Large Academic Institution Research Articles

Abstract 4134345: Diastolic Dysfunction And The Risk Of Stroke And Major Bleeding

Background: Diastolic dysfunction (DD) is associated with adverse cardiovascular outcomes including atrial fibrillation. Whether DD is independently associated with incident ischemic stroke/transient ischemic attack (TIA) and with bleeding events is not well established. Aims: To examine the association of presence and severity of DD with the risk of incident ischemic stroke/TIA and major bleeding. Methods: A total of 219,667 patients who underwent at least one echocardiogram between 2010 and 2022 at a large academic institution and were followed for at least 3 months were included. Patients with prior history of stroke or TIA (n=21,505, 10%) were excluded. Smart key-phrase search was applied to echocardiographic reports to classify patients into 4 groups, based on the most severe DD assessment: Normal (n=113,265), grade I (n=21,981), grade II (n=7,215), and grade III (n=1,627). Patients in whom the presence of DD could not be determined (n=54,074) were excluded. The final study cohort (n=144,088) was followed to the endpoint of hospital admission for ischemic stroke/TIA or for major bleeding. Results: Over a median follow-up of 3.4 years, 3482 (2.4%) patients were hospitalized for stroke/TIA and 6994 (4.9%) for major bleeding. After adjusting for several confounding variables (Table), DD remained a strong predictor of incident stroke/TIA (hazard ratio (HR)=1.34 per grade increase in DD, p<0.001, Figure) and of major bleeding (HR=1.32 per grade increase in DD, p<0.001, Figure). These results were similar in patients with (n=11,508, 8%) or without prior history of atrial fibrillation. Conclusions: Patients with DD have a heightened risk of ischemic cerebrovascular accidents and major bleeding independent of the presence of atrial fibrillation. These risks escalate with the severity of DD. DD should be considered when counseling patients regarding their risk profile and management options.

Abstract 4137587: Need for Testing Standardization and Improved Treatment of Elevated Lipoprotein(a) at a Large Urban Academic Medical Center

Background: Lipoprotein(a) [Lp(a)] is causally linked to ASCVD events and aortic stenosis. Some guidelines now recommend screening of Lp(a) at least once in an adult’s lifetime. Currently, there is inconsistency in measurement modality (mg/dL vs. nmol/L), but most guidelines recommending testing in nmol/L due to less variability and improved standardization. We sought to determine the Lp(a) measurement practices, including testing modality and downstream interventions, at a large academic medical institution. Methods: We evaluated all patient encounter data at UT Southwestern Medical Center (UTSW) between January 1, 2017 to December 31, 2021 for any Lp(a) measurement. High Lp(a) was defined as >50mg/dL or >125 nmol/L. Aggregate data were used to summarize patient demographics, relevant ASCVD co-morbidities, and lipid lowering prescriptions. Chart-review was conducted on patients with high Lp(a) to assess referrals to specialty clinics. Results: From 2017 to 2021, there were 1,065 Lp(a) measurements among 938 patients, representing fewer than 0.1% of all patients with labs at UTSW. Most were ordered by cardiologists (71%). Lp(a) tests ordered by cardiologists increased 69% annually but remained stagnant for other specialties (figure 1, lines). Median Lp(a) levels across all tests were 17mg/dL and 43nmol/L. Lp(a) was high in 30% of all initial tests. A higher proportion of tests ordered in 2021 by cardiologists (84%) were in nmol/L, the recommended standard, compared with other specialties (55%) (figure 1, bars). Patients with high Lp(a) found by a non-cardiologist were infrequently referred to cardiology (16%), and 53% of patients with high Lp(a) were prescribed lipid lowering therapy within 3 months. Conclusion: Lp(a) testing at a major academic medical center was rare and only marginally increased during the 5-year study period. Measurement frequency and assay varied widely between specialties, and there were potential opportunities for downstream interventions. In addition to improving awareness of Lp(a), there is an opportunity to standardize practice patterns regarding its measurement and implications.

Understanding faculty perspectives on health equity curriculum implementation in graduate medical education: a qualitative study.

