Health Science Center Research Articles

A203 PERORAL ENDOSCOPIC MYOTOMY (POEM) FOR COMPLEX ACHALASIA AND THE POEM DIFFICULTY SCORE: AN UPDATE

Abstract Background POEM for achalasia can be challenging in patients with complex achalasia (CA) (i.e., type III achalasia, multiple prior treatments, prior myotomy, and sigmoid type). The POEM difficulty score (PDS) identifies factors that contribute to challenging POEM procedures. (Figure 1) Here, we present an update on the PDS in a series of patients with non-CA and CAs. Aims Our aim was to determine whether, with the introduction of the TT-J knife with waterjet functionality, the PDS still maintains a strong correlation with procedural efficiency and technical difficulty. Methods We retrospectively reviewed patients who underwent POEM for achalasia between May 2018 to July 2023 at the Kingston Health Sciences Center. 139 consecutive POEMs were performed, with 74 CAs. Primary outcomes include correlation of procedural efficiency with the PDS. Secondary outcomes include clinical success at the last followup and adverse events. Demographics and procedural variables were compared with descriptive statistics (mean ± SD; median, min-max range) and the Mann-Whitney U-test. Pre and post-POEM Echkhardt scores were compared using the Wilcoxon signed-rank test. Results 74 (56.7% male) complex and 65 (55.4% male) non-complex POEM procedures were carried out. The mean age is 56.7 ± 16.5 years and 47.3 ± 20.2 years in CA and non-CA respectively. PDS correlates moderately with procedural efficiency with a correlation coefficient of 0.595 (Spearman’s Pampersand:003C0.001). A subanalysis is available in Table 1. The mean efficiency for non-CA was 3.3min/cm±1.2. The median PDS for non-CA was 1 (0-5). In comparison, the mean efficiency for CA were 3.3min/cm ± 1.3 (type III), 5.3min/cm ± 2.3 (prior myotomy), 4.0min/cm ± 1.7 (≥4 prior procedures), and 5.2min/cm ± 2.4 (sigmoid type). The median PDS for CA was 3 (0-6) (type III), 4 (0-8) (prior myotomy), 3 (0-8) (≥4 prior procedures), and 3 (0-6) (sigmoid type). CA and non-CA POEM procedures were completed with 97% and 98% clinical success, respectively. Conclusions PDS continues to moderately correlate with procedural efficiency using the TT-J knife. However, the presence of spastic contractions correlated poorly with procedural efficiency. Thus, it may be omitted with the use of the TT-J knife. The order of increasing difficulty of POEM in CA appears to be type III, prior myotomy, sigmoid type, and ≥4 prior procedures. Multi-center prospective studies are needed to validate PDS in different clinical settings. Table 1: Sub-analysis of individual PDS factors and procedural velocity Figure 1: Peroral Endoscopic Myotomy (POEM) difficulty score (PDS): "FOODS" Funding Agencies None

A144 ZENKER’S PERORAL ENDOSCOPIC MYOTOMY (Z-POEM) OUTCOMES IN TREATMENT OF ZENKER’S DIVERTICULUM: A RETROSPECTIVE CASE SERIES

Abstract Background Zenker’s diverticulum (ZD) is an outpouching of tissue in an area of the posterior hypopharynx called the Killian triangle. ZD is associated with dysphagia, regurgitation, cough and recurrent aspirations. Open surgical repair has been the traditional treatment approach but has high morbidity (0-40%) and mortality (0-9.5%). Endoscopic intervention with septotomy is a less invasive approach with lower complications and shorter recovery times. However, technical success rates range between 56.4-100%, and recurrences occur in 0-32% of patients. Recent studies have shown promising results for peroral endoscopic myotomy treatment of ZD (Z-POEM), although data is limited. Aims In this first Canadian case series, we assess the safety and efficacy of Z-POEM, a novel approach for managing ZD. Methods This is a retrospective case series of all patients who underwent Z-POEM for ZD at Kingston Health Sciences center between July 2021-2023. Data collected included patient demographics, symptoms [Kothari Haber Score (KHS)] pre and post Z-POEM, ZD size and prior treatments. Technical outcomes were also analyzed including the procedure time and the Z-POEM Difficulty Score (ZPDS), which ranges from 0-3 based on maneuverability, fibrosis, and oozing. Clinical success was defined as complete or near-complete resolution of symptoms (i.e. KHS ampersand:003C2), and recurrence was defined as KHS of 3 or more. Lastly, we recorded adverse events and hospital length of stay. Results This case series included 9 patients (6 males and 3 females). The mean age ± standard deviation (SD) was 66.1 ± 10.64 years. One patient had two separate Z-POEM procedures and those were analyzed separately (total sample size = 10). The mean duration of symptoms before the procedure was 31.2 ± 10.12 months and the mean size of ZD was 2.25 ± 1.10 cm. Two patients had prior treatments before their Z-POEM procedure. The median preprocedural KHS was 6 (range 3-10) with dysphagia being the most commonly reported symptom in 80% of patients. In terms of technical outcomes, the mean procedural time was 32.3 ± 13.21 mins, and the median ZPDS score was 2. Most patients required 4-6 clips, with one patient requiring 11 clips for closure. No adverse events or periprocedural complications were reported. 9/10 patients (90%) were discharged one day after the procedure, and one patient required a longer stay (4 days) for observation. Clinical success was achieved in 8/10 patients (80%) of patients with a KHS score of 0 at mean 12 months follow-up. The remaining two patients (20%) had a KHS score of 3 at follow-up suggesting some persistent symptoms. Conclusions Z-POEM is safe and effective in management of ZD with high technical and clinical success rates in the short-term. Larger-scale studies are required to determine the long-term clinical efficacy of Z-POEM in treatment of ZD. Funding Agencies None

