Major Outcomes Research Articles

Effect of remimazolam vs propofol on emergence from general anesthesia in patients undergoing cerebral endovascular procedures: A randomized controlled, non-inferiority trial

Study objectiveThis study aimed to compare the time to emergence from general anesthesia with remimazolam versus propofol in patients undergoing cerebral endovascular procedures. DesignA prospective, double-blind, randomized controlled, non-inferiority trial. SettingAn academic hospital. PatientsAdult patients scheduled for cerebral endovascular procedures. InterventionsPatients were randomized at a 1:1 ratio to undergo surgery under general anesthesia with remimazolam (0.1 mg kg−1 for induction and 0.3–0.7 mg kg−1 h−1 for maintenance) or propofol (1–1.5 mg kg−1 for induction and 4–10 mg kg−1 h−1 for maintenance). MeasurementsThe primary outcome was the time to emergence from anesthesia. The non-inferiority margin was −2.55 min in group difference. Major secondary outcomes included hypotension during induction, incidence of postoperative delirium and Modified Rankin Scale (mRs) at 30 days and 90 days after surgery. Main resultsOf the 142 randomized patients, 129 completed the trial. In the modified intention-to-treat analysis, the mean time to emergence from anesthesia was 16.1 [10.4] min in the remimazolam group vs. 19.0 [11.2] min in the propofol group. The group difference was −2.9 min [95% CI -6.5, 0.7] (P = 0.003 for non-inferiority). The remimazolam group had lower rate of hypotension during induction (11.3% vs 25.4%, P = 0.03) and use of vasopressors during surgery (29.6% vs 62.0%, P < 0.001). The two groups did not differ in postoperative delirium and mRs at 30 and 90 days after surgery. ConclusionsIn patients undergoing cerebral endovascular procedures, remimazolam did not increase the time from anesthesia vs propofol.

Unraveling the Role of Tumor Necrosis Factor-Alpha in Diabetic Peripheral Neuropathy: A Systematic Review and Meta-Analysis.

Diabetic peripheral neuropathy (DPN) is a prevalent and debilitating complication of diabetes mellitus, leading to sensory abnormalities, decreased balance, and increased risk of foot problems. Although tumor necrosis factor-alpha (TNF-α) has emerged as a potential factor in the pathogenesis of DPN, its role remains contested. This study intends to thoroughly analyze the association between TNF-α and DPN by combining data from various global studies. This systematic review and meta-analysis adhered to the Preferred Reporting Items for Systematic Reviews and Meta-Analyses guidelines and included 23 articles investigating TNF-α levels in DPN patients for systematic review and 11 articles for meta-analysis. Data were extracted, and heterogeneity was examined. A random-effect model was chosen due to high heterogeneity. The major outcome measure across studies was serum TNF-α levels. The meta-analysis found a significant mean difference of 15.2464 (95% confidence interval = 4.4963; 25.9965) under the random-effect model due to the substantial heterogeneity (I2 = 98.1%) among included studies. The meta-analysis indicates a consistent elevation in TNF-α levels in individuals with DPN compared to those without neuropathy. This underlines the potential of TNF-α as a biomarker and contributor to diabetic neuropathy. Despite heterogeneity, the study's extensive scope and systematic approach enhance the trustworthiness and generalizability of the findings.

Intraoral Microscopic Versus Robot-Assisted Sialolithotomy and Sialendoscopy for Submandibular Stones.

Sialendoscopy has remained the standard of treatment for sialolithiasis; however, large stones impacted in the submandibular gland hilum often require an intra-oral combined approach. Patients treated for submandibular hilar sialolithiasis from 2015 to 2021 at two tertiary centers were stratified into two groups based on the surgical technique: Intraoral Microscopic-Assisted Sialolithotomy (IMAS) versus Robot-Assisted Sialolithotomy and Sialendoscopy (RASS). We compared the characteristics of retrieved stones, surgical success rate, operative time, and post-operative complications in both techniques. True surgical success was defined as successful stone extraction without reoccurrence within 12 months. The RASS technique was attempted in 60 patients and successful in 56 (93.3%) cases whereas the IMAS technique was performed in 52 patients and successful in 48 (92.3%) cases. The longest dimension of the predominant retrieved calculi was 9.6 ± 3.1 mm (range, 5-18 mm) for the robotic technique and 10 ± 4.8 mm (range, 5-30 mm) for the microscopic technique. The operative time for the robotic technique excluding robot setup time was 70.6 ± 24.8 min compared to 61.9 ± 42.4 min for microscopic technique (p = 0.018). No major adverse outcomes were reported; however, temporary lingual paresthesia was found in ten robotic (16.7%) and five microscopic (9.6%) cases. The two techniques were comparable in terms of efficacy and safety for large stones. The robot has the advantage of intraoral high dynamic maneuverability and improved surgeon posture while the microscopic technique has the advantage of intraoral tactile feedback. The procedure was significantly shorter in duration with the microscope. 3 Laryngoscope, 134:2170-2176, 2024.

