Exact Sum Research Articles

Outcomes after implementing a heart failure diuretic pathway in an emergency department setting

Among patients with acute decompensated heart failure (HF), national and international loop diuretic therapy recommendations may not be followed in the emergency department (ED). To examine if loop diuretic treatment and patient disposition from the ED differed after implementing a clinical pathway based on national HF guidelines. Using an observational, pre- and post-intervention design, after clinical pathway implementation, loop diuretic medications and clinical outcomes were retrieved from medical records. Analyses included Pearson's Chi-square or Fisher's exact test, 2-sample T-test or Wilcoxon rank sum test. Of 182 pre- and 122 post-intervention patients, mean (SD) patient age was 67.9 (13.4) years and 44.2% were Caucasian. There were no between-group differences in pre-ED visit loop diuretic prescription or dosages. More post-intervention ED patients received at least one dose of loop diuretic (94.3% vs. 81.9%, p=0.010); however, the overall dose (mg) across groups was lower than the home dose and was not based on national guideline expectations. Doses from home to ED decreased less in the post-intervention group for patients who received doses at both time points and for all patients: p=0.047 and p=0.048, respectively. There was no between-group differences in short-stay unit (SSU) admissions, p=0.33. Post-intervention patients were hospitalized from the ED (p=0.050) and SSU (p=0.005) less often than pre-intervention patients. Discharge to home from the ED or SSU increased in the post-intervention period; 16.4% vs. 4.9%, p=0.009. Among ED patients treated for HF, diuretic dosing was non-optimized. New interventions are needed to enhance adherence to national guidelines.

Patients with von Willebrand disease in China: Results of an online survey.

Little is known about the clinical characteristics of von Willebrand disease (VWD) patients in China, the impact of Covid-19 on them and their genetic mutation. To describe the clinical characteristics of a group of VWD patients in China, the impact of Covid-19 on them and their genetic mutation. An online survey using a self-designed questionnaire was conducted among patients within a WeChat group of VWD patients in China. Data were analysed using t-test, the Chi-square test, Fisher's exact test and rank sum test. Data from a total of 96 patients were collected. Several important findings are yielded. Above all, type 3 patients accounted for over half of the surveyed patients. Secondly, a surprising rate (>40%) of patients had experience of being misdiagnosed. Thirdly, treatment regimens were dominated by cryoprecipitate, blood-derived FVIII and plasma, and only a small percentage of patients received prophylaxis. Fourthly, we identified 17 new von Willebrand factor (VWF) mutant genes which merit further investigation. Additionally, Covid-19 was found to pose some challenges for the patients. In China, the high rates of type 3 patients and misdiagnosis suggest that most of the VWD patients may never be diagnosed in China. When it comes to diagnosis and treatment, there is a large gap between developing countries like China and developed countries.

Prolonged Therapy Is Not Associated with Delayed Identification of Recurrent Intra-Abdominal Infection.

Background: The Study to Optimize Peritoneal Infection Therapy (STOP-IT) Trial identified an association between prolonged antibiotic therapy and delayed identification of recurrent intra-abdominal infection (IAI). However, this association has not been observed in other studies. The purpose of this study was to evaluate the association between recurrent IAIs and the duration of antibiotic agents. Patients and Methods: Adult patients from 2016 to 2020 who underwent a source control procedure for a colon-related complicated IAI were identified. Patients not meeting the inclusion criteria were excluded. Demographics, comorbidities, post-operative antibiotic duration, and presence of secondary intra-abdominal infection were recorded. The primary outcome was the time to identification of secondary IAI. Delayed identification of recurrent infection was identified as 10 or more days following source control procedure. Statistical analysis using χ2, Fisher exact, and Wilcoxon rank sum were used where appropriate. Results: Seventy-six of the patients identified met inclusion criteria, and 17 (22.4%) of those patients had a recurrent IAI. Patients with recurrent infections were slightly younger (64 vs. 60 years; p = 0.01) and had lower rates of pre-operative anticoagulation (50.8% vs. 17.6%). There were no differences in the initial length of antibiotic therapy after source control between the recurrent infection and non-recurrent groups (p = 0.6). There was a difference in total days of antibiotic use between the two groups, with the recurrent infection group averaging 10 more days of antibiotic use than the non-recurrence group (p < 0.0001). In those patients with a recurrence, there were no differences in median days to identification (9 vs. 11.5 days; p = 0.29) or the rate of those with delayed identification of recurrent infection (44.4% vs. 75%; p = 0.33). Conclusions: Similar to the STOP-IT Trial we failed to identify an association between the duration of post-operative antibiotic agents and recurrent infection. However, we further failed to identify an association between the prolonged post-operative courses and the timing of identification of the recurrent infection. Further evaluation is needed to determine if prolonged therapy delays the identification of recurrent infection.

