Lebanon Hospital Research Articles

The Broken Promise of Institutional Psychiatry: Sexuality, Women and Mental Illness in 1950s Lebanon

This article traces the case of Hala, a woman chronic patient of the Lebanon Hospital for Mental and Nervous Disorders (LHMND) in late 1950s Lebanon. Her story reveals a conglomeration of actors, expertise and technologies that regulated both her sexuality and mental illness, as she was moved, returned, then moved again, from the care of the family to the care of the psychiatric institution. By reconstructing an ethnographic case of the story of Hala, the article tackles an under-investigated area of research at the intersection of subjectivity, sexuality, psychiatry and family life. The case of Hala illustrates an on-going tension in defining and diagnosing mental illness for women between two forms of care: institutional psychiatry on one hand—promising a quick return of patients to society—and the family on the other, with its own understandings of what constitutes abnormality for women. Having lived at the hospital for more than twenty years, Hala’s voice and experience provide a powerful contribution to the ethnographic history of psychiatry in Lebanon. The article tackles questions on competing psychiatric and social authorities and the formation of psychiatric subjectivities. It also provides methodological and ethical reflections on the use of archives when conducting ethnographic research on psychiatry from the global peripheries. The case of Hala illustrates the patient’s own experience of LHMND’s policies of social rehabilitation in the late 1950s. It adds to a broader understanding of the processes that have led to the pathologizing of sexuality in under-studied societies such as Lebanon and the Middle East.

CML-296: First-Line Treatment Outcomes of CML Patients in a Real-World Data Setting in Lebanon

Context: BCR–ABL-targeting tyrosine kinase inhibitors (TKIs) constitute the cornerstone of treatment for CML, leading to a life expectancy that is currently very close to that of age-matched individuals in the general population. Objective: To describe aspects of CML in a real-world data setting in Lebanon, including responses to first-line treatment with the first-generation TKI imatinib compared to those with the second-generation TKIs dasatinib and nilotinib. To evaluate the proportion of patients eligible for an attempt to stop TKI treatment. Design: Medical charts of patients diagnosed with CML between 2003 and 2019 were reviewed and updated in January 2020. Settings: Lebanese patients from two university medical centers in Beirut, Mount Lebanon Hospital and Hotel-Dieu de France Hospital, were included. Patients: The registry covered 70 patients, of which 54 patients were included. Inclusion criteria were patients older than 18 years, confirmed diagnosis with CML based on BCR-ABL PCR, and available follow-up data in the clinical chart for at least 2 years. Outcomes: Major and deep molecular responses were based on BCR-ABL1 levels; time of attaining these responses and duration of sustained responses were measured. The reason for switching to another TKI was noted (‘treatment failure’ or ‘intolerance’). Eligibility criteria for an attempt to stop TKI were based on the EURO-SKI trial. Modality of Treatment: Imatinib was given at a dose of 400 mg once daily, nilotinib 300 mg twice daily, and dasatinib 100 mg once daily. Results: 70% of patients were treated with imatinib and 30% with a second-generation TKI. 14% of patients discontinued their first-line treatment, mainly due to intolerance (10%) or treatment failure (5%). At 24 months, deep molecular response (MR4.0 and MR4.5) was achieved, at 15.3% and 40.3%, respectively, for imatinib, and 22% and 33.5%, respectively, for second-generation (p=1). The 5-year cumulative incidence of eligibility for TKI cessation attempt was 37%. Conclusion: We report the experience in CML from two health care institutions in Beirut, Lebanon. There was no statistically significant difference in response between the first- and second-generation TKIs. The criteria for an attempt to stop TKI therapy were met by one-third of patients.

AML-295: Clinical Characteristics and Outcome of Acute Leukemia in Lebanese Patients: A Retrospective Observational Analysis

