Center Electronic Medical Record Research Articles

Physostigmine reversal of delirium from second generation antipsychotic exposure: a retrospective cohort study from a regional poison center

Introduction Physostigmine is an effective antidote for antimuscarinic delirium. There is little evidence for its use to reverse delirium following second generation antipsychotic exposure. The purpose of this study is to describe the safety and effectiveness of physostigmine in reversing delirium from second generation antipsychotic exposure. Methods This is a retrospective cohort study of all patients reported to a single regional poison center treated with physostigmine following a second generation antipsychotic exposure from January 1, 2000 to April 15, 2021. The poison center electronic medical record was queried to identify cases and for data abstraction. The primary outcome was the positive response rate to physostigmine, as determined by two trained abstractors. Secondary outcomes included physostigmine dosing, and adverse events. Results Of 147 charts reviewed, 138 individual patients were included, and the response to physostigmine was reported in 128 patients. The most common second-generation antipsychotic exposure was quetiapine (97; 70.3 percent). A positive response to physostigmine was noted in 106/128 (82.8 percent) patients [95 percent confidence interval 68.9–83.6 percent]. Median number of physostigmine doses was 1 (interquartile range 1–3; range 1–9). The median total physostigmine dose received was 2 mg (interquartile range 2–6 mg; range 0.15–30 mg). The positive physostigmine response rate for patients with an antimuscarinic co-ingestion was not significantly different compared to patients with a different co-ingestion or no co-ingestion (25/34 versus 81/94; P = 0.09). Adverse events were reported in four (2.9 percent) patients, including one death. Discussion A positive response to physostigmine to treat antimuscarinic delirium from second generation antipsychotic exposure was reported in 82.8 percent of patients, which is similar to previous physostigmine studies. Adverse events were infrequent, and included diaphoresis (one 0.7 percent), seizure (one; 0.7 percent), and bradycardia (one; 0.7 percent). One (0.7%) patient suffered a cardiac arrest 60 minutes after receiving physostigmine to treat antimuscarinic delirium following having received increasing clozapine doses over the previous month. Conclusions In this study, physostigmine appears to be a safe and effective treatment for antimuscarinic delirium from second generation antipsychotic exposure. Further studies are needed to validate the safety and effectiveness of physostigmine for this indication.

Applying Machine Learning Models Derived From Administrative Claims Data to Predict Medication Nonadherence in Patients Self-Administering Biologic Medications for Inflammatory Bowel Disease.

Adherence to self-administered biologic therapies is important to induce remission and prevent adverse clinical outcomes in Inflammatory bowel disease (IBD). This study aimed to use administrative claims data and machine learning methods to predict nonadherence in an academic medical center test population. A model-training dataset of beneficiaries with IBD and the first unique dispense of a self-administered biologic between June 30, 2016 and June 30, 2019 was extracted from the Commercial Claims and Encounters and Medicare Supplemental Administrative Claims Database. Known correlates of medication nonadherence were identified in the dataset. Nonadherence to biologic therapies was defined as a proportion of days covered ratio <80% at 1 year. A similar dataset was obtained from a tertiary academic medical center's electronic medical record data for use in model testing. A total of 48 machine learning models were trained and assessed utilizing the area under the receiver operating characteristic curve as the primary measure of predictive validity. The training dataset included 6998 beneficiaries (n = 2680 nonadherent, 38.3%) while the testing dataset included 285 patients (n = 134 nonadherent, 47.0%). When applied to test data, the highest performing models had an area under the receiver operating characteristic curve of 0.55, indicating poor predictive performance. The majority of models trained had low sensitivity and high specificity. Administrative claims-trained models were unable to predict biologic medication nonadherence in patients with IBD. Future research may benefit from datasets with enriched demographic and clinical data in training predictive models.

Endoscopic Endonasal Anterior Skull Base Meningoencephalocele and Cerebrospinal Fluid Leak Repair: Our Intraoperative and Postoperative Protocol and Long-term Outcomes

Abstract Objective We evaluated the long-term outcomes from a single neurosurgeon and otolaryngologist team using a specific operative protocol for repair and postoperative evaluation. Design The charts of patients undergoing endoscopic endonasal repair of meningoencephaloceles (MECs) and cerebrospinal fluid (CSF) leaks were retrospectively reviewed from 2015 to 2023. Intraoperative steps of the repair and reconstruction were analyzed. Patients' postoperative assessments and complications were analyzed. Setting Loyola University Medical Center's electronic medical record database. Participants Forty-three patients (32 female) aged between 11 and 81 years. Main Outcome Measures Long-term outcomes of patients who underwent endoscopic endonasal repair of MECs and CSF leaks by a single team and protocol. We hypothesized that there would be minimal complications and no recurrences, requiring secondary operation. Results The most common site for MECs was the cribriform plate. Lumbar drain opening pressures ranged from 10 to 35 cm H2O with 18 out of 34 patients having the lumbar drain removed immediately postoperatively. The median hospital stay was 3 days. The average length of follow-up was 3.8 years. No recurrences or secondary operations were noted in all patients. One patient had a sinonasal infection that was successfully treated. Eight patients were noted to have venous stenosis and underwent further evaluation. Conclusion This study represents one of the largest long-term analyses of outcomes by a single team. Our specific protocol for the endoscopic endonasal repair of anterior skull base MECs and CSF leaks is safe and effective. These patients should be evaluated and treated for elevated intracranial pressure following the repair.

