Electronic Medical Record Search Research Articles

Social Media Use Among Young Adults With Connective Tissue Disorders: Cross-Sectional Pilot Study.

BackgroundYoung people with genetic conditions often face challenges coping with their health condition. It can be difficult for them to meet someone with a similar condition, which is important for reinforcement of chronic illness management recommendations. Social media is used by 97% of young people in the United States and may provide those with these disorders a space for emotional expression and support. However, there is a scarcity of literature related to the use of social media among adolescents with genetic conditions as an indicator of their perception regarding their own condition.ObjectiveThe purpose of this pilot study was to obtain preliminary data to assess and understand social media use by young people with connective tissue disorders and determine whether they use social media to connect with patients with similar conditions or whether they would be interested in doing so.MethodsWe undertook a pilot study of selected connective tissue disorders occurring in young people between the ages of 11 and 25 years, including Marfan syndrome; Ehlers-Danlos syndrome subtypes classical, classical-like, cardiac-valvular, and vascular; Beals congenital contractual arachnodactyly; and Alport hereditary nephritis. The study took place within one pediatric clinical system. Patients were identified through electronic medical record search and International Classification of Diseases, Ninth Revision, coding at a Midwest university–based clinical system. Study subjects completed a short survey describing their experiences with their connective tissue disorders, their means of self-expression, their existing network of persons to communicate with, and their use of social media. Data analysis included nominal and bivariate regressions to compare social media use in relation to age.ResultsOur 31 participants (42% response rate) were 55% female (17/31) and their average age was 18 years (SD 5). All participants used social media and there were no statistically significant differences between social media use and age. The majority of participants (25/30, 83%) reported that they never used social media to discuss their condition (P=.09), and only 17% (5/30) knew someone online with a similar condition (P=.50). Most participants (19/30, 63%) said they would communicate with someone with a similar disorder (P=.64).ConclusionsWe found that young individuals with connective tissue disorders use at least one type of social media. A majority did not use social media to discuss their condition or know someone online with a similar condition. However, many persons were interested in finding others similarly affected. Social media could serve as a platform for young people with connective tissue disorders to connect. Peer support is important in disease management and adolescent development. Future studies should aim at understanding social media use among young people with connective tissue disorders and helping them connect with other people who have similar conditions.

Asthma is associated with increased risk of intubation but not hospitalization or death in coronavirus disease 2019

Asthma is associated with increased risk of intubation but not hospitalization or death in coronavirus disease 2019

Stump Appendicitis: Clinical and CT Findings

OBJECTIVE. Recurrent inflammation of the appendiceal stump after appendectomy is rare; published case series have included no more than six patients. The purpose of this study was to report the clinical and CT findings in a larger original series. MATERIALS AND METHODS. A combined PACS and electronic medical record search identified the cases of 14 patients (nine men, five women; mean age, 42.8 years) with a confident diagnosis of stump appendicitis evaluated at CT. In seven cases, CT images obtained at the initial presentation of appendicitis were available for review. Relevant clinical and CT findings were reviewed by three abdominal radiologists in consensus. RESULTS. The mean time interval between initial appendectomy and stump appendicitis was 5.1 years (range, 5 weeks-17.5 years); seven cases occurred within 1 year of appendectomy. Ten (71%) of initial appendectomies were performed by a laparoscopic approach. CT showed the mean appendiceal stump length was 3.2 cm (range, 1.3-7.0 cm); residual stump length measured 2 cm or longer in all but one case. Appendicoliths were identified at the stump in seven (50%) cases; the mean diameter was 0.9 cm and mean maximal attenuation, 247 HU. Extensive inflammatory changes surrounded the appendiceal stump at CT in all cases, including peristump abscess in four (29%) cases. Seven of the 14 patients (50%) went on to open surgical management with either remnant appendectomy or partial ileocecectomy. CONCLUSION. Stump appendicitis has a characteristic CT appearance and may occur within the first year after appendectomy or many years later. A long (≥ 2 cm) appendiceal stump from laparoscopic appendectomy and retained appendicolith may predispose adult patients to recurrent obstruction and inflammation.

330 Preliminary Report of Drive Through COVID-19 Screening Process in a Large Suburban Hospital

Study Objective: During the COVID-19 pandemic, the volume of patients presenting to the emergency departments (EDs) exceeded ED capacities. Many health systems have implemented drive-through (DT) screening and testing for patients with COVID-19 symptoms for public health screening and to add to surge capacity. The objective of this investigation was to describe both the testing and clinical outcomes of patients evaluated by a hospital system-based DT screening strategy early in the 2020 COVID-19 pandemic. This is a retrospective, observational study of patients who were triaged to a DT COVID-19 screening area at one of eight hospitals in the health system between March 12 and April 15, 2020. Patients were evaluated by Advanced Practice Providers (APPs) through a car window, with vital signs, a focused clinical evaluation, and nasopharyngeal swabs for COVID-19 per clinical judgment. Post-evaluation instructions for care were also provided. An electronic medical record search was performed to identify patients’ returns to the EDs and their return disposition. Outcomes were return visits, disposition on return, mortality, and results of COVID-19 testing for those tested. During the study period, we included 7061 patients from all hospitals (Range 12-2660/hospital) of which 58.0% were female, and 48.0% Caucasian. The average age of subjects was 44.1 y/o (Range 0-97). Abnormal vital signs were identified in 1633(23.1%) patients on initial DT. Of those 296(4.2%) had a fever >=100.4 F, 1355(19.2%) had tachycardia (HR>100 bpm), 174(2.5%) had hypoxia (SpO2<94%), 7(0.09%) were hypotensive (Sys BP<90), and 26(0.4%) had tachypnea (R>24). COVID-19 testing was performed for 1407(19.9%) patients during the initial DT screening of whom 381(27.1%) were positive for COVID-19-19. An in-system ED revisit occurred in 688(9.7%) patients with a median(IQR) time from initial DT evaluation of 4.3(2.2) days. Returning patients were admitted 27.7% of the time (185/668). Revisit rates were slightly decreased when testing was done during the initial drive through (7.9% vs 9.9%, p=0.03). Of admitted patients, 9/668 died during hospitalization. DT screening for COVID-19 appears to be an effective tool to provide screening and augment surge capacity during this pandemic. Limitations of this work include an early pandemic study population with a high prevalence of disease, and a follow-up method that utilized a single health system which may have underestimated the rate of return visit. However, we identified that a measurable proportion of patients required emergency evaluation, with complications including hospital admission and death. We identify the need for DT screening programs to incorporate outcome measurements into their program.