Context: The molecular characteristics of AML disease remain widely unknown in Lebanon. Cytogenetics and molecular testing in AML are becoming routine practice for disease classification and prognosis. Objective: Our aim was to describe patients’ characteristics and outcome, investigating the association between karyotype on diagnosis, and survival in the Lebanese population. Design: Medical records were retrospectively reviewed for AML patients diagnosed between January 2008 and December 2018. The last update of the data was done in February 2019. Setting: Patients included were treated at Mount Lebanon Hospital University Medical Center or Hotel-Dieu de France University Hospital. Patients: 54 patients were included. Inclusion criteria comprised patients diagnosed with AML and receiving treatment, and availability of data on all sequences of therapy. Patients diagnosed with AML-M3 were not included in the study. Treatment: Fit patients received induction therapy as high dose cytarabine + anthracycline. Then if complete remission: consolidation as cytarabine. Older unfit patients received hypomethylating agent azacytidine. Results: 53.7% were male, median age was 57.06 years at diagnosis. According to FAB classification, the majority (18.5%) were AML-M4, the least (1.9%) M6 and 24.1% were non identifiable. 74.1% were de novo and 16.7% were post-MDS with azacitidine as the major culprit drug. 9.7% were secondary to solid tumors. On diagnosis, 22.6% had hyperleukocytosis and 28.6% were in aplasia. 41.5%, 13.2% and 5.7% were respectively in the intermediate, high, and low risk group. FLT3 was positive in 7.5% of tested cases and NPM1 in 3.8%. No patient was found to have t(16;16) or inversion 16. PML-RARA was positive in 7.5% of patients. 54.7% achieved complete remission, 7.5% were in partial remission and 32.1% were primary refractory. 82.75% relapsed after remission. DFS was 18.4 months with a median OS of 17.8 months ranging from 10.6 months for high-risk group and 20.4 months for the low-risk group. No significant statistical correlation was found between karyotype on diagnosis and survival [P =0.4]. Conclusion: Our study is the first to describe AML characteristics in Lebanon. Multicenter studies are needed to clarify if the Lebanese population has the same molecular and survival pattern as others described in international data.

Comorbidities and Negative Prognostic Factors in Lebanese Patients Presenting with Acute Decompensated Heart Failure with Preserved Ejection Fraction: A Multicenter Retrospective Study

Background: Congestive heart failure is responsible for repeated hospital admissions. It is classified into three types: (1) Heart Failure with reduced ejection fraction, (2) Heart failure with mid-range ejection fraction, and (3) Heart failure with preserved ejection fraction (HFpEF). It is essential to describe the risk factors of HFpEF patients' profiles as targeting them is crucial for management. Aim: Our retrospective study aims to identify the clinical and echocardiographic characteristics associated with HFpEF and its mortality among hospitalized patients with acute decompensated heart failure. Methods: 390 patients of all age groups presenting with acute heart failure decompensation at Mount Lebanon Hospital (MLH) and Middle East Institute of Health (MEIH, Bsalim) were recruited retrospectively between January 2014 and December 2016. We included 133 cases of HFpEF and collected data on each case including: baseline characteristics and comorbidities, electrocardiograms, laboratory studies, and echocardiographic parameters. Results: The 133 Lebanese patients having HFpEF were elderly (76 ± 10 years), with predominantly female gender (56%). Hypertension (87.96%) and diabetes (53.38%) were the most frequently reported comorbidities. The overall in-hospital mortality was 4.5%. Data was compared between living and deceased patients and the frequency of valvular heart disease (p=0.005) and chronic kidney disease (p=0.018) was significantly higher among deceased patients. Right ventricular (RV) dilation on echocardiography was significantly correlated with mortality. Elevated troponin, increased creatinine, hypochloremia, hyponatremia, and anemia were all lab markers associated with increased mortality (p<0.05). Conclusion: Patients with HFpEF represent 43.5% of all decompensated HF cases, with chronic kidney disease, valvular heart diseases, anemia and troponinemia, being the predominant risk factors for adverse clinical outcomes. HFpEF remains an enormous burden on cardiologists for appropriate evaluation, triage, and management.

It's all in the details: A call for administering the COVID-19 vaccine in Lebanon through a transparent and un-politicized collaborative approach.

It's all in the details: A call for administering the COVID-19 vaccine in Lebanon through a transparent and un-politicized collaborative approach.

Epidemiology of Breast Cancer in Young Lebanese Women Under the age of 40 Years: Retrospective Study in Lebanon between the Years 2011 and 2017

