Wisconsin Hospital Research Articles

Effectiveness of a Mobile App (Meds@HOME) to Improve Medication Safety for Children With Medical Complexity: Protocol for a Randomized Controlled Trial.

This study will pilot-test the mobile app, Medication Safety @HOME-Meds@HOME intervention to improve medication administration accuracy, reduce preventable adverse drug events, and ultimately improve chronic care management for children with medical complexity (CMC). The Meds@HOME app was co-designed with CMC families, secondary caregivers (SCGs), and health professionals to support medication management for primary caregivers (PCGs) and SCGs of CMC. We hypothesize that Meds@HOME will improve caregivers' medication administration accuracy, reduce preventable adverse drug events, and ultimately improve chronic care management. This study aims to evaluate the effectiveness of Meds@HOME on medication administration accuracy for PCGs and SCGs. This study will recruit up to 152 PCGs and 304 SCGs of CMC who are prescribed at least 1 scheduled high-risk medication and receive care at the University of Wisconsin American Family Children's Hospital. PCGs will be randomly assigned, for the 6-month trial, to either the control group (not trialing Meds@HOME) or the intervention group (trialing Meds@HOME) using 1:1 ratio. The Meds@HOME app allows caregivers to create a child profile, store medication and care instructions, and receive reminders for upcoming and overdue care routines and medication refills. Surveys completed both at the start and end of the trial measure demographics, medication delivery knowledge, confidence in the CMC's caregiving network, and comfort with medical information. Univariate and multivariate generalized estimation equations will be used for primary statistical analysis. The primary outcome is the PCG's rate of medication administration accuracy measured as correct identification of each of the following for a randomly selected high-risk medication: indication, formulation, dose, frequency, and route at baseline and after 6 months. Secondary outcomes include SCG medication administration accuracy (indication, formulation, dose, frequency, and route), count of University of Wisconsin hospital and emergency department encounters, PCG-reported medication adherence, count of deaths, and PCG medication confidence and understanding. Recruitment for this study began on November 29, 2023. As of May 15, 2024, we have enrolled 94/152 (62%) PCGs. We expect recruitment to end by August 1, 2024, and the final participant will complete the study by January 28, 2025, at which point we will start analyzing the complete responses. We expect publication of results at the end of 2025. The Meds@HOME mobile app provides a promising strategy for improving PCG medication safety for CMC who take high-risk medications. In addition, this protocol highlights novel procedures for recruiting SCGs of CMC. In the future, this app could be used more broadly across diverse caregiving networks to navigate complex medication routines and promote medication safety. ClinicalTrials.gov NCT05816590; https://clinicaltrials.gov/study/NCT05816590. DERR1-10.2196/60621.

Association of complicated appendicitis with geographic and socioeconomic measures in children

BackgroundComplicated appendicitis, considered a marker of delay in accessing surgical care among children, has been inconsistently associated with race, socioeconomic status, insurance type, rurality, and distance to care. This statewide assessment measured factors associated with complicated appendicitis while overcoming limitations of prior work, namely, selection bias and use of inexact socioeconomic status measures. MethodsChildren (<18 years) undergoing appendectomy for appendicitis in Wisconsin from 2018 to 2021 were identified in the Wisconsin Hospital Association database. Patient residence and hospital locations were used to determine rurality, travel distances, and socioeconomic status as measured by Area Deprivation Index, Child Opportunity Index, Community Need Index, and county-level poverty rates. Multivariable logistic regression was used to assess factors associated with complicated appendicitis. ResultsAmong 5,881 children undergoing appendectomy, 1,375 (23.4%) had complicated appendicitis. Adjusting for other variables, complicated appendicitis was associated with younger age (adjusted odds ratio 0.90 per year increase); Hispanic White race/ethnicity (adjusted odds ratio 1.40–1.63); distance to the hospital where surgery was performed (adjusted odds ratio 1.16–1.17 per 10-mile increase); and very low Child Opportunity Index (adjusted odds ratio 1.29), Community Need Index (adjusted odds ratio 1.20 per 1-score increase), and county-level poverty (adjusted odds ratio 1.02 per 1% increase). Insurance type, rurality, and Area Deprivation Index were not associated with complicated appendicitis. Residential county-level complicated appendicitis rates (0.0%–50.0%) had moderate correlation to pediatric county-level poverty rates (rs=0.43). ConclusionComplicated appendicitis was associated with Child Opportunity Index, Community Need Index, and county-level poverty but not insurance type, rurality, or Area Deprivation Index. There was geographic variability in complicated appendicitis rates, with modest correlation to county-level poverty. Targeted interventions among Hispanic populations and those with travel- and socioeconomic status–related barriers to care may be beneficial in preventing complicated appendicitis among children.

