Loyola University Medical Center Research Articles

A-140 Reducing cell count bias with the GloCyte® Automated Cell Counter for CSF: an observational study at Loyola University Medical Center

Abstract Background Accurate STAT cerebrospinal fluid (CSF) cell counts are critical in supporting diagnoses of meningitis, malignancy, demyelinating disease, and hemorrhage. Limitations of automated analyzers to achieve acceptable linearity for the clinically relevant range has maintained manual CSF cell counting as the preferred method. Manual cell counting, performed with a hemocytometer and bright field microscope, is time-consuming, requires specialized skills and depends on human interpretation. This subjectivity inherently introduces the potential for non-random error in the enumeration of both total nucleated cells (TNC) and red blood cells in CSF by manual methods. The purpose of this study was to evaluate and compare the level of bias inherent in manual determination (TNC) in CSF as compared to the GloCyte Automated Cell Counter. Methods Result bias data for CSF specimens processed in the hematology lab at Loyola University Medical Center, a quaternary care 547-bed academic medical center in Maywood, IL, was analyzed for manual cell counting using a Neubauer-improved hemocytometer and GloCyte, an FDA-cleared cell counting device employing fluorescence technology to automate RBC and TNC counts in under 5 minutes, with linearity down to 0 cells/µL. Result bias was determined by defining the “expected result” for both GloCyte and hemocytometer as the initial cell count determined at a 1:5 dilution of a freshly-collected CSF sample and calculating the expected cell count for subsequent serial dilutions of 1:10, 1:20, 1:50, 1:100 for each method. The actual TNC count and the disparity of the actual result from the expected result was recorded as bias. Results Data are summarized below in the Table, and indicate a lower bias for GloCyte compared to manual counts across the range of dilutions. Conclusions This study demonstrates that GloCyte can be implemented as a means of effectively mitigating the reporting bias of CSF TNC counts performed with a Neubauer-improved hemocytometer.

A-340 Analysis of OrganOx Liver Perfusate at the Point-of-Care on the Abbott iSTAT and Nova Glucometer to Support Clinical Evaluations of Donor Livers Prior to Transplantation

Abstract Background The recently FDA-approved OrganOx Metra normothermic perfusion system for maintaining donor livers under physiologic conditions prior to transplantation comes equipped with a limited onboard blood gas analyzer for monitoring pO2, pCO2 and temperature. In clinical practice, however, additional biomarkers are used to assess the functional performance of the donor liver, including perfusate lactate clearance and glucose utilization. Liver perfusate contains a mixture of packed red blood cells, albumin, heparin, antibiotic, and solutions of amino acids and electrolytes and bile salts to support metabolic function, and is a specimen type that is not approved by the FDA. Implementation of the OrganOx Metra at Loyola University Medical Center (LUMC), a quaternary care transplant center, led to the validation of liver perfusate for the evaluation of glucose and lactate at the point-of-care (POC) using the Nova STATStrip Glucometer and Abbott iSTAT CG4 cartridge, respectively. Methods Lactate was measured on the Abbott iStat CG4 cartridge, and glucose which was measured using the Nova STATStrip Glucometer. Recovery studies were performed by mixing liver perfusate (non-centrifuged, n=16 independent specimen) with heparinized whole blood. Results The average recovery for the evaluation of lactate was 100% (range = 78 to 122%), and the average recovery for glucose was 109% (range = 93 to 112%). Conclusions Recovery studies evaluating matrix effect for the analysis of lactate (Abbott iSTAT, CG4) and glucose (Nova STATStrip) in liver perfusate indicate that the matrix of the perfusate does not affect the analytical accuracy, as compared to heparinized whole blood, the FDA-approved specimen type. Measurement of the OrganOx liver perfusate for lactate and glucose on these POC devices demonstrates reliable assessments to guide transplant teams in evaluating the viability of donor livers.

The surgical management of third ventricle region tumors

ObjectivesThe goal of this study was to characterize the largest known cohort of patients presenting with different tumor pathologies in the third ventricle region to better understand outcomes of surgical management. MethodsAll patients undergoing surgical intervention on tumors in or encroaching upon the third ventricle at Loyola University Medical Center between the years 1986–2021 were reviewed. Information recorded included presenting symptoms, pre- and post-operative interventions, tumor pathology, operative technique, extent of resection (EOR), and approach of operation. The primary clinical outcome was Karnofsky Performance Status (KPS) score. ResultsNinety-seven patients underwent 123 operations. Forty-six (47.4 %) patients were female, and the median age at operation was 39 years. Eighty-seven (70.7 %) operations were open, and 36 (29.3 %) were endoscopic. Gross total resection (GTR) was achieved in 34.4 % of operations, near-total resection (NTR) in 31.5 %, subtotal resection in 25.0 %, and biopsy alone in 9.3 %. Median KPS increased pre- to postoperatively, regardless of surgical technique. Adjusting for preoperative KPS, age, and operation number, regression analysis demonstrated a trend that lesser EOR is associated with lower KPS at most recent follow-up (p=0.031 for NTR vs GTR, p=0.022 for biopsy vs GTR). There was no statistically significant association between the most recent KPS and either open or endoscopic surgical technique, with or without adjusting for the previously stated factors (p=0.26). There was no association between postoperative complication rates or age with either surgical technique. ConclusionsHere, we characterize a large cohort of patients presenting for neurosurgical evaluation of tumors in the region of the third ventricle. Our results demonstrate a trend that a more aggressive resection may yield better KPS outcomes. Additionally, both open and endoscopic techniques lead to a similar improvement in clinical outcome and rates of complication. While ultimate surgical approach and technique is determined by individual tumor characteristics, patient health status, and surgeon expertise, ability to resect the tumor in its entirety should be taken into consideration.