Background: Breast cancer is the most common non-skin malignancy affecting females in the world. In Lebanon, breast cancer rates are gradually increasing and young females are being more frequently affected. Few studies are available concerning this particular population. Objectives: This study aims to estimate the epidemiology of breast cancer in the young Lebanese females below the age of 40 with identification of variable characteristics and risk factors of the disease and ultimately, comparing our findings to other Arab countries. Methods: Breast cancer cases diagnosed at ≤ 40 years of age between 2011 and 2017 were collected from patient’s files in the Lebanese Hospital Geitaoui and Mount Lebanon Hospital, including the variable risk factors and tumors characteristics. The statistical data analysis was performed using SPSS statistics software. Results: 862 females were diagnosed with breast cancer in the aforementioned hospitals and forty-four were ≤ 40 years. The prevalence of breast cancer in the young Lebanese females is found to be 5.1%. Majority of cases (81.8%) were initially detected by breast self-examination. 20.5% had a positive family history. Infiltrative ductal carcinoma is the predominant histological subtype and grade 2 the most common histological grade. Estrogen and progesterone receptors are positive in 26 subjects and HER2/Neu receptors positive in 17 subjects. Most of cases were in stage 2A. Only 2 patients had BRCA gene testing done. Conclusion: The early onset breast cancer is not only related to the presence of a positive family history; other factors should be actively investigated. Breast self-examination should be considered as a screening method of breast cancer in young females at high risk.

The Use of Telemedicine for Child Psychiatric Consultations in an Inner-city Hospital

The Use of Telemedicine for Child Psychiatric Consultations in an Inner-city Hospital Puja Desai MD1, Adedotun Adewale1, Matthias Manuel1, Kosha Shah1, Nastasia Nianiaris1, Roy Vega1,2 1 Department of Pediatrics, Bronx Lebanon Hospital Center 2 Department of Emergency Medicine, Bronx Lebanon Hospital Center Background: Similar to other urban hospitals in the United States, the volume and complexities of pediatric psychiatric patients seen in our emergency department has increased tremendously in the last few years. Due to the shortage of mental health care providers in lower socioeconomic …

Risk of Serious Bleeding with Antiplatelet Therapy for Secondary Prevention Post Ischemic Stroke in Middle East Population

IntroductionStroke is a devastating disease, causing significant mortality and long-term disability worldwide. Since the bulk of ischemic strokes is attributed to atherothrombosis, secondary prevention with antiplatelet agents is essential to decrease the recurrence of stroke. Aspirin, as well as clopidogrel monotherapy, has been shown to reduce the relative risk of recurrent stroke. However, concerns regarding the efficacy and safety of dual antiplatelet approach still exist. Stroke patients are particularly susceptible to bleeding complications, which might be due to advanced age and comorbidities. Our study assessed the risk of serious bleeding among adult patients on antiplatelet therapy for secondary prevention after stroke who were admitted to Mount Lebanon Hospital (MLH) between 2010 and 2015. It also studied the effect of the antiplatelet therapy, including dose and combination in increasing the risk of bleed.MethodsA retrospective monocentric study included 454 patients who were admitted for ischemic cerebrovascular accident (CVA) between 2010 and 2015, and discharged on antiplatelet therapy for secondary prevention. Those patients’ records were followed to assess the percentage of patients who developed a major bleed after initiation of antiplatelet therapy.ResultsThe risk of serious bleed was highest with aspirin 100 mg monotherapy and dual antiplatelet therapy (DAPT) (Aspirin 100 mg + Clopidogrel 75 mg). Bleeding risk was high during the first three months of therapy. However, the highest risk of bleed exists during the duration extending between three months and one year for both aspirin 100 mg monotherapy and DAPT. Moreover, there was an established relation between patients’ related factors and bleeding risk. Advanced age and smoking were found to contribute to increasing this risk.ConclusionAspirin 100 mg monotherapy and DAPT are associated with the highest risk of bleeding. Although this exists regardless of the duration of antiplatelet therapy, it is highest during the duration extending between three months and one year post initiation of antiplatelet therapy.

