Initial Approach Research Articles

1266. Refining Antimicrobial Stewardship by De-escalating Vancomycin Using MRSA (Methicillin Resistant Staphylococcus aureus) Nasal Screening in a Community Hospital Setting

Abstract Background Our institution has prioritized appropriate use of anti-Methicillin-resistant Staphylococcus aureus (MRSA) drugs such as vancomycin. The overuse of anti-MRSA drugs contributes to drug toxicities and development of resistant organisms such as vancomycin-resistant enterococcus (VRE). Recent studies show that MRSA nasal surveillance screening has a high negative predictive value of 96.5% in all types of pneumonia. At our community hospital a decentralized pharmacist-driven MRSA nares screening protocol was novel. We report the results of implementing a MRSA nares screening protocol for vancomycin de-escalation in pneumonia patients. Methods A decentralized pharmacist reviewed patients with a diagnosis of pneumonia and prescribed vancomycin. The pharmacist ensured that a culture-based MRSA nares screen was performed within 48 hours of admission, if not already ordered. If the nares screen returned negative and respiratory cultures did not grow MRSA at 48 hours, the decentralized pharmacist contacted the medical team to recommend discontinuing vancomycin. Reasons for exclusion included a positive respiratory culture for MRSA within the prior 7 days, septic shock, alternative site of MRSA infection, and greater than 48 hours of anti-MRSA therapy at time of swab collection. Results 164 patients were reviewed by pharmacy between 6/16/22 and 4/25/23. 98% of MRSA nares screening had been performed within 48 hours of admission. MRSA screen was ordered by the decentralized pharmacist in 44% of patients. 89% of patients screened were negative for MRSA and reviewed for de-escalation of vancomycin. In 40% of patients, vancomycin was discontinued after recommendations by the decentralized pharmacist, with 95% of the recommendations accepted by the primary hospitalist physician. 37% of patients' vancomycin was discontinued by the attending physician. Overall, 77% of patients with negative MRSA nasal screen results were successfully de-escalated. Conclusion Our data highlights the effectiveness of close physician-pharmacy collaboration. Most nares cultures were negative for MRSA allowing for de-escalation of antibiotics. Pharmacist recommendations were accepted majority of the time. Given the data, we plan to apply this approach for other ongoing stewardship initiatives. Disclosures All Authors: No reported disclosures

Research priorities for improving menstrual health across the life-course in low- and middle-income countries

ABSTRACT Background Research on menstrual health is required to understand menstrual needs and generate solutions to improve health, wellbeing, and productivity. The identification of research priorities will help inform where to invest efforts and resources. Objectives To identify research priorities for menstrual health across the life-course, in consultation with a range of stakeholder groups from a variety of geographic regions, and to identify if menstrual health research priorities varied by expertise. Methods A modified version of the Child Health and Nutrition Research Initiative approach was utilized to reach consensus on a set of research priorities. Multisector stakeholders with menstrual health expertise, identified through networks and the literature, were invited to submit research questions through an online survey. Responses were consolidated, and individuals were invited to rank these questions based on novelty, potential for intervention, and importance/impact. Research priority scores were calculated and evaluated by participants’ characteristics. Results Eighty-two participants proposed 1135 research questions, which were consolidated into 94 unique research questions. The mean number of questions did not differ between low- and middle-income country (LMIC) and high-income country (HIC) participants, but significantly more questions were raised by participants with expertise in mental health and WASH. Sixty-six participants then ranked these questions. The top ten-ranked research questions included four on ‘understanding the problem’, four on ‘designing and implementing interventions’, one on ‘integrating and scaling up’, and one on ‘measurement’. Indicators for the measurement of adequate menstrual health over time was ranked the highest priority by all stakeholders. Top ten-ranked research questions differed between academics and non-academics, and between participants from HICs and LMICs, reflecting differences in needs and knowledge gaps. Conclusions A list of ranked research priorities was generated through a consultative process with stakeholders across LMICs and HICs which can inform where to invest efforts and resources.