Health system barriers and predictors of prenatal care utilization at a large academic medical center

IntroductionThis retrospective cohort study recognizes a profound need to address rising rates of maternal morbidity and mortality, especially its disproportionate impact on ethnic and racial minorities. Timely access to high-quality prenatal care is essential, the absence of which is associated with increased risk of adverse maternal and fetal outcomes. The persistence of racial and ethnic disparities in pregnancy outcomes, despite accounting for income and education level, suggests that barriers to care are also significantly limited by psychosocial and health system barriers.MethodsThis retrospective cohort study analyzed several potential barriers to prenatal care among postpartum patients who delivered at Loyola University Medical Center in Maywood, Illinois, such as transportation, parking, childcare, clinic wait times, scheduling difficulties, and knowledge about the impact of COVID-19 on pregnancy. Participants were screened daily for eligibility and consented to participate from February to May 2022, a total of three months. Eligible patients were given a 10-question paper survey that also assessed out-of-pocket costs and suggestions to improve prenatal care attendance and satisfaction. During the study period, there were 251 eligible deliveries. 197 patients (77.3%) were consented and participated in the survey. 194 (98.4%) were eligible for post-chart review; 21 patients (10.6%) declined to participate, 33 patients (16.8%) did not complete the survey, and 3 surveys (1.5%) were lost. Retrospective chart reviews were conducted for PNC utilization, pregnancy comorbidities and outcomes, and demographic information. Data underwent Fischer analyses, chi-squared analyses, and ANOVAs. Institutional Review Board-approved, participants consented for research and quality improvement, including medical record data use.ResultsAmong 194 patients, average reported barriers to PNC were 2.14, with “difficulty scheduling appointments” (39.6%) and “couldn’t leave work or school” (30.2%) most common. Despite most patients reporting a similar number of barriers, timing disparities based race and ethnicity, education, and income were observed. Hispanic patients initiated PNC later than non-Hispanic White patients (13w6d vs. 10w5d; p = 0.009). Twelfth-grade education or less initiated PNC bachelor's degree holders (16w vs. 11w; p < 0.001). Patients who made < 45 k annually initiated later than > 140 k (13w3d vs. 9w1d; p = 0.02). Patients who reported “long wait times” initiated prenatal care an average of 2w2d later than patients not facing this barrier, at 14w1d vs. 12w0d, respectively (p = 0.01).ConclusionsLower socioeconomic status and ethnic minority patients exhibit delayed PNC start that are linked to adverse outcomes. Noteworthy discrepancies within the surveyed cohorts, despite comparable reported barriers, hint at the existence of supplementary, interconnected obstacles specific to these patients. Future efforts should tackle common issues specific to various sociodemographic groups to address disparities in pregnancy outcomes.

Single Center Neurosurgical Outcomes and Trends in Endoscopic Endonasal Resection of 297 Sellar/Suprasellar Tumors Stratified by Duration of Neurosurgical Career

Endoscopic endonasal transsphenoidal surgery (EETS) is a common treatment for sellar and suprasellar tumors. While endoscopic training has improved over the years and formal fellowship training is now broadly available, the operative nuances of EETS conjectures the existence a learning curve as a neurosurgeon matures with experience. We aim to evaluate operative outcomes of three different experience levels of neurosurgeons over time at a single institution. We reviewed all adult patients who underwent EETS at Loyola University Medical Center by three early career, one mid-career, and two late career neurosurgeons from 2007 to 2023. A comparative assessment of patient demographics, tumor features, and surgical outcomes was done using metrics such as length of surgery, rates of gross total resection (GTR) and symptomatic improvement (SI), new postoperative steroid dependence, and development of diabetes insipidus (DI). T-tests and Chi-Square were used to statistically evaluate the study cohorts. A total of 297 patients underwent EETS. One hundred and three (35%) were operated on by an early career, 122 (41%) by a mid-career, and 72 (24%) by a late career neurosurgeon. Late-career surgeons had shorter operation times (144 vs. 180 minutes with early and mid-career, p=0.029) and increased GTR rates (p=0.008). There were no significant differences between the SI rates amongst various surgeon experience levels. Although not statistically significant, early-career neurosurgeons had lower rates of new postoperative steroid dependence. Patients of early career surgeons experienced significantly less DI (15% vs 40%, p=0.004). Late-career neurosurgeons had shorter operation lengths, achieved higher rates of GTR, and their patients experienced significantly higher rates of DI. Overall outcomes remained stable throughout the course of 16 years between different surgeon experience levels.