Risk factors for treatment of asymptomatic bacteriuria in a rural health system.

In an effort to expedite the publication of articles, AJHP is posting manuscripts online as soon as possible after acceptance. Accepted manuscripts have been peer-reviewed and copyedited, but are posted online before technical formatting and author proofing. These manuscripts are not the final version of record and will be replaced with the final article (formatted per AJHP style and proofed by the authors) at a later time. Asymptomatic bacteriuria is often inappropriately treated, leading to antimicrobial-related adverse events and contributing to antimicrobial resistance. This study examined the asymptomatic bacteriuria treatment rate at a rural Wisconsin health system and the patient-specific factors that may be influencing clinicians' decisions to treat. This is a retrospective descriptive report of patients admitted from January to May 2022 at 7 rural Wisconsin hospitals. Patients were included if they were a hospitalized adult with asymptomatic bacteriuria. Patients were excluded if they had a urinary tract abnormality, active infection, symptoms of a urinary tract infection, a planned urological surgery, or treatment or prophylaxis for a urinary tract infection within 72 hours of admission, were immunocompromised, or were transferred from an outside facility. Electronic and manual chart abstraction were used for data collection. Of 429 patients with a positive urine culture, 137 patients with asymptomatic bacteriuria were included in the study. The median age was 75 years, and most patients were female (80.3%). The treatment rate of asymptomatic bacteriuria was 78.1%, amounting to 393 days of unnecessary antimicrobial therapy. Symptoms of fatigue (P = 0.014) and altered mentation (P < 0.006) and urinalysis results of nitrite positivity (P = 0.026) and pyuria (P < 0.001) were each independently associated with antimicrobial treatment. Despite guideline recommendations to avoid treatment of asymptomatic bacteriuria, treatment rates in rural hospitalized patients remain high. Nonspecific signs and symptoms of altered mentation and fatigue as well as laboratory findings of nitrite positivity and pyuria were factors associated with a decision to treat. Future stewardship efforts should speak to the poor specificity of these factors.

Prior emergency medical services utilization is a risk factor for in-hospital death among patients with substance misuse: a retrospective cohort study

BackgroundSubstance misuse poses a significant public health challenge, characterized by premature morbidity and mortality, and heightened healthcare utilization. While studies have demonstrated that previous hospitalizations and emergency department visits are associated with increased mortality in patients with substance misuse, it is unknown whether prior utilization of emergency medical service (EMS) is similarly associated with poor outcomes among this population. The objective of this study is to determine the association between EMS utilization in the 30 days before a hospitalization or emergency department visit and in-hospital outcomes among patients with substance misuse.MethodsWe conducted a retrospective analysis of adult emergency department visits and hospitalizations (referred to as a hospital encounter) between 2017 and 2021 within the Substance Misuse Data Commons, which maintains electronic health records from substance misuse patients seen at two University of Wisconsin hospitals, linked with state agency, claims, and socioeconomic datasets. Using regression models, we examined the association between EMS use and the outcomes of in-hospital death, hospital length of stay, intensive care unit (ICU) admission, and critical illness events, defined by invasive mechanical ventilation or vasoactive drug administration. Models were adjusted for age, comorbidities, initial severity of illness, substance misuse type, and socioeconomic status.ResultsAmong 19,402 encounters, individuals with substance misuse who had at least one EMS incident within 30 days of a hospital encounter experienced a higher likelihood of in-hospital mortality (OR 1.52, 95% CI [1.05 – 2.14]) compared to those without prior EMS use, after adjusting for confounders. Using EMS in the 30 days prior to an encounter was associated with a small increase in hospital length of stay but was not associated with ICU admission or critical illness events.ConclusionsIndividuals with substance misuse who have used EMS in the month preceding a hospital encounter are at an increased risk of in-hospital mortality. Enhanced monitoring of EMS users in this population could improve overall patient outcomes.

Reprint of: How He Did It – The James S. Tweddell Approach to Single Ventricle Palliation in Patients With Hypoplastic Left Heart Syndrome

This article will detail Dr. James Tweddell's operative technique and considerations for 26 all three stages of SVP in patients with HLHS. This will include the Norwood Procedure with 27 Right-Ventricle-to-Pulmonary-Artery Conduit (Sano Modification), Bidirectional Glenn 28 (Superior Cavopulmonary Connection), and Extracardiac, Fenestrated Fontan Completion (Total 29 Cavopulmonary Connection). These techniques are the culmination of over 20 years of experience 30 and represent the final techniques he employed at both Children's Hospital of Wisconsin and 31 Cincinnati Children's Hospital Medical Center.