143 - Diastolic Dysfunction among HIV Infected African American Population

Background: Cardiac involvement has been documented among HIV infection. The aim of the current study was to analyze the prevalence of cardiac dysfunction among HIV infected African American population. The aim was also to see the relation between CD4 count and the occurrence of diastolic dysfunction. Materials and Methods: 261 HIV infected African American patients who were seen in the Bronx Lebanon hospital and clinics between 2009 and 2014 were retrospectively analyzed. We reviewed the Echocardiogram of all these patients from electronic medical records. Lowest CD4 count and median CD4 count of the patient was also reviewed. Presence of hypertension, diabetes mellitus, hyperlipidemia, presence or absence of smoking; drug usage was also analyzed. Left ventricular mass index and Left ventricular mass was noted. 24 patients had incomplete data and were excluded leaving behind 237 patients. Mean age of the entire study sample was 58. Microsoft Excel 2013 was used for statistical analysis. Results: Mean lowest CD 4 count of the entire sample was 214. The prevalence of systolic dysfunction was 20% and diastolic dysfunction was 78%. Most of the diastolic dysfunction was mild. Grade 1 DD—71%.;Grade 2—22%; grade 3 DD—1% and grade 4 DD—0.5%. Mild systolic dysfunction was seen in 5%, moderate in 8% and severe in 7%. Mean right ventricular systolic pressure of the entire sample was 39. Mean Left ventricular mass index—115. Mean left ventricular mass—206. Coronary artery disease was seen in 7% of the patients. Lower CD4 count was associated with higher left ventricular mass index. (P value-.006). On multivariate analysis involving hypertension, drug use, age, coronary artery disease lower CD4 count had predicted diastolic dysfunction (pvalue- < 0.05). Conclusion: HIV infected African American patients have higher prevalence of diastolic dysfunction compared with the general population. Lower CD 4 count had predicted higher left ventricular mass index. These findings suggest HIV patients manifest mild functional and morphological cardiac manifestations which are independently associated with HIV infection. Also the prevalence of diastolic dysfunction is higher in this population ie 78% when compared to other studies which documented prevalence between 30–40%. This demonstrates HIV infected African American have more chances of diastolic dysfunction than other ethnic groups.

The role of 68Ga-DOTA-NOC PET/CT in evaluating neuroendocrine tumors: real-world experience from two large neuroendocrine tumor centers.

Our aim was to assess the role of Ga-DOTA-NOC PET/CT as a tool for the management of neuroendocrine tumors (NETs), evaluating the clinical impact on patients from two large NET centers in different geopolitical settings. This is a retrospective study of patients with NETs who underwent Ga-DOTA-NOC PET/CT at Royal Liverpool University Hospital (UK) and at Mount Lebanon Hospital (Lebanon). Indications for imaging and findings of the PET/CT along with demographic and clinical outcome data were recorded and evaluated. Four hundred and forty-five patients fulfilled the inclusion criteria, with a median age at the time of diagnosis of 56 (range: 3-90) years; 248 (55.7%) patients were male.Ga-DOTA-NOC PET/CT was indicated for staging in 193 (43.4%) patients, for diagnosis in 124 (27.9%) patients, for follow-up in 97 (21.7%) patients, and for identification of a primary NET site in 31 (7%) patients.One hundred and four (27.9%) patients underwent Ga-DOTA-NOC PET/CT for the primary diagnosis of NET, of whom 66 (52.7%) patients presented with a clinical suspicion of NET, 10 (8.3%) patients presented with a biochemical suspicion of NET only, and 48 (38.8%) patients presented with a suspicious NET lesion discovered on another imaging modality. The most common clinical presentation was typical carcinoid syndrome [4 (33%) patients].Results on the basis of histology were used as the gold standard for the diagnosis in 57% of patients and the remaining on the basis of follow-up as per established clinical consensus. Sensitivity, specificity, negative-predictive value, and positive-predictive value of PET/CT were 87.1, 97.7, 79.6, and 98.7%, respectively, for the entire sample. Accuracy was measured using the receiver operating characteristic curve analysis with an area under the curve of 0.924 (95% confidence interval: 0.874-0.974). Ga-DOTA-NOC PET/CT is a highly sensitive and specific study for the diagnosis and follow-up of patients with neuroendocrine tumors. These results support the use of Ga-DOTA-NOC PET/CT contributing significantly toward the clinical management of NET patients.

Risk for Type 2 Diabetes Among SNAP Participants With Prediabetes

This study explored food security status among Supplemental Nutrition Assistance Program (SNAP) participants with prediabetes in relation to food choice decisions over a 30-day benefit cycle that potentially increases the risk of Type 2 diabetes. A cross-sectional, quantitative design based on food choice process model constructs was used. SNAP participants (&lt;em&gt;n &lt;/em&gt;= 36) with prediabetes, aged 21–70 years, were recruited as outpatients from Bronx Lebanon Hospital Center and completed self-reported questionnaires on demographics and health, food security, and food frequency over time. Descriptive statistics, Pearson chi square tests, and regression analysis were performed using SPSS. Two post-hoc tests, the Friedman’s test, and Wilcoxon signed-rank test were used to measure the difference in means between food groups. Using a multiple response analysis, the 11 food categories had the greatest variation for Week 1, compared to Weeks 2–4. Use of coping strategies to minimize hunger was limited. Very low food security associated with certain coping strategies disrupted eating patterns that affected food variation over time and increased the intake of non-nutrient-dense foods. Changing SNAP’s benefit allotments, and making mandatory, a nutrition package and nutrition education, may increase food security and nutrient-dense food variation thereby decreasing the risk for Type 2 diabetes.

