Initial Presentation Of Patients Research Articles

OCT Patterns of Macular Edema in Intermediate Uveitis

Objective. To evaluate characteristic OCT morphological characteristic of initial presentation and chronic recurrent macular edema (ME) in patients with intermediate uveitis.Materials and methods. The study included 35 patients (46 eyes) with uveitic macular edema in intermediate uveitis. The first episode of macular edema was diagnosed in 20 patients (26 eyes), 15 patients (20 eyes) present with chronic recurrent macular edema. OCT was performed on the Optovue RTVue XR Avanti. The following OCT morphological characteristic were evaluated: integrity of IS/OS line, the presence of hyperreflective foci, inner nuclear layer cysts, Henle fibers layer cysts, small single cysts, diffuse retinal thickening without cystic changes, the presence of subretinal detachment.Results. Four OCT morphological variants of uveitic macular edema were identified: diffuse macular edema, small single cysts, cysts in Henle fibers layer and the inner nuclear layer with and without subretinal detachment. In the group with diffuse macular edema, the median duration of macular edema was 3 months, macular edema with Henle fibers cysts, inner nuclear layer cysts with subretinal detachment presented after 5 months (median), small single cysts and cystic changes in the layer of Henle fibers and the inner nuclear layer were detected at later times (12 and 36 months, respectively). A strong negative correlation was found between best-corrected visual acuity and central retinal thickness in chronic recurrent uveitic macular edema (correlation coefficient — 0.7, p = 0.0001), while a moderate negative correlation was established in macular edema at initial presentation (correlation coefficient — 0.55, p = 0.0031). Integrity of IS/OS line was observed significantly more often (p = 0.002) in chronic recurrent macular edema (10 (83.3%)) than at initial presentation (2 (16.6%)). In the presence of IS/OS disruption, best-corrected visual acuity was significantly lower (p = 0.016).Conclusion. Identified four OCT morphological variants of uveitic macular edema were characterized by different periods of its duration, which may reflect different stages of macular edema evolution. Chronic recurrent macular edema and ME at initial presentation in uveitis are distinguished by different OCT predictors, which should be taken into account in assessing the effectiveness of treatment and prognosis of visual acuity.

PREBOA versus ER-REBOA impact on blood utilization and resuscitation requirements: A pilot analysis.

Partial occlusion of the aorta is a resuscitation technique designed to maximize proximal perfusion while allowing a graduated amount of distal flow to reduce the ischemic sequelae associated with complete aortic occlusion. The pREBOA-PRO catheter affords the ability to titrate perfusion as hemodynamics allows; however, the impact of this new technology for resuscitative endovascular balloon occlusion of the aorta (REBOA) on blood use and other resuscitative requirements is currently unknown. We hypothesize that patients undergoing REBOA with the pREBOA-PRO catheter will utilize partial occlusion, when appropriate, and decrease overall resuscitative requirements when compared to patients undergoing REBOA with the ER-REBOA catheter. The entire American Association for the Surgery of Trauma Aortic Occlusion for Resuscitation in Trauma and Acute Care Surgery registry was used to compare resuscitation requirements between all ER-REBOA and pREBOA. Unpaired t tests were used to compare resuscitation strategies including packed red blood cells (PRBCs), fresh frozen plasma (FFP), platelets, cryoprecipitate, crystalloids, and need for pressors. When comparing ER-REBOA (n = 800) use to pREBOA (n = 155), initial patient presentations were similar except for age (44 years vs. 40 years, p = 0.026) and rates of blunt injury (78.4% vs. 78.7% p < 0.010). Zone 1 occlusion was used less often in ER-REBOA (65.8 vs. 71.7, p = 0.046). Partial occlusion was performed in 85% of pREBOA compared with 11% in ER-REBOA ( p < 0.050). Vitals at the time of REBOA were worse in ER-REBOA and received significantly more units of PRBCs, FFP, platelets, and liters of crystalloids than pREBOA ( p < 0.05). Rates of ARDS and septic shock were lower in pREBOA ( p < 0.05). When comparing pREBOA to ER-REBOA, there has been a rise in Zone 1 and partial occlusion. In our pilot analysis of the Aortic Occlusion for Resuscitation in Trauma and Acute Care Surgery registry, there was a reduction in administration of PRBCs, FFP, platelets, and crystalloids. Although further prospective studies are required, this is the first to demonstrate an association between pREBOA, partial occlusion, and reduced blood use and resuscitative requirements. Therapeutic/Care Management; Level IV.

Fournier's Gangrene Mortality Index (FGMI): A New Scoring System for Predicting Fournier's Gangrene Mortality.

