Large Tertiary Care Institution Research Articles

Social support mediates social frailty with anxiety and depression

BackgroundAnxiety and depression are prevalent comorbidities in patients with chronic obstructive pulmonary disease (COPD). However, existing research has yielded conflicting findings regarding the effects of social frailty on anxiety and depression. The primary aim of this study is to validate the relationship between social frailty and social support with anxiety and depression in patients with acute exacerbations of COPD (AECOPD) and to investigate whether social support could explain the variations in prior study outcomes for patients with AECOPD.MethodsOf the 315 patients hospitalized with AECOPD at the respiratory intensive care unit of a large tertiary care institution in Sichuan Province of China, between August 2022 and June 2023 who were surveyed, 306 were included in the analysis after excluding missing data. We conducted a logistic regression analysis to examine the associations of social frailty and social support with anxiety and depression and performed mediation analyses to examine whether social support mediates the relationship of social frailty with anxiety and depression.ResultsThe logistic regression analysis revealed that social frailty did not associate anxiety or depression in patients with AECOPD. The mediation analysis supported this idea and indicated that while social frailty does not directly influence anxiety or depression, it can through social support.ConclusionsThe findings suggest that while social frailty may not directly impact anxiety or depression in patients with AECOPD, social support plays a crucial mediating role. Enhancing social support can indirectly alleviate anxiety and depression among these patients. Enhancing social support networks should thus be prioritized by healthcare providers and family members to improve mental health outcomes in this patient population.

Hip Dysplasia in Patients with Charcot-Marie-Tooth Disease: Unraveling an Underrecognized Condition

BackgroundCharcot-Marie-Tooth (CMT) hip disease is poorly understood, in part because the associated neuropathy may obfuscate symptoms, and little data exist to guide management or potential screening programs. The purpose of this study was to report our CMT hip experience from a single large tertiary care institution. MethodsA retrospective review of all patients diagnosed with CMT disease was performed after approval from our center’s institutional review board. Patient demographic data were gathered from the electronic medical record. Patient presentation and physical exam findings were recorded, and all available radiographic imaging were reviewed for signs of hip pathology. When performed, details of surgical treatment were recorded. Descriptive statistics were performed to summarize pathology, characteristics, and procedural outcomes. ResultsWe identified 358 patients diagnosed with CMT, of which 96 patients (27%) had imaging of their hips. Of this subcohort, 20 (21%) had evidence of acetabular dysplasia (AD). This subcohort of CMT patients with confirmed AD was referred to orthopaedics at a mean age of 11 ± 6 years. Diagnosis of AD in CMT patients was most common between the ages of 10 and 16. Treatment often consisted of complete redirectional acetabular osteotomy. At a mean follow-up of 33 ± 28 months, symptomatic resolution was achieved in all but 2 hips (88%) with no significant complications. ConclusionsIn our series, the incidence of AD among CMT patients with hip imaging was 21%. CMT patients were diagnosed with AD at 11 ± 6 years old, most commonly between the ages of 10 and 16. While the clinical presentation and age at presentation were variable, surgery (typically a complete redirectional osteotomy ± femoral derotation osteotomy) was generally successful, with the majority of patients achieving symptomatic resolution and a low complication rate at final follow-up. Key Concepts(1)Charcot-Marie-Tooth (CMT) hip disease is poorly understood.(2)This study sought to report the rate of diagnosis and management of acetabular dysplasia in a CMT pediatric patient population at a single large tertiary care center.(3)While clinical presentation and age were variable, surgery was generally successful in the management of CMT hips. Level of EvidenceLevel IV: case series

Predicting Failure of Conservative Airway Management in Infants with Robin Sequence: The EARN Factors.

Evaluate infants with Robin Sequence (RS) who were successfully treated with conservative airway measures alone vs. those who failed and eventually underwent surgical airway intervention after a protracted course of conservative management. Retrospective review of prospectively gathered database. Large tertiary care institution. Infants diagnosed with RS (n = 122) who underwent primary airway management at a single institution from 1994-2020. Patient demographics, nutritional and respiratory status, laboratory values, and polysomnographic results were compared between patients who were discharged after successful conservative airway management (Group 1, n = 61) and patients that underwent surgical airway intervention after failing a prolonged course of conservative management (Group 2, n = 61). Receiver operating characteristic (ROC) curve analysis was done to assess continuous variables that may predict failure of conservative airway management. 122 infants with RS were investigated. While several variables were significantly different between groups, the following polysomnographic EARN factors, with cut points, were identified as most predictive of failed conservative airway management: ETCO2 (max) > 49 mmHg, AHI > 16.9 events/hour, OAHI REM >25.9 events/hour, OAHI Non-REM > 23.6 events/hour. We identified factors in infants with RS that were associated with severe UAO that failed to improve despite weeks of conservative airway management. Our results may expedite earlier definitive treatment of these critical patients and reduce risks for known complications of prolonged UAO.

Creating a Surgical Biobank: The Hershey Medical Center Experience.

Tissue harvesting at the time of surgery offers surgeons and scientists a unique opportunity to discover and better understand disease pathophysiology. Tissue biobanking presents challenges in patient consents, specimen collection, preparation, and storage, but the potential for scientific discovery justifies the effort. Although the number of tissue biobanks is increasing worldwide, information regarding necessary infrastructure, process flow, and management of expected obstacles is lacking. To provide a framework and motivation for clinician scientists intending to start an intestinal tissue biobank under their direction. The Carlino Family Inflammatory Bowel and Colorectal Diseases Biobank is housed at the Milton S. Hershey Medical Center. Review. Implementation of a surgical tissue biobank at a large tertiary care institution. Assess critical challenges and obstacles over the years as well as keys to the success of the program. Over 2 decades, the institutional biobank grew from an IBD biobank to one which now incorporates thousands of surgical specimens representing numerous colorectal diseases. This was done through a process of refinement focusing on patient recruitment and an efficient consenting and specimen management process. The biobank's success is further insured by institutional, external, and philanthropic support; scientific collaborations; and sharing of biological specimens with other groups of dedicated researchers. This is a single-center experience in collecting surgically resected colorectal specimens. Surgical specimen biobanks are essential in studying disease cause using genomics, transcriptomics, and proteomic technologies. Therefore, surgeons, clinicians, and scientists should build biobanks at their institutions to promote further scientific discovery and improve specimen diversity.

Speech and Language outcomes in Auditory Neuropathy Spectrum Disorder (ANSD) children managed with amplification

ObjectiveTo evaluate speech and language outcomes in children with Auditory Neuropathy Spectrum Disorder (ANSD) without significant comorbidities who received hearing rehabilitation in the form of hearing aids and/or cochlear implantation. MethodsRetrospective chart review of pediatric ANSD patients at a large academic tertiary care institution from 2010 to 2019. Patients were included if they received a diagnosis of bilateral ANSD, had minimal to no comorbidities, and had speech and language testing (SLT) on at least two occasions. Results51 patients were reviewed and 7 met inclusion criteria. Average age at ANSD diagnosis was 1 year and 11 months, and average age of hearing aid fitting was 3 years and 3 months. Hearing loss ranged from mild to profound, with four of the children wearing behind (BTE) hearing aids and three eventually receiving cochlear implants. Four of five patients who received hearing aids prior to their first speech and language evaluation demonstrated a delay at their initial evaluation, and all five patients continued to demonstrate a delay at their most recent evaluation, despite appropriate audiologic management and speech and language therapy. There were two patients who were unaided at the time of their initial and latest evaluations; one patient showed a delay at both timepoints, and one patient showed no speech delay at either timepoint. ConclusionsPediatric ANSD patients, who are otherwise typically developing and received hearing rehabilitation and speech and language therapy, continue to show a speech and language delay (SLD). This outcome underscores the importance of close monitoring of speech and language development, providing early amplification and/or cochlear implantation, and promoting additional education and psychosocial support.

Abstract 15040: Atrial Arrhythmia Burden and Mortality in Patients With Congenitally Corrected Transposition of The Great Arteries (ccTGA)

Background: Patients with ccTGA have a high incidence of atrial arrhythmias and premature failure of the systemic right ventricle. We sought to better define this risk. Methods: A retrospective review of all clinical data for patients with ccTGA followed at a large tertiary care institution was performed. The primary outcome was a composite of death and cardiac transplantation. Results: A cohort of 165 patients (age 41±16 years, 53% male) were followed for 11±8 years; 41 patients died, 7 underwent cardiac transplantation, and 4 underwent VAD placement. Male sex (HR 2.7, p=0.002), older age (HR 1.04, p<0.001), clinical heart failure symptoms (HR 7, p<0.001), heart failure hospitalization (HR 4.9, p<0.001), syncope (HR 1.8, p=0.04) and pulmonary hypertension (HR 2.77, p<0.001) were significant predictors of the primary outcome. Atrial fibrillation (HR 3.5, p=0.002), atrial flutter (HR 3.05, p=0.04), and prolonged QRS duration (HR 1.01, p=0.004) on the first ECG, as well as right and left atrial enlargement (HR 4, p<0.001 and 3.7, p<0.003) and severe systemic AV valve regurgitation (HR 3.8, p=0.03) on the first echocardiogram were associated with poor outcomes. Atrial arrhythmias occurred in 110(67%) patients: atrial fibrillation in 75(45%), atrial flutter in 50(30%), and supraventricular tachycardia in 16(9.7%) patients. Arrhythmias were largely asymptomatic in 109(66%) patients, while 25(14.5%) experienced palpitations, dizziness or presyncope, and 10(6%) presented with decompensated heart failure. Cardioversion and antiarrhythmic therapy were utilized in 53(32%) patients. Surgical pulmonary vein isolation or atrial MAZE were performed in 15(9%) patients, cryoablation of the CTI in 3 patients, and surgical ablation of an accessory pathway in 2 patients. One or more catheter ablation procedures were also performed in 18(11%) patients. Conclusions: Atrial fibrillation and flutter, heart failure, prolonged QRS duration, systemic AV valve regurgitation and pulmonary hypertension predict worse outcomes in ccTGA. Although asymptomatic in a majority of patients, atrial arrhythmias are associated with significant morbidity and mortality. Whether a rhythm control strategy even in asymptomatic patients may improve outcomes remains unknown.

Clinicopathologic Characteristics and Postsurgical Follow-Up of Noninvasive Follicular Thyroid Neoplasm with Papillary-Like Nuclear Features in the Postnomenclature Revision Era.