PP130 The Effectiveness Of Extracorporeal Shock Wave Therapy For Plantar Fasciitis: A Systematic Review And Meta-analysis

IntroductionExtracorporeal shock wave therapy (ESWT) has been used since the 1990s to treat various musculoskeletal disorders, but there is considerable controversy regarding the effectiveness of ESWT. Our aim was to conduct a systematic review of randomized controlled trials (RCT) to investigate the effectiveness of ESWT for plantar fasciitis.MethodsA comprehensive search was conducted via electronic databases including MEDLINE, Embase, the Cochrane Controlled trials register, and 5 Korean databases from inception date to April 2022. Two review authors independently assessed studies for inclusion and risk of bias, and extracted study data. Major outcomes were pain relief, function, and quality of life.ResultsWe identified a total of 48 RCTs comparing ESWT with corticosteroid injection (n=14), conventional therapies (n=19), and sham control (n=21). Most studies included participants with chronic heel pain diagnosed as plantar fasciitis. All trials were susceptible to bias. In terms of pain results, ESWT showed no significant difference when compared with the steroid injection group and the conventional therapy group, and significant pain relief was confirmed only compared to the sham control group (Mean Difference -1.71; 95% confidence interval [CI] -2.44,-0.98; I2=70%;). Functional outcomes were significantly improved in the ESWT group compared to the steroid injection group (standardized mean difference 0.45; 95% CI 0.27,0.63; I2=0%) and the sham control group (SMD 0.84, 95% CI 0.23,1.45; I2=91%), but no significant difference was found when compared to the conventional therapy group.ConclusionsBased upon the currently available low certainty evidence because of wide clinical diversity and varying treatment protocols of included trials, ESWT is associated with improved function and may be associated with pain reduction in plantar fasciitis. Further evidence is needed from well-designed studies with a standard dose and treatment protocol.

A user‐friendly calculator to estimate length of time from initial presentation to need for full‐time care or death in individual patients with Alzheimer’s disease

AbstractBackgroundAlzheimer’s disease (AD) exhibits substantial variability in its initial presentation and rate of progression. Our goal was to understand AD progression well enough to create a calculator that uses presented clinical features to estimate the length of time from initial presentation to major disease outcomes in individual patients with AD.MethodThe variability in rate of AD progression is strongly related to the variability in specific disease signs and symptoms identified at initial presentation. We developed a longitudinal Grade of Membership prediction algorithm and demonstrated its ability, based on initial presentation of six fixed covariates and 73 time‐varying clinical signs and/or symptoms, to accurately predict time to need for full‐time care (FTC) and death in two groups: a mainly white, clinic‐based group of AD patients (N = 229), and a statistically representative community‐based sample of Hispanic (N = 211) and non‐Hispanic (N = 62) older adults with MCI or AD. We then created an online calculator for use by physicians, relatives, or patients to generate these predictions.ResultThe calculator is implemented as an online, freely available R Shiny web app: https://cnd‐columbia.shinyapps.io/AD_Calc/. The user is prompted for current clinical information about the patient. Most of this information can be gleaned from patient observation, healthcare providers, or medical records. Unknown items can be skipped or sensibly approximated. The calculator generates individual‐specific survival‐probability curves, including median survival time, over the next 10 years. It also generates conditional probabilities of need for FTC in a way that allows the overall survival time to be decomposed into time free of need for FTC and time in need of FTC. The calculator does not predict which specific individuals would die before the median versus after the median; that prediction cannot be done.ConclusionGiven the substantial variability over individuals in rate of disease progression, knowing the statistics of the individual‐specific survival times as well as the times to need for FTC can be of great value to patients with AD, their caregivers, and health care providers. The new calculator meets this need. In the future, the calculator also can be extended to predict time to other important disease milestones.

Relationship between Baseline Physical Activity and Generalized Anxiety Disorder and Major Depressive Disorder Treatment Outcomes.

Generalized anxiety disorder and major depressive disorder often benefit from medication and psychotherapy. Our aim was to determine whether a correlation exists between patient baseline physical activity and response to treatment. This was a retrospective study that included adult patients with anxiety and depression who received outpatient care for their conditions by providers in the Department of Psychiatry and Psychology of the Mayo Clinic in Jacksonville, Florida. Statistical analyses were used to analyze whether Rapid Assessment of Physical Activity scores as a measure of baseline exercise correlated to changes in Patient Health Questionnaire-9 (PHQ-9) scores or Generalized Anxiety Disorder-7-item scale (GAD-7) scores during treatment for anxiety or depression. Factors including age, sex, smoking status, and caffeine intake also were analyzed. When comparing change in GAD-7 or PHQ-9 scores from baseline to follow-up during treatment for anxiety or depression, there was no significant difference based on Rapid Assessment of Physical Activity scores. Caffeine intake had a direct correlation with PHQ-9 scores from baseline to 12 to 24 weeks but no correlation with GAD-7 scores. Overall, the amount of physical activity a patient participates in before anxiety or depression treatment does not appear to affect improvement outcomes. Caffeine intake may improve depression severