Individual Charts Research Articles

Hepatitis D virus (HDV) prevalence in Austria is low but causes considerable morbidity due to fast progression to cirrhosis.

BackgroundHepatitis D virus (HDV) coinfection aggravates the course of hepatitis B virus (HBV). The prevalence of HDV in Austria is unknown.ObjectiveThis national study aimed at (i) recording the prevalence of HDV‐infection in Austria and (ii) characterizing the “active” HDV cohort in Austria.MethodsA total of 10 hepatitis treatment centers in Austria participated in this multicenter study and retrospectively collected their HDV patients between Q1/2010 and Q4/2020. Positive anti‐HDV and/or HDV‐RNA‐polymerase chain reaction (PCR) results were retrieved from local database queries. Disease severity was assessed by individual chart review. Viremic HDV patients with clinical visits in/after Q1/2019 were considered as the “active” HDV cohort.ResultsA total of 347 anti‐HDV positive patients were identified. In 202 (58.2%) patients, HDV‐RNA‐PCR test was performed, and 126/202 (62.4%) had confirmed viremia. Hepatocellular carcinoma was diagnosed in 7 (5.6%) patients, 7 (5.6%) patients underwent liver transplantation, and 11 (8.7%) patients died during follow‐up. The “active” Austrian HDV cohort included 74 (58.7%) patients: Evidence for advanced chronic liver disease (ACLD, i.e., histological F3/F4 fibrosis, liver stiffness ≥10 kPa, varices, or hepatic venous pressure gradient ≥6 mmHg) was detected in 38 (51.4%) patients, including 2 (5.3%) with decompensation (ascites/hepatic encephalopathy). About 37 (50.0%) patients of the “active” HDV cohort had previously received interferon treatment. Treatment with the sodium‐taurocholate cotransporting polypeptide inhibitor bulevirtide was initiated in 20 (27.0%) patients.ConclusionThe number of confirmed HDV viremic cases in Austria is low (<1% of HBV patients) but potentially underestimated. Testing all HBV patients will increase the diagnostic yield. More than half of viremic HDV patients had ACLD. Improved HDV testing and workup strategies will facilitate access to novel antiviral therapies.

Abstract 8899: DOAC Use for Stroke Prevention in Patients with Atrial Fibrillation and Elevated Body Mass Index

Background: The incidence of comorbid obesity and atrial fibrillation (AF) has been increasing. Direct Oral Anticoagulants (DOACs) have become the first-line agents for cerebrovascular accident (CVA) prophylaxis in patients with AF due to their superior efficacy and lower bleeding risk when compared to coumadin. The incidence of acute ischemic CVA while on a DOAC in the non-obese population is 1.2%. Evidence on the efficacy of DOACs in preventing AF related CVAs in the obese population is limited. Methods: Electronic medical records from 8 hospitals within the same health system were queried. Patients age &gt; 18 years with a BMI &gt; 40 kg/mm 2 and AF on a DOAC (Rivaroxaban, Apixaban, or Dabigatran) were included in our study. Individual charts from 2010 to 2020 were reviewed for neuroimaging (computed tomography and MRI) following the start date of a DOAC confirming the presence or absence of an acute hemorrhagic or ischemic CVA. Results: We included 1935 patients in the study. Acute ischemic CVA was noted in 17 patients (0.9%) by head CT (11/17 confirmed by MRI). Hemorrhagic CVA was noted in one patient (0.1%) by head CT. 155 (8%) had a head CT without evidence of CVA, of which, 5 (3.2 %) had evidence of an acute ischemic CVA by MRI. Therefore, 22 patients (1.1%) had evidence of acute ischemic CVA on neuroimaging. The remainder of patients (N = 1762, 91.1%) did not have indications for neuroimaging and were considered to have successful CVA prophylaxis. In total, 1912 (98.8%) of patients with a BMI &gt; 40 treated with a DOAC for AF did not demonstrate neuroimaging evidence of CVA. Conclusions: Although we expected to find higher CVA rates due to ineffective anticoagulation in the obese population, DOACs appear to be an effective therapy for CVA prophylaxis in obese patients with AF. The incidence of acute ischemic CVA in the obese population while on a DOAC is comparable to the non-obese population. Further prospective studies are needed to confirm the findings of this analysis.

Abstract 10854: Acute Venous Thromboembolism in Patients with Elevated Body Mass Index, Can We Prescribe Direct Oral Anticoagulants

Background: Due to the efficacy and lower bleeding risk of direct oral anticoagulants (DOACs) compared to coumadin, they are becoming the treatment of choice for acute venous thromboembolism (VTE). There is limited data in using DOAC’s for treatment of VTE (deep vein thrombosis (DVT) or pulmonary embolism (PE)) in patients with morbid obesity (body mass index &gt;40 kg/mm 2 ). We conducted a retrospective study to examine the rates of recurrence (failure of treatment) in patients diagnosed with an acute VTE. Methods: Electronic health record (EHR) from 8 hospitals in the Beaumont Health system were queried. A retrospective review of patients &gt; 18 years old with morbid obesity who were diagnosed with a DVT or PE and treated with a DOAC (rivaroxaban, apixaban or dabigatran) from 2010 to 2020 was performed. Individual charts were reviewed for ultrasound as well as computed tomography angiography results confirming the presence of an acute or chronic DVT or pulmonary embolism. To assess for recurrence, imaging studies performed 3 months after original diagnosis were studied. Results: 461 patients were included. The mean age was 58.9 years old with a range of 18-88 years old. Majority of patients were female (65.9%). The mean BMI was 46.5 with standard deviation of 7.4. 337 (73.1%) had an acute diagnosis of DVT or PE. When reassessing imaging 3 months after original diagnosis, only 2 (0.6%) patients had findings of recurrence (formation of new DVT or PE). Conclusion: In patient with morbid obesity, DOACs appear to be an effective therapy for treatment of DVT and PE. Further prospective studies are needed to confirm the findings of this analysis.

