Large Medical Center Research Articles

Traditional cardiovascular risk factors and coronary microvascular disease in women and men- a single center study

Abstract Introduction Coronary microvascular dysfunction (CMD) is a common, often missed, cause for effort intolerance and angina symptoms, and is associated with adverse clinical outcomes. Risk factors for the development of CMD have not been fully elucidated, and studies examining sex associated differences in traditional cardiovascular risk factors (TCRs) for obstructive coronary artery disease (CAD) in patients with CMD have yielded conflicting results. Although several non-invasive methods for the evaluation of CMD exist, currently, catheter-based invasive assessment is the gold standard for the diagnosis of coronary microvascular dysfunction. Purpose To examine the association between TCR and CMD and sex associated differences in TCR, in a prospective cohort of patients undergoing invasive microvascular function evaluation in a large tertiary medical center. Methods In this single center, prospective registry, we enrolled patients with non-obstructive CAD undergoing clinically indicated invasive assessment of coronary microvascular function between November 2019 and March 2023. Measurements of microvascular function included CFR, IMR, RRR as well as FFR. Pathologic CFR was defined as <2.5 or <2. Associations between coronary microvascular dysfunction, traditional cardiovascular risk factors, and sex were assessed using univariate and multivariate regression models. Results Overall, 245 patients with non-obstructive CAD were included in the analysis (62.9% female; median age 68 (interquartile range [IQR]: 59,75). Microvascular dysfunction was diagnosed in 141 patients (57.5%). The prevalence of microvascular dysfunction was similar in women and men in the entire cohort (59.0% vs. 57.0%; p=0.77). In 41 patients diagnosed with functional microvascular dysfunction there were more women than men (70.7% vs. 29%). When using a threshold of CFR<2.5 no association was found between traditional risk factors for coronary atherosclerosis and CMD regardless of whether CMD was structural or functional. In women, but not in men, older age and the presence of previous ischemic heart disease were associated with lower coronary flow reserve (CFR) (β=-0.29; p<0.01 and β=-0.15; p=0.05, respectively) and lower resistive reserve ratio (RRR) (β=-0.28; p<0.01 and β=-0.17; p=0.04, respectively). When using a threshold of <2.0 for CFR similar results were found. Conclusion The prevalence of TCRs was similar in patients with and without CMD. In women, older age and previous IHD were associated with lower CFR and RRR values while no association between TCRs and indices of CMD was found in men. It is likely that there are other, currently unknown risk factors for CMD as well as unique risk factors for each of its endotypes, beyond TCRs. It is unclear which parameter of microvascular dysfunction is the most accurate, and whether different parameters should be used in women and men. Large-scale multi-center studies to further evaluate these issues are needed.Variables associated with CMDStudy inclusion process

Does infection with COVID-2019 during labor increase the risk for obstetric anal sphincter injuries?

To investigate the association between coronavirus disease 2019 (COVID-19) infection during the peripartum period and obstetric anal sphincter injuries (OASIS). A retrospective cohort study was conducted, including all singleton vaginal deliveries and cesarean deliveries due to failed vacuum extraction, between June 2020 and January 2022 at a large tertiary medical center. OASIS complication during childbirth was compared between women with and without peripartum diagnosis of COVID-19, defined as a positive polymerase chain reaction test obtained within 1 week before delivery or up to 3 days after delivery. Universal screening for COVID-19 was implemented. A logistic regression model was used to adjust for confounding variables. The study included 22 911 women, among whom 468 (2.0%) tested positive for COVID-19 and 22 443 women had no COVID-19 diagnosis. After adjusting for confounding variables, peripartum infection with COVID-19 was found to be independently associated with OASIS (adjusted odds ratio 4.38, 95% confidence interval 2.00-9.61; P < 0.001). Infection with COVID-19 during the peripartum period significantly increases the risk for OASIS by more than fourfold. These findings emphasize the importance of understanding the impact of COVID-19 on birth complications, such as OASIS, to improve public health measures and enhance obstetric outcomes during pandemics.

Spatial and Racial/Ethnic Variation in the Prevalence of Cesarean Delivery in a South Carolina Medical Center.