A216 MODERATE TO SEVERE ACUTE UPPER GASTROINTESTINAL BLEEDING IN RURAL NORTHERN ONTARIO: AN EPIDEMIOLOGICAL ANALYSIS OF AETIOLOGIES, GEOGRAPHIC LIMITATIONS, AND OUTCOMES

Abstract Background Hospitalizations for upper gastrointestinal bleeds (UGIBs) are resource-demanding as they often require blood transfusion, endoscopy, and intensive care unit admission. Referral centers that provide higher levels of care to remote regions treat illnesses, including UGIB, in much later stages of disease and of higher severity. The Thunder Bay Regional Health Sciences Center (TBRHSC) is a referral center servicing over 250,000 people over a geographically expansive region of Northern Ontario. Despite known barriers to accessing care, little data is currently available to guide our understanding of UGIB aetiologies, severity, and outcomes among patients living remotely in Canada. Aims This retrospective study aimed to evaluate epidemiological data among patients with UGIB at TBRHSC. Methods Of 441 patients with a discharge diagnosis of gastrointestinal hemorrhage from 2016–2022, inclusion criteria were met for 333. Patients under 18 y or with lower GIB were excluded. Patients were classified as regional if their primary address was outside the District of Thunder Bay. Results Patients were highly comorbid (median CCI = 5) and presented with a median (IQR) GBS of 9 (6) and Clinical Rockall Score of 3 (1). Of those who received inpatient endoscopy (n=248), findings included erosive gastritis (21%), gastric ulcer (14%), esophagitis (12%), duodenal ulcer (8%), AVM (7%), and variceal (6%). No definite lesion was observed in 62 patients (22%). The median (IQR) Complete Rockall Score was 4 (2) with major stigmata of recent hemorrhage found in 20%. There was a high prevalence (19%) of cirrhosis, of which 83% had a history of liver decompensation. In 49% of cirrhotic patients, culprit lesions did not include portal hypertensive gastropathy or variceal bleeding. Regional patients accounted for 14% of the population and travelled an average of 424 km to seek care at TBRHSC. Regional patients were younger and required more ICU admissions (p=0.01). ICU admission primarily due to UGIB was 5.4% and all-cause thirty-day mortality was 3.3%. Oral anti-coagulation use prevalence was 43.2% and was associated with a longer length of stay (pampersand:003C0.0001), higher proportion of all-cause 30-day mortality (pampersand:003C0.005). Forty-eight patients did not receive endoscopy due to bleeding stability, palliation, and preference. Conclusions Patients with UGIB at TBRHSC are a highly multimorbid population with a significantly burden of anticoagulant use, cirrhosis, and variceal bleeding. Comparative analysis with metropolitan centers will expand our understanding for providing UGIB care in Northern Ontario. Funding Agencies NOAMA

A149 SAFETY AND EFFICACY OF ENDOSCOPIC SUBMUCOSAL DISSECTION FOR ESOPHAGOGASTRIC NEOPLASMS IN A CANADIAN SETTING

Abstract Background Endoscopic submucosal dissection (ESD) is a technique that has been developed in Japan and is increasingly being adopted by western countries for treatment of superficial gastrointestinal neoplasms. Aims In this study, we aim to present the safety and efficacy of ESD for esophageal and gastric neoplasms in a Canadian setting, given the limited data regarding the outcomes of ESD in North America Methods Data of 100 patients with superficial upper GI neoplasms (esophageal and gastric) who underwent ESD between 2016 and 2022 in Kingston Health Sciences Centre, a tertiary hospital in Kingston, Ontario, were retrospectively reviewed. Demographics and lesion characteristics, ESD technique, and outcomes in terms of efficacy and safety were analyzed. Results 100 patients were included in the study. 67% of the lesions were esophageal. The median diameter was 4.6cm and median area was 11.94cm2. Outcomes were favorable with technical success 98%, en bloc resection 96%, R0 resection 89% and curative resection 80%. Upstage in pathology from index biopsy was seen in 42% of the lesions. Adverse events were infrequently encountered (8%) and included delayed bleeding, aspiration, and pain. Conclusions ESD is a safe and effective modality for accurately diagnosing and treating early and superficial esophagogastric neoplasms when performed by trained endoscopists. Further research is required, however, to increase the adoption of this technique across Canada. Procedural Details Funding Agencies None