PANORAMIC REVIEW OF OPEN FRACTURES, DESCRIPTION, EPIDEMIOLOGY, ASSESSMENT, CLASSIFICATION, TREATMENT AND COMPLICATIONS

Introduction: An open or exposed fracture is a fracture that has communication with the external environment through a skin wound. Usually these types of severe fractures require treatment by the orthopedic and plastic surgery team to address both bone and soft tissue injuries. Objective: to detail current information related to open fractures, description, epidemiology, evaluation, classification, treatment and complications. Methodology: a total of 33 articles were analyzed in this review, including review and original articles, as well as clinical cases, of which 20 bibliographies were used because the other articles were not relevant to this study. The sources of information were PubMed, Google Scholar and Cochrane; the terms used to search for information in Spanish, Portuguese and English were: exposed fractures, open fractures, acute trauma, compartment syndrome, vascular injury, debridement. Results: the general average age of onset is 45.5 years, the incidence decreases in men and increases in women with age. Automobile accidents are the most common cause of open fractures of the lower limbs, accounting for approximately 34.1% of these injuries. The highest incidence of open fractures in males is between 15 and 19 years, the highest incidence in females is between 80 and 89 years. Conclusions: Knowledge of the management of open fractures is of vital importance, due to the fact that this type of fracture presents a high risk of infections, as well as other types of complications. The initial approach to the injured individual with an open fracture should be based on the principles of Advanced Trauma Life Support (ATLS). Clinical and imaging evaluation is important in this type of fracture, as well as recognizing the value of the classification systems that play a critical role when treating surgically. Irrigation and debridement remain the gold standards for proper wound management. The most important point in the treatment of an open fracture is proper lavage and debridement. KEY WORDS: trauma, open fractures, bone exposure, treatment.

STK11 loss leads to YAP1-mediated transcriptional activation in human KRAS-driven lung adenocarcinoma cell lines

Serine Threonine Kinase 11 (STK11) loss of function (LoF) correlates with anti-PD-1 therapy resistance in patients with KRAS-driven lung adenocarcinoma (LUAD). The molecular mechanisms governing this observation remain unclear and represent a critical outstanding question in the field of lung oncology. As an initial approach to understand this phenomenon, we knocked-out (KO) STK11 in multiple KRAS-driven, STK11-competent human LUAD cell lines and performed whole transcriptome analyses to identify STK11-loss-dependent differential gene expression. Subsequent pathway enrichment studies highlighted activation of the HIPPO/YAP1 signaling axis, along with the induction of numerous tumor-intrinsic cytokines. To validate that YAP1-mediated transcriptional activation occurs in response to STK11 loss, we pursued YAP1 perturbation as a strategy to restore an STK11-competent gene expression profile in STK11-KO LUAD cell lines. Together, our data link STK11 loss with YAP1-mediated transcriptional activation, including the upregulation of immune-evasion promoting cytokines IL-6, CXCL8 and CXCL2. Further, our results raise the intriguing possibility that YAP1 antagonism may represent a therapeutic approach to counter anti-PD-1 therapy resistance in STK11-null, KRAS-driven LUADs by modulating tumor-intrinsic gene expression to promote a “hot” tumor immune microenvironment.

Unrelated parallel batch processing machine scheduling with time requirements and two-dimensional packing constraints

In various complex manufacturing systems such as wafer fabrication, ceramic processes, and additive manufacturing, a single machine often performs multiple distinct jobs simultaneously, requiring non-overlapping positions in the 2D-plane. As the demand for manufacturing with two-dimensional (2D) packing constraints continues to rise, there is an urgent need to address the integrated scheduling of batch processing machines (BPMs) and 2D packing. However, only a limited number of studies have explored BPM scheduling problems with 2D packing constraints. In this study, we focus on the scheduling of unrelated parallel BPMs to process jobs with non-identical sizes, unequal release dates, and due dates. To model the machine’s capacity, we move beyond the traditional one-dimensional knapsack approach and consider it as a 2D rectangle, taking into account the 2D packing constraints. It is crucial to ensure that no overlapping or stacking occurs within the machine’s capacity under these constraints. To address this problem, we propose a mixed integer linear programming model as the initial approach. Additionally, we develop an adaptive large neighborhood search (ALNS) heuristic specifically designed for handling large instances. The ALNS incorporates eleven removal operators and seven insertion operators, offering a comprehensive exploration and improvement of solutions. To tackle the packing procedure, we adopt two distinct packing patterns, namely Skyline and Open Space. These patterns play a significant role in optimizing the packing of jobs within the machine’s capacity. Furthermore, we conduct extensive computational experiments, generating 48 categories of instances with varying job attributes. These experiments serve to compare the performance of the two packing patterns and validate the effectiveness of our ALNS approach. In conclusion, our research addresses the critical gap in BPM scheduling problems with 2D packing constraints. By introducing a mixed integer linear programming model and developing the ALNS heuristic with diverse operators, coupled with the adoption of different packing patterns, we present a comprehensive approach to tackle this complex problem. Computational experiments are conducted to compare packing patterns and verify the performance of our ALNS method.