INCIDENTAL RIGHT VENTRICULAR ABNORMALITIES ON SINGLE PHOTON EMISSION CT SCAN SIGNIFICANTLY PREDICTS DEVELOPMENT OF PULMONARY HYPERTENSION IN BLACK FEMALES

SESSION TITLE: Pulmonary Vascular Disease Posters SESSION TYPE: Original Investigation Posters PRESENTED ON: October 18-21, 2020 PURPOSE: Single Photon Emission Computed Tomography (SPECT) imaging is a diagnostic tool used to risk-stratify patients presenting with chest pain for myocardial ischemia. While SPECT abnormalities of the right ventricle (RV) are known to correlate with invasive hemodynamic measures of disease severity and prognosis in patients with pulmonary hypertension (PH), the prognostic significance of isolated RV abnormalities on SPECT studies in black females who do not carry a PH or cardiac diagnosis is unknown. METHODS: This was a retrospective study. Using the electronic medical record search engine (EMERSE) tool, we identified 12,000 SPECT studies completed at our center between 1/1/07 and 1/1/20. After excluding studies with abnormalities of left ventricular perfusion, elevated cardiac risk, and previous diagnoses of PH, and focusing on black females, we identified 943 unique studies for analysis, and categorized them by the presence or absence of RV abnormalities, including hypertrophy, dilation, or increased uptake. Patient characteristics, including age and body mass index (BMI) at the time of index SPECT study (time zero), were obtained from the medical record, and patients were followed until either an event occurred or the study period ended (2/1/20). The primary outcome was mortality, secondary outcomes included hospital admission and a diagnosis of PH, defined as an estimated right ventricular systolic pressure (RVSP) > 35 mmHg on echocardiogram. Patients lost to follow-up were censored at the time of their last clinical encounter. Multivariable Cox Proportional Hazards models and logistic regression models, adjusted for age and BMI, were used in the analysis. This study was reviewed and approved by the UC Institutional Review Board (IRB 2019-1282). RESULTS: A total of 943 black females were included in this analysis, with a median age of 52 years and a median BMI of 33. The median duration of follow-up was 10.5 years, and 10.3% of patients died during the follow-up period. In the full cohort, RV abnormalities were present in 4% of patients, and PH was subsequently diagnosed in 18.3% of patients during follow-up (median RVSP 45 mmHg). Age was the only significant predictor of readmission (HR 1.01, p=0.007) or mortality (HR 1.07, p=1E-14). RV abnormalities (OR 3.2, p=0.001), age (OR 1.04, p=4E-8), and BMI (OR 1.02, p=0.004) all significantly and independently predicted development of PH. CONCLUSIONS: RV abnormalities incidentally found on otherwise normal SPECT studies were significantly predictive of the development of PH in black females, even after adjustment for age and BMI. The combination of these factors may be useful in risk-stratification of black female patients for PH, and identify high-risk patients who would benefit from a more comprehensive workup for PH and serial echocardiographic evaluation. CLINICAL IMPLICATIONS: RV abnormalities on SPECT imaging may help risk-stratify black females for PH DISCLOSURES: no disclosure on file for Rachel Baker; Chair of a Committee relationship with PHA Please note: PHA Medically Led Sessions, PHA Preceptorship Added 05/22/2020 by Jean Elwing, source=Web Response Removed 05/22/2020 by Jean Elwing, source=Web Response Educator relationship with PH CME Programs - PHA, Simply Speaking, Impact PH Please note: Intermittent, Ongoing Added 05/22/2020 by Jean Elwing, source=Web Response, value=Honoraria Principal Investigator relationship with Actelion, Arena, Reata, United Therapeutics Please note: Ongoing - University is Paid Directly Added 05/22/2020 by Jean Elwing, source=Web Response, value=Grant/Research Support Advisory Committee Member relationship with United Therapeutics Please note: $5001 - $20000 Added 06/05/2020 by Jean Elwing, source=Web Response, value=Consulting fee Principal Investigator relationship with Lung LLC, Liquidia, Phase Bio, Complexa, Gossamer Bio Please note: Ongoing - University is Paid Directly Added 05/22/2020 by Jean Elwing, source=Web Response, value=Grant/Research Support Member of a Committee relationship with PHA Please note: PHA Education Committee Added 05/22/2020 by Jean Elwing, source=Web Response Removed 05/22/2020 by Jean Elwing, source=Web Response Advisory Committee Member relationship with Liquidia, Acceleron Please note: $1001 - $5000 Added 06/05/2020 by Jean Elwing, source=Web Response, value=Consulting fee Advisory Committee Member relationship with Acceleron Please note: $5001 - $20000 Added 06/05/2020 by Jean Elwing, source=Web Response, value=Consulting fee Removed 06/05/2020 by Jean Elwing, source=Web Response Grant - Entelligence Award relationship with Actelion Please note: >$100000 Added 05/25/2020 by Arun Jose, source=Web Response, value=Grant/Research Support No relevant relationships by Francis McCormack, source=Web Response No relevant relationships by Humna Abid Memon, source=Web Response

Dorsal Midbrain Syndrome: Clinical and Imaging Features in 75 Cases.