While racial/ethnic disparities in cesarean delivery have been noted in the literature, less is known about the intersection between individual-level race/ethnicity and community-level social vulnerability as factors in cesarean delivery. The goal was to use medical record data from a large medical center combined with census tract-level data to examine patterns of social vulnerability, racial population distribution, and prevalence of cesarean delivery. Data were obtained from electronic medical records of patients from a large medical center in South Carolina from 2019 to 2020. The outcome variable was cesarean delivery (yes/no), and covariates included the year of delivery; age of patient; race/ethnicity; spoken language; BMI categories; clinical indications of anemia, hypertension, preeclampsia, and diabetes; and census tract Social Vulnerability Index (SVI). Generalized linear mixed models for multilevel binary logistic regression were used to test the main hypothesis that the census tract level Social Vulnerability Index is positively associated with cesarean delivery. Among a total of 5011 patients, we found that non-Hispanic Black mothers were more likely to have cesarean deliveries compared with non-Hispanic White mothers. After controlling for census tract-level SVI, the individual-level race/ethnicity association was no longer significant. Significant spatial autocorrelation across census tracts was evident for cesarean delivery prevalence, non-Hispanic Black population, and SVI. A high prevalence of cesarean delivery tended to cluster with high SVI and a high non-Hispanic Black population. We found that non-Hispanic Black mothers were more likely to have cesarean deliveries, which was explained by census tract differences in the SVI.

Predictors of seropositivity to SARS-CoV-2 among employees at a large urban medical center

BackgroundBefore SARS-CoV-2 vaccination availability, medical center employees were at high risk of COVID-19. However, risk factors for SARS-CoV-2 infection in medical center employees, both healthcare and non-healthcare workers, are poorly understood.MethodsFrom September-December 2020, free IgG antibody testing was offered to all employees at a large urban medical center. Participants were asked to complete a questionnaire on work and non-work related risk factors for COVID-19 infection.ResultsSARS-CoV-2 seropositivity was found in 4.7%. Seropositivity was associated with close contact with COVID-19 cases with or without the use of adequate personal protective equipment (PPE), (OR 3.1 [95% CI 1.4–6.9] and OR 4.7 [95% CI 2.0–11.0] respectively), never wearing a mask outside of work (OR 10.1 [95% CI 1.9–57]), and Native Hawaiian/Pacific Islander race (OR 6.3 95% CI (1.6–25)].ConclusionsAmong workers in a large urban medical center, SARS-CoV-2 seropositivity was associated with work-related COVID-19 close contacts and low mask use outside of work, suggesting that non-workplace close contacts are also relevant routes of COVID-19 spread among healthcare workers.

Unlocking the Potential of Secondary Data for Public Health Research: Retrospective Study With a Novel Clinical Platform.

Clinical routine data derived from university hospitals hold immense value for health-related research on large cohorts. However, using secondary data for hypothesis testing necessitates adherence to scientific, legal (such as the General Data Protection Regulation, federal and state protection legislations), technical, and administrative requirements. This process is intricate, time-consuming, and susceptible to errors. This study aims to develop a platform that enables clinicians to use current real-world data for testing research and evaluate advantages and limitations at a large university medical center (542,944 patients in 2022). We identified requirements from clinical practitioners, conceptualized and implemented a platform based on the existing components, and assessed its applicability in clinical reality quantitatively and qualitatively. The proposed platform was established at the University Medical Center Hamburg-Eppendorf and made 639 forms encompassing 10,629 data elements accessible to all resident scientists and clinicians. Every day, the number of patients rises, and parts of their electronic health records are made accessible through the platform. Qualitatively, we were able to conduct a retrospective analysis of Parkinson disease over 777 patients, where we provide additional evidence for a significantly higher proportion of action tremors in patients with rest tremors (340/777, 43.8%) compared with those without rest tremors (255/777, 32.8%), as determined by a chi-square test (P<.001). Quantitatively, our findings demonstrate increased user engagement within the last 90 days, underscoring clinicians' increasing adoption of the platform in their regular research activities. Notably, the platform facilitated the retrieval of clinical data from 600,000 patients, emphasizing its substantial added value. This study demonstrates the feasibility of simplifying the use of clinical data to enhance exploration and sustainability in scientific research. The proposed platform emerges as a potential technological and legal framework for other medical centers, providing them with the means to unlock untapped potential within their routine data.

Financial toxicity screening in an urban underserved patient population with cancer.