CTNI-46. UPFRONT VERSUS DEFERRED TREATMENT IN LOWER GRADE IDH-MUTANT GLIOMAS: A SINGLE-CENTER RETROSPECTIVE ANALYSIS

Abstract BACKGROUND IDH-mutant gliomas are a diverse group of gliomas possessing a mutation in the isocitrate dehydrogenase enzyme. The treatment for both oligodendroglioma (1p/19q co-deleted) and astrocytoma includes resection followed by radiation therapy and chemotherapy. However, there is debate over the optimal timing of adjuvant treatment after surgery. An initial observation approach is sometimes pursued, particularly after gross total resection in young adults. We sought to examine the impact of timing of treatment in order to inform clinical decision-making. METHODS We identified 286 biopsied or resected glial tumors treated at MD Anderson Cancer Center from July 2015 to June 2022. Tumors were categorized using available molecular data based on the WHO 2021 diagnostic criteria. Progression-free survival was analyzed using Kaplan-Meier estimates. RESULTS Of 286 tumors, 232 had identified IDH-mutation, of which 89 were 1p/19q co-deleted and 143 were non-co-deleted. Of oligodendroglioma patients, 71 received either upfront chemotherapy, radiation or both and 18 received treatment upon progression; of astrocytoma patients, 96 were treated upfront and 47 received treatment at progression. Among oligodendroglioma patients, there were no significant differences in PFS between treatment timing groups (75.6 vs 66.7 months, P = 0.18). There was additionally no difference between oligodendroglioma patients treated initially with PC or PCV regimens vs temozolomide (not reached vs 75.4 months, P = 0.24). Among astrocytoma patients, upfront treatment was associated with longer PFS (93.8 vs 45.2 months, P < 0.01). Patients with low-risk grade 2 gliomas (age <40 and gross total resection) also showed longer PFS with upfront treatment (138.0 vs 45.2 months, P = 0.03). CONCLUSION Overall, the results in this molecularly defined cohort suggest a progression-free survival benefit from upfront treatment in IDH-mutant lower grade gliomas, including in low-risk gliomas. The optimal timing and nature of adjuvant treatment for lower grade gliomas remains a matter of debate.

Influence Maximization in social networks using discretized Harris’ Hawks Optimization algorithm

Influence Maximization (IM) is the task of determining k optimal influential nodes in a social network to maximize the influence spread using a propagation model. IM is a prominent problem for viral marketing and helps significantly in social media advertising. Previous Greedy and Reverse Influence Sampling-based IM approaches are ineffective in real-world social networks due to their significant computational cost and execution time. Further, even heuristic approaches applied to IM generally yield minimal performance gain relative to the decreased time complexity. This presents a challenge in developing cost-effective algorithms with low execution time that can handle diverse social networks. In this paper, we propose the discretization of the nature-inspired Harris’ Hawks Optimization meta-heuristic algorithm using community structures for optimal selection of seed nodes for influence spread. In addition to Harris’ Hawks’ intelligence, we employ a neighbor scout strategy algorithm to avoid blindness and enhance the searching ability of the hawks. Further, we use a candidate nodes-based random population initialization approach, and these candidate nodes aid in accelerating the convergence process for the entire populace, reducing the total computational cost. We evaluate the efficacy of our proposed DHHO approach on eight social networks using the Independent Cascade model for information diffusion. We observe that DHHO is comparable or better than competing meta-heuristic approaches for Influence Maximization across five metrics, and performs noticeably better than competing heuristic approaches.