Intervention Targets to Optimize Antibiotic Prescribing on Discharge from the Hospital to Nursing Homes

Background: Approximately half of antibiotics used in nursing home (NHs) are initiated in acute care hospitals prior to NH admission. Optimizing antibiotic prescribing on hospital discharge to these facilities presents an opportunity to improve NH antibiotic use. We aimed to identify intervention targets to optimize antibiotic use on discharge from the hospital to NHs. Methods: This was a multicenter, cross-sectional study across 9 acute care hospitals in Oregon, Wisconsin, and Washington. We selected a 20% random sample of adult (age &gt;18) inpatients prescribed at least one antibiotic on discharge from the hospital to a NH between 2016-2018. We excluded patients discharged from the emergency department or an intensive care unit. Study data were electronically extracted from patients’ electronic health records and supplemented with manual chart review. Antibiotic optimization opportunities were determined by an infectious diseases (ID) physician or ID pharmacist and classified as definitely, possibly, or unlikely. Expert reviewers also recorded the type of optimization opportunity and the rationale for each determination. A gamma lasso algorithm was used to identify patient-level characteristics associated with definite optimization opportunity, which were then included in a logistic regression model. Results: There were 2761 antibiotic prescriptions among 2215 patients. Mean (standard deviation) age was 71.9 (14.3) years and 48.8% were male. Most discharges (83.1%) were prescribed one antibiotic, 15.2% were prescribed two antibiotics, and 1.8% were prescribed three antibiotics. The most frequently prescribed antibiotics were cephalexin (10.4%), vancomycin (9.8%), and amoxicillin clavulanate (8.4%). Among the 2761 antibiotic prescriptions, expert reviewers determined that 18.4% could definitely be optimized, 36.0% could possibly be optimized, and 45.3% unlikely could have been optimized. Among the 508 definite antibiotic optimization opportunities, 25.2% were to subtract the antibiotic, 56.3% were to change the antibiotic, 11.0% were to change the dose, 25.0% were to change the duration, 0.8% were to change the route, and 1.8% were to change the schedule. Patient-level characteristics found to be associated with definite antibiotic optimization opportunity included age over 80 years (odds ratio (OR)=1.44, 95% confidence interval (CI): [1.14, 1.82]), length of stay &lt; 8 days (OR=1.40, 95% CI: [1.09, 1.81]), discharge with multiple antibiotic prescriptions (OR=1.92, 95% CI: [1.39, 2.63]), and discharge with prescription for oral vs intravenous (IV) antibiotics (OR=2.08, 95% CI: [1.49, 2.95]). Conclusion: We identified several patient and antibiotic characteristics which may serve as intervention targets to optimize antibiotic prescribing on discharge from the hospital to nursing homes.

Pixels to precision: Remote thoracic and pediatric cardiac surgery mentorship with Rods&amp;Cones® Technology in Kigali, Rwanda

Surgery is the final frontier in global medicine; yet, access to essential surgical services in low- and middle-income countries remains a significant barrier to equitable care. With a rise in non-communicable diseases and a shortage of skilled surgeons, the need for mentorship becomes crucial to capacity building. The COVID-19 pandemic acted as a catalyst for remote mentorship, leading to the development of innovative solutions such as Rods&amp;Cones&amp;reg;. Herein, we describe one example of remote mentorship conducted across a distance of more than 7,700 miles between King Faisal Hospital in Rwanda and the University of Wisconsin Hospital in the US. This paper aims to demonstrate how advances in remote mentorship technology can overcome existing barriers and aid in expanding the global surgical workforce in thoracic surgery.

Alcohol Withdrawal Severity Measures for Identifying Patients Requiring High-Intensity Care.