169 Background: Cancer-related financial hardship is associated with treatment delays, non-adherence and adverse survival outcomes. Racial/ethnic minorities and low-income households are disproportionately impacted by financial toxicity. The Comprehensive Score for Financial Toxicity (COST) measure is used to measure financial toxicity in research but has not been validated in low-income, racially diverse cancer patient populations. Methods: We conducted this study at a large urban medical center from January-August 2023. We included cancer patients on systemic therapy for at least 2 months with ECOG performance status 0-2. Participants completed the COST measure, the Functional Assessment of Cancer Therapy: General (FACT-G) and the European Organization for Research and Treatment of Cancer (EORTC) QOL to assess health-related quality of life (HRQOL). Cancer diagnosis/stage, demographic data, and social work/financial counseling interventions were abstracted. Factor analyses were conducted to determine the underlying factor structure of the COST measure responses and bivariate analyses were conducted to identify relationships between COST scores and other data. Results: 100 patients participated in the study; the average age was 65 and both sexes were equally represented. Most patients reported African American (67%) race/ethnicity. 72% of patients held less than a 4-year college degree, 22 % were unemployed and 55% reported a yearly household income of less than $35,000. Lung (46%) and gastrointestinal (38%) cancers were the most represented. 73% were enrolled in a government sponsored insurance program (Medicare, Medicaid). The average COST score among participants was 22 [range 0-44] and mean FACT-G and EORTC scores were 16.5 [range 0-28] and 59.6 [ range 0 – 100] respectively. Fifty-eight patients were referred to social work or financial counseling for financial interventions. Factor analysis revealed three predominant factors among the COST responses (Eigenvalues &gt; 1) including Factor 1: items 3, 7, 8, 9, 10, 11; Factor 2: item 4; Factor 3: item 5. COST was weakly associated with FACT-G and EORTC (Pearson range 0.27 – 0.37). The most highly correlated value was between the COST and EORTC physical wellbeing subscale (Pearson 0.38). The COST score was significantly associated with income, with higher incomes reporting less financial toxicity (p = 0.004). No significant differences in COST scores were noted across gender, race, or level of education. Conclusions: Low levels of financial toxicity were detected using the COST measure in a diverse, low-income cancer patient population despite many patients being referred to social work/financial counseling. Compared to similar studies, we found a weaker correlation between the COST measure and HRQOL. These findings suggest that the COST measure may need to be further adapted for use in underserved populations and patients with government sponsored insurance.

Vein Visualisation Technology for Peripheral Intravenous Access in Paediatric Patients: A Clinical Decision-Making Tool.

The aim of this study is to develop a clinical decision-making tool to guide utilisation of vein visualisation technologies and enhance chances of successful peripheral intravenous catheter (PIVC) insertion, using data collected from a vascular access team in a large paediatric medical centre in the United States. Quantitative two-phase, cluster analysis design. The study consisted of the following two phases: (1) a quantitative retrospective chart review to evaluate clinician utilisation and preference for vein visualisation technologies and (2) a quantitative prospective design, including a post-discharge retrospective chart review, to confirm utilisation of vein visualisation technologies and factors influencing clinician decision-making. A total of 16 groups were created based on the cluster analysis and expert clinician input. The results of first-attempt success analyses identified optimal device recommendations for each of the 16 patient groups. For patients older than 2 years old, the NIR device was more likely to result in first-attempt success regardless of BMI or access site and the NIR device was most optimal for almost all categories of paediatric patients regardless of BMI or access site. The transilluminator was found to be the most optimal device to use with younger patients (< 2 years old) who are underweight. Vein visualisation technology is recommended by professional nursing organisations to improve PIV access. Yet, adoption of this useful technology to aid selection of an optimal vein for insertion and visualisation during insertion is limited. This is the first study to develop a clinical decision-making tool for vein visualisation technology in PIVC insertion. Vein visualisation technology allows for a rapid, thorough assessment of patients' vasculature to determine an optimal site for PIVC placement beyond what is visible to the naked eye or achievable using traditional methods. The tool was designed to guide healthcare professionals towards successful first attempt PIVC insertions, thereby improving patient outcomes and efficiency of care. None.

Abstract C172: Diversifying translational research models to address outcomes disparities in lung cancer

Abstract Introduction: Racial disparities in lung cancer remains a persistent and challenging problem, with African Americans experiencing the highest mortality of any race or ethnic group. Emerging evidence suggests that multiple biological factors affect the development and progression of lung cancer. Three-dimensional organoid culture models have become important instruments to use for biomarker analysis and drug sensitivity screening. Despite this strong rationale and potential, there is a lack of representative preclinical models from African American patients with lung cancer. Furthermore, there are no studies evaluating the ability to create organoids successfully using samples from different races. As such, our goal was to establish a diverse biobank of organoid models and determine the rate of successful development based on race and other factors. Methods: Patients with lung cancer from a large urban medical center were recruited to participate in the study from 2021 to 2024. Specimens were collected from surgical pulmonary resection or endobronchial biopsy. Each tissue specimen was divided into 3 pieces and allocated for genomic, transcriptomic and organoid development. Once collected, specimens allocated for organoid development were processed within 8 hours. Cells were isolated from tissues by mechanical and enzymatic dissociation and plated in Matrigel drops overlayed with optimized organoid media. Patient demographics, tumor characteristics and method of specimen collection were recorded. Results: A total of 29 patients consented to the study and had evaluable specimens collected. Mean age was 67 years. Fifty-five percent of patients (16/29) were female. White patients were 55 percent of cohort (16/29), while Black patients made up 45% (13/29). Approximately 62 (18/29) percent of patients were diagnosed with adenocarcinoma, followed by squamous cell carcinoma in 28 percent (8/29) of patients. Tumor stage was 55%, 28%, 3% and 14% for stages I, II, III and IV respectively. Overall, there was a successful organoid development rate of 69 percent (20/29). There was a strong trend toward higher success rates in Black patients compared to White patients (85% vs. 56%, p = 0.10). There were no significant differences in successful organoid development based on gender (p = 0.43), histology (p = 0.18) or tumor stage (p = 0.84). Conclusions: Establishment of a racially diverse set of organoid models will be an invaluable tool for biomarker discovery and for screening novel therapeutic agents. Black patients appear to have similar to improved propensity for successful organoid development. Future efforts should be focused on creating diverse biobanks to strengthen precision oncology efforts for Black patients, collectively helping to reduce racial outcomes disparities in patients with lung cancer. Citation Format: Amanda Pilling, Hollis Hutchings, Avi Cohen, Shirish Gadgeel, Ikenna Okereke. Diversifying translational research models to address outcomes disparities in lung cancer [abstract]. In: Proceedings of the 17th AACR Conference on the Science of Cancer Health Disparities in Racial/Ethnic Minorities and the Medically Underserved; 2024 Sep 21-24; Los Angeles, CA. Philadelphia (PA): AACR; Cancer Epidemiol Biomarkers Prev 2024;33(9 Suppl):Abstract nr C172.