Dorsal midbrain syndrome (DMS) consists of a constellation of clinical features, including reduced upgaze, pupillary light-near dissociation, lid retraction, convergence retraction, and eye misalignment. This syndrome results mostly from intrinsic or extrinsic mesodiencephalic tumors or strokes, obstructive hydrocephalus, failure of cerebrospinal fluid shunting to correct obstructive hydrocephalus, and head trauma. Published reports that include imaging corroboration are based on relatively small cohorts and have not included comprehensive patient self-reports on the impact of these abnormalities on quality of life. We conducted a retrospective review of cases of DMS identified between 1998 and 2019 at the University of Michigan using the Electronic Medical Record Search Engine. Patients were included only if they had been evaluated by a neuro-ophthalmologist and had a corroborative imaging abnormality. We collected data on symptoms and on neuro-ophthalmic and neurologic signs. We reviewed brain imaging reports on all 75 patients, and the study neuroradiologist analyzed the imaging in 57 patients. Using a uniform list of questions, we conducted telephone interviews of 26 patients to assess lingering symptoms and their impact on quality of life. There were 75 patients, only 5 of whom were younger than 10 years. Neoplasms accounted for 47%, strokes (mostly thalamic) for 25%, nonneoplastic masses for 12%, nonneoplastic hydrocephalus for 7%, traumatic brain injury for 5%, and demyelination for 4%. Reduced upgaze occurred in 93% of patients, being completely absent or reduced to less than 50% amplitude in 67%. Convergence retraction on attempted upgaze occurred in 52%, horizontal misalignment in 49%, vertical misalignment in 47%, and pupillary light-near dissociation in 37%. Optic neuropathy attributed to chronic papilledema occurred in only 3%. Three or more neuro-ophthalmic signs were present in 84%, and only 4% had a single sign-reduced upgaze. Imaging features did not correlate with the frequency or severity of clinical signs. There was some improvement in the clinical signs among the patients with stroke but no change among the patients with neoplasms. In the 26 telephone interviews, patients with neoplasms reported that imbalance had a greater impact on quality of life than did diplopia. Patients with strokes reported that imbalance had the greatest impact initially but that its effect dissipated. Neither group reported lingering effects of impaired upgaze. This large series expands on the clinical profile of DMS. Neoplasms and strokes were the most common causes. Obstructive hydrocephalus alone, identified as a major cause in the largest previously published series, was uncommon. At least 3 neuro-ophthalmic signs were present in nearly all patients, with upgaze deficit as predominant. Unlike an earlier report, this study found no correlation between brain imaging and clinical signs. Neuro-ophthalmic signs persisted even after neoplasms were successfully treated and improved only slightly after stroke. Telephone interviews with patients revealed that diplopia and upgaze deficit had less lasting impact on quality of life than did ataxia and concurrent nonneurologic problems.

Patient survey reports association between compression stocking use adherence and stasis dermatitis flare frequency