Ambulatory Surgery Center in Rural Uganda: A Novel Approach to Providing Surgical Care.

Despite evidence that ambulatory surgery is safe with faster recovery compared to in-patient hospitalization, surgeons in low- and middle-income countries like Uganda have been hesitant to embrace this practice. Kyabirwa Surgical Center (KSC) is the first freestanding ambulatory surgery center (ASC) in rural Uganda. We aim to report the impact of a rural ASC since its establishment, in alleviating surgically-treatable morbidity within its catchment area. KSC is located in Jinja, Uganda. The center's electronic medical record was used to analyze the utilization of services, and the Uganda Bureau of Statistics was used to calculate KSC's catchment area. Effectiveness was calculated using disability-adjusted life years (DALYs) averted. Between July 2019 and December 2021, 7,391 patients (57.7% female, 42.3% male) visited KSC from a catchment area of 570,790 people. Of 1,355 procedures, 64.6% were general surgery, 21.3% endoscopy, 9.2% gynecological/genitourinary), 2.8% ENT, 1.5% colorectal, and 0.6% orthopedics. There were no postoperative hospital admissions for complications or mortalities. From the seven most common procedures with an associated disability weight, 2,193.16 total DALYs were averted. ASCs can be effective in addressing surgical care gaps in Uganda by increasing the yearly surgical capacity of the local catchment area and averting DALYs within the population.

Building an Electronic Medical Record System Exchanged in FHIR Format and Its Visual Presentation.

Currently, the Taiwan Electronic Medical Record Exchange Center uses the Clinical Document Architecture (CDA) framework, which is based on the international medical standard. The CDA R2 standard, defined in 2005, is used for cross-institution retrieval of electronic medical records (Ministry of Health and Welfare, Information Department, 2021). However, CDA R2 only supports the exchange of clinical documents and is limited to the XML format. Due to the lack of a standardized framework for medical data exchange in Taiwan, different standards and specifications result in different data interface methods between systems, requiring customization for each system by healthcare institutions or the government. The inconsistency in data formats requires healthcare institutions and the government to spend more time on data parsing and mapping, resulting in slow integration of medical data. In this study, we simulated healthcare institutions using Fast Healthcare Interoperability Resources (FHIR) for medical information exchange and utilized the exchanged medical information to create a dynamic dashboard to assist healthcare professionals in making medical decisions. To ensure information security, we employed Hyper Text Transfer Protocol Secure (HTTPS) for secure transmission, which encrypts the transmitted medical record data using the Transport Layer Security (TLS) protocol, preventing deliberate interception and tampering of medical record data between the two systems. Finally, to test the load and performance of static and dynamic resources and web applications, we conducted a system performance evaluation using Apache JMeter. The results of this study demonstrate that replacing the gateway of the Electronic Medical Record Exchange Center with an FHIR server effectively reduces the time and cost spent by developers on data format conversion while also mitigating the information security risks associated with the previous VPN solution. Additionally, by utilizing dynamic charts, healthcare professionals are assisted in making medical decisions.