Gender diversity in adolescents with polycystic ovary syndrome.

The objective of our study was to describe the prevalence of gender diverse (GD) youth among adolescents with polycystic ovary syndrome (PCOS). We conducted a retrospective chart review on patients who met NIH criteria for PCOS in our Multidisciplinary Adolescent PCOS Program (MAPP). We compared those with PCOS to MAPP patients who did not meet PCOS criteria as well as to non-PCOS patients from the Adolescent Specialty Clinic (ASC). Variables analyzed included gender identity, androgen levels, hirsutism scores, and mood disorders. We used chi-square, Fisher's exact, t-tests, and Wilcoxon rank sum tests to compare groups. Gender identities self-reported as male, fluid/both or nonbinary were pooled into the GD category. Within the MAPP, 7.6% (n=12) of PCOS youth self-identified as GD compared to 1.8% (n=3) of non PCOS youth (p=0.01, chi-square). When compared to non-PCOS GD adolescents from ASC (4.4%; n=3), the difference to PCOS youth was no longer significant (p=0.56). Among MAPP patients, gender diversity was associated with higher hirsutism scores (p<0.01), but not higher androgen levels. In PCOS, depression/anxiety was higher in GD vs cisgender youth (100% vs. 37.6%, p<0.01 and 77.8% vs. 35.8%, p=0.03 respectively). Gender diversity was observed more commonly in those meeting PCOS criteria. PCOS GD youth were more hirsute and reported more depression/anxiety. Routine screening for differences in gender identity in comprehensive adolescent PCOS programs could benefit these patients, as alternate treatment approaches may be desired to support a transmasculine identity.

Point-of-Care Ultrasound Training during Nephrology Fellowship: A National Survey of Fellows and Program Directors.

Point-of-care ultrasound (POCUS)-performed by a clinician during a patient encounter and used in patient assessment and care planning-has many potential applications in nephrology. Yet, US nephrologists have been slow to adopt POCUS, which may affect the training of nephrology fellows. This study sought to identify the current state of POCUS training and implementation in nephrology fellowships. Concise survey instruments measuring attitudes toward POCUS, its current use, fellow competence, and POCUS curricula were disseminated to (1) 912 US nephrology fellows taking the 2021 Nephrology In-Training Examination and (2) 229 nephrology training program directors and associate program directors. Fisher exact, chi-squared, and Wilcoxon rank sum tests were used to compare the frequencies of responses and the average responses between fellows and training program directors/associate program directors when possible. Fellow and training program directors/associate program directors response rates were 69% and 37%, respectively. Only 38% of fellows (240 respondents) reported receiving POCUS education during their fellowship, and just 33% of those who did receive POCUS training reported feeling competent to use POCUS independently. Similarly, just 23% of training program directors/associate program directors indicated that they had a POCUS curriculum in place, although 74% of training program directors and associate program directors indicated that a program was in development or that there was interest in creating a POCUS curriculum. Most fellow and faculty respondents rated commonly covered POCUS topics-including dialysis access imaging and kidney biopsy-as "important" or "very important," with the greatest interest in diagnostic kidney ultrasound. Guided scanning with an instructor was the highest-rated teaching strategy. The most frequently reported barrier to POCUS program development was the lack of available instructors. Despite high trainee and faculty interest in POCUS, the majority of current nephrology fellows are not receiving POCUS training. Hands-on training guided by an instructor is highly valued, yet availability of adequately trained instructors remains a barrier to program development. This article contains a podcast at https://www.asn-online.org/media/podcast/CJASN/2022_09_21_CJN01850222.mp3.

Bleeding After Hemorrhoidectomy in Patients on Anticoagulation Medications.