Fournier's gangrene is an aggressive, rapidly progressing, and life-threatening necrotizing fasciitis of the perineal and genital regions. Various scoring systems have been developed for predicting survival and prognosis in Fournier's gangrene. This retrospective study aimed to evaluate the effectiveness of the newly developed Fournier's gangrene mortality index (FGMI) in predicting mortality associated with Fournier's gangrene. The study included patients over the age of 18 years who were followed-up with a diagnosis of Fournier's gangrene in the general surgery clinics of three different hospitals in Şanlıurfa province between 2014 and 2024. The patients included in this study were divided into two groups: deceased (n = 20) and surviving (n = 149). In FGMI, the parameters used were age, creatinine level, albumin level, lymphocyte percentage, and neutrophil-to-lymphocyte ratio. Based on the total score and risk assessment, <5 points were categorized as low-to-moderate mortality risk and ≥5 points as high mortality risk. A total of 169 patients with a diagnosis of Fournier's gangrene were included in the study; 87 were men (51.48%). The median age of all patients was 53 (40-63) years; 20 patients (11.8%) died. The Laboratory Risk Indicator for Necrotizing Fasciitis (LRINEC) score did not show a statistically significant difference between the deceased and surviving groups (p = 0.5). Compared to the survivors, the deceased had higher neutrophil counts, neutrophil percentages, neutrophil-to-lymphocyte ratios, platelet-to-lymphocyte ratios, and C-reactive protein-to-albumin ratios, whereas lymphocyte counts, lymphocyte percentages, eosinophil counts, eosinophil percentages, monocyte counts, and monocyte percentages were lower, and these differences were statistically significant. According to receiver operating characteristic (ROC) analysis, the ROC-area under the curve for predicting mortality based on an FGMI score of ≥5 was 0.88 (95% CI: 0.80-0.95) with a sensitivity of 90% and a specificity of 70% (p < 0.001). Univariate risk analysis was performed, and the odds ratio revealed that mortality risk in patients followed-up for Fournier's gangrene with a FGMI score of ≥5 was 20 times higher (4.48-90.91) (p < 0.001). The results reveal that the FGMI score is a scoring system that can predict mortality at the initial clinical presentation of patients with Fournier's gangrene. Another important finding of the present study is that the LRINEC score was not sufficiently effective in predicting mortality.

A Comparison of Scoring Systems to Identify Patients at Increased Risk From Traumatic Rib Fractures

Patients with rib fractures from traumatic injuries may suffer increased morbidity, an increased hospital stay, an increased length of time in the intensive care unit (ICU), pulmonary complications resulting in the need for mechanical ventilation, and increased mortality. Some studies have focused on developing specific scoring systems to triage and to help identify patients most at risk for the most severe complications. One such protocol is the RibScore. At our institution, we use and modified the Pain, Inspiratory Effort, Cough score (mPIC score) to help stratify patients most likely to require ICU admission. This study compared our protocol with the previously published and validated RibScore. This was a retrospective review of patients with traumatic rib fractures presenting to our trauma center between 2018 and 2022. The primary outcomes evaluated were overall length of stay (LOS) and ICU LOS, with a secondary outcome of rates of intubation. We collected basic patient demographics, as well as data on methods to control analgesia, whether a nerve block was performed, and if the patient was mobilized. We calculated an mPIC score and a RibScore for these patients. We used an initial mPIC score of <5 to indicate the need for ICU admission. Statistical analysis was performed with a value of a P value of <0.05 deemed statistically significant. Through Cox regression analysis we found that an mPIC score <5 is associated with a doubling of both the risk to remain in ICU, and in hospital, compared to an mPIC score of≥5. The overall LOS was also significantly higher in the former (median 4d versus 6d, P=0.037). It was also associated with higher rates of intubation (14% versus 2.3%, P=0.021) and ICU admission (82% versus 51%, P=0.007). Similarly, a RibScore of 4-6 was associated with a statistically significant increase in the median overall LOS (2d; P=0.008) and ICU LOS (2d; P<0.001), as well as a statistically significant increase in the rates of intubation (14% versus 2.1%, P<0.006) and ICU admission (83% versus 51%), when compared to a RibScore of 0-3. Patients with rib fractures are at an increased risk of morbidity and mortality. The use of radiographic signs has been used to aid clinicians in accurately stratifying patients with traumatic rib fractures who are at increased risk. Here, we utilize two methods of stratifying patients, the previously described RibScore, which we used as our gold standard and our institutional mPIC score. As has been previously published, we found that a RibScore>3 is associated with significant increases in the rates of intubation. We also found an increase in overall and ICU LOS; this correlates with our mPIC score of <5. Comparing the two scores, we found a percentage agreement of 88.7%. One advantage of our mPIC score over the RibScore is its ability to be easily and rapidly scored at the bedside upon initial patient presentation and throughout the patient's stay by both physicians and nurses, triaging patients upon admission and at later times, during their stay. To our knowledge this is the first time another method of stratifying patients has been compared to the RibScore, and using the mPIC score may give the clinician an opportunity to identify patients most at risk, aiding in their disposition and management.