Alcohol withdrawal syndrome (AWS) may progress to require high-intensity care. Approaches to identify hospitalized patients with AWS who received higher level of care have not been previously examined. This study aimed to examine the utility of Clinical Institute Withdrawal Assessment Alcohol Revised (CIWA-Ar) for alcohol scale scores and medication doses for alcohol withdrawal management in identifying patients who received high-intensity care. A multicenter observational cohort study of hospitalized adults with alcohol withdrawal. University of Chicago Medical Center and University of Wisconsin Hospital. Inpatient encounters between November 2008 and February 2022 with a CIWA-Ar score greater than 0 and benzodiazepine or barbiturate administered within the first 24 hours. The primary composite outcome was patients who progressed to high-intensity care (intermediate care or ICU). None. Among the 8742 patients included in the study, 37.5% (n = 3280) progressed to high-intensity care. The odds ratio for the composite outcome increased above 1.0 when the CIWA-Ar score was 24. The sensitivity, specificity, positive predictive value (PPV), and negative predictive value (NPV) at this threshold were 0.12 (95% CI, 0.11-0.13), 0.95 (95% CI, 0.94-0.95), 0.58 (95% CI, 0.54-0.61), and 0.64 (95% CI, 0.63-0.65), respectively. The OR increased above 1.0 at a 24-hour lorazepam milligram equivalent dose cutoff of 15 mg. The sensitivity, specificity, PPV, and NPV at this threshold were 0.16 (95% CI, 0.14-0.17), 0.96 (95% CI, 0.95-0.96), 0.68 (95% CI, 0.65-0.72), and 0.65 (95% CI, 0.64-0.66), respectively. Neither CIWA-Ar scores nor medication dose cutoff points were effective measures for identifying patients with alcohol withdrawal who received high-intensity care. Research studies for examining outcomes in patients who deteriorate with AWS will require better methods for cohort identification.

Abstract WP50: Analyzing Post Discharge Follow-Up of a Disparate Population Utilizing Mobile Integrated Health

Introduction: Transition of care (TOC) to home for many stroke patients is suboptimal. Recent studies estimate 30-day all-cause readmission of stroke patients at 17.4%. The Wisconsin (WI) Coverdell Stroke Program partnered with the Milwaukee Fire Department- Mobile Integrated Health Program (MFD-MIH) and Milwaukee County hospitals three times since January 2019. The aim of our MIH focused partnership was to improve follow up care and care coordination after an acute stroke hospitalization to a vulnerable urban population. Methods: A charter, project algorithm, and referral forms were created to guide our work. Patient referral forms and MFD-MIH home visit summaries were sent via secure email. Upon receiving a home visit referral from the hospital MFD-MIH attempted to engage the patient within two business days. After a completed visit, MFD-MIH sent a summary form to the referring hospital mimicking post-discharge data metrics in Get With The Guidelines® (GWTG). Upon receiving the summary form, hospital abstractors entered the data into GWTG. The data was then analyzed by the Coverdell team. Results: As of May 2023, 73 stroke patients have received a home visit from MIH-MFD with data entry in GWTG. Analysis of the third iteration of the program will occur after it ends in April 2024. We compared our first two MIH projects to all Wisconsin hospitals entering into the GWTG Post-Discharge tab. Our results showed: • Coverdell MIH hospitals outperform WI hospitals in Blood Pressure Monitoring by Patient and Appointment Scheduled Prior to Discharge • Coverdell MIH hospitals underperform WI hospitals in ED Visits , Falls Reported by Patient , Medication Stoppage and Tobacco Use Conclusions: Many factors influenced our data. First, the population in the Coverdell MIH program was from an urban environment with more proximate post-discharge resources. All WI hospitals do not share this setting. Secondly, MIH data collection involves an in-person home visit. Conversely, WI hospitals data collection occurred via a phone call or chart review. The Coverdell MIH method facilitates a collegial environment where more truthful disclosures may result.

Incidence and outcomes of fever of unknown origin after kidney transplant in the modern era.

While presumably less common with modern molecular diagnostic and imaging techniques, fever of unknown origin (FUO) remains a challenge in kidney transplant recipients (KTRs). Additionally, the impact of FUO on patient and graft survival is poorly described. A cohort of adult KTRs between January 1, 1995 and December 31, 2018 was followed at the University of Wisconsin Hospital. Patients transplanted from January 1, 1995 to December 31, 2005 were included in the "early era"; patients transplanted from January 1, 2006 to December 31, 2018 were included in the "modern era". The primary objective was to describe the epidemiology and etiology of FUO diagnoses over time. Secondary outcomes included rejection, graft and patient survival. There were 5590 kidney transplants at our center during the study window. FUO was identified in 323 patients with an overall incidence rate of .8/100 person-years. Considering only the first 3years after transplant, the incidence of FUO was significantly lower in the modern era than in the early era, with an Incidence Rate Ratio (IRR) per 100 person-years of .48; 95% CI: .35-.63; p<.001. A total of 102 (31.9%) of 323 patients had an etiology determined within 90days after FUO diagnosis: 100 were infectious, and two were malignancies. In the modern era, FUO remained significantly associated with rejection (HR=44.1; 95% CI: 16.6-102; p<.001) but not graft failure (HR=1.21; 95% CI: .68-2.18; p=.52) total graft loss (HR=1.17; 95% CI: .85-1.62; p=.34), or death (HR=1.17; 95% CI: .79-1.76; p=.43. FUO is less common in KTRs during the modern era. Our study suggests infection remains the most common etiology. FUO remains associated with significant increases in risk of rejection, warranting further inquiry into the management of immunosuppressive medications in SOT recipients in the setting of FUO.