Post-hemorrhoidectomy bleeding is a serious complication after hemorrhoidectomy. In the setting of a new wave of anticoagulants, we aimed to investigate the relationship of post-operative anticoagulation timing and delayed bleeding. We performed a retrospective analysis of all patients undergoing hemorrhoidectomy at a single institution over a 10-year period. Fisher's exact and Wilcoxon Rank Sum tests were utilized to test for association between delayed bleeding and anticoagulation use. Between January 2011 and October 2020, 1469 hemorrhoidectomies were performed. A total of 216 (14.7%) were taking platelet inhibitors and 56 (3.8%) other anticoagulants. Delayed bleeding occurred in 5.2% (n = 76) of which 47% (n = 36) required operative intervention. Mean time to bleeding was 8.7days (SD ±5.9). Time to bleeding was longer in those taking antiplatelet inhibitors vs. non-platelet inhibitors vs. none (11 vs. 8 vs. 7 days, P = .05). Among anticoagulants (n = 56), novel oral anticoagulants were more common than warfarin (57% vs 43%) and had a nonsignificant increase in delayed bleeding (31% vs 16%, P = .21). Later restart (>3days) of novel anticoagulants after surgery was associated with increased bleeding (10.5% vs 61.5%, P=.005). On multivariable analysis, only anticoagulation use (OR 4.5, 95% CI: 2.1-10.0), male sex (OR 1.8, 95% CI: 1.1-2.9), and operative oversewing (OR 3.5, 95% CI: 1.8-6.9) were associated with delayed bleeding. Post-hemorrhoidectomy bleeding is more likely to occur with patients on anticoagulation. Later restart times within the first week after surgery was not associated with a decrease in bleeding.

DNA methylation and multiple pollutants exposures from petrochemical industries

BACKGROUND: This study aims to clarify the association between exposure levels, SNPs, and DNA methylation in residents living in areas with multiple industrial pollutants. METHODS: We compared DNA methylation between high (HE) and low exposure (LE) groups, and analyzed association between urine concentrations of As, Hg, and V with DNA methylation, respectively among 159 residents near No. 6 Naphtha Cracking Complex in Taiwan. HE (n=78) and LE (n=81) were based on urine PAHs exposure biomarker 1-OHP and V concentrations. All participants were analyzed for 11 pollutants urine exposure biomarkers, DNA methylation, and 11 SNPs. RESULTS: Urine levels of 1-OHP, V, As, Hg, Cr, Mn, Sr, and Tl were significantly increased in HE compared to LE. We identified 68 CpG probes corresponding to 45 known human genes using Wilcoxon’s rank sum test comparing between HE and LE. We used DAVID for pathway analysis and found 16 pathways associated with exposure in KEGG pathway hsa04940: Type I diabetes mellitus (two gene hits PTPRN2, HLA-B,). We further used correlation analysis and found 70 CpG probes associated with urinary As levels, two with Hg, and 46 with V, which correspond to 62, none, and 32 known human genes, respectively. GSEA pathway analysis found four biological pathways associated with As (including ascorbate and aldarate metabolism), four with Hg (including linoleic acid metabolism), while no pathways were found associated with V. Fisher’s exact test and Wilcoxon rank sum test results showed 11 SNPs significantly associated with CpG probes methylation. Linear regression revealed rs11085020 (NFIC) and rs199442 (NSF) could be associated with exposure, the translated proteins of which are associated with activating gene transcription and replication, and vesicle-mediated transport, respectively. CONCLUSIONS: We identified industrial pollutants-associated SNPs, DNA methylation, and biological pathways among exposed population. KEYWORDS petrochemical industry, air pollution, heavy metal, polycyclic aromatic hydrocarbon, DNA methylation, SNPs

Bone Lesions Detected on Breast MRI: Clinical Outcomes and Features Associated with Metastatic Breast Cancer.

To determine prevalence and frequency of malignancy among bone lesions detected on breast MRI and to identify clinical and imaging features associated with bone metastases from breast cancer (BC), as bone lesions are suboptimally evaluated on breast imaging protocols and can present a diagnostic challenge. This IRB-approved retrospective review of breast MRIs performed from June 2009 to June 2018 identified patients with bone lesions. Demographic, clinical, and MRI features were reviewed. Clinical outcome of bone lesions was determined based on pathology and/or additional diagnostic imaging. All benign lesions had ≥ 2 years of imaging follow-up. Statistics were computed with Fisher's exact and Wilcoxon rank sum tests. Among all patients with breast MRI, 1.2% (340/29 461) had bone lesions. Of these, 224 were confirmed benign or metastatic BC by pathology or imaging follow-up, with 70.1% (157/224) be- nign and 29.9% (67/224) metastatic. Bone metastases were associated with BC history (P < 0.001), with metastases occurring in 58.2% (53/91) of patients with current BC, 17.9% (14/78) patients with prior BC, and 0.0% (0/55) without BC. Bone metastases were associated with invasive and ad- vanced stage BC and, on MRI, with location in sternum, ribs, or clavicles, larger size, multiplicity, andT1 hypointensity (all P < 0.01 in tests of overall association). Of clinically confirmed breast MRI-detected bone lesions, 30% were bone metastases; all were detected in patients with current or prior BC. Metastases were associated with advanced stage, invasive carcinoma, larger lesion size, multiplicity, low T1 signal, and non-spine location.

