Electronic Medical Record Review Research Articles

Evaluation of Tricyclic Antidepressant Deprescribing in the Treatment of Diabetic Peripheral Neuropathy within Federally Qualified Health Centers

BackgroundTricyclic antidepressants (TCAs) are a treatment option for diabetic peripheral neuropathy (DPN). Existing evidence demonstrates the prolonged use of TCA therapy increases the risk of cognitive decline and dementia, likely due to the anticholinergic effects of these medications. The anticholinergic activity is thought to contribute significantly to the observed increase in cognitive decline and dementia risks associated with long-term TCA use. There is little information available to describe the usage patterns of TCAs in DPN, particularly within underserved populations who receive care at Federally Qualified Health Centers (FQHCs). ObjectivesThe objective of this study was to characterize: 1) prescribing patterns of TCAs as a treatment for DPN and 2) evidence of deprescribing attempts in a FQHC population. MethodsA retrospective chart review of electronic medical record (EMR) data for patients at two different FQHCs was performed. A convenience sample of 100 adults ≥ 18 years of age was stratified into two age groups, 18-55 years, and 55+ years. All patients had a diagnosis of Type 1 or Type 2 diabetes mellitus and had been prescribed TCAs in the previous four years and had a visit with a primary care provider (PCP) in the past 12 months. ResultsThe study population was comprised of 100 individuals. Seventy-four of 100 were persistent users of TCAs at the time of data collection, and the mean duration of utilization was 54.8 months. In total, 104 TCAs were prescribed across 100 individual patients. Of all 104 prescribed TCAs, 66 (63%) were prescribed at a rate that exceeded thresholds associated with a higher risk of dementia. Black older adults prescribed TCAs were more likely to exceed this dose threshold. Conclusion65% of patients used TCAs with a strength, frequency, and duration that exceeded risk thresholds for dementia in an older adult population. Interventions preventing use of or deprescribing TCAs in patients with DPN should be conducted for the potential benefits of preventing or delaying cognitive impairment and promoting equitable care.

Don't Fear the Bleed: Assessing Postoperative Bleeding Incidence After Instituting a Standardized Prophylactic Heparin Protocol in Bariatric Patients.

Background: Bariatric surgery is a frequently performed procedure in the United States, accounting for ∼40,000 procedures annually. Patients undergoing bariatric surgery are at high risk for postoperative thrombosis, with a venous thromboembolism (VTE) rate of up to 6.4%. Despite this risk, there is a lack of guidelines recommending postoperative VTE prophylaxis and it is not routine practice at most hospitals. The postoperative bleeding rate after bariatric surgery is only 1.5%; however, the risk of bleeding may lead to hesitancy for more liberal VTE prophylaxis. Methods: This is a retrospective analysis of bariatric surgeries at a single institution in 2019 and 2021. Data were obtained from the Metabolic and Bariatric Surgery Accreditation and Quality Improvement Program (MBSAQIP) and electronic medical record review for all patients undergoing sleeve gastrectomy (SG), Roux-en-Y gastric bypass (RYGB), or conversion to RYGB. The primary outcomes were composite bleeding events, which included postoperative transfusion, postoperative endoscopy or return to operating room (OR) (for bleeding), intra-abdominal hematoma, gastrointestinal (GI) bleeding, or incisional hematoma. Results: There were a total of 2067 patients in the cohort, with 1043 surgeries in 2019 and 1024 surgeries in 2021. There was no difference between bleeding events after instituting a deep venous thrombosis (DVT) prophylaxis protocol in 2021 (27 versus 28 events, P = .76). There was no difference in individual bleeding events between 2019 and 2021. Additionally, there was no significant difference in the rate of VTE between 2019 and 2021 (2 versus 5 events, P = .28). Conclusions: After instituting a standard protocol of prophylactic heparin postdischarge, we did not find an increased rate of bleeding events in patients undergoing bariatric surgery. Thus, surgeons can consider prescribing postdischarge chemical VTE prophylaxis without concern for bleeding.

Use of Respiratory and Contact Precautions to Decrease the Spread of SARS-CoV-2 Infection Was Not Associated with a Decrease in Endometritis-Intra-Amniotic Infection.

To decrease the spread of severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2) on the Mount Sinai Hospital's obstetric service, additional contact and respiratory precautions for patients and staff were implemented. Patients were allowed only one support person, SARS-CoV-2 tested on admission, and required to mask during hospitalization. Staff were required to wear masks and eye shields, gloves for all patient care, and gowns for care with SARS-CoV-2-infected patients. This study determined if the risk of endometritis/intra-amniotic infection (IAI) changed under the new pandemic precautions. A single-center, historical cohort study via electronic medical record review compared singleton deliveries among patients who labored during the "pandemic period" (from March 1 through May 31, 2020) with those who labored during the "prepandemic period" (March 1 through May 31, 2019) to determine if the risk of endometritis/IAI differed. The analysis was done using logistic regression with inverse probability of treatment weighting (IPTW) to adjust for possible differences in obstetric practice and patient population between the two periods. Four percent (53/1,318) of patients in the pandemic period and 5.1% (82/1,596) of patients in the prepandemic period were diagnosed with endometritis/IAI (p = 0.15). Compared with patients who delivered in the prepandemic period, those who delivered during the pandemic period had a higher body mass index at delivery (median: 28.36 [interquartile range, IQR: 25.70, 32.07] vs. 28.00 [IQR: 25.23, 31.50], p = 0.01) and experienced fewer digital exams (median: 4 [range: 1, 10] vs. 4 (range: 1, 19], p = 0.004), a practice not included in the SARS-CoV-2 prevention strategy. In multivariable logistic regression with IPTW adjusting for risk factors for endometritis/IAI, period of delivery was not associated with endometritis/IAI (odds ratio = 0.76, 95% confidence interval [0.52, 1.11], p = 0.15). The use of respiratory and contact precautions to limit the spread of SARS-CoV-2 was not associated with risk of endometritis/IAI. · Pandemic infection control precautions were not associated with a decrease in endometritis/IAIs.. · The early months of the pandemic were associated with the performance of fewer digital cervical exams.. · The early months of the pandemic were associated with a higher BMI at delivery..

