Large Academic Center Research Articles

Gender Based Differences in Electronic Medical Record Utilization in an Academic Ophthalmology Practice

PurposeTo evaluate gender differences in EMR interaction among female and male ophthalmologists at a large tertiary academic center. DesignRetrospective, cross sectional analysis MethodsData from Electronic Medical Record (EMR) system log files and health system administrative data from May 2022 to May 2023 were collected at an academic center. Primary outcomes were differences in time spent interacting with the EMR and In-basket message load between male and female ophthalmologists. Statistical analysis was adjusted for each physicians’ patient panel size, patient panel gender breakdown, and number of appointments. ResultsThere were 30 ophthalmologists, 8 (27%) of whom were female. There was a significantly shorter mean length of employment, defined as years of employment at this institution, for female ophthalmologists (5.62 ± 8.24 vs 15.26 ± 13.34 years, p=0.028). In the 12-month analysis period, there was no significant difference in the total number of patients seen between female and male ophthalmologists. However, female ophthalmologists spent 69.6% more total time in the EMR system (24,553 vs 14,480 minutes/MD, p<0.001), and 70.9% more cumulative time on clinical tasks (18,424 vs 10,887 minutes/MD, p<0.001). Female ophthalmologists spent 114% more time than male counterparts on placing orders, scheduling tasks, and responding to in-basket messages (6484 vs 3024 minutes/MD, p<0.001). Female ophthalmologists also received 750% higher volume of patient notification messages (187 vs 22, p<0.001). ConclusionsIn our cohort, male ophthalmologists’ mean duration of employment was nearly 3 times longer than female ophthalmologists. Despite comparable patient panels and appointment completion rates, female ophthalmologists spent significantly more time in the EMR system and received significantly more in-basket messages and tasks. These findings underscore the need for further studies addressing gender disparities and promoting gender equity in ophthalmology practice settings.

Plate Osteosynthesis of Proximal Humerus Fracture is Associated with Significant Complications and Poor Functional Score for Patients Older than 45 Years Old: A Cohort Study

BackgroundDespite the introduction of new implants and biomechanical improvements for proximal humerus fractures (PHF), the complication rate remains significant, particularly in older adults. This study aimed to identify risk factors for complications and failure following plate osteosynthesis for PHF and discuss an age cut-off that surgeons should consider for complications. MethodsAdults with PHF treated with the proximal humerus internal locking system (PHILOS) at our large tertiary academic referral center between 2015 and 2020 were retrospectively identified. Univariate analysis was used to compare patients with and without complications. Then, a multivariate regression analysis was conducted to assess the possible complication risk factors. The receiver operating characteristic (ROC) curve of age was drawn to predict complication-free and favorable functional outcomes at the most recent follow-up. Oxford Shoulder Score (OSS) was considered favorable if OSS<10. ResultsA total of 135 patients were identified, with a mean age of 44 years (range 18-85 years) and a mean follow-up duration of 4.6 years (range 2-8 years). Complications were observed in 19 cases (14.1%), namely nonunion (n=5), avascular necrosis (n=1), infection (n=1), intra-articular screw perforation (n=1), arthritic changes (n=5), and superior humeral head migration (n=5). Eight patients (5.9%) needed revision surgery. Older age (OR=1.09) and Neer IV class (OR= 8.3) were associated with an increased likelihood of complication (P<0.001, P=0.02, respectively) in logistic multinominal regression analysis. The ROC curve for age in predicting complication-free cases had an area under the curve (AUC) of 0.829, indicating age as a significant predictor of ORIF outcomes in PHF (P<0.05). The optimalcut-off for age was 44 years, which yielded a sensitivity of 100% and a specificity of 65.7. The age ROC curve for predicting favorable OSS (OSS<10) had an of 0.829, indicating that age could predict the favorable OSS outcomes of ORIF in PHF. The optimal age cut-off was 46 years, yielding a sensitivity of 70.0% and a specificity of 78.6%. ConclusionThe outcomes of ORIF for PHF in patients older than 45 years are associated with significantly higher complication rates and poorer functional outcomes. Surgeons should possibly consider other treatment options for PHF in each older patient individually, especially with Neer type IV fractures.

Ulcerative Jejunitis in Celiac Disease: A Thirty-Year U.S. Experience.