Nephrotic syndrome in children during the COVID-19 pandemic

The COVID-19 pandemic resulted in public health measures and fewer viral infections, which trigger the nephrotic syndrome. Our objectives were to characterize the effect of the COVID-19 pandemic on children with nephrotic syndrome. This single-center retrospective chart review compared children with nephrotic syndrome one year before the pandemic with the first wave of the pandemic. Epidemiologic events, clinical characteristics, and health care utilization were compared using paired t-tests, Fisher’s exact tests and Wilcoxon Rank Sum tests. Among 96 children the mean age was 10.7 ± 5.28 years. The distribution was minimal change disease (16.7%), focal segmental glomerulosclerosis (12.5%), membranous nephropathy (1%) and not biopsied (69.8%). Medication responsiveness was steroid-sensitive (25%), frequently relapsed (54%) and steroid-resistant (20.8%). There were 14 new diagnoses of nephrotic syndrome pre-pandemic and 18 during the pandemic. Fewer relapses during the pandemic were likely due to fewer viral illnesses from public health measures during the pandemic.

Sums of Squares Polynomial Program Reformulations for Adjustable Robust Linear Optimization Problems with Separable Polynomial Decision Rules

We show that adjustable robust linear programs with affinely adjustable box data uncertainties under separable polynomial decision rules admit exact sums of squares (SOS) polynomial reformulations. These problems share the same optimal values and admit a one-to-one correspondence between the optimal solutions. A sum of squares representation of non-negativity of a separable non-convex polynomial over a box plays a key role in the reformulation. This reformulation allows us to find adjustable robust solutions of uncertain linear programs under box data uncertainty by numerically solving their associated equivalent SOS polynomial optimization problem using semi-definite linear programming. We illustrate how the quality of the adjustable robust solution of a robust optimization problem with polynomial decision rules improves as the degree of the polynomial increases. Our results demonstrate that the adjustable robust solutions approach the actual optimal solution as the degree of the polynomial increases from one to fifteen.

Steep rise in drug use-associated infective endocarditis in West Virginia: Characteristics and healthcare utilization.

IntroductionLife-threatening infections such as infective endocarditis (IE) are increasing simultaneously with the injection drug use epidemic in West Virginia (WV). We utilized a newly developed, statewide database to describe epidemiologic characteristics and healthcare utilization among patients with (DU-IE) and without (non-DU-IE) drug use-associated IE in WV over five years.Materials and methodsThis retrospective, observational study, incorporating manual review of electronic medical records, included all patients aged 18–90 years who had their first admission for IE in any of the four university-affiliated referral hospitals in WV during 2014–2018. IE was identified using ICD-10-CM codes and confirmed by chart review. Demographics, clinical characteristics, and healthcare utilization were compared between patients with DU-IE and non-DU-IE using Chi-square/Fisher’s exact test or Wilcoxon rank sum test. Multivariable logistic regression analysis was conducted with discharge against medical advice/in-hospital mortality vs. discharge alive as the outcome variable and drug use as the predictor variable.ResultsOverall 780 unique patients had confirmed first IE admission, with a six-fold increase during study period (p = .004). Most patients (70.9%) had used drugs before hospital admission, primarily by injection. Compared to patients with non-DU-IE, patients with DU-IE were significantly younger (median age: 33.9 vs. 64.1 years; p < .001); were hospitalized longer (median: 25.5 vs. 15 days; p < .001); had a higher proportion of methicillin-resistant Staphylococcus aureus (MRSA) isolates (42.7% vs. 29.9%; p < .001), psychiatric disorders (51.2% vs. 17.3%; p < .001), cardiac surgeries (42.9% vs. 26.6%; p < .001), and discharges against medical advice (19.9% vs. 1.4%; p < .001). Multivariable regression analysis showed drug use was an independent predictor of the combined outcome of discharge against medical advice/in-hospital mortality (OR: 2.99; 95% CI: 1.67–5.64).Discussion and conclusionThis multisite study reveals a 681% increase in IE admissions in WV over five years primarily attributable to injection drug use, underscoring the urgent need for both prevention efforts and specialized strategies to improve outcomes.