Attitudes and Likelihood of Outpatient Cervical Ripening via Single Balloon Foley Catheter Among OB/GYN Providers, Nurse Practitioners, and Obstetric Labor &amp; Delivery Nurses

Introduction/Objectives: In certain parts of the United States and other developed nations, cervical ripening using the Foley catheter has already been introduced into the outpatient setting. An approved protocol exists at Loyola University Medical Center (LUMC), however usage is nonexistent. The primary aim of this study was to determine the current level of knowledge and familiarity regarding outpatient cervical ripening among OBGYN physicians and labor and advanced practice nurses at LUMC. The secondary aim of the study was to elucidate willingness to offer outpatient cervical ripening and potential reasons for support and hesitancy of this practice. Methods: We created an 8-question anonymous survey to elucidate the current level of knowledge regarding outpatient cervical ripening and potential reasons that a provider may have in support of and against outpatient cervical ripening. The survey was distributed among General OBGYN attendings, fellows, residents, labor and delivery (LD) and advanced practice (APN) nurses at LUMC. Descriptive statistics and Fisher’s exact test was performed on categorical data. An ordinal logistic regression model was used to compare the odds of being more likely to offer outpatient cervical ripening between attendings and resident physicians and the odds of being familiar with outpatient cervical ripening. Results: 45 obstetric care providers completed the survey (comprising 20 OB/GYN residents, 10 General OB/GYN attendings, 13 LD, and 2 APN nurses). The response rate was 72%. 73% of all respondents had some degree of familiarity with outpatient cervical ripening, while 84% were familiar with the current body of research on this practice. Overall, the willingness to offer outpatient cervical ripening was 55% for the group, with only 11% unwilling. There was no difference in the willingness to offer outpatient cervical ripening between attendings and resident physicians (OR = 1.25, 95% CI: 0.32 – 4.88; p = .75) (Table 1). Major factors that drove willingness to offer were decreased induction to delivery time (77%) and patient convenience (85%). Major factors that drove unwillingness to offer OP cervical ripening were lack of fetal monitoring (66%), increased communication from patients (66%), and additional utilization of clinic resources/time for protocol implementation (66%). Resident physicians were significantly more likely to report familiarity with the current research on outpatient cervical ripening than nurses (OR=5.04; 95% CI: 1.24-20.45; p=.02) and attending physicians (OR=4.13; 95% CI: 1.05-17.78; p=.04). There was no difference in familiarity with research behind the practice between physicians and nurses respondents (p=.85). There was no association between those who reported the level of familiarity with the concept of outpatient cervical ripening and their willingness to offer (OR = 1.52, 95% CI: 0.40 – 5.78; p = .54) (Table 2). Conclusions: Moving preinduction cervical ripening to an outpatient setting is equally efficacious and safe when compared to inpatient cervical ripening. However, despite having an existing protocol for cervical ripening using a Foley Balloon, this practice is not currently utilized at LUMC. Our survey suggests that though physicians and nurses are familiar with the concept and the research behind the practice, there are limiting factors for use. Further education regarding outpatient cervical ripening are essential for increasing practice adoption.

Development and Evaluation of a Cesarean Hysterectomy Simulation Model

Introduction: Cesarean hysterectomy is a life-saving procedure considered during postpartum hemorrhage in cases of uterine atony refractory to management, placenta accreta spectrum, or other obstetric complications. The procedure has high morbidity and mortality despite the rising rates of worldwide and in the United States. A high percentage of OB/GYN residents graduate without preparedness to perform this procedure post-residency, citing insufficient residency exposure as the primary contributor. This study aims to use evaluation and assessment tools to validate a low-cost, low-fidelity cesarean hysterectomy model at multiple OB/GYN residency training sites across the United States to increase resident confidence and proficiency in performing this critical procedure. Materials and Methods: Model Design and Development: Gynecologic surgeons from two OB/GYN residencies reviewed the literature for cesarean hysterectomy education and simulation. A low fidelity, anatomically accurate model was developed for cesarean hysterectomy simulation purposes. Efforts were made to optimize for anatomic layout and realistic feel, particularly for the anatomic structures relevant to cesarean hysterectomy: uterine vessels, anterior and posterior peritoneum, relation of anterior uterus to the bladder and ureters. Study Design: The study received institutional board review exemption at the Loyola University Medical Center (LUMC) and the University of Toledo (UT). During the last two months of the academic calendar, OB/GYN residents were offered the opportunity to perform a cesarean hysterectomy on the model. Demographics were collected in addition to the number of cesarean and abdominal hysterectomies performed as well as the confidence in cesarean hysterectomies independently. A uniform set of surgical instruments with both appropriate and inappropriate tools were made available for residents to choose from. Throughout the simulation, residents were asked to verbalize each step being performed. One faculty rater at each institution was trained to use the objective and standardized assessment tools and had completed an inter- and intra-rater reliability assessment. All residents were evaluated using the same two objective assessment tools. The two validated assessment tools used to evaluate resident performance using the model were the Task Specific Checklist and the Global Rating Scale. The former assessed residents on a “performed or not” basis on 14 surgical steps specific to cesarean hysterectomy. The latter used a scale of 1 to 5, with higher values representing more advanced skill, to evaluate respect for tissue handling, time and motion, instrument handing, knowledge of instrument selection, operation flow, assistant use, and familiarity with the procedure. Results: A total of 26 residents, 18 of 19 at LUMC and 8 of 17 at UT, completed the cesarean hysterectomy simulation between May and June 2022. At LUMC, no graduating residents had performed a cesarean hysterectomy in their residency. At UT, graduating residents had performed up to 2. All of the residents, including PGY-4s, stated that they either disagree or strongly disagree with the statement “I feel confident performing cesarean hysterectomy independently.” As hypothesized, the median resident scores on the Task Specific Checklist and Global Rating scale correlated with increasing PGY level. The combined TSC+GRS score was a median of 40 out of 49 total for the PGY-4 class, while the PGY-1 class had a median combined TSC+GRS score of 12 of 49. The PGY-2 and -3 class had TSC+GRS scores of 14 and 28 respectively. The simulation model was well-received with a median 4/5 rating for improving comfort level with cesarean hysterectomy and a median 4/5 rating for model realism. Each uterine model cost $6.00 and took approximately 20 minutes to build. The optional base constructed for supporting the model, cost a one-time fee of $160. All materials used for construction were easily available online. Discussion: This study validated an affordable, easily reproducible model that highlights the most important anatomy relevant to a cesarean hysterectomy. The model was developed, produced, and tested at two residency programs with a total of 26 residents participating in the study. This is the first low-fidelity cesarean hysterectomy model inclusive of relevant surgical steps and offers near-real visceral feel that has been developed and assessed for validity. This multisite study created a realistic model with high reproducibility at a low cost. Limitations of this study included the fact that only 27 residents participated in the study from only two institutions. In addition, faculty evaluators were not blinded to the residents they rated. The model is a reliable and affordable way to introduce this procedure at residency programs, particularly those that do not perform a substantial number of cesarean hysterectomies.