NIMG-02. DEVELOPING A RADIOMIC HIERARCHICAL GAUSSIAN PROCESS BOOSTING MODEL TO PREDICT PRIMARY TUMOR ORIGIN FROM MULTICENTRIC LONGITUDINAL MRI DATA OF BRAIN METASTASES

Abstract Focal neurologic deficits due to brain metastases might be the initial presentation in patients with cancer. Common approaches to investigate the occult primary malignancy include a whole-body PET-CT, whole-body MRI, studying tumor markers, or histopathological examination. Most of these modalities are expensive, time-consuming, invasive, and delay treatment. The field of radiomics leverages quantitative features extracted from images to improve the decision-making process in clinical practices. Although not easily understandable, these features are proxies for the tumor’s shape, contour, texture, and intensity patterns. They can help understand tumor heterogeneity, predict tumor behavior, and assess treatment response. We propose a robust radiomic workflow using longitudinal MRI data from 914 high-resolution imaging studies from 12 different centers (Ocaña-Tienda et al. (2023), Ramakrishnan et al. (2023), Wang et al. (2023)) to predict the origin of brain metastases from brain MRI scans. After using ensemble feature selection methods, we trained three fixed-effects and one mixed-effects multiclass classification model to account for longitudinal data. Fixed-effects logistic regression and support vector kernel models performed the worst (AUC 0.74 and 0.75, respectively), while the random forest performed better (AUC 0.97). The mixed-effects hierarchical Gaussian process boosting (GPBoost) model performed the best with an accuracy of 85.8%, precision of 85.4%, sensitivity of 85.8%, specificity of 95.7%, and an AUC of 0.98. In one-versus-rest classification, the GPBoost model identified the primary tumor as melanoma with the highest accuracy (96.1%) and non-small cell lung cancer with the lowest accuracy (89.0%). Developing such models holds great promise in reducing patient and institutional costs, improving time to effective treatment, and enhancing overall survival rates through personalized therapy approaches. In the future, we hope that incorporating newer patient data and refining the model to improve external validity would enable more accurate and generalizable predictions, leading to better clinical outcomes across diverse populations.

The Impact of COVID-19 on Cholesteatoma Diagnosis and Treatment.

This investigation aimed to examine the effects of the COVID-19 pandemic on treatment delays and the severity of initial disease presentation in cholesteatoma patients treated in the prepandemic and pandemic periods. This retrospective cohort study was of patients who underwent primary surgical management of cholesteatoma between October 2018 and December 2021, split between the prepandemic (October 2018 to February 2020) and pandemic (April 2020 to December 2021) time periods. Data collected included time from referral to otology clinic visit, time of diagnosis, and time of surgical interventions. The extent of cholesteatoma disease and surgery, hearing loss levels, and the need for additional surgical intervention were also considered. The datasets were compared using the Wilcoxon rank-sum test. Eighty-six patients met inclusion criteria, 36 of whom were treated prepandemic and 50 after March 2020. Of the examined variables, only time from diagnosis to surgery and case duration were significantly different between the two cohorts, with the pandemic cohort experiencing less time between initial diagnosis and surgery (51.4 days prepandemic vs. 38.4 days pandemic, p = 0.02) and shorter case duration (221.0 minutes prepandemic vs. 171.8 minutes pandemic, p = 0.0008). There was nodifference between the severity of presentation in the prepandemic and pandemic populations. There was no significant difference in disease severity or delays in treatment when comparing the prepandemic to the pandemic population. There was a quicker time from referral to surgery and decreased surgical times during the pandemic.

Nature and impact of symptoms at time of initial presentation for patients with glioblastoma.

In patients diagnosed with glioblastoma (GBM), minimal data exist on the pathway to presentation and the impact of symptoms on survival outcomes. This study aims to detail the symptoms that occur at time of initial presentation, the response to subsequent intervention, and the factors that predict survival in patients managed for GBM. A retrospective audit was performed from established prospective databases in patients managed consecutively with radiation therapy (RT) for GBM between 2016 and 2019. The major endpoint was median overall survival (mOS). Analysis was performed to determine associations with clinical factors including presenting symptom, performance status, tumour site and extent of resection. The level of carer support and objective perception of carer mastery was also assessed. Overall, 182 patients with GBM were eligible for analysis. The majority of patients presented directly to Emergency (52%), with the most common initial presenting symptom being personality change in 23% of patients. The primary symptoms resolved pre-operatively in 47% of patients, with 9% having worse symptoms postoperatively. The mOS was 16.5 months (95% CI: 14.5-18.5). ECOG Scores 0-1 were associated with improved mOS at both initial ECOG (P < 0.001) and ECOG at 6 months (P = 0.006). Recognised Carer Mastery (P = 0.007) but not presence of carer (P = 0.35) was associated with improved mOS. In patients with GBM initial presenting symptoms, level of performance status and role of carer influence clinical outcomes and survival. These findings can assist to guide clinicians and supportive care services to optimise future patient care.

Does Area Deprivation Index Predict Worse Initial Preoperative Patient-Reported Outcomes in Patients Who Underwent Microfracture for Osteochondral Lesions of the Talus?