Trial of labor after two cesarean sections: A retrospective case-control study.

The objective of this study was to compare neonatal and maternal outcomes among women with two previous cesarean deliveries who undergo trial of labor after two cesarean section (TOLA2C) versus elective repeat cesarean delivery (ERCD). Our primary outcome was neonatal intensive care unit (NICU) admission. Secondary outcomes included APGAR score <7 at 5 min, TOLA2C success rate, uterine rupture, postpartum hemorrhage, maternal blood transfusion, maternal bowel and bladder injury, immediate postpartum infection, and maternal mortality. This retrospective cohort study was undertaken at a community medical center from January 1, 2008 to December 31, 2018. Inclusion criteria were women with a vertex singleton gestation at term and a history of two prior cesarean sections. Exclusion criteria included a previous successful TOLA2C, prior classical uterine incision or abdominal myomectomy, placenta previa or invasive placentation, multiple gestation, nonvertex presentation, history of uterine rupture or known fetal anomaly. Maternal and neonatal outcomes were assessed using Fisher exact test and Wilcoxon rank sum test. A total of 793 patients fulfilled study criteria. There were no differences in neonatal intensive care unit admissions or 5-min APGAR scores <7 between the two groups. Sixty-eight percent of women who underwent TOLAC (N=82) had a successful vaginal delivery. The uterine rupture rate was 1.16% (N=1) in the TOLA2C group with no case of uterine rupture in the ERCD group. No difference in maternal morbidity was noted between the two groups. No maternal or neonatal mortalities occurred in either group. There was no difference in maternal or neonatal morbidity among patients in our study population with two previous cesarean sections who opted for TOLA2C versus ERCD.

Genotype-phenotype analysis and prognosis in children with primary distal renal tubular acidosis

Objective: The purpose of this study was to investigate the relationship between genotypes and clinical phenotypes of primary distal renal tubular acidosis (dRTA) in children. Methods: Clinical information, genetic testing information and follow-up data (until March 2021) of children with dRTA from Children's Hospital of Chongqing Medical University (from January 2010 to December 2020) were analyzed retrospectively. According to different pathogenic genes, patients were divided into SLC4A1 gene and ATP6V0A4+ATP6V1B1 gene groups. Age at onset, clinical manifestations and laboratory findings were compared. Self-comparisons of height standard deviation score (HtSDS), weight standard deviation score (WtSDS), blood pH and serum potassium before and after treatment were tested. T-test, Fisher's exact test and rank sum test were used to analyze among groups. Results: Among 27 children with dRTA (16 boys and 11 girls), the age of onset was 33.4 (10.0, 36.0) months.There were 22 patients (81%) with SLC4A1 gene variation, 3 patients (11%) with ATP6V1B1 gene variation and 2 patients (8%) with ATP6V0A4 gene variation. Totally 22 patients (81%) with renal calcium deposition, 19 patients (70%) hypokalemia, 18 patients (67%) short stature, 16 patients (59%) malnutrition, 16 patients (59%) rickets, and 15 patients (56%) polydipsia and polyuria. Noteworthily, the genotyping results indicated that the age at onset in SLC4A1 gene group was older than that in ATP6V0A4+ATP6V1B1 gene group, with a statistically significant difference (27.3 (12.0, 36.0) vs. 8.2 (2.5, 15.0) months, H=6.33, P=0.012). However, there were no significant differences in clinical manifestations or laboratory test results (all P>0.05). Furthermore, the course of disease was 3.9 (1.3, 6.0) years and the follow-up period was 3.1 (1.0, 4.5) years in 27 patients. In addition, there were no significant differences in recovery rate of clinical manifestations and last laboratory findings between SLC4A1 gene group and ATP6V0A4+ATP6V1B1 gene group (all P>0.05). HtSDS and WtSDS of those patients significantly increased after treatment (-3.2±1.9 vs. -2.1±1.1, -2.5±1.5 vs. 0±1.9, t=-2.94, -5.44, both P<0.01). Serum K+ and blood pH were restored eventually ((3.2±0.5) vs. (4.0±0.5) mmol/L, 7.27±0.07 vs. 7.37±0.07, t=-4.92, -5.25, both P<0.01). Totally 14 patients had normalized serum potassium, 12 patients had normalized blood pH, but only 4 patients had normalized serum bicarbonate concentration and normal base excess. Conclusions: The age of onset of patients who had SLC4A1 gene mutation was older than that of patients with ATP6V0A4 gene and ATP6V1B1 gene mutations. However, there was no obvious correlation between the condition and prognosis of the dRTA patients and pathogenic genes. Early diagnosis, early treatment, regular follow-up and timely adjustment of the dosage of medication can significantly improve the prognosis of dRTA in children. Serum bicarbonate concentration and actual base excess might not be the necessory indicators to assess clinical recovery.