Patient Decision Making Surrounding Epidural Use in Labor

Introduction/Objectives: Labor is thought to be one of the most painful experiences in a woman’s life, similar to pain caused by complex regional pain syndromes. Epidural analgesia has been proven to provide excellent pain relief, and many women in the United States choose this during their labor course. The decision to use, or not to use, neuraxial analgesia is complex and multifactorial, and has historically generated debate amongst patients and obstetric providers. In addition, many patients will also change their minds about desiring an epidural in labor during their admission to Labor &amp; Delivery based on various factors encountered. This study aimed to determine the number of patients who change their mind about epidural in labor. We also aimed to characterize the factors involved in patients’ decision about epidural analgesia during labor and to determine if these factors change throughout the labor and delivery course. Methods: This study was a single-center, non-randomized, cross-sectional study that was performed at Loyola University Medical Center in the Labor &amp; Delivery unit. The study population included all full-term nulliparous patients that were admitted to Labor &amp; Delivery for full term labor or induction of labor. Patients were eligible if they were 18 years of age or older, and able to read, speak, and complete the study questionnaire in English. Exclusion criteria included previous vaginal delivery, contraindication to vaginal delivery, no plan to deliver during admission, and contraindication to epidural analgesia. The patients completed one questionnaire about preferences for epidural and influencing factors prior to delivery, and one questionnaire after delivery with similar questions. Demographics were collected, as well as data about complications and details of their labor and delivery course. Results: A total of 199 patients completed the study. The epidural rate was higher in patients who planned to receive it (n = 141/144 or 97.9%) than in patients who did not plan to receive an epidural (n = 49/55 or 89.1%). Further, there was significant discordance between patients’ plans for an epidural and receipt of the medication. That is, only three (1.5%) patients who planned to receive an epidural did not receive one. Conversely, 49 (24.6%) patients who did not plan to receive an epidural received one. Compared to patients who did not plan to receive an epidural, those who planned to receive the medication reported that their OBGYN physician (OR = 3.31, 95% CI: 1.80 – 6.06; p &lt; .001), Anesthesiology physician (OR = 2.73, 95% CI: 1.50 – 4.96; p = .001), and labor nurse (OR = 2.50, 95% CI: 1.38 – 4.53; p =.002) were more important sources of information. Further, when compared to patients who did not plan to receive an epidural, those who planned to receive the medication reported they wanted to be more comfortable during the course of labor (OR = 4.84, 95% CI: 2.50 – 9.39; p &lt; .001), that receiving an epidural would make their labor experience more enjoyable (OR = 27.17, 95% CI: 11.72 – 63.00; p &lt; .001), and that getting an epidural was safe (OR = 5.91, 95% CI: 2.96 – 11.80; p &lt; .001). Conclusions: In conclusion, this study found that the majority of patients in our study population chose to receive an epidural in labor, regardless of their plans at the start of their admission. The most important factors in the decision were discussions with the OBGYN and Anesthesiology physicians. Patients who decided to receive an epidural, despite planning not to, reported that they wanted to be more comfortable during their labor course and that receiving an epidural would make their labor experience more enjoyable.

The prognostic value of blood cellular indices in pulmonary embolism.

Prognostication in acute pulmonary embolism (PE) requires reliable markers. While cellular indices such as neutrophil-to-lymphocyte ratio (NLR), platelet-to-lymphocyte ratio (PLR), and systemic immune-inflammation index (SII) appear promising, their utility in PE prognostication needs further exploration. We utilized data from the RIETE registry and the Loyola University Medical Center (LUMC) to assess the prognostic value of NLR, PLR, and SII in acute PE, using logistic regression models. The primary outcome was 30-day all-cause mortality. We compared their prognostic value versus the simplified Pulmonary Embolism Severity Index (sPESI) alone. We included 10 085 patients from RIETE and 700 from the LUMC. Thirty-day mortality rates were 4.6% and 8.3%, respectively. On multivariable analysis, an elevated NLR (>7.0) was associated with increased mortality (adjusted odds ratio [aOR]: 3.46; 95% CI: 2.60-4.60), outperforming the PLR > 220 (aOR: 2.36; 95% CI: 1.77-3.13), and SII > 1600 (aOR: 2.52; 95% CI: 1.90-3.33). The c-statistic for NLR in patients with low-risk PE was 0.78 (95% CI: 0.69-0.86). Respective numbers were 0.66 (95% CI: 0.63-0.69) and 0.68 (95% CI: 0.59-0.76) for intermediate-risk and high-risk patients. These findings were mirrored in the LUMC cohort. Among 9810 normotensive patients in RIETE, those scoring 0 points in sPESI and with an NLR ≤ 7.0 (35% of the population) displayed superior sensitivity (97.1%; 95% CI: 95.5-98.7) and negative predictive value (99.7%; 95% CI: 99.5-99.8) than sPESI alone (87.1%; 95% CI: 83.9-90.3, and 98.7%; 95% CI: 98.4-99.1, respectively) for 30-day mortality. The NLR is a significant prognostic marker for 30-day mortality in PE patients, especially useful to identify patients with very low-risk PE.

