Jackson Memorial Hospital Research Articles

Abstract 4144502: Comparing Readmission Rates and Exercise Capacity Following Left Ventricular Assistive Device Placement With and Without Post-Operative Inpatient Rehabilitation

Introduction: Patients with heart failure may undergo mechanical assistive device placement as a bridge to heart transplantation or for destination therapy. Thereafter, patients may be discharged home or admitted to inpatient rehabilitation. Research Question: We hypothesized that within 8 months, patients admitted to inpatient rehabilitation (IR) would have fewer readmissions and greater exercise capacity compared to patients discharged home following left ventricular assistive device (LVAD) placement. Aim: The readmission rates and exercise capacity of patients admitted to (IR) were compared to those discharged home within 8 months of (LVAD) placement. Methods: Readmission rates, impairment percentages (IP) (determined by Activity Measure for Post-Acute Care scores) and walking distance after (LVAD) placement between March 1 st , 2020 to November 30 th , 2022 were collected via retrospective chart review at Jackson Memorial Hospital. Adults with heart failure and heart assistive device (ICD10 code Z95.811), discharged home or admitted to the Christine E. Lynn Rehabilitation Center for at least 7 consecutive days within 8 months were included. Patients who were noncompliant, expired, transferred, or unable to ambulate were excluded. 24 patients were admitted to rehab, and 16 were discharged home. Statistical significance was denoted at the 0.05 level using the Mann-Whitney U Test. Results: There was a higher proportion of females in the rehab group (45.8%) and males in the no rehab group (93.8%) (p=0.02). The groups were otherwise comparable. Average (IP) at hospital discharge was higher for the rehab group (51.79%, SD 17.65) compared to the no rehab group (14.20%, SD 18.93) (p<.001). Average post-(LVAD) walking distance (feet) at hospital discharge was higher for the no rehab group (305, SD 206.72) compared to the rehab group (127.73, SD 132.11) (p=0.005). Within 8 months, there was no significant difference between groups. Average readmissions were higher for the no rehab group (1.375, SD 0.957) compared to the rehab group (0.958, SD 1.49) (p= 0.059), but was not statistically significant. Conclusions: Patients with greater (IP) and shorter walking distances were admitted to rehab and became functionally comparable to the no rehab group by 8 months. Though readmission rates were lower for the rehab group, this was not statistically significant. Additional studies are warranted to evaluate the impact of (IR) following (LVAD) placement.

Evaluating the potential role of determinants of health on encephalocele patient outcomes - a combined retrospective study and systematic review.

To evaluate the outcomes and demographics of encephalocele patients who were born and received treatment in our neonatal ICU and conduct a PRISMA literature review. An Institutional Review Board (IRB)-approved retrospective cohort study was undertaken to investigate the results of treating encephalocele patients at Jackson Memorial Hospital (JMH) from 1998 to 2022. The study focused on assessing outcomes and the impact of maternal socioeconomic factors, such as religion, age, and education, along with the timing of diagnosis, in connection with a systematic review. A total of 20 encephalocele patients were identified (13 females and 7 males), with 15 having available medical records for review. Most of these cases involved occipital encephaloceles (73.3%). Maternal ages at the time of delivery ranged from 15 to 42years, with a mean age of 27.3years. The average gestational age at birth was 37weeks. Ten cases had a prenatal diagnosis documented, occurring between 12 and 24.5weeks of gestation. Three of the surviving patients had records of prenatal counseling that included discussions about termination. No infections were reported. Among the 15 cases, 11 patients (73.3%) were alive at the last follow-up, with a mean age at follow-up of 4.12years, ranging from 6weeks to 15years post-birth. Hydrocephalus was noted in 26.7%. Only 1 mother had completed high school. Most mothers were either on Medicaid (9 patients) or uninsured (3 patients), with only 3 having commercial insurance. Religious affiliations varied among the mothers, with 14 out of 15 identifying with a particular religion. The systematic review identified 22 articles from various countries, with 11 articles meeting the inclusion criteria for qualitative analysis. These articles revealed potential maternal risk factors for encephaloceles, including low-nutrient diets, inadequate folic acid intake, young maternal age, advanced maternal age, low socioeconomic status, and limited educational attainment. In the twenty-first century, there is a positive trend in the survival rates of children born with encephalocele. However, maternal factors such as low socioeconomic status and limited educational attainment remain prominent, affecting their ability to access timely prenatal care and impacting follow-up medical care for these children.