A Whole New World: Changes in the Nursing Home Infection Preventionist Role in Response to the COVID-19 Pandemic

BackgroundNursing home (NH) infection prevention and control (IPC) programs struggled before the COVID-19 pandemic. As the pandemic began, NHs were challenged with frequently changing directives including isolation, testing, visitation, and reporting. Within a larger research project, we compared changes in the infection preventionist (IP) role pre-COVID (before March 2020) and during the pandemic.Methods78 Michigan NHs participated in a 12-month program to reduce healthcare-associated infections from 2018-2021. A 36-question survey on IPC characteristics was sent before starting each of four cohorts. Surveys were completed by IPs, nursing directors, or NH administrators. We compared IPC characteristics pre- and intra-COVID using Fisher's exact test and Wilcoxon Rank Sum to assess significance in categorical and continuous descriptors, respectively.Results74 (94.8%) NHs completed the survey, 56 pre-COVID (before March 2020) and 18 during COVID (> one year after COVID was identified in Michigan). Full-time equivalent (FTE) for the IP role was similar between the two groups, but hours worked per week increased significantly from an average 20 to 38 hours per week (p< 0.001). Half of respondents in 2021 reported working 40 hours or more on IPC activities. Despite the additional workload, the IP did not have a significant decrease in their non-IP responsibilities (e.g., staff educator, employee health). Pre-COVID, 21.8% of NHs were enrolled in CDC's National Health Safety Network (NHSN). As mandatory COVID reporting into NHSN began mid-2021, its use contributed to an average of five additional hours per week. Inter-facility notification of resident infections was done by a variety of methods, with facility-to-facility telephone calls increasing during COVID.ConclusionsCOVID-19 has dramatically added to the IP workload in NH settings with no reduction in their other non-IP responsibilities. With reporting requirements unlikely to decrease soon, investment into staffing is needed to reduce staff burnout, maintain quality of care, and resident safety.

Selecting patients for magnetic resonance imaging cognitive versus ultrasound fusion biopsy of the prostate: A within-patient comparison.

ObjectivesTo compare overall agreement between magnetic resonance imaging (MRI)–ultrasound (US) fusion biopsy (FB) and MRI cognitive fusion biopsy (CB) of the prostate and determine which factors affect agreement for prostate cancer (PCa) who underwent both modalities in a prospective within‐patient protocol.Patients and MethodsFrom August 2017 to January 2021, patients with at least one Prostate Imaging Reporting & Data System (PI‐RADS) 3 or higher lesion on multiparametric MRI underwent transrectal FB and CB in a prospective within‐patient protocol. CB was performed for each region of interest (ROI), followed by FB, followed by standard 12 core biopsy. Patients who were not on active surveillance were analysed. The primary endpoint was agreement for any PCa detection. McNemar's test and kappa statistic were used to analyse agreement. Chi‐square test, Fisher's exact test and Wilcoxon rank sum test were used to analyse disagreement across clinical and MRI spatial variables. A multivariable generalized mixed‐effect model was used to compare the interaction between select variables and fusion modality. Statistics were performed using SAS and R.ResultsNinety patients and 98 lesions were included in the analysis. There was moderate agreement between FB and CB (k = 0.715). McNemar's test was insignificant (p = 0.285). Anterior location was the only variable associated with a significant variation in agreement, which was 70% for anterior lesions versus 89.7% for non‐anterior lesions (p = 0.035). Discordance did not vary significantly across other variables. In a mixed‐effect model, the interaction between anterior location and use of FB was insignificant (p = 0.411).ConclusionIn a within‐patient protocol of patients not on active surveillance, FB and CB performed similarly for PCa detection and with moderate agreement. Anterior location was associated with significantly higher disagreement, whereas other patient and lesion characteristics were not. Additional studies are needed to determine optimal biopsy technique for sampling anterior ROI.