A236 THE EFFECTIVENESS AND SAFETY OF DUAL ADVANCED THERAPIES IN PATIENTS WITH INFLAMMATORY BOWEL DISEASE: A CASE-SERIES

Abstract Background Patients with inflammatory bowel disease (IBD) refractory to medical therapy and patients with IBD and concurrent extra-intestinal manifestations (EIMs) pose a challenge within gastroenterology. The small number of approved agents for IBD limits therapeutic options for this population. Utilizing a combination of newer biologic therapies with favourable safety profiles may provide a safe and efficacious option for treating patients with refractory disease or patients with well-controlled IBD but uncontrolled EIMs. Aims The aim of our study was to assess the safety and efficacy of dual advanced therapies for patients with IBD. Methods Patients at London Health Sciences Centre and St. Joseph’s Healthcare Centre on dual advanced therapies for inflammatory bowel disease were retrospectively assessed for a minimum period of 12 months. Major bacterial infection, adverse events, endoscopic, histologic, and clinical remission of IBD, and remission of EIMs of IBD were assessed. Results Five patients with Crohn’s disease receiving dual advanced therapies were identified. Stricturing Crohn’s disease was the predominant phenotype in 80% of the patients. One patient had perianal fistulizing disease. Dual therapy was initiated for concurrent management of EIMs in 80% of patients (enteropathic arthritis in 2 patients, spondyloarthritis in 2 patients, rheumatoid arthritis in 1 patient) and for refractory IBD in one patient. The majority of patients were on a combination of a tumour-necrosis-factor inhibitor and vedolizumab. Other advanced therapies included JAK inhibitors and ustekinumab. The patients were predominantly female (80%) and age at diagnosis was ampersand:003C50 years old in 80% of patients. No adverse events or major bacterial infections were observed during dual therapy. At the end of follow-up, all 5 patients were in clinical remission of their IBD and 4 patients demonstrated endoscopic remission. Only 60% of patients had remission of their EIMs within the follow-up period. Conclusions Our findings suggest that dual advanced therapies are safe and may represent a long-term treatment option for complicated patients with IBD. Funding Agencies None

A67 REDUCING INAPPROPRIATE GAMMA-GLUTAMYL TRANSFERASE TESTING FOR INPATIENTS: A QUALITY IMPROVEMENT INITIATIVE IN LAB WASTE REDUCTION APPLYING THE MODEL FOR CONTINUOUS IMPROVEMENT

Abstract Background Review of the literature identifies a rising trend in laboratory testing, with over 30% of tests estimated to be inappropriately repeated. Laboratory overutilization increases healthcare costs, and can lead to overdiagnosis, overtreatment and negative health outcomes. Indications for repeat Gamma Glutamyl Transferase (GGT) testing in adults are limited, particularly repeat testing within the same admission. Aims Our aim was to reduce the inappropriate ordering of repeat GGT testing by 25% for all inpatients at the London Health Sciences Centre (LHSC) over a one-year study period. Methods An interprofessional team was created to help engage relevant stakeholders, collect baseline data and reassess the indications for GGT testing. A combination of root cause analysis tools, specifically the Ishikawa diagram and Pareto chart, were employed to identify potential factors contributing to the overutilization of GGT testing. After prioritizing potential solutions, intervention bundles were developed, and Plan-Do-Study-Act (PDSA) cycles were created to target correctable factors. In PDSA cycle #1, the process started by eliminating GGT as a laboratory testing option in the three most commonly used admission order care sets. Considering the hierarchy of intervention effectiveness, PDSA cycle #2 involved implementing a computerized Clinical Decision Support (CDS) system to restrict the reordering of GGT tests within 72 hours of the same admission. Results Baseline data showed that in 2022, a total of 62,542 GGT tests were ordered, with an average of approximately 5,200 GGT tests ordered per month. Of these, 16.4% were ordered through the top 3 most prevalent admission order care sets, and around 25% of all GGT tests were repeats within 72 hours of admission. Referring to Figure 1, PDSA cycle #1 yielded no significant reduction in GGT testing. PDSA cycle #2 successfully reduced the proportion of repeat GGT tests ordered by 12% within two months of implementation, leading to an estimated annualized cost savings of approximately $37,440. Conclusions Our results establish the effectiveness of CDS systems in reducing laboratory testing overutilization, suggesting their superiority to individual care set targeting interventions, and emphasize the potential for cost-effective CDS development in contemporary healthcare. Funding Agencies None

A284 EVALUATING THE INCIDENCE OF MAJOR GASTROINTESTINAL BLEEDING IN PATIENTS WITH CIRRHOSIS ON ANTICOAGULATION THERAPY: A TERTIARY SINGLE CENTRE EXPERIENCE