Despite increased awareness of persistent healthcare disparities, integrating health equity education into medical residency curricula needs urgent expansion. The Accreditation Council for Graduate Medical Education (ACGME) mandates addressing healthcare disparities and social determinants of health, but implementation remains insufficient due to pervasive barriers. To explore residency faculty perspectives at one institution surrounding implementing a health equity curriculum within their programs. Between November 2022 and April 2023, qualitative interviews and focus groups were conducted with residency faculty participants (n = 13) from a large academic medical institution. Participants were recruited via an internal email list directory of program directors. Semi-structured sessions explored faculty perspectives on health equity curriculum implementation. Data analysis utilized template analysis and thematic coding. Faculty perceived barriers included limited time for teaching health equity, challenges in prioritizing health equity content within the curriculum, lack of formal training and expertise, discomfort in leading discussions, and institutional barriers such as resource allocation and lack of buy-in. Findings underscored the need for institutionally supported faculty development and protected learning time for health equity education. Despite participant recruitment and representation limitations, the study provides valuable insights for addressing curricular challenges. This study highlights critical areas for improving health equity curriculum implementation in graduate medical education. Addressing these faculty barriers can enhance resident competency in identifying and addressing healthcare disparities. The study received approval from the Thomas Jefferson Institutional Review Board (IRB #22E.762).

Disparities in Patient Portal Activation and Usage at a Large Pediatric Academic Institution.

Access to personal medical information promotes patient understanding of health issues and enables patient self-advocacy of healthcare needs. The advent of electronic medical record systems and the 2016 21st Century CURES Act promoted and encouraged patient access to personal medical information, yet technology-dependent modalities have often disadvantaged certain communities. We sought to evaluate whether disparities existed in access to patient portals at our institution, the main pediatric care provider in an area serving one million children. We evaluated the activation of patient portal accounts at our institution over the past decade (2010-2021). Portal activation data were analyzed by ethnic background and language preference and income information available based on primary home access location. Further, we evaluated portal activation rates over time and across institutional interventions. A logistic regression model was used to identify important demographic associations with portal account status. Over 1 million patients were served at our pediatric institution over the study period with 47.7% having ever activated their patient portals. Univariate analyses and ultimately logistic regression modeling demonstrated significant differences in portal activation by ethnicity (odds ratio (confidence interval):1.36 (1.34, 1.37)), language preference (1.39 (1.37, 1.40)), and median household income (1.00001 (1.00001, 1.00001)). Interim interventions were successful in improving portal activation rates. Overall, electronic medical record portal activation was less prevalent among Hispanic, non-English speakers, and patients living in communities with lower median household income. Opportunities for interventions exist to reduce healthcare disparities in these underserved communities.

Impact of Artificial Intelligence-Based Autosegmentation of Organs at Risk in Low- and Middle-Income Countries

Radiation therapy (RT) processes require significant human resources and expertise, creating a barrier to rapid RT deployment in low- and middle-income countries (LMICs). Accurate segmentation of tumor targets and organs at risk (OARs) is crucial for optimal RT. This study assessed the impact of artificial intelligence (AI)-based autosegmentation of OARs in 2 LMICs. Ten patients, comprising 5 head and neck (HN) cancer patients and 5 prostate cancer patients, were randomly selected. Planning computed tomography images were subjected to autosegmentation using an Food and Drug Administration-approved AI software tool and manual segmentation by experienced radiation oncologists from 2 LMIC RT clinics. The control data, obtained from a large academic institution in the United States, consisted of contours obtained by an experienced radiation oncologist. The segmentation time, DICE similarity coefficient (DSC), Hausdorff distance, and mean surface distance were evaluated. AI significantly reduced segmentation time, averaging 2 minutes per patient, compared with 57 to 84 minutes for manual contouring in LMICs. Compared with the control data, the AI pelvic contours provided better agreement than did the LMIC manual contours (mean DSC of 0.834 vs 0.807 in LMIC1 and 0.844 vs 0.801 in LMIC2). For HN contours, AI provided better agreement for the majority of OAR contours than manual contours in LMIC1 (mean DSC: 0.823 vs 0.821) or LMIC2 (mean DSC: 0.792 vs 0.748). Neither the AI nor LMIC manual contours had good agreement with the control data (DSC < 0.600) for the optic nerves, chiasm, and cochlea. AI-based autosegmentation generates OAR contours of comparable quality to manual segmentation for both pelvic and HN cancer patients in LMICs, with substantial time savings.