Lung cancer in nonsmokers- A risk factor analysis

Institutions:stony brook medical centerrationaleLung Cancer screening for the high-risk smoking population has been proven to save lives. However, in 2022, 20% of newly diagnosed lung cancers (47,300) were in nonsmokers. These patients were found to be diagnosed at later stages. This may be at least partly due to not meeting criteria for and participating in current lung cancer screening. This study aims to describe characteristics of a never smoker patient population to help identify common risk factors which might merit inclusion in lung cancer screening and thus improve patient outcomes. MethodsThis retrospective single center study included never-smoker patients diagnosed with lung nodules and never-smoker patients diagnosed with lung cancer from 2016 to 2022. Data was obtained from the Stony Brook Medical Center electronic medical record. 16,056 patients were identified as never-smokers who were asked by the medical assistant if they ever smoked in their lifetime. Patients were eliminated if they had any smoking history up to first diagnosis date. Demographics, radiology, histology, diagnosis dates, comorbidities, smoking status, and exposures collected through ICD10 codes and not self-reported, were investigated. ResultsOf 16,056 never-smoking patients, 9315 (58.02%) were females diagnosed with lung nodules and 6741 (41.98%) were males diagnosed with lung nodules.The univariate analysis showed significant differences between gender, age at nodule diagnosis, and patients with and without comorbidities including chronic obstructive pulmonary disease (COPD), hypertension (HTN), and family history (FHX) of lung cancer. The percentage of lung cancer patients among females was significantly higher than among males. Patients having lung cancer were older. The percentages of lung cancer patients with these comorbidities were significantly higher than those without. However, there was no significant difference found between patients with and without diabetes mellitus (DM).The multivariable logistic regression suggested that age at nodule diagnosis and comorbidities including COPD (which included asthma, emphysema and chronic bronchitis) and family history of lung cancer were significantly associated with lung cancer. Older patients and patients with those comorbidities had a higher risk of developing cancer than those who were younger or without those comorbidities. The study excluded HTN and included age at nodule diagnosis in the logistic regression model as HTN was found to be protective against lung cancer due to age at lung nodule diagnosis. Please refer to the appendix for further details. ConclusionNever-smoker patients who were older and with COPD and Family History of lung cancer had higher risk of developing lung cancer than younger patients without these comorbidities. In this study, gender had no impact on outcome.

Isolated Anterior Talofibular Ligament (ATFL) vs Combined ATFL and Calcaneofibular Ligament Suture Tape Augmentation for the Treatment of Lateral Ankle Instability: Are Outcomes Equivalent?

The Broström procedure with suture tape augmentation has become commonplace for surgical treatment of chronic lateral ankle instability. However, there is no consensus among surgeons whether internal bracing of the ATFL alone or a combined ATFL and calcaneofibular ligament (CFL) internal brace produces superior clinical outcomes. This retrospective study aims to investigate whether isolated internal bracing of the ATFL has comparable outcomes to combined ATFL and CFL brace. There were 85 patients from a single tertiary medical center's electronic medical record identified who underwent an ATFL or ATFL and CFL reconstruction between January 2017 and December 2020. Postoperative outcomes including patient satisfaction, ankle instability, ankle pain, and the need for revision surgery at 1-year follow-up were evaluated. Forty-eight patients underwent isolated ATFL reconstruction, and 37 underwent combined ATFL and CFL reconstruction. The choice was made between the 2 options based on surgeon preference. At 1-year follow-up, postoperative outcomes were statistically indistinguishable between the 2 treatment groups. The modified Broström reconstruction with ATFL and CFL reconstruction with an internal brace did not produce superior functional outcomes measured at 1 year compared to isolated ATFL reconstruction. Further investigation of long-term functional outcomes is needed to evaluate the long-term efficacy of combined or single-ligament reconstruction.Level of Evidence: Level III, retrospective study.

Increasing access to pathology services in low- and middle-income countries through innovative use of telepathology.

In low- and middle-income countries (LMICs), surgical care can be limited by access to pathology services. In Uganda, the pathologist-to-population ratio is less than 1 to 1 million people. The Kyabirwa Surgical Center in Jinja, Uganda, created a telepathology service in collaboration with an academic institution in New York City. This study demonstrated the feasibility and considerations of implementing a telepathology model to supplement the critical pathology needs of a low-income country. This was a retrospective, single-center study of an ambulatory surgery center with pathology capability using virtual microscopy. The remote pathologist (also known as a telepathologist) controlled the microscope and reviewed histology images transmitted across the network in real time. In addition, this study collected demographics, clinical histories, the surgeon's preliminary diagnoses, and the pathology reports from the center's electronic medical record. Nikon's NIS Element Software was used as a dynamic, robotic microscopy model with a video conferencing platform for communication. An underground fiber optic cable established Internet connectivity. After a two-hour tutorial session, the lab technician and pathologist were able to proficiently use the software. The remote pathologist read (1) pathology slides with inconclusive reports from external pathology labs, and (2) tissues labeled by the surgeon as suspicious for malignancy, which belonged to patients who lacked financial means for pathology services. Between April 2021 and July 2022, tissue samples of 110 patients were examined by a telepathologist. The most common malignancies on histology were squamous cell carcinoma of the esophagus, ductal carcinoma of the breast, and colorectal adenocarcinoma. With the increasing availability of video conference platforms and network connections, telepathology is an emerging field that can be used by surgeons in LMICs to improve access to pathology services, confirming histological diagnosis of malignancies to ensure appropriate treatment.