A synthetic multivariate exponentially weighted moving average scheme for monitoring of bivariate Gamma distributed processes

AbstractSeveral scholarly works intrinsically assume that the frequency and magnitude of events are two independent variables . However, in many practical situations, it is necessary to consider the dependence between these two characteristics of events. In this paper, two Smith–Adelfang–Tubbs (SAT) models, namely, the four‐ and the five‐parameter bivariate Gamma distributions (BGD) with a particular dependency parameter, are first reviewed. Then, a synthetic multivariate exponentially weighted moving average (synthetic MEWMA, or SMEWMA) type scheme is proposed to monitor the individual BGD observations (subgroups of size one) generated from those two specific SAT models. The Monte‐Carlo simulation method is developed to evaluate the run length () properties of the recommended SMEWMA BGD scheme in both the zero‐state and the steady‐state cases. Furthermore, we discuss the average run length (ARL) of the proposed SMEWMA BGD scheme with different design parameters, and then compare both the zero‐state and the steady‐state out‐of‐control ARL performances of the recommended SMEWMA BGD scheme with those of the classic MEWMA chart, the paired individual Gamma chart, and the MCUSUM chart. Simulation results suggest that the overall performance of the recommended SMEWMA BGD scheme is superior to the other comparative schemes. Finally, the implementation of the proposed SMEWMA BGD scheme is illustrated with a natural flood event dataset .

Surveillance of Monoclonal Gammopathy of Undetermined Significance: A Proposed Change

Background:Monoclonal gammopathy of undetermined significance (MGUS) is a diagnosis that is often incidentally made after a serum protein electrophoresis (SPEP) is ordered as part of the evaluation for multiple nonspecific symptoms and is often ordered by non-hematologists. Currently, there is a lack of guidance regarding the extent of evaluation and follow-up required for these patients.Objective:Determine whether the risk stratification of the abnormal SPEP predicted progression to multiple myeloma (MM) or other lymphoplasmacytic malignancies (LPM) and could act as a guideline for appropriate follow-up in attempts to provide evidence-based, higher value care.Design:A retrospective review was performed of patients referred to the county hematology clinic for an abnormal SPEP from 2012 to 2019. The SPEP results were then risk-stratified and individual patient charts were reviewed to determine the symptomatology present at the time it was ordered, as well as the clinical course of the patients over time.Main Measures:Patients were stratified into low, low-intermediate, high-intermediate, and high risk groups for progression to MM based on the Mayo Clinic criteria. Additional information was also analyzed including the number of SPEP tests per patient, the indication stated for ordering the SPEP, and the presence of symptoms that are associated with MM at the time the SPEP was ordered, including anemia, renal failure, hypercalcemia, and bone lesions (commonly known as “CRAB symptoms”).Results:We abstracted data from 436 patients referred to the hematology clinic associated with a large county hospital system for an abnormal SPEP. The most common documented reasons for SPEP testing were increased creatinine (35%), protein gap (12%), and decreased hemoglobin (11%). Of these patients, 24 (5.5%) developed MM, 19 of whom were stratified into the high-intermediate risk group. More than a thousand SPEP results were obtained in the low and low-intermediate risk groups with only 5 patients diagnosed with MM. In the high-intermediate and low-intermediate risk groups, between 2-3 SPEP tests were performed prior to making the diagnosis of MM. In the low risk group, 6 SPEP tests were performed prior to reaching the MM diagnosis. Among the 5 patients in the low and low-intermediate risk groups who developed MM, all 5 had one or more of the CRAB symptoms at the time of the initial SPEP.Conclusion:Of the patients with MGUS who progressed to MM, approximately 80% were in the high-intermediate risk group. Of the remaining patients who progressed to MM from the lower risk groups, all had one or more of the previously mentioned CRAB symptoms, a higher percentage compared to the low and low-intermediate risk groups overall. In the absence of symptomatic disease, there is insufficient evidence to support serial SPEP testing in the lower risk patients. The use of evidence-based risk stratification may minimize unnecessary testing and hematology referrals while resulting in significant cost-savings and higher value care. [Display omitted] DisclosuresNo relevant conflicts of interest to declare.

Investigation of Factors That Discriminate Myeloid Malignancies from Leukemoid Reactions