Ulcerative jejunitis (UJ) or ulcerative enteritis (UE) is a rare complication of celiac disease (CeD). Guidelines regarding diagnosis and management are missing and these cases have seldom been reported in the United States. Single center case-series of CeD in which UE developed at a large academic center in the USA. Clinical presentation, diagnosis, treatment, and evolution of disease were collected. Eight cases were identified (6M/2F, mean age 59.5 (38-77) years). Presentations included intestinal obstruction (n=3), GI hemorrhage (n=3), and malabsorption (n=2). Ulcers were present in the duodenum in 4 patients, and exclusively past the angle of Treitz in only 4 cases, which makes the term ulcerative enteritis (UE) more appropriate than UJ. Six out of eight had T-cell receptor (TCR) clonal gene rearrangements and two had definite aberrant T cells. Corticosteroids were tried in all patients without improvement and 5 underwent surgical resection. Three patients received cladribine. One patient received an autologous stem cell transplant, followed by ruxolitinib. Two were subsequently diagnosed with enteropathy-associated T-cell lymphoma (EATL), including one with cerebral EATL, and 1 died from hemophagocytic syndrome. Two are still alive, including one only on GFD and two were lost to follow-up after surviving at least 30 months post treatment. UE seems a more appropriate term to describe an ulcerative complication of CeD at high risk of obstruction or bleeding. Steroids were not effective. Treatment outcomes were variable, but with a 50% death rate.

Optimal anticoagulation strategy for left ventricular assist device patients undergoing thoracentesis: a retrospective study

Abstract Background Left ventricular assist devices (LVADs) are associated with thromboembolic risks necessitating anticoagulation, yet balancing these risks with bleeding concerns remains challenging. Current practice involves warfarin with a target INR of 2-3 alongside anti-platelet therapy. However, consensus on anticoagulation management is lacking, particularly during sub-therapeutic INR or procedural settings. Common strategies include bridging anticoagulation with heparin or enoxaparin, temporary cessation of anticoagulation during the procedure or uninterrupted anticoagulation. Purpose To evaluate and compare the incidence of bleeding and thromboembolic events in LVAD patients undergoing thoracentesis, with a focus on determining the optimal anticoagulation strategy during procedures. Methods Retrospective data was collected over one year from LVAD patients undergoing thoracentesis at a large academic center. Patients were categorized into ‘bridge’ (received intravenous heparin for bridging during thoracentesis) and ‘no-bridge’ (did not receive bridging anticoagulation) groups. Warfarin was paused before procedure and resumed after procedure in both groups. Baseline characteristics, including age, sex, race, BMI, LVAD type, and INTERMACS profile, were recorded. Primary outcomes were major bleeding and thromboembolic events within 30 days of warfarin cessation. Statistical analysis used t-test/Wilcoxon for continuous variables and Chi-square/Fisher exact test for categorical variables. A p-value &amp;lt;0.05 was considered significant. Results During the study, twenty LVAD patients underwent thirty-two thoracenteses (nineteen bridge, thirteen no-bridge). The demographics were similar among the two groups. Warfarin was held for an average of 5.5 ± 4.6 days before and resumed 4.1 ± 4.6 days after the procedure in the bridge group and 3.8± 3.2 days before and 1.7 ± 2.5 days after in the no-bridge group. Major bleeding occurred in 73.7% of bridge group cases versus 30.8% of no-bridge group cases (p=0.059). 63.2% of bridge group patients had a bloody pleural effusion on thoracentesis compared to 46.2% of no-bridge group patients (p value= 0.34). Average transfusion requirements were 2.8 units and 2 units in the bridge and the no-bridge groups respectively (p=0.658). Thromboembolic events included a 10.5% ischemic CVA rate in the bridge group, with none in the no-bridge group. No other arterial thromboembolic events, pump thrombosis or DVT/PE were observed in either group. Conclusion In LVAD patients undergoing thoracentesis, a non-bridging strategy does not appear to elevate the risk of thrombosis compared to a bridging approach. Moreover, the incidence of bleeding, while not statistically significant, trended higher in the bridging group.

PO0430: Design and Implementation of an Ultrasound-Based High Dose Rate Prostate Brachytherapy (HDR-PB) Program in a Large Academic Center

PO0430: Design and Implementation of an Ultrasound-Based High Dose Rate Prostate Brachytherapy (HDR-PB) Program in a Large Academic Center

Using Mortality and Morbidity Conferences in Advanced Practice Nurse Education to Enhance Student Self-Efficacy.