Nirmatrelvir-Ritonavir Reduced Mortality in Hospitalized Patients with COVID-19 During the Omicron Outbreak: Real-World Evidence from Beijing.

The efficacy of nirmatrelvir-ritonavir for hospitalized patients with COVID-19 has not been fully established. We conducted a retrospective analysis of hospitalized COVID-19 patients with high risk for disease progression at Beijing Chaoyang Hospital from October 15, 2022, to March 31, 2023. Patients ≥18 years old who were hospitalized with COVID-19 within 5 days of symptom onset were included. Baseline data were obtained from the routine electronic health record database of the hospital information system. Outcomes were monitored at 28 days via electronic medical record reviews or telephone interviews. We identified 1120 patients hospitalized with COVID-19 during the study period. After exclusions, 167 nirmatrelvir-ritonavir users and 132 controls were included. 28-day all-cause mortality rate was 12.0% (20/167) in the nirmatrelvir-ritonavir group, versus 22.7% (30/132) in the control group (unadjusted log-rank p = 0.010; HR = 0.49, 95% confidence interval [CI] = 0.28-0.86, IPTW-adjusted HR = 0.58, 95% CI = 0.40-0.86). The 28-day disease progression rates did not differ between the two groups (unadjusted HR = 0.59, 95% CI = 0.34-1.02, IPTW-adjusted HR = 0.73, 95% CI = 0.50-1.06). Nirmatrelvir-ritonavir significantly reduced all-cause mortality and disease progression within 28 days among patients aged ≥65 years without ≥2 vaccine doses. We found significantly reduced all-cause mortality in the nirmatrelvir-ritonavir group, particularly in elderly patients who were incompletely vaccinated. Future randomized controlled studies are needed to validate our findings.

Cost consequence analysis of adding semaglutide to treatment regimen for patients with Type II diabetes in Saudi Arabia

IntroductionSemaglutide, a Glucagon-like Peptide-1 Receptor Agonist (GLP-1 RA), is often prescribed for managing type 2 diabetes, particularly in cases unresponsive to other hypoglycemic agents. Despite its popularity, the real-world efficacy and cost-effectiveness of Semaglutide relative to other treatments remain understudied. ObjectiveThis study aimed to examine the direct medical cost and consequences of adding Semaglutide to the treatment regimen for patients with type 2 diabetes in Saudi Arabia. MethodsWe conducted a single-center, retrospective review of Electronic Medical Records (EMRs) for adults with type 2 diabetes. Patients who had been on Semaglutide for at least three months were matched with those receiving alternative hypoglycemic therapies. Exclusions were made for patients with cancer, incomplete EMRs, or lacking prescription data. Investigated outcomes included changes in HbA1C levels and weight, and the direct costs comprised medications, clinic visits, and emergency care. Baseline adjustments were made through inverse probability treatment weighting, and uncertainty was assessed via bootstrapping with 10,000 replications. ResultsOut of 350 patients meeting the criteria, 116 were on Semaglutide. Predominantly females (62%), the cohort had an average age of 60 and a disease duration of 22 years. The difference in HbA1C (%) reductions between Semaglutide and non-Semaglutide users over 3,6, and 12 months were 0.154 (95% CI: –0.452-0.483), –0.031(95% CI: –0.754-0.239), –0.16(95% CI: –1.425-0.840), respectively. Semaglutide users did experience modest weight reductions ranging from 0.42 kg to 1.16 kg. The annual additional direct medical cost for Semaglutide was USD 4,086.82 (95% CI: $3,710.85 - $4,294.99). ConclusionAlthough Semaglutide induced modest weight reductions, it did not offer significant advantages in lowering HbA1C levels compared to other hypoglycemic treatments. These findings suggest the need for further research involving larger and more diverse cohorts to corroborate these findings.

Abstract 3722: Immunotherapy efficacy in advanced hepatocellular carcinoma in a diverse and underserved population in the United States