Neurodevelopmental Outcomes of Children Born to Women Who Traveled to a Zika Virus-Endemic Region During Pregnancy

Abstract Background Zika virus (ZIKV) exposure during pregnancy causes a wide range of congenital malformations and developmental deficits, but we do not know whether potential ZIKV exposure during pregnancy without a formal ZIKV diagnosis results in worse developmental outcomes. Pregnant women without symptoms are not recommended to be tested for ZIKV infection per CDC guidelines. However, ZIKV infections can be asymptomatic, which means that pregnant women may have unknowingly been infected with ZIKV during travel to an endemic region. Our study aims to determine whether neurodevelopmental outcomes of children born to women with a travel history to a ZIKV-endemic region at the height of the pandemic are worse than children without a maternal travel history. Methods We identified women who presented to a maternal-fetal medicine clinic within the University of Wisconsin Hospitals and Clinics system in Madison, WI, between 2015-2018 and recently traveled to a ZIKV-endemic region (n=175) and conducted a retrospective chart review. Children with no maternal travel history to a ZIKV-endemic region were identified by state registry data and matched based on month of birth and gestational age (n=189). Developmental outcomes were defined from regular screening tools obtained during well child visits, the Ages and Stages Questionnaire (ASQ-3), and the Modified Checklist for Autism in Toddlers (MCHAT). We compared the number of “No Concern”, “Borderline” and “Concern” ASQ scores between groups using a generalized linear mixed effects model with a logit link function. The number of Low, Medium or High MCHAT risk scores at 18 and 24 months were compared between groups using Fisher’s exact test. Birth weight, maternal age and maternal race were included as covariates. All reported p-values are two-sided and P&amp;lt;0.05 was used to define statistical significance. Results Cases had a significantly higher rate (13.9%) of borderline/concern scores in the ASQ screening tool compared to controls (7.7%) at 16-22 months (p=0.0288), which appeared to be driven by differences in the personal-social domain where more cases (16.1%) had borderline/concern scores than the controls (5.5%, p=0.0348). There were no differences seen at 9-15 months or at 23-36 months. We also found that cases had higher rates of moderate-high risk scores (10.3%) on the MCHAT compared to controls (2.2%) at 18 months (p=0.0240), but this difference wasn’t statistically significant at 24 months. There were no differences in birth weight, maternal age and gestational age between groups. Very few of the mothers (18.3%) reported 1 or more signs or symptoms consistent with a ZIKV infection, and of the 105 women with ZIKV testing, 103 were negative. Conclusions Our findings indicate that children born to mothers who traveled to a ZIKV-endemic region during pregnancy, regardless of the maternal ZIKV testing result, had worse developmental screening scores around 18 months of age. This suggests that children with maternal travel history to a ZIKA-endemic region should be regularly monitored and receive early formal developmental testing as needed.

Assessing the relationship between cyanobacterial blooms and respiratory-related hospital visits: Green bay, Wisconsin 2017–2019

Potential acute and chronic human health effects associated with exposure to cyanobacteria and cyanotoxins, including respiratory symptoms, are an understudied public health concern. We examined the relationship between estimated cyanobacteria biomass and the frequency of respiratory-related hospital visits for residents living near Green Bay, Lake Michigan, Wisconsin during 2017–2019. Remote sensing data from the Cyanobacteria Assessment Network was used to approximate cyanobacteria exposure through creation of a metric for cyanobacteria chlorophyll-a (ChlBS). We obtained counts of hospital visits for asthma, wheezing, and allergic rhinitis from the Wisconsin Hospital Association for ZIP codes within a 3-mile radius of Green Bay. We analyzed weekly counts of hospital visits versus cyanobacteria, which was modelled as a continuous measure (ChlBS) or categorized according to World Health Organization's (WHO) alert levels using Poisson generalized linear models. Our data included 2743 individual hospital visits and 114 weeks of satellite derived cyanobacteria biomass indicator data. Peak values of ChlBS were observed between the months of June and October. Using the WHO alert levels, 60% of weeks were categorized as no risk, 19% as Vigilance Level, 15% as Alert Level 1, and 6% as Alert Level 2. In Poisson regression models adjusted for temperature, dewpoint, season, and year, there was no association between ChlBS and hospital visits (rate ratio [RR] [95% Confidence Interval (CI)] = 0.98 [0.77, 1.24]). There was also no consistent association between WHO alert level and hospital visits when adjusting for covariates (Vigilance Level: RR [95% CI] 0.88 [0.74, 1.05], Alert Level 1: 0.82 [0.67, 0.99], Alert Level 2: 0.98 [0.77, 1.24], compared to the reference no risk category). Our methodology and model provide a template for future studies that assess the association between cyanobacterial blooms and respiratory health.