Impact of Acute Exacerbation of Idiopathic Pulmonary Fibrosis on Lung Transplant Outcomes.

Acute exacerbations of idiopathic pulmonary fibrosis (AE-IPF) are acute, significant respiratory deteriorations in patients with IPF and can lead to increased morbidity and mortality. It remains unclear how AE-IPF impacts lung transplant (LTX) outcomes. All adult patients who were listed for LTX between July 2005 and October 2020 at the Loyola University Medical Center with a diagnosis of IPF were included. Pretransplant characteristics and posttransplant outcomes were gathered via retrospective chart review. The primary outcome was short- and long-term survival for patients transplanted during stable IPF versus those with AE-IPF. One hundred fifty-nine patients were included in this study, 17.6% of whom were transplanted during AE-IPF. AE-IPF patients were more likely to have higher oxygen needs pretransplant, have higher lung allocation score, and were more likely to be intubated or be on extracorporeal membrane oxygenation as compared with stable IPF patients. Survival by AE status at transplant did not differ at 90 d or 1 y posttransplantation. There were also no significant differences in rates of severe primary graft dysfunction or acute rejection within 1 y. Patients with AE-IPF were more likely to have higher oxygenation requirements and higher lung allocation score at the time of LTX than those with stable IPF. Despite this, there were no differences in survival at 90 d, 1 y, or 3 y, or differences in incidence of severe primary graft dysfunction or acute cellular rejection. Transplantation of patients with AE-IPF has clinical outcomes comparable with transplantation of patients with stable IPF. This contrasts with previous studies examining LTX in patients with AE-IPF.

Evaluating the Impact of the COVID-19 Pandemic on Late-Canceled and No-Show Appointments at the Department of Neurological Surgery.

The coronavirus disease 2019 (COVID-19) pandemic resulted in unprecedented restrictions on the general public and disturbances to the routines of hospitals worldwide. These restrictions are now being relaxed as the number of vaccinated individuals increases and as the rates of incidence and prevalence decrease; however, they left a lasting impact on healthcare systems that is still being felt today. This retrospective study evaluated the total number of canceled or missed outpatient clinic appointments in a Neurological Surgery department before and after peak COVID-19 restrictions and attempted to assess the impact of these disruptions on neurosurgical clinical attendance. We also attempted to compare our data with the data from another surgical subspecialty department. We evaluated 32,558 scheduled appointments at the Loyola University Medical Center Department of Neurological Surgery, as well as 139,435 scheduled appointments with the Department of Otolaryngology. Appointments before April 2020 were defined as pre-COVID, while appointments during or after April 2020 were defined as post-COVID. Here, we compare no-show and non-attendance rates (no-shows plus late-canceled appointments) within the respective time range. Overall, we observed that before COVID-19 restrictions were put into place, there was an 8.9% no-show rate and a 17.4% non-attendance rate for the Department of Neurological Surgery. After COVID restrictions were implemented, these increased to 10.9% and 18.3%, respectively.Greater no-show and cancellation rates (9.8% in the post-COVID era vs 8.0% in the pre-COVID era) were associated with varying socioeconomic and racial demographics. African-American patients (2.56 times higher), new-visit patients (1.67 times higher), and those with Medicaid/Medicare insurance policies (1.48 times higher) were at the highest risk of no-show in the post-COVID era compared to the pre-COVID era.

Endoscopic Endonasal Approach for Residual and Recurrent Craniopharyngioma after Transcranial Approach: A Multi-institutional Experience

Abstract Objectives While the endoscopic endonasal approach (EEA) has become a well-established surgery for resection of craniopharyngiomas (CP), the utility of this procedure following subtotal resection from open transcranial approach (TCA) surgery has yet to be explored. Here we present a multi-institutional case series of patients who underwent EEA for treatment of recurrent CP originally treated by TCA, demonstrating the viability of this approach as salvage surgery. Design Retrospective cohort. Setting Loyola University Medical Center and University of Pittsburgh Medical Center. Participants Patients who underwent EEA for recurrent CP following an initial TCA between 2003 and 2018. Main Outcome Measures Gross total resection (GTR) rate, surgical complications, visual outcomes, and endocrine outcomes Results Patients who underwent EEA for recurrent CP following a prior TCA had a GTR rate of 77%. EEA reoperation was not associated with worsening of visual outcomes as compared with the primary TCA (0% visual worsening after EEA reoperation vs. 40% after primary TCA, p = 0.055). While primary TCA resulted in worsening endocrinopathies in 100% of patients (including seven patients with permanent diabetes insipidus), subsequent EEA for re-resection of CP resulted in stable (30.8%) or improved (69.2%) endocrine function in all patients (p &lt; 0.001). Conclusions EEA achieves reasonable GTR rates and is an effective, safe surgical option for recurrent CP postinitial TCA. This approach demonstrated stable or improved visual and endocrinologic outcomes in all patients within our two-institution series. Thus, EEA should be considered as an efficacious form of retreatment in cases of progressive and recurrent CP.