In Reply to Sedgh

We are pleased to learn more about Dr. Sedgh and colleagues’ experiences with a resident and fellow quality improvement (QI) incentive program at Bronx–Lebanon Hospital Center and Maimonides Medical Center. They join a group of teaching hospitals, including Yale–New Haven Hospital, Children’s Hospital of Colorado, Duke University Medical Center, Palmetto Health, St. Joseph’s Hospital and Medical Center, and San Francisco General Hospital, that have also implemented programs similar to our University of California, San Francisco Resident and Fellow Quality Improvement Incentive Program.1 It is increasingly clear that this model can be used effectively in a wide variety of clinical settings, including university, children’s, community, and public teaching hospitals. Our experience with this approach continues to demonstrate important improvements in patient experience, quality of care, and health care value while building resident and fellow competence and improving the clinical learning environment. Since our published report, we have continued to work on ambitious goals. Our patient satisfaction measures are at their highest level. We have increased and sustained our observed institution-wide hand hygiene compliance to over 90%. This year, we increased the percentage of patients who were discharged before noon, improving patient throughput. Our work to reduce laboratory test volume has resulted in over $2 million in savings in three years.2 We have also expanded our work on program-specific QI goals, now including several fellowship programs. In these projects, each residency or fellowship program develops and implements an improvement goal specific to that program’s needs and aligned with health system priorities. Over the last two years, over two-thirds of our programs have achieved their goals. These resident- and fellow-led projects have improved preventive services, clinical practice, medication monitoring, patient education, clinical documentation, transitions of care, communication between clinical services, and patient education. Projects have included improvements in both inpatient and outpatient settings. We believe that programs similar to ours and others, such as those described by Dr. Sedgh, which engage learners in institutionally aligned QI efforts, can improve patient care outcomes, health care value, and the clinical learning environment. Robert B. Baron, MD, MS Professor of medicine and associate dean for graduate and continuing medical education, Division of General Internal Medicine, Department of Medicine, University of California, San Francisco, School of Medicine, San Francisco, California; [email protected] Glenn Rosenbluth, MD Associate professor of pediatrics, Division of Hospital Medicine, Department of Pediatrics, and director of quality and safety programs, Office of Graduate Medical Education, University of California, San Francisco, School of Medicine, San Francisco, California. Adrienne L. Green, MD Professor of medicine, Division of Hospital Medicine, Department of Medicine, University of California, San Francisco, School of Medicine, and associate chief medical officer, UCSF Medical Center, San Francisco, California. Arpana R. Vidyarthi, MD Consultant, Division of Internal Medicine, Singapore General Hospital, and associate professor of education and Health Systems and Services Research, Duke-NUS Graduate Medical School, Singapore.

Abdominal Aortitis Associated with Crohn Disease

Bronx Lebanon Hospital Center, Bronx, New York, USA Correspondence: Dr Hassan Tariq, Bronx Lebanon Hospital Center, 1650 Selwyn Avenue, Suite 10C, Bronx, New York 10457, USA. Telephone 718-900-1234, e-mail htariq@bronxleb.org Received for publication July 31, 2013. Accepted September 19, 2013 Case Presentation A 26-year-old woman who was diagnosed with Crohn disease when she was 12 years of age presented with a two-week history of nausea, vomiting, worsening diarrhea and bilateral lower abdominal pain. The patient had a protracted history of Crohn disease treated with mesalamine, tapering short courses of corticosteroids for exacerbations and then 6-mercaptopurine therapy initiated three years before this presentation. Nine months before the patient presented, she was also started on subcutaneous adalimumab and maintained on a dose of 40 mg every other week. Her white blood cell count was 10×109/L (65.5% segmented neutrophils, 28.9% lymphocytes, 4.8% monocytes), with a hemoglobin level of 123 g/L and a platelet count of 164 ×109/L. An abdominal computed tomography scan revealed multifocal areas of mural thickening with narrowing in the colon (Figure 1), long-segment minimal thickening with narrowing of the upper abdominal aorta and maximal luminal narrowing in an infrarenal aortic segment (Figure 2). These findings were suggestive of aortitis, which is very rarely associated with Crohn disease.