Category: Ankle; Arthroscopy Introduction/Purpose: The relationship between socio-economic factors and health outcomes is of considerable interest. Social deprivation can be defined as lack of access to resources and opportunities considered essential for modern living. Several studies have investigated the impact of social deprivation on surgical outcomes. Patients who experience more social deprivation may have an initial presentation that is objectively worse compared to patients with a higher socioeconomic status. For example, socially deprived scoliosis patients may initially present with larger Cobb angles. Limited literature on the impact of social deprivation on initial presentation of patients who require surgical intervention for an osteochondral lesion (OCL) of the talus exists. This study aimed to investigate the association between social deprivation and preoperative patient-reported outcomes. Methods: Institutional review board approval was obtained (IRB 20020136). An institution-based registry was created with foot and ankle patient data from three surgeons that were prospectively collected and retrospectively analyzed. The database was queried for patients who underwent talar dome OCL microfracture and completed preoperative Foot and Ankle Ability Measure Activities of Daily Living (FAAM ADL) questionnaires between September 2013 and February 2024. Home addresses were used to determine Area Deprivation Index (ADI) state and national levels to capture social deprivation. Inclusion criteria were patients with an OCL diagnosed with advanced imaging and patients with completed preoperative FAAM ADL scores. Patients with prior ipsilateral foot or ankle surgeries or no recorded home address were excluded. Linear regression and correlation analyses were performed to investigate the relationship between ADI and preoperative FAAM ADL scores. Secondary analyses on the impact of ADI on other clinical variables were performed. Results: Sixty patients met inclusion criteria. The mean age was 32.5±15.2 years with a mean body mass index (BMI) of 29.8±7.58, evenly split between sexes. The mean preoperative FAAM ADL score as 62.4±23.5. Differences between female and male preoperative FAAM ADL scores reached significance (55.7 vs. 69.2, p = 0.026). The regression coefficient for ADI and preoperative FAAM ADL scores at the national (adjusted R2 = 0.005, p = 0.262) and state (adjusted R2 = 0.017, p = 0.160) levels failed to reach significance. Mean national ADI was 53.4±26.2 and state ADI was 4.97±2.87. Correlation analysis of other clinical variables studied, such as OCL size (p = 0.668) and BMI (p = 0.1316), did not demonstrate a statistically significant correlation with ADI. Conclusion: These findings contribute to the data regarding the interplay between socio-economic factors and health outcomes, particularly in the context of patients who underwent microfracture for a talus OCL. Larger sample sizes and including patients who opted for nonoperative treatment should be explored.

Racial discrepancies in initial presentation and diagnosis of patients with endometrial cancer.

89 Background: Endometrial cancer incidence and mortality are increasing, particularly in Black patients who have more aggressive non-endometrioid subtypes. Racial disparities in mortality may be partially contributable to early clinical factors including recognition of symptoms, type of evaluation, and referral timing. We evaluated differences in factors related to symptom appraisal and delays in diagnosis by race and histology. Methods: In this retrospective cohort study, we included patients diagnosed with endometrial cancer from 01/01/2019 to 09/01/2023 at a single institution who were enrolled in the Discovery and Evaluation of Testing for Endometrial Cancer in Tampons (DETECT) study. Demographic characteristics and factors regarding initial presentation and workup were obtained from the electronic medical record. We evaluated patient-reported length and type of symptoms at initial presentation, diagnostic imaging type, and time from initial presentation to time of imaging, tissue sampling, and referral to gynecologic oncology. We assessed differences by race and histology (endometrioid vs. non-endometroid) using chi-square and Kruskal-Wallis tests and analysis of variance. Results: Of the 335 patients included in our analysis, 237 (70.7%) had endometrioid and 98 (29.3%) had non-endometrioid histology. Patients with endometrioid histology were significantly more likely to be younger, White, non-smokers, and have higher obesity levels by body mass index than those with non-endometrioid histology (p=&lt;0.01). The length of symptoms at time of initial presentation was significantly longer in Black patients overall (p=0.01) and in Black patients with endometrioid histology compared to their White counterparts (p=0.04). A similar trend was seen in patients with non-endometrioid histology but was not statistically significant (p=0.15). There was no difference in type of symptoms reported. The type of imaging (p=0.005) differed significantly between endometrioid and non-endometrioid groups. White patients were more likely to have a transvaginal ultrasound performed at initial presentation (p=0.004). Black patients with endometrioid endometrial cancer were more likely to have a longer time period from initial presentation to referral to gynecologic oncology (p=0.04) despite having a shorter time between initial presentation and endometrial sampling (p=0.04). Conclusions: In our cohort, Black patients with endometrial cancer were more likely to have experienced symptoms for a longer time period prior to presentation, less likely to be evaluated with transvaginal ultrasound, and had a longer time period between initial presentation and referral to gynecologic oncology compared to White patients. Raising awareness and targeting these early steps in evaluation and detection of endometrial cancer may help decrease racial disparities in outcomes.

