with fibular free flap mandibular reconstruction. Methods: After institutional review board (IRB) approval and written informed consent, fifty-six patients were randomly allocated to perineural catheter with ropivacaine infiltration (ROPI) or systemic analgesia (CONTROL). In the ROPI group, an epidural catheter was placed by the surgeon before closure, and ropivacaine 0.2% 15 mL, followed by 4 mL/h during 48 h, was administered. The primary outcomes were pain scores and morphine consumption during the 48 h postoperative period. We also measured ropivacaine concentration at the end of infusion. Finally, we retrospectively assessed long-term pain up to 10 years using electronic medical charts. Results: Perineural infiltration of ropivacaine significantly reduced pain scores at the harvest site only at day 1, and did not influence overall postoperative opioid consumption. Ropivacaine assay showed a potentially toxic concentration in 50% of patients. Chronic pain was detected at the harvest site in only one patient (ROPI group), and was located in the cervical area in the case of disease progression. Discussion: Although the catheter was visually positioned by the surgeon, continuous ropivacaine infiltration of the common peroneal nerve did not significantly reduce postoperative pain, but induced a blood concentration close to the toxic threshold at day 2. Further studies considering other infiltration locations or other dosing schemes should be tested in this context, both to improve efficacy and reduce potential toxicity.

The incremental value of exercise ECG to myocardial perfusion SPECT for prediction of cardiac events

Abstract Background Both myocardial perfusion SPECT (MPS) and exercise ECG (Ex-ECG) are known to carry prognostic information in patients with chronic coronary syndrome (CCS). However, it is not fully understood if combining MPS and Ex-ECG results improves risk prediction. Current guidelines no longer recommend Ex-ECG for diagnostic evaluation of CCS, but adding Ex-ECG results to MPS could be of incremental prognostic importance. Purpose The study aimed to assess the incremental prognostic value of Ex-ECG to MPS results in patients with CCS. Methods A single-center study of 908 consecutive patients with CCS (age 63±9 years, 49% male) who underwent a MPS with Ex-ECG. Subjects were followed for five years. The clinical endpoint was a composite of cardiovascular death (CV), acute myocardial infarction (AMI), unstable angina and unplanned PCI. National registry data and electronic medical charts were used for end point allocation. Results Combining the findings of MPS and Ex-ECG resulted in concordant evidence of ischemia in 72 patients (8%) or absence of ischemia in 634 patients (70%). Dis-concordant results were found in 202 patients (22%; MPS−/Ex-ECG+, n=126 and MPS+/Ex-ECG−, n=76). During follow-up 95 composite cardiac events occurred (CV deaths n=6, AMI n=27, unstable angina n=34 and unplanned PCI n=28). Kaplan-Meier curves display an increased risk of cardiac events in patients with any combination of abnormal stress test results (Figure 1). In a multivariable regression model (adjusting for age, sex, smoking, known IHD, diabetes, dyslipidaemia and exercise capacity) MPS was the strongest predictor of cardiac events regardless of Ex-ECG results (MPS+/Ex-ECG−, Hazard ratio (HR) = 3.0, p=0.001 or MPS+/Ex-ECG+, HR=4.0, p&amp;lt;0.001). However, an abnormal Ex-ECG almost doubled the risk of event in subjects with a normal MPS (MPS−/Ex-ECG+, HR=1.9, p=0.04). Conclusions Combining the results from MPS and Ex-ECG in patients with chronic coronary syndrome lead to an improved prediction of future cardiac events. Even though MPS is the stronger predictor, there is an incremental prognostic value of adding data from Ex-ECG to MPS, especially in patients with normal MPS findings. Funding Acknowledgement Type of funding sources: Public Institution(s). Main funding source(s): Swedish Heart and Lung Foundation, Region of Scania

The Impact of Data Management on the Achievable Dose and Efficiency of Computed Tomography During the COVID-19 Era: A Facility-Based Ambispective Study.