Abstract Background Patients with chronic liver disease, especially those with cirrhosis, face an increased risk of bleeding and thrombosis due to hemostasis dysregulation. In such cases, prescribing anticoagulation therapy requires a cautious approach, given the inherent risk-reduction in thrombosis alongside a suspected elevated bleeding risk. Aims Perform a retrospective study to evaluate anticoagulation safety and gastrointestinal bleeding incidence in cirrhotic patients. Methods A retrospective study was conducted at the University Hospital of London Health Sciences Centre, involving patients who attended outpatient hepatology clinics between 2010 and 2022. To be eligible, patients had to be 18 years or older and have confirmed cirrhosis through imaging, radiology, or pathology. They were monitored for up to 5 years for the primary outcome, which was major gastrointestinal bleeding requiring hospitalization. Exclusions included patients with underlying hematologic or thrombotic conditions contributing to abnormal hemostasis beyond cirrhosis and those who underwent liver transplantation. Descriptive statistics were provided, such as means and standard deviations for continuous variables, and proportions/percentages for categorical ones. Group comparisons utilized the Student's t-test for continuous variables and chi-squared tests for categorical variables. Univariate and multivariate logistic regression were employed to calculate odds ratios and their associated 95% confidence intervals for the primary outcome Results We retrospectively enrolled 300 patients, with 34.0% having cirrhosis and anticoagulation history. The average age was 63.1 years [95% CI 61.7 – 64.6], and 43.7% were female. Atrial fibrillation was the primary reason for anticoagulation (53.9%). Cirrhotic patients on anticoagulation had a 13.1% bleeding rate, while those without had 18.6% (p-value = 0.207, not significant). Univariate analysis suggested a possible link between anticoagulation and bleeding risk (OR 1.51 [95% CI 0.79 – 2.89]). No covariates predicted bleeding in univariate logistic regression. In multivariate analysis adjusting for age and sex, the odds ratio remained at 1.50 [95% CI 0.78 – 2.88]. The study hints at a higher bleeding risk in cirrhotic patients on anticoagulation, but more statistical power is needed, either through a larger sample or a multicenter approach. Conclusions To further investigate the association between anticoagulation and bleeding risk in cirrhotic patients, a larger multicentre study with increased enrollment is required. Nonetheless, interim findings do suggest the potential existence of an associated bleeding risk in cirrhotic patients undergoing anticoagulation therapy, albeit with a small observed effect size and uncertain clinical significance. Funding Agencies None

A31 DYSPLASIA IN COLONIC POLYPS: PREPARING FOR A RESECT AND DISCARD STRATEGY IN CANADA

Abstract Background While diminutive colorectal polyps have a negligible cancer risk, current management involves resecting and submitting all polyps for histological assessment. This is a substantial burden and cost to the healthcare system. The European Society of Gastrointestinal Endoscopy (ESGE) has recommended a “resect-and-discard strategy” without histological evaluation as an acceptable strategy when high-confidence endoscopic characterization of colorectal polyps is achieved. However, a resect and discard strategy has not been adopted yet in Canada. Aims The objective of this study was to determine the prevalence and characteristics of polyps removed at our center based on size. Methods We retrospectively reviewed colonoscopies and pathology reports at Kingston Health Sciences Center from January to December 2020. Based on the pathology report, polyps were classified as diminutive (1-5mm), small (6-9mm) or large (ampersand:003E or = 10mm). We recorded histology and the presence of high-grade dysplasia (HGD) or cancer. Results Out of 2218 colonoscopies, 2945 polyps were removed. 1703 (57.8%) polyps were diminutive with only two (0.1%) having focal HGD and none having cancer. 699 (23.7%) polyps were classified as small with three (0.4%) having HGD and none having cancer. The large polyp group had 543 (18.4%) polyps, of which 87 (16%) showed HGD and 15 (2.8%) exhibited cancer. The specific histologic findings are shown in Table 1. Endoscopy reports specifically mentioned concern of dysplasia in one out of the five polyps with HGD in the diminutive and small groups. Conclusions As expected, most polyps were either diminutive or small (81.5%). Neither of these groups had cancer and only 5 had HGD. Adopting a resect and discard strategy at our center for diminutive polyps has the potential for significant cost savings with negligible risk of missing a high-risk polyp. The next steps would involve assessing optical diagnosis sensitivity and specificity for diminutive and small polyps. Histological characterization of polyps within each size range Funding Agencies None

A79 PATIENT AND PHYSICIAN PERSPECTIVES ON IMPLEMENTION OF BEDSIDE INTESTINAL ULTRASOUND FOR THE ASSESSMENT OF INFLAMMATORY BOWEL DISEASE