Burnout in neurosurgery in the post-pandemic era

ObjectiveBurnout syndrome impacts one of two neurosurgeons and negatively impacts both the individual and institution. The impact of burnout on neurosurgeons may have increased due to the SARS-COV-2 pandemic. Characteristics of burnout may differ among neurosurgeons and non-neurosurgeon physicians, and this may better target wellness initiatives designed to alleviate burnout. MethodsValidated burnout inventories (Maslach Burnout Inventory; MBI) were provided to physicians, including neurosurgeons, at a single, large academic institution. Rates of burnout and specific characteristics of burnout were compared. Free-response answers describing specific characteristics of burnout were also collected for neurosurgeons. ResultsA total of 294 physicians responded to the survey, including 40 neurosurgeons. The rate of burnout between neurosurgeons and non-neurosurgeons did not differ (39% vs 34%; p=0.631), but there were notable differences in the characteristics of burnout. Neurosurgery respondents were more likely to report depersonalization (p<0.001), and an additional 42.5% of neurosurgeon respondents reported a “period of hardship,” which may lead to subsequent burnout. Neurosurgeons also more frequently reported higher feelings of personal accomplishment (p<0.001). Targeted wellness interventions specific to neurosurgeons may alleviate and prevent burnout. ConclusionsWe show that although the rate of burnout does not differ for neurosurgeons, the characteristics of burnout may. This may represent the key to providing specialty-specific targeted interventions to alleviate burnout. Further, there is a significant proportion of neurosurgeons at risk for subsequent burnout for which additional importance must be placed to prevent progression to burnout.

7147 A Retrospective Evaluation of Biochemical and Clinical Criteria of Permanent Hypoparathyroidism After Total Thyroidectomy and Their Associated Outcomes

Abstract Disclosure: D.G. Su: None. S. Tsou: None. W. Shen: None. Q. Duh: None. C. Graves: None. I. Suh: None. Background: Postoperative hypoparathyroidism (hypoPT) is the most common complication of total thyroidectomy and carries long-term morbidity. However, reported incidences vary widely due to nonstandardized measurement practices and absence of a universally accepted definition. This study aims to evaluate various definitions of hypoPT and to identify influencing factors such as diagnosis and operative duration. Methods: We performed a retrospective analysis of patients with a diagnosis of hypoPT (ICD-9: E20, E20.0, E20.8, E20.9, E89.2) between January 2012 and January 2019 at a single large academic institution, and only included those who had underwent a total thyroidectomy six months prior. Definitions based on low parathyroid hormone (PTH) values (PTH &amp;lt; 10 pg/mL), low calcium levels (corrected calcium [Ca] &amp;lt; 8.5 mg/dL or ionized Ca [iCa] &amp;lt; 1.1 mmol/L), and postoperative supplementation (elemental calcium or vitamin D) were evaluated at 6 and 12 months postoperatively. Postoperative hypocalcemic symptoms were graded by disease severity (based on the presence of numbness/paresthesia, muscle spasms/aches, and Chvostek/Trousseau signs). Patient demographics, operative and pathological characteristics, and use of parathyroid autotransplantation were recorded. Results: Of 879 patients with hypoPT ICD-9 diagnoses, 124 (14%) underwent a total thyroidectomy and were included. Our cohort was 64% female with a median age of 52.9 years. Fifty-one patients (41%) had low PTH levels, 49 (39%) had low calcium levels, and only 26 (21%) had both low PTH and calcium. Of 94 patients (76%) with hypocalcemic symptoms, 68 (73%) required long-term calcium or vitamin D supplementation. Twenty-eight (22.6%) patients had either an ED visit or readmission for hypocalcemia postoperatively. One hundred seven patients (86%) had a pathologic diagnosis of malignancy, of which 37% had extrathyroidal extension, 25% vascular invasion, and 36% positive margins. Those who underwent parathyroid autotransplantation (33%) were less likely to meet biochemical definition of hypoPT (p = 0.0312). Dosage of calcium/vitamin D supplementation did not correlate with symptom grade. Conclusions: Postoperative hypocalcemic symptoms and long-term calcium/vitamin D supplementation were the most common characteristics found in our permanent hypoPT cohort. However, substantial heterogeneity in defining postoperative hypoPT exists, with no definition capturing the full spectrum of affected patients. Further research is necessary to develop reliable diagnostic criteria or biomarkers for hypoPT prediction and management. Presentation: 6/2/2024

State opioid prescribing laws and associations with radiotherapy delays and radiotherapy completion.