The integration of morbidity and mortality (M and M) conferences into advanced practice nurse (APN) nursing curricula is a novel approach aimed at enhancing education, reflective learning, and continuous improvement. M and M conferences have traditionally been a standard practice for medical specialties, yet a gap exists in their utilization within APN education. A quasiexperimental pilot study with 20 student registered nurse anesthetists was conducted at a large urban academic center. The General Self-Efficacy Scale was utilized to evaluate student self-efficacy and confidence in managing adverse events. Significant improvement in self-efficacy scores (p = .003) postintervention indicated the educational benefits of M and M conferences. All participants reported increased confidence in navigating unexpected events. The M and M conference is a valuable tool within APN education for cultivating self-efficacy and confidence in navigating adverse events. [J Nurs Educ. 2024;63(X):XXX-XXX.].

A Resident Narrative Medicine Curriculum to Promote Professional Identity Development: Story-Based Sessions Grounded in Narrative Learning Theory.

Empathy, reflection, and social connectedness are important skills for physician identity development and are increasingly challenged by burnout. Humanities-based interventions like narrative medicine (NM) are emerging in medical education to promote these skills. Only 17% of such initiatives target graduate medical learners. Furthermore, interventions are inconsistent in approach and theory representation. NM uses story-based learning to promote reflection and group discussion. Inspired by narrative learning theory, we developed NM sessions for residents to foster healthy identity development. Ninety-minute sessions were integrated into curricula for PGY 1-PGY 3 internal medicine-primary care residents at two large academic centers. Sessions involved engagement with a narrative source (stories, poems, art), personal reflection, and group discussion. Topics ranged from burnout to difficult patients. Participants completed anonymous postsession surveys assessing satisfaction, attitudes, and skills. Fifteen sessions occurred from 2021 to 2023, with three to 10 residents per session. Fifty residents completed between one and four sessions, with 68 survey responses (response rate: 88%). Over 95% ranked 4-5 out of 5 for overall impression (n = 67) and personal value (n = 65) of sessions. Sessions were highly enjoyable (M = 4.8), with mean scores of >4 out of 5 for impact on wellness, appreciation of work values, social connectedness, and patient care. NM sessions demonstrated measurable improvements in several domains of professional performance including wellness, job satisfaction, and patient care, while promoting camaraderie and emotion processing. Our materials offer tremendous potential for promoting healthy identity formation.

The impact of institutional measures on optimal use of intravenous immunoglobulin.

Intravenous immunoglobulin (IVIG) shortage represents an emerging issue in transfusion medicine. Limited data are available to determine effective strategies for optimal use. The objective of this retrospective observational study was to determine the impact of institutional measures on IVIG use at a large academic center. IVIG infusions from November 26, 2018 to September 25, 2022 were categorized according to their appropriateness (Recommended, Option of treatment, or Unrecommended), based on provincial guidelines, and separated into three phases: Reference, Transition, and Post-Implementation phases, the latter following the adoption of restrictive measures, including mandatory standardized order forms, a blood bank gatekeeping strategy, and the creation of a stewardship committee. A total of 5431 IVIG infusions were administered to 544 patients, accounting for 295,033 g. The most common indication categories were neurology (30.4%), immunology (29.0%), and hematology (17.4%). From Reference to Post-Implementation phase, IVIG infusions decreased from 2275 to 2000 with unrecommended indications dropping from 9.5% to 7.4% (p = 0.01), and a global reduction of 23.0% (from 131,163 g to 100,936 g of IVIG). Decrease in chronic immunomodulation accounted for 48.3% of total reduction (14,610 g of 30,227 g), whereas single-use immunomodulation, 40.5% (12,237 g of 30,227 g). Moreover, an absolute reduction of 16.9% was observed in orders exceeding the recommended doses (20.8% to 3.9%; p < 0.0001). Together, the unrecommended and excessive IVIG doses decreased from 19,975 g (15.2%) to 6670 g (6.6%). A global reduction in IVIG use and a preferential decrease in the unrecommended orders were observed, most likely attributable to the bundle of restrictive strategies implemented.

Pediatric Dermatology eConsultation in Academic Centers: A Collaborative Model for Optimized Outpatient Care.