A Patient Event Diary Improves Self-Management In Pediatric Sickle Cell Disease Patients

IntroductionPromotion of chronic illness self-management is crucial to improve outcomes of children with sickle cell disease (SCD). Improvements in patient outcomes and quality of life as well as enhancement in health literacy and patient agency are also imperative. Through an event diary developed by the Bronx Lebanon Hospital Sickle Cell Program, our pediatric SCD patients are better able to track significant health events and health care appointments. This study seeks to validate the effectiveness of the patient event diary as a tool for improvement in self management, allowing for improvement in medication and clinic visit compliance, as well as in a reduction in number of emergency room visits. Additionally, the education section at the beginning of the diary has become an integral teaching tool and reference for patients and their families. It is our hypothesis that the event diary as an educational tool, a self management tool, and a tool for providers, will lead to better management of chronic illness and improved patient outcomes. MethodsWe utilized laboratory and demographic data from the Bronx Lebanon Hospital Center patient electronic medical record between July 2011 and July 2013. Our sample included a population of 50 sickle cell disease patients aged 0 to 21, median age being 7 years. Sickle cell disease types included SS (64%), SC (32%), Sβ+ thalassemia and Sβ0thalassemia (4%). We used a paired, two tailed t-test to assess patients' medication compliance on vitamin D (22 patients) and hydroxyurea (14 patients) through 25-hydroxyvitamin D (25-OHD) and MCV (mean corpuscular volume) levels, respectively. Increased MCV was used as a proxy to indicate improved medication compliance in patients on hydroxyurea. We compared patients on hydroxyurea and vitamin D six months before receiving the event diary and six months after.Additionally, we compared compliance with hematology clinic visits one year before and one year after receiving the event diary. We also compared the number emergency room visits during the year before and the year after patients received the event diary. Results25-OHD data from six months after receiving the event diary showed significantly improved compliance with vitamin D treatment (M = 47, SD = 20) as compared to six months before receiving the event diary (M = 26, SD = 15), t(20) = 2.1, p < 0.05. Additionally, there was a statistically significant improvement in MCV levels six months after receiving the event diary (M=101.6, SD=9.6), as opposed to six months before receiving it (M=97.7, SD=5.6), t(12)=2.2, p<0.05. When looking at patient hematology clinic appointment compliance, there was an improvement, however not statistically significant, in compliance with appointments between one year before (M=33.3%, SD=41.7%) and one year after patients received the event diary (M= 27.2%, SD=30.3%), t(17)=2.1, p=0.2. Emergency department visits did decrease, however not significantly, one year before receiving the event diary (M=1.8, SD=2.5) to one year after receiving the event diary (M= 1.3, SD=1.9), t(47)=2.0, p=0.17. ConclusionsThese data suggest the patient event diary has significantly improved patient self-management. We believe this effect is due to enhanced understanding of disease processes and increased confidence and skills in self-management of the disease. There is improved compliance with hydroxyurea and vitamin D, as well as a trend toward improvement in clinic visit compliance and decreased emergency room visits. The patient event diary is crucial to improved patient outcomes in the pediatric SCD population, and may be useful for other pediatric populations with chronic illness. It is a significant part of our current practice and our ability to teach and empower patients and their families to manage sickle cell disease while at home. Additionally, this tool allows for better management of patients by providers. The event diary helps to elucidate difficulties in patient self-management and gives better insight into complications patients are experiencing at home. In the future, we hope to see that with improved patient knowledge of sickle cell disease and self-management facilitated by use of the event diary, there will be significantly fewer emergency room visits, fewer hospital admissions, and most important, quality of life. Disclosures:Moulton:HRSA: Research Funding; New York State Grant: Research Funding.

Vitamin D Level and Its Correlation With Hemoglobin In Pediatric Sickle Cell Disease Patients