Characterization and comparison of rhythm disturbances after atrial or arterial switch surgeries for dextro-transposition of the great arteries: a long-term follow-up study

Abstract Introduction and objectives Dextro-transposition of the great arteries (D-TGA) is a congenital heart disease (CHD) palliated with atrial switch (ATR-S) and, more recently, with arterial switch (ART-S). As late complications from ATR-S are expected, novel challenges from ART-S surgery arises. Our aim was to evaluate these patients’ (pts) arrhythmic disturbances after a long-term follow-up. Methods We retrospectively analyzed D-TGA pts born between 1974 and 2001 and followed in Adult CHD Outpatient Clinic at a tertiary care hospital. Clinical records were used to collect pts data. Results A total of 79 pts were enrolled with a mean follow-up time after surgery of 27±6 years. Pts median age was 27 years-old and 46% were female. 54% were submitted to ATR-S, while 46% underwent ART-S; median age at intervention was 13 months and 10 days, respectively. Focusing arrhythmic events (Table 1), almost all ART-S pts remained in sinus rhythm versus 64% of ATR-S (p=0.002). The latter presented significantly higher frequencies of arrythmias (41% vs 3%, p < 0.001), mainly atrial flutter or fibrillation (26% vs 0%), as well as bradyarrhythmias (12% vs 0%). Chronotropic incompetence was also more frequent after ATR-S (46% vs 9%, p=0.011). Inversely, intraventricular (IV) conduction disturbances were more frequent after ART-S (54% vs 15%, p < 0.001), the majority due to incomplete right bundle branch block. Cardiac Implantable Electronic Devices (CIED) were implanted in 6 pts (5 pacemakers and 1 implantable cardioverter defibrillator) and 1 patient was submitted to catheter ablation of cavotricuspid isthmus, all of them from ATR-S group. The overall median time to first arrhythmia was 23±9 years. Conclusion ATR-S presented significantly fewer pts in sinus rhythm and higher rates of chronotropic incompetence, as well as need for CIED. Additionally, ATR-S pts had higher rates of arrhythmia development, namely supraventricular (SV) ones. These findings highlight the advantages of ART-S over ATR-S in reducing SV arrhythmias occurrence. Curiously, IV conduction disturbances, mainly incomplete right bundle brunch block, were more frequent after ART-S. This fact emphasizes the importance of long-term follow-up of all pts, regardless of the initial surgical approach, as ART-S pts were not arrhythmic-free. Our work raises awareness for arrhythmic disturbances in this subgroup of CHD pts, irrespective of surgical strategy adopted.Table 1

Pathophysiological features of neuroendocrine tumors in cyanotic congenital heart disease: a systematic review

Abstract Background Patients with cyanotic congenital heart disease (CCHD) have an increased risk to develop pheochromocytomas or paragangliomas (PPGL), which are rare neuroendocrine tumours molecularly driven by the activation of the hypoxia-inducible factor 2-alpha (HIF-2α ). Purpose To define the clinical characteristics of CCHD-PPGL patients. Methods An international multicentre CCHD-PPGL consortium from 8 countries was stablished. The group performed a systematic review of clinic-pathological features of 149 CCHD-PPGL cases and compared to 1559 CCHD non-PPGL patients. Results CCHD-PPGL were predominantly women (56.4%) with univentricular heart (UVH) (55.0%), followed by tetralogy of Fallot (23.5%). Most patients remained unoperated (28.6%) or had only undergone a palliative procedure (25.8%), and the mean saturation at diagnosis was 84.0%. The median age at PPGL diagnosis was 27.0 yo [20-38]. Pheochromocytoma (PCC) occurred in 36.9% of patients, abdominal or thoracic paraganglioma (TA-PGL) in 40.3%, carotid body paraganglioma (CB-PGL) in 14.7% and a combination in 8.0%. Most CB-PGLs were non-secreting, non-symptomatic tumors while PCC and TA-PGL were mostly noradrenalin-secreting and symptomatic tumors. Metastatic disease was documented in 10.3% of non-CB and none in CB-PGL . Comparing to patients with PCC or TA-PGL, CB-PGL patients were predominantly female (81.8% vs 52.0%), older at time of diagnosis (43 yo [36.0 – 52.0] vs 25.0 yo [19.0-35.0], p<0.01) and with a longer period of cyanosis at diagnosis (37.0 [23-47] vs 23.0 [13-46], p<0.01). Patients with Fontan procedure were mostly men (63.3%) who developed a noradrenalin-secreting PCC or a TA-PGL (42.0% and 58.0% respectively) at an earlier age than non-Fontan patients (22.0yo [18.0-27.0] vs 29.0yo [21.0-41.0], p<0.01). Patients with Eisenmenger physiology were female patients (100%) who developed mostly CB-PGL, non-secreting tumors (54.5%) and were older at diagnosis (48.0 yo [42-58]). Compared to a cohort of 1599 CCHD non- PPGL patients, CCHD-PPGL were predominantly women (57.7% vs 44.8%, p<0.01), with forms of UVH (53.7% in CCHD-PPGL vs 14.1% in CCHD, p <0.01 ) and were mainly unoperated and palliated patients (27.1% and 26.4% respectively vs 10.0% and 5.3% in CCHD, p <0.01). CCHD-PPGL patients showed lower levels of oxygen saturation (80.0% [76.0-85.0] vs 84.0% [80.0-88.0], p<0.01) and higher haematocrit levels (60.0% [52.0-66.5] vs 53.3% [46.3-62.0], p<0.01) than CCHD without PPGL. Conclusions Patients with CCHD and lifelong cyanosis, and especially those with Eisenmenger physiology, probably develop CB-PGL as an adaptive response to chronic systemic hypoxemia, present a good clinical course, and usually do not require an initial surgical approach. In patients with Fontan circulation, the risk of developing a sympathetic thoracic-abdominal PPGL persists, despite correction of hypoxemia, possibly due to the initial hypoxemia during adrenal medulla post-natal development.