Management of Acquired Hemophilia: A Real-World Experience, 2007-2023

Introduction.Acquired hemophilia A (AH) is a rare, potentially life-threatening, bleeding disorder caused by the development of autoantibodies directed against coagulation factor VIII (FVIII). Incidence is 1-1.5 per million people per year with a morality rate as high as 22% and is especially dangerous in the elderly. Since autoantibodies rarely resolve spontaneously, initial management involves controlling acute bleeding episodes, and immunosuppressive treatment (IST) to eradicate the autoantibodies to restore hemostasis. There are no evidence-based guidelines for the management of AH and treatment decisions rely on the clinical judgement and expertise of the treating provider, which impacts overall health outcomes. There is a dearth of prospective, controlled clinical trials to guide management of AH and much of the reported data come from observational studies and extrapolation from studies on patients with congenital hemophilia complicated by inhibitors. Methods.Retrospective chart review of AH patients treated by a single provider at Jackson Memorial Hospital from 2007 through May 2023 utilizing in-house medical record systems and supplemental external health records from transferring facilities. Partial remission (PR) was defined as FVIII activity >50 IU/dL and no active bleeding after stopping hemostatic drugs >24 hours. Complete remission (CR) was defined as PR plus negative inhibitor, prednisone tapered to <15 mg/day, and cessation of other IST. Results.We identified 17 patients with first episode of AH with laboratory evidence of acquired FVIII inhibitor (aFVIIIi) (see Table 1). The majority were male (76%), Hispanic (53%) and White (88%). The median age at diagnosis was 72 (range 31-88). While 65% of cases were idiopathic, other associated conditions included malignancy and trauma. The median aFVIIIi was 23.2 BU/mL (range 2.2-400) and median FVIII activity was 1% (range 0-12) at presentation. The most common presenting symptom was hematoma (59%) followed by mucocutaneous bleeding (41%). Hematuria was also seen frequently and initially attributed to another cause. To control bleeding, 47% received activated prothrombin complex concentrate (aPCC), 17% received recombinant factor VIIa, and 12% received emicizumab. Emicizumab was initiated at an outside facility lacking bypassing agents for one patient, while the other had bleeding with neutropenic sepsis. All patients received IST with glucocorticoids; cyclophosphamide was used in 82%, rituximab in 41%, and IVIG in 12%. For patients with appropriate follow-up (median follow-up 707 days), 7/9 (78%) achieved a CR to IST and 2/9 (22%) developed PR. The median time to PR was 41 days and median time to CR was 168 days in patients who achieved those respective responses. Five patients (29%) responses were not assessable due to lack of appropriate follow-up. Three patients (17%) had a clinically evident relapse requiring retreatment at 617, 730, and 1427 days after initial response. Ultimately, three patients (17%) died or were discharged to hospice within a median of 8 days, but only one death was directly related to bleeding (which was prior to receiving any appropriate hemostatic agents). Discussion.We report a single-provider experience on patients treated for AH, with focus on acute management and CR due to its impact on health outcomes. Our experience confirms the importance of initiating IST early in diagnosis and tapering as FVIII levels recover, finding the lowest effective dose to eradicate the inhibitor. It should be noted that bypassing agents are not always required if bleeding is not significant. While no one who received hemostatic agents died of hemorrhage, several patients required dozens of doses of these expensive medications. Recent reports using emicizumab off-label for AH suggest effective hemostasis in the acute phase, which was successful in two patients described here. Monitoring the response to emicizumab is more challenging due to lab interference with PTT and single-stage factor assays, and therefore requires bovine assays that are costly, untimely, and not widely available. A large proportion of patients referred from outside lacked appropriate follow-up after initial diagnosis for acute management. For optimal long-term outcomes, patients with AH should have ongoing follow up with periodic lab monitoring as relapses may occur several years after initial response in 17% or more of patients.

(126) Long-term Functional Outcomes for Men with Priapism Secondary to Recreational Use of Intracavernosal Injectables: A Multi-center Follo- up Study

Abstract Introduction Ischemic priapism is a urologic emergency which results in permanent erectile dysfunction if not managed immediately. There is a dearth of studies evaluating long term erectile function after episodes or treatment for priapism. Objective We evaluated the functional outcomes of a larger, multi-institutional population of men with priapism due to recreational use of ICIs. Methods Men who presented with ischemic priapism due to recreational use of ICIs to Cedars-Sinai Medical Center (Los Angeles, CA), University of California at San Francisco (San Francisco, CA), and Jackson Memorial Hospital (Miami, FL) from January 2010 to December 2018 were contacted via telephone. All participants completed the five-item international index of erectile function (IIEF-5). Results A total of 19 men aged 24 – 59 (mean 47.9) were recruited from the 3 sites. Mean follow up was 77.2 months (+/− 27.6). 17 men (89%) were white; the one man was Asian (5.5%) and one man was Hispanic (5.5%). Seven men (37%) had been diagnosed with ED prior to their priapism episode however none of the men had a prescription for ICIs. Four men (21%) required no intervention at all, eleven men (58%) required phenylephrine irrigation alone, four men (21%) required distal shunting. No men required proximal shunting. None of the men had no ED, 31.6% had mild ED, 36.8% had mild-moderate ED, 26.3% had moderate ED, and 5.3% had severe ED. Mean IIEF-5 for the population was 13.4 (+/− 3.9). Strengths of our study included the large population size give the relative rarity of this condition as well as the geographic diversity of our population. Limitations include our low overall recruitment rate and lack of objective measures of erectile function prior to priapism. Conclusions Men who suffer ischemic priapism secondary to recreational use of ICIs appear to retain some erectile function following their priapism episode. Nevertheless, 100% report some level of ED. This is likely due a combination of adequate erectile function at baseline and expeditious treatment of priapism in a minimally invasive manner. Disclosure No

Abstract 2824: Metabolomics in radiotherapy-induced early adverse skin reactions in breast cancer patients

Abstract Background: Early adverse skin reactions (EASRs) are common side effects of postoperative adjuvant radiotherapy (RT) that significantly impact the quality of life (QOL) of breast cancer patients. This study used global metabolomics profiles of breast cancer populations to identify metabolic pathways and biomarkers that are significantly associated with RT-induced EASRs to identify potential targets for precision interventions. Methods: Using a frequency-matched study design, pre-RT urine samples from 60 female breast cancer patients receiving RT after breast-conserving surgery were metabolically profiled. Patients were recruited from the University of Miami Sylvester Comprehensive Cancer Center and Jackson Memorial Hospital. Using MetaboAnalyst 3.0, we performed metabolomic data analysis, visualization, and interpretation on 84 candidate metabolites from a dataset of 478 total compounds. Student’s t-tests, correlation analyses, pathway enrichment, and topology analyses were conducted sequentially to identify metabolite biomarkers and pathways associated with RT-induced EASRs. Results: The study population consisted of 24 African American (40%), 18 non-Hispanic white (30%), 14 Hispanic white (24%), and 4 “other” (7%) patients with frequency matched by race/ethnicity and body mass index (BMI) categories (i.e., normal, overweight, and obesity) to have an equal number of high (n=30) and low (n=30) EASRs. Seven metabolic pathways were significantly associated with RT-induced EASRs, including alanine, aspartate, and glutamate metabolism; caffeine metabolism; pentose and glucuronate interconversions; glycine, serine, and threonine metabolism; beta-alanine metabolism; pantothenate and CoA biosynthesis; and glutathione metabolism. The alanine, aspartate, and glutamate metabolism pathway had the lowest false discovery rate (FDR)-adjusted p-value (p=0.0028) and the highest pathway impact value (0.60) of all enriched metabolic pathways. Thirteen metabolite biomarkers were significantly associated with RT-induced EASRs, including the principal compound of interest glutamate. Conclusions: In our study of breast cancer patients receiving adjuvant RT, alanine, aspartate, and glutamate metabolism had the highest impact value and significant FDR-adjusted p-value in predicting RT-induced EASRs. Our findings suggest that glutaminase inhibitors may have broader clinical applications in preventing RT-induced EASRs in addition to their potential enhancement of chemotherapy by triggering metabolic crises in tumor cells. Keywords: breast cancer, metabolomics, radiation therapy, and early adverse skin reactions. Citation Format: Alexandra N. McMahon, Cristiane Takita, Jean L. Wright, Eunkyung Lee, Joshua J. Kleinman, Isildinha M. Reis, Jennifer J. Hu. Metabolomics in radiotherapy-induced early adverse skin reactions in breast cancer patients [abstract]. In: Proceedings of the American Association for Cancer Research Annual Meeting 2023; Part 1 (Regular and Invited Abstracts); 2023 Apr 14-19; Orlando, FL. Philadelphia (PA): AACR; Cancer Res 2023;83(7_Suppl):Abstract nr 2824.