Abstract Background New tools for evaluating Inflammatory Bowel Disease (IBD) activity and complications are needed to deliver timely disease management and improve patient outcomes. Point of care (POC) intestinal ultrasound (IUS) is safe, inexpensive, and less invasive compared to standard endoscopy and imaging. Aims To evaluate the implementation of POC IUS within an ambulatory IBD clinic at the QEII Health Sciences Center. Methods This was a retrospective evaluation of a cohort of patients who had undergone IUS within the Nova Scotia Collaborative Inflammatory Bowel Diseases Clinic (NSCIBD) between January 18, 2023 and August 13, 2023. Medical records were reviewed retrospectively. Patient demographics, disease-related characteristics, perceived impact of IUS on need for endoscopy, perceived impact of IUS on IBD management, and clinical utility of IUS were collected. Surveys were administered prospectively to referring care providers and patients following IUS. Patient surveys assessed IUS satisfaction, acceptance of other methods to assess IBD activity, whether IUS improved knowledge of illness, and impact on quality of life (QoL). Results One physician completed 107 IUS exams on 92 patients at the NSCIBD clinic over a nine-month period. Of 92 patients, 47 (51%) were male and 78 (85%) had Crohn’s disease. 53 patients provided an email and consented to survey participation. 34 responses were submitted (64%). There were 97 responses (91%) from 12 referring gastroenterology specialist clinicians. Ninety-three percent of responses show IUS reports were very helpful (60%) or somewhat helpful (33%). More than a third (37%) of IUS exams were reported to delay or prevent the need for endoscopic evaluation, and 34% were reported to prompt a therapeutic change. Of available tools, IUS had the highest proportion of patients who felt it was completely acceptable (77%), compared to colonoscopy (41%), stool sampling (50%), blood tests (71%), and computed tomography/magnetic resonance imaging (47%). Most (89%) indicated IUS caused either no discomfort (68%) or little discomfort (21%), with no patient reporting a lot of discomfort. Some patients (41%) reported that IUS improved their understanding of their illness, and 38% believe it improved their QoL. Conclusions POC IUS offers an accurate, less invasive option for monitoring IBD activity compared to traditional investigations. There is limited data on implementation of, and patient and clinician perspectives regarding use of IUS and its clinical implications. Even early in implementation, POC IUS has clear benefits. This study suggests that IUS is highly acceptable to patients for investigating/monitoring their illness. Treating clinicians find significant value in IUS and report that it can prevent the need for endoscopic evaluation and prompt changes in therapeutic management. Funding Agencies None

A138 ENDOSCOPIC SUBMUCOSAL DISSECTION OUTCOMES IN T1B COLORECTAL CANCER: A SINGLE CENTER EXPERIENCE

Abstract Background Endoscopic submucosal dissection (ESD) has transformed the approach to gastrointestinal neoplasms, particularly in managing T1 colorectal cancer(CRC) with superficial submucosal invasion (SMI), which is considered curative when other high-risk features are absent. Aims The aim of this study is to describe a single center’s experience with safety, and technical and clinical outcomes for patients undergoing ESD with T1b CRC, as well as explore differences in outcomes depending on depth of SMI. Methods This is a retrospective, single center study of patients who underwent ESD for suspected CRC at the Kingston Health Sciences Center, Ontario, Canada between October 2016 and April 2023. Patients with T1b CRC on their final pathology were included. We analyzed patient demographics, tumor characteristics, and technical outcomes. Patients were followed to determine cancer-free survival and tumor recurrence. Patients were stratified and compared by depth of SMI on their final pathology. Results A total of 32 patients with 33 T1b CRCs were included. 19 lesions had superficial SMI, and 14 had deep SMI on final specimens. Two procedures were aborted due to suspected deep invasion or fibrosis limiting ESD. The mean procedure time was 74.5 minutes and the mean efficiency was 12.3 min/cm3. ESD had high en-bloc (90.9%) and R0 (78.7%) resection rates, and there was no significant difference regardless of depth of SMI (p=0.08 and 0.372, respectively). 24 of 33 lesions had biopsy prior to ESD, and 22 of 24 lesions with previous histology (91.7%) had upgrade in pathology on their final ESD specimen. 2 patients had adverse events, and both were managed supportively. A total of 9 patients (27%) went on to have surgery. Those with deep SMI were more likely to have surgery (5% vs 57%, pampersand:003C0.005). The most common reason was lymphovascular invasion (44%). However, in the 7 patients who had complete ESD procedure and subsequent surgery, none had residual cancer on their surgical specimens, or malignant lymph nodes. The follow-up period for all patients ranged from 1 to 43 months with a mean follow-up time of 14.9 months. Of those who did not have surgery, all were cancer free at a mean follow up time of 16.2 months. Within the group of patients who had surgery, all were cancer free at a mean follow up time of 11.6 months. 5 patients died during the follow up period. None were from procedural related complications or disease recurrence. Conclusions ESD for T1b CRC is safe with high en-bloc and R0 resection rates. Patients with deep SMI were more likely to go on to have surgery, though this was frequently due to an additional high risk feature. Recurrence rates were low, but studies with longer follow up are needed. Funding Agencies None

Lymph node yield: Impact on oncologic outcomes in oral cavity cancer.