Risk of spontaneous intracerebral hemorrhage associated with NOACs compared with aspirin and warfarin: A long-term single hospital follow-up study

BackgroundNon-vitamin K antagonist oral anticoagulants (NOACs) are currently the mainstay treatment for preventing thrombosis-induced ischemic stroke in patients with atrial fibrillation (AF), deep vein thrombosis (DVT), or previous infarction. However, such management may potentially induce antithrombotic-associated intracranial hemorrhage, leading to significantly adverse clinical outcomes. To investigate the risk of spontaneous intracranial hemorrhage (sICH) in patients under therapeutic anticoagulation. MethodsThis retrospective cohort study used a database established by Kaohsiung Veterans General Hospital to estimate the risk of first onset sICH in patients with AF, DVT or previous stroke who were 18 years old or older, and who had been on at least three months continuous long-term treatment with the oral anticoagulants aspirin, warfarin, or NOACs. In addition, we used propensity-score matching to minimize bias and Cox proportional hazards ratio to compare the risk of sICH among patients prescribed these anticoagulants. ResultsWe analyzed the data of 546 patients (182 aspirin users, 182 warfarin users, and 182 NOAC users). 180 (20 taking aspirin, 74 warfarin, and 86 NOACs) developed new onset sICH before seven years. No new onset cases were found after 7 years. Importantly, those taking NOACs were found to be at a higher risk of early onset hemorrhage (47.80 %) compared to the groups taking aspirin (11.10 %) and warfarin (47.80 %) with a median time-to-occurrence being 2.50, 4.00, and 4.40 years, respectively. ConclusionsThough NOACs prevented ischemic stroke, they were used with a higher risk of early onset spontaneous ICH at our large medical center.

B - 137 Analyzing Completion Time on a Created Forced Choice Trial of the Hopkins Verbal Learning Test – Revised (HVLT-R) to Measure Engagement in a Mixed Clinical Sample

Abstract Objective We created a forced choice recognition trial (FCR) for the HVLT-R, including recording completion time (FCompT), to evaluate the utility of combining completion time with accuracy scores when using performance validity tests (PVTs). Method Participants included 29 clinically referred patients at a large medical center who completed the HVLT-R in addition to multiple free-standing and embedded PVTs including the TOMM, Word Choice Test (WCT), Reliable Digit Span (RDS), and the Dot Counting Test (DCT) as part of a larger battery of neuropsychological tests in an outpatient setting. Data from the sample (M age = 64.79, SD = 13.86; M education = 15.65, SD = 2.47; 62.1% females) were analyzed using correlation and linear regression. Results The HVLT-R FCR trial correlated with the TOMM-10, r(19) = 0.75, p = &amp;lt;0.001, TOMM trial 1, r(17) = 0.75, p = &amp;lt;0.01, the DCT r(12) = −0.71, p = &amp;lt;0.01, and the FCompT, r(29) = −0.72, p = &amp;lt;0.001. The FCompT was correlated with RDS, r(28) = −0.46, p = 0.03, TOMM-10, r(19) = −0.64, p = &amp;lt;0.01, and TOMM trial 1, r(17) = −0.61, p = &amp;lt;0.01. FCompT significantly predicted FCR accuracy b = −0.72, t(29) = −5.41, p &amp;lt; 0.001. Conclusions The HVLT-R FC and FCompT strongly correlated with free-standing and embedded PVTs. Data demonstrates that a longer completion time predicts poorer performance on FCR. Results demonstrate the value of measuring completion time for specific PVTs, in addition to providing support for the addition of a FCR trial to the HVLT-R.