The Challenges and Hidden Concerns of Cloud-based Electronic Medical Record Exchange

The Challenges and Hidden Concerns of Cloud-based Electronic Medical Record Exchange

S1084 Endoscopic Ultrasound-Guided vs Percutaneous Drainage for the Management of Post-Operative Pancreatic Fluid Collections After Distal Pancreatectomy

Introduction: Post-operative pancreatic fluid collections (POPFCs) remain a significant source of morbidity after distal pancreatectomy. Drainage can be performed using percutaneous or endoscopic approaches, but comparative data are limited. This study compared endoscopic ultrasound-guided drainage (EUSD) with percutaneous drainage (PTD) in the management of symptomatic POPFCs after distal pancreatectomy. The primary aim is to compare rates of clinical success, defined as symptomatic improvement and radiographic resolution without requiring an alternate drainage modality. Secondary outcomes included technical success, total number of interventions, time to resolution, rates of adverse events (AEs), and POPFC recurrence. Methods: Adults who underwent distal pancreatectomy from January 2012 to August 2021 and developed symptomatic POPFC were identified retrospectively from a single academic center electronic medical record and a prospectively maintained pancreatic surgery database. Demographic data, procedural data, and clinical outcomes were abstracted. Quantitative variables were described with median and interquartile ranges and compared using a two-tailed t-test. In addition, categorical data were reported as frequencies and compared using Chi-squared or Fisher exact tests. Results: Of 1046 patients that underwent distal pancreatectomy, 217 met study inclusion criteria (median age 60 years, 51.2% female) of whom 106 underwent EUSD and 111 PTD. There were no significant differences in baseline characteristics including age, gender, pathology, and POPFC size (Table). PTD was generally performed earlier after surgery (10 vs. 27 days; p = < 0.001) and more commonly in the inpatient setting (82.9% vs. 49.1%; p≤0.001). EUSD was associated with a significantly higher rate of clinical success (92.5% vs. 76.6%; p=0.001), fewer median number of interventions (2 vs. 4; p≤0.001), and lower rate of POPFC recurrence (7.6% vs. 20.7%; p=0.007). Drain dwell time was shorter for patients who underwent PTD (37 vs. 46 days; p=0.013). AEs were more frequent after EUSD but did not reach a level of statistical significance (10.4% vs 6.3%, p=0.28); with approximately 1/3 of EUSD AEs due to stent migration. Conclusion: In patients with POPFCs after distal pancreatectomy, EUSD was associated with higher rates of clinical success, fewer interventions, and lower rates of recurrence. EUSD should be considered for management of POPFCs in centers with technical expertise. Table 1. - Baseline characteristics and clinical outcomes of patients who developed post-operative pancreatic fluid collections after distal pancreatectomy Baseline Characteristics EUSDN =106 PTDN = 111 P value Age, years, median (IQR) 60 (48-68) 60 (55-68.5) 0.09 Female, no. (%) 52(49.1) 59 (53.1) 0.54 Laparoscopic surgery, no. (%) 56 (52.8) 34(30.6) 0.002 Pancreatic pathology, no. (%) Ductal adenocarcinoma 43 (31.1) 40 (29.7) Neuroendocrine tumor 32 (30.2) 33 (29.7) Intraductal papillary mucinous neoplasm 12 (11.3) 8 (7.2) Other* 19 (17.9) 30 (27.0) Inpatient, no. (%) 52 (49.1) 92(82.9) < 0.001 Presence of solid necrosis, no. (%) 48 (45.3) 11 (9.9) < 0.001 Infected POPFC, no. (%) 42 (39.6) 30 (27.0) 0.06 Maximum diameter in cm, Median (IQR) 7.4 (5.2-10.0) 6.7 (5.1-10.0) 0.45 Time to drainage from surgery, days, median (IQR) 27.0 (13.5-46.5) 10.0 (7.00-18.3) < 0.001 Clinical Outcomes Clinical success, no. (%) 98 (92.5) 85 (76.6) 0.001 Technical success, no. (%) 106(100) 111(100) Procedure related adverse events, no. (%) 11(10.4) 7 (6.3) 0.28 Number of interventions, median (IQR) 2 (2-4) 4 (2-6) < 0.001 Time to drain removal, days, median, (IQR) 45.5 (31.5-73.0) 37.0 (24.0-61.0) 0.013 Recurrence, no. (%) 8 (7.6) 23 (20.7) 0.007 Footnotes: EUSD: EUS-guided drainage; PTD: Percutaneous drainage; POPFC: Post-operative pancreatic fluid collection*Other pathologies: serous cystadenoma (EUSD n=2; PTD n=3), sarcoma (EUSD n=3; PTD n=6), chronic pancreatitis (EUSD n=3; PTD n=5), insulinoma (EUSD n=1; PTD n=5), other metastatic disease (EUSD n=10; PTD n=11).