Abstract The incidence of hepatocellular cancer (HCC) in the Bronx is 61% higher than the rest of New York State. Underserved populations are not well represented in clinical trials of immune checkpoint inhibitors. The purpose of this study is to analyze the efficacy of immunotherapy treatment in a diverse and underserved patient population in the Bronx. Study demographics include 194 patients treated with ICI at the Montefiore Einstein Comprehensive Cancer Center (MECCC) between 2017 and 2022. A retrospective electronic medical record (EMR) review was conducted of all adult patients and this sample size was identified as having advanced HCC treated with immunotherapy. Outcome parameters such as overall survival and disease control rate assessed by radiologists using the Modified Response Evaluation Criteria in Solid Tumors (mRECIST 1.1) were reported. Survival was evaluated using parameters such as baseline serum alpha-fetaprotein(AFP) level, its evolution at the 3-month re-evaluation mark, the Child-Pugh(CP) class and MELD-Na score at the time of diagnosis. Categorical variables were analyzed by Chi-squared test and survival was analyzed using Kaplan-Meier (KM) curves.  MECCC patients were 40.7% Hispanic and 20.6% Black, compared with 3% and 2% respectively in the landmark IMbrave 150 study. Median overall survival (mOS) on ICI was 9.0 months, 25.0 months for the 100 (51.5%) favorable-prognosis Child Pugh A (CPA) patients included in HCC clinical trials. Disease control rate (DCR) was 58.5% among 123 evaluable patients per mRECIST 1.1. Baseline liver function, as defined by CP and Model for End Stage Liver Disease-Sodium (MELD-Na), correlated with survival (p<0.001). Hepatitis C Virus (HCV) and alcoholism were over-represented relative to National Cancer Institute (NCI) data (56.2% vs 4.7% and 38.7% vs 8.2%, respectively).   HCV treatment correlated with prolonged survival in infected patients (p=0.0017). AFP decline correlated with response (p=0.001). Hispanic patients lived longer when clinical variables were controlled for (mOS 52 vs 23 months; p=0.011).  In summary, our patient population differed significantly in racial composition and etiology of liver disease from clinical trial populations on which ICI was tested. In an underserved HCC population, ICI yielded a DCR of 58.5% and low rates of severe toxicity. This work highlights ICI efficacy in minority groups, a need for earlier HCC diagnosis and for studies of genetics and environmental factors in Hispanics with HCC.  Citation Format: Fernand Bteich, Lydia Bioh, Kush Desai, Chenxin Zhang, Anahat Kaur, Rahel A. Levy, Aaron Wang, Sharmin Sultana, Andreas Kaubisch, Milan M. Kinkhabwala, Sarah Bellemare, Shabnam A. Fidvi, Devaraju Kanmaniraja, Robert G. Berkenblit, Jee-Young Moon, Adebola A. Adedimeji, Clara Y. Tow, Yvonne M. Saenger. Immunotherapy efficacy in advanced hepatocellular carcinoma in a diverse and underserved population in the United States [abstract]. In: Proceedings of the American Association for Cancer Research Annual Meeting 2024; Part 1 (Regular Abstracts); 2024 Apr 5-10; San Diego, CA. Philadelphia (PA): AACR; Cancer Res 2024;84(6_Suppl):Abstract nr 3722.

Telehealth Medication Abortion in Primary Care: A Comparison to Usual in-Clinic Care.

Providing abortion in primary care expands access and alleviates delays. The 2020 COVID-19 public health emergency (PHE) led to the expansion of telehealth, including medication abortion (MAB). This study evaluates the accessibility of novel telehealth MAB (teleMAB) initiated during the PHE, with the lifting of mifepristone restrictions, compared with traditional in-clinic MAB offered before the PHE at a Massachusetts safety-net primary care organization. We conducted a retrospective electronic medical record review of 267 MABs. We describe sociodemographic, care access, and complete abortion characteristics and compare differences between teleMAB and in-clinic MABs using Chi-squared test, fisher's exact test, independent t test, and Wilcoxon rank sum. We conducted logistic regression to examine differences in time to care (6 days or less vs 7 days or more). 184 MABs were eligible for analysis (137 in-clinic, 47 teleMAB). Patients were not significantly more likely to receive teleMAB versus in-clinic MAB based on race, ethnicity, language, or payment. Completed abortion did not significantly differ between groups (P = .187). Patients received care more quickly when accessing teleMAB compared with usual in-clinic MAB (median 3 days, range 0 to 20 vs median 6 days, range 0 to 32; P < . 001). TeleMAB patients had 2.29 times the odds of having their abortion appointment within 6 days compared with in-clinic (95% CI: 1.13, 4.86). TeleMAB in primary care is as effective, timelier, and potentially more accessible than in-clinic MAB when in-person mifepristone regulations were enforced. TeleMAB is feasible and can promote patient-centered and timely access to abortion care.

A second chance for a new heart? The role of metabolic and bariatric surgery in patients with end-stage heart failure

Obesity is an independent risk factor for heart failure (HF). Substantial weight loss has been shown to reverse obesity-related cardiomyopathy. This study aimed to report our institution's experience with laparoscopic sleeve gastrectomy (LSG) in patients with morbid obesity and end-stage HF. Between 2018 and 2022, 26 patients with end-stage HF were referred for LSG. Of 26 patients, 16 underwent an operation, and 10 did not. After institutional review board approval, a retrospective electronic medical record review was performed to evaluate (i) age, (ii) preoperative weight, (iii) decrease in body mass index (BMI) score, (iv) whether the patient underwent heart transplantation, and (v) mortality. Data analysis was performed using Stata/SE (version 17.0; StataCorp). The Wilcoxon rank-sum test was used to compare continuous variables between the cohorts, and the Pearson chi-square test was used for binary variables with Bonferroni correction applied. The LSG and non-LSG cohorts had comparable ages (P=.088) and starting BMI score (P=.918), and a proportion of patients had a ventricular assist device (P=.191). Patients who underwent LSG lost significantly more weight than the patients who did not, with an average decrease in BMI score of 8.9kg/m2 (SD, ±6.13) and 1.1kg/m2 (SD, ±4.10), respectively (P=.040). Of note, 6 patients (37.5%) who underwent LSG eventually underwent transplantation, compared with 2 patients (20.0%) from the matched cohort (P=.884). Of the 26 patients, there were 6 deaths: 2 (12.5%) in the LSG cohort and 4 (40.0%) in the non-LSG cohort (P=.525). LSG may be safe and effective for weight loss in patients with HF. This operation may provide patients affected by obesity with end-stage HF the lifesaving opportunity to achieve transplant candidacy.