122 Background: In July 2018, Missouri introduced a 7-day limit for initial opioid prescriptions, though there was an exemption for cancer-related pain. However, some worry that the exemptions may be inadequate for patients with cancer who experience cancer-related pain. Since some courses of radiotherapy can cause pain (eg, mucositis, esophagitis), appropriate opioid access is important for helping patients complete radiotherapy in a timely manner, which is associated with oncologic outcomes. Methods: Patients with cancer of all ages treated with radiotherapy from 2018-2019 at a large academic institution in Missouri were identified. More recent data were excluded due to the COVID-19 pandemic and Missouri Medicaid expansion. Trends over time in the proportion of missed/delayed radiotherapy fractions, incomplete radiotherapy courses, and a composite measure of excessive delays (≥5 days) or incomplete course were evaluated in linear and linear probability models. Additional analyses included patients from Illinois, an adjacent state without opioid prescribing legislation, and we subsequently performed difference-in-differences analyses comparing the outcomes from pre- to post- Missouri opioid legislation between the states. We conducted unadjusted analyses as well as analyses adjusted for age, sex, site, radiotherapy modality and fractions, as well as other covariates that could impact access to radiotherapy (ZIP code deprivation, distance from the facility, insurance status, and social work referral for unmet needs). Subgroup analyses focused on patients with head and neck cancer and lung cancer receiving definitive radiotherapy, who are at high risk of radiotherapy-related pain. Results: A total of 2613 and 1518 patients from Missouri and Illinois were identified, respectively. 4.7% of fractions were missed/delayed, 3.7% of patients did not complete treatment, and 8.1% of patients had either an incomplete course or excessive delays. There were no statistically significant increases (ie, worsening) in any outcome in any quarter after opioid policy implementation, and there were significant decreases in the composite outcome in multiple post-policy quarters in both unadjusted and adjusted analyses. In difference-in-differences analyses comparing trends over time with patients from Illinois, there were no significant associations of policy implementation with any of the outcomes. Results were similar in subgroup analyses for patients with head and neck and lung cancers. Conclusions: Missouri legislation limiting opioid prescribing for non-cancer-related pain was not associated with significant changes in a patient’s ability to undergo radiotherapy. Limitations of the study include evaluation of a single center in a single state and the lack of other intermediate outcomes important to patients including access to opioid medication itself, which we will examine in future work.

WP6.9 - Essential Surgery Skills Course: A One Week Training Program to Prepare Surgeons for Humanitarian Deployment

Abstract Background Medical students, surgical trainees, and surgical faculty are increasingly interested in incorporating global surgery into their clinical practices and professional careers. However, many concerns remain about the preparation of surgeons for operating in resource-limited settings and their exposure to critical procedures such as cesarean sections, hysterectomies, or fracture reductions. In an attempt to address these concerns, academic institutions have developed advanced professional training programs for the global surgeon. Methods A six-day essential surgery skills conference was created at a large academic institution that provides trainees and surgeons with an overview of common surgical scenarios across orthopedics, urology, obstetrics, gynecology, general surgery, anesthesia and ultrasound in the form of didactics, simulations, and wet labs. Results 11 surgical trainees from four large academic institutions attended the essential surgery skills conference. Trainees attended sessions on point of care ultrasound, regional anesthesia, general anesthesia, hysterectomies, cesarean sections, post-partum hemorrhage, fracture reduction and fixation, ureteral injuries, and humanitarian deployment. A pre and post-test was administered. Improvement was noted in the trainees scores on the post-test in their knowledge of surgical subspecialty care. Trainees also reported feeling better prepared for humanitarian deployment. Conclusion Global surgery conferences can be designed to provide a networking and collaboration forum for improving access to surgical services worldwide. One-week predeparture conferences that discuss essential technical skills and relevant global surgery knowledge may better prepare surgeons to operate in resource-limited settings.