Healthcare resource utilization and quality of life in patients with sarcoidosis-associated pulmonary hypertension.

A retrospective, observational cohort study was conducted to generate real‐world evidence in adult patients diagnosed with sarcoidosis‐associated pulmonary hypertension (SAPH) at a referral center in England between 2012 and 2019. Data from the referral center electronic medical record database were linked to the National Health Service Hospital Episode Statistics database to collect and analyze patient demographics, clinical characteristics, comorbidities, treatment patterns, health‐related quality of life (HRQoL; assessed using the EmPHasis‐10 questionnaire), healthcare resource utilization (HCRU), costs, and survival. Sixty‐two patients with SAPH were identified. At diagnosis, 84% were in WHO functional class III and presented with significant pulmonary hemodynamic impairment. Cardiovascular and respiratory comorbidities were commonly reported prediagnosis. Median EmPHasis‐10 score at diagnosis was 34, indicative of poor HRQoL. In the 1st year after diagnosis, median (Q1, Q3) per‐patient HCRU was 1 (0, 2) all‐cause inpatient hospitalizations; 3 (2, 4) same‐day hospitalizations; and 9 (6, 11) outpatient consultations. In 24 patients who were hospitalized longer than 1 day in the 1st year after diagnosis, the median duration of hospitalization was 4 days. With a median follow‐up of 1.8 years, the median overall survival was 2.9 years. In this cohort of patients with SAPH, poor HRQoL and high HCRU were observed following diagnosis. To our knowledge, this is the first study to report on HRQoL and HCRU in patients with SAPH. More research is needed on treatment options for this population with high unmet needs.

The effect of race, employment, and poverty on outcomes in chimeric antigen receptor therapy for DLBCL patients.

e18506 Background: Limited information is known about how socioeconomic (SES) factors contribute to outcomes after CAR T-cell therapy for relapsed/refractory (R/R) diffuse large B-cell lymphoma (DLBCL). While racial and SES disparities have been demonstrated to effect outcomes after Autologous Stem Cell Transplant for DLBCL patients, little is known about this association after CAR T. Methods: Using data from Moffitt Cancer Center's electronic medical record system, we retrospectively evaluated patients diagnosed with DLBCL at our center who underwent CART therapy (n = 200). Data was analyzed by residential area deprivation index (ADI) for patients receiving CAR T therapy for R/R DLBCL at a single tertiary care center. Survival and CAR T-related toxicity outcomes were evaluated based on patient baseline characteristics, disease features, and demographics using multivariable Cox proportional-hazards (PH) regression model and multivariable logistic regression model. Patient socioeconomic status was represented by area deprivation index ranking mapped through 9-digit zip codes. Results: The study included 200 patients receiving CAR T therapy at Moffitt Cancer Center for R/R DLBCL; median age was 65; 46.8% were female, 53.2% male; 89.8% white, 10.2% non-white; median ADI rank of 4. As for disease characteristics; 18.9% had double/triple hit lymphoma by FISH for MYC and BCL2 or 6 translocations; 83.6% had extranodal disease sites. Patients were treated with a median of 3 prior lines of therapy, and most patients (81%) had stage III/IV lymphoma at time of leukapheresis for CAR T. 8.38% of patients experienced grade 3 or higher cytokine-release syndrome (CRS), and 34.6% of patients experienced grade 3 or higher neurotoxicity. Area deprivation index and education level did not significantly contribute to overall survival when adjusted for other clinical features on multivariable Cox PH regression analysis. However, unemployment negatively impacted overall survival (HR = 4.296, P = 0.0243). Progression-free survival was unaffected by ADI, education level, or employment. In terms of CAR T-related toxicities, demographic features did not affect the risk for grade 3 CRS on multivariable logistic regression model. On Wilcoxon rank testing, area of deprivation indices did not significantly differ among patients with or without grade 3 CRS. Conclusions: These results suggest that ADI and other SES factors do not significantly contribute to progression free survival, CRS or neurotoxicity. This study shows unemployment was a significant predictor for poor overall survival after CAR T in patients with DLBCL. This is the first study to evaluate the significance of SES, race, and employment on DLBCL patients after CAR T. Future efforts should be used to investigate measures to increase employment and understand factors associated with unemployment.

Families Chose In-Person Visits over Telehealth for Pediatric Weight Management during the COVID-19 Pandemic.