Introduction It has been well characterized that people living with sickle cell disease are more likely than the general population to be vitamin D deficient. New literature suggests there is an association between vitamin D deficiency and increased anemia in patients with chronic anemia. To date, this has been examined only in patients with end stage renal disease, heart failure, and anemia of other chronic diseases, but not in sickle cell disease, a chronic inflammatory disease with an elevation in inflammatory markers. Vitamin D has been shown to increase erythroid precursor proliferation by increasing erythropoietin sensitivity. It is also thought that vitamin D has pleiotropic effects, which may have influence on the bone marrow. Additionally, vitamin D has been shown to suppress pro-inflammatory cytokines, which causes a decrease in the anemia of chronic inflammation. Severe vitamin D deficiency also causes hyperparathyroidism, which leads to an inhibition of endogenous production of erythropoietin. Our hypothesis implies supplementation of vitamin D will improve anemia of vitamin D deficient sickle cell patients. Methods We utilized laboratory and demographic data from the Bronx Lebanon Hospital Center's patient electronic medical record between November 2009 and July 2013. Our sample included a population of 50 sickle cell disease patients aged 0 to 21 who were vitamin D deficient (serum 25-hydroxyvitamin D (25-OHD) &lt;30ng/ml). Sickle cell disease types included SS (64%), SC (32%), Sβ+ thalassemia and Sβ0 thalassemia (4%). Using a linear mixed model with an autoregressive correlation structure to account for variance within the subject, we examined the association between time dependent 25-OHD level (ng/ml) and hemoglobin in (g/dl), as well as between 25-OHD and reticulocyte percentage over time in days. We began at the time of first supplementation of 25-OHD to the most recent blood levels in each patient. Results After adjusting for mean corpuscular volume (MCV), hemoglobin, sickle cell type and hydroxyurea (Table 1), there was a linear increase in reticulocyte percentage over time associated with increasing 25-OHD levels (β = 0.000060, SE = 0.000030, p =0.050). However, after controlling for MCV, gender, race, sickle cell type, and hydroxyurea (Table 2), we found trend of a negative association between 25-OHD and hemoglobin levels, which was statistically significant (β = -0.000017, SE = 0.000007, p =0.017). Conclusion Our results did not support our original hypothesis, which stated that supplementation of vitamin D in vitamin D deficient sickle cell patients would lead to an improvement in anemia. However, a trend was noted of a decrease in hemoglobin with increasing 25-OHD. In turn, there was a statistically significant increase in reticulocyte percentage with increasing 25-OHD. This is suggestive that there is increased hemolysis with increased erythropoiesis caused by increasing 25-OHD. This is seen even when controlling for patients taking hydroxyurea. Further study is required to elucidate this possible correlation. It is important to examine this relationship further, as supplementing vitamin D in vitamin D deficient sickle cell disease patients is becoming standard of care for improvement in bone density. It is unclear what potential implications this may have on increased production of sickle cells from the bone marrow, including a possible increase in hemolysis and a worsened anemia. Disclosures: Seelaboyina: Bronx Lebanon Hospital: Employment.

Induction of labor at 41 weeks of pregnancy among primiparas with an unfavorable Bishop score

To determine the rate and factors associated with the successful Induction of Labor (IOL) in nulliparous patients undergoing scheduled IOL at 41 weeks of gestational age (GA) with an unfavorable cervix. This was a retrospective analysis that included nulliparous patients who presented to the Labor and Delivery unit at the Bronx Lebanon Hospital Center between 2011 and 2012 for elective IOL at 41 weeks of GA. The Bishop score was assessed upon admission and IOL agents were used in compliance with ACOG guidelines in different combinations, based on the obstetrical team preference. Labor and Delivery Unit of the Bronx Lebanon Hospital. Nulliparous patients with 41 weeks of pregnancy for elective induction of labor. Seventy-six patients were included in the study. GA was confirmed using a combination of the last menstrual period and a dating sonogram during pregnancy. This was a retrospective chart review that included nulliparous patients who presented to the Labor and Delivery unit at the Bronx Lebanon Hospital Center between October 2011 and October 2012 for elective IOL at 41 weeks of gestational age with an unfavorable cervix defined as a Bishop score of 6 or less. The overall successful rate of IOL in a combination of different maternal factors with different agents for induction in nulliparous patients undergoing scheduled IOL with an unfavorable Bishop score at 41 weeks of GA was 51.32 %. Factors associated with successful IOL were younger age [22.3 years vs. 25.1(p = 0.015)], lower BMI [25 vs. 28.1(p = 0.46)] and lower maternal weight [64.75 kg vs. 74.02 (p = 0.28)]. Maternal height was not a contributing factor; the artificial rupture of membranes, epidural anesthesia and the prostaglandins used did not contribute. Use of cervical balloon and oxytocin was associated with failed IOL. Patients undergoing IOL at 41 weeks with an unfavorable cervix had a successful rate of 51.32 %. Younger maternal age, lower weight, and lower BMI were associated with successful IOL.