DIPG-25. Patterns of cerebrospinal fluid diversion and survival in children with diffuse intrinsic pontine glioma: a report from the International Diffuse Intrinsic Pontine Glioma Registry

BACKGROUND: There are no standard practice guidelines for cerebrospinal (CSF) diversion for diffuse intrinsic pontine glioma (DIPG), nor clear understanding of potential for palliation and life-prolongation. We evaluated CSF diversion characteristics in children with DIPG to determine incidence, indications, symptom effects, and survival. METHODS: Data were extracted from subjects registered in the International DIPG registry (IDIPGR). Univariable analyses was performed using the Fisher’s exact test or Wilcoxon rank sum test. Survival was estimated using the Kaplan-Meier method. RESULTS: Evaluable patients (n=542) met criteria for DIPG diagnosis by central radiologic review; of those, 126 (23%) had permanent CSF diversion. Median time from diagnosis to diversion was 0.5 months (IQR 0.1-4.5 months). Those with permanent diversion were significantly younger (median 5.4 years vs 7.0 years, p<0.001) and had higher incidence of hydrocephalus at diagnosis (65.3% vs 11.9%, p<0.001). Permanent CSF diversion did not significantly impact overall survival (OS) (p=0.4), even amongst the 124 patients with hydrocephalus at presentation (p=0.20). Those with permanent diversion prior to radiation therapy demonstrated longer median OS than those in whom diversion was placed after radiation (14.3 vs 9.6 months, p=0.001). Patients reported significantly less headache and vomiting at last follow up after permanent CSF diversion compared to pre-diversion (p<0.0001 and p=0.001, respectively), however steroid use was also significantly higher at last follow-up after CSF diversion (p<0.001). CONCLUSIONS: Amongst an international cohort, DIPG patients who had permanent CSF diversion were significantly younger and had higher rates of hydrocephalus at initial presentation than those without permanent diversion. Symptoms of increased intracranial pressure improved in those with CSF diversion, although a direct effect may be confounded by increased steroid use. Permanent CSF diversion did not prolong overall survival in this large cohort of patients, even amongst those who presented with hydrocephalus.

OTHR-16. Nutritional screening of U.S. pediatric central nervous system tumor survivors

INTRODUCTION: Adult survivors of pediatric central nervous system (CNS) tumors are at the highest risk for morbidity and late mortality among all childhood cancers – owed in part to chronic health condition burden, which intersects with environmental and lifestyle factors. Their weight epidemiology has not been previously characterized. METHODS: An institutional, cross-sectional study was carried out amongst young adults ages 18-39 years, previously treated for pediatric CNS tumors and seen in our specialty survivorship clinic from January 2016 to December 2021. Sociodemographic, clinical, and treatment information was extracted from medical records and summarized by descriptive statistics. Anthropometric information extracted from clinical visit records was used to calculate body mass index (BMI) and weight status category according to CDC guidelines. RESULTS: We identified 200 survivors, 47% male and 53% female. Median age was 26 years (range 18-39); patients were median 16.5 years (range 1.5-34.2) from initial diagnosis. Most common primary diagnoses were low grade-glioma (51.0%) and embryonal tumor (20.5%.) One hundred and five (52.5%) survivors had received prior cranial radiation; 81 (40.5%) had an endocrinologic disorder at time of visit. Amongst the entire cohort, 39% were healthy weight, 5% were underweight, 27% overweight, 21% obese, and 8% severely obese. CONCLUSION: The majority of young adult survivors seen in our clinic were not healthy weight by BMI definition. The distribution of BMI groups appears comparable to contemporary studies of the general young adult U.S. population. For those with decreased muscle mass, a previously recognized issue in pediatric CNS tumor survivors, BMI may underestimate body fat. By abstract presentation, univariable analyses will be performed using the Fisher’s exact test or Wilcoxon rank sum test to assess for undernutrition and overnutrition risk factors. Our refined understanding of the nutritional epidemiology in this population will allow for more strategic diet and exercise interventions.