Background: With the onset of the coronavirus disease 2019 (COVID-19) pandemic, telehealth was implemented as a method of care delivery in many pediatric weight management programs (PWMPs). To compare patient/family preference of telehealth vs. in-person visits, we analyzed patient visits during a period when families were given the option of scheduling in-person or telehealth visits for both new and follow-up visits during the pandemic. Methods: A retrospective review was done of our center's electronic medical record of patient visits from July 1, 2020 to December 31, 2020. Results: There were 1356 completed PWMP visits, with 977 (72.1%) done in-person and 379 (27.9%) done by telehealth. Telehealth was selected more often for follow-up visits (31.4%) compared with new visits (18.8%) [odds ratio (OR) = 2.052, p = 0.008]. Black patients (30.5%) selected telehealth more often than White patients (26.1%, OR = 1.371; p = 0.03). Conclusions: Although telehealth increases flexibility and increases options to families, in-person clinic visits seem to be preferred especially for an initial visit.

Severe Acute Respiratory Syndrome Coronavirus 2 Reinfection Associates With Unstable Housing and Occurs in the Presence of Antibodies

BackgroundThe factors associated with severe acute respiratory coronavirus 2 (SARS-CoV-2) reinfection remain poorly defined.MethodsWe identified patients with SARS-CoV-2 infection and at least 1 repeat reverse transcription polymerase chain reaction result a minimum of 90 days after the initial positive test and before 21 January 2021. Those with a repeat positive test were deemed to have reinfection (n = 75), and those with only negative tests were classified as convalescents (n = 1594). Demographics, coronavirus disease 2019 (COVID-19) severity, and treatment histories were obtained from the Boston Medical Center electronic medical record. Humoral responses were analyzed using SARS-CoV-2–specific enzyme-linked immunosorbent assays and pseudovirus neutralizations in a subset of reinfection (n = 16) and convalescent samples (n = 32). Univariate, multivariate, and time to event analyses were used to identify associations.ResultsIndividuals with reinfection had more frequent testing at shorter intervals compared with the convalescents. Unstable housing was associated with more than 2-fold greater chance of reinfection. Preexisting comorbidities and COVID-19 severity after the initial infection were not associated with reinfection. SARS-CoV-2 immunoglobulin G levels and pseudovirus neutralization were not different within the early weeks after primary infection and at a timepoint at least 90 days later in the 2 groups. In the convalescents, but not in those with reinfection, the late as compared with early humoral responses were significantly higher.ConclusionsReinfection associates with unstable housing, which is likely a marker for virus exposure, and reinfection occurs in the presence of SARS-CoV-2 antibodies.

Inverse probability weighting for selection bias in a Delaware community health center electronic medical record study of community deprivation and hepatitis C prevalence

To demonstrate how selection into a healthcare facility can induce bias in an electronic medical record-based study of community deprivation and chronic hepatitis C virus infection, in order to more accurately identify local risk factors and prevalence. We created a catchment model that attempted to define the probability of selection into a retrospective cohort. Then using the inverse of this probability, we compared naïve unweighted and weighted models to demonstrate the impact of selection bias. ZIP code-level ecological plots of the cohort demonstrated that there was a pattern of the community deprivation, hepatitis C outcome, and distance to the health center (an intuitive proxy for being within catchments). The naïve multilevel analysis found that living in an area with greater deprivation resulted in 1.25 times greater odds of HCV (95% CI: 1.06, 1.48), whereas the weighted analysis found less certainty of this effect due to a selection bias. We observed that selection into the catchment area of the studied healthcare facility may bias the association of community deprivation and hepatitis C. This may be mitigated through inverse probability weighting.

Postoperative Mortality in Patients With Cirrhosis: Reconsidering Expectations.

A diagnosis of cirrhosis increases a patient's risk of postoperative mortality. Surgeons are reticent to operate when cirrhosis is known unless no option is available. This study aimed to identify the modern perioperative risk in cirrhotic patients undergoing intervention under general anesthesia for non-transplant operations. A retrospective chart review was conducted utilizing the Rush Medical Center electronic medical record. All patients over 18 years of age with a diagnosis of cirrhosis undergoing intervention between 2009 and 2019 were reviewed. 90-day mortality rates in patients grouped by Child's score, Model for End-Stage Liver Disease (MELD), and Model for End-Stage Liver Disease with sodium incorporated (MELDNa) were compared to previously accepted rates. 93 patients (46% women) aged 22-72years of all Child-Turcot-Pugh (CTP) (40% A, 36% B, and 25% C) classifications and MELD/MELDNa ranging 6-40 were analyzed. 90-day mortality of the entire population was 16%, significantly lower than expected based on CTP score (16% vs. 32%; P = .0005), MELD (16% vs. 41%; P < .0001), and MELDNa (16% vs. 46.8%; P < .0001). This was also true for CTP-B patients (12% vs. 30%; P = .025), CTP-C patients (35% vs. 70%; P = .0002), patients with MELD >14 (27% vs. 70%; P < .001), and patients with MELDNa >14 (23% vs. 70%; P < .0001). Data indicate that perioperative mortality is lower than widely accepted. This suggests the need for a national database study using a representative population to determine the risk of mortality for patients with cirrhosis having surgery in recent times. Accurate estimation of this risk allows for meaningful discussion between physicians and patients when deciding to proceed with elective, necessary operations.