Creation of a data commons for substance misuse related health research through privacy-preserving patient record linkage between hospitals and state agencies.

Substance misuse is a complex and heterogeneous set of conditions associated with high mortality and regional/demographic variations. Existing data systems are siloed and have been ineffective in curtailing the substance misuse epidemic. Therefore, we aimed to build a novel informatics platform, the Substance Misuse Data Commons (SMDC), by integrating multiple data modalities to provide a unified record of information crucial to improving outcomes in substance misuse patients. The SMDC was created by linking electronic health record (EHR) data from adult cases of substance (alcohol, opioid, nonopioid drug) misuse at the University of Wisconsin hospitals to socioeconomic and state agency data. To ensure private and secure data exchange, Privacy-Preserving Record Linkage (PPRL) and Honest Broker services were utilized. The overlap in mortality reporting among the EHR, state Vital Statistics, and a commercial national data source was assessed. The SMDC included data from 36522 patients experiencing 62594 healthcare encounters. Over half of patients were linked to the statewide ambulance database and prescription drug monitoring program. Chronic diseases accounted for most underlying causes of death, while drug-related overdoses constituted 8%. Our analysis of mortality revealed a 49.1% overlap across the 3 data sources. Nonoverlapping deaths were associated with poor socioeconomic indicators. Through PPRL, the SMDC enabled the longitudinal integration of multimodal data. Combining death data from local, state, and national sources enhanced mortality tracking and exposed disparities. The SMDC provides a comprehensive resource for clinical providers and policymakers to inform interventions targeting substance misuse-related hospitalizations, overdoses, and death.

Enhancing the Value of Surgical Entrustable Professional Activities through Integrative Learning Analytics

To demonstrate the value of integrating surgical resident Entrustable Professional Activity (EPA) data into a learning analytics platform that provides meaningful feedback for formative and summative decision-making. Description of the Surgical Entrustable Professional Activities (SEPA) analytics dashboard, and examples of summary analytics and intuitive display features. Department of Surgery, University of Wisconsin Hospital and Clinics. Surgery residents, faculty, and residency program administrators. We outline the major functionalities of the SEPA dashboard and offer concrete examples of how these features are utilized by various stakeholders to support progressive entrustment decisions for surgical residents. Our intuitive analytics platform allows for seamless integration of SEPA microassessment data to support Clinical Competency Committee (CCC) decisions for resident evaluation and provides point of training feedback to faculty and trainees in support of progressive autonomy.

Fundamentals of blood banking in anesthesiology: A problem-based learning simulation session as an addition to a novel curriculum of transfusion medicine education for anesthesiology residents

We have previously published a novel transfusion medicine curriculum for first-year anesthesiology residents, making available open access learning materials. We now present a curriculum iteration, by incorporating resident feedback and developing an additional “capstone” session for use at the end of the rotation that integrates several learning points into a practical problem-based simulation. This iteration of the curriculum was piloted with the 2019–2020 PGY-1 anesthesiology residents of the University of Wisconsin Hospitals and Clinics. Pre-course and post-course surveys, which assessed trainee understanding of course topics, were used to subjectively evaluate the usefulness of the curriculum. Results of the surveys demonstrated post-test mean scores were significantly increased when compared with the equivalent pre-course questions. This suggests the piloted curriculum iteration serves as a useful tool for resident learning. As an adjunct to our previous existing materials, in the spirit of open-access education, we share this additional curriculum material, consisting of four patient cases with 16 questions that can be used immediately for teaching purposes.

Orbital Artifacts on MRI.