A comparison of handheld versus cart-based ultrasound in the evaluation and diagnosis of carpal tunnel syndrome

BackgroundCarpal tunnel syndrome (CTS) is responsible for over 90 % of median nerve neuropathies. Though a clinical diagnosis, evaluation of nerve conduction via electrodiagnostic studies (EDX) and median nerve cross sectional area (CSA) through sonographic imaging provides supporting evidence and insight into disease severity. The advent of handheld ultrasound devices offers a portable, cost-effective and non-invasive method for median nerve assessment, yet its accuracy compared to traditional cart-based ultrasound has not been assessed in this setting. Methods43 consecutive patients who presented to an outpatient orthopedic clinic within a large academic institution for symptoms consistent with CTS between August 2023 and April 2024 were included. Handheld sonography was performed with the Clarius Convex L20 HD3 8–20 MHz transducer. The GE Venue Go with a 4–20 MHz linear transducer was used for conventional cart-based ultrasound evaluation. A paired t-test was performed to compare the mean cross-sectional area (CSA) measured with the GE machine to the mean CSA measured with the Clarius transducer (p < 0.05). ResultsThe average CSA measurement obtained with the GE was 14.21 ± 4.89 mm2. The average CSA measurement obtained with the Clarius handheld transducer was 13.54 ± 4.50 mm2. The mean difference between the GE and Clarius groups was 0.62 mm2 (95 % CI = −1.47 to 2.71), p = 0.55. ConclusionCSA measurements of the median nerve obtained by a handheld ultrasound transducer are comparable to those measured by a traditional cart-based ultrasound machine for carpal tunnel diagnosis. The adoption of handheld ultrasounds in clinical settings holds the potential for quicker, more precise diagnoses and broader access to imaging.

Abstract 21: Feasibility of Harnessing Umbilical Cord Tissue for Alveolar Cleft Repair: A Collaboration between a Large Academic Institution and a Private Family Cord Blood Bank

Abstract 21: Feasibility of Harnessing Umbilical Cord Tissue for Alveolar Cleft Repair: A Collaboration between a Large Academic Institution and a Private Family Cord Blood Bank

Salivary Gland Neoplasm of Uncertain Malignant Potential (SUMP) (Milan IVB) and Its Subgroups: A Multi-Institutional Analysis of Risk of Neoplasm and Malignancy.

Fine needle aspiration (FNA) plays a crucial role in their initial assessment of salivary gland neoplasms. In the Milan System for Reporting Salivary Gland Cytopathology (MSRSGC), the category of Salivary Gland Neoplasm of Uncertain Malignant Potential (SUMP) categorizes lesions with ambiguous features. This study aims to investigate the risk of neoplasm (RON) and risk of malignancy (ROM) within different subgroups of SUMP lesions using data from three large academic institutions. We analyzed salivary gland (FNA) cases from three academic institutions post-MSRSGC implementation. Salivary gland FNA cases categorized as Milan IVB (SUMP) with subsequent surgical pathology follow-up were analyzed. Cases were divided into basaloid, oncocytic, and clear cell SUMP subtypes, with RON and ROM assessed and compared. Out of 1377 MSRSGC cases, 231 were SUMP (16.8%), with 101 subjected to surgical pathology follow-up. The overall ROM for SUMP was 20.8%, with variations of 10% to 29.5% observed amongst institutions, but no significant difference was observed among three institutions (p = 0.15). Basaloid and oncocytic SUMP displayed 17.1% and 20.5% ROM, respectively, without significant disparity. However, all clear cell SUMP cases were malignant on surgical resection. This study highlights the variability in ROM for SUMP lesions and the significantly higher ROM in SUMP cases with clear cell features. These findings emphasize the importance of accurately subcategorizing SUMP lesions, particularly those with clear cell features, for appropriate clinical management.

A Case Series of Primary Cutaneous Sarcomatoid Carcinoma With Aberrant Smooth Muscle Actin Expression: A Clinicopathologic and Immunophenotypic Study.