Endoscopic Endonasal Anterior Skull Base Meningoencephalocele and Cerebrospinal Fluid Leak Repair: Our Intraoperative and Postoperative Protocol and Long-term Outcomes

Abstract Objective We evaluated the long-term outcomes from a single neurosurgeon and otolaryngologist team using a specific operative protocol for repair and postoperative evaluation. Design The charts of patients undergoing endoscopic endonasal repair of meningoencephaloceles (MECs) and cerebrospinal fluid (CSF) leaks were retrospectively reviewed from 2015 to 2023. Intraoperative steps of the repair and reconstruction were analyzed. Patients' postoperative assessments and complications were analyzed. Setting Loyola University Medical Center's electronic medical record database. Participants Forty-three patients (32 female) aged between 11 and 81 years. Main Outcome Measures Long-term outcomes of patients who underwent endoscopic endonasal repair of MECs and CSF leaks by a single team and protocol. We hypothesized that there would be minimal complications and no recurrences, requiring secondary operation. Results The most common site for MECs was the cribriform plate. Lumbar drain opening pressures ranged from 10 to 35 cm H2O with 18 out of 34 patients having the lumbar drain removed immediately postoperatively. The median hospital stay was 3 days. The average length of follow-up was 3.8 years. No recurrences or secondary operations were noted in all patients. One patient had a sinonasal infection that was successfully treated. Eight patients were noted to have venous stenosis and underwent further evaluation. Conclusion This study represents one of the largest long-term analyses of outcomes by a single team. Our specific protocol for the endoscopic endonasal repair of anterior skull base MECs and CSF leaks is safe and effective. These patients should be evaluated and treated for elevated intracranial pressure following the repair.

Long-term quality of life outcomes in patients undergoing microsurgical resection of vestibular schwannoma

BackgroundWhile previous studies have assessed patient reported quality of life (QOL) of various vestibular schwannoma (VS) treatment modalities, few studies have assessed QOL as related to the amount of residual tumor and need for retreatment in a large series of patients. Objective: To assess patient reported QOL outcomes following VS resection with a focus on extent of resection and retreatment. MethodsA retrospective chart review was performed using single-center institutional data of adult patients who underwent VS resection by the senior authors between 1989-2018 at Loyola University Medical Center. The Penn Acoustic Neuroma Quality of Life (PANQOL) survey was sent to all patients via postal mail. ResultsFifty-five percent of 367 total patients were female with a mean age of 61.6 years (SD 12.63). The mean period between surgery and PANQOL response was 11.4 years (IQR: 4.74-7.37). The median tumor size was 2 cm (IQR: 1.5-2.8). The mean total PANQOL score was 70 (SD 19). Patients who required retreatment reported lower overall scores (μdiff = -10.11, 95% CI: -19.48 to -0.74; p = 0.03) and face domain scores (μdiff = -20.34, 95% CI: -29.78 to -10.91; p < .001). There was no association between extent of resection and PANQOL scores in any domain. ConclusionIn an analysis of 367 patients who underwent microsurgical resection of VS, extent of resection did not affect PANQOL scores in contrast to previous reports in the literature, while the need for retreatment and facial function had a significant impact on patient-reported outcomes.

Abstract TP252: Forward Head Posturing as a Significant Risk Factor for Posterior Circulation Infarcts

Objective: Forward head posturing (FHP) has been associated with chronic anatomic vertebral artery disturbances possibly leading to posterior circulation ischemia. The data supporting FHP as a true risk factor of posterior circulation stroke has not been well established. We aim to study if patients with severe cervical myalgias and FHP have an increased risk of posterior circulation stroke. Methods: We identified all adult patients with posterior circulation stroke and diagnosis of cervical myalgia at Loyola University Medical Center from January 2018 to January 2023. Information on demographics and comorbidities were also collected. We then identified matched pair case-controls (based on age and gender) with non-stroke cervical myalgia patients in the same 5-year period. We compared the relevant comorbidities, C2 tilt angle, and C2-C7 tilt angle of patients to their matched controls to for statistical difference. Results: 76 patients (38 cases and 38 controls) with an average age of 64 years, including 38 (50%) females met our inclusion criteria. The average C2 tilt of cases was 22.9 degrees compared to 17.7 degrees in controls, and the average C2-C7 tilt of cases was 18.9 degrees in cases compared 10.5 degrees in controls. There were no significant differences between relevant comorbidities (including hypertension, hyperlipidemia, diabetes, atrial fibrillation, hyper-coagulopathy, or body mass index) of cases and controls. There was a significant difference of 5.2 degrees higher C2 tilt and 8.1 degrees higher C2-C7 tilt in cases compared to controls respectively (p-value = 0.03). Conclusion: In this single-center retrospective analysis, we found that after controlling for age, gender, and comorbidities, patients with posterior circulation stroke were more likely to have significantly higher C2 and C2-C7 cervical tilt (worse FHP based on radiographic standards) compared to their matched control counterparts.

Thromboinflammatory Biomarkers of Cardiorenal Syndrome in Patients With End-Stage Renal Disease.