(088) Impact of Testosterone Replacement Therapy on Adverse Cardiovascular Events in Hypogonadism Patients: A Comprehensive Evaluation of Physiological and Supraphysiological T Levels

Abstract Introduction Sustained treatment with elevated levels of exogenous testosterone (T) has been linked to various adverse events, particularly concerning cardiovascular risks. However, there is currently a lack of sufficient literature that comprehensively describes the overall safety profile of supraphysiologic testosterone levels. Objective To compare the safety profiles and rates of polycythemia, venous thromboembolism (VTE), major adverse cardiac events (MACE), deep vein thrombosis (DVT), myocardial infarction (MI), and stroke between hypogonadism patients treated with testosterone replacement therapy (TRT) at physiological and supraphysiological testosterone levels. Methods We identified patients with hypogonadism (&amp;lt;300 ng/dL) who underwent testosterone replacement therapy (TRT) at our institution through electronic medical record review. Patients lacking records of their first encounter, documented medical history, sufficient follow-up, or post-TRT adverse event data were excluded from the analysis. Supraphysiological testosterone levels were defined as &amp;gt;1000 ng/dL. The included patients were retrospectively analyzed using two-way nonparametric testing for continuous variables and chi-square and Fisher exact tests for categorical variables (α = 0.05). Results From a cohort of 537 men diagnosed with hypogonadism, we included 184 patients who underwent testosterone replacement therapy (TRT). Among these patients, 135 (73.4%) were treated to achieve physiological testosterone levels, with a median level of 468.0 ng/dL (interquartile range, IQR = 308.0-644.5), while 49 patients (26.6%) were treated to attain supraphysiologic testosterone levels, with a median level of 1552 ng/dL (IQR = 1279-1700). Before initiating TRT, there was no significant difference in testosterone levels between the two groups (p = 0.11). Moreover, no significant differences were found between the groups in terms of a history of diabetes mellitus (DM; p = 0.422) or prostate cancer (p = 0.29). However, significant differences were observed in the history of hypertension (HTN; p = 0.003) and hyperlipidemia (HLD; p = 0.006), with more patients in the physiologic testosterone group having a diagnosis of HTN and HLD prior to treatment. Regarding adverse events, there were more cases of polycythemia in the supraphysiologic testosterone group compared to the physiologic testosterone group (p &amp;lt; 0.001; 35.4% vs. 7.0%). Interestingly, there was no significant difference in the rate of other adverse events after TRT between the two groups, including venous thromboembolism (VTE; p = 0.285), major adverse cardiovascular events (MACE; p = 0.768), deep vein thrombosis (DVT; p &amp;gt; 0.999), myocardial infarction (MI; p = 0.562), and stroke (p &amp;gt; 0.999). Conclusions Despite widespread concerns, these findings suggest that although patients treated to achieve supraphysiologic testosterone levels had a higher incidence of polycythemia, there were no significant differences in the rates of other adverse events after TRT between patients treated to attain physiological versus supraphysiologic testosterone levels. Disclosure Any of the authors act as a consultant, employee or shareholder of an industry for: Consultant for AbbVie, Marius, Tolmar, Endo, Petros, Boston Scientific, Coloplast Investor: Sprout.

Early Clinical Outcomes of “Lemon-Dropped” Complex Primary Total Joint Arthroplasty Patients to a Tertiary Care Center

BackgroundIn the era of value-based care, pressures lead to cherry-picking healthier patients and lemon-dropping riskier patients to higher levels-of-care. This study examined whether “lemon-dropped” primary total joint arthroplasty (pTJA) patients require increased health care resources and experience worse outcomes. MethodsThis was a retrospective cohort study of all pTJAs at one tertiary care center in 2022, excluding bilaterals, acute fractures, oncologic cases, and conversion hips. Patients were classified via referral pattern as simple or complex (referred for medical or surgical complexity). Primary outcomes were implant costs and any emergency department visit, readmission, reoperation, or complication within 90 days. Secondary outcomes were distance traveled to the hospital, anesthesia type, estimated blood loss, case duration, time in the recovery unit, length of stay, and discharge disposition. Outcomes were assessed via electronic medical record review and analyzed via Fisher’s exact and unpaired Welch’s t-tests. ResultsIn total 641 pTJAs (322 hips, 319 knees) met inclusion criteria; 10.3% were complex referrals. Complex patients were younger (59 versus 66 years, P < .05) and more often non-White (41 versus 31%, P < .001), non-English speaking (11 versus 7%, P < .001), and had nonprimary osteoarthritis as a surgical indication (59 versus 12%, P < .001), but had similar Charlson Comorbidity Index and American Society of Anesthesiologists scores. Complex patients had increased odds of 90-day emergency department visits (OR [odds ratio] = 2.11, P = .04), 90-day complications (OR = 2.63, P < .001), and non-home discharge (OR = 2.60, P = .006); higher mean relative implant costs (1.31x, P < .001); longer time in the operating room (181 versus 158 minutes P < .001), time in surgery (125 versus 105 minutes, P < .001), and length of stay (3.2 versus 1.7 days, P = .005). Conclusions“Lemon-dropped” pTJAs had worse early clinical outcomes and higher health care utilization, despite a control group with patients ill enough to utilize a tertiary care center as their medical home. Reimbursement models and evaluation metrics must account for these differences.