Sex differences in clinical presentation, treatment response, and side effects of nutritional therapy among patients at nutritional risk: a secondary analysis of the randomized clinical trial EFFORT

Considering sex-specific factors has become an increasingly recognized area for research and practice, in the field of clinical nutrition, there is insufficient evidence regarding differences in clinical presentation, treatment response, and side effects of nutritional therapy among female and male patients. We hypothesized that the clinical presentation, response to nutritional therapy, and side effects from the intervention would differ in the two sexes. This secondary analysis investigated differences among female and male patients at risk for malnutrition regarding initial presentation, clinical outcomes, and treatment response in patients included in the Effect of Early Nutritional Support on Frailty, Functional Outcomes, and Recovery of Malnourished Medical Inpatients Trial (EFFORT), a randomized controlled trial comparing individualized nutritional support to usual care. Of 2028 patients included in the trial, 964 were females and 1064 were males. The nutritional history and clinical presentation of female patients was different: they consumed less food and had a greater loss of appetite than the male population. Male patients had higher risk for mortality at 180 d [27% compared with 19%; adjusted hazards ratio (HR): 1.35; 95% CI: 1.12, 1.63] and further adverse clinical outcomes. However, there was no difference in the effect of nutritional support on mortality among female and male patients (HR: 0.76; 95% CI: 0.45, 1.27, compared with HR: 0.81; 95% CI: 0.54, 1.21, respectively; P-interaction = 0.939). Results of this multicenter randomized trial suggest that multimorbid female inpatients have a different clinical presentation and are more prone to loss of appetite and reduced daily dietary intake than male inpatients. Importantly, the favorable response to nutritional interventions was similar in both sexes. This trial was registered at clinicaltrials.gov as NCT02517476.

Prevalence and severity of depression and anxiety in infertile female patients attending an academic hospital in central South Africa

Background. Infertility has an incidence of 15 - 20% in South Africa (SA). It may lead to the development of psychological disorders such as anxiety and depression. Objective. To determine the prevalence of depression and anxiety among infertile women attending the Infertility Clinic at a tertiary hospital in central SA. Methods. In this prospective analytic cross-sectional study, information captured included sociodemographic variables such as age, employment status, type and duration of infertility, marital status, type of marriage and education level. The Patient Health Questionnaire-9 (PHQ-9) and the Generalized Anxiety Disorder-7 (GAD-7) test were used to screen for depression and anxiety, respectively.Results. In total, 100 of 108 infertile women completed all the questionnaires correctly. Forty-two (42.0%) of the patients were &gt;35 years and 58.0% were married, with five (8.6%) being in a polygamous marriage. Fifty-three (53.0%) women had never been pregnant before. The prevalence of depression was 53.0%, with 45.0% of these patients showing moderate to moderately severe levels of depression. The level of education was significantly associated with depression (p&lt;0.025). Half of the participants (50.0%) screened positive for anxiety, with 12 (24.0%) having severe anxiety. In total, 40.0% of the participants screened positive for both anxiety and depression. No statistically significant association was observed between depression or anxiety and age, duration of infertility, marital status and employment status. Conclusions. Depression and anxiety disorders are common and often underdiagnosed in women undergoing infertility treatment. Practitioners should screen for these conditions at the initial patient presentation and refer patients for psychological support.

Initial Clinical Presentation of Systematic Lupus Erythematosus (SLE) Patients in Cipto Mangunkusumo Hospital

Background. Systemic Lupus Erythematosus (SLE) is a systemic autoimmune disease characterized by highly diverse and nonspecific symptoms with clinical presentations involving more than one organ system which often leads to delayed diagnosis and poor prognosis. This study aims to understand patients’ initial clinical presentation in order to enhance early detection and establish an early diagnosis. Methods. This descriptive cross-sectional quantitative study included patients who commenced their visits to the Rheumatology Clinic at RSCM from May 2021-December 2022. A consecutive sampling method was used, and data were analyzed for age, gender, symptom onset, as well as patients' initial clinical presentations (SPSS 25.0). Results. Out of 231 subjects, 96.1% were females. A total of 38.1% of the patients belonged to the 21-30 age group, and symptom onset was most commonly observed in the 0-1 year age group, accounting for 67.5%. Approximately 24.2% of the patients exhibited constitutional manifestations with involvement of other organs, including musculoskeletal (87.4%), mucocutaneous (84%), hematologic (3.,5%), renal (33.3%), and neuropsychiatric (8.7%) systems. Lungs, heart, blood vessels, gastrointestinal and hepatic systems, eyes, obstetric, and endocrine involvements were not found in this study. Among the 231 subjects, 44.2% of them had simultaneous involvement of two organs, which emerged as their initial clinical presentation. Conclusion. Musculoskeletal and mucocutaneous involvement were most commonly observed as the initial clinical presentation of SLE patients at RSCM, followed by hematologic, renal, and neuropsychiatric involvement.