B - 80 The Long-Term Memory Sign in Adults Referred for Neuropsychological Evaluation

Abstract Objective We investigated the clinical utility of the newly described long-term memory (LTM) sign in adults referred for neuropsychological evaluation. Individuals with dementia often report short-term episodic memory decline or no memory decline, but rarely report long-term episodic memory decline. The LTM sign refers to patient self-report of long-term episodic memory decline, that is equivalent to/or greater than, subjective short-term episodic memory decline. Method The LTM sign was endorsed on a pre-visit intake form and established during clinical interview in 568 patients (M age = 63, SD = 14.3) referred for neuropsychological evaluation at a large medical center in the Northwest United States. Results In our sample of 568 patients, 79 (14%) reported the LTM sign. In 79 patients with the LTM sign, 45 were diagnosed with a primary psychiatric disorder (57%), 23 were diagnosed with mild neurocognitive disorder (29%), seven had no cognitive or psychiatric diagnosis (9%), and four had dementia (5%). The LTM sign was most common in those with a history of trauma in childhood or adolescence (52/79, 66%) and substance use disorders (50/79, 63%). Conclusions The LTM sign was rare in dementia, but common in those with a current psychiatric diagnosis. These findings support the literature on episodic memory decline in dementia populations and suggests that encoding of early memories and/or retrieval of old memories is negatively impacted by a current psychiatric disorder, traumatic events in childhood and adolescence, and lifetime history of substance use disorder. The LTM sign is a valuable addition to the clinical interview of neuropsychological patients.

COVID-19 vaccine uptake in a predominantly minoritized cohort hospitalized during the early pandemic in New York City

BackgroundMinoritized communities in the United States have had higher COVID-19 mortality and lower vaccine uptake. The influence of previous SARS-CoV-2 infection, initial disease severity, and persistent symptoms on COVID-19 vaccine uptake in Black and Latinx communities has not been examined. ObjectiveTo investigate whether initial COVID-19 severity, persistent symptoms, and other correlates affected vaccine uptake in a predominantly minoritized cohort hospitalized for COVID-19 during the early pandemic in New York City. DesignIn this historical cohort study, we abstracted electronic health record data on demographics, comorbidities, hospital oxygen requirements, symptoms at 3 and 6 months post-admission, COVID-19 vaccinations through November 2022, and influenza vaccinations during the 2018–2019 through 2021–2022 seasons. Unadjusted and adjusted odds ratios were estimated through logistic regression analyses of correlates of COVID-19 vaccination, on-time vaccination, and boosting. ParticipantsSurvivors among the first 1186 adult patients hospitalized for COVID-19 between March 1 and April 8, 2020 at a large quaternary care medical center in Northern Manhattan. Main MeasuresUptake of at least one COVID-19 vaccine dose, uptake of at least one booster, and on-time vaccination. Key ResultsThe 890 surviving individuals were predominantly Latinx (54%) and Non-Hispanic Black (15%). Most had one or more comorbidities (67%), and received at least one COVID-19 vaccine dose (78%). Among those vaccinated, 57% received at least one booster, and 31% delayed vaccination. 67% experienced persistent symptoms. Multiple logistic regression showed no association between vaccine uptake and disease severity or symptom persistence. However, older age and influenza vaccination during the COVID-19 era were associated with increased vaccination, booster uptake, and on-time vaccination. ConclusionsPinpointing drivers of vaccine uptake and hesitancy is critical to increasing and sustaining COVID-19 vaccination as the field transitions to annual boosters. The association between influenza vaccination and increased vaccine uptake suggests that bundling vaccines for adults may be an effective delivery strategy.

SARS-COV-2 SEROSURVEY OF HEALTHY, PRIVATELY OWNED CATS PRESENTING TO A NEW YORK CITY ANIMAL HOSPITAL IN THE EARLY PHASE OF THE COVID-19 PANDEMIC (2020-2021).

SARS-CoV-2, the cause of the ongoing COVID-19 pandemic, not only infects humans but is also known to infect various species, including domestic and wild animals. While many species have been identified as susceptible to SARS-CoV-2, there are limited studies on the prevalence of SARS-CoV-2 in animals. Both domestic and non-domestic cats are now established to be susceptible to infection by SARS-CoV-2. While serious disease in cats may occur in some instances, the majority of infections appear to be subclinical. Differing prevalence data for SARS-CoV-2 infection of cats have been reported, and are highly context-dependent. Here, we report a retrospective serological survey of cats presented to an animal practice in New York City, located in close proximity to a large medical center that treated the first wave of COVID-19 patients in the U.S. in the Spring of 2020. We sampled 79, mostly indoor, cats between June 2020 to May 2021, the early part of which time the community was under a strict public health "lock-down". Using a highly sensitive and specific fluorescent bead-based multiplex assay, we found an overall prevalence of 13/79 (16%) serologically-positive animals for the study period; however, cats sampled in the Fall of 2020 had a confirmed positive prevalence of 44%. For SARS-CoV-2 seropositive cats, we performed viral neutralization test with live SARS-CoV-2 to additionally confirm presence of SARS-CoV-2 specific antibodies. Of the thirteen seropositive cats, 7/13 (54%) were also positive by virus neutralization, and two of seropositive cats had previously documented respiratory signs, with high neutralization titers of 1/1024 and 1/4096; overall however, there was no statistically significant association of SARS-CoV-2 seropositivity with respiratory signs, or with breed, sex or age of the animals. Follow up sampling of cats showed that positive serological titers were maintained over time. In comparison, we found an overall confirmed positive prevalence of 51% for feline coronavirus (FCoV), an endemic virus of cats, with 30% confirmed negative for FCoV. We demonstrate the impact of SARS-CoV-2 in a defined feline population during the first wave of SARS-CoV-2 infection of humans, and suggest that human-cat transmission was substantial in our study group. Our study provide a new context for SARS-CoV-2 transmission events across species.