Identification of Patients with Pentosan Polysulfate Sodium-Associated Maculopathy through Screening of the Electronic Medical Record at an Academic Center.

Aims This chart review of a quaternary academic medical center electronic medical record (EMR) aimed to identify patients at risk of development of maculopathy with exposure to pentosan polysulfate sodium (PPS). Methods A review of electronic medical records of a quaternary medical center of patients with either documented exposure to PPS or diagnosis of interstitial cystitis (IC) from 2007 to 2019 was performed for retinal imaging and visual acuity; the study was conducted in August of 2019. Results 216 charts were included for analysis, of which 96 had documented eye exams and 24 had retinal imaging done. We identified three patients with maculopathy in the context of long-term exposure to PPS via chart review, and one additional patient was identified by referral. The median PPS exposure duration was 11 years (range 7 to 19 years). Median logMAR BCVA OD 0.6 range was 0.0–1.9 (approximate Snellen equivalent 20/80 range (20/20–20/1600)) and OS 0.7 range was 0.1–1.9 (approximate Snellen equivalent 20/100 range (20/25–20/1600)). Ultrawidefield color fundus imaging and fundus autofluorescence revealed findings of pigmentary changes and patchy macular atrophy. Optical coherence tomography (OCT) demonstrated outer retinal thinning and increased choroidal transmission coincident with areas of atrophy seen on fundus imaging. Conclusions Less than half of patients at risk for development of maculopathy due to exposure to PPS had received eye examinations, suggesting that those at risk are not receiving adequate screening. We found two patients with PPS maculopathy who had relatively preserved central vision, one patient with bitemporal vision loss, and one patient who developed vision loss in both eyes.

4441 Comparing 3 methods of assessment of psoas area as a proxy for sarcopenia in predicting short-term outcomes in trauma patients 55 years and older

OBJECTIVES/GOALS: Specific Aim 1 To examine sex distribution of psoas cross sectional area (CSA) on CT imaging in a cohort of trauma patients age 55 and older. We will use three methods of assessing psoas CSA: psoas CSA averaged between left and right, average psoas CSA adjusted for height, and average psoas CSA adjusted for body surface area (psoas index). Specific Aim 2 Use multivariable logistic regression prediction modeling to compare the 3 methods of CT psoas muscle measurement widely used in the literature in their ability to predict a composite of in-hospital morbidity and mortality in trauma patients ages 55 and older. METHODS/STUDY POPULATION: The Maine Medical Center Trauma Registry is maintained by the Trauma Surgery Service at Maine Medical Center in Portland, Maine, the only Level-1 trauma center in the state. After receiving approval from the Institutional Review Board of Maine Medical Center for this retrospective cohort study, we queried the Maine Medical Center Trauma Registry for all adults 55 years and older who underwent evaluation by the Trauma Service between January 1, 2015 and January 1, 2019. In the case of multiple admissions within the study time period, only a patient’s index admission was used. MaineHealth IMPACS imaging software was used to measure bilateral psoas CSA on each patient CT. The Maine Medical Center electronic medical record was queried for additional clinical information including the ICD codes associated with each patient encounter. Data analysis was performed using R statistical software (R project, Vienna, Austria). Data is reported as median + IQR for CSA measurements. The agreement between the three methods of quantifying psoas CSA was evaluated using Pearson correlation (R package “stats”). Inter-rater reliability of psoas muscle measurements was evaluated using intra-class correlation (R package “irr”). Prediction models for the composite outcome of in-hospital morbidity and mortality were constructed using multivariable logistic regression. Bootstrapping was used for internal validation and shrinkage to avoid overfitting. Models including psoas CSA were compared to a baseline model without psoas CSA to evaluated incremental added predictive ability. RESULTS/ANTICIPATED RESULTS: This cohort provides a basis for examining the population distribution of psoas CSA in adults 55 years and older. IN addition to a high level of agreement between the three methods of measuring psoas CSA (Spearman coefficient &gt; 0.9), there was also high level of inter rater reliability in psoas muscle assessment (intraclass correlation 0.9). We anticipate that psoas CSA adjusted for body surface area will add the most incremental predictive ability to a model predicting in-hospital morbidity and mortality. DISCUSSION/SIGNIFICANCE OF IMPACT: Given the heterogeneity of health status amongst elderly trauma patients, a major challenge lies in the rapid objective identification of those elderly trauma patients who are frail. Due to the limitations in current frailty measures, there has been a surge of interest in surrogate markers of frailty, such as muscle mass, as predictive factors of poor outcomes after trauma.Several studies have found that sarcopenia is associated with post injury morbidity and mortality. Estimates of the prevalence of sarcopenia among trauma patients vary across studies due to differences in definition and sample characteristics. In order to appropriately categorize patients as sarcopenic, the population distribution of psoas CSA on CT must be established. The psoas measurement that best correlates with outcomes has yet to be determined, and it is unclear which measurement should be implemented in usual practice. Our main objective is to improve the outcomes of sarcopenic patients hospitalized with trauma by implementing in the future patient-centered interventions which will account for sarcopenia.