INTRODUCTIONExtreme neutrophilic-predominant leukocytosis is frequently alarming to clinicians and often triggers expedited evaluation to distinguish between myeloid malignancies (MM), such as chronic myeloid leukemia (CML), and non-malignant etiologies. The term “leukemoid reaction” has been used to describe the latter case - episodes in which a patient's white blood cell (WBC) count is greater than 50k/μL from causes other than leukemia. MM account for only a minority of neutrophilic leukocytosis, but diagnostic testing for these entities involves expensive and time-consuming sequencing tests. Therefore, it would be valuable to identify factors that are routinely and rapidly available and that can distinguish between these identities to prioritize work-ups and allow for more judicious use of molecular testing. Prior studies attempting to address this problem have been limited to small case series or have focused on a single diagnosis. We sought to identify such factors using a large data set with modern testing modalities.METHODSAdult patients > 18 years of age with extreme neutrophilic leukocytosis from 2000-2020 at a tertiary care hospital were included. Extreme neutrophilic leukocytosis was defined as a leukocyte count greater than 50k/μL on at least 1 occasion, with granulocytes accounting for more than 50% of leukocytes. Patients were excluded if the cause of their leukocytosis was iatrogenic (e.g., G-CSF). Researchers performed individual chart review to determine the cause of a patient's leukocytosis, grouping each into one of four categories: (i) leukemoid reactions (LR); (ii) MM; (iii) non-myeloid malignancies; and (iv) mixed leukemoid and malignant etiologies (e.g., a leukemoid reaction in a patient with an underlying myeloproliferative neoplasm). The following patient characteristics were analyzed at the time of first presentation with WBC > 50k/μL: age, hemoglobin, MCV, platelet count, differential, LDH, uric acid, ferritin, and CRP.RESULTSWe identified 214 patients who fit our inclusion criteria: MM accounted for 67/214 (31%) cases, while 101/214 (47%) described LRs. Non-myeloid neoplasms accounted for 19/214 patients and 27/214 had mixed etiologies.Our primary aim was to identify factors that distinguish between MM and LR. Mean age at presentation did not differ (68.7 vs. 67.5, p=0.64), though 6-month mortality was much higher in those diagnosed with LR vs MM (63.3% vs. 13.4%, p<0.01). When patients with MM were discovered to have extreme leukocytosis, they tended to have higher white counts on initial presentation (105.7 vs 56.7, p<0.01) and higher peak white counts during a given hospitalization (123.4 vs 63.0, p<0.01). White counts >80k/μL on presentation were 99% specific (with sensitivity 48%) in identifying MM.Analysis of the differentials revealed that LR were more neutrophil predominant (83% vs. 59%, p<0.01) and that “significant neutrophilia” (defined as neutrophilia >90%) was 97% specific (27% sensitive) in distinguishing LR from MM. Mild eosinophilia (absolute eosinophils >500/μL) and basophilia (absolute basophils >200/μL) were 72% and 58% sensitive and 80% and 95% specific, respectively, for MM.The discriminative power of a myelocyte bulge was also analyzed. MM tended to have more metamyelocytes (6.3% vs. 1.6%, p<0.01) and myelocytes (5.8% vs 0.7%, p<0.01), though a true “myelocyte bulge” (absolute myelocytes > metamyelocytes) was only 37% sensitive and 87% specific in distinguishing between MM and LR.Lastly, meeting any one of the parameters in our composite outcome (Table 2) proved 99% sensitive and 68% specific for MM.CONCLUSIONSIn our retrospective analysis of extreme neutrophilic leukocytosis, the most common cause was leukemoid reactions, which were associated with far greater mortality than malignant etiologies. Patients with MM had higher admission and peak white counts. They also tended to present with eosinophilia and basophilia, and though neither universally defined MM, the combination of these parameters was specific for distinguishing between our groups. The presence of blasts, too, was specific for MM, though notably, were also seen in rare LRs. Finally, the sensitivity of our composite outcome suggests that patients who meet none of those criteria may be able to avoid unnecessary workups for MM. Notable negative results included findings that platelets, CRP, and LDH were not useful in discriminating between LR and MM. [Display omitted] DisclosuresNo relevant conflicts of interest to declare.

Incidence and Characteristics of CD20 Monoclonal Antibody-Induced Interstitial Pneumonitis

Background:CD20 monoclonal antibody therapy is the backbone of treatment for B-cell non-Hodgkin lymphoma. Several studies have described an association between the use of rituximab and non-infectious interstitial pneumonitis, with estimates ranging from 3.9% to 8.4%. 1-3 However, several novel CD20 monoclonal antibodies have been introduced in the past decade, with obinutuzumab gaining FDA approval in 2013, ofatumumab first approved in 2014, and rituximab/hyaluronidase human approved as a subcutaneous route of rituximab in 2017. While the use of these agents has rapidly increased in clinical practice, the incidence of pneumonitis with these agents is not well known. Thus, we have performed a retrospective review of patients with B cell lymphoma treated with CD20 monoclonal antibody therapy to determine the incidence and characteristics of pneumonitis with these novel agents.Methods:We evaluated all patients at the University of North Carolina at Chapel Hill with B-cell lymphoma who were treated with CD20 monoclonal antibody therapy from 2014 to 2020. We performed individual chart review to verify the presence of interstitial pneumonitis, as defined by presence of respiratory symptoms (cough, dyspnea, fever, chest pain) in addition to imaging findings (pulmonary opacity on chest X-ray and/or ground glass opacities on chest computed tomography (CT)) without alternative cause (CHF with pulmonary edema, COPD flare, infectious cause including bacterial, fungal or viral pneumonia/bronchitis). We extracted demographic data, comorbid conditions, tobacco use history, and timing of pneumonitis related to CD20 monoclonal antibody exposure. We determined rates of pneumonitis based on agent and chemotherapy backbone.Results:We identified 18 cases of chart-confirmed interstitial pneumonitis over a six-year period, out of 2,207 patients treated with CD20-monoclonal antibody therapy. Seven (39%) were current or former smokers, with a median of 30 pack-years smoked. Five (29%) had a history of hypersensitivity reaction to rituximab infusion. Pneumonitis developed after a median of 4 cycles, and 16 days from the most recent CD20 monoclonal antibody infusion. Ten (56%) had diffuse large B-cell lymphoma, 4 (22%) had mantle cell lymphoma, and 1 (6%) each had follicular lymphoma, chronic lymphocytic leukemia, hairy cell leukemia, and Waldenstrom's macroglobulinemia. Eight cases (44%) occurred among patients being treated with R-CHOP, 2 (11%) were treated with BR, 2 (11%) were receiving single agent rituximab, although several other regimens were represented. Most cases occurred in patients being treated with infusional rituximab, but the rate remained quite low (14/1654, 0.8%). Four occurred in patients receiving subcutaneous rituximab hycela out of 167 treated patients (2.4%), less than prior estimates of pneumonitis with monoclonal antibody therapy. Most cases of pneumonitis were treated with steroids (n=15, 83%), although none required infliximab or anti-TNF agents, and no cases of pneumonitis were fatal. Most notably, we did not identify any cases of pneumonitis among patients treated with ofatumumab (n=51) or obinutuzumab (n=58).Conclusion:This retrospective review reinforced the safety of novel anti-CD20 agents, with low rates of interstitial pneumonitis among patients treated with infusional or subcutaneous rituximab. Cases that did occur were effectively treated with steroids, and there were no fatalities associated with pneumonitis. Ofatumumab and obinutuzumab were not associated with any cases of interstitial pneumonitis.Bibliography1. Katsuya H, Suzumiya J, Sasaki H, et al. Addition of rituximab to cyclophosphamide, doxorubicin, vincristine, and prednisolone therapy has a high risk of developing interstitial pneumonia in patients with non-Hodgkin lymphoma. Leuk Lymphoma. 2009;50(11):1818-1823. doi:10.3109/104281909032587802. Salmasi G, Li M, Sivabalasundaram V, et al. Incidence of pneumonitis in patients with non-Hodgkin lymphoma receiving chemoimmunotherapy with rituximab. Leuk Lymphoma. 2015;56(6):1659-1664. doi:10.3109/10428194.2014.9630753. Liu X, Hong X-N, Gu Y-J, Wang B-Y, Luo Z-G, Cao J. Interstitial pneumonitis during rituximab-containing chemotherapy for non-Hodgkin lymphoma. Leuk Lymphoma. 2008;49(9):1778-1783. doi:10.1080/10428190802270886 [Display omitted] DisclosuresGrover: Novartis: Consultancy; Genentech: Research Funding; ADC: Other: Advisory Board; Kite: Other: Advisory Board; Tessa: Consultancy. Dittus: BeiGene: Other: Advisory Board; Seattle Genetics: Research Funding; AstraZeneca: Research Funding; Genentech: Research Funding.