The demand for pediatric dermatology services in the U.S. is high, especially at large academic healthcare centers. eConsultation programs provide a solution to poor in-person access by offering diagnostic and management support to primary care providers (PCPs). To determine the real-world utility of eConsultation in pediatric dermatology within a closed system at a major academic center, we assessed the outcomes, diagnostic and management concordance, and predictors of eConsult completion of an asynchronous provider-to-provider pediatric dermatology eConsult program. Retrospective cohort study of 900 consecutive outpatient pediatric dermatology eConsult referrals from PCPs at a tertiary academic center from 2017 to 2021. Of 900 eConsult referrals, 621 (69%) were completed without the need for in-person dermatology follow-up. 46 (5%) were completed but required follow-up. 233 eConsult referrals (26%) were declined, primarily due to medical complexity. Thirty referrals (3%) were declined because of inadequate clinical photos. The PCP communicated eConsult recommendations to the patient/family on an average of 1.6 days (SD 3) after receiving the completed eConsult. eConsults for adolescents were less likely to be completed compared to infants (p = 0.03). Diagnostic and management concordance between PCP and dermatologist was 78% and 67%, respectively. Provider-to-provider eConsultation provides rapid speciality guidance to PCPs managing low-complexity skin conditions in pediatric outpatients. The lower rate of management plan concordance compared to diagnostic concordance suggests that eConsultation improves outpatient skin management by PCPs.

Phenotyping Adherence Through Technology-Enabled Reports and Navigation (the PATTERN Study): Qualitative Study for Intervention Adaptation Using the Exploration, Preparation, Implementation, and Sustainment Framework.

Older adults with multiple chronic conditions (MCC) and polypharmacy often face challenges with medication adherence. Nonadherence can lead to suboptimal treatment outcomes, adverse drug events, and poor quality of life. To facilitate medication adherence among older adults with MCC and polypharmacy in primary care, we are adapting a technology-enabled intervention previously implemented in a specialty clinic. The objective of this study was to obtain multilevel feedback to inform the adaptation of the proposed intervention (Phenotyping Adherence Through Technology-Enabled Reports and Navigation [PATTERN]). We conducted a formative qualitative study among patients, clinicians, and clinic administrators affiliated with a large academic health center in Chicago, Illinois. Patient eligibility included being aged 65 years or older, living with MCC, and contending with polypharmacy. Eligibility criteria for clinicians and administrators included being employed by any primary care clinic affiliated with the participating health center. Individual semistructured interviews were conducted remotely by a trained member of the study team using interview guides informed by the Exploration, Preparation, Implementation, and Sustainment Framework. Thematic analysis of interview audio recordings drew from the Rapid Identification of Themes from Audio Recordings procedures. In total, we conducted 25 interviews, including 12 with clinicians and administrators, and 13 with patients. Thematic analysis revealed participants largely found the idea of technology-based medication adherence monitoring to be acceptable and appropriate for the target population in primary care, although several concerns were raised; we discuss these in detail. Our medication adherence monitoring intervention, adapted from specialty care, will be implemented in primary care. Formative interviews, informed by the Exploration, Preparation, Implementation, and Sustainment Framework and conducted among patients, clinicians, and administrators, have identified intervention adaptation needs. Results from this study could inform other interventions using the patient portal with older adults.

Time-Driven, Activity-Based Cost Analysis of Pars Plana Vitrectomy in Rhegmatogenous Retinal Detachment at a Large Academic Center

Purpose: To perform a time-driven, activity-based cost analysis of retinal detachment (RD) surgery and compare it with reimbursement rates. Methods: This economic analysis at a single academic institution used time-driven, activity-based costing methodology to determine the cost of rhegmatogenous RD repair with primary pars plana vitrectomy. A process flow map was created to highlight each surgical case’s operative episodes, including clinical follow-ups. Time logs were obtained from the electronic health record for each operative phase and clinical follow-up. The overhead and anesthesia costs were collected from the institution’s cost accounting system. The direct material and personnel costs were obtained from internal financial data. Results: Seventy-six cases that met the inclusion criteria were included in the cost analysis study. The time-driven, activity-based cost of RD was $6247.17, and the reimbursement was $5442.91. Therefore, each procedure had a net negative loss of $804.26. To break even, the average operation time would need to be reduced from the determined average of 90.49 minutes to 64.90 minutes. Conclusions: This study found that Medicare underestimates the true cost of RD surgery. Changes in referral patterns may be motivated by reimbursement rates lower than the cost of the procedure, which could ultimately affect patient access to care.