Background: Noninvasive encapsulated follicular variant papillary thyroid carcinoma (EFVPTC) was reclassified as "noninvasive follicular thyroid neoplasm with papillary-like nuclear features" (NIFTP) in 2016. Most existing studies that examined outcomes included patients managed as EFVPTC and only retrospectively reclassified as NIFTP. This is the first study to evaluate the clinicopathologic, molecular, and surveillance characteristics of patients diagnosed with NIFTP at the time of surgery and managed based on this diagnosis. Methods: We performed a retrospective cohort study of consecutive cases diagnosed as NIFTP from June 2016 to October 2021 identified from electronic medical records at a large tertiary care institution. Patients with coexisting low-risk thyroid cancers ≥1.0 cm in size or any size aggressive histology were excluded, and review of demographic, clinical, imaging, cytologic, and molecular genetic data was performed. Initial care was delivered according to existing clinical guidelines, with a consensus institutional plan for five-year follow-up after surgery. Results: Among 79 patients with 84 nodules diagnosed as NIFTP after surgery, 83.5% (66/79) were women and the mean age was 51 years (range, 21-84). Mean NIFTP size was 2.4 cm (range 0.15-8.0). On ultrasound, the majority of nodules were categorized as thyroid imaging, reporting and data system TI-RADS 3 (55.3%, 42/76), and TI-RADS 4 (36.8%, 28/76). On cytology, they were typically diagnosed as Bethesda III (69.1%, 47/68) or Bethesda IV (23.5%, 16/68). Molecular testing was performed on 62 nodules, and molecular alterations were found in 93.5% (58/62). The most common alterations identified in NIFTP were RAS mutation (75.4%, 43/57), THADA fusion (12.3%, 7/57), and BRAFK601E mutation (7.0%, 4/57). Fifty-two (65.8%) patients underwent lobectomy and 27 (34.2%) total thyroidectomy, and no patient received completion thyroidectomy. Twenty-one patients (26.5%) had coexisting papillary or follicular microcarcinoma. None of the patients received radioiodine ablation. On a mean follow-up of 28.5 months (range, 6-69 months), no structural or biochemical recurrences were observed. Conclusions: In this large cohort of patients with NIFTP diagnosed at the time of surgery and managed typically by lobectomy with no radioiodine ablation, no evidence of tumor recurrence was identified on a limited follow-up. This finding supports indolent clinical course of NIFTP.

Coronary Artery Disease Does Not Influence Outcomes of Iliac Vein Stenting

Although coronary artery disease (CAD) is a well-known prognosticator for worse outcomes of peripheral artery revascularization, the influence of CAD on the outcomes of lower extremity venous intervention is unknown. Our objective was to determine the impact of CAD on patient symptoms and reintervention rates after iliac vein stenting. We analyzed patients at a large tertiary care institution undergoing iliac vein stenting from August 2011 to June 2021. The venous clinical severity score was used to quantify symptoms. We stratified patients into two cohorts: those with CAD at the time of index procedure (CAD+) and those without (CAD−). Major reoperation was defined as any procedure using venography and minor reoperation as endovenous sclerotherapy or laser ablation. The two cohorts were compared with the 1-tailed independent samples t test for continuous variables and χ2 tests for categorical variables. Univariate and multivariate odds ratios (OR) of minor and major reintervention were determined using logistic regression models. Kaplan-Meier log-rank analysis was used to assess reintervention-free survival. Among 634 patients, we identified 76 (12.0%) CAD+ and 558 (88.0%) CAD−. The CAD+ group was significantly older, had a larger mean body mass index, and a larger mean CEAP class (Table). In addition, CAD+ patients had significantly higher rates of diabetes, hypertension, smoking history, and cancer (Table). CAD+ patients were also more likely to have an active venous leg ulcer at the time of iliac vein stent. The OR for a patient needing major reintervention was significantly higher for the CAD+ cohort on univariate analysis (OR: 1.93 [95% confidence interval [CI]: 1.06-3.39], P = .025), but only trended toward significance on multivariate analysis (OR: 1.79 [95% CI: 0.93-3.35], P = .072). The OR for any reoperation, major or minor, did not differ significantly between cohorts on univariate (OR: 1.12 [95% CI: 0.66-1.94], P = .686) or multivariate analysis (OR: 1.51 [95% CI: 0.85-2.74], P = .166). The CAD+ cohort had a larger mean number of reoperations, but the difference was not significant (2.1 vs 1.8, P = .128). The change in venous clinical severity score from the time of the index vein stent procedure did not significantly differ between the two cohorts at any follow-up time point in the 6 years after iliac vein stent (Table). Although CAD has a detrimental effect on the outcomes of peripheral artery disease interventions, this study indicates that CAD has no such impact on the outcomes of iliac vein stents.TablePreoperative characteristics, perioperative details, and postoperative outcomes of coronary artery disease (CAD)+ vs CAD− cohortsVariableCAD− (n = 558)CAD+ (n = 76)P valueDemographics and comorbidities Age (SD)60.3 (13.4)67.8 (10.7)<.001 Sex: male219 (39.4%)35 (46.7%).28 Diabetes105 (18.8%)38 (50.0%)<.001 HTN63 (82.9%)63 (82.9%)<.001 BMI (SD)26.2 (5.1)29.4 (7.5)<.001 Smoking Hx104 (18.6%)23 (30.3%).026 Cancer Hx51 (9.1%)20 (26.3%)<.001Perioperative details VCSS composite (SD)10.7 (3.7)11.4 (5.1).164 CEAP class mean (SD)3.5 (1.0)3.8 (1.4).037 Stent positionUnilateral224 (40.1%)33 (43.4%).673Bilateral334 (59.9%)43 (56.6%) Number of stents placed (SD)2.2 (1.0)2.1 (1.0).32Postoperative outcomes Days of follow-up (SD)770.8 (676.9)1001.1 (865.7).012 Number of total reoperations (SD)1.1 (1.3)1.4 (1.5).078 Number of reoperations in patients w/ ≥1 reoperation (SD)1.8 (1.2)2.1 (1.4).128 Univariate OR major reoperation1.93 [95% CI: 1.06-3.39].025 Multivariate OR major reoperation1.79 [95% CI: 0.93-3.35].072 Univariate OR any reoperation1.12 [95% CI: 0.66-1.94].686 Multivariate OR any reoperation1.51 [95% CI: 0.85-2.74].166 ΔVCSS 1st postoperative visit (SD)3.6 (4.4)3.3 (4.4).509 ΔVCSS 1-year follow-up (SD)6.4 (5.4)5.7 (6.9).289 ΔVCSS 2-year follow-up (SD)7.4 (5.6)7.7 (6.3).7 ΔVCSS 3-year follow-up (SD)8.2 (5.3)7.7 (5.7).406 ΔVCSS 4-year follow-up (SD)8.8 (4.9)8.5 (5.9).538 ΔVCSS 5-year follow-up (SD)9.1 (4.8)9.0 (5.4).839 ΔVCSS 6-year follow-up (SD)9.4 (4.7)9.1 (6.2).61BMI, Body mass index; CEAP, Clinical, Etiology, Anatomic, Pathophysiology; CI, confidence interval; HTN, hypertension; OR, odds ratio; SD, standard deviation; VCSS, venous clinical severity score. Open table in a new tab