Man with episodic abdominal pain andjaundice.

A 51-year-old man without a past medical history presented to our emergency department with 2 months of intermittent epigastric pain radiating to the back, tan stools, fatigue, and weight loss. He denied current alcohol use. He appeared diffusely jaundiced. His abdomen was soft with mild epigastric tenderness and a negative Murphy sign. Serum analysis showed total bilirubin 13.7, aspartate transaminase 207, alanine transaminase 463, alkaline phosphatase 634, lipase > 4000, elevated carcinoembryonic antigen/carbohydrate antigen 19-9, and negative hepatitis panel. Imaging included point-of-care (POC) ultrasound (Figure 1, Video 1), computed tomography (CT; Figure 2), magnetic resonance imaging (MRI; Figure 3), and endoscopic retrograde cholangiopancreatograph (ERCP; Figure 4). Our patient had obstructive jaundice. POC ultrasound revealed a distended gallbladder with sludge without signs of acute cholecystitis. The dilated common bile duct >10 mm (normal < 6 mm) and dilated pancreatic duct >5 mm (normal < 3 mm) were consistent with the rare double duct sign. Dilatation without a clear etiology was confirmed on MRI and CT. ERCP revealed a duodenal ulcer with biopsy positive for invasive, poorly differentiated adenocarcinoma. Finally, a pancreaticoduodenectomy revealed a tumor of the pancreatic head. Etiologies of the double duct sign include neoplasms of the pancreatic head and ampulla of Vater and less commonly choledocholithiasis and chronic pancreatitis.1 Overall prevalence of associated malignancy varies from 58% to 100%.2 However, the presence of jaundice is strongly associated with malignancy whereas absence with benign conditions.3-5 Isodense culprit neoplasms are often not visualized on advanced imaging. As initial presentation of pancreatic cancer is insidious, the ominous presence of this sign should raise concerns for malignancy. The authors would like to thank Daniela Galan Alonso, MD, Department of Radiology, Jackson Memorial Hospital. Video.1 Point-of-care ultrasound of pancreas revealing double duct sign. Gallbladder (star), pancreatic duct (arrow), and common bile duct (circle). Please note: The publisher is not responsible for the content or functionality of any supporting information supplied by the authors. Any queries (other than missing content) should be directed to the corresponding author for the article.

Interactive, Educational, and Fun? Yes, Learning Labs are Back!

Back to table of contents Previous article Next article Annual MeetingFull AccessInteractive, Educational, and Fun? Yes, Learning Labs are Back!Nick ZagorskiNick ZagorskiSearch for more papers by this authorPublished Online:26 Feb 2023https://doi.org/10.1176/appi.pn.2023.03.3.31AbstractAttendees can learn about such topics as entering a career in academic medicine and mastering social media, as well as improving their use of telepsychiatry in a post-pandemic world.Love it or loathe it, social media is becoming a massive platform for spreading news and information about mental health. Several sessions at this year’s Annual Meeting will discuss the role of social media in psychiatric practice, including a special presentation that will be a part of APA’s Learning Labs. Social Media–Related Sessions“#American Idols—the Role of Influencers in Shaping the Public’s Understanding and Utilization of Mental Health Care.” Chair: Anna Russell, D.O.“Alternatives to Facts: Mental Health Impact of Social Media, Phone Applications, and Technology.” Chair: Pratik Bahekar, M.B.B.S.“The Future of Mental Health Is Social Media.” Chair: Simone Ariel Bernstein, M.D.“Technologies to Advance Access to Mental Health: Social Media, Texting, and 988.” Chair: John Luo, M.D.“#American Idols—the Role of Influencers in Shaping the Public’s Understanding and Utilization of Mental Health Care.” Chair: Anna Russell, D.O.“Social Media and Psychiatry: Effects of Social Media on Users, Research, Advocacy, Networking, and Intervention Opportunities.” Chair: Mariana Pinto Da Costa, M.D.“Social Media for Seniors: Pros, Cons, and Scams.” Chair: Maria D. Llorente, M.D.“Virtually Represented: The Impact of Social Media Usage on Trainee Wellness.” Chair: Carisa Maureen Kymissis, M.D.“Mission-Based Media Collaborative Work Concerning ‘Controversial’ Topics in Psychiatry.” Chair: Jessica Gold, M.D.“Using Social Media to Educate, Advocate, and Empower.” Chair: Jake Goodman, M.D., M.B.A.Yes, APA’s popular educational workshops are making a grand return at the San Francisco meeting. The eight interactive sessions slated for this year include the panel session titled “Using Social Media to Educate, Advocate, and Empower,” which will be chaired by Jake Goodman, M.D. Goodman, a psychiatry resident at the University of Miami’s Jackson Memorial Hospital, became a social media sensation during the COVID-19 pandemic with a series of photos and videos advocating for mental health awareness and detailing his own challenges with depression to his more than 2 million followers. “Social media can appear overwhelming and intimidating. And that’s OK. We never had a lecture in medical school about how to create a video or write a tweet to educate the public about a new medical advancement,” Goodman said. But with a little help from the panelists, participants can learn how to write engaging content and build an online brand. All they need to do is bring a phone and an open mind.Other Learning Labs slated for this year include the following:Transcranial Magnetic Stimulation [TMS]: Future Innovations and Clinical Applications for Psychiatric Practice: This panel session will highlight the many high-tech advances in TMS since the first magnetic device was cleared in 2008, as well as low-tech strategies any clinician can use to optimize TMS therapy.Launching and Navigating a Successful Career in Academic Medicine: Any young physician interested in academia has a chance to learn from one of the best: Laura A. Roberts, M.D., M.A., the Katharine Dexter McCormick and Stanley McCormick Memorial Professor and chair of psychiatry and behavioral sciences at Stanford University School of Medicine.Crises Simulation Lab: In this returning event, participants will learn some of the basics of how to respond effectively in a crisis—natural or manmade—and get a chance to play one of many responder roles in a simulation of a crisis event.Learning Neuroscience Through Interactive Activities: Who said learning can’t be fun? Attendees at this workshop will get to experience the “Brain-ival” as they form teams and tackle puzzles, trivia, and more. Along the way, they will also learn important elements of neuroscience, the foundation of psychiatric knowledge.LAI Workshop: Long-acting injectable antipsychotics are a highly effective yet highly underused option for treating patients with schizophrenia and other psychotic disorders. Donna Rolin, Ph.D., A.P.R.N., director of the psychiatric mental health nurse practitioner program at the University of Texas at Austin School of Nursing, will offer important details on how to prepare and administer these injections.How to Set Up a Tele-Practice: While many psychiatrists are using telehealth services today, undoubtedly many still have questions on technical and regulatory guidelines. This interactive session will review the important considerations related to establishing and/or maintaining a fully virtual or hybrid practice. Topics include equipment selection, licensure requirements, maintaining privacy, and more.Hearing Voices: In this moving workshop, attendees will get an idea of what it’s like to experience auditory hallucinations. It is hoped that participants will gain empathy and reassess their thoughts on positive symptoms as they attempt to carry out routine clinical activities while experiencing distracting audio stimuli designed by people with lived experience. ■ ISSUES NewArchived