Internal and External Validation of the High-2-Low Model: A Predictive Score for Venous Thromboembolism after Allogeneic Transplant

Introduction: In patients undergoing allogeneic hematopoietic cell transplantation (HCT), venous thromboembolism (VTE) remains a serious complication that lacks validated risk assessment models to guide optimal timing and implementation of thromboprophylaxis. We recently derived the HIGH-2-LOW score that incorporated 7 simple clinical predictors assessed at day 30 post-transplant (Table 1, PMID 33570631). In this present study, we performed validation in two independent datasets.Methods: We selected consecutive patients undergoing first allogeneic HCT from Fred Hutchinson Cancer Research Center (FHCRC, 2015-2019) and MD Anderson Cancer Center (MDACC, 2016-2020). Patients who died, received therapeutic anticoagulation, or did not engraft platelets at day 30 were excluded (Table 2). Day 30 was chosen as the index date because most patients would be transfusion-dependent before that time. We used a combination of ICD9/10 codes and natural language processing (NLP) algorithms to identify possible cases of VTE, followed by confirmation via individual chart review. VTE was defined as radiology-confirmed pulmonary embolism (PE), lower-extremity deep venous thromboembolism (LE-DVT), or catheter-related DVT (CR-DVT). Covariates were captured and weighted according to the original model, except that grade 2-4 was used instead of grade 3-4 GVHD. Discrimination was assessed in each cohort by fitting logistic regression models with VTE and PE/LE-DVT outcomes at 100 days to estimate the c statistic, where a higher c statistic is desirable. Both continuous scores and categorical models were assessed. Kaplan Meier failure curves were plotted to compare the final risk stratification with high- vs. low/intermediate-risk groups.Results: The two cohorts (n=772 in FHCRC, n=1109 in MDACC) had similar characteristics in age, sex, race, weight, disease, and conditioning intensity. Key differences between the two cohorts included a higher number of umbilical cord transplants at FHCRC (vs. haploidentical at MDACC), higher numbers of acute GVHD at FHCRC (due to differences in grading criteria), fewer historical CR-DVT at FHCRC (4.0% vs. 6.8%), and more anticoagulation treatment at day 30 at FHCRC (9.0% vs. 3.5% - excluded). Incident VTE was 2.5% by 100 days and 7.8% by 365 days at FHCRC; incident VTE was 5.4% by 100 days and 9.4% by 365 days at MDACC (Table 2). Incident PE or LE-DVTs were similar in the two cohorts.When treated as a continuous score, every 1-point increase in the HIGH-2-LOW score was associated with odds ratio (OR) of 1.55 for VTE (1.06-2.27, c=0.64) and 2.50 (1.40-4.44, c=0.84) for PE/LE-DVT in the FHCRC cohort. The same increase was associated with OR of 1.93 (1.55-2.39, c=0.64) for VTE and 2.46 (1.61-3.76, c=0.79) for PE/LE-DVT in the MDACC cohort (Table 3). A total of 24% and 19% of patients were classified as high-risk (2+ points), respectively. High vs. low/intermediate-risk was associated with OR of 2.99 (1.20-7.49, c=0.62) for VTE and 19.93 (2.38-166.67, c=0.81) for PE/LE-DVT in the internal validation cohort. High vs. low/intermediate-risk was associated with OR of 4.58 (2.69-7.79, c=0.66) for VTE and 12.05 (3.17-45.81, c=0.77) for PE-LE-DVT in the external validation cohort. The VTE risk stratification separated early and persisted beyond 100 days (Figure 1).Conclusion: Despite differences in HCT and patient characteristics, the HIGH-2-LOW score identified ~20% of allogeneic HCT recipients at high-risk for VTE, particularly that of PE or LE-DVT, in both independent validation cohorts. The lower-than-expected absolute VTE incidence in the FHCRC cohort was likely driven by the increasing use of anticoagulation immediately post-transplant (exclusion criteria); however, the model retained similar OR with modest discrimination in both cohorts. In patients with prior history of PE/LE-DVT off anticoagulation, or those with prolonged admission and at least 1 additional risk factors from the HIGH-2-LOW score (2+ points), VTE prophylaxis should be considered upon platelet engraftment. [Display omitted] DisclosuresLee: Kadmon: Research Funding; Syndax: Research Funding; Takeda: Research Funding; Pfizer: Research Funding; Novartis: Other: clinical trials, Research Funding; JANSSEN: Other; Incyte: Research Funding; AstraZeneca: Research Funding; Amgen: Research Funding; National Marrow Donor Program: Membership on an entity's Board of Directors or advisory committees. Shpall: Bayer HealthCare Pharmaceuticals: Honoraria; Novartis: Consultancy; Takeda: Patents & Royalties; Affimed: Patents & Royalties; Magenta: Honoraria; Magenta: Consultancy; Navan: Consultancy; Novartis: Honoraria; Axio: Consultancy; Adaptimmune: Consultancy.