PO-623-01 ABLATION STRATEGIES IN PATIENTS WITH CONGENITAL HEART DISEASE AND ATRIAL BAFFLES

Patients with D-Transposition of the Great Arteries (D-TGA) palliated with atrial switch have a high incidence of atrial arrhythmias and pose a particular challenge for ablation. We sought to analyze ablation strategies in this population. An in-depth analysis of ablation data in patients with D-TGA, atrial baffles, and atrial arrhythmia ablations performed at a large tertiary care institution. A cohort of 26 patients with D-TGA and atrial switch (73% male; systemic RV EF 35±11%, mean age at first ablation 37.4±7.2 years) underwent a total of 31 procedures, 26 de novo and 5 redo ablations. For patients with no prior intervention (21, 81%), ablation revealed cavotricuspid isthmus dependent flutter (CTI-flutter, 71%), scar-related intra-atrial reentry (IART, 57%), and focal atrial tachycardia (FAT, 9.5%) (Figure A). Patients with prior outside interventions for CTI-flutter (5, 29%) demonstrated conduction across the CTI in 3/5 (60%) cases. However, patients requiring redo ablation after an index ablation at our institution (5, 29%) demonstrated bi-directional block across the CTI and different, new arrhythmia substrates at the next procedure (80% IART, 40% FAT). Intracardiac echocardiography and electroanatomic mapping were used in all contemporary cases. A screw-in atrial lead was used in 4 procedures as a stable fiduciary reference for mapping, as the coronary sinus ostium was inaccessible. Achieving bi-directional block across the CTI often required ablating on both sides of the baffle (retroaortic access, 81%; using a baffle leak, 11.5%; trans-baffle puncture, 7.7%, or using a VSD, 3.8%). Combined approaches were necessary in 23% of patients to reach critical tissue and achieve optimal contact force (Figure B). Irrigated contact force sensing catheters were used, targeting a significant effect on the electrograms and demonstration of bi-directional CTI block (Figure C). Despite the complex anatomy and atrial reconstruction, cavotricuspid isthmus flutter is still the most common arrhythmia in this population, and bi-directional block often requires additional ablation approaches to reach the target tissue on either side of the baffle. Once CTI block is achieved, further recurrences are due to different, new arrhythmia substrates- IART and FAT.

Abstract 16391: Systemic Ventricular Dysfunction and Long Term Outcomes in Patients With D-transposition of the Great Arteries (D-TGA), Atrial Switch, and Systemic Right Ventricle Physiology