Implementation of an integrated infectious disease and substance use disorder team for injection drug use-associated infections: a qualitative study

BackgroundHospitalizations for severe injection drug use-related infections (SIRIs) are characterized by high costs, frequent patient-directed discharge, and high readmission rates. Beyond the health system impacts, these admissions can be traumatizing to people who inject drugs (PWID), who often receive inadequate treatment for their substance use disorders (SUD). The Jackson SIRI team was developed as an integrated infectious disease/SUD treatment intervention for patients hospitalized at a public safety-net hospital in Miami, Florida in 2020. We conducted a qualitative study to identify patient- and clinician-level perceived implementation barriers and facilitators to the SIRI team intervention.MethodsParticipants were patients with history of SIRIs (n = 7) and healthcare clinicians (n = 8) at one implementing hospital (Jackson Memorial Hospital). Semi-structured qualitative interviews were performed with a guide created using the Consolidated Framework for Implementation Research (CFIR). Interviews were transcribed, double coded, and categorized by study team members using CFIR constructs.ResultsImplementation barriers to the SIRI team intervention identified by participants included: (1) complexity of the SIRI team intervention; (2) lack of resources for PWID experiencing homelessness, financial insecurity, and uninsured status; (3) clinician-level stigma and lack of knowledge around addiction and medications for opioid use disorder (OUD); and (4) concerns about underinvestment in the intervention. Implementation facilitators of the intervention included: (1) a non-judgmental, harm reduction-oriented approach; (2) the team’s advocacy for PWID as a means of institutional culture change; (3) provision of close post-hospital follow-up that is often inaccessible for PWID; (4) strong communication with patients and their hospital physicians; and (5) addressing diverse needs such as housing, insurance, and psychological wellbeing.ConclusionIntegration of infectious disease and SUD treatment is a promising approach to managing patients with SIRIs. Implementation success depends on institutional buy-in, holistic care beyond the medical domain, and an ethos rooted in harm reduction across multilevel (inner and outer) implementation contexts.

Ralph L. Sacco, 65, Dies: Stroke Expert With a Talent for Architectural Design.

Ralph L. Sacco, 65, Dies: Stroke Expert With a Talent for Architectural Design.

Ralph L. Sacco, 65, Dies: Stroke Expert With a Talent for Architectural Design.

Ralph L. Sacco, 65, Dies: Stroke Expert With a Talent for Architectural Design.

Abstract B123: Prevalence of COVID-19 among hematology/oncology patients and providers of a community-facing county health system during the B1.1.529 (“Omicron”) SARS-CoV-2 variant wave

Abstract Introduction: The SARS-CoV-2 (COVID-19) pandemic continues in the United States, and patients actively receiving chemotherapy are known to be at enhanced risk for developing symptomatic disease. Our study evaluated the prevalence of COVID-19 among patients and providers of our community-facing county health system during the B1.1.529 (“Omicron”) COVID-19 variant wave. Methods: We retrospectively analyzed patients that received care and clinical providers whom worked at the Jackson Memorial Hospital Hematology/Oncology clinic in Miami, Florida from December 1st, 2021 through April 30th, 2022. After categorizing basic demographic factors for individuals whom tested positive for COVID-19 during the study timeframe, we analyzed additional risk factors leading to COVID-19 positivity including, but not limited to, vaccination status, previous COVID-19 positivity, and active receipt of chemotherapeutics. We then analyzed outcomes related to COVID-19, including treatment with advanced COVID-19 therapies such as oral or intravenous antivirals, monoclonal antibodies, convalescent plasma, steroids, or interleukin-6 inhibitors; interactions with inpatient services including emergency department (ED)/urgent care visits, inpatient and/or ICU admissions, and deaths from COVID-19. We finally assessed quality outcomes such as delay in cancer-directed therapy. This study was approved by the University of Miami IRB and Jackson Health System Clinical Trials Office. Results: 498 patients and 18 providers were retrospectively analyzed during the study timeframe. 49 patients tested positive for COVID-19 (9.84%), while 6 providers tested positive (33.3%) (p = 0.015). Patients whom tested positive were 51.0% female (n = 25), 26.5% Black (n = 13), 73.5% Hispanic/Latinx (n = 36), and 2.05% Asian (n = 1). Only 6.12% patients had tested positive for COVID-19 previously (n = 3), and 42.9% were considered unvaccinated (n = 21) while 14.3% were boosted (n = 7). 73.5% (n = 36) presented with symptomatic disease, 46.9% (n = 23) sought care at an ED/urgent care, 32.6% (n = 13) were admitted to the hospital, 6.12% were admitted to the ICU (n = 3), and 16.3% (n = 8) received advanced therapeutics. There were 2 (8.0%) COVID-19-related deaths (and another outside our study timeframe) among 23 non-COVID-19 related deaths in the patient population (p = 0.75). More than half of the patients whom tested positive experienced a cancer treatment delay (n = 27/49; 55.1%). Conclusions: The prevalence of COVID-19 positivity in our patient cohort during the initial Omicron wave mirrored local, state, and national trends, however a statistically significant greater proportion of our providers tested positive. COVID-19 positivity conferred appreciable disparities in the presentation of disease as well as receipt of cancer treatment. COVID-19 positivity was more likely to result in symptomatic disease and ED/urgent care visit in cancer patients without previous COVID infection and unvaccinated status. COVID-19 accounted for 8.0% of our clinic’s total mortality. Citation Format: Aliya Khan, Samuel A. Kareff, Priscila Barreto-Coelho, Sunil Iyer, Brian Pico, Michele Stanchina, Giselle Dutcher, José Monteiro de Oliveira Novaes, Aparna Nallagangula, Gilberto Lopes. Prevalence of COVID-19 among hematology/oncology patients and providers of a community-facing county health system during the B1.1.529 (“Omicron”) SARS-CoV-2 variant wave [abstract]. In: Proceedings of the 15th AACR Conference on the Science of Cancer Health Disparities in Racial/Ethnic Minorities and the Medically Underserved; 2022 Sep 16-19; Philadelphia, PA. Philadelphia (PA): AACR; Cancer Epidemiol Biomarkers Prev 2022;31(1 Suppl):Abstract nr B123.