Primary cutaneous sarcomatoid squamous cell carcinoma can show significant histologic overlap with other malignant spindle cell tumors, posing a diagnostic challenge. Even with a wide array of immunohistochemical markers, the exact line of differentiation can be a challenge to identify in some cases. The picture is further complicated by the aberrant expression of myofibroblastic markers [such as smooth muscle actin (SMA)] by these neoplasms, along with a concomitant loss of conventional epithelial markers. The histologic differential diagnoses of primary cutaneous sarcomatoid squamous cell carcinoma include desmoplastic melanoma, leiomyosarcoma, and spindle cell atypical fibroxanthoma/pleomorphic dermal sarcoma (AFX/PDS). A retrospective analysis of 16 cases of PCSSCCs with SMA expression, obtained from large academic institutions, was performed and is summarized below. The tumors were in the scalp (6 cases), arm (4 cases), leg (2 cases), face (2 cases), hand (1 case), and neck (1 case). Immunohistochemical studies were performed in all cases with the following antibodies: AE1/AE3, CAM 5.2, MNF-116, p63, p40, CK5/6, S-100, SOX10, SMA, desmin, calponin, H-caldesmon, CD10, CD68, CD163, and CD34. Histopathologically, all cases were classified as high-grade malignant poorly differentiated neoplasms. Tumors were characterized by an infiltrative neoplasm that involved the entire reticular dermis and, in 7 cases, the subcutaneous fat. Three cases were associated with a well-differentiated squamous cell component. The neoplasms were composed of atypical spindle and epithelioid cells arranged in long and intersecting fascicles. All neoplasms were positive for epithelial markers (at least 1 marker), and all cases were strongly positive for SMA. Our data emphasize the diagnostic utility of multiple epithelial markers as a first screening tool in the detection and workup of malignant cutaneous sarcomatoid neoplasms. Awareness of SMA expression in these tumors can complicate its diagnosis, and it is important to recognize this aberrant immunophenotype to facilitate definitive diagnosis and avoid misdiagnosis.

CALMER Conflict: A Novel Curriculum for Graduating Medical Students to Manage and Defuse Patient-Provider Conflict.

Workplace violence disproportionately affects healthcare workers and verbal aggression from patients frequently occurs. While verbal de-escalation is the first-line approach to defusing anger, there is a lack of consistent curricula or robust evaluation in undergraduate medical education. To develop a medical school curriculum focused on de-escalation skills for adult patients and evaluate effectiveness with surveys and an objective structured clinical examination (OSCE). We implemented this curriculum in the "Get Ready for Residency Bootcamp" of a single large academic institution in 2023. Forty-four fourth-year medical students PROGRAM DESCRIPTION: The curriculum consisted of an interactive didactic focused on our novel CALMER framework that prioritized six evidence-based de-escalation skills and a separate standardized patient practice session. The post-curriculum survey (82% response rate) found a significant increase from 2.79 to 4.11 out of 5 (p ≤ 0.001) in confidence using verbal de-escalation. Preparedness improved with every skill and curriculum satisfaction averaged 4.79 out of 5. The OSCE found no differences in skill level between students who received the curriculum and those who did not. This evidence-based and replicable de-escalation skill curriculum improves medical student confidence and preparedness in managing agitated patients.

Mid-term outcomes of total hip arthroplasty in patients younger than 30 years.