The role of coagulopathy and subdural hematoma thickness at admission in predicting the prognoses of patients with severe traumatic brain injury: a multicenter retrospective cohort study from China.

Traumatic brain injury (TBI) is one of the diseases with high disability and mortality worldwide. Recent studies have shown that TBI-related factors may change the complex balance between bleeding and thrombosis, leading to coagulation disorders. The aim of this retrospective study was to investigate the prediction of coagulopathy and subdural hematoma thickness at admission using the Glasgow Outcome Scale (GOS) in patients with severe TBI at 6 months after discharge. In this retrospective cohort study, a total of 1006 patients with severe TBI in large medical centers in three different provinces of China from June 2015 to June 2021 were enrolled after the exclusion criteria, and 800 patients who met the enrollment criteria were included. A receiver operating characteristic (ROC) curve was used to determine the best cut-off values of platelet (PLT), international normalized ratio (INR), activated partial thromboplastin time (APTT), and subdural hematoma (SDH) thickness. The ROC curve, nomogram, calibration curve, and the decision curve were used to evaluate the predictive effect of the coagulopathy and Coagulopathy-SDH(X1) models on the prognoses of patients with severe TBI, and the importance of predictive indicators was ranked by machine learning. Among the patients with severe TBI on admission, 576/800 (72%) had coagulopathy, 494/800 (61%) had SDH thickness ≥14.05mm, and 385/800 (48%) had coagulopathy combined with SDH thickness ≥14.05mm. Multivariate logistic regression analyses showed that age, pupil, brain herniation, WBC, CRP, SDH, coagulopathy, and X1 were independent prognostic factors for GOS after severe TBI. Compared with other single indicators, X1 as a predictor of the prognosis of severe TBI was more accurate. The GOS of patients with coagulopathy and thick SDH (X1, 1 point) at 6 months after discharge was significantly worse than that of patients with coagulopathy and thin SDH (X1, 2 points), patients without coagulopathy and thick SDH (X1, 3 point), and patients without coagulopathy and thin SDH (X1, 4 points). In the training group, the C-index based on the coagulopathy nomogram was 0.900. The C-index of the X1-based nomogram was 0.912. In the validation group, the C-index based on the coagulopathy nomogram was 0.858. The C-index of the X1-based nomogram was 0.877. Decision curve analysis also confirmed that the X1-based model had a higher clinical net benefit of GOS at 6 months after discharge than the coagulopathy-based model in most cases, both in the training and validation groups. In addition, compared with the calibration curve based on the coagulopathy model, the prediction of the X1 model-based calibration curve for the probability of GOS at 6 months after discharge showed better agreement with actual observations. Machine learning compared the importance of each independent influencing factor in the evaluation of GOS prediction after TBI, with results showing that the importance of X1 was better than that of coagulopathy alone. Coagulopathy combined with SDH thickness could be used as a new, accurate, and objective clinical predictor, and X1, based on combining coagulopathy with SDH thickness could be used to improve the accuracy of GOS prediction in patients with TBI, 6 months after discharge.

Integrating Fitness Training in Oncologic Care: Lessons Learned from a Large Telemedicine Trial