Lymph node metastases are associated with poor prognosis in oral cavity squamous cell carcinoma (OCSCC). In other cancers, clinical guidelines on the number of lymph nodes removed during primary surgery, lymph node yield (LNY), exist. Here, we evaluated the prognostic capacity of LNY on regional failure, locoregional recurrence, and disease-free survival (DFS) in patients with OCSCC treated by primary neck surgery. This retrospective cohort study took place at Sunnybrook Health Sciences Centre in Toronto, Canada and involved a chart review of all adult patients with treatment-naive OCSCC undergoing primary neck dissection. For each outcome, we first used the maximally selected rank statistics and an optimism-corrected concordance to identify an optimal threshold of LNY. We then used a multivariable Cox proportional hazards model to assess the association between high LNY (>threshold) and each outcome. Among the 579 patients with OCSCC receiving primary neck dissection, 61.7% (n = 357) were male with a mean age of 62.9 years (standard deviation: 13.1) at cancer diagnosis. When adjusting for sociodemographic and clinical factors, LNY >15 was significantly associated with improved DFS (adjusted HR [aHR]: 0.73, 95% CI: 0.54-0.98), locoregional recurrence (aHR: 0.68, 95% CI: 0.49-0.95), and regional failure (aHR: 0.61, 95% CI: 0.39-0.93). Our study findings suggested high LNY to be a strong independent predictor of various patient-level quality of surgical care metrics. The optimal LNY we found (15) was lower than the conventionally recommended (18), which calls for further research to establish validity in practice.

Building Statewide Quality Improvement Capacity to Improve Cardiovascular Care and Health Equity: Lessons from the Tennessee Heart Health Network

Many states with high rates of cardiovascular disease (CVD) lack statewide quality improvement (QI) infrastructure (for example, resources, leadership, community) to address relevant health needs of the population. Academic health centers are well positioned to play a central role in addressing this deficiency. This article describes early experience and lessons learned in building statewide QI infrastructure through the Tennessee Heart Health Network (Network). A statewide, multistakeholder network composed of primary care practices (PCPs), health systems, health plans, QI organizations, patients, and academic institutions was led by the University of Tennessee Health Science Center (UTHSC), an academic health center, to improve cardiovascular health by supporting dissemination and implementation of patient-centered outcomes research (PCOR) evidence-based interventions in primary care. PCPs were required to select and implement at least one of three interventions (health coaching, tailored health-related text messaging, and pharmacist-physician collaboration). Thirty statewide organizational partners joined the Network in year one, including 18 health systems representing 77 PCPs (30.0% of 257 potentially eligible PCPs identified) with approximately 300,000 patients. The organizational partners share EHRs for the ongoing tracking and reporting of key health metrics, including hypertension control and delivery of tobacco cessation counseling. Of the 77 PCPs, 62 continue participation after year two (80.5% retention). Main barriers to participation and reasons for discontinuing participation included reluctance to share data and changes in leadership at the health system level. These 62 PCPs selected the following interventions to implement: health coaching (41.9%), tailored health-related text messages (48.4%), and pharmacist-physician collaboration (40.3%). Academic health centers have broad reach and high acceptability by diverse stakeholders. Tennessee's experience illustrates how academic health centers can serve as platforms for building a statewide infrastructure for disseminating, implementing, and sustaining QI interventions at the practice level. Assessment of Network impact is ongoing.

Clinical Characteristics and Treatment Outcomes of Prurigo Nodularis: A Retrospective Study.

Prurigo nodularis (PN) is a complex chronic skin disease characterized by severe pruritic nodules. PN is often associated with mental health disorders and chronic medical comorbidities. Until recently, PN treatment has been challenging and difficult. This study aims to describe the demographic, clinical characteristics, and comorbidities associated with PN. Also, we aim to describe the effectiveness of systemic therapies, including methotrexate, cyclosporine, and narrow band ultraviolet (NB-UVB) in adult patients with PN. This is a retrospective chart review of adult patients diagnosed with PN at Hamilton Health Science Center and/or McMaster University in Hamilton, Ontario, between 2015 and 2023. The study included 81 patients (57% female). The mean age was 52.8 years, and the mean age of PN diagnosis was 50 years. Reported symptoms included: itching (100%), dry skin (53%), pain (17%), and burning sensation (5%). Lower and upper extremities were the most common areas involved in 93% and 69%, respectively. Mental health disorders were present in 79% of patients, with depression (58%) and anxiety (52%) being the most common. Atopic dermatitis was the most common skin comorbidity noted. Treatments used included cyclosporine, and NB-UVB, and MTX, which resulted in significant improvement of pruritus in 38%, 35%, and 31% of patients, respectively, at week 16. PN is associated with increased risk of mental health disorders and other medical comorbidities. Cyclosporine, methotrexate, and NB-UVB therapy may be effective treatment options, however clinicians must consider the potential short- and long-term adverse effects of these treatments.