To describe artifacts on orbital MRI, which led to an incorrect radiology report. Retrospective chart review of patients identified from the orbital databases at the Royal Adelaide Hospital and University of Wisconsin Hospital. Patients who had artifacts on orbital MRI that led to an incorrect radiology report were included. Records were evaluated for age at imaging, gender, MRI sequence, laterality, and location of artifact, radiological characteristics and misdiagnosis, and cause of artifact. Data were collected from 7 patients (3 male) who had a median age of 61 years at the time of imaging. Five artifacts resulted from fat-suppression failure with 4 of these cases misdiagnosed as inflammatory changes and 1 misdiagnosed as neoplastic infiltration. The OD was involved in 4 cases. Six cases were in the inferior orbit region. Fat-suppression failure artifacts may arise in the inferior orbit region and can be mistaken for inflammatory or neoplastic orbital disease. This may prompt additional investigations such as orbital biopsy. Clinicians should be aware of artifacts which can affect orbital MRI and lead to potential misdiagnosis.

Duration of Time CD4/CD8 Ratio is Below 0.5 is Associated with Progression to Anal Cancer in Patients with HIV and High-Grade Dysplasia.

A CD4/CD8 ratio <0.5 is associated with increased risk of advanced anal disease (AAD) but it is unknown if duration below 0.5 matters. The purpose of this study was to determine if duration of a CD4/CD8 ratio <0.5 is associated with increased risk of invasive anal cancer (IC) in people living with HIV and high-grade dysplasia (HSIL). This single institution, retrospective study used the University of Wisconsin Hospital and Clinics Anal Dysplasia and Anal Cancer Database. Patients with IC versus HSIL alone were compared. Independent variables were mean and percentage of time the CD4/CD8 ratio was <0.5. Multivariate logistic regression was performed to estimate the adjusted odds of anal cancer. We identified 107 patients with HIV infection and AAD (87 with HSIL, 20 with IC). A history of smoking was significantly associated with the development of IC (95% in patients with IC vs. 64% in patients with HSIL; p = 0.015). Mean time the CD4/CD8 ratio was <0.5 was significantly longer in patients with IC compared with patients with HSIL (7.7 years vs. 3.8 years; p = 0.002). Similarly, the mean percentage of time the CD4/CD8 ratio was <0.5 was higher in those with IC versus those with HSIL (80% vs. 55%; p = 0.009). On multivariate analysis, duration CD4/CD8 ratio was <0.5 was associated with increased odds of developing IC (odds ratio 1.25, 95% confidence interval 1.02-1.53; p = 0.034). In this retrospective, single-institution study of a cohort of people living with HIV and HSIL, increasing duration the CD4/CD8 ratio was <0.5 was associated with increased odds of developing IC. Monitoring the number of years the CD4/CD8 ratio is <0.5 could inform decision making in patients with HIV infection and HSIL.

You Can't Say "No" to That! (A "Difficult Patient" Story)

You Can't Say "No" to That!(A "Difficult Patient" Story) Ingrid Berg As a sequela of COVID-19, my rural Wisconsin hospital has been jam-packed for months with patients for whom we routinely provide care and many for whom we do not. An exodus of health care workers and other constraints have made the transfer of critically ill patients very difficult. In this disquieting "new-normal" of our work life, we routinely must call bigger cities throughout our state to find beds for complex patients. So, it was not surprising when a young patient, an IV drug user in sepsis from a heart infection, was admitted to me in the middle of the night. In less disheartening times, before the pandemic, this patient would have been transferred promptly to the big-city hospital. Now, though, the possibility of finding an open bed is next to impossible. Resigned, I placed admission orders, continued antibiotics and fluids, and crossed my fingers. Then the unexpected happened: a bed opened up, and we could send her at once! The patient had a harsh heart murmur. It was likely that a "vegetation" was clinging to the valve, between the right upper and lower chambers of her heart. A vegetation is a clump of debris, such as platelets, clotting proteins, and bacteria that is a menace to the body. Her chest imaging looked like her infection had already spread to her lungs. A definitive diagnosis for endocarditis requires a special ultrasound with a probe that goes down through the esophagus, a procedure performed by cardiologists. It's a serious infection, one that requires weeks of IV antibiotics and is best monitored by infectious disease specialists. Sometimes, cardiothoracic surgeons are called upon to strip away the infection at the site, depending on how badly the valve has been slayed or the size of the vegetation. My only recommendation for a young, otherwise healthy patient in this scenario, is transfer. All of these reasons for transfer were lolling around in my tired head when the night-time [End Page 14] nursing supervisor approached me and said, "We have a problem." When the patient was updated about the transfer, she balked: "She says she is tired and refusing to go," the supervisor began. "She doesn't feel like getting into an ambulance in the middle of the night and she doesn't care if her condition is life-threatening. She knows we can't force her to go and she will only talk about it again in the morning." The cartoon version of myself at that moment had bugged-out eyes, a dropped jaw, fists tight and clenched at my sides, and steam coming out of my head. I can look past a patient's self-neglect, poor medication adherence, abysmal communication, alcohol and drug addiction, and other crimes. But saying no to a bed at a tertiary care facility? Unacceptable! I marched down the quiet hallway and into her room. She was lying on her side, facing the door, one IV in a thin arm. I was confident I could reason with her once I explained the scarcity of beds and the medical necessity of transfer. But she was having none of it. I was calm until I could no longer maintain my cool: "You can't give up this bed!" "Maybe in the morning," she insisted, yawning. "But not now. I am tired and want to rest!" "But there might not be a bed in the morning," I countered. "And your infection can be life-threatening." (This is true, but we both knew she wasn't dying at this very moment.) "I am not going anywhere!" She raised her voice and then closed her eyes. And she was right. I had no choice but to keep her. I could not kick her out of the hospital because she was making a poor choice, and I was frustrated for having to manage the fallout of that decision. Giving her antibiotics and fluid boluses to bolster her blood pressure was certainly within my scope of practice. And fretting. Fretting is always within my scope of practice; not that my scope of practice matters when all the big...