ObjectiveTo provide insights from patients and clinicians regarding the benefits and barriers of the introduction of a telerehabilitation fitness program into the oncologic care of people with late-stage cancer. DesignThis study is a qualitative assessment of the COllaborative Care to Preserve PErformance in Cancer trial, which involved the insertion of a telerehabilitation fitness program into the oncologic care of patients with late-stage cancer. SettingA large midwestern medical center. ParticipantsThirty-one patients who matched the overall demographics of the study participants as well as 3 oncologists, 2 physical therapist fitness care managers (FCMs), nurse pain care manager, and 2 supervisory physicians involved in the study. InterventionsFive hundred sixteen patients with late-stage (IIIC or IV) cancer were randomly assigned to 1 of 3 arms: a control group that received usual oncologic care and 2 intervention groups. The members of the latter continued with their usual care but also received either 6 months of a fitness program, with or without the addition of pain management assistance. All components were delivered via telemedicine with the fitness program consisting of progressive resistance and walking components. Main Outcome MeasuresPerceived benefits and shortcomings of the intervention were obtained via written narratives from the patients and as well as through interviews with the oncologists, FCMs, nurse pain care manager, and supervisory physicians involved in the study. ResultsThematic analysis revealed 87% (27/31) of the participants found the program helpful. Regular contact with someone who understood their situation, helped improve their function, and encouraged active engagement in their care was perceived as particularly beneficial. The FCMs who worked remotely with participants to coordinate their exercise programs agreed that regular interactions with the patient facilitated engagement, education, and meaningful goal setting. The oncologists were supportive of the intervention but had concerns about patient suitability. The supervisory physicians noted a number of institutional barriers such as oncology workflows and the need for better sharing of information across disciplines. ConclusionsA fitness program delivered via telemedicine was perceived as beneficial by the patients, the FCMs, and the supervising physicians. Success hinged on the quality of the interaction between patients and the FCMs. Institutional barriers to implementation seem similar to those encountered by many new programs that need to be inserted into the workflows of busy clinics and practices.

Immunophenotypic, genetic, and clinical characterization of adult T-cell leukemia/lymphoma: A single tertiary care center experience in the United States.

Adult T-cell leukemia/lymphoma (ATLL) is an aggressive mature T-cell neoplasm caused by human T-cell lymphotropic virus type 1 (HTLV-1). Its most common immunophenotype is CD4+/CD7-/CD25+, although unusual immunophenotypes can occur and may lead to misdiagnosis. The immunophenotypes, cytogenetics, molecular features, clinical presentations, treatment, and prognosis of 131 patients with ATLL were retrospectively studied in a large tertiary medical center in the United States. All cases showed loss of CD7 expression. While 82.4% of cases demonstrated CD4+, 17.6% exhibited unusual phenotypes, including CD4+/CD8+ (6.9%), CD4-/CD8- (2.3%), CD5- (3.1%), CD2-, and CD3-. The most common cytogenetics abnormalities included polysomy 3 (34.6%), translocation 1 (23.1%), and abnormalities found on chromosome 11 (30.8%) and chromosome 14 (26.9%). The common gene mutations identified by the next-generation sequencing study were TP53 (16.7%), TBL1XR1 (16.7%), EP300 (14.3%), and NOTCH1 (14.3%). TBL1XR1 mutation is associated with genetic instabilities. There was no significant difference between the clinical presentations of these 2 groups. Adult T-cell leukemia/lymphoma exhibits versatile immunophenotypic, cytogenetic, and molecular features. Simultaneous involvement of blood, lymph nodes, and other organs, along with hypercalcemia in a patient from an endemic area, necessitates HTLV-1 testing to avoid underdiagnosis of this dismal disease that might need aggressive chemotherapy followed by bone marrow transplant.

CT-306 Evaluation of the Healthcare System Burden Associated With Intravenous Treatment for Paroxysmal Nocturnal Hemoglobinuria

ObjectiveTo delineate steps in the intravenous (IV) treatment workflow with ravulizumab for paroxysmal nocturnal hemoglobinuria (PNH) from a healthcare system perspective and to identify steps that could potentially be simplified with an oral therapy. DesignIndividual in-depth semi-structured qualitative interviews were conducted with 5 US hematologists between October and December 2023. Participating physicians were from large medical centers (academic and community-based) experienced in treating PNH patients with IV ravulizumab. The interview data were analyzed to identify steps in the IV treatment workflow, leading to the development of a process map covering treatment decision/planning to outpatient administration. Physicians’ perspectives on process complexities related to IV treatment and steps that could be simplified through the adoption of an oral therapy were collected. ResultsThe approximate time from treatment decision to administration ranged from 2 to 4 weeks. Delays were primarily attributed to limited vaccination access in community settings and insurance approvals. Additional delays occurred, particularly for offlabel-dosing schedules, for example for breakthrough hemolysis, due to added complexity of obtaining insurance approvals. Patients spent an average of 3–4 hours for treatment administration at the infusion center. The lack of flexibility in scheduling, given that infusion centers were operating at full capacity, was noted. Hypothetically, with an oral treatment, alleviated steps would include treatment scheduling and administration at infusion centers. ConclusionsThe study revealed complexities associated with IV treatment with ravulizumab for PNH from a healthcare system perspective. Given that IV treatment is resource- and time-intensive for both patients and providers and that infusion centers are operating at full capacity, adopting an oral treatment could potentially enhance infusion center capacity and improve scheduling flexibility for other competing conditions. Further studies are warranted to understand the IV treatment burden from the perspectives of additional healthcare personnel (nurses, pharmacists) and patients.