Contrast-free left ventricular lead implantation for cardiac resynchronization therapy: a retrospective cohort study

Abstract Background Left ventricular lead (LVL) implantation can be challenging in Cardiac Resynchronization Therapy (CRT). Therefore, contrast is commonly used to visualize the coronary venous system. However, contrast use is correlated with substantial risks such as contrast-induced nephropathy and anaphylactic reaction. Case studies suggest feasibility of LVL implantation without coronary sinus (CS) venography. Purpose We aimed to compare the procedure characteristics, outcome, and safety of contrast-free and contrast-aided LVL implantation. Methods 346 LVL implantations performed between 2017 and 2019 were analyzed. 167 were contrast free (No-Contrast Group: NCG), and 179 were contrast-aided (Contrast Group: CG). The intervention duration, fluoroscopy duration, and radiation dose were evaluated. The primary outcome was procedural success. The secondary outcomes were LVL position, LVL threshold value, QRS duration and LVEF. Operative complications and lead revisions were surrogates for the intervention’s safety. Results The LVL implantation success rate varied from 62.9% in the NCG to 96.6% in the CG (Figure 1). Contrast-free interventions were associated with shorter procedure and fluoroscopy durations, and smaller radiation doses (100.8±41.0 vs 131.1±50.0min (p<0.01), 15.7±11.2 vs 26.0±17.5min (p<0.01) and 475.3±422.7 vs 897.3±779.1Gy.cm2 (p<0.01) respectively). The intraoperative LVL threshold values were equivalent (0.96±0.65 in the NCG vs 1.05±0.65V in the CG, TOST-p<0.01), and contrast use did not significantly influence the follow-up LVL threshold, QRS shortening and LVEF increase (1.11±0.55 vs 1.22±0.93V (p=0.62), -10.5±28.3 vs -13.2±26.3ms (p=0.16) and 2.3±8% vs 4.1±8.4% (p=0.40)). More intraoperative complications (CS dissection, perforation, mechanically-induced arrhythmia and other respiratory or circulatory problems) were observed during the contrast-aided procedures (9.5% in the CG versus 1.9% in the NCG, p=0.04). However, the postoperative complication rates (ICU admission, pericardial effusion, pneumothorax, infection and LVL revision) did not differ (9.5% in the NCG, 12.8% in the CG, p=0.55). In contrast-free LVL implantation failure cases, intraoperatively crossing over from the NCG to CG did not result in longer procedures or different intraprocedural complication rates (131.8±46.8 vs 131.1±50.0min in the CG (p=0.9) and 6.5% vs 9.5%, (p=0.6)). Conclusion Contrast-free LVL implantation was associated with shorter intervention and fluoroscopy durations and less radiation. Less intraoperative complications were observed without contrast, and the postoperative complication rate was similar to contrast-aided procedures. This technique was successful in almost 2/3 of the cases. In case of failure and crossover to contrast, the initial contrast free attempt did not result in more adverse events than in fully contrast-aided procedures. It is therefore reasonable to consider an initial contrast-free approach for CRT implantation.Compared groups

Exposomic Signatures of Cervical Pain.