Introduction: Patients with D-TGA palliated with atrial switch operations have the morphologic right ventricle in the systemic position. There is increased risk of atrial arrhythmias and systemic right ventricle (SRV) failure. We sought to analyze the long term outcomes of these patients. Methods: All patients with D-TGA and SRV followed in the Adult Congenital Heart Disease Clinic of a large tertiary care institution were reviewed. A comprehensive retrospective analysis of the medical record was performed, including consult notes, ECGs, echocardiograms and electrophysiology reports. Results: A total of 154 patients (63% male) aged 29±11 years were followed for a mean of 10±9 years (range 0-51). During follow-up, 3 patients underwent cardiac transplantation and 15 died; 5 had sudden death, 2 had cardiogenic shock, 5 had non-cardiac death (i.e., infective endocarditis, sepsis) and 3 had unknown causes of death. Heart failure symptoms were present in 53(34%) patients. Severe SRV systolic dysfunction occurred in 37(24%) patients, with a mean EF of 23±5.5%; moderate SRV dysfunction occurred in 67(44%) patients, mean EF 35±4%. Sinus node dysfunction was present in 75(49%) patients, complete AV block in 9(5%) patients, and a pacemaker placed in 60(39%) patients, with cardiac resynchronization therapy in 5. Atrial arrhythmias occurred in 94(61%) patients and ablations were performed in 47(31%) patients. An ICD was implanted in 37 patients; 5 patients had appropriate shocks, but 7 had inappropriate shocks due to atrial arrhythmias. Age (HR 1.07, p=001), heart failure symptoms (HR 4.9, p= 0.007), severe SRV enlargement (HR 3.7, p=0.03), severe systolic dysfunction (HR 5.4, p=0.003), severe systemic AV valve regurgitation (HR 5.2, p=0.002) and a QRS duration&gt; 122ms (HR 3.7, p=0.02) were significant predictors of mortality. The 15 year probability of sudden death was 3.2%(95% CI 0-6.9%). Conclusions: Atrial arrhythmias are common after atrial switch operations secondary to atriotomy scars. Further studies will need to determine whether restoration of sinus rhythm or cardiac synchrony may prevent further deterioration of the systemic right ventricle. Severe SRV dysfunction and prolonged QRS duration &gt;122ms were significantly correlated with mortality.

A tertiary center experience of multiple myeloma patients with COVID-19: lessons learned and the path forward

BackgroundThe COVID-19 pandemic, caused by SARS-CoV-2 virus, has resulted in over 100,000 deaths in the USA. Our institution has treated over 2000 COVID-19 patients during the pandemic in New York City. The pandemic directly impacted cancer patients and the organization of cancer care. Mount Sinai Hospital has a large and diverse multiple myeloma (MM) population. Herein, we report the characteristics of COVID-19 infection and serological response in MM patients in a large tertiary care institution in New York.MethodsWe performed a retrospective study on a cohort of 58 patients with a plasma-cell disorder (54 MM, 4 smoldering MM) who developed COVID-19 between March 1, 2020, and April 30, 2020. We report epidemiological, clinical, and laboratory characteristics including the persistence of viral detection by polymerase chain reaction (PCR) and anti-SARS-CoV-2 antibody testing, treatments initiated, and outcomes.ResultsOf the 58 patients diagnosed with COVID-19, 36 were hospitalized and 22 were managed at home. The median age was 67 years; 52% of patients were male and 63% were non-White. Hypertension (64%), hyperlipidemia (62%), obesity (37%), diabetes mellitus (28%), chronic kidney disease (24%), and lung disease (21%) were the most common comorbidities. In the total cohort, 14 patients (24%) died. Older age (> 70 years), male sex, cardiovascular risk, and patients not in complete remission (CR) or stringent CR were significantly (p < 0.05) associated with hospitalization. Among hospitalized patients, laboratory findings demonstrated elevation of traditional inflammatory markers (CRP, ferritin, D-dimer) and a significant (p < 0.05) association between elevated inflammatory markers, severe hypogammaglobulinemia, non-White race, and mortality. Ninety-six percent (22/23) of patients developed antibodies to SARS-CoV-2 at a median of 32 days after initial diagnosis. The median time to PCR negativity was 43 (range 19–68) days from initial positive PCR.ConclusionsDrug exposure and MM disease status at the time of contracting COVID-19 had no bearing on mortality. Mounting a severe inflammatory response to SARS-CoV-2 and severe hypogammaglobulinemia was associated with higher mortality. The majority of patients mounted an antibody response to SARS-CoV-2. These findings pave a path to the identification of vulnerable MM patients who need early intervention to improve outcomes in future outbreaks of COVID-19.

Improving Decision Making in Empiric Antibiotic Selection (IDEAS) for Gram-negative Bacteremia: A Prospective Clinical Implementation Study.

Timely selection of adequate empiric antibiotics has become increasingly difficult due to rising resistance rates and the competing desire to apply antimicrobial stewardship (AMS) principles. Individualized clinical prediction models offer the promise of reducing broad-spectrum antibiotic use and preserving/improving adequacy of treatment, but few have been validated in the clinical setting. Multivariable models were used to predict the probability of susceptibility for gram-negative (GN) bacteria in bloodstream infections (bacteremia) to ceftriaxone, ciprofloxacin, ceftazidime, piperacillin-tazobactam, and meropenem. The models were combined with existing resistance-prediction methods to generate optimized and individualized suggestions for empiric therapy that were provided to prescribers by an AMS pharmacist. De-escalation of empiric antibiotics and adequacy of therapy were analyzed using a quasi-experimental design comparing two 9-month periods (pre- and postintervention) at a large academic tertiary care institution. Episodes of bacteremia (n = 182) were identified in the preintervention and postintervention (n = 201) periods. Patients who received the intervention were more likely to have their therapy de-escalated (29 vs 21%; aOR = 1.77; 95% CI, 1.09-2.87; P = .02). The intervention also increased the proportion of patients who were on the narrowest adequate therapy at the time of culture finalization (44% in the control and 55% in the intervention group; aOR = 2.04; 95% CI, 1.27-3.27; P = .003). Time to adequate therapy was similar in the intervention and control groups (5 vs 4 hours; P = .95). An AMS intervention, based on individualized predictive models for resistance, can influence empiric antibiotic selections for GN bacteremia to facilitate early de-escalation of therapy without compromising adequacy of antibiotic coverage.