1984. Implementation of an integrated infectious disease and substance use disorder team for the treatment of severe injection-related infections

Abstract Background Hospitalizations for severe injection drug use-related infections (SIRIs) are characterized by high costs, frequent patient-directed discharge, and high readmission rates. Beyond the health system impacts, these admissions can be traumatizing to people who inject drugs (PWID), who often receive inadequate treatment for their substance use disorders (SUD). The Jackson SIRI team was developed as an integrated infectious disease/SUD treatment team for patients hospitalized at a public safety-net hospital in Miami, Florida in 2020. In order to facilitate implementation of this team, we conducted a qualitative study of patients and providers to identify barriers and facilitators to the team’s success. Methods Participants were patients with history of SIRIs (n=7) at the Jackson Memorial Hospital (JMH) and healthcare providers (HCPs) (n=8) at JMH. Semi-structured qualitative interviews were performed with a guide created using the Consolidated Framework for Implementation Science (CFIR). Interviews were transcribed and double coded by study team members using determinants adapted from the CFIR. Results Key barriers to SIRI team success included: 1) complexity of SIRI and SUD care requiring multidisciplinary teams and resources; 2) lack of resources for PWID experiencing homelessness, financial insecurity, and uninsured status; 3) stigma and lack of knowledge around addiction and medications for SUD; and 4) suspected understaffing and underfunding for the team. Facilitators of team success included: 1) holistic, integrated care being more efficient and effective than fragmented care; 2) the team’s advocacy for PWID as a means of institutional culture change; 3) provision of close post-hospital follow-up for an often-abandoned population; 4) non-judgmental, harm reduction-oriented approach; and 5) addressing diverse needs such as housing, insurance, and psychological wellbeing. Conclusion Integration of infectious disease and substance use disorder treatment is a promising approach to managing patients with SIRIs; however, success depends on institutional buy-in, holistic care beyond the medical domain, and an ethos rooted in harm reduction. Disclosures Susanne Doblecki-Lewis, MD, MSPH, Gilead Sciences: Grant/Research Support.

604. Effect of rifabutin in dolutegravir dosing: a case series

Abstract Background Tuberculosis (TB) is the leading cause of death in human immunodeficiency virus (HIV) infected people worldwide. Patients with HIV who have latent TB are 20-30 times more likely to develop active TB. Integrated antiretroviral therapy (ART) early in the treatment for tuberculosis is recommended due to improved morbidity and mortality, however, there can be serious drug interactions. Rifamycins are potent inducers of the CYP3A4 isoform, which can cause sub-therapeutic concentrations of anti-retroviral drugs, among these, rifabutin (RBN) is a less potent inducer of CYP3A4. Pharmacokinetic (PK) studies done on healthy adults showed that rifampin decreased dolutegravir (DTG) concentrations by more than 50 % whereas RBN decreased it by 30%. RBN has been preferred given that its favorable pharmacokinetic and toxicity profile. Currently there are no studies examining the use of RBN and DTG in co-infected persons. This is a case series of 4 co-infected patients receiving both agents who underwent PK analysis. Methods Retrospective analysis of patients in the respiratory care unit (RCU) at Jackson Memorial Hospital in Miami. We included adult patients, admitted to the RCU, with a concomitant diagnosis of HIV and active TB disease who received DTG and RBN, and for which DTG and RBN plasma concentrations were measured for therapeutic drug monitoring (TDM). A non-compartmental analysis was performed and the area under the concentration-time curve (AUC) was calculated for DTG and RBN. Results We report 4 patients (Figure 1) that met criteria and underwent PK analysis. All patients with TB who were treated with RBN had low concentrations of DTG, requiring higher doses of DTG (Table 1 &amp; 2). After adjustments based on PK analysis, there was evidence of a favorable response to treatment in 2 patients, with a less than robust in the 2 others. Adequate suppression of viral load could not be determined for 3 of the patients because of the short observation time. Figure 1:Timelines of patients describing admission and HIV and tuberculosis treatment providedDTG, dolutegravir. RFB, rifabutin. VL, viral load. AFB, Acid fast bacilli. LAD, lymphadenopathy. TAF, Tenofovir alafenamide. FTC, Emtricitabine. TDF, Tenofovir Disoproxil Fumarate. INH, Isoniazid. PYZ, Pyrazinamide. BID, twice a day. QD, daily. IRIS, Immune reconstitution inflammatory syndrome. GU, genitourinary. TB, tuberculosis.Table 1:Patients’ pharmacokinetics of DTGAUCX-Y, area under the concentration-time curve from time X to Y hours; AUC0-tau, area under the concentration-time curve from time zero to the end of the dosing interval; DTG, dolutegravir; TDM, therapeutic drug monitoring. a) AUC0-6 was calculated.Table 2:Patients’ pharmacokinetics of RBNAUCX-Y, area under the concentration-time curve from time X to Y hours; AUC0-tau, area under the concentration-time curve from time zero to the end of the dosing interval; RBN, Rifabutin; TDM, therapeutic drug monitoring. a) All RBN doses given every 24 hours, b) RBN value was trace and AUC was not calculated. Conclusion All patients with HIV and TB who were treated with RBN had low concentrations of DTG. This case series demonstrates that for optimal concomitant use of rifabutin and dolutegravir it is highly recommended to use TDM. Prospective clinical studies are needed to further determine the PK interactions between RBN and DTG and virologic response to treatment. Disclosures All Authors: No reported disclosures.

S1198 Treatment and Hepatocellular Carcinoma Screening Patterns Among Black Patients With Chronic Hepatitis B

Introduction: Significant racial disparities exist in Hepatitis B virus (HBV) infection across the nation, from screening variability to treatment patterns and clinical outcomes. The Black community bears a disproportionately large disease burden. In this study, we sought to compare the disease courses between Black patients seen at a private tertiary referral center vs. those evaluated at a high-volume county safety net hospital. Methods: Using informatics, we identified adult patients with chronic HBV based on ICD-10 codes, who had ≥1 clinic visit between January 1, 2010 and December 31, 2020 at University of Miami Hospital (UM) and Jackson Memorial Hospital (JM). We conducted retrospective chart review to gather demographic and clinical data. We used descriptive statistics, Kruskal-Wallis, and Pearson’s chi squared tests to evaluate for differences between Black patients at each hospital with the significance interval set to p < 0.05. Analyses were conducted using STATA 17.0. Results: Of 649 Black patients detected by informatics, 364 had confirmed HBV with 306 seen at UM and 58 at JM. Compared to JM, UM patients were significantly older, English speakers, and privately insured (p < 0.001) (Table). Most common birth countries included Haiti and the USA, among others (Figure). 78.8% of UM patients were evaluated by Hepatology, compared to 41.1% at JM. More JM patients had active hepatitis, and 15.5% had a high viral load (HBV DNA PCR >20,000) compared to 3.3% at UM. Patients seen at UM were more likely to be treated, 52.9%, vs. 24.6% at JM and placed on newer regimens (ie Tenofovir [TAF] and Entecavir). UM patients were significantly more likely to undergo HbeAg and HbeAb testing, compared to their JM counterparts. Black patients at JM were significantly more likely to have alcoholic liver disease, ascites, and orthotopic liver transplantation. Although more UM patients underwent surveillance for hepatocellular carcinoma (HCC), there was ultimately no significant difference in patients being diagnosed with HCC between hospitals. Conclusion: These findings suggest that significant differences in demographics, referral patterns, laboratory evaluation, and management exist between Black patients at UM vs. JM, despite both hospitals being affiliated with the same academic institution. Our analysis on JM patients is ongoing and will be crucial to inform future interventions aimed at standardizing and providing evidence-based HBV care across medical centers.Figure 1.: Geographic distribution of Black patients’ most common birth countries. Green UM, Orange JM. Table 1. - Comparison of demographics, screening, and management patterns between Black patients at JM vs. those at UM Variable Blacks @ JM (n = 58) Blacks @ UM (n = 306) p-value Median Age, years (IQR) 54 (45-63) 59 (47-66) 0.0001 Male Gender, % 68.3 63.7 0.24 US Born, % 50.9 32.7 0.012 Department seen by, %Hepatology 41.4 78.8 < 0.001 General Internal MedGastroenterology 62.11.7 8.814.1 < 0.0010.008 HbeAg / HbeAb checked, % 52.6 78.5 < 0.001 Active hepatitis, % 19 2.9 < 0.001 High viral load ( >20,000), % 15.5 3.3 < 0.001 Currently on Treatment, % 24.6 52.9 < 0.001 Tenofovir TDF TAF EntecavirAdefovirLamivudine 13.813.713.113.40.68.6 31.412.11.75.201.6 0.0070.740.00140.0780.540.003 Alcoholic Liver Disease, % 14 1.8 < 0.001 Ascites, % 22.8 7.3 < 0.001 OLT, % 26.3 1.8 < 0.001 HCC Screening, %FibroscanAFPSurveillance imaging (< 6 months) 17.542.1158.9 3178.377.9 0.04< 0.0010.003 Diagnosed with HCC 5.1 5.9 0.71 AFP = alpha-fetoprotein; OLT = orthotopic liver transplantation; HCC = hepatocellular carcinoma.

Prevalence and Outcomes of COVID-19 among Hematology/Oncology Patients and Providers of a Community-Facing Health System during the B1.1.529 ("Omicron") SARS-CoV-2 Variant Wave.

Simple SummaryThe COVID-19 pandemic continues, and cancer patients are at high risk for both contracting as well as dying from the infection. There is not as much data known about newer COVID-19 variants such as Omicron compared to earlier waves for patients with cancer. In this study, we retrospectively evaluated how COVID-19 positivity affected both patients and their providers in our community-facing cancer clinic. We found that 33.3% compared to 8.7% of cancer providers versus patients, respectively, tested positive for COVID-19 from December 2021 through April 2022 (p = 0.038). Furthermore, we saw that almost two-thirds of cancer patients experienced delays in receiving cancer treatments. Finally, over 10% of cancer patients (4 of 90) died during the Omicron wave. This study confirms that COVID-19 remains a formidable infection in terms of cancer patients’ treatment as well as livelihood, and continues to result in considerable health care disparities for disadvantaged populations.(1) Background: the SARS-CoV-2 (COVID-19) pandemic continues, and patients actively receiving chemotherapy are known to be at enhanced risk for developing symptomatic disease with poorer outcomes. Our study evaluated the prevalence of COVID-19 among patients and providers of our community-facing county health system during the B1.1.529 (“Omicron”) COVID-19 variant wave. (2) Methods: We retrospectively analyzed patients that received care and clinical providers whom worked at the Jackson Memorial Hospital Hematology/Oncology clinic in Miami, Florida, USA, from 1 December 2021 through 30 April 2022. We assessed demographic variables and quality outcomes among patients. (3) Results: 1031 patients and 18 providers were retrospectively analyzed. 90 patients tested positive for COVID-19 (8.73%), while 6 providers tested positive (33.3%) (p = 0.038). There were 4 (10.3%) COVID-19-related deaths (and another outside our study timeframe) and 39 non-COVID-19-related deaths (89.7%) in the patient population (p = 0.77). COVID-19 accounted for 4.44% of our clinic’s total mortality, and delayed care in 64.4% of patients. (4) Conclusions: The prevalence of COVID-19 positivity in our patient cohort mirrored local, state, and national trends, however a statistically significant greater proportion of our providers tested positive. Almost two-thirds of patients experienced a cancer treatment delay, significantly impacting oncologic care.

P8.001: Robotic-Assisted Living Donor Nephrectomy: High Technology Incorporated for Patient Benefit

Background: Kidney transplantation (KT) provides increased survival for patients with end-stage renal disease (ESRD). Living donation (LD) is a cornerstone in the increase of the pool of donors available, especially due to recipients requiring less time on the waitlist and need for ongoing dialysis along with evidence for longer graft survival. One of the barriers for LD is the burden of the procurement surgery, that has traditionally been performed by open or laparoscopic hand-assisted technique. We report here a case series of 22 patients submitted to robotic-assisted left donor nephrectomy. Methods: Prospectively collected data of patients submitted to robotic-assisted left donor nephrectomies at the Jackson Memorial Hospital, University of Miami, Miami Transplant Institute, in the period of Aug-2021 to Mar-2022, during the first phase of implantation of the Transplant Robotic Program. Data relative to the pre-operative, intra-operative and post-operative periods were collected, including clinic-demographic characteristic of the patients, surgical metrics, and pathology findings. Continuous variables were analyzed with Student t-test, categorical variables were analyzed with chi-square test. A p-value of less than 0.05 was considered to be statistically significant. Results: 22 patients were included, of those 10 (45.5%) were male. The median age was 40 (30-49.3) years old. Of all cases analyzed, 16 (72.7%) donated the kidney to a related family member. The donor kidney graft anatomy was conventional (single artery, single vein, single ureter) in 19 (86.4%) of the cases. There was 1 (4.5%) case with multiple arteries that was successfully reconstructed in the back-table operation. There were anatomical technical difficulties in 5 (22.7%) cases. A Pffanenstiel incision was used in 10 (45.5%) cases for graft extraction from the abdomen. The median extraction time was 90.5 (IQR 56.5-225.2) seconds. The median intra-operative robotic console time was 102 (IQR 89.8-119.2) min. Robotic stapler devices were used in 21 (95.5%) cases. Foley catheter was removed in the operating room in 21 (95.5%) cases. The median length of stay was 1.23 (IQR 1.0-1.4) days. Graft function was immediate in 20 (90.1%) of the cases, and slow in 2 (9.9%) cases. Macroscopic procurement damage was appreciated in 5 (22.7%) cases. There was 1 (4.5%) postoperative readmission, 4 (18.2%) postoperative complications, and no surgical re-intervention needed. None of the patients had to be converted to laparoscopic or open operation associated to the procedures. There was no statistically significant difference between the groups analyzed. Conclusion: Robotic-assisted left donor nephrectomy is a safe procedure associated with minor risk of complications, and should be stimulated in the transplant centers where robotic surgery is available.

346.11: Miami Protocol for Liver Deceased Donors After Circulatory Death: Increased 1-Year Overall Survival for Selected Patients

Background: The use of deceased donors after circulatory death (DCD) for liver transplantation (LT) is still underutilized. It provides an acceptable solution to increase the organ donor pool without affecting outcomes. We analyzed data of DCD donors for LT in order to identify risk factors for graft and patient survival. Methods: This was a retrospective cohort study using data reviewed by screening SRTR/UNOS of patients that underwent liver transplantation with DCD donor at the University of Miami, Jackson Memorial Hospital in Miami, FL from 2017 to 2019. Different surrogates were analyzed, including donor, recipient, procurement and transplant operation characteristics. The primary outcome was patient and graft survival. Continuous variables were analyzed using a 2-sided student t-test. Categorical variables were presented as frequencies and proportion and compared using chi-squared or Fisher’s exact test as appropriate. Univariable Cox proportional hazards models were fit in order to assess the impact of individual covariables on the instantaneous rate of events, with time-to-event analysis also being ascertained through Kaplan-Meier estimates. Results: 54 cases were analyzed with a median MELD score of 18.5. Alcoholic cirrhosis was the most prevalent etiology for liver disease. There was 1 case with intra-hepatic biliary stricture, and 7 patients with anastomotic strictures that required stenting. The 1-year survival rate following liver transplant using DCD donors was 90.7%. The total cold ischemic time (CIT) (HR 1.9, 95% CI 1.1-3.2) and diagnosis of rejection (HR 9, 95% CI 1.1-78.8) were statistically significant affecting graft failure. Estimated blood loss (EBL) with HR of 1.1 (95% CI 1.1-1.2) was found to be statistically impacting survival rate. Conclusion: DCD donors are excellent options to increase the availability of organs for patients waiting for a LT. CIT and EBL are the main predictors of poor outcomes and thus should be carefully taken into account when matching organs to recipients.

Physician and Parent Perceptions on Plant-Based Beverages as Substitutes for Cow's Milk: A Single City Survey.

This study assessed physician and parent perceptions regarding plant-based beverage consumption in children. We surveyed 128 physicians and 215 parents of patients at University of Miami and Jackson Memorial Hospital. Among physicians, 52% recommended plant-based beverages, typically soy (33%), for cow's milk allergy (32%). Only 40% of physicians knew the typical protein content of plant-based beverages compared to cow's milk. Most physicians (54%) did not discuss potential health risks of plant-based beverages with patients. Among parents, 48% had children <2 years old, and 22% purchased a plant-based beverage, most commonly almond beverage (39%), due to perceived health benefits (54%). In total, 85% of parents believed that plant-based beverages are nutritionally superior or equivalent to cow's milk. Most parents (52%) depended on physicians for information on plant-based beverages. Overall, less than one third of physicians and parents believed that plant-based beverages should be called milk. There is a lack of knowledge among physicians and parents regarding plant-based beverage use as a dairy substitute in children. Despite parents relying on physicians for health information, physicians are not routinely counseling parents. Removing the label "milk" from plant-based beverages may improve consumer awareness of their nutritional differences and circumvent potential associated health risks in children.