We evaluated risk factors associated with cervical pain (CP) among officers and enlisted members of the U.S. Army and Marine Aviation community using an exposomic approach. Specifically, we aimed to determine the factors associated with reported CP. This is a retrospective cohort study that utilized the Medical Assessment and Readiness System housed at Womack Army Medical Center to evaluate the longitudinal data taken from medical and workforce resources. This study included 77,864 active duty AMAC members during October 2015-December 2019. Multivariable mixed-effects logistic regression was used to assess the relationship between the independent variables of rank, service time, deployment, Armed Forces Qualification Test score, tobacco use, alcohol use, age, gender, race, ethnicity, body mass index, marital status, and education level and the dependent variable, incidence occurrence of CP. The total analysis included 77,864 individuals with 218,180 person-years of observations. The incidence rate of CP was 18.8 per 100 person-years, with a 12% period prevalence. Cervical pain was independently associated with rank, service time, Armed Forces Qualification Test score, and alcohol use (all P < .05). Our longitudinal exposomic signatures-based approach aims to complement the outcomes of data science and analytics from Medical Assessment and Readiness System with validations of objective biochemical indicator species observed in Army and Marine Aviation community members suffering from CP. This initial approach using parallel track complementarity has the potential of substantiating the underlying mechanisms foundational to design prospective personalized algorithms that can be used as a predictive model. Finally, a specific evaluation of occupational risk factors may provide insight into factors not readily ascertained from the civilian literature.

A Guide to Expanding the Use of Buprenorphine Beyond Standard Initiations for Opioid Use Disorder.

Buprenorphine has become an important medication in the context of the ongoing opioid epidemic. However, complex pharmacologic properties and varying government regulations create barriers to its use. This narrative review is intended to facilitate buprenorphine use-including non-traditional initiation methods-by providers ranging from primary care providers to addiction specialists. This article briefly discusses the opioid epidemic and the diagnosis and treatment of opioid use disorder (OUD). We then describe the basic and complex pharmacologic properties of buprenorphine, linking these properties to their clinical implications. We guide readers through the process of initiating buprenorphine in patients using full agonist opioids. As there is no single recommended approach for buprenorphine initiation, we discuss the details, advantages, and disadvantages of the standard, low-dose, bridging-strategy, and naloxone-facilitated initiation techniques. We consider the pharmacology of, and evidence base for, buprenorphine in the treatment of pain, in both OUD and non-OUD patients. Throughout, we address the use of buprenorphine in children and adolescent patients, and we finish with considerations related to the settings of pregnancy and breastfeeding.

PREVALENCE OF OSTEOPOROSIS IN HIV-INFECTED PATIENTS INITIATING ANTI-RETROVIRAL DRUGS LIVING IN JOHANNESBURG

Low-energy fractures complications are a major public health issue that make osteoporosis even worse. In sub-Saharan Africa, the prevalence of osteoporosis varies from 18.2% to 65.8%. There was no change in bone mineral density between HIV-infected and non-HIV-infected women in Sub-Saharan Africa, where HIV is widespread. Other investigations that demonstrated that HIV-infected people had poor BMD both before and after starting anti-retroviral treatment did not consistently show a low BMD finding. Inflammation-mediated bone remodelling has been associated with low BMD in HIV-infected patients. Antiretroviral Therapy has been demonstrated to exacerbate bone loss in addition to the pre-existing intrinsic risk of developing osteoporosis.Question: Is there loss of bone in HIV-infected patients before initiating ART?The patients who were HIV-positive and enrolled in the ADVANCE research were retrospectively reviewed on a desk. All of the 1053 individuals in the ADVANCE research had a DXA scan performed to evaluate BMD as part of the initial screening and recruitment approach. The ADVANCE research enrolled HIV-positive people and randomly assigned them to three ART arms.A total of 400 patients were reviewed. Of these 400 records reviewed, 62.3% were female. 80% of the participants were younger than 40 years old, and 3% were older than 50 years. 82% were virally suppressed with less than 50 viral copies. The prevalence of osteopenia was 25.5% and osteoporosis was 2.8%, observed in predominantly African female participants aged between 30 and 39 years.The findings of this study confirm that there is pre-existing bone loss among HIV-infected ART naïve individuals. Approximately 28.3% in our study had clinically confirmed evidence of bone loss and of these, 2.8% of the entire cohort had osteoporosis. Bone loss was most prevalent in black females who are virologically suppressed.