Establishment of Myocardial Strain Measurement Data in Pediatric Patients Without Structural Heart Disease: A Single Center Study.

Accurate assessment of LV systolic function remains a challenge, especially in the pediatric population. Myocardial strain measurement by 2D speckle tracking echocardiography (2DSTE) is a relatively new modality for assessment of regional and global myocardial wall motion. This study aims to establish the normative value among various pediatric age groups at a large pediatric tertiary care institution and to describe the challenges encountered in establishing such strain data. Transthoracic echocardiograms were acquired in 121 healthy children (age 0-21years) and were retrospectively analyzed. The global longitudinal strain (GLS) was obtained by 2D speckle tracking using Philips Epiq7® and QLAB post processing software. The normative value for left ventricular GLS (%) obtained in our study was - 20.8 ± 2.3 (< 1year); - 21.4 ± 2.2 (1-4years); - 19.6 ± 2.4 (5-9years); - 19.4 ± 2.6 (10-14years); - 18.9 ± 3.0 (15-21years). There was a statistically significant difference in GLS between the different age groups. The BMI (kg/m2) of assessed subjects were 14.6 ± 2.3 (< 1year); 16.3 ± 1.5 (1-4years); 16.7 ± 2.3 (5-9years); 21.3 ± 4.6 (10-14years); 23.9 ± 5.9 (15-21years). There was no significant difference in GLS by gender or by BMI found in our study. We present our experience with establishment of normative values of 2DSTE in our pediatric echocardiography lab. This study shows that age is the major determinant of variation in peak GLS in healthy subjects, emphasizing the importance of establishment of normative data among various age groups in pediatrics.

Abstract P2-08-29: Recent demographic changes show significant impact on age distribution and clinical characteristics of women presenting with de novo stage IV breast cancer

Abstract Introduction: Breast cancer is the most common cancer in women. In 2013, 16% of US women presenting with de novo Stage IV breast cancer cases were under age 50. The purpose of our study was to analyze the demographics and clinical characteristics of patients with de novo Stage IV breast cancer at our large tertiary care institution in the view of dramatic changes in the racial and ethnic makeup of Suffolk County, Long Island over the last 10 years. Methods: Our study is a retrospective chart review of 159 female patients who presented with de novo Stage IV breast cancer to our institution during the years 2007-2019. Patients with recurrent Stage IV breast cancer were excluded. Charts of patients were reviewed and the following data was recorded: age at diagnosis, race, insurance status, menopausal status, presenting symptoms, family history, setting in which breast cancer was diagnosed, tumor histology, and sites of metastasis. Data was further subdivided into younger (under age 50) and older age groups (over age 69). Characteristics were compared using these groups. Results: Data analysis revealed median age at diagnosis of 61, with a range between 26 and 92. 25% percent of women were under age 50, 50% ages 50-69 and 25% percent were 70 years of age or older. Over the last decade, proportion of younger women with de novo Stage IV breast cancer did not change significantly while there was a 14% increase in women presenting between ages 50 to 69, and 86% in the older subgroup. 80% were Non-Hispanic White, 9% Hispanic, 7% African-American. Over this past decade, non-Hispanic whites increased by 27%, 175% increase in Hispanics, and 20% increase in African-Americans. Overall, women were well-insured with 90% in younger group and 100% in older group having coverage at time of presentation. 60% of younger group were first diagnosed by their primary care physician compared to 42% of older group. Only 17% of younger group were diagnosed incidentally compared to 40% of older group. A majority of women had a known mass prior to diagnosis, 72% in younger group and 75% older group. 35% of younger group presented with other symptoms such as bone pain, weight loss compared to 52% of older group. 27% of younger women initially presented with an unrelated condition compared to 47% of older group. Proportion of patients with family history of breast cancer were similar, 57% in younger group and 52% in older group. Overall, 26% were premenopausal. 73% had invasive ductal cancer. Majority had hormone receptor positive tumors, 65% in younger group compared to 82% older group. Finally, 54% of patients presented with multiple metastatic sites, 30% in both younger and older groups. Conclusion: Our study analyzed the demographics and clinical characteristics of patients with de novo Stage IV breast cancer at our large tertiary care institution over the last 10 years. The proportion of women 50 or younger diagnosed with de novo Stage IV breast cancer was 25% percent compared to 16% nationwide. The proportion of women presenting at age 70 or older has significantly increased over the past decade. This may be due to improving women’s life expectancy in the US but changes in patterns of screening of older women needs to be evaluated as well. Over this past decade there was a 175% increase in Hispanic women presenting with de novo Stage IV breast cancer. This is in the setting of changing demographics of Suffolk County, Long Island which has increased its Hispanic population by 2% over the past 4 years according to census data. This dramatic change in mostly insured patients highlights the need for improved awareness and community outreach in this population. Citation Format: Adam Khorasanchi, Lea Baer, Alison Stopeck, Andrzej Kudelka, Jules Cohen. Recent demographic changes show significant impact on age distribution and clinical characteristics of women presenting with de novo stage IV breast cancer [abstract]. In: Proceedings of the 2019 San Antonio Breast Cancer Symposium; 2019 Dec 10-14; San Antonio, TX. Philadelphia (PA): AACR; Cancer Res 2020;80(4 Suppl):Abstract nr P2-08-29.