Your Blood is Out for Delivery: Considerations of Shipping Time and Temperature on Degradation of RNA from Stabilized Whole Blood.

Remote research studies are an invaluable tool for reaching populations in geographical regions with limited access to large medical centers or universities. To expand the remote study toolkit, we have previously developed homeRNA, which allows for at-home self-collection and stabilization of blood and demonstrated the feasibility of using homeRNA in high temperature climates. Here, we expand upon this work through a systematic study exploring the effects of high temperature on RNA integrity through in-lab and field experiments. Compared to the frozen controls (overall mean RIN of 8.2, n = 8), samples kept at 37°C for 2, 4, and 8 days had mean RINs of 7.6, 5.9, and 5.2 (n = 3), respectively, indicating that typical shipping conditions (~2 days) yield samples suitable for downstream RNA sequencing. Shorter time intervals (6 hours) resulted in minimal RNA degradation (median RIN of 6.4, n = 3) even at higher temperatures (50°C) compared to the frozen control (mean RIN of 7.8, n = 3). Additionally, we shipped homeRNA-stabilized blood from a single donor to 14 different states and back during the summer with continuous temperature probes (7.1 median RIN, n = 42). Samples from all locations were analyzed with 3' mRNA-seq to assess differences in gene counts, with the transcriptomic data suggesting that there was no preferential degradation of transcripts as a result of different shipping times, temperatures, and regions. Overall, our data support that homeRNA can be used in elevated temperature conditions, enabling decentralized sample collection for telemedicine, global health, and clinical research.

African American patient perspectives on barriers and facilitators to tobacco-cessation treatment.

African American veterans who use tobacco use evidence-based tobacco-cessation treatment less than other racial/ethnic groups, contributing to higher tobacco-related treatment burden for them. This study aimed to assess barriers and facilitators African American patients face before engaging in Veterans Health Administration behavioral tobacco-cessation treatment services, as an initial step to identify new implementation strategies. African American veterans (N = 30) who use tobacco at a large Veterans Affairs Medical Center completed interviews about perceived barriers and facilitators to behavioral treatment, views on telehealth, and suggested care improvements. We used a combination of deductive and inductive analytic approaches and identified four themes: (1) Ambivalence towards Quitting Tobacco: Patients described how low motivation to quit and intense withdrawal symptoms impede treatment engagement, despite known health risks; (2) Limited Interaction with Health Care System: Patients described how histories of mistrust and stigma toward treatment impact engagement with the health care system, resulting in lack of awareness of treatment options and preference for self-reliance in quitting; (3) Individualized Factors for Engagement: Patients described how persistent providers, access to telehealth modalities, personal health complications exacerbated by tobacco use, and benefits of positive lifestyle change increase motivation for treatment; and (4) Suggestions for Culturally Tailored Treatment Engagement: Patients expressed a desire for more African American group-specific outreach, including targeted advertisement and culturally aware providers to combat mistrust of the health care system. Findings indicate that generating patient-driven implementation strategies such as tailored education and proactive outreach are necessary to increase engagement of African American patients in tobacco-cessation treatment programs. (PsycInfo Database Record (c) 2024 APA, all rights reserved).

High glycated albumin is associated with early neurological deterioration in patients with acute ischemic stroke

BackgroundGlycated albumin (GA) is an indicator of glycemic variability over the past 2–4 weeks and has suitable characteristics for predicting the prognosis of ischemic stroke during the acute phase. This study evaluated the association between early neurological deterioration (END) and GA values in patients with acute ischemic stroke (AIS).MethodsWe assessed consecutive patients with AIS between 2022 and 2023 at two large medical centers in Korea. END was defined as an increase of ≥ 2 in the total National Institutes of Health Stroke Scale (NIHSS) score or ≥ 1 in the motor NIHSS score within the first 72 h of admission. We evaluated various glycemic parameters including fasting glucose (mg/dL), hemoglobin A1c (%), and GA (%).ResultsIn total, 531 patients with AIS were evaluated (median age: 69 years, male sex: 66.3%). In the multivariable logistic regression analysis, GA value was positively associated with END (adjusted odds ratio [aOR] = 3.24, 95% confidence interval [CI]: 1.10–9.50). Initial NIHSS score (aOR = 1.04, 95% CI: 1.01–1.08) and thrombolytic therapy (aOR = 2.06, 95% CI: 1.14–3.73) were also associated with END. In a comparison of the predictive power of glycemic parameters for END, GA showed a higher area under the curve value on the receiver operating characteristic curve than fasting glucose and hemoglobin A1c.ConclusionsHigh GA values were associated with END in patients with AIS. Furthermore, GA was a better predictor of END than fasting glucose or hemoglobin A1c.