Total hip arthroplasty (THA) has predominantly been utilized to treat older patients with primary osteoarthritis. However, recent improvements in surgical technique and implant materials have increased implant longevity, making THA a viable option for younger patients (< 30years old). While trend analyses indicate an expanding utilization of THA in younger patients with non-OA diagnoses, current data on mid- and long-term THA outcomes in this population are limited. This study aims to describe the demographics, perioperative data, and implant survivorship of patients younger than 30years undergoing THA. A retrospective study across two large urban academic medical institutions identified 135 patients aged < 30years who underwent 155 primary THAs between 2012 and 2017, with up to 10-year clinical follow-up. Baseline demographics, surgical indications, intraoperative details, and postoperative outcomes were analyzed. The mean age at surgery was 24.9 years (range 18-29). Osteonecrosis of the femoral head (55.5%), developmental hip dysplasia (28.3%), and arthritis (15.5%) were the primary indications. Most surgeries utilized the posterior approach (64.5%), manual technique (65.8%), and Ceramic-on-Polyethylene articulation (71.6%). Seven patients (4.5%) were readmitted within 90-days of surgery, including three non-orthopedic-related readmissions (1.9%) and four orthopedic-related readmissions (2.6%). Dislocations were reported in two patients (1.3%). There were six all-cause revisions (3.9%), four aseptic (2.6%) and two septic (1.3%). Kaplan-Meier analysis showed 10-year survival from implant retaining reoperation was 98.7%, 10-year survival from all-cause revision was 96.1%, and 10-year survival from aseptic revision was 97.4%. With a 10-year aseptic implant survivorship rate of 97.4%, THA is a reliable surgical intervention for patients younger than 30 years of age who have severe hip pathology. Further studies are warranted for a more comprehensive understanding of mid- and long-term survivorship risk factors in this demanding population, facilitating improved risk assessment and informed surgical decisions.

Exploring Health Inequalities and Presurgical Attitudes on Postsurgical Outcomes in Spine Surgery

The influence of social determinants of health on health disparities is substantial. However, their impact on postsurgical outcomes in spine can be challenging to ascertain at the community level. This study aims to explore the interplay between presurgical attitudes, area deprivation index (ADI), income, employment status, and body mass index (BMI) on postsurgical outcomes at 3, 6, 9, and 12 months after elective spine surgery. The study involved 127 patients who underwent elective spine surgery between August 2021 and August 2022 at a large academic institution. The main objective involved a prospective analysis of presurgical attitudes, coupled with a retrospective assessment of ADI, income, employment status, and BMI over 3, 6, 9, and 12 months following elective spine surgery using a univariate analysis. Utilizing the univariate analyses, ADI displayed a significant correlation with increased Patient-Reported Outcomes Measurement Information System and Visual Analog Scale scores both before surgery and at the 3-, 6-, and 9-month postsurgical intervals (P < 0.05). One year after surgery, patients in the lowest income group (annual income under $25,000) consistently demonstrated the highest Patient-Reported Outcomes Measurement Information System pain (8.00, P= 0.022). Patients who were not employed had significantly lower levels of social support (P= 0.042) and confidence in the health care system (P= 0.009). Individuals who were unemployed were most likely to be readmitted six weeks after surgery (P < 0.001). Presurgical attitudes, ADI, income, employment status, and BMI were important factors associated with improved surgical outcome measurements, indicating potential focal points for combating health disparities in spinal surgery patients.

Laparoscopic Vecchietti procedure: pearls for success

To present an effective strategy for optimizing the care of patients with Müllerian agenesis who desire surgical management for the creation of a neovagina with the laparoscopic Vecchietti procedure. This video provides a framework for patient evaluation and selection, surgical strategy, and postoperative care regimen to provide optimal postprocedural outcomes. Academic Hospital. This is a 22-year-old patient with Müllerian agenesis who was unsuccessful with conservative strategies for vaginal lengthening and sought care for neovagina creation. The patient underwent preoperative pelvic floor physical therapy and vaginal dilation, both of which were ineffective in producing adequate vaginal lengthening. We then performed a laparoscopic Vecchietti procedure. The procedure occurred at a large academic institution with two obstetrics-gynecology subspecialty surgeons providing perioperative care. A vaginal length of 7 cm was achieved, which was sustained at >12 months. The patient was managed by a multidisciplinary team using our established care regimen, with follow-up demonstrating a sustained positive treatment outcome. The vaginal length at more than 1 year after the procedure measured 7 cm. Using a methodological, patient-focused approach and an experienced multidisciplinary team can optimize immediate- and long-term surgical outcomes for patients with Müllerian anomalies who do not have acceptable success with conservative methods.

Direct to Patient Synchronous Teledermatology During COVID-19 Pandemic.