Harnessing the epic electronic medical record to track indwelling ureteral stents in a pediatric population

Retention of indwelling ureteral stents due to loss to follow-up can result in significant harm to patients, often requiring multiple trips to the operating room. Despite widespread use of electronic medical records, there are few standardized options for urologists to track ureteral stents and no data on the rate of retained stents in a pediatric population. This pilot quality improvement project aims to: 1) develop a simple process to track indwelling ureteral stents using the Epic electronic medical record and 2) determine the incidence of forgotten stents in a pediatric population. We identified that operating room staff scan a barcode for ureteral stents at the time of surgery to log the stent as "Implanted" in the patient's medical record. The stent can later be marked as "Explanted" at the time of removal. A report was designed within Epic to identify all patients with a ureteral stent implanted from April 2014 to June 2019at our hospital. We reviewed the records of patients whose stents had never been marked as "Explanted" to determine if any had a retained stent. A workflow was then designed to ensure staff would mark stents as "Explanted" at the time of removal and to periodically run the report within Epic to ensure that all patients with ureteral stents in place have appropriate follow-up. Our report identified 152 ureteral stents with a status of "Implanted". 3 patients did not have evidence of stent removal documented in their medical record. Follow up with these patients revealed stent removal at an outside location. Current approaches to stent tracking are laborious with limitations to adherence. The Epic software directly incorporates stent tracking into the individual patient chart allowing for easy implementation and follow up. Our study revealed no retained stents in our pediatric population. All patients with ureteral stents placed at a single institution over a 5-year period were easily identified using an automated Epic report. Through this report, we will prevent morbidity associated with stent retention. This technique could easily be implemented at other hospital systems that use Epic, and similar reporting tools could be designed within other electronic medical record systems. The incidence of ureteral stent retention in the pediatric population is likely significantly lower than for their adult counterparts.

Secondary Precipitants of Atrial Fibrillation and Anticoagulation Therapy.

BackgroundAtrial fibrillation (AF) commonly occurs in the setting of acute conditions. We aimed to identify the acute conditions associated with secondary AF (AF precipitants) including pneumonia/sepsis, pneumothorax, respiratory failure, myocarditis, pericarditis, alcohol intoxication, thyrotoxicosis, cardiothoracic surgery, other surgery in patients with newly diagnosed AF and determine their association with subsequent oral anticoagulant use.Methods and ResultsWe assembled a cohort of patients in the UMass Memorial Healthcare system with a new diagnosis of AF with and without AF precipitants. We used combinations of International Classification of Diseases, Tenth Revision (ICD‐10) codes, Current Procedural Terminology codes, laboratory values, imaging reports, and physician notes including discharge summary texts to identify AF precipitants. We then manually reviewed the individual charts to validate presence of AF precipitants. The study sample consisted of 185 patients with and 172 patients without AF precipitants. Pneumonia/sepsis, myocardial infarction, respiratory failure, and cardiothoracic surgery were the most common precipitants identified. In multivariable analyses adjusting for age, sex, patient comorbidities, left atrial enlargement, left ventricular ejection fraction, and antiplatelet use, patients with AF precipitants were less likely to receive subsequent anticoagulation therapy at 30 days after the initial AF diagnosis (odds ratio, 0.31; 95% CI, 0.19–0.52). The association was persistent after excluding men with CHA2DS2‐VASc score <2 and women with CHA2DS2‐VASc score <3.ConclusionsOur study highlights lower usage of oral anticoagulant in secondary AF in contemporary clinical practice.

Immune checkpoint inhibitors for cancer and venous thromboembolic events

BackgroundImmune checkpoint inhibitors (ICIs) are widely used cancer treatments. There are limited data on the risk for developing venous thromboembolism (VTE) among patients on an ICI. MethodsThis was a retrospective study of 2854 patients who received ICIs at a single academic centre. VTE events, defined as a composite of deep vein thrombosis or pulmonary embolism, were identified by individual chart review and blindly adjudicated using standard imaging criteria. A self-controlled risk-interval design was applied with an ‘at-risk period’ defined as the two-year period after and the ‘control period’, defined as the two-year before treatment. The hazard ratio (HR) was calculated using a fixed-effect proportional hazards model. ResultsOf the 2854 patients, 1640 (57.5%) were men; the mean age was 64 ± 13 years. The risk for VTE was 7.4% at 6 months and 13.8% at 1 year after starting an ICI. The rate of VTE was > 4-fold higher after starting an ICI (HR 4.98, 95% CI 3.65–8.59, p < 0.001). There was a 5.7-fold higher risk for deep vein thrombosis (HR 5.70, 95% CI 3.79–8.59, p < 0.001) and a 4.75-fold higher risk for pulmonary embolism (HR 4.75, 95% CI 3.20–7.10, p < 0.001). Comparing patients with and without a VTE event, a history of melanoma and older age predicted lower risk of VTE, while a higher Khorana risk score, history of hypertension and history of VTE predicted higher risk. ConclusionsThe rate of VTE among patients on an ICI is high and increases after starting an ICI.

Dynamic Cushioning: Obesity and Trauma Patients Undergoing Exploratory Laparotomy

Traumatic injuries account for 10% of all mortalities in the United States. Annually the global estimated population of overweight and obese individuals rises in number. It is well established in the literature that obesity is associated with worse outcomes in trauma patients. While body mass index, or BMI is not an independent predictor of increased morbidity or mortality after trauma laparotomy, we hypothesized that it may place patients at increased risk of postoperative complications and have lasting significant negative effects on quality of life in a manner disproportionate to normal-weight patients. The trauma registry of an academic level 1 trauma hospital was queried for laparotomies following either blunt or penetrating traumatic injury from 2015 to 2019. Individual patient charts were reviewed. Patients were divided into three groups, according to Body Mass Index (BMI) cut-offs as normal weight (BMI < 25 kg/m2), overweight; BMI 25-29.9 kg/m2), and obese (BMI ≥ 30 kg/m2). Demographics, intraoperative management and outcomes were compared between groups, after which complications were regressed based on BMI to evaluate the impact BMI had on each. Records of 197 trauma patients who underwent exploratory laparotomies were analyzed. There was no significant difference in demographics or injury severity score (ISS) between groups. BMI had a direct positive association with intensive care unit length of stay (r=0.239 [0.103, 0.367]), P < 0.001), hospital length of stay (r=0.197 [0.059, 0.328], P = 0.005) and return to OR (OR=1.057, [1.010, 1.109], P = 0.017). There was no significant relationship between BMI and in-hospital or 90-d mortality. Our findings show that with increasing BMI, postoperative complications increase following laparotomy for trauma. As rates of obesity increase, trauma surgeons must be prepared to anticipate plans of care from patient presentation to well beyond discharge to cope with more complex postoperative and post-hospital clinical courses.