Abstract 15645: Budget Impact Analysis of PrecisionCHD, an Artificial Intelligence Guided, Integrated Genetic-Epigenetic Test for Assessing CHD, Demonstrates Extensive Cost Savings Compared to Conventional Methods

Coronary heart disease (CHD) costs the United States healthcare system at least $216 Billion in treatment cost and $147 billion in lost productivity annually. Therefore, there is an urgent need for cost-effective solutions to reduce both the human and economic burden of CHD. Because the initial CHD diagnostic approach has a large impact on subsequent costs and healthcare outcomes, risk bearing entities are keen to determine the optimal algorithmic approach for guiding the use of CHD diagnostic tools. In order to better understand the economic and clinical impact of a newly developed Precision Epigenetic test for assessing CHD status, PrecisionCHD, we conducted a budget impact analysis comparing the use of PrecisionCHD to the use of conventional exercise ECG and coronary computed tomographic angiography (CCTA) (in a 75:25 ratio) as the initial diagnostic assessment of CHD using nationally published cost estimates, generally accepted side effects, sensitivity and specificity metrics for each test, with all positive tests resulting in the initiation of moderate to high dose statin therapy as per treatment guidelines. Our analysis showed that for an insurance plan with 1 million covered individuals, a $20 co-pay for office visits and 10% co-insurance, the use of PrecisionCHD over exercise ECG and CCTA would result in $92 million in annual cost savings with a significant portion of those savings being secondary to the inferior performance of exercise ECG. Increasing the number of CCTA test performed increases the number of CHD cases detected, but also results in greater costs including costs secondary to contrast dye induced kidney damage. We conclude that the use of PrecisionCHD for CHD detection can improve healthcare outcomes and decrease CHD related costs. Given current trends in the developments in epigenetics-based approaches, it is likely that this advantage will increase further.

Approach to diagnosis and treatment to urologic emergencies

Acute urinary retention, which is an emergency presents a significant challenge, for healthcare providers especially among elderly men. This condition often leads to dysfunction and genital pain causing distress and anxiety for those affected. The likelihood of experiencing acute urinary retention increases with age, with men in their 70s facing a 10% risk that escalates to, over 30% in their 80s. Dealing with both dysfunction and acute pain adds complexity to the clinical management of these cases. This summary highlights the role played by emergency physicians in the management of this troubling urologic emergency. The initial approach involves conducting an evaluation that includes assessing medical history performing physical examinations and conducting relevant diagnostic tests. Promptly identifying the causes, which can range from prostatic hyperplasia and urethral strictures to infections or neurogenic conditions is crucial. Pain relief is an immediate concern, prompting the administration of analgesics to alleviate patient discomfort. Concurrently, urinary catheterization, skillfully performed by the emergency physician, effectively resolves the urinary obstruction, providing substantial relief. Referral to urologists ensures a comprehensive etiological assessment and the formulation of an individualized management plan. In summary, effectively managing retention, with associated erectile dysfunction and genital pain, requires a collaborative effort between emergency physicians and urological specialists. By identifying the cause, providing skilled pain management and expertly performing urinary catheterization emergency physicians play a crucial role in relieving patient discomfort.

General Image Manipulation Detection Using Feature Engineering and a Deep Feed-Forward Neural Network

Within digital forensics, a notable emphasis is placed on the detection of the application of fundamental image-editing operators, including but not limited to median filters, average filters, contrast enhancement, resampling, and various other operations closely associated with these techniques. When conducting a historical analysis of an image that has potentially undergone various modifications in the past, it is a logical initial approach to search for alterations made by fundamental operators. This paper presents the development of a deep-learning-based system designed for the purpose of detecting fundamental manipulation operations. The research involved training a multilayer perceptron using a feature set of 36 dimensions derived from the gray-level co-occurrence matrix, gray-level run-length matrix, and normalized streak area. The system detected median filtering, mean filtering, the introduction of additive white Gaussian noise, and the application of JPEG compression in digital Images. Our system, which utilizes a multilayer perceptron trained with a 36-feature set, achieved an accuracy of 99.46% and outperformed state-of-the-art deep-learning-based solutions, which achieved an accuracy of 97.89%.