To the Editor: Compression stocking use for stasis dermatitis is an effective treatment to control symptoms, especially during acute flares.1Raju S. Hollis K. Neglen P. Use of compression stockings in chronic venous disease: patient compliance and efficacy.Ann Vasc Surg. 2007; 21: 790-795Abstract Full Text Full Text PDF PubMed Scopus (220) Google Scholar The annual health care cost of stasis dermatitis is $195 to $515 million, including unnecessary hospitalizations.2Weng Q.Y. Raff A.B. Cohen J.M. et al.Costs and consequences associated with misdiagnosed lower extremity cellulitis.JAMA Dermatol. 2017; 153: 141-146Crossref PubMed Scopus (98) Google Scholar High rates of noncompliance (60%-70%) with compression stocking use have been documented, but underlying factors are not well understood.1Raju S. Hollis K. Neglen P. Use of compression stockings in chronic venous disease: patient compliance and efficacy.Ann Vasc Surg. 2007; 21: 790-795Abstract Full Text Full Text PDF PubMed Scopus (220) Google Scholar We sought to characterize the patient-reported concerns that influence adherence to prescribed use of compression stockings. A cross-sectional survey was conducted at Saint Louis University with Institutional Review Board approval. An electronic medical record search identified patients who were seen in the outpatient dermatology clinic between February 1, 2017, and May 1, 2018, and were coded with International Classification of Diseases, 10th Revision I87.2 for stasis dermatitis. We reviewed patient records to confirm a board-certified dermatologist had diagnosed stasis dermatitis and recommended compression stocking use at the most recent office visit. We contacted 111 eligible patients, and 100 consented to participate. After obtaining verbal consent by phone, a physician administered an 11-item questionnaire (available online as Supplemental Material via Mendeley at https://doi.org/10.17632/gcfvmthr24.1). A flare was defined as an uncomfortable increase in symptoms, such as edema, erythema, pruritus, or weeping. Baseline characteristics of the sample (n = 100) and responses are described in Table I. Only 26% of patients reported wearing stockings daily as recommended (ie, ≥12 hours daily). A statistically significant association (P = .02) between flare frequency and compression stocking use was observed (Fig 1). Approximately 5% of patients with daily stocking use reported very frequent flares (≥3 times weekly), whereas 64% who reported no stocking use had very frequent flares. The most common reasons cited by patients for noncompliance with the physician recommendation, listed in order of frequency, were inability to put on the stockings, discomfort, unclear how the treatment will help, and cost.Table IPatient demographics and interview responsesVariableResult∗Data are presented as number (%), as mean ± SD, or as indicated. (N = 100)Demographics and medical history Female54 (54) Age, y68.8 ± 12.0 Use of topical steroids61 (61) History of hospitalization for cellulitis22 (22)Interview responses Knowledge of physician recommended stocking use91 (91) General understanding of how stockings work74 (74) Knowledge of hours recommended by the physician<8 h/d2 (2)8-12 h/d9 (10)12-16 h/d15 (16)>16 h/d7 (8)Unknown58 (64) Knowledge of compression strength36 (39) Patient use of compression stockingsAlmost daily26 (26)2-3 times/wk11 (11)3-5 times/wk21 (21)Not at all42 (42) Hours compression stockings worn when used(n = 58)<8 h/d11 (19)8-12 h/d22 (38)12-16 h/d17 (29)>16 h/d8 (14) Number of times reason cited for noncompliance with recommended treatmentInability to put on the compression stockings31Discomfort (too tight)25Unclear how the treatment will help13Cost12Other (too hot, appearance, other medical conditions, physician's lack of emphasis)11 Patient-reported interventions to increase complianceEducation regarding tips for putting on the stockings30Prescription for a slightly lower strength of compression26Financial assistance14Additional education from the physician regarding the utility of compression stockings12∗ Data are presented as number (%), as mean ± SD, or as indicated. Open table in a new tab The cross-sectional design does not permit drawing conclusions about the temporal relationship between compression stocking use and flare prevention. Sampling from a single, Midwestern academic institution limits the generalizability, and all telephone survey research is subject to recall bias. The sample size limited our ability to conduct stratified analysis. Patients expressed frustration with the inability to apply compression stockings because of tightness, poor fit, texture, or warmth. Although not as common, some patients reported out-of-pocket cost as a barrier. Furthermore, patients reported wanting physicians to provide more education about compression stocking application and ways of relieving discomfort. Physicians can provide such education during office visits. Early morning application, professionally fitted stockings, and donning-doffing devices can be promoted. If patients cite discomfort, physicians could prescribe a lower strength or recommend an alternate material. Local medical supply companies can help reduce out-of-pocket costs and offer patient assistance in selecting optimal fit, fabric, color, and length. At the initial encounter, we recommend referral to a local medical company that can assist in optimal stocking design and coordinate insurance benefits whenever possible. At subsequent visits, we recommend physicians regularly address barriers to compression stocking use. These simple interventions can contribute to improved patient compliance with compression stocking use and reduced flare frequency.

Electronic Medical Record Search Engine (EMERSE): An Information Retrieval Tool for Supporting Cancer Research.

PURPOSEThe Electronic Medical Record Search Engine (EMERSE) is a software tool built to aid research spanning cohort discovery, population health, and data abstraction for clinical trials. EMERSE is now live at three academic medical centers, with additional sites currently working on implementation. In this report, we describe how EMERSE has been used to support cancer research based on a variety of metrics.METHODSWe identified peer-reviewed publications that used EMERSE through online searches as well as through direct e-mails to users based on audit logs. These logs were also used to summarize use at each of the three sites. Search terms for two of the sites were characterized using the natural language processing tool MetaMap to determine to which semantic types the terms could be mapped.RESULTSWe identified a total of 326 peer-reviewed publications that used EMERSE through August 2019, although this is likely an underestimation of the true total based on the use log analysis. Oncology-related research comprised nearly one third (n = 105; 32.2%) of all research output. The use logs showed that EMERSE had been used by multiple people at each site (nearly 3,500 across all three) who had collectively logged into the system > 100,000 times. Many user-entered search queries could not be mapped to a semantic type, but the most common semantic type for terms that did match was “disease or syndrome,” followed by “pharmacologic substance.”CONCLUSIONEMERSE has been shown to be a valuable tool for supporting cancer research. It has been successfully deployed at other sites, despite some implementation challenges unique to each deployment environment.

Autism and attention-deficit/hyperactivity disorders and symptoms in children with neurofibromatosis type 1.