Abstract P1-01-14: Axillary assessment by Systemic Axillary Sonography (SAS) for axillary disease treated with neoadjuvant chemotherapy

Abstract Objective. For patients with breast cancer related lymph node metastases, neoadjuvant chemotherapy (NAC) can de-escalate axillary surgery. A radiologic marker (RM) is commonly placed at the time of the initial biopsy to ensure removal of that node at final surgery, but the utility of this marker is largely debated. Systematic Axillary Sonography (SAS) consists of a thorough sonographic axillary staging before and after NAC with possible post NAC node biopsy and has been previously suggested as an alternative. The primary aim of this study was to assess the effectiveness of SAS in axillary evaluation after NAC. The secondary aim was to compare the effectiveness of SAS to RM. Methods. A retrospective analysis of prospectively collected data from 95 patients from 2010 to 2020 at University of Miami Hospital and Jackson Memorial Hospital. Study inclusion criteria were positive axillary lymph node (LN) biopsy, NAC, performance of SAS and axillary surgery. Results. 89 patients were analyzable. The median age was 49±12. All patients had clinical axillary exam and axillary US with positive LN biopsy. 62 patients had additional breast MRI before treatment. All patients had clinical axillary exam and axillary US after chemotherapy. 58 patients had post-treatment MRI and 49 repeated axillary LN biopsy. Pre-treatment clinical exam of the axilla had a sensitivity of 73%. When MRI was added the sensitivity rose to 95%. Since axillary US and positive axillary node biopsy were a prerequisite, the sensitivity of pre-NAC US cannot be assessed. After chemotherapy, all patient underwent axillary examination and US assessment. Repeated axillary clinical exam had low sensitivity of 31% and high specificity of 85%. Repeat MRI exam showed low sensitivity and specificity of 53% and 49% respectively. Post-NAC US without subsequent LN biopsy had a sensitivity of 55% with specificity of 67%. The addition of repeat axillary LN biopsy increased the sensitivity of SAS to 100%. 59 patients in our group had RM placed during pre-NAC axillary LN biopsy. 24 underwent axillary dissection without sentinel lymph node biopsy (SLNB) and 35 patients had a SLNB. The RM was retrieved in 32/35 patients. The “clipped” node was also sentinel node in 66% (12/35). The final pathology revealed benign results in all “clipped” non-sentinel nodes. 18% (6/33) of patients with “clipped” node were diagnosed with axillary metastases in “non-clipped” lymph nodes. Conclusion. SAS is a cheap, quick and reliable method facilitating pre and post-treatment assessment and restaging of the axilla after NAC. Post-NAC biopsy, when indicated, better defines eligibility for axillary surgery decreasing morbidity and cost. In this study, placement of a RM was of no significant benefit. Patient characteristicsRaceTumor gradeWhite, non-hispanic19Gr 13White-hispanic46Gr 240Black, non-hispanic18Gr 346Asian3Receptor statusUnknown3HR+/HER2-42Age49+/-12HR+/HER2+19BMI29+/-5.7HR-/HER2+7Menopausal statusHR-/HER2-21Premenopausal49Tumor sizePostmenopausal40T19T238T328T414LN statusN158N221N310 Citation Format: Siarhei Melnikau, Christina Layton, Tolga Ozmen, Megan Allen, Eli Avisar. Axillary assessment by Systemic Axillary Sonography (SAS) for axillary disease treated with neoadjuvant chemotherapy [abstract]. In: Proceedings of the 2021 San Antonio Breast Cancer Symposium; 2021 Dec 7-10; San Antonio, TX. Philadelphia (PA): AACR; Cancer Res 2022;82(4 Suppl):Abstract nr P1-01-14.

Valproic Acid Induced Thrombocytopenia and Dysmegakaryopoiesis in a Pediatric Patient

Abstract Introduction/Objective Valproic acid is a branched short chain fatty acid derivative that is used primarily to treat epilepsy as well as mood disorders, certain types of headaches, and neuropathic pain. It is commonly prescribed in the pediatric population and has shown to be effective for refractory epilepsy with adequate seizure control. Serious side effects may be prominent if the medication is not kept at the therapeutic range. A wide variety of known hematologic problems can be encountered including but not limited to anemia, thrombocytopenia, and leukopenia. Methods/Case Report We present a case of a pediatric patient with a past medical history significant for history of seizure disorder and who presented to Jackson Memorial Hospital for intermittent fevers and multiple unexplained bruises for 3 weeks as well as fatigue and weakness.The patient was recently started on valproic acid. Complete blood count (CBC) was obtained and showed a platelet count of 23 x10(3)/mcL with WBC of 3.5 x10(3)/mcL and hemoglobin of 9.7 g/dL.Serum valproate concentration was critically high (154 mg/L). Trephine biopsy showed a normocellular marrow (60%) showing maturing trilineage hematopoiesis and scattered atypical megakaryopoiesis characterized by small forms that are seen in relatively loose interstitial clusters (Figure 1). The marrow aspirate smears were characterized by cellular spicules with dysmegakaryopoiesis including numerous small hypolobated forms with frequent forms showing separated nuclei (Figure 2, 3, and 4). Blasts did not appear increased, comprising overall 1% of marrow cellularity. Karyotype studies revealed a normal female karyotype, 46, XX. FISH studies using probes commonly detected in MDS were negative. Next generation sequencing was negative for AML specific mutations including GATA1 and GATA2 mutations. Results (if a Case Study enter NA) N/A Conclusion This case report highlights the significant hematologic adverse effects of valproic acid, specifically pancytopenia with dysmegakaryopoiesis, raising the clinical suspicion of potential myelodysplastic syndrome. Critically high level of valproic acid (154 mg/L) and normalization of CBC after the stoppage of the medication strongly suggests that valproic acid can cause severe bone marrow suppression and specific morphologic atypia in the megakaryocytic lineage thus introducing a potential diagnostic pitfall. Because the CBC returned to normal, bone marrow biopsy was not repeated.