Evaluating yield and utilization of ganglioside antibody testing in clinical practice

Background and objectivesGanglioside antibodies can help diagnose distinct acute and chronic inflammatory neuropathies including axonal variants of Guillain-Barre syndrome, Miller-Fisher syndrome (MFS), multifocal motor neuropathy, and chronic sensory ataxic neuropathies. Because ganglioside antibody testing may be routinely ordered in patients with suspected inflammatory neuropathy, we sought to evaluate its yield and utilization in clinical practice. MethodsWe performed a retrospective chart review of all patients at London Health Sciences Centre who underwent ganglioside antibody testing between April 2019 and August 2023. The disease phenotype was determined for each patient, and the proportion of all tests that yielded a true-positive result was calculated. Ganglioside antibody positivity was classified as a true-positive result if the disease phenotype was robustly associated with the detected ganglioside antibody and there was no other more likely diagnosis. ResultsWe identified 92 patients who underwent ganglioside antibody testing. One patient (1%) was classified as having a true-positive result; this patient had GQ1b-IgG positivity with MFS. Among 92 patients tested, 20 patients (22%) had a disease phenotype that was considered to be robustly associated with ganglioside antibody positivity. ConclusionsThe yield of ganglioside antibody testing in clinical practice is low. We found that this testing is frequently ordered in patients with disease phenotypes that are not robustly associated with ganglioside antibody positivity, indicating that suboptimal test utilization is a primary contributor to its low yield. Restricting ganglioside antibody testing to patients with characteristic disease phenotypes would be valuable to improving yield and utilization of this testing.

Epidemiology of spinal cord injury and spinal cord injury–induced urinary tract stones in Taiwan: A 2005–2015 population-based cohort study

Context Patients with spinal cord injury (SCI) can develop urinary tract stones (UTSs) up to years after the injury, which is especially common in the first few months. However, relevant epidemiological studies and up-to-date epidemiological data for SCI in Taiwan are lacking. Purpose To estimate SCI and SCI-induced UTS incidence and trauma severity, neurological deficits, and injury site in patients with SCI-induced UTSs in Taiwan. Design Retrospective cohort study. Patient sample: Taiwan National Health Insurance Research Database (NHIRD) data and death data from the Department of Health and Welfare Data Science Center (HWDC) collected over 2005–2015 from 13,977 patients with SCI aged >18 years. Outcome measures Cumulative incidence (CI), incidence density (ID), relative ratios (RRs), odds ratios (ORs), and hazard ratios (HRs) were measured. Methods By using Cox regression, we assessed UTS risk in patients with SCI. Results Although standardized SCI incidence demonstrated a decreasing trend annually, the average annual incidence remained at 60.4 per million. Most (65.7%) of the included patients were men. SCI incidence was 1.98 times higher in men than in women. The most common injury site was the cervical spine (63.8%); the incidence at this site was 2.83 times higher in men than in women. Most (76.1%) of the patients had traumatic SCI (TSCI), and the standardized incidence of TSCI and non-TSCI was 45.9 and 14.4 per million, respectively. 46.1% of the patients had severe SCI (RISS ≥ 16). Over the 11-year follow-up period, UTSs occurred in 10.4% of the patients, with a standardized incidence of 2.39 per 100 person-years, and UTS risk was 1.56 times higher in men than in women. Age of 45–65 years, SCIs at multiple sites, and neurological deficits (e.g. paraplegia) were noted to be UTS risk factors. Finally, UTS onset mainly occurred in the first year after SCI. Conclusion The risk of UTS among patients with SCI is influenced by age, sex, injury site, and paraplegia but not by paralysis resulting from other neurological deficits. Even though SCI incidence is declining annually, severe SCI remains a significant issue. Therefore, continuing to reduce SCI incidence and strengthening urinary tract management in patients with SCI are essential for reducing UTS occurrence and their impact on health.

IPEC Core Competencies in Action: Developing Emory’s IPE-ACTS Program through Collaborative Interprofessional Teamwork

In this “How-to,” we describe the development of IPE-ACTS (Interprofessional Education – Achieving Collaborative Team Solutions), a new required interprofessional (IPE) training program for first-year Woodruff Health Sciences Center (WHSC) students at Emory University.

The Military Health History: An Educational Initiative to Improve Veteran Healthcare.

As a result of the nature of military service, veterans are a unique patient population with many special health considerations. For various reasons, measures are often not taken by clinicians to address such special considerations. This results in a healthcare disparity for veterans first described by Dr. Jeffrey Brown in 2012. To address this disparity, we introduced "the military health history" to third-year medical students at a large medical school in the southeastern United States. Our objective was to assess the effectiveness of this educational intervention and determine its potential role in creating a future in which veteran healthcare is of the highest quality. This study was approved as a quality assurance/quality improvement project by both Louisiana State University Health Science Center and Southeast Louisiana Veteran Healthcare System IRB offices. A short lecture outlining the components of the military health history was presented to 186 third-year medical students. The students were given the opportunity to answer five survey questions before and after the lecture. These questions assessed the students' current confidence performing a military health history, perceived importance of doing so, and likelihood of future implementation. To determine useful retention of the lecture material, the post-lecture survey was readministered to the same population sample 6 months after the lecture. A series of repeated measures analyses of variance were conducted to examine changes in mean levels of confidence, importance, and likelihood of ascertaining military history during a patient encounter at pre- and post-presentation as well as at the 6 month follow-up. Results revealed a significant effect of time on importance, Wilks' Lambda = 0.74, F (2, 87) = 15.41, P < 0.001; confidence, Wilks' Lambda = 0.61, F (2, 87) = 27.58, P < 0.001; and likelihood of ascertaining a military history during a future patient encounter, Wilks' Lambda = 0.46, F (2, 88) = 50.58, P < 0.001. Results are demonstrated in detail in Table I of the manuscript. The lecture resulted in a statistically significant increase over 6 months in both the likelihood and confidence parameters. The team believes that this result indicates that the students demonstrated useful retention of the lecture material. Our hope is that these students continue to employ the military health history throughout their years of clinical work. In the future, we plan to survey veterans immediately following Veterans Health Administration clinic visits with members of our study population to assess the patient's perceived benefit of the military health history. The team will continue to investigate ways in which military health curricula can be implemented in undergraduate medical education.