To evaluate if autism symptoms and diagnoses are more common in children with neurofibromatosis type 1 (NF1) than in typically developing children, to which levels, and to determine if co-occurring attention-deficit/hyperactivity disorder (ADHD) symptomatology accounts for this increase. We searched hospital electronic medical records (EMR) for International Classification of Diseases, 10th Revision NF1 and co-occurring diagnoses codes. We recruited a subsample of 45 children (mean age 9y 2mo; SD 2y 7mo; range 5-12y; 22 males, 23 females) and collected parental reports of autism symptomatology, adaptive behavior, and behavioral problems that were compared to those of 360 age- and sex-matched controls from the Simons Simplex Collection (SSC) with autism spectrum disorder (ASD; SSC-ASD) or typically developing (SSC-TD). The EMR search identified 968 children with NF1; 8.8% had ADHD and 2.1% had ASD co-occurring diagnoses. In the subsample, the mean autism scale score for participants with NF1 was below cut-off for significant autism symptoms. Participants with NF1 had significantly more autism and behavioral symptoms than SSC-TD participants, and significantly less than SSC-ASD participants, with one exception: ADHD symptom levels were similar to those of SSC-ASD participants. In analyses that controlled for internalizing, ADHD, and communication scores, the difference in autism symptom levels between participants with NF1 and typically developing controls disappeared almost entirely. Our results do not support an association between NF1 and autism, both at the symptom and disorder levels. Diagnoses of attention-deficit/hyperactivity disorder (ADHD) were more common in children with neurofibromatosis type 1 (NF1) than in the general child population. Diagnoses of autism spectrum disorder were no more common in children with NF1 than in the general child population. Increases in autism symptoms did not reach clinically significant thresholds. Co-occurring ADHD symptoms accounted for increased autism questionnaire scores. Adaptive behavior in participants with NF1 showed normal socialization but lower communication proficiency.

SAT-172 FDG PET/CT in Benign vs. Malignant Adrenocortical Tumors

18F-fluorodeoxyglucose positron emission tomography computed tomography (FDG PET/CT) is frequently used for evaluation of indeterminate adrenal nodules.The objective of this study was to evaluate the diagnostic performance of FDG PET/CT in distinguishing benign adrenocortical adenomas (ACA) from adrenocortical carcinoma (ACC).We identified 139 patients in our institution who completed both FDG PET/CT and adrenal biopsy or adrenalectomy from 2001 to 2019 using the institutional Electronic Medical Record Search Engine (EMERSE). Patients with adrenal pathology revealing non-adrenocortical tumors were excluded. The imaging characteristics of ACAs were compared with ACCs.Sixteen patients with ACAs and 50 patients with ACC were identified; of the latter, 30 were excluded, because FDG PET/CT imaging was completed after adrenalectomy. The average age of the ACC vs. ACA group was 48±14 and 52±17 years, respectively, with a gender composition of 35% and 25% men, respectively. All 20 patients with ACC had FDG avid lesions, defined by imaging report and increased ratio of adrenal tumor maximum standardized uptake value (SUVmax) to hepatic parenchymal average SUV (SUVmean) of greater than 2.5. Among those with ACAs, 11 had positive, 1 had mildly positive, 3 had indeterminate, and 1 had negative FDG PET/CT findings according to the report. Ratio of adrenal SUVmax to hepatic SUVmean was greater in ACC compared to ACA (13.5 versus 1.6, respectively, p = 0.13), but did not reach statistical significance, likely due to the small sample size and unavailability of SUV ratios for all lesions.Our study identified a large number of ACAs that were deemed FDG avid but without adrenal SUVmax to hepatic SUVmean ratio of greater than 2.5. Although the sensitivity, and therefore the negative predictive value, of FDG PET/CT scan is excellent for the diagnosis of ACC, our data does not allow for the calculation of specificity. This is due to the selection bias inherent in our patient population referred for evaluation of unusual adrenal masses, and the fact that ACAs with negative FDG PET/CT often do not undergo surgery or biopsy, and therefore pathology results are not available. Despite this limitation, our findings show that calculation of the ratio of adrenal SUVmax to hepatic SUVmean, rather than lesion SUVmax alone, helps for characterization of adrenal lesions as malignant vs. benign, and that a negative FDG PET/CT is valuable in excluding ACC.

A Cloud Framework Design for A Disease Symptom Self-inspection Service

The establishment of a symptom self-inspection service faces will face many challenges related to how to best acquire, store, and analyze the available data. In view of the problems, a cloud framework symptom self-inspection service model is proposed in this article. A Hadoop cluster is set up to store massive medical data and provide indexing so as to produce acceptable electronic medical record search response times. A cluster of the distributed search nodes based on Lucene can be used for real-time retrieval, data analysis, and privacy filtering from a massive collection of electronic medical records. The implementation of symptom check-up services is discussed, including the selection of search nodes, the establishment of medical records index files, the ranking and sorting of medical records similarity. Experimental results demonstrate that our proposed cloud framework model serves as a scalable and effective self-inspection health symptom service.

An Analysis of Specialty-Specific Microsurgical Head and Neck Reconstruction: A Look at a Single Institution and National Trends Over a Decade.

Head and neck free flap (HNFF) reconstructions have historically utilized a multidisciplinary approach between otolaryngology head and neck surgery (OHNS) and plastic surgery (PS). However, there seems to be a trend toward both the extirpative and reconstructive portions being performed by OHNS. We aimed to elucidate the volume trend in HNFF reconstruction over the last decade. Data were collected by 3 modalities: electronic medical record search of patients who underwent HNFF surgery at our institution (2013-2018), survey data from microsurgery fellowship programs (2007-2017), and National Surgical Quality Improvement Program (NSQIP) query of cases receiving designated HNFF Current Procedural Terminology codes (2011-2016). Data were analyzed with trends in HNFF reconstruction as our primary outcome. At our institution, HNFF reconstructions increased 4-fold (59-227). Percentage of cases by PS decreased from 18.6% to 6.0%, whereas that of OHNS increased 81.4% to 94.0% (P = 0.009). Survey data, completed by microsurgery fellowship program directors (23/81 [27.2%]), revealed the number of OHNS programs in 2007 performing 100 or more HNFF cases compared with PS was 40% (6/15) to 12.5% (1/8) (P = 0.172). By 2016, that number increased significantly for OHNS to 73.3% (11/15), whereas that of PS remained stagnant at 12.5% (1/8) (P = 0.005). According to NSQIP data, the percentage of cases performed by PS in 2011 was 52%, which was greater than OHNS's share of 43%. The other 5% was allotted to either orthopedic, oral and maxillofacial surgery, or general surgery. In 2013, those numbers reached a peak for PS at 55% and a nadir for OHNS at 36%. However, by 2016, the percentage of HNFF cases reversed. where 58% of cases were performed by OHNS and only 38% by PS. When comparing the 2011 data to the 2016 data, OHNS had a 134% increase, whereas PS had a 27% decrease (P = 0.003). Head and neck free flap reconstruction has grown dramatically over the last 10 years. Plastic surgeons are performing fewer cases, whereas otolaryngology head and neck surgeons perform more as indicated by institutional, microsurgery fellowship program director survey, and NSQIP data.