Compliance with follow-up in an inner-city population treated with intramuscular methotrexate for suspected ectopic pregnancy

ObjectiveTo evaluate compliance with follow-up among inner-city patients with ectopic pregnancy treated with methotrexate, in addition to assessing outcome. MethodsRetrospective analysis of all patients evaluated for first-trimester bleeding and diagnosed with ectopic pregnancy at the Bronx Lebanon Hospital Center, New York, USA, from October 2007 to March 2011. Compliance and complications were evaluated for all patients who received medical treatment with methotrexate. ResultsNinety-nine patients with hemodynamically stable ectopic pregnancies were identified. Therapy with methotrexate was effective in 87 (87.9%) cases. Only 10 (10.1%) patients were fully compliant during follow-up after methotrexate administration. There were no differences according to ethnicity. Number of follow-up visits after treatment significantly affected compliance. ConclusionImprovements in selection criteria for therapy and simplification of follow-up for patients with medically managed ectopic pregnancy are required.

738: Pregnancy complications and outcomes in women perinatally infected with human immunodeficiency virus

perinatally infected with human immunodeficiency virus Maria Miraz, Omar Duenas-Garcia, Daniella Fonseca, Priya Prasad, Maria Timoney, Rodney Wright Bronx Lebanon Hospital Center, Obstetrics and Gynecology, Bronx, NY, Montefiore Medical Center/Albert Einstein College of Medicine, Obstetrics & Gynecology and Women’s Health, Bronx, NY OBJECTIVE: To describe the pregnancy outcomes of women with perinatally acquired HIV (PAH) compared to those with non perinatally acquired HIV (NPAH), and to determine if factors such as ethnicity and income affect the pregnancy outcomes in these patients. STUDY DESIGN: We performed a retrospective case control study of HIV infected women who delivered in a large South Bronx NY hospital between January 2005 and December 2011. Cases were PAH patients and NPAH patients served as controls. The Student’s t-test was used for continuous variables and Chi square for categorical variables. Bivariate analyses were performed to determine the associations between birth outcome and pregnancy outcome with factors such as viral load, CD4 count and method of contracting HIV using both linear and logistic regression. RESULTS: 13 pregnancies were identified in the PAH group and 170 NPAH pregnancies. PAH patients were younger (mean age 21) compared to NPAH (mean age 31). 69% of PAH patients were Hispanic compared to 34% of NPAH (p 0.02). 23% of PAH and 27% of NPAH had some form of mental health problem (p ns). The median BMI for PAH patients was 26 where the mean BMI for NPAH was 31 (p 0.01). 37% of all patients reported some form of domestic or family violence (p ns). Preterm delivery and low birthweight were significantly higher in PAH (p 0.001). Median age at delivery for PAH was 35.4 weeks. Only 31% of PAH had an undetectable viral load at delivery compared to 78% of NPAH (p 0.001). PAH were 7.8x less likely to have an undetectable viral load at delivery but there were no mother to child HIV transmissions in the PAH group. There were two HIV infected infants born in the NPAH group to mothers with limited prenatal care (p 0.001). CONCLUSION: In a very high risk HIV infected patient population, numerous psychosocial factors may play a role in determining birth outcome. Careful attention to all of these factors may be key to eliminating mother to child transmission of HIV and improving birth outcomes.

Sa1647 Surveillance of Gastric Ulcer in a Hispanic and African American Predominant Community

Surveillance of Gastric Ulcer in a Hispanic and African American Predominant Community Prospere Remy, Haritha R. Chelimilla, Umair Siddiqui, Harish Patel, Myrta Daniel, David Widjaja Medicine, Bronx Lebanon Hospital Center, Bronx, NY Background: Endoscopic surveillance for benign gastric ulcer (GU) has been a common practice although it is neither recommended by the US GI societies nor is cost effective. Furthermore, the yield of the endoscopic surveillance in Hispanic and African American community has not been studied, particularly with the advent of Helicobacter Pylori (HP) treatment. Purpose: To analyze key factors and outcomes associated with endoscopic surveillance of GU in our South Bronx hospital. Methods: Persons aged 18 years or older who were diagnosed with GU on initial esophagogastroduodenoscopy (EGD) at GI division of Bronx Lebanon Hospital Center between January 1, 2002 and April 3

Pelvic Inflammatory Disease

Bronx Lebanon Hospital Center, Albert Einstein College of Medicine, Bronx, NY Financial Disclosure: The author did not report any potential conflicts of interest.