Characteristics of electrolyte imbalance and pseudo-bartter syndrome in hospitalized cystic fibrosis children and adolescents

IntroductionPseudo-Bartter syndrome (PBS) is a rare manifestation of Cystic fibrosis (CF) and can often be the initial presentation in these patients, however, due to significantly overlapping symptoms it is often misdiagnosed as simple dehydration or Bartter syndrome. The objective of our study was to highlight the key features of PBS and electrolyte imbalance in CF patients helping in early and prompt diagnosis. MethodWe performed a retrospective study from January 2015 to December 2019 at the Aga Khan University Hospital (AKUH), Pakistan. CF patients aged from 1–18 years, admitted at AKUH were enrolled and their laboratory data and individual charts were reviewed. Patients were categorized into three groups based on their serum electrolyte profile and their clinical findings were compared. ResultWe enrolled 72 CF patients, out of which 42 (58%) were categorized into the Normal Electrolyte (NE) group, 19 (26%) into the Electrolyte Imbalance (EI) group and 11 (15%) in the PBS group. Out of 11 cases, 6 (54.54%) patients in PBS group presented with features consistent with PBS leading to CF diagnosis labeled as “early presenters”. Mean age of patients in the PBS group was 3.81± 0.86 years and their age at diagnosis were significantly lower as compared to other groups. Gastrointestinal disturbances including diarrhea, vomiting and constipation were more common in the EI and PBS groups. Polyuria was most common in the PBS (72%) group. Length of hospital stay showed no significant difference. ConclusionPseudo-Bartter syndrome can be a presenting feature of cystic fibrosis. Electrolyte imbalance should be anticipated in hospitalized CF children and adolescent.

S1376 Yield of Duodenal Biopsy for Disaccharidase Testing in Patients Undergoing Endoscopy for Gastrointestinal Symptoms

Introduction: Disaccharidase deficiencies (DD) often lead to GI symptoms. Recent studies suggest underestimated prevalence of sucrase-isomaltase deficiency (SID) in adults. DD testing often involves small bowel biopsy for disaccharidase activity (maltase, sucrase, palatinase, and lactase). This study aimed to examine the diagnostic yield of disaccharidase testing in patients undergoing endoscopy for GI symptoms. Methods: This case-control study evaluated yield of disaccharidase testing performed Dec 2017 - May 2021 at an academic tertiary-care hospital. Data were extracted via EMR, recording results from disaccharidase testing via a spectrophotometry test (Quest Laboratory), using duodenal biopsy samples. Individual charts were reviewed for data from pre-endoscopy clinic visits, laboratory results, and endoscopy and pathology reports. Data were analyzed after dividing patients into 3 groups: 1. normal disaccharidase testing, 2. isolated lactase deficiency (LD), and 3. Multiple DDs (>1 DD). For categorical variables, Chi-squared testing or Fisher’s exact test and for continuous variables, ANOVA with Tukey’s post-hoc test was used. Results: 387 patients were identified with disaccharidase testing (mean age 47.4 years, 74.7% female, 65.3% Hispanic, mean BMI 26.1 kg/m2). 203 patients (52.5%) had isolated LD and 36 patients (9.3%) had SID (2 DD N = 13, 3 DD N = 15, pan-DD N = 8), with LD accounting for 1 DD in 97.2% of those with >1 DD. African Americans were more likely to have LD compared to non-Hispanic whites (OR = 4.8, P = 0.01). LD Patients were likely to have nausea (OR = 0.51, P = 0.005). No other individual pre-endoscopy symptom was solely predictive of DD. Hgb and iron deficiency anemia were not associated with DD. LD and SID were associated with abnormal duodenal histology (LD: OR = 2.3, P = 0.02; SID: OR = 4.5, P < 0.0001). Among patients with SID, 14 had abnormal duodenal histology and 3 were diagnosed with celiac disease. LD patients were more likely to have H. pylori gastritis (OR = 3.8, P = 0.001). Conclusion: In this large series of 387 patients who underwent disaccharidase testing, LD (52.5%) and SID (9.3%) were common. Underlying GI disorders like celiac disease and peptic injury are contributors to DD, corresponding to the abnormal duodenal histology seen in 14/36 patients with SID. 20 patients had normal duodenal histology, raising the question of possible primary SID. Further adult pan-DD cases are reported. DD may be a primary or comorbid cause of upper GI symptoms, diagnosed via duodenal biopsy.

External validation of a novel signature of illness in continuous cardiorespiratory monitoring to detect early respiratory deterioration of ICU patients

Objective: The goal of predictive analytics monitoring is the early detection of patients at high risk of subacute potentially catastrophic illnesses. An excellent example of a targeted illness is respiratory failure leading to urgent unplanned intubation, where early detection might lead to interventions that improve patient outcomes. Previously, we identified signatures of this illness in the continuous cardiorespiratory monitoring data of intensive care unit (ICU) patients and devised algorithms to identify patients at rising risk. Here, we externally validated three logistic regression models to estimate the risk of emergency intubation developed in Medical and Surgical ICUs at the University of Virginia. Approach: We calculated the model outputs for more than 8000 patients in the University of California—San Francisco ICUs, 240 of whom underwent emergency intubation as determined by individual chart review. Main results: We found that the AUC of the models exceeded 0.75 in this external population, and that the risk rose appreciably over the 12 h before the event. Significance: We conclude that there are generalizable physiological signatures of impending respiratory failure in the continuous cardiorespiratory monitoring data.