PurposeThis study primarily aimed to evaluate the effectiveness of computational data management and analytical software for establishing departmental diagnostic reference levels (DRLs) for computed tomography (CT) scanning in clinical settings, and monitor achievable doses (ADs) for CT imaging, particularly during the coronavirus disease 2019 (COVID-19) era. Secondarily, it aimed to correlate these standards with national and international benchmarks.Patients and MethodsThis ambidirectional cohort study enrolled 4668 patients (6419 CT-based examinations) who visited King Fahd Hospital of the University from May 25, 2021, to November 4, 2021. Participants’ demographic data were acquired from their electronic medical charts, in addition to all corresponding CT-dose determinant parameters. The study was divided into two phases (pre- and post-data management) based on the implementation of digital data management software.ResultsIn both phases of the study, the size-specific dose estimate (SSDE) was the most significant confounder of dose determination compared to the dose-length product (DLP) and computed tomography dose index (CTDI) (P = 0.003). The head was the most frequently imaged body region (pre-implementation, 1051 examinations [35.1%]; post-implementation, 1071 examinations [31.3%]; P = 0.001), followed by the abdominal region (pre-implementation, 616 examinations [20.6%]; post-implementation, 256 examinations [7.48%]; P = 0.001). Based on the SSDE, DLP, and volume CTDI, the average per-section radiation exposure among organ-based scanning type was highest for the lumbar spine during the pre- and post-implementation periods.ConclusionData management software enabled the establishment of DRLs and reduction of ADs in CT examinations, which consequently improved key performance indicators, despite the ergonomic complexities of COVID-19. Institutions are encouraged to apply DRLs and ADs via automatic systems that monitor patient dose indices to evaluate aggregate results.

Association between weight-loss history and weight loss achieved in clinical obesity management: Retrospective chart review.

Weight history and its association with the weight loss achieved in a publicly funded clinical obesity management program were examined in 9348 patients. Weight history (frequency and magnitude of weight losses) was collected through questionnaires at enrollment, and weight change was assessed with retrospective electronic medical chart review. The majority of patients reported developing overweight prior to the age of 40 years and having lost at least 4.5kg (10lb) of weight at least once in their lifetime. Those who had an earlier onset of overweight had a higher frequency of past weight loss and had more cumulative weight loss over their lifetime. In women, but not men, earlier age of overweight onset and lifetime weight loss were associated with modestly greater weight loss at the clinic. Women with greater weight-loss history also have modestly greater weight loss at the obesity management clinic. Thus, successful long-term obesity management, particularly for women, may include a series of repeated attempts at weight loss that should not be viewed as failures but could be viewed instead as practice.

Advanced clinical parameters: A complementary hydroxyurea adherence evaluation in sickle cell anemia treatment.

Given the complex pathology of sickle cell anemia (SCA) and low adherence to hydroxyurea (HU) treatment, there is a need to seek parameters that identify recent changes in patient status. The advanced clinical parameters (ACPs) allow an early analysis of hematopoiesis. We aimed to draw the demographic profile of non-adherent SCA patients and to verify the use of ACPs as a measure of HU treatment adherence. In a cross-sectional study, we divided 83 SCA subjects treated with HU into Children (<12 years old) and adolescents/adults (≥12 years old). Their hemogram with the ACPs, electronic medical charts and pharmacy claim data were analyzed. Non-adherent ≥12 years old patients had significantly increased WBC, absolute neutrophil, lymphocyte, monocyte, and basophil counts, RBC, RET, RDW, and PLT, and significantly decreased MCV and MCH. Subjects in the adolescent/adult group with IG† ≥0.035 cells/mm3 had the RR for non-adherence increased by 4.6 times (p= .014), and the systemic immune inflammation index (SII) of non-adherent patients was also significantly higher (p= .042). IG† presents clinical utility in early identification of non-adherence to HU, especially when combined with other parameters, suggesting the evaluation of ACPs in laboratory routine, as they can be easily implemented.