Cardiovascular disease is a prevalent complication in patients with end-stage renal disease (ESRD) on maintenance hemodialysis. In the ESRD patient population, cardiovascular mortality is 20 times higher compared to the general population. The strong relationship between both illnesses can be explained through cardiorenal syndrome (CRS). CRS encompasses a spectrum of disorders involving both the heart and kidneys in which acute or chronic dysfunction in one organ may induce a similar effect in the other organ. Current literature reveals that inflammation and thrombosis are integral to CRS development. Hence, this study aims to demonstrate whether thromboinflammatory biomarkers and laboratory parameters correlate with ESRD progression and the development of CRS. Ninety-five ESRD patients were recruited at Loyola University Medical Center hemodialysis unit. Epic chart analysis was used to determine patients with CRS. Biomarkers (C-reactive protein, tumor necrosis factor alpha, interleukin-6, Annexin V, L-fatty acid binding protein, monocyte chemoattractant protein 1, nitric oxide, von Willebrand factor, D-dimer, and plasminogen activator inhibitor-1) were profiled using the enzyme-linked immunosorbent assay method in patients with and without CRS in the ESRD cohort. All biomarkers were significantly elevated in ESRD patients compared to normal controls (P < .05) and laboratory parameters, ferritin (521.99 ± 289.33) and PTH (442.91 ± 1.50). Through EPIC chart analysis 47% of ESRD patients have CRS. D-dimer and TNF-α were significantly elevated in patients with CRS compared to patients without CRS. This study suggests that biomarkers, D-dimer, and TNF-α, can be good predictors of CRS in ESRD patients.

COMMUNICATION PREFERENCES OF PATIENTS WITH LIMITED ENGLISH PROFICIENCY IN THE OTOLARYNGOLOGY CLINIC SETTING

In the United States, people with limited English proficiency (LEP) and lower health literacy have reduced access to care and poorer health outcomes. There is a lack of data on how to best provide language assistance services in the ambulatory setting. This study will evaluate what type of professional language interpretation services are preferred by LEP patients in the otolaryngology clinic population. Our study aims are 1) to assess the communication preferences of patients with LEP in the healthcare setting regarding interpreter services, 2) to determine if there are specific LEP patient demographics that correlate with communication preferences in the healthcare setting regarding interpreter services, and 3) to determine if there is a correlation between health literacy and degree of language barrier, and if there is, to what degree, and how may this affect the patient’s preferences and experience. LEP adult patients and adult caregivers of pediatric patients treated at 5 of Loyola University Medical Center Otolaryngology clinic sites will be consented and given a one-time study questionnaire to complete in their native language. The questionnaire will ask about the patient’s background, place of birth, primary place of birth, primary language, years living in the United States, self-reported English language proficiency and fluency, self-reported health status, and preferences for the type of language support services. Health literacy will be assessed with the Brief Health Literacy Screen. Targeted interventions can potentially be designed and incorporated in the healthcare setting based on the data and identified communication preferences and the demographic correlations. This in turn has the potential to reduce healthcare disparities and improve outcomes for LEP patients.

686. Management and Outcomes of Patients Referred to a Specialty Clinic for C. difficile Infection

Abstract Background Clostridioides difficile infection (CDI) poses an urgent threat in the United States with an estimated 223,900 cases of hospitalization and 12,800 estimated deaths in 2017. CDI manifestations range from diarrhea, pseudomembranous colitis, to fulminant colitis. Due to spores that are unaffected by current antimicrobial therapies, recurrence remains a common challenge. Patients with 2 or more episodes have an estimated 40-65% rate of recurrence. We reviewed the management and outcomes of patients referred to our specialty CDI clinic. Methods A retrospective chart review was conducted on all new patients presenting to the Loyola University Medical Center CDI clinic between 01/01/2021 and 12/31/2021. Each chart was reviewed for demographic information, comorbidities that may confound diagnosis, and characteristics that place the patient at high risk of recurrent CDI. Visits were characterized by the number of prior CDI episodes, timeline of recurrences, and prior therapies used. 30- and 60-day symptom recurrence were assessed. Results A total of 48 new patients presented to the CDI clinic. The median age was 63 years, 64.5% were white, and 64.5% were female. Patients presenting with recurrent CDI accounted for 79% of cases (38/48), with 48% (13/48) of patients having two or more recurrences. The most common decision for initial management was to not give further antimicrobials and monitor for symptoms (35%). 12% of patients only required monitoring while 23% of patients had a questionable CDI diagnosis and were referred elsewhere for further evaluation. For the 30 patients who received treatment, vancomycin or fidaxomicin tapers were selected 73% (22/30) and bezlotoxumab 20% (6/30) of the time. 8.6% (2/23) of patients with a history of two or more CD episodes had recurrence. Overall, patients experienced a subsequent recurrence rate of 12.5% (6/48) and 15% (7/48) at 30 and 60 days, respectively. The number of times each management approach was selected for initial patient appointments. The number of times each treatment regimen was selected when a patient was deemed to need antibiotic therapy. The percentage of patients who had either recurrence or resolution at 60 days after the end of therapy. Conclusion CDI is a difficult-to-treat infection with many patients suffering from multiple recurrences. Dedicated outpatient follow-up is important for monitoring therapy and excluding alternate etiologies. Expert management of CDI through a dedicated clinic results in lower recurrence for high-risk patients and spared 35% of patients further antimicrobial exposure. Disclosures Larry H. Danziger, PharmD, Ferring Pharmacetuicals: Advisor/Consultant Andrew M. Skinner, MD, Academy for Continued Healthcare Learning: Honoraria|American Society of Healthcare Pharmacists: Honoraria|Ferring Pharmaceuticals: Honoraria|MJH Life Sciences: Honoraria

Development and external validation of multimodal postoperative acute kidney injury risk machine learning models.