Abstract TMP86: Effects of Tenecteplase versus Alteplase in Stroke Patients With Large Vessel Occlusions Who Achieve Full Recanalization

Introduction: Tenecteplase improves reperfusion and functional outcomes in stroke patients with large vessel occlusion. TNK is more specific for fibrin than TPA, however, it is unclear if this effect could increase efficacy of mechanical thrombectomy (MT). We aimed to determine if TNK is associated with higher recanalization rates and better clinical outcomes than TPA in patients who undergo MT. Methods: Electronic medical record review of acute stroke patients with LVO, age over 18 years, who received both thrombolysis with either TNK or TPA, and underwent MT at a tertiary medical center from January 2017 to April 2023 was performed. Use of TPA was converted to TNK on 1/11/2022 per hospital policy. Number of passes and time to full recanalization (defined as TICI 3) were recorded. Primary outcome was mRS at 90 days. Secondary outcomes were NIHSS at 24 hours and at discharge. Primary safety outcome was parenchymal hematoma type 2 (PH2) intracerebral hemorrhage. A t-test was used to examine association between outcomes and thrombolysis type. Fischer’s exact test was used to determine differences in recanalization and hemorrhage rates. Results: Of the 284 patients included, 213 received TPA and 71 received TNK. Mean age was 68, and 50.0% were females. Forty-three patients (60.6%) who received TNK, and 96 patients (45.1%) who received TPA achieved TICI 3 score (P=0.028). There was no difference in time to recanalization (38.5 min versus 32 min, p=0.872), median number of passes (1 versus 1, p=0.934), median 90-day mRS (2 versus 1.5, p=0.434), or the rate of PH2 hemorrhage (0% versus 2.3%, p=0.336) for TNK vs TPA in patients with TICI 3 recanalization. Median NIHSS at presentation (18.0 versus 16.0, p=0.398), at 24 hours (8.0 versus 7.0, p=0.406), and at discharge (3.0 versus 4.0, p=0.383) were similar for all patients receiving TNK and TPA, respectively. Conclusions: In our retrospective analysis, TNK showed a higher rate of TICI 3 recanalization for patients with LVO, who both received thrombolysis and underwent MT. There was no difference between TNK and TPA for number of passes, time to recanalization, parenchymal hematoma rate, and clinical outcomes in patients who achieved TICI 3. Overall clinical outcomes were also similar, irrespective of recanalization grade.

Predictors of Anterior Cruciate Ligament Re-tear and Return to Sport in Adolescent Athletes

Objectives: The purpose of this study was to characterize recent epidemiologic trends of ACL injuries and re-tear rates in high school adolescents and determine variables associated with sustaining secondary ACL injury. We hypothesized protective rehabilitation factors (i.e., greater time to return to sport, formal sport clearance, and physical therapy compliance) would decrease the risk of secondary ACL injury. Methods: A prospectively maintained database from a single institution with standardized data collection focused on ACL injuries was retrospectively reviewed for all patients 18 or younger who underwent primary ACL reconstruction between 2015 to 2020. Patients were eligible for inclusion in this study if they were between the ages of 13-18 years old, participated in sporting activity in high school, and underwent evaluation and primary ACLR at a single institution. Electronic medical records (EMR) were reviewed for patient demographic information and documentation review from prior injury/surgery. This information included the following: age, sex, body mass index (BMI), school grade (if documented), race, sport played, mechanism of injury (contact versus non-contact), time to return to sport (RTS), and number of post-operative physical therapy (PT) visits. Injury in contact and non-contact sport were defined based on the level of impact on the mechanism of injury sustained. Contact injury was defined as impacted collision with another person or object directly prior to injury onset. Non-contact injuries include isolated twisting movements of the knee without a sustained direct impact injury due to another player or object. Time to RTS was defined as the number of months following ACL reconstruction surgery until the patient was documented clear to return to sporting activity by the operating surgeon. Number of PT visits was calculated by EMR review of documented PT visits. Results: A total of 387 pediatric patients were included in statistical analysis. Of these patients, 72 (19%) sustained a secondary ACL injury and 315 (81%) did not. The overall mean age at primary ACLR and standard deviation was 16.0 ± 1.4 years (range 12-18 years). By univariable analysis, age at primary ACLR, time to RTS, and follow-up duration were all associated with secondary ACL injury (p &lt; 0.05). Patients with a secondary ACL injury were significantly younger than those who did not sustain a subsequent ACL tear (16.2 ± 1.3 versus 15.5 ± 1.6 years, respectively, p = 0.0026). Time to RTS following primary ACL injury was shorter in patients who sustained a secondary ACL injury (7.9 ± 2.0 months versus 8.9 ± 2.5 months, p = 0.0361). Cox regression analysis performed demonstrated as age at primary ACLR increases by 1 year, the rate of secondary ACL injury decreases by 29%. Similarly, a 1-month delay in return to sport decreases the rate of secondary ACL injury by 17%. Conclusions: Younger age and longer time to return to sport following ACL injury are significant variables associated with sustaining secondary ACL injury in the pediatric patient population. Counseling of young adolescent athletes should include adequate physical therapy compliance and allowing for adequate healing and time to return to sport.

Outcomes in patients with pancreatic and ampullary cancer whose tumors harbor pathogenic APC mutations.