Preventable Anesthesia-Related Adverse Events at a Large Tertiary Care Center: A Nine-Year Retrospective Analysis

Anesthesiologists have studied adverse events during anesthesia dating back to the original critical incident studies of the 1970s. Despite improvements, adverse events continue to occur. The purpose of this study was to characterize anesthesia-related adverse events within a single large tertiary care institution and to distinguish preventable adverse events from those that are not preventable. A retrospective review of all cases referred to the Performance Improvement (PI) Committee at a large academic medical center from 2007 to 2015 was performed. The primary adverse event and underlying cause of the event were determined using a two-reviewer system for each case. Univariate analysis was performed to determine overall characteristics of cases, the underlying causes of adverse events, and whether the event was preventable; p < 0.05 was considered significant. A total of 1,424 records were referred to the PI Committee during the study period. After exclusions, 747 cases were included in the final analysis. Respiratory complications (n = 245) were the most frequently reported adverse event type. The most common respiratory events included unplanned reintubations, aspirations, and respiratory arrests. A large proportion of the adverse events (42.8%) may have been preventable. In particular, respiratory, trauma, and medication adverse events were often preventable. Anesthesia-related adverse events continue to occur even though the field is considered at the forefront of patient safety. Respiratory, trauma, and medication events were often preventable, and these represent areas to allocate resources to improve patient safety and perioperative outcomes.

Sensitivity of prenatal ultrasound for detection of trisomy 18

Objectives: To evaluate the sensitivity of prenatal ultrasound (US) for trisomy (T18) diagnosis and describe US findings in a large tertiary care institution in the USA.Materials and methods: This was a retrospective cohort of all T18 cases diagnosed at our institution from October 2004 to October 2014 based on prenatal or postnatal genetic diagnostic testing. We included all women with a fetus affected by T18 who had a comprehensive US by a maternal–fetal medicine specialist performed at our institution. US findings were reviewed, classified by organ system, and categorized as an anomaly or soft marker. Chi-square or t-test was used for statistical analysis.Results: We included 128 cases of T18 with confirmed cytogenetic analysis −110 (86%) of which were diagnosed prenatally or suspected by cell-free DNA and confirmed postnatally, and 18 of which underwent neonatal blood sampling alone. One hundred and twenty-one (95%) had at least one abnormal US finding. Anomalies were more frequently identified on US at ≥20 weeks as compared with <20 weeks (93% versus 76%; p = .004). The mean number of findings detected per fetus was 5.1 ± 3.0. Fetuses diagnosed by postnatal sampling alone had a similar number of US exams performed and number of abnormal findings compared to those diagnosed prenatally.Conclusion: Ninety-five percent of fetuses with T18 had at least one abnormal US finding. This sensitivity of is higher than reported in most prior studies, but is not 100%, and should be considered when counseling women regarding prenatal diagnosis of T18.Rationale: Historical detection rates for abnormal sonographic findings in trisomy 18 fetuses range from 70% to 100%. These studies are limited by small sample sizes. This is a contemporary study of ultrasound findings in a large group of women with confirmed trisomy 18 by prenatal or postnatal genetic diagnosis. We provide expansive detail on soft markers and anomalies broken down by organ-system and gestational age.

Spectrum of central nervous system tuberculosis: An experience from a large tertiary care institution of India

ObjectivesCentral nervous system (CNS) is an important site for extrapulmonary tuberculosis. The present study evaluated the spectrum of CNS tuberculosis in a high tuberculosis endemic region. MethodsThe study included 306 cases of CNS tuberculosis. All cases were assessed for clinical evaluation and neuroimaging. All cases were followed up for 3 months. Modified Barthel index was used to assess the outcome. ResultsOut of 306 cases of CNS tuberculosis, 174 (56.86%) had intracranial tuberculosis, 55 (17.97%) had spinal tuberculosis, 15 (4.91%) had both intracranial and spinal pathology. Sixty-two (20.26%) patients had disseminated tuberculosis. Two-hundred and fourteen (69.9%) cases had tuberculous meningitis. Disseminated tuberculosis patients had significantly poor modified Barthel index and 3-month outcome. Culture positivity was significantly higher in the disseminated group. Ten (27.02%) out of 37 culture positive tuberculous meningitis cases had multi-drug-resistant tuberculosis. On multivariate analysis disseminated tuberculosis, baseline modified Barthel index ≤12, and stage 3 predicted poor outcome. Fifty-five patients had spinal tuberculosis. Thirty-four (75.56%) patients with Pott's spine improved with antituberculosis treatment and only 11 (24.44%) patients had modified Barthel index ≤12, after 3 months. ConclusionsIn tuberculosis-endemic areas a varied form of CNS tuberculosis is frequent. CNS tuberculosis is often part of disseminated tuberculosis.