The Effect of Extreme Alkalemia upon Presentation to the Emergency Department on Patient Outcomes

Background/Objectives: The prognostic significance of alkalemia found in an initial emergency department (ED) evaluation has not been described thus far. Methods: We retrospectively reviewed the records of all patients aged 18 years or older evaluated in the ED of one large academic referral center during 2000–2023. Included patients were those with at least one measurement of pH ≥ 7.55 upon initial ED presentation. Alkalemia was deemed primarily metabolic (PM) if PCO2 was ≥35 mmHg and primarily respiratory (PR) if bicarbonate levels were ≤24 mEq/L. The primary outcome was survival 30 days from ED presentation. Results: Of 2440 patients included, 199 (8.1%) had PM and 1494 (61.2%) had PR. Alkalemia severity was not correlated with prognosis. Survival at 30 days was significantly (p &lt; 0.001) lower in the PM group (78.9%) compared with that of either the PR (95.3%) or the combined etiology (92.2%) groups. Multivariate survival analysis after balancing potential observed confounders using propensity score matching revealed the type of alkalemia (PM vs. PR) to be a significant predictor of 30-day mortality (aHR 1.73; 95% C.I. = [1.07 to 2.82]; p = 0.026), irrespective of age, other laboratory values obtained on ED evaluation (including pH), past medical history, or vital signs on presentation. Conclusions: In patients presenting to the ED with significant alkalemia, the mechanism of alkalemia, i.e., primarily metabolic versus primarily respiratory, rather than the absolute degree of alkalemia, is associated with increased mortality.

12351 Real World Performance of the Afirma Xpression Atlas in Bethesda V and Vi Thyroid Nodules: A Private Practice Experience

Abstract Disclosure: M.S. Tkach: None. E. Coughlin: None. A. Pinero-Pilona: None. Fine Needle Aspiration (FNA) is a cornerstone of the diagnosis of thyroid cancer. The Bethesda System for Reporting Thyroid Cytopathology (BS-TCP), developed in 2010, and genomic sequencing classifiers (GSC) now allow clinicians to objectively identify the risk of malignancy of thyroid nodules (“TN”) prior to surgical interventions. For further characterization, the Afirma Xpression Atlas (XA) was created and launched in May 2018, utilizing RNA sequencing to evaluate fusions and variants. As of 2023, the Afirma XA panel includes 905 genomic variants and 235 fusions from 593 genes. Post-validation studies for the Afirma XA have focused on large academic centers, but applicability or extrapolation to smaller endocrinology practices is less clear, potentially due to different patient population and thyroid cancer prevalence. This study was designed to analyze and measure the performance of the Afirma XA in BS-TCP V and VI TN classified as GSC suspicious for malignancy in a small endocrinology practice. We conducted a retrospective cohort analysis comparing all BS-TCP V and VI TN with their respective final surgical pathology results between June 2018 and December 2023. 76 TN meeting the criteria for BS-TCP V or VI classification were identified. We excluded any TN (12 total) for which pathology data was unavailable; reasons ranged from lack of patient follow-up to patient's death with no autopsy available. Forty-seven thyroid TN were therefore included, and the BS-TCP VI category was the predominant cytopathology discovered, representing 78.7% of the TN in this group. Afirma XA was able to identify genomic alterations in 78.7% of all included TN (thus 78.7% is its sensitivity). Sensitivity of XA was found to be 70% in BS-TCP V (n=10) and 81.1% in BS-TCP VI (n=37). 83% of the analyzed TN were from female patients and 17% were from male patients; there was no statistically significant difference between XA frequency in TN from male vs. female patients. 100% of all BS-TCP V and VI TN (n=47) as determined by the cytopathologist were associated with cancer on pathology; thus, the sensitivity of the cytopathology itself is 100%, and positive predictive value of XA in both groups was 100%. Age and nodule size were not significantly associated with XA presence or absence overall. XA was overwhelmingly comprised of BRAF :p:V600E c.1799T&amp;gt;A mutations: 70.2% of of XA findings showed this mutation (50% in V and 75.6% in VI). Our percentage of XA on BS-TCP V and VI nodules reflects similarity to prior large studies in academic centers. Based on this data, we conclude that XA is a valuable tool for high-risk TN classification and treatment guidance; it can both aid in surgical planning and determine options for potential pharmacotherapy. We conclude that in our study, the relation between XA and cytopathology in BS-TCP V and VI nodules correlates well with data from large academic center studies, even in a small private practice. Presentation: 6/3/2024

Promotion and Tenure Database Creation and Utilization: A 12-Year History.