P072 Takayasu's Arteritis and Inflammatory Bowel Diseases: Different Immune-Mediated Disorders or a Rare Extra-Intestinal Manifestation?: Case Series and Literature Review

BACKGROUND: Takayasu's arteritis (TA) is a chronic granulomatous inflammatory vasculitis of unknown etiology that affects large arteries, especially the aortic arch and its branches, and is rarely associated with inflammatory bowel disease (IBD) (1). In most cases where this association is described in the literature, TA occurs after the diagnosis of IBD, with a time lapse of 10 to 36 months, and maintains a positive correlation with the activity of intestinal disease (2). This study aims to report a series of six cases of concomitant TA and IBD, determining its clinical features, diagnostic methods, their relationship with intestinal disease activity and responses according to therapeutic interventions. The authors also performed a review of the current literature in this field. METHODS: Patients were identified at our IBD unit through electronic medical record searches including the keywords “Takayasu”, “arteritis” and “vasculitis”. Data regarding patient characteristics, disease phenotype and treatment were retrospectively collected from identified patients using a standardized chart review. RESULTS: Six patients (50% male) with TA were identified in a total of 2,749 patients with IBD (46.8% CD, 53, 2% UC). Four patients had Crohn’s disease (CD) and 2 had ulcerative colitis (UC). The mean age of the patients at diagnosis was 33 years old (18–63). In 5 patients, TA occurred after the diagnosis of IBD, and 4 patients had another associated extra-intestinal manifestation. Vascular surgery was required in 2 patients due to extensive lesions and inflammatory activity. Most patients were clinically treated with corticosteroids, immunomodulators and anti-TNF agents. Simultaneous occurrence of both AT and CD is quite rare (1 in 10 billion) (3). However, the existence of common physiopathological pathways indicates that these conditions may be strongly associated 4. Moreover, since both diseases can be treated with the same agents, diagnostic delay may occur. CONCLUSIONS: The report of this case series reinforce, based on the literature reviewed, that a linkage among TA and IBD may exist. In view of the limitations of the retrospective study design further investigations are needed. Moreover, the possible role of genetic links and immune factors (T helper 1 and T helper 17 cells, cytokines, chemokines) should be explored.

Hypocholesterolemia in cats: a multicenter retrospective study of 106 cats.

The aim of this study was to describe the clinicopathologic findings and associated diseases found in a population of hypocholesterolemic cats referred to two tertiary care facilities. An electronic medical record search was performed at two veterinary university referral centers to identify cats with serum cholesterol values below the reference interval between January 2004 and 2016. Clinicopathologic data were reviewed for each case and cats were classified into specific disease categories based on clinical diagnosis. Median cholesterol values were compared between disease categories, as well as between survivors and non-survivors. In total, 106 hypocholesterolemic cats were included. The median age of the cats was 6 years (range 0.24-18 years). The most common disease categories were gastrointestinal (25.9%), hepatobiliary (19.8%), hematologic (14.8%) and urogenital (14.8%). Though median serum cholesterol values did not differ significantly between survivors and non-survivors, cats with concurrent hypoalbuminemia were at higher risk (odds ratio 15.6, 95% confidence interval 5.2-46.6; P <0.0001) of not surviving to discharge than cats with normal serum albumin concentrations. Taken together, our data suggest that while the degree of hypocholesterolemia did not appear to influence survival rates, the concurrent presence of hypocholesterolemia and hypoalbuminemia was associated with a worse prognosis.

2383. Epidemiological and Clinical Features of Clostridioides difficile Infections in Pediatric Oncology and Transplant Patients