Background: During the COVID-19 pandemic, teledermatology became a popular mode of health care delivery. Thus, deciphering which diagnoses are best suited for synchronous video visits is important to guide providers on appropriate patient care. Methods: We conducted a retrospective study of 1,647 submitted synchronous video visits from September 1, 2020 to March 31, 2021 at a single, large academic institution. Results: Video visits' follow-up rate was significantly associated with diagnosis subtype (p < 0.001). Compared with patients with skin lesions and nonskin dermatologic conditions, patients with a rash had higher odds of being recommended to have their follow-up visit as a video visit (odds ratio [OR] = 0.222, p < 0.001; OR = 0.296, p < 0.001). Patients with a rash had lower odds of being recommended to have their follow-up visit as an in-person office visit when compared with skin lesions (OR = 9.679, p < 0.001), nonskin dermatologic conditions (OR = 4.055, p < 0.001), and other skin dermatologic conditions (OR = 2.23, p < 0.01). Demographically, employed, middle-aged patients with private insurance made up the majority of video visit usage. African American patients were less likely to utilize a video visit compared with Asian patients (OR = 2.06, p < 0.038). Conclusions: Certain dermatologic diagnoses, most notably rashes, are more conducive to video visit management. Rashes made up 86% of new patient video visits, were more likely to have video visit follow-up if needed and were more likely to not require further follow-up indicating that the management of rashes from initial diagnosis to completion in care is suitable for video visit management.

Cleaning and Durability of Upper Extremity Orthotics: A Patient's Perspective.

Introduction We aimed to evaluate orthotic hygiene, preference for immobilization material, and frequency of unplanned orthotic adjustments and replacements. Methods All patients with fiberglass casts, thermoplastic splints, or prefabricated braces who presented at a large private academic institution between January 2020 and July 2023 were provided an 11-item survey assessing the length of immobilization, frequency of orthotic changes, orthotic hygiene, preference of immobilization, and whether patients recall instructions regarding orthotic care. Results A total of 385 surveys were collected, consisting of 96 (24.9%) casts, 202 (52.5%) thermoplastic splints, and 87 (22.6%) prefabricated braces. Patients were most frequently immobilized for two to six weeks. Of those, 106 (27.5%) patients required an unplanned adjustment or replacement. Almost half (182 patients, 47.3%) attempted to clean their orthotics, which was significantly greater among thermoplastic splints. A total of 229 (59.5%) respondents reported either not receiving or were unsure if they received instruction on proper orthotic hygiene. Conclusion Orthotic care and hygiene instructions are often overlooked or not retained by patients. Nearly one-third of patients required an unplanned adjustment or replacement, which was most frequent with thermoplastic orthotics.

What Is the Value Proposition of Evidence-Based Guidelines? An Application of the Operative Value Index for Lumbar Fusions

Elective lumbar fusions have received criticism for inappropriate utilization. Here, we use a novel Operative Value Index (OVI) to assess whether "indicated," evidence-based lumbar fusions are associated with increased value (outcomes per dollar spent). This study is a retrospective analysis of a prospective observational cohort of 294 patients undergoing elective lumbar fusions at a single large academic institution. All patients were preoperatively evaluated by a panel of neurosurgeons for concordance with evidence-based medicine (EBM), determined through guidelines from the North American Spine Society. Oswestry Disability Index (ODI) scores were collected for all patients both preoperatively and at 6-months postoperatively. Time-driven activity-based costing was employed to determine both direct and indirect intraoperative costs. The OVI was defined as the percent improvement in ODI per $1000 spent intraoperatively. Generalized linear mixed model regression, adjusting for confounders, was performed to assess whether EBM-concordant surgeries were associated with higher OVI. Of 294 elective lumbar fusions, 92.9% (n= 273) were EBM-concordant. The average total cost of an EBM-concordant lumbar fusion was $17,932 (supplies: $13,020; personnel: $4314), compared to $20,616 (supplies: $15,467; personnel: $4758) for an EBM-discordant fusion. Average OVI was 2.27 for a concordant fusion, compared to 0.11 for a discordant fusion. Generalized linear mixed model analysis revealed that EBM-concordant cases were associated with significantly higher OVI (β-coefficient 2.0, P < 0.001). EBM-concordant fusions were associated with 2% greater improvement in ODI scores from baseline for every $1000 spent intraoperatively. Systematic methods for increasing guideline adherence for lumbar fusions could therefore improve value at scale.