Trends in faculty demographic composition, promotion success, and retention are important considerations in Academic Health Centers (AHC). This paper reviews the design, implementation, and utility of a faculty promotion and tenure (P&T) database (PROMO/TE©) over 12years in a large southwestern academic health center. Review of the system design, portfolio creation, P&T tracking, interface with other faculty databases, and lessons learned will be offered. PROMO/TE© was developed to improve the P&T packet creation, application, and review process in one College and was expanded to other colleges at the AHC. The PROMO/TE© system is integrated with Workday® and FACFACTS© to track trends in recruitment, attrition, and P&T trends across gender, underrepresented minorities, and other subgroups. PROMO/TE© has several advantages including improving communication, transparency, uniformity, and efficiency in the P&T packet creation, application, and review process. Increased cost savings ($217,198 annually) were noted with elimination of hard copy packets and decreased time spent. The first college reviewed 743 dossiers in the PROMO/TE© system since its creation in 2012 and there has been on average a 10% increase in P&T approvals since its inception. PROMO/TE© facilitates and tracks trends in the P&T process and has many benefits as well as significant cost savings. PROMO/TE© serves as a potential model for other institutions.

12382 A Prospective Analysis of De Novo Thyroglobulin Antibodies in Patients with Differentiated Thyroid Cancer Using the Italian Thyroid Cancer Observatory Repository

Abstract Disclosure: B.S. Neutel: None. G. Grani: None. S. D'elia: None. C. Durante: None. A.G. Gianoukakis: None. The prevalence and significance of newly developed (de novo) thyroglobulin antibodies (dnTgAb) in patients with differentiated thyroid cancer (DTC) who were initially thyroglobulin antibody (TgAb) negative, is not well established. We sought to examine the phenomenon of dnTgAb using the Italian Thyroid Cancer Observatory (ITCO) database. Beginning in 2013, the ITCO repository prospectively collected clinical data on DTC management in a consecutive series of newly diagnosed patients treated in large academic centers distributed across Italy. Patients were managed by treating physicians based on perceived best practice. Pre-specified parameters were collected. Clinical status, investigations, and treatments were updated periodically. We formulated inclusion and exclusion criteria to mirror previously published literature studying dnTgAb. Patients included in the analysis were initially TgAb negative at their first postoperative check and had no evidence of persistent disease at their 1 year follow up visit. The dnTgAb group included patients who were initially TgAb negative and then developed TgAb on at least one measurement from the second postoperative check or later. All patients included in the study had at least 3 years of follow up and 3 TgAb measurements. At the time of analysis, 5360 patients were without persistent disease at 1 year. 2107 of these patients had a least 3 years of follow up and 3 TgAb measurements. 334 patients with positive TgAb at their first lab check and an additional 124 patient with incomplete data were excluded. 1649 patients met criteria for inclusion. Median follow up time was 1.85 years. DnTgAb occurred in 4.3% of patients (n=71). We found no statically significant difference in gender, tumor size, tumor focality, extrathyroidal extension, AJCC stage and ATA risk level between the persistently negative TgAb group and the dnTgAb group. Only primary tumor vascular invasion occurred at a higher rate in patients within the dnTgAb group when compared to the persistently negative group (p=0.012). Structural DTC recurrences occurred in 1.4% (n=22) of persistently TgAb negative patients and 5.6% (n=4) of patients with dnTgAb (p=0.02).This is the largest and first prospective cohort used to evaluate the prevalence and clinical significance of dnTgAb. DnTgAb occurred at a clinically relevant rate and there was a statistically significant relationship between detection of dnTgAb and structural DTC recurrence. The study is limited by the small overall recurrence rates and the exclusion of patients with less than 3 years of follow up. Presentation: 6/3/2024

Comprehensive Dynamic 3-Dimensional Analysis of the Tricuspid Valve in Functional Tricuspid Regurgitation: Implications for Prophylactic Tricuspid Valve Intervention