693 Background: APC (adenomatous polyposis coli) is master regulator of the WNT signaling and beta-catenin pathway. Pathogenic (path) mutations in APC are well known for their connection to familial adenomatous polyposis, but germline (G) mutations in APC can give rise to other cancers, and somatic (S) mutations in APC can be found in multiple cancer subtypes. The clinical relevance for tumors that harbor path APC mutations is unknown. Methods: An established database of patients whose tumors have undergone genetic testing (Next-generation DNA sequencing, NGS) was queried for the presence of an APC mutation. Each APC mutation identified was assessed using the NCI Clinvar data base for determination of a path/likely path APC mutation. Patient/disease characteristics and treatment (tx) information were captured from electronic medical record review. Median overall survival (OS) was defined from the time of diagnosis of advanced/metastatic disease until death. Median time to progression (TTP) for each tx regimen was defined from the initiation of tx until documented disease progression. Results: A database of over 13000 patients entered from 2018 to present included 133 patients (1%) with G- or S-APC mutations, of which 41 were identified as path/likely path. Of the 41 patients, 56% were male, 73% were Caucasian and 24% African Americans, with a median age of 67 (range 34-90). Only 32% of patients had known G-APC mutations, but 34% had a second primary cancer, and 37% had a family history of known G-APC mutation-associated cancers. Only one patient had clinical manifestations of a polyposis syndrome. Of the 13 patients with known G-APC mutations, clinical characteristics were similar to the larger group, except that 100% of the G-APC-mutated patients were Caucasian, and the rate of family history of APC-associated cancers was 54%. Fifty-four percent of the overall group of 41 patients had a pathological diagnosis of pancreatic cancer, while the remaining 46% were ampullary or duodenal cancers. (Only 2 patients [5%] had tail of the pancreas cancers). Of the 37 patients who had somatic tumor NGS, only 70% harbored a KRAS gene mutation. For the OS analysis (n=24), the mOS was 11.7 months (range 5.2 – 56.9). Of the 22 patients evaluable for TTP, the mTTP for 5FU-based tx was 5.8 months, and 6.4 months for gemcitabine-based tx. Conclusions: APC-mutated pancreatic and ampullary cancers are uncommon, but exhibit survival rates, as well as TTP on both 5FU and gemcitabine-based txs that are similar to that seen with most pancreatic adenocarcinomas. However, 30% of APC-mutated cancers are KRAS wild type, and may harbor other driving mutations. As the loss of APC function triggers an accumulation of beta-catenin, targeted therapies that inhibit beta-catenin-regulated transcription and downregulate WNT-related signaling could be a promising tx approach for patients whose tumors harbor path/likely path APC mutations.

Factors Affecting Patient Reported Outcomes Following Tibial Plateau Fracture

Background/Objective: &#x0D; Tibial Plateau Fractures (TPFs) account for ~1% of all fractures and ~8% of all fractures in the elderly. Despite the frequency and severity of TPFs there is a paucity of data evaluating factors that affect patient recovery after injury and surgical fixation. We hypothesized that patient reported outcomes are modulated by several variables including patient demographics, comorbidities, injury characteristics, and Social Determinants of Health (SDH).  &#x0D; Methods: &#x0D; In this retrospective cohort study, we collected the interval patient reported outcome scores (PROs) of patients with TPFs treated with open reduction internal fixation occurring between February 2013 and November 2020. PROs included 1) Visual Analog Scale (VAS) pain scores, 2) Patient-Reported Outcomes Measurement Information System (PROMIS) Pain Interference (PI) scores, and 3) Physical Function (PF) survey scores. Patient demographics, comorbidities, fracture characteristics, insurance status, and area deprivation index (ADI) of the patient’s residence were collected via electronic medical record review. Bivariate analyses of PRO scores to the aforementioned factors were performed using generalized estimating equations to account for participant repeated measures, with p&lt;0.05 being considered significant. &#x0D; Results: &#x0D; 196 patients were evaluated with &gt;1 year follow-up. It was determined that patients’ insurance status affected their VAS (p0&lt;.001), PI (p&lt;0.001), and PF (p&lt;0.001) scores. Patient ADI affected VAS (p&lt;0.001) and PI (p=0.0026), with increased ADI scores resulting in worse PROs. Diabetes and depression were found to negatively impact VAS (p=0.010 &amp; 0.008 respectively) and PI (p=0.0044 &amp; 0.0048, respectively). Additionally, age and sex both influence VAS (p=0.0006 &amp; 0.0033, respectively), and compartment syndrome was associated with decreased PF (p=0.0206).  &#x0D; Conclusion and Potential Impact: &#x0D; To our knowledge, this is the first investigation to evaluate the effect of SDH on patient recovery following surgical fixation of TPFs—suggesting that insurance status and residence ADI scores are associated with worsened PROs. Further investigation is necessary to identify if these factors are independent of other covariates. 

Is Subcapital Realignment for Slipped Capital Femoral Epiphysis a Reproducible Technique? Midterm Results.