Optical coherence tomography features in vitreoretinal lymphoma compared with non-infectious uveitis

BackgroundVitreoretinal lymphoma (VRL) is a rare intraocular malignancy that poses a diagnostic challenge due to the non-specific clinical presentation that resembles uveitis. The use of spectral domain optical coherence tomography (SD-OCT) has emerged as a valuable imaging tool to characterize VRL. Therefore, we sought to determine the specific OCT features in VRL compared to the uveitides.MethodsRetrospective chart review of patients who were seen at Mayo Clinic from January 1, 2010 through December 31, 2022.The medical records and SD-OCT images at time of initial presentation were reviewed in patients with biopsy-proven VRL, intermediate uveitis, or biopsy-confirmed sarcoid posterior uveitis. Patients with VRL or similar uveitides including intermediate uveitis or sarcoid posterior uveitis were included.ResultsThere were 95 eyes of 56 patients in the VRL group and 86 eyes of 45 patients in the uveitis group, of whom 15 (33.3%) were diagnosed with intermediate uveitis and 30 (66.7%) with sarcoid chorioretinitis. The SD-OCT features more commonly seen at initial presentation in VRL patients (vs. uveitis) included preretinal deposits (31.6% vs. 9.3%, p = 0.002), intraretinal infiltrates (34% vs. 3.5%, p < 0.001), inner retinal hyperreflective spots (15.8% vs. 0%, p < 0.001), outer retinal atrophy (22.1% vs. 2.3%, p < 0.001), subretinal focal deposits (21.1% vs. 4.7%, p = 0.001), retinal pigmented epithelium (RPE) changes (49.5% vs. 3.5%, p < 0.001), and sub-RPE deposits (34.7% vs. 0%, p < 0.001). Features more frequently seen in uveitis included epiretinal membrane (ERM) (82.6% vs. 44.2%, p < 0.001), central macular thickening (95.3% vs. 51.6%, p < 0.001), cystoid macular edema (36% vs. 11.7%, p < 0.001), subretinal fluid (16.3% vs 6.4%, p = 0.04), and subfoveal fluid (16.3% vs. 3.2%, p = 0.003). Multivariate regression analysis controlling for age and sex showed absence of ERM (OR 0.14 [0.04,0.41], p < 0.001) and absence of central macular thickening (OR 0.03 [0,0.15], p = 0.02) were associated with VRL as opposed to uveitis.ConclusionOCT features most predictive of VRL (vs. uveitis) included absence of ERM and central macular thickening.

Improving LDCT screening rates within a large multidisciplinary community based practice using integrated ACR accredited imaging centers.

e13582 Background: Lung cancer remains the leading cause of cancer-related death in the US, accounting for about 22% of such deaths. Lung cancer detected by low-dose computed tomography (LDCT) screening is discovered at an early stage 64-85% of the time. The benefits of LDCT screening have been demonstrated in numerous trials, but there has been difficulty in establishing programs that screen a high percentage of eligible patients. We present data from the first 18 months of our lung cancer screening program that is designed to provide the highest quality screening, follow-up and access to prevention, diagnosis, and treatment including clinical trials within their local communities. Methods: New York Cancer and Blood Specialists (NYCBS) is a community practice with over 50 locations across NY. While most lung cancer screening programs are hospital-based, NYCBS has a series of American College of Radiology (ACR) accredited imaging centers that perform these screenings and are closely affiliated with oncology, primary care, Ob-Gyn, nephrology, urology and other specialty medical and surgical practices. These centers are strategically located in areas that have high rates of tobacco use as suggested by heat map data from the NY City Community Health Survey . Upon initial patient presentation, all NYCBS and affiliated sites screen patients with tablet-based questionnaires that prompt additional questions during follow-up appointments. Patients with positive findings are discussed during a monthly, system-wide multidisciplinary lung nodule review conference. Follow-up interventions include referrals to pulmonology, interventional radiology, or further imaging with PET/CT. Per ACR guidelines, patients not requiring acute intervention continue with follow-up CT. Results: In 2023, 29,501 patients were screened with an in-office questionnaire. Of those patients, 3,606 were eligible for screening, 225 declined, and 896 (29%) high risk patients proceeded to undergo LDCT screening. In screened patients, 128 underwent follow-up CT, 36 patients had findings requiring immediate intervention, and 6 were diagnosed with lung cancer. 5 of these patients were diagnosed with stage I and 1 patient was diagnosed with stage IV lung cancer. Conclusions: LDCT screening is a proven method to discover early stage lung cancer and improve the survival rate of diagnosed patients but has not been well adopted in practice. With access to a diverse array of multidisciplinary practices across NY and integrated accredited imaging centers, we have increased the accessibility of lung cancer screening and improved transitions to follow-up care. Nationally, only 4.5% of patients at high risk are screened, however, we found that with our approach to patient care, we have achieved among the highest reported screening rates in eligible individuals.

Does Elective Admission vs. Emergency Department Presentation Affect Surgical Outcomes in Metastatic Spine Surgery?