ObjectivesUnderstanding of changes in tricuspid annulus (TA) during secondary or functional tricuspid regurgitation (TR) is currently limited and its surgical management relies on limited 2-dimensional (2D) imaging. The aims of the study were to: 1) track and measure changes in TA using 3-dimensional (3D) echocardiography during complete cardiac cycle in patients with functional TR when compared to no TR, and 2) compare TAPSE derived from 2D and 3D coordinates as a measure of RV function when compared to standard method of fractional area change (FAC). DesignIntraoperative 3D echocardiography data was collected prospectively followed by post processing software analysis to track and reconstruct changes throughout the cardiac cycle. SettingData was collected from 108 patients undergoing left sided heart surgery at two large academic centers – Beth Israel Deaconess Medical Center in Boston, MA and Rhode Island Hospital, Providence, RI between from November 2018 to April 2020. ParticipantsFinal dataset (n=92) included two groups: no significant functional tricuspid regurgitation (NTR) group (n=74), defined as ≤ mild tricuspid regurgitation (TR) and TA < 35 mm, and a significant functional TR (FTR) group (n=18), defined as ≥ moderate TR. Interventions3D TEE datasets were analyzed, and the motion of TA coordinates was tracked during complete cardiac cycle in 2D and 3D planes using post-processing and software analysis. Computational modeling of TA motion was performed using computer-aided design. In further analysis, reconstructed and 3D printed models of TV were developed for the two groups. Measurements and Main ResultsPatients in FTR group had larger TA size during the cardiac cycle with less overall excursion and reduced annular dynamism. 3D motion of TA for lateral (L), anterolateral (AL) and posterolateral (PL) coordinates was lower in FTR group compared to NTR group [(18±6.8 vs 13.6±8.5, p=0.02), (15.2±5.5 vs 11.3±6.0, p=0.009) and (17.6±6.6 vs 12.3±5.2, p=0.002) respectively]. TAPSE derived from 3D planes was more accurate for RV function assessment (AUC 0.704, p = 0.011) than 2D TAPSE (AUC 0.625, p = 0.129). Finally, in the FTR group, the anteroseptal-posterolateral (AS-PL) diameter was consistently larger during all phases of cardiac cycle, in comparison with septo-lateral (S-L) diameter. Conclusion3D echocardiographic assessment of TA helps better understand its geometry and dynamism in functional TR, and is more accurate than 2D measurements for RV function assessment.

Impact of a Disease-Focused Electronic Health Record Dashboard on Clinical Staff Efficiency in Previsit Patient Review in an Ambulatory Pulmonary Hypertension Care Clinic.

We aimed to improve the operational efficiency of clinical staff, including physicians and allied health professionals, in the previsit review of patients by implementing a disease-focused dashboard within the electronic health record system. The dashboard was tailored to the unique requirements of the clinic and patient population. A prospective quality improvement study was conducted at an accredited pulmonary hypertension (PH) clinic within a large academic center, staffed by two full time physicians and two allied health professionals. Physicians' review time before and after implementation of the PH dashboard was measured using activity log data derived from an EHR database. The review time for clinic staff was measured through direct observation, with review method-either conventional or newly implemented dashboard-randomly assigned. Over the study period, the median number of patients reviewed by physicians per day increased slightly from 5.50 (interquartile range [IQR]: 1.35) before to 5.95 (IQR: 0.85) after the implementation of the PH dashboard (p = 0.535). The median review time for the physicians decreased with the use of the dashboard, from 7.0 minutes (IQR: 1.55) to 4.95 minutes (IQR: 1.35; p < 0.001). Based on the observed timing of 70 patient encounters among allied clinical staff, no significant difference was found for experienced members (4.65 minutes [IQR: 2.02] vs. 4.43 minutes [IQR: 0.69], p = 0.752), while inexperienced staff saw a significant reduction in review time after familiarization with the dashboard (5.06 minutes [IQR: 1.51] vs. 4.12 minutes [IQR: 1.99], p = 0.034). Subjective feedback highlighted the need for further optimization of the dashboard to align with the workflow of allied health staff to achieve similar efficiency benefits. A disease-focused dashboard significantly reduced physician previsit review time while that for clinic staff remained unchanged. Validation studies are necessary with our patient populations to explore further qualitative impacts on patient care efficiency and long-term benefits on workflow.

Evaluating Real-World Experience With Maribavir for Treatment of Refractory/Resistant Cytomegalovirus in Renal Transplant Recipients.

Maribavir was recently approved by the FDA, expanding treatment options for post-solid-organ transplant refractory/resistant CMV. We sought to describe the post-marketing experience with maribavir at a large academic transplant center. This was a retrospective observational study of all renal transplant recipients treated with maribavir for refractory/resistant CMV DNAemia/disease. CMV viral loads, immunosuppression regimens and management, resistance testing, and antiviral therapy durations were reviewed. Outcomes of interest included treatment success, defined as undetectable CMV DNAemia for two consecutive weeks or detected but unquantifiable DNAemia for five consecutive weeks, as well as the emergence of antiviral resistance, and recurrent DNAemia. From 2021 to 2023, 5/10 (50%) patients achieved durable virologic suppression with maribavir (classified as responders). Among responders, 2/5 (40%) experienced low-level CMV DNAemia recurrence (defined as a viral load less than 1000 IU/mL) within 8 weeks of antiviral discontinuation. Among nonresponders, 2/3 (66.7%) were found to have UL97 protein mutations associated with maribavir resistance identified 85 and 75 days after initiation of maribavir. Two patients are currently on maribavir with clinical outcomes that are yet to be determined. Responders had a mean reduction of 200mg (SD-274mg) in mycophenolate dosing with nonresponders having a mean increase of 167mg (SD-764mg). Maribavir, often in conjunction with mycophenolate dose reduction, was effective for many patients with refractory/resistant CMV DNAemia at our transplant center, though several experienced recurrent DNAemia. In patients who did not respond to therapy, resistance to maribavir was frequently detected. Clinicians treating these patients should remain vigilant for rebound CMV DNAemia and consider repeat antiviral resistance testing.