The modified Dunn procedure, which is based on the development of an extended retinacular flap containing the blood supply for the femoral head, allows anatomic reestablishment in patients with moderate to severe slipped capital femoral epiphysis (SCFE). Some controversy exists regarding the short-term to midterm risk of avascular necrosis (AVN) and other complications resulting from the surgical technique. (1) What percentage of patients treated with an extended retinacular flap during the modified Dunn procedure for SCFE with a moderate (slip angle from 30° to 60°) or severe slip (slip angle equal or greater than 60°) develop symptomatic AVN, and what percentage underwent further surgery or had other complications? (2) What femoral head-neck alignment and position parameters relative to the greater trochanter are achieved after surgery? (3) Can we identify radiographic signs of osteoarthritis at a minimum of 4 years after surgery? Between January 2006 and December 2018, we treated 61 patients for SCFE. During this time, we generally used the modified Dunn procedure when the slip angle was ≥ 30°. Based on this indication, the modified Dunn procedure was performed in 37 patients (41 hips) during that time period, and those patients were potentially eligible for this retrospective study. Because bilateral hips in the same patient are not statistically independent, for our analyses, we analyzed only the hip with the longer follow-up time. Of those who remained, 11% (4) were lost before the minimum study follow-up of 48 months or had incomplete datasets, leaving 89% (33) for analysis here at a median follow-up of 80 months (range 49 to 208 months). Periacetabular osteotomy or subtrochanteric rotational femoral osteotomy was added under the same anaesthesia time in 33% (11 patients). We added periacetabular osteotomy in 24% (8) when intraoperative anterior instability was present in external rotation. A femoral rotational osteotomy was added in 9% (3) when posterior instability was present in flexion and internal rotation. The mean ± standard deviation age at the time of surgery was 13 ± 1 years, and 33% (11 of 33) of patients were female. The mean slip angle was 51° ± 16º, and 15% (5) of hips had unstable slips, defined as an inability to walk with or without crutches. We documented chronic presentations in 82% (27) of patients, acute and chronic in 12% (4), and acute in 6% (2). The rate of symptomatic AVN was determined by reviewing all radiographs obtained at the latest follow-up interval. Further surgery and other complications were assessed through an electronic medical record review. Radiographic morphologic parameters were measured before surgery and at a minimum follow-up of 4 years by two senior orthopaedic surgeons. Radiographs obtained at the latest follow-up visit were also screened for signs of osteoarthritis by the same surgeons. At the latest follow-up, 3% (1 patient) of patients developed symptomatic AVN and underwent further surgery and 3% (1) underwent revision surgery for screw breakage after a high-energy fall. Postoperatively, the alpha angle was restored to 39º ± 6º, the anterior head-neck offset was restored to 8 ± 3 mm, the neck-shaft angle was 136º ± 6º, and the presence of a positive Klein line decreased from 64% (21 hips) to 0% (0 hips). No patients showed radiographic signs of osteoarthritis at the minimum follow-up of 4 years. In this series, the modified Dunn procedure in moderate and severe slips was a reproducible procedure, and few patients developed symptomatic AVN or experienced other complications. Hip morphology was restored, but a longer follow-up duration and a detailed analysis of the results from other centers is warranted to assess the possible long-term risk of progression to AVN or osteoarthritis. Level IV, therapeutic study.

Correlates of Depression in ART Adherence among Youths in Lilongwe, Malawi.

Despite collaborative efforts to improve mental health services among youths living with HIV (YLHIVs) aged 15-24, evidence shows that many suffer from depression. We established the correlates of depression and how it affects ART adherence. Structured questionnaires, a Patient Health Questionnaire 9 depression scale assessment, in-depth interviews, and Electronic Medical Record reviews were conducted at the Lighthouse Trust Martin Preus Centre (MPC) ART clinic in Lilongwe from April 2021 to October 2022. A total of 303 YLHIVs aged 15-24 were on ART, and 7 key informants were recruited. Bivariate and multivariate logistic regression analyses were performed using STATA V14.1. A thematic content analysis was used for qualitative data. Forty-six per cent of recruits were male, and fifty-four per cent were female. Seventy-one per cent were aged 20-24, and twenty-nine per cent were aged 15-19. Twenty-three per cent of the YLHIVs had depression symptoms, of whom seventy-nine per cent were aged 20-24 years. Twenty-two per cent had an unsuppressed viral load (non-adherent). Sixty-seven per cent of non-adherent participants were aged 20-24. There was no factor associated with ART non-adherence. Source of income (p = 0.003), alcohol consumption (p = 0.010), and sexual behaviour (p = 0.014) were associated with depression. Sexual behaviour was statistically significantly associated with depression (p = 0.024. The themes were a lack of basic needs, a lack of privacy, psychological trauma, incomplete disclosure, a shortage of psychosocial providers, and a knowledge deficit of ART providers to screen for depression. This study shows that depression is considerably high among YLHIVs in Malawi and linked to ART non-adherence. Strengthening mental health training for providers and routinely screening YLHIVs for depression would help in the early identification and management of depression, thereby improving ART adherence.

Complications following surgical management of Haglund's triad: A retrospective, single-center analysis

BackgroundHaglund's triad consists of Haglund's deformity, insertional Achilles tendinosis, and retrocalcaneal bursitis and is most commonly managed surgically through Haglund's resection, bursectomy, and Achilles tendon detachment-reattachment using a central tendon-splitting approach stabilized with a double row suture construct. This procedure has demonstrated consistently good outcomes; however, we have anecdotally identified a higher complication rate performing this surgery compared with the published literature. Accordingly, we sought to evaluate this further. MethodsWe performed a retrospective electronic medical record review of 44 consecutive patients (10 men, 34 women) who underwent surgical correction of Haglund's triad. Patient age, gender, laterality, body mass index, follow-up duration, complications encountered, and revision surgery performed were analyzed. ResultsSignificant differences were identified for gender and incidence of complications (p = 0.01424), with women having a greater incidence of complications than men and duration of follow-up (p = 0.0432) where women endured a longer follow-up period. No other significant differences for complications were identified for age (p = 0.192), laterality (p = 0.5535), or body mass index (p = 0.9532) irrespective of gender. Complications occurred in 50 % of patients with most complications persisting at the final follow-up. ConclusionWe identified a significantly greater incidence of complications for women compared to men for operative management of Haglund's triad regardless of age, laterality, or body mass index. Further analysis of the effect gender has on operative management of Haglund's triad seems warranted so that measures to mitigate complications can be developed, especially since complications persisted for those patients who encountered them which negatively affected their outcomes. Level of EvidenceIII-Therapeutic study: Retrospective comparative analysis at a single institution CategoryRearfoot and Ankle Reconstruction

Cerebral autoregulation monitoring using the cerebral oximetry index after neonatal cardiac surgery: A single-center retrospective cohort study