Association of Kawasaki disease with urbanization level and family characteristics in Taiwan: A nested case-control study using national-level data.

Kawasaki disease (KD) is an inflammatory vasculitis disorder of unknown etiology. It is a rare but fatal disease and the leading cause of acquired coronary heart disease in children under the age of 5 years. We examined the association of KD with the demographics of family members, parents' characteristics, and perinatal factors in Taiwanese children. This nested case-control study used data from Taiwan's Health and Welfare Data Science Center and initially included children born in Taiwan between January 1, 2006, and December 31, 2015 (n = 1,939,449); the children were observed for KD development before the age of 5 years (n = 7870). The control group consisted of children without KD who were matched with each KD case by sex and birth date at a ratio of 8:1. The odds ratio (ORs) of the aforementioned associations were estimated using conditional logistic regression. The risk of KD decreased in children with younger parents [<25 years; younger maternal age, OR = 0.72, 95% confidence interval (CI), 0.66-0.79; younger paternal age, OR = 0.68, 95% CI, 0.59-0.78], lower socioeconomic status, more than 2 siblings (OR = 0.80, 95% CI, 0.73-0.89), and siblings with a history of KD (OR = 4.39, 95% CI, 3.29-5.86). Children living in suburban (OR = 0.95, 95% CI, 0.90-1.00) and rural (OR = 0.81, 95%CI, 0.74-0.90) areas exhibited a lower risk of KD than children living in urban areas. In conclusion, a higher incidence rate of KD was observed in children aged <5 years who had an urban lifestyle, had siblings with KD, were born to older mothers, and belonged to high-income and smaller families. Parental allergic or autoimmune diseases were not associated with the risk of KD.

Deep learning system for true- and pseudo-invasion in colorectal polyps

Over 15 million colonoscopies were performed yearly in North America, during which biopsies were taken for pathological examination to identify abnormalities. Distinguishing between true- and pseudo-invasion in colon polyps is critical in treatment planning. Surgical resection of the colon is often the treatment option for true invasion, whereas observation is recommended for pseudo-invasion. The task of identifying true- vs pseudo-invasion, however, could be highly challenging. There is no specialized software tool for this task, and no well-annotated dataset is available. In our work, we obtained (only) 150 whole-slide images (WSIs) from the London Health Science Centre. We built three deep neural networks representing different magnifications in WSIs, mimicking the workflow of pathologists. We also built an online tool for pathologists to annotate WSIs to train our deep neural networks. Results showed that our novel system classifies tissue types with 95.3% accuracy and differentiates true- and pseudo-invasions with 83.9% accuracy. The system’s efficiency is comparable to an expert pathologist. Our system can also be easily adjusted to serve as a confirmatory or screening tool. Our system (available at http://ai4path.ca) will lead to better, faster patient care and reduced healthcare costs.

Long-Term Survival and Cancer Risk in the Hepatitis C Virus-Infected Patients After Antiviral Treatment: A Nationwide Cohort Study.

Background: Exposure to the Hepatitis C virus (HCV) has been identified as one of the most critical risk factors for Hepatocellular carcinoma (HCC). Interferons and direct-acting antivirals (DAAs) have been used to treat HCV infection with high rates (95%) of prolonged virological response, a suitable safety profile, and good compliance rates. Methods: We obtained information from Taiwan's Health and Welfare Data Science Center. (HWDSC). In this observational cohort research, patients with HCV who received a diagnosis in Taiwan between 2011 and 2018 were included. Results: 78,300 untreated HCV patients were paired for age, sex, and index date with 39,150 HCV patients who received interferon or DAAs treatment. Compared to the control group, the Interferon or DAAs treatment sample has fewer low-income individuals and more hospitalization requirements. The percentage of kidney illness was reduced in the therapy group compared to the control group, but the treatment group had a greater comorbidity rate of gastric ulcers. Interferon or DAA therapy for HCV-infected patients can substantially lower mortality. All cancer diagnoses after HCV infection with interferon treatment aHR 95% CI = 0.809 (0.774-0.846), Sofosbuvir-based DAA aHR 95% CI = 1.009 (0.737-1.381) and Sofosbuvir free DAA aHR 95% CI = 0.944 (0.584-1.526) showing cancer-protective effects in the INF-treated cohort but not DAA. Conclusion: Following antiviral therapy, women appear to have a more substantial preventive impact than men against pancreatic, colorectal, and lung cancer. Interferon or DAAs treatment effect was more significant in the cirrhotic group.