Lymphocele Complication After Kidney Transplant: Current Literature Review and Management Algorithm.

Kidney transplant is the best treatment option for patients with end-stage renal disease. It reduces mortality and improves the quality of life. However, kidney transplant presents medical and surgical complications, and one of the most common is the posttransplant lymphocele. Lymphocele complication has an incidence of up to 20% and presents with variable clinical symptoms, which are directly associated with the size and compression effect on the adjacent organs. There are reported risk factors that favor the appearance of lymphocele. Despite known factors, there are more relevant factors (male sex, deceased donor, and corticosteroids) to carry out a stricter follow-up. The treatment of lymphoceles can vary according to the severity of the symptoms, characteristics of the collection, and the patient's clinical status. Despite the high recurrence, percutaneous intervention is the initial approach in this condition. If percutaneous aspiration, drainage, and sclerotherapy are unsuccessful, then open or laparoscopic fenestration can be performed; laparoscopy is the standard of treatment since it is highly effective and has few adverse effects.

The big bang vs. phased approach: ASCO standard implementation within a large academic medical center.

419 Background: The implementation of quality improvement initiatives within a large academic medical center can present as challenging and complex. Research findings indicate that the most successful of the large service corporations maintain a strong focus on the small, functional units who carry out the core activities that involve interaction with customers. (Quinn J, Baruch J, Zien K. Innovative Explosion: Using Intellect and Software to Revolutionize Growth Strategies. New York: Free Press; 1997.) This phased approach allows a larger medical center the opportunity to target implementation around one or two sites at a time with a focus on the staff education, workflow processes, and technology integration. Our institution found that the big bang approach can pose as a threat to the success of implementation at a large academic medical center. Methods: The initial approach taken by our large academic medical center was the roll out of all required ASCO PC4 standards throughout the entire enterprise: the big bang approach. This approach would entail the implementation of 7 standards, 17 sub-standards within 15 sites and over 84 departments within the span of one year. Instead, we took the phased approach: a less burdensome, more efficient, and cost-effective strategy. Between 11/2023 1/2023, we implemented a total of 6 standards within two sites and 3 departments. In the span of three month, a multidisciplinary approach was applied, engaging all levels of employees at each site, including MDs, NPs, MAs and Front Desk Staff. The two sites identified were strategically selected based on current resources and initiative alignment with those of ASCO requirements. On 1/30/23 the two sites went live with 6 ASCO standards. Results: Some challenges in implementation included training of staff in a timely manner, influencing the change of behavior, and education retention of staff. Despite the challenges faced, between 2/6/23 and 3/24/23 data showed adequate engagement and compliance. 567 patients were identified by for patient tracking through developed reporting, 328 patients had a chart review or a follow-up from the oncology care coordinator. Between 1/30/23 and 3/24/23, 61% of patients were screened for SDOH needs with 32 referrals to a community health worker, 8 referrals to social service and 12 interventions with patients indicating self-harm. 100% of patients received education around OMH, with a total of 1,923 MyChart messages sent to patients regarding support with ACP. 68.8% of clinician completed adequate goals of care documentation to meet standard requirements and new workflow. Conclusions: A phased approach of first piloting ASCO's PC4 quality program at 2 sites within our large cancer center was successful. The experiential knowledge gained will allow more efficient role out of necessary staff education, workflow processes, and technology integration to support wider adoption across our center.

Dolor abdominal agudo médico y quirúrgico. Proceso diagnóstico y terapéutico en urgencias

Acute abdominal pain is one of the most common consultations in emergency departments. It encompasses a wide spectrum of possible diagnoses, from mild gastroenteritis to a life-threatening disease such as aortic aneurysm rupture. The vast majority of patients are discharged, considering it to be nonspecific pain. There are no pathognomonic laboratory tests, although the combination of leukocytosis with an elevated C-reactive protein (CRP) level can point to, depending on the location, a disease that requires imaging tests, such as acute appendicitis. Abdominal ultrasound is the recommended test for the initial approach and computed tomography has the greatest diagnostic resolution. Pain must be treated in all cases, whereas emergency surgery is reserved for severe diseases.

Why criteria? How inspectors make judgements

This paper argues that Ofsted's initial approach to the use of criteria encouraged a misguided view of how inspection judgements should be made and, at worst, militated against the professional discussion between inspectors and schools that should always have been at the heart of the process.