ObjectiveTo investigate whether cerebral autoregulation is impaired after neonatal cardiac surgery and whether changes in autoregulation metrics are associated with different congenital heart defects or the incidence of postoperative neurologic events. MethodsThis is a retrospective observational study of neonates undergoing monitoring during the first 72 hours after cardiac surgery. Archived data were processed to calculate the cerebral oximetry index (COx) and derived metrics. Acute neurologic events were identified by an electronic medical record review. The Skillings-Mack test and the Wilcoxon signed-rank test were used to analyze the evolution of autoregulation metrics over time; the Mann-Whitney U test was used for comparison between groups. ResultsWe included 28 neonates, 7 (25%) with hypoplastic left heart syndrome and 21 (75%) with transposition of the great arteries. Overall, the median percentage of time spent with impaired autoregulation, defined as percentage of time with a COx >0.3, was 31.6% (interquartile range, 21.1%-38.3%). No differences in autoregulation metrics between different cardiac defects subgroups were observed. Seven patients (25%) experienced a postoperative acute neurologic event. Compared to the neonates without an acute neurologic event, those with an acute neurologic event had a higher COx (0.16 vs 0.07; P = .035), a higher percentage of time with a COx >0.3 (39.4% vs 29.2%; P = .017), and a higher percentage of time with a mean arterial pressure below the lower limit of autoregulation (13.3% vs 6.9%; P = .048). ConclusionsCOx monitoring after cardiac surgery allowed for the detection of impaired cerebral autoregulation, which was more frequent in neonates with postoperative acute neurologic events.

Factors influencing outcome in patients with perforated peptic ulcer disease at a South African tertiary hospital.

Perforated peptic ulcer (PPU) is associated with significant morbidity and mortality, particularly in low to middle income countries. This study aimed to scrutinise the clinical course of patients diagnosed with PPU and identify modifiable factors to improve outcomes. A retrospective review of the hybrid electronic medical record (HEMR) database at Grey's Hospital was performed. All patients diagnosed with PPU between January 2013 and December 2020 were entered into the study. The variables collected include age, ethnicity, comorbid profile, Boey score, type of surgery performed and complications. These factors were analysed to determine the factors responsible for morbidity and mortality. One hundred and ninety four patients were diagnosed with PPU during the study period. Six patients were treated non-operatively, all of whom survived. In the surgically treated group, omental patch repair was performed in 159 (84.5%) patients, and primary closure in 26 (13.8%) patients. The leak rate was 32% in the cohort that underwent relaparotomy and the overall mortality was 14%. There was no significant relationship between the type of repair performed and outcome. All patients had a Boey score of 1 or more. The following factors were found to increase the probability of in-hospital mortality: age > 40 years (OR: 8.49, 95% CI 2.46-29.29 p < 0.01), female gender (OR: 2.509, CI 0.98-6.37, p = 0.048), need for relaparotomy (OR: 0.398, CI 0.17-0.91, p = 0.027) and Boey score > 1 (OR: 46.437, CI 6.13-350.28, p < 0.01). A Boey score > 1 was the only variable that increased the likelihood of finding a leaking repair at relaparotomy (p < 0.01). The Boey score was a significant predictor of mortality and leak rate in our patients with PPU. Adding age as a variable may improve the ability to predict mortality in our setting, while the impact of gender and ethnicity needs further investigation.

Time to Resolution of Iron Deficiency: A 10-Year Single State Retrospective Review

Introduction: Iron deficiency can have clinical consequences even without anemia, including fatigue, exercise intolerance and mood disorders. The time from laboratory diagnosis to resolution of iron deficiency has not been previously evaluated. Methods: In a retrospective review of electronic medical record (EMR) data from a single state health system, we identified patients meeting laboratory criteria for iron deficiency (defined as a ferritin level &amp;lt; 25 ng/mL). Patients with at least one follow-up ferritin level of any value within 3 years were included in the final cohort. Patients with a follow-up ferritin &amp;gt; 50 ng/mL at any time point within 3 years were classified as having resolved iron deficiency. Diagnoses of interest included iron deficiency anemia (IDA), as well as other conditions where iron deficiency is routinely assessed and treated irrespective of anemia, namely heart failure (HF) and restless leg syndrome (RLS). Descriptive statistics and time to event analyses (via Cox proportional hazards regression) were performed to determine time to resolution of iron deficiency in the cohort and characteristics predictive of achieving resolution. Results: We identified 13,084 patients with iron deficiency detected between 2010 to 2020. The majority of patients were female (86.6%) and White (79.3%); 57.3% had an EMR diagnosis of IDA (Table 1). We found that 5,485 (41.9%) had resolution of iron deficiency within 3 years of diagnosis, while 7,599 (58.1%) had unresolved iron deficiency. Among those with resolved iron deficiency, the median time to resolution was 1.9 years (IQR 0.8, 3.9 years). Factors associated with resolution of iron deficiency included increasing age (aHR 1.42 [95% CI 1.31 - 1.54], p &amp;lt; 0.001 for age &amp;gt; 60), male gender (1.49 [1.39 - 1.59], p &amp;lt; 0.001) and a diagnosis of HF (1.23 [1.11 - 1.36], p &amp;lt; 0.001) (Table 2). Black race (0.75 [0.68 - 0.83], p &amp;lt; 0.001) and absence of an EMR diagnosis of IDA, HF or RLS (0.75 [0.71 - 0.81], p &amp;lt; 0.001) were associated with a lower likelihood of iron deficiency resolution. Conclusion: Prolonged and unresolved iron deficiency were prevalent in this cohort, with young age, female gender and Black race increasing risk of non-resolution. Interventions are needed to raise awareness of the clinical consequences of non-anemic iron deficiency and of diagnostic ferritin thresholds.