Background Clostridioides difficile infection (CDI) is the most common cause of healthcare-associated diarrhea-causing significant morbidity and mortality in adults. The epidemiology and clinical course of CDI in children, especially with cancer are poorly defined. We aim to describe the clinical, epidemiological features and outcomes of CDI, and identify risk factors for recurrence in a pediatric oncology centerMethodsThis is a retrospective cohort study of CDI in pediatric oncology and hematopoietic stem cell transplant (HSCT) patients in 2016 and 2017. CDI cases were identified by electronic medical record search for positive C. difficile PCR tests. CDI episodes were classified as incident, duplicate or recurrent and community-onset (CO), hospital-onset (HO), or community-onset healthcare facility associated (COHCFA) using National Healthcare Safety Network surveillance definitions. Demographics, underlying diagnosis, CDI characteristics, drug exposure, and outcomes were analyzed. Risk factors for CDI recurrence were assessed by logistic regression.ResultsOne hundred-eighty patients developed 305 CDI episodes; 233 (78%) were incident, 65 (22%) recurrent, and 7 duplicate and removed from the analysis. Recurrence occurred after 51 incident episodes (Table 1). Median age (range) was 5.7 (0.5–25.5) years. Underlying diagnoses were leukemia/lymphoma (56%) and solid/brain tumors (42%). 87 (29%) received HSCT. Almost all patients received antibiotics 4 weeks prior to CDI. 14% received laxatives 72 hours prior to CDI. 50% of patients were neutropenic. The median (range) duration of diarrhea was 10.0 (1–77). Thirty patients (15%) were hospitalized due to CDI, for a median (range) of 3 (1–49) days. 16% had a delay in chemotherapy due to CDI. There was no ICU admissions nor death due to CDI. None of the evaluated variables was identified as a significant risk factor for CDI recurrence by logistic regression (Table 3).ConclusionCDI in pediatric oncology and transplant patients ran a generally mild course, associated with chemotherapy delay and hospitalization in a small fraction, and no attributable ICU admission nor death. CDI recurred in less than a quarter of patients. Risk factors for CDI recurrence were not identified. DisclosuresRandall Hayden, MD, Abbott Molecular: Advisory Board; Quidel: Advisory Board; Roche Diagnostics: Advisory Board

2368. Molecular Epidemiology of Clostridioides difficile Infections in Pediatric Oncology and Transplant Patients

BackgroundThe incidence of Clostridioides difficile infection (CDI) has been rising among children, both in the community and hospital setting. The genomic variability and molecular epidemiology of CDI in children, especially with cancer are poorly understood. We aim to evaluate the molecular epidemiology and relatedness of C. difficile isolates among inpatient and outpatient pediatric oncology and stem cell transplant patients (POTP) using whole-genome sequencing (WGS).MethodsThis was a retrospective cohort study of CDI in POTP in 2016. CDI cases were identified by electronic medical record search for positive C. difficile toxin PCR tests. Retrieved residual stool specimens were cultured anaerobically using pre-reduced CCMB-TAL broth (Anaerobe Systems, Inc.), toxin-producing C. difficile isolates were determined using a cell culture cytotoxicity assay with neutralization (TechLab, Inc.), and WGS was performed, followed by core genome MLST (cgMLST). Variability of the isolates was summarized by strain type (ST), and a minimum spanning tree was constructed, defining clusters of genomically related isolates as those with < 7 alleles difference. Plausible epidemiologic links among the closely related strains such as receiving care on the same inpatient unit on the same day or on the same unit but on different days within 8 weeks before CDI were evaluated to identify potential transmission events.ResultsAmong 141 CDI episodes in 89 patients; 103 stool samples were cultured, and 101 (98%) isolates were sequenced identifying 23 different strain types in 81 (80%) isolates. 34 (38%) patients had multiple episodes of CDI. 16 clusters of related isolates were identified (figure), 10 (62%) of which involved only multiple specimens from the same patient. For the 6 clusters involving multiple patients, epidemiologic investigation revealed only 2 (33%) potential transmission events.ConclusionWGS identified a highly diverse group of C. difficile isolates among POTP with CDI. Although WGS identified clusters of closely related isolates in multiple patients, epidemiologic investigation of shared inpatient exposures identified potential transmission in only two clusters. C. difficile transmission was uncommon. DisclosuresRandall Hayden, MD, Abbott Molecular: Advisory Board; Quidel: Advisory Board; Roche Diagnostics: Advisory Board.

2400. Are Multiple Clostridioides difficile Infections in Pediatric Oncology Patients Related to Recurrence of the Same Isolate or Re-infections with Different isolates?

BackgroundPediatric oncology and hematopoietic stem cell transplant patients (POTP) are at increased risk for Clostridioides difficile infection (CDI) and recurrence. It is unknown whether recurrent CDI is related to the same C. difficile strain as the initial CDI. We describe genomic relatedness of C. difficile strains in patients with multiple CDI using whole-genome sequencing (WGS).MethodsThis was a retrospective cohort study of CDI in POTP in 2016. CDI cases were identified by electronic medical record search for positive C. difficile toxin PCR tests. Patients with multiple CDI episodes were identified. CDI episodes were classified as incident, duplicate or recurrent using National Healthcare Safety Network (NHSN) definitions. Retrieved residual stool specimens were cultured anaerobically, toxin-producing C. difficile isolates were determined using a cell culture cytotoxicity assay with neutralization and WGS was performed followed by core genome MLST (cgMLST). Variability of the isolates was summarized by strain type (ST), and a minimum spanning tree was constructed, defining genomically related isolates as those with <7 allele difference.ResultsEighteen patients had 51 positive C. difficile samples. CDI were classified as incident in 31 (61%) episodes, recurrent in 18 (36%), and duplicate in 2 (3%). Isolates from 47 (92%) samples were sequenced, identifying 14 different strain types (ST) in 41 (87%) isolates. Of the 31 incident CDI, 13 (42%) episodes occurred 8 weeks or more after the initial incident CDI. Among those 13 incident CDI, 7 (54%) had prior CDI due to a related isolate. Of the 18 recurrent CDIs, 10 (55%) were due to an isolate related to the previous incident CDI and 5 (28%) were due to an isolate unrelated to the incident CDI. The relatedness of the remaining 3 recurrent episodes could not be evaluated because no isolate was available for sequence analysis.ConclusionCDI classification of incident vs. recurrent infection using NHSN definition might be not applicable in POTP. WGS showed that more than half of CDI episodes classified as incident were actually a recurrence of a previous C. difficile strain. Similarly, some CDI episodes classified as recurrent were actually re-infection with a different stain.DisclosuresRandall Hayden, MD, Abbott Molecular: Advisory Board; Quidel: Advisory Board; Roche Diagnostics: Advisory Board

Indications and Patterns of Use for Parenteral Nutrition in Pediatric Oncology.