580-P: Clinical and Psychological Differences in Depression in Distressed Teens with Type 1 Diabetes (T1D)

Introduction: Teens with T1D are at risk for depression and diabetes distress. While diabetes distress is typically more predictive of A1C, less is known about teens experiencing both concerns. In teens with T1D with elevated diabetes distress, we explored clinical and psychological differences between those with or without depression. Methods: At baseline of a psychosocial intervention trial, teens (N=173) with PAID-T scores ≥30 (elevated diabetes distress) reported demographics and Patient Reported Outcomes (PROs) of depression, general/T1D resilience, diabetes quality of life (QoL) , and family conflict. A1C and pump use were extracted from medical records. Using Fisher’s exact, X-square, and Wilcoxon rank sum tests, we compared demographics, pump use, A1C, and PROs by depression status (clinical cutoff of PHQ-8 ≥10) . Results: Distressed teens with depression (34%) were more likely to be female and have unemployed caregivers. Compared to participants without depression, distressed teens with depression reported lower resilience and QoL and higher distress and family conflict. There were no differences in mean HbA1c or insulin pump use. Conclusions: Screening for depression is an important clinical initiative-teens with general and T1D-specific mood concerns are at risk for multiple psychosocial challenges that may warrant intervention and may be impacted by social determinants of health. Disclosure S.R.Scott: None. J.Yi-frazier: None. M.B.O'donnell: None. C.Zhou: None. F.Malik: n/a. C.Pihoker: None. D.Desalvo: Consultant; Dexcom, Inc., Insulet Corporation, Research Support; Insulet Corporation. M.Bradford: None. A.Rosenberg: None. M.E.Hilliard: None. Funding NIH 1R01DK121224-01

Palliative Care and Burn Care: Empirically Derived Referral Criteria.

Burns frequently require complex interdisciplinary care. Specialist palliative care (PC) minimizes suffering, aids in decision making, and provides family support in addition to end-of-life care. Specialist PC is a limited resource, best conserved by identifying persons most likely to benefit from a PC referral. Little guidance is available for clinicians on whether and when to refer to PC. This study's purpose was to identify referral criteria using a mixed-methods approach. Data were examined for between-group differences using Fisher's exact, chi-square, or Wilcoxon Rank Sum tests. Qualitative thematic analysis was used to analyze PC provider notes to describe interventions provided. These data formed initial referral criteria, which were reviewed by an expert panel. Significant between-group differences included dying in the burn center; whether multiple patients were transported to the burn center from one event; and ventilator days. Four themes emerged from qualitative analysis. These included managing physical aspects of care; clarifying goals of care; managing end-of-life care; and managing patient/family psychosocial distress. Expert panel input clarified referral criteria language and supplemented the proposed criteria. We present empirically derived referral criteria to guide burn providers in referring persons for specialist PC. Subsequent testing is required to determine their efficacy in improving patient/family outcomes.

Piloting use of an out-of-pocket cost tracker among gynecologic cancer patients

Our objective was to evaluate uptake and satisfaction with an out-of-pocket (OOP) cost tracker as a means for cancer patients to manage their personalized costs of care and to identify characteristics associated with usage. Within a longitudinal survey evaluating financial toxicity among gynecologic cancer patients on active systemic therapy over a 6-month period, we provided paper worksheets for participants to voluntarily track expenses. We assessed usage and satisfaction at 3 and 6months using frequency and percentage. We used Fisher's exact test and Wilcoxon rank sum analysis to evaluate patient characteristics based upon usage. Participants were encouraged to submit their completed cost tracker worksheets. Fifty-three of 121 (44%) participants reported ever using the OOP cost tracker. Most users reported it was easy to use (97%, 100%) and helpful (86%, 72%); however, fewer users rated it as useful for budgeting (42%, 26%) at 3 and 6months, respectively. More patients who knew their insurance premium were users compared to non-users (74.4% vs. 54.4%, p=0.04). Among thirteen users who submitted their completed cost tracker worksheets, non-medical costs (i.e., transportation) had the highest monthly out of pocket costs (mean $213, range $0-587). User feedback included suggestions to enhance the cost tracker with educational tutorials or a reminder system. Future studies should explore if cost tracker uptake and satisfaction are enhanced with the addition of reminders and whether usage decreases financial toxicity or increases patient self-efficacy in managing the costs of cancer care.