Comorbidities and medical complexities of mobility device users: a retrospective study

Objective To determine the medical complexities and comorbidities of individuals who utilise wheeled mobility devices. As well as, to examine costly events including the number of urinary tract infections (UTIs), hospitalizations, urgent care(UC)/emergency department (ED) visits that are commonly seen in this population over a period of time one year prior to and one year post receiving their wheeled mobility equipment. Design/Setting A retrospective data review of 857 individual medical charts at a Level 1 Trauma Hospital and Clinic System Participants 330 male and female (24–92 years old) mobility device users with a wide range of diagnoses, of which: 56 used manual wheelchairs (MWC),138 scooters (POV), 123 power wheelchairs without integrated standing (PWC), and 13 power wheelchairs with integrated standing (iS-PWC). Results Overall, 92% (n = 304) had at least three medical comorbidities and medical complexities. The most common comorbidity was pain (91%). A change was noted in a lower incidence of UTIs in those using an iS-PWC, respectively 23% with at least 1 UTI in the year prior to and 8% in the year after the mobility device evaluation. Conclusions The large number of comorbidities and medical complexities amongst all mobility device users is concerning. The burden and the accompanying healthcare costs of this population is high. The potential that iS-PWC and other interventions could have on reducing these issues should be explored further. Implications of rehabilitation Regardless of a person's primary diagnosis or the wheeled mobility device they use, 100% have at least one and 92% have at least three comorbidities and medical complexities if they spend the majority of their day sitting The high healthcare cost situations such as Emergency Department visits, Urgent Care visits, hospitalizations, and Urinary Tract Infections are present across those that use all mobility device types and the means to potentially reduce these incidences should be further explored The introduction of integrated standing within a power wheelchair, as a means to minimize the frequency of comorbidities and medical complications, should also be investigated further

130. Tranexamic acid use is associated with reduced intraoperative blood loss during spine surgery in Marfan syndrome

<h3>BACKGROUND CONTEXT</h3> Sixty percent of patients with Marfan syndrome (MFS) have scoliosis, of which up to 50% will typically require surgical intervention. Chief among surgical concerns in MFS patients undergoing scoliosis correction is the increased risk for intraoperative bleeding due to hemostatic deviations secondary to aortic dilatation, rheological disturbances, endothelial injury, and abnormal levels of clotting factors. Tranexamic acid (TXA) is an anti-fibrinolytic agent that has been demonstrated to reduce blood loss secondary to traumatic injury or surgical intervention, and the subsequent need for transfusion. However, the efficacy of TXA in connective tissue disorders, like MFS, is controversial given the interaction between the clotting cascade and the endothelium of the vasculature. To our knowledge, no other study has previously reported on the utility of TXA in the surgical management of MFS-associated scoliosis. <h3>PURPOSE</h3> The objective of this study was to assess the effect of TXA on intraoperative blood requirements in MFS patients undergoing spinal fusion. <h3>STUDY DESIGN/SETTING</h3> Retrospective review, single institution. <h3>PATIENT SAMPLE</h3> Administrative databases were queried for patients with MFS who underwent spinal fusion for scoliosis between 2000 and 2020 by one surgeon. We excluded operations spanning <3 vertebral levels, along with those related to growing rods (insertion or distraction) or postoperative infection. Sixty-one patients with MFS met inclusion criteria, of whom 23 were treated with TXA and 38 were not. <h3>OUTCOME MEASURES</h3> The following outcomes were assessed and compared between MFS patients treated with and without TXA during spinal fusion: estimated intraoperative blood loss and allogenic blood transfusion requirements. <h3>Methods</h3> The individual charts (including operative and anesthesia notes) of all patients were personally reviewed by study team members to identify MFS patients who received TXA during spinal fusion and their surgical outcomes. Statistical analysis was performed to compare demographic variables and surgical outcomes – using chi-square or t tests, as appropriate. A p-value of < 0.05 was considered significant. <h3>Results</h3> There was no significant difference in patient age, gender, curvature severity, or number of levels fused between the groups. Patients with MFS who were treated with TXA experienced significantly less intraoperative blood loss (625 ± 229 ml, p = 0.008) compared to those who were not. Likewise, we detected a significant difference in total quantity of transfused allogeneic blood products (1.3 ± 0.5, p = 0.013), though there was no difference in transfusion rates between each group (p = 0.317). <h3>Conclusions</h3> We demonstrate the efficacy of TXA in hemostasis during surgical treatment of MFS-associated scoliosis. Our study suggests that the vascular effects secondary to connective tissue deficiency in MFS does not interfere with TXA mechanism of action. <h3>FDA DEVICE/DRUG STATUS</h3> Unavailable from authors at time of publication. Tranexamic acid: not approved for this indication.