Approximately 20% of patients with metastatic spine disease develop symptomatic spinal cord compression, and these patients can present urgently to the emergency department (ED) or, in a more organized fashion, to a clinic. In a cohort of patients undergoing metastatic spine surgery, we sought to (1) determine the rate of ED presentation, (2) identify preoperative and perioperative risk factors associated with ED presentation, and (3) evaluate whether ED vs. clinic presentation impacts long-term outcomes. A single-institution, multi-surgeon, retrospective cohort study was undertaken of patients undergoing metastatic spinal tumor surgery between 02/2010 and 01/2021. The primary exposure variable was presentation setting, dichotomized to the ED vs. clinic. The primary outcomes were postoperative functional status, measured with the Karnofsky Performance Scale (KPS) and McCormick Scale (MMS), local recurrence (LR), and overall survival (OS). Secondary outcomes included complications and readmissions. A total of 311 patients underwent metastatic spine surgery (51.7% ED vs. 48.3% clinic). Those presenting to the ED had higher rates of smoking (21.7% vs. 16.0%, p = 0.02), were more likely to have 2+ comorbidities (47.2% vs. 32.7%, p = 0.011), and were more likely to have public insurance (43.5% vs. 32.0%, p = 0.043). Preoperative KPS was lower in ED patients (p < 0.001), while the Bilsky score was higher (p = 0.049). ED patients had higher rates of oligometastatic disease (p = 0.049), higher total decompressed levels (p = 0.041), and higher rates of costotransversectomy (p = 0.031) compared to clinic patients. Length of stay was significantly longer for ED patients (7.7 ± 6.1 vs. 6.1 ± 5.8 days, p = 0.020), and they were less likely to be discharged home (52.2% vs. 69.3%, p = 0.025). ED presentation was significantly associated with shorter overall survival (HR =1.53 95% CI = 1.13-2.08, p = 0.006). Of patients undergoing metastatic spine disease, approximately half presented through the ED vs. clinic. ED patients had higher rates of smoking, public insurance, and higher Bilsky score. ED patients also underwent more extensive surgery, had longer LOS, were less likely discharged home, and most importantly, had a shorter overall survival. These results suggest that initial presentation for patients undergoing surgery for metastatic spine disease significantly impacts outcomes, and signs/symptoms of metastatic spine disease should be recognized as soon as possible to prevent ED presentation.

ACUTE EXUDATIVE POLYMORPHOUS VITELLIFORM MACULOPATHY AS THE INITIAL PRESENTATION OF HUMAN IMMUNODEFICIENCY VIRUS INFECTION.

To describe the occurrence of acute exudative polymorphous vitelliform maculopathy as the initial presentation in a HIV-positive patient. Observational case report of one patient and literature review. An active 21-year-old white woman presented to the emergency department with anterior segment complaints. Her best-corrected visual acuity was 20/20 in both eyes. Fundus examination revealed numerous, polymorphous, bleb-like lesions at the posterior pole, corresponding, on structural imaging (optical coherence tomography) to subretinal detachments. The bleb-like lesions on infrared imaging were slightly autofluorescent on fundus autofluorescence. Swept-source optical coherence tomography angiography showed signal attenuation because of the presence of subretinal fluid in the choriocapillaris segmentation. Multimodal imaging findings were suggestive for acute exudative polymorphous vitelliform maculopathy. Hence, a systemic blood workup was performed. The workup returned positive for HIV, and an antiviral therapy was introduced. The fortuitous diagnosis of HIV having as the initial presentation acute exudative polymorphous vitelliform maculopathy in an asymptomatic patient highlights the value of a thorough clinical examination and multimodal imaging in correctly diagnosing this rare disorder and its cause. This case report could prove helpful to clinicians faced with this rare scenario.

The Effect of Radial Inclination on the Stage of Kienbock Disease at the Time of Initial Diagnosis.

Negative ulnar variance is a widely accepted risk factor for the development of Kienbock disease (KD). Variation in radial inclination has been proposed as a risk factor, but evidence thus far has been inconclusive. We aim to clarify the relationship between radial inclination and KD. A retrospective analysis of all KD patients from a single institution from 2007 to 2021 was conducted. Radiographs were reviewed to measure anatomic parameters and stage of disease. An exploratory multinomial regression model was created to examine the association of patient age, radial height, ulnar variance, radial inclination, volar tilt, scapholunate angle, duration of symptoms prior to evaluation, history of wrist trauma, and diagnosis of diabetes with stage of disease. Fifty-seven cases of KD were identified, with a mean duration of disease of 33.3 months. A history of trauma to the wrist was common (53%) and significantly associated with stage of disease at initial presentation. Twenty-seven cases (47%) were stage IIIB or greater. The average initial radial inclination, radial height, and ulnar variance was 21.9°, 10.7 mm, and -1.23 mm, respectively. A multinominal logistic regression model revealed decreased initial radial inclination is associated with Lichtman stage IIIB or greater at the time of initial patient presentation. A correlation exists between decreased radial inclination and more advanced KD at presentation, suggesting this may be a risk factor for disease progression. This correlation is strengthened by our finding of decreased ulnar variance being associated with later stage at presentation, which is one of the most widely accepted proposed risk factors for development and progression of disease. IV.