Combined Surgical Resection and Laser Interstitial Thermal Therapy for Glioblastoma: Technical Note.

Glioblastoma multiforme (GBM) is an aggressive intracranial malignancy that confers a poor prognosis despite maximum surgical resection and chemoradiotherapy. Survival decreases further with deep-seated lesions. Laser interstitial thermal therapy (LITT) is an emerging minimally invasive technique for tumor ablation shown to reduce tumor burden effectively, particularly in deep-seated locations less amenable to gross total resection. We describe our initial technical experience of using the combination of LITT followed by surgical resection in patients with GBMs that exhibit both an easily accessible and deep-seated component. Patients with GBM who received concurrent LITT and surgical resection at our institution were identified. Patient demographic and clinical information was procured from the University of Texas MD Anderson Cancer Center electronic medical record along with preoperative, postoperative, and 1-month follow-up magnetic resonance imaging (MRI). Four patients (n = 2 male, n = 2 female) with IDH-wild type GBM who received combined LITT and surgical resection were identified and analyzed retrospectively. All patients received chemoradiotherapy before presentation. All but one patient (75%) received resection before presentation. Median age was 54 years (range: 44-56 years). Median length of hospital stay was 6.5 days (range: 2-47 days). Median extent of combined ablation/resection was 90.4%. One of the four patients experienced complications in the perioperative or immediate follow-up periods. Local recurrence was observed in one patient during the follow-up period. Malignant gliomas in deep-seated locations or in close proximity to white matter structures are challenging to manage. LITT followed by surgical resection may provide an alternative for tumor debulking that minimizes potential morbidities and extent of residual tumor. Further studies comparing this approach with standard resection techniques are warranted.

625 Characteristics of Patients With Obscure Gastrointestinal Bleeding in an Urban Academic Center

INTRODUCTION: Gastrointestinal bleeding is a significant clinical problem accounting annually for over 500,000 hospital admissions and 840,000 emergency room visits (1). Intestinal angioectasia (AEC) are an important cause of this bleeding, however, there is a lack of knowledge about this population's demographics. Aortic valve disease (Heyde's syndrome) and hereditary hemorrhagic telangiectasia (HHT) have been the most established etiologies and do not account for the majority of cases or increasing incidence. We sought to identify characteristics of patients with AEC, a condition increasing in incidence. METHODS: One urban academic center's electronic medical record was searched using ICD 9 and 10 codes to identify patients with gastrointestinal AEC. Those with aortic valve disease and HHT were removed. The control group included only those ages 65 and older. Demographic information was collected (age, gender, race, insurance and body mass index (BMI)), and the groups were further broken down into BMI &gt;30 and BMI &lt;30. The presence of diabetes mellitus (DM), chronic kidney disease (CKD), and diverticular disease was found. RESULTS: There was a total of 835 patients in the AEC cohort (average age of 65) that were compared to a control population of 318,923. More patients had a BMI &gt;30 when compared to control (37.89% v 33.57%, P = 0.009). Additionally, the AEC cohort had more patients with DM (42.99% v 9.04%, and 20.87%, P &lt; 0.001), CKD (35.21% v 5.00% and 11.72%, P &lt; 0.001), and diverticular disease (36.89% v 2.85% and 6.78%, P &lt; 0.001) than the total control and the control group with known BMIs. Demographics were similar between groups in the categories of gender, types of insurance and race. However, the AEC cohort had more patients that identified as black (30.74% v 11.16%, P &lt; 0.001). CONCLUSION: Clinically, the increasing incidence of obscure gastrointestinal bleeding due to AEC is due to the increasing prevalence of complex chronic diseases that contribute to this condition. Our results showed that CKD and older age are risk factors. Additionally, we found that a BMI &gt; 30 and DM are associated with a higher incidence of AEC. Diverticular disease was found to be a co-existing condition. Recognizing these risks and associated diseases is necessary to decrease the risk of bleeding from AEC, which can be very difficult to manage clinically with risk of significant morbidity and economic impact to healthcare.