An Analysis of the Otolaryngology Workforce in Pennsylvania.

This study aims to analyze the distribution of otolaryngologists between urban and rural counties in Pennsylvania. Retrospective database. American Academy of Otolaryngology-Head and Neck Surgery (AAO-HNS) database and Centers for Medicare and Medicaid Services (CMS) Database. The AAO-HNS database (Entnet.org) and the CMS Database were used to identify otolaryngologists, their primary location, and their state of training. The 2023 Rural-Urban Continuum Codes were used to classify metropolitan (codes 1-3) and nonmetropolitan counties (codes 4-9) and determine county populations. A total of 388 otolaryngologists were identified across 67 Pennsylvania counties (33 metropolitan, 34 nonmetropolitan), 80% of which were male. There were 354 otolaryngologists in metropolitan counties serving 11.2 million people, with an average of 2.4 otolaryngologists per 100,000 people (/100 k). The majority of otolaryngologists (n = 235, 60.6%) are located in counties designated by code 1. There were 34 otolaryngologists in nonmetropolitan counties serving 1.8 million people, with an average of 2.4 otolaryngologists/100 k. Montour County (code 6) is home to a large academic center and accounts for 14/34 otolaryngologists in the nonmetropolitan counties. With the exception of Montour County, the remaining nonmetropolitan counties averaged 1.0 otolaryngologist/100 k. Only 3 metropolitan counties did not have otolaryngologists compared to 19 nonmetropolitan counties without otolaryngologists. Most otolaryngologists received their residency training in Pennsylvania (n = 177). New York (n = 35) and Maryland (n = 24) were the second most common states for training. There is a lack of otolaryngologists in rural counties of Pennsylvania, except in counties home to large academic centers.

Multimodal Imaging Characteristics and Correlation to Outcomes in Patients with CRAO Presenting to a Large Academic Center

PurposeTo characterize a large modern cohort of patients with central retinal artery occlusion (CRAO) by describing presenting features and outcomes relating to manually segmented optical coherence tomography (OCT) features, angiographic reperfusion, and visual recovery. DesignRetrospective clinical cohort study. MethodsPatients with CRAO (ICD-10: H34.1) initially presenting to a tertiary referral center between January 2017 and December 2021 were included. Demographics, eye exam findings, fundus photographs, OCT, and fluorescein angiography (FA) were analyzed. Main outcome measures included total and inner retinal thickness on macular OCT, reperfusion, visual outcomes, and development of neovascularization. Results145 eyes of 144 patients with mean age at of 69.4±13.6 years were included. The mean time to presentation was 1.6±4.2 days, with 19% examined within 4.5 hours and 26% within 6 hours of vision loss. 19% had cilioretinal artery (CLRA) sparing. Mean initial visual acuity (VA) was 1.68±1.10 LogMAR (CLRA sparing) compared to 2.53±0.58 LogMAR (non-CLRA sparing), P<0.001. 32% had elevated inflammatory makers. Out of 47 eyes with final fluorescein angiography, one-third showed some reperfusion. Final vision was 1.40±1.16 LogMAR (CLRA sparing) compared to 2.46±0.81 (non-CLRA sparing), P<0.001. A third of patients improved in VA in both groups, 27% of patients gained more than 2 lines of vision in the CLRA sparing group and 36% in the non-CLRA sparing group. 17% improved to better than 20/200 in CLRA-sparing and 4% in non-CLRA sparing. 11% developed neovascularization all in non-CLRA sparing. In a multiple linear regression, VA at presentation was associated with regaining vision of 2 lines or more (OR=2.603, P=0.007). OCT showed progressive thinning over time, reaching lowest measurements at 6 months, and stabilizing thereafter. ConclusionsIn this modern cohort of acute CRAO patients, presentation to a tertiary facility within 12 hours of symptoms was seen in almost half of the patients. Final visual acuity improved in almost a third of the patients, however, vision better than the legal blindness limit was rare (∼5%). Interestingly, a third of patients had some mild elevation of systemic inflammatory markers. Better visual acuity at presentation was associated with visual gain, while baseline OCT values had poor correlation with final outcome.