Children with cancer are at risk of treatment related gastrointestinal toxicity and malnutrition. Intestinal dysfunction may preclude or limit use of enteral nutrition, and parenteral nutrition (PN) may be required. Published indications for PN use in children with cancer are generally nonspecific. We sought to describe patterns of use, indications, and frequency of PN prescription in children with cancer and propose indicators to guide appropriate PN use. Retrospective chart review of children with cancer receiving inpatient PN in a tertiary referral pediatric hospital over 12months was performed using electronic medical record search and paper records. Data were summarized using descriptive statistics. PN was prescribed to 88 patients in 111 episodes. Total use (2377days) represented 24% of annual inpatient days in all children with cancer. Primary clinical indications were mucositis (40%), feed intolerance (29%), postoperative (16%), or "other" (15%), (including nasogastric tube refusal (n = 6)). Patients with hematological cancer had longer median episodes (19 vs 12.5days) and earlier commencement of PN after diagnosis (50 vs 80days) than children with nonhematological cancer. Most PN episodes longer than 28days were in children with hematopoietic stem cell transplant (HSCT). Inpatient PN use is common in childhood cancer. Indications include mucositis, feed intolerance, and surgical management. Patterns of use are influenced by cancer diagnosis and treatment, with greater use in children with hematological cancer and HSCT. Improved understanding and specific indications may guide appropriate PN prescription and minimize unnecessary risk, cost, and inconsistency in care.

Identifying and rectifying prescriptions of long-acting antimuscarinic and beta-agonist inhalers without inhaled corticosteroids to asthma patients: an audit from a UK general practice surgery

BackgroundIn the UK 5.4 million people receive treatment for asthma. Patients diagnosed with asthma should not be prescribed a long-acting muscarinic antagonist (LAMA), or a long-acting beta 2 agonist (LABA) without co-prescription of an inhaled corticosteroid (ICS), due to the increased risk of death.AimTo identify patients with asthma (+/− COPD), who have a current prescription for a LABA/LAMA without an ICS.MethodAudit criteria were derived from guidelines relevant to the Asthma UK national review, with standards of 100%. An electronic medical record search identified patients prescribed a LABA/LAMA without an ICS. Patients without a coded diagnosis and those with a diagnosis of asthma (+/− COPD) were identified for action.ResultsFifty-four patients from the practice population (n = 11 293) were prescribed a LABA/LAMA without an ICS. Of these, 7% (n = 4) did not have a relevant coded diagnosis. Of the remaining 50 patients, 16% (n = 8) had a diagnosis of asthma (+/− COPD). Re-audit results found 3% (n = 2) of patients did not have a relevant coded diagnosis. Patients with an asthma (+/−COPD) diagnosis on a LABA/LAMA without an ICS decreased to 11% (n = 7).ConclusionSuboptimal coding and potentially risky prescriptions were identified. Interventions were to ensure patients have a coded diagnosis, review LABA/LAMA without ICS prescriptions, discuss audit results with practice prescribers, and to activate electronic alerts to prompt safe prescriptions. Following re-audit, the patients with asthma (+/− COPD) still on a LABA/LAMA have been offered appointments to clarify their asthma diagnosis or to explain the risks associated with LABA/LAMA prescription without an ICS.

Abstract 2: A Disappearing Act: Trends in Head and Neck Free Flap Reconstruction over the Last Decade

BACKGROUND: Head and neck free flap (HNFF) reconstruction are complex cases often times requiring expertise in microvascular surgery. A multidisciplinary approach has historically been utilized between otolaryngologists (ENT) and plastic surgeons (PS), however, both the extirpative and reconstructive portions are now performed by ENT. We aim to elucidate the trend in volume of HNFF reconstruction over the last decade. METHODS: Data was collected from 2007 to 2017 by three modalities: electronic medical record (EMR) search of patients who underwent HNFF surgery at our institution, NSQIP query of cases receiving designated HNFF CPT codes, and survey data regarding volume from microsurgery fellowship program directors (MFPD). The data were analyzed with trends in HNFF reconstruction as our primary outcome. RESULTS: From 2013 to 2017 at our institution, the total number of HNFF microvascular reconstruction increased 4-fold (59 to 227). The percentage of cases by PS decreased from 18.6% to 6.0% while that of ENT increased 81.4% to 94.0% (p=0.009). Survey data, completed by 35 MFPD, revealed the number of ENT programs in 2007 performing ≥100 HNFF compared to PS was 40% to 12.5% (p=0.172). By 2016, that number increased significantly for ENT to 73.3% while that of PS remained stagnant at 12.5% (p=0.005). According to NSQIP data, from 2011 to 2016, HNFF volume for ENT trended up to 58% from 43% while that of PS trended down, 52% to 38% (p=0.003). CONCLUSION: HNFF reconstruction has grown dramatically over the last ten years. Plastic surgeons are performing less cases while ENT performs more as indicated by institutional, microsurgery fellowship program director survey, and NSQIP data. Understanding volume trends allows residency and fellowship directors to address shortages in training curricula mandated by the ACGME.