12. Late spinal infections are more common among pediatric vs adult spinal deformity patients

<h3>BACKGROUND CONTEXT</h3> Late-onset postoperative infections after surgical correction of spinal deformity represent an uncommon, but significant complication of spine surgery. The incidence of late infection following posterior spinal fusion (PSF) in pediatric patients with AIS has been reported to be up to 7.5%. However, there is limited literature on late infections following ASD surgery suggesting that this phenomenon may be less frequent in adults. <h3>PURPOSE</h3> The objective of this study is to characterize the incidence, timing, and pathogenic etiology of late spinal infections after instrumentation for spinal arthrodesis in both age groups who present with spinal deformity. <h3>STUDY DESIGN/SETTING</h3> Retrospective review, single institution <h3>PATIENT SAMPLE</h3> Institutional data was retrospectively queried from 2000 to 2015 to identify patients who underwent instrumented PSF. Patients with more than 12 months follow-up, spinal arthrodesis spanning greater than 5 levels, and idiopathic or degenerative spinal pathology were selected for inclusion. A total of 1113 patients met inclusion criteria<b>:</b> 607 pediatric AIS patients and 506 adult spinal deformity patients. Within the pediatric AIS cohort, 76.1% (462/607) were female compared to 70.9% (359/506) within the ASD cohort. Mean follow-up was 3.9 ± 2.86 years for the AIS patients vs 4.6 ± 3.16 years for the ASD patients. <h3>OUTCOME MEASURES</h3> The following outcomes were assessed and were compared by age cohort of less than 21 vs greater than or equal to 21 years: rate of late-onset spinal infection, timing of late-onset spinal infection, and causative microorganism(s) associated with late-onset spinal infections. Demographic and surgical data were also compared between the two cohorts. <h3>METHODS</h3> The individual charts of all patients were personally reviewed by study team members to identify those who went on to develop late spinal infections. We classified late-onset as spinal infections occurring beyond 6 months (180 days) from the index operation. Diagnosis was established on the basis of return to the operating room for intraoperative bacterial cultures and sensitivities, and irrigation and debridement. <h3>RESULTS</h3> A total of 26 (4.29%) AIS patients and 2 (0.4%) ASD patients developed a late postoperative spinal infection (p = 0.01). Average onset of infection was 4.2 years (1.0-11.6) in the AIS group and 4.0 years (0.6-7.3) in the ASD group. There were significant differences in number of levels fused and reported blood loss between the two groups (p <0.001). After controlling for these intraoperative factors, age remained a significantly correlated with onset of late spinal infection (p < 0.001). Cutibacerium acnes and coagulase-negative Staphylococci were the most commonly detected microorganisms for both groups. <h3>CONCLUSIONS</h3> Pediatric patients are at significantly increased risk for late-onset postoperative spinal infections compared to adults. Skin and indolent organisms are the primary identifiable causative agents in both cohorts. Further research on these differences in infection patterns among adolescents and adults may help tailor personalized management protocols. <h3>FDA DEVICE/DRUG STATUS</h3> This abstract does not discuss or include any applicable devices or drugs.

Racial differences in indications for obstetrical toxicology testing and relationship of indications to test results

Despite illicit substance use in pregnancy occurring across all demographic groups, minority pregnant and delivering patients with a low income tend to undergo testing at a higher rate than their counterparts. National guidelines for indications do not exist and ordering of toxicology testing may be applied inequitably. This study aimed to evaluate whether any documented indications in a large cohort of patients were associated with a positive toxicology test and whether indications for urine toxicology testing were applied consistently to different demographic groups. This was a retrospective cohort study reviewing pregnant and delivering patients who underwent toxicology testing on obstetrical units at 1 institution from May 30, 2015, to December 31, 2018. Age, race, marital status, median income of residential ZIP code, indications for testing, and test results were collected for each patient by individual chart review. Indications included preterm complications (preterm prelabor rupture of membranes or preterm labor), abruption or hypertension, reported substance use, fetal complications, maternal complications, and none. Multivariate logistic regression models were analyzed for the association between indication and test result and the likelihood of marijuana as the sole positive test result. Logistic regression was used to evaluate the relationship of indication for testing with maternal race. Among 20,274 births, 551 patients underwent toxicology testing during the study period. No indication for drug toxicology testing was associated with a positive result, except reported current or previous substance use. Compared with White patients, Black and Hispanic women were 4.26 times (95% confidence interval, 2.55-7.09) and 5.75 times (95% confidence interval, 2.89-11.43) more likely to have toxicology testing for an indication other than reported substance use, respectively. Of all patients with positive test results (n=194), 48% tested positive for marijuana only. Compared with their White counterparts, Black and Hispanic pregnant and delivering patients may be more frequently toxicology tested for indications less clearly associated with illicit substance use. The absence of evidence-based guidelines for toxicology testing on obstetrical units risks inequitable care and stigmatization of patient groups.

Impact of steroid use and glucose control on surgical outcomes in diabetic gynecologic oncology patients

<h3>Objectives:</h3> The objective of this study was to assess the impact of preoperative steroid use and glucose control on postoperative outcomes for diabetes mellitus (DM) gynecologic oncology patients undergoing surgery. <h3>Methods:</h3> This retrospective cohort study included all gynecologic oncology patients admitted for inpatient surgery on an enhanced recovery protocol (ERP) between 10/2016 and 12/2018 with the addition of further patients with DM until 9/2019. The utilization of preoperative steroids has largely been adopted in most ERP patients. At our institution, 8mg intravenous dexamethasone is frequently used. Individual chart review was completed to identify the primary outcome of postoperative complications including: DKA, surgical site infection, ileus, DVT/PE, CVA, MI, AKI, unplanned ICU admission, pulmonary complications, and blood transfusions. Secondary outcomes included length of hospital stay (LOS) and readmission rate. SPSS v. 25 was used for statistical analysis. <h3>Results:</h3> 684 patients were identified and 184 (26.9%) had coexisting type I or II DM. Demographics including CCI, race, diagnosis, and surgical complexity were similar between groups. Patients with DM tended to be older, have a larger body mass index (BMI), and longer operative times. The overall complication rate was 32.5%. Patients with DM were more likely to have postoperative complications (77.5% vs. 15.9%, P=0.0001), increased LOS (4.0±4.6 vs. 3.1±1.9 days, P=0.001), though no difference in readmission rate was observed (10.3% vs. 7.6%, P=0.25). Patients were more likely to have postoperative complications if they had at least one documented serum glucose greater than 300 (74.1% vs 26.8%, P=0.0001) or an average serum glucose greater than 180mg/dL in the first 24 hours (80.0% vs 24.8%, P=0.0001). 54.3% of DM patients got preoperative steroids with no difference in complication or readmission rates seen (p=0.1; p=0.7). <h3>Conclusions:</h3> Diabetic patients are at a much higher risk for postoperative complications after gynecologic oncology surgery. There was no increased risk for postoperative complications in DM patients who received steroids as part of the ERP. However, poorly controlled glucose levels in the immediate postoperative period were associated with a higher rate of complications. Adequate blood glucose control perioperatively for these high-risk patients undergoing surgery is vital given the increased risk of postoperative complications and length of stay.