Abstract A022: Comparing prostate specific antigen dynamics between Black patients and White patients

Abstract Background: Black men are the most have the highest prostate cancer (PCa) mortality across all US population groups. We have previously demonstrated how mathematical modeling can be used to understand prostate-specific antigen (PSA) dynamics and predict patient-specific responses to treatment. We hypothesize that we can use mathematical modeling to investigate differences in PSA dynamics between black and white men undergoing androgen deprivation therapy (ADT) treatment modalities for both black and white patients that will ultimately reduce disparities. Methods: We received data for 57 PCa patients from the Veterans Affairs Hospital and Medical College of Wisconsin (N = 47 white, N = 10 black). To compensate for the lack of data for black patients, propensity score matching was used to match 15 white patients to 10 black patients based on their Eastern Cooperative Oncology Group (ECOG) score, age, and tumor burden. Our previously developed stem cell enrichment model was used to investigate the primary differences in response dynamics between the white and black patient cohorts. [1] Results: Parameter optimization was used to determine appropriate model parameter values to accurately describe the data. Parameters were sequentially chosen to be patient-specific or uniform within each individual patient cohort in a leave-one-out analysis. Parameter analysis showed that the stem cell self-renewal rates significantly differed between white and black patients (p = 0.0455). Further analysis did not show any significant differences between patient cohorts for the remaining model parameters. Conclusions: Our results suggest that stem cell self-renewal is the parameter driving differences in PSA dynamics between white and black patients. Though propensity score analysis allowed for a more equal comparison between the black and white patient cohorts, additional patient data is needed to validate these results. Future work will include acquiring additional data and completing race-specific model analysis for black and white patients. Citation Format: Alexandria Johnson. Comparing prostate specific antigen dynamics between Black patients and White patients [abstract]. In: Proceedings of the 15th AACR Conference on the Science of Cancer Health Disparities in Racial/Ethnic Minorities and the Medically Underserved; 2022 Sep 16-19; Philadelphia, PA. Philadelphia (PA): AACR; Cancer Epidemiol Biomarkers Prev 2022;31(1 Suppl):Abstract nr A022.

Classification Algorithm Analysis for Breast Cancer

Breast cancer in women is a type of disease that is the main cause of death in women according to world breast cancer data. Therefore, early detection of breasts is needed significantly to improve life. If a woman has been identified, then rehabilitation and treatment on an incentive basis are needed to reduce the worse. This study used a dataset collected by the University of Wisconsin Hospitals, Madison (https://atapdata.ai/). This research conducted experiments using several data mining classification strategies to predict breast cancer using machine learning algorithms. The Support Vector Machine (SVM), K-Nearest Neighbor (KNN), Naive Bayes, Random Forest, Decision Tree, Deep Learning (H2O), and Neural Network are used to classify algorithms. From these algorithms’ classification, we compare accuracy, best classification, and compare algorithm performance with curve ROC (RapidMiner Studio Core) to see which performance algorithm has the best quality for classification. From the analysis results, the deep learning algorithm with Tanh and Exprectifier activation function has a good accuracy of 93.14%, and the best classification with 89.62%. In addition, deep learning has found the best quality from the ROC curve results on the dataset used in this research.