To develop and externally validate machine learning models using structured and unstructured electronic health record data to predict postoperative acute kidney injury (AKI) across inpatient settings. Data for adult postoperative admissions to the Loyola University Medical Center (2009-2017) were used for model development and admissions to the University of Wisconsin-Madison (2009-2020) were used for validation. Structured features included demographics, vital signs, laboratory results, and nurse-documented scores. Unstructured text from clinical notes were converted into concept unique identifiers (CUIs) using the clinical Text Analysis and Knowledge Extraction System. The primary outcome was the development of Kidney Disease Improvement Global Outcomes stage 2 AKI within 7 days after leaving the operating room. We derived unimodal extreme gradient boosting machines (XGBoost) and elastic net logistic regression (GLMNET) models using structured-only data and multimodal models combining structured data with CUI features. Model comparison was performed using the receiver operating characteristic curve (AUROC), with Delong's test for statistical differences. The study cohort included 138 389 adult patient admissions (mean [SD] age 58 [16] years; 11 506 [8%] African-American; and 70 826 [51%] female) across the 2 sites. Of those, 2959 (2.1%) developed stage 2 AKI or higher. Across all data types, XGBoost outperformed GLMNET (mean AUROC 0.81 [95% confidence interval (CI), 0.80-0.82] vs 0.78 [95% CI, 0.77-0.79]). The multimodal XGBoost model incorporating CUIs parameterized as term frequency-inverse document frequency (TF-IDF) showed the highest discrimination performance (AUROC 0.82 [95% CI, 0.81-0.83]) over unimodal models (AUROC 0.79 [95% CI, 0.78-0.80]). A multimodality approach with structured data and TF-IDF weighting of CUIs increased model performance over structured data-only models. These findings highlight the predictive power of CUIs when merged with structured data for clinical prediction models, which may improve the detection of postoperative AKI.

#2724 THROMBO-INFLAMMATORY BIOMARKERS OF CARDIORENAL SYNDROME IN PATIENTS UNDERGOING MAINTENANCE HEMODIALYSIS IN END STAGE RENAL DISEASE

Abstract Background and Aims Cardiovascular disease is a highly common complication in patients with end stage renal disease (ESRD) on maintenance hemodialysis. In the ESRD patient population, cardiovascular mortality is 20 times higher compared to the general population. The strong relationship of both illnesses can be explained through cardiorenal syndrome (CRS). CRS encompasses a spectrum of disorders involving both the heart and kidneys in which acute or chronic dysfunction in one organ may induce similar effect in the other organ. The diagnosis, prognosis and risk stratification of CRS is poorly understood. Current literature reveals that inflammation and thrombosis are integral to CRS development and key cardiac and renal biomarkers are elevated in CRS patients. Hence, this study aims to demonstrate that thrombo-inflammatory biomarkers and laboratory parameters give a telling narrative of ESRD progression to CRS. Method Plasma samples were collected from 95 ESRD patients which were recruited with an approved IRB protocol at Loyola University Medical Center hemodialysis unit. Normal human plasma (NHP) was obtained from a commercial source (George King Biomedical, Overland Park, KS). Thrombo-inflammatory biomarkers, including Annexin V, MPO, Troponin, L-FABP, VEGF, D-dimer, TNF-alpha, IL-6, CRP, eNOS, Nitrotyrosine, MDA, NEFA, NO, vWF and MCP-1 were measured using commercially available ELISA methods. Cardiovascular comorbidities and laboratory parameters were obtained from EPIC chart analysis. Results were then statistically analyzed using GraphPad Prism v.9; the results were compiled into mean ± SEM, percent change comparison to NHP, analyzed for significance. Results Several cardiovascular comorbidities were seen in the 95 ESRD patient samples including AF (22%), PAD (29%), HF (24%), CAD (22%), DVT (15%), COPD (6.5%), and PE (5.3%). Overall, 25% of the ESRD patients have CRS. Laboratory parameters, ferratin (521.99 ±289.33) and PTH (442.91 ± 1.50) were elevated in ESRD patients. Most of the thrombo-inflammatory CRS biomarkers were elevated in ESRD patients. Biomarkers including Annexin V (ESRD 7.57 ± 5.24, 23.64% vs. 6.125 ± 8.29, p&amp;lt; 0.001), L-FABP (106599.43 ± 176728.97, 1983% vs. 5116.33 ± 1767.88, p&amp;lt;0.0001), D-dimer (ESRD 1447.01 ± 2103, 650.53% vs. 192.8 ± 212.9, p&amp;lt;0.0001), TNF-alpha (ESRD 2.52 ± 1.06, 35.87% vs. 1.85 ± 1.20, p&amp;lt;0.0001), IL-6 (ESRD 5.211 ± 10.36, 317.21% vs. 1.25 ± 1.24, p &amp;lt;0.0001), CRP (ESRD 14.53 ± 14.11, 2214.43% vs. 0.63 ± 0.99, p&amp;lt; 0.0001), NO (ESRD 34.74 ± 19.74, 151.74% vs. 13.8 ± 5.60, p&amp;lt;0.0001), vWF (ESRD 200.7 ± 25.89, 183.03% vs. 70.91 ± 23.13 p&amp;lt; 0.0001) and MCP-1 (148.4 ± 56.09, 67.49% vs. 88.6 ± 27.25, p&amp;lt;0.0001) showed significant increase when compared to NHP. Conclusion This study suggests that thrombo-inflammatory biomarkers and laboratory parameters may be helpful in indicating CRS in ESRD patients. Ultimately, these biomarkers can now be readily used to correlate against other biomarker findings and studied further to determine their accuracy in prognosis and diagnosis of CRS.