Initial Presentation of SLE among the Different South African Ethnic Groups

Background: Systemic lupus erythematosus (SLE) is a chronic, immune-mediated, inflammatory multi-organ disease. It is characterized by a variety of clinical features including abnormalities of the joints, skin, kidneys, lungs, heart, blood and brain. In addition to gender, genetic, environmental, hormonal and chemical factors appear to play a role in disease activity. Previous studies in South Africa have shown an increasing trend of new diagnoses of SLE patients, with increasing target organ damage but there is an obvious distinction between different organs in terms of incidence. The primary aim of this study was to identify the major initial presentation of SLE patients among the three main South African ethnic groups: Black, Mixed ethnicity, and White. Material and Methods: This was a retrospective descriptive and analytic study in which patients with SLE were compared among the three ethnic groups in South Africa. Data was obtained from patient’s records contained in the Enterprise Content Management System (ECM) and medical records. Results: A total of 198 patients were seen in the Rheumatology Division with SLE between March 1993 and November 1999. The study showed that the most affected group was the mixed ethnicity population (81.4%), followed by the black African group (11.6%), then the white group (7%). Arthritis was the most frequent disorders among the three-different ethnic groups. However, there appear to be some differences in the autoantibody profile.&#x0D; Conclusion:This study focused on the initial presenting symptoms. A long-term cohort on the development of the disease may yield further results on possible ethnic differences, and continued research into susceptibility loci and phenotypic associations in enriched multi-ethnic cohorts and looking for the causes of death among the three ethnic groups and related to the first presentation is suggested.

Do Race and Socioeconomic Status Affect Date of Initial Presentation and Repair of Patients with Cleft lip ± Palate and Head Shape Conditions?

ObjectiveTo evaluate regarding the effect of race and socioeconomic status (SES) on the timing of cleft lip and/or palate (CL ± P), craniosynostosis, and plagiocephaly presentation to clinic and possible repair.Design/MethodsA retrospective review of patients with CL ± P and head shape conditions from Jan 2001 to Feb 2022 were included. Age at first plastic surgery clinic appointment, age at repair if applicable, gender, race, and zip code were collected. The Validated Child Opportunity Index (COI) scale was calculated based on zip code as a measure of SES. Kruskal-Wallis tests and Dunn's procedures were used for continuous variables and post hoc pairwise comparisons.Results2733 patients with CL ± P, 9974 with plagiocephaly/brachycephaly, and 59 patients with craniosynostosis were included. Among patients with CL ± P, Black and Hispanic patients presented significantly later to both first plastic surgery clinic appointment and age at repair than White patients ( P &lt; .001). White patients and higher SES were associated with a significantly earlier date of initial presentation to plastic surgery clinic for head shape conditions ( P &lt; .001).ConclusionsRace and SES may play an important role in the delay of first presentation to plastic surgery clinic and subsequent repair for these patient populations. Further educational efforts must be provided to ensure equitable care. This single institutional study may serve to encourage other academic centers to analyze the timing of care for our pediatric patients.

Abstract 327: Implementation of Bronchoalveolar Lavages as a Quality Improvement Initiative in Out-of-Hospital Cardiac Arrest Patients

Patients who suffer OHCA are at risk for early onset pneumonia due to loss of airway protection, emergency airway access and intubation, CPR, mechanical ventilation, among other complications. It is difficult to accurately diagnose early onset pneumonia post OHCA due to multi-organ dysfunction post arrest and radiography findings confounded by non-infectious inflammation from CPR and aspiration. As a result, a substantial number of patients receive empiric antibiotics. A bronchoalveolar lavage (BAL) can screen for the presence of bacteria in the lungs and aid in identifying the incidence of early onset pneumonia after OHCA. We implemented a quality improvement (QI) initiative to collect a BAL on initial patient presentation to our hospital in May 2018. We conducted an observational, retrospective study to assess the impact of BAL implementation on empiric antibiotic prescribing. We used a rigorous study definition of pneumonia requiring at least two of the following positive within the same 24-hour period: BAL, chest radiography, and/or a fever &gt;38°C. We compared rates of antibiotic prescription in the first 7 days of hospitalization for patients receiving a BAL to those without, as well as rates of antibiotic prescriptions before and after implementation of the BAL QI initiative. Implementation of initial BAL collection was successful and resulted in a 66% increase of BALs (from 44 to 73 BALs) collected compared to an average from the prior 2 years. We hypothesized rates of antibiotic prescription would decrease post-implementation of BAL collection; however, there was no statistically significant change in rate of antibiotic prescription (Figure 1) over the initial 7-day hospitalization period X 2 ( Df = 1, N = 3247) = 0.68, p = 0.54. Over 80% of patients with pneumonia received antibiotics, roughly 60% of OHCA patients received antibiotics despite no pneumonia diagnosis by any definition. Further study is needed to alter these practices and reduce antibiotic overuse.