Patient-Reported Outcomes Can Be Used to Identify Patients at Risk for Total Knee Arthroplasty Revision and Potentially Individualize Postsurgery Follow-Up

BackgroundPatient-reported outcomes are increasingly used as complementary measures to clinical outcomes in total knee arthroplasty (TKA). However, their prognostic importance has yet to be established. We aimed to determine whether the long-term revision risk in TKA relates to pain and Knee Society Score (KSS) measures at baseline, 1, and 2 years. MethodsThis was a registry-based study of primary TKA procedures at a large tertiary care institution between 1995 and 2010. Patients completed pain and KSS questionnaires both preoperatively and at 1 and 2 years of follow-up. Clinical information including revision outcomes and mortality was collected and recorded by trained registry personnel. Age and gender-adjusted Cox regression models were used to assess the association between pain and KSS measures and revisions and mortality as outcomes. ResultsBoth the 1-year and 2-year pain and KSSs were significantly associated with the risk for revisions (P < .0001 for trend). The risk for revision was 50%-100% higher among individuals reporting poor or fair KSS at 1 year. Similarly, ≥10 points worsening on the KSS was associated with about 2-fold higher risk for revision (hazard ratio, 2.50; 95% confidence interval, 1.25-5.47). The predictive power of the 1- and 2-year KSS diminished but persisted for revisions that occurred furthest from the reporting time points. The results with pain scores were similar but stronger than the KSS. ConclusionPatient-reported outcomes in TKA have long-term prognostic importance and should be taken into account when planning frequency of aftercare of TKA patients.

Risk of Adverse Events Following ERCP in Patients with Cirrhosis

Introduction: Patients with cirrhosis may be at increased risk for adverse events due to endoscopic retrograde cholangiopancreatography (ERCP) because of underlying ascites, coagulopathy, biliary abnormalities, encephalopathy and concern for decompensation. There are limited data regarding the safety of ERCP in cirrhosis and complications that may ensue. Our aim was to assess the risk of post-ERCP adverse events in patients with cirrhosis. Methods: A retrospective review of all ERCP procedures performed between 2012 and 2015 at a large tertiary care institution. Adverse events of cirrhotic patients were compared with a control group of randomly selected non-cirrhotic patients who underwent ERCP. Univariate analysis was performed using chi-square and ANOVA tests. Multivariate logistic regression was used to examine associations leading to adverse events. Results: Out of 1610 ERCPs, 129 procedures were performed in 56 patients with cirrhosis that were compared to 123 procedures in 79 non-cirrhotic patients (Table 1). Primary sclerosing cholangitis was the most frequent indication for ERCP in cirrhosis. The cirrhosis group had major hepatic functional compromise (Child-Turcotte-Pugh (CTP) class B and C, 55.8% and 17.8%, respectively) Thirty-day procedure-related adverse events included post-ERCP pancreatitis, hemorrhage, cholangitis and death (Table 2). Overall incidence of adverse events was higher in the cirrhosis group (19.4% vs 9%; p=0.019), with a trend towards increased risk of bleeding (1.6% vs 6.2%; p=0.065). Generally, complications were numerically higher in CTP class B and C patients (11.8% vs 22.2% vs 21.7%; p=0.424) with cholangitis more common with CTP class C cirrhosis (2.9% vs 4.2% vs 17.4%; p= 0.048). Sphincterotomy was more frequently performed in non-cirrhotic patients (42.6% vs 27.1%; p=0.011) with a higher rate of overall complications (p=0.001) and post-ERCP pancreatitis (p=0.004) in this group. Multivariate analysis identified sphincterotomy (OR=5.15, 95% CI 2.32-11.42; p < 0.001) and cirrhosis (OR=3.40, 95% CI 1.51-7.65; p=0.002) as significant predictors of post-ERCP adverse events.Table 1: Univariate analysis comparing ERCPs in cirrhotic vs. non-cirrhotic patientsTable 2: Adverse events associated with ERCPConclusion: Post-ERCP complications occur at a higher rate in patients with cirrhosis. Primary sclerosing cholangitis is the major indication for ERCP in our cohort of cirrhotic patients. Our data suggest that increased risks for bleeding and cholangitis may be the cause for the higher complication rate, although larger multicenter studies are needed to explore these potential associations.

Duration of Postoperative Atrial Fibrillation After Cardiac Surgery Is Associated With Worsened Long-Term Survival

Studies of the effects of postoperative atrial fibrillation (poAF) on long-term survival are conflicting, likely because of comorbidities that occur with poAF and the patient populations studied. Furthermore, the effects of poAF duration on long-term survival are poorly understood. We utilized a prospectively collected database on outcomes of cardiac surgery at a large tertiary care institution between August 2001 and December 2010 with survival follow-up through June 2015 to analyze long-term survival of patients with poAF. In addition, we identified patient- and procedure-related variables associated with poAF, and estimated overall comorbidity burden using the Elixhauser comorbidity index. Survival was compared between patients with poAF (n= 513) and a propensity score matched control cohort, both for all patients and separately for subgroups of patients with poAF lasting less than 2 days (n= 218) and patients with prolonged poAF (n= 265). Patients with poAF were older and had a higher burden of comorbidities. Survival was significantly worse for patients with poAF than for the matched control group (hazard ratio 1.43, 95% confidence interval: 1.11 to 1.86). That was driven by decreased survival among patients with prolonged poAF (hazard ratio 1.97, 95% confidence interval: 1.37 to 2.80), whereas survival of patients with poAF for less than 2 days was not significantly different from that of matched controls (hazard ratio 0.91, 95% confidence interval: 0.60to 1.39). After close matching based on comorbidity burden, prolonged poAF is still associated with decreased survival. Therefore, vigilance is warranted in monitoring and treating patients with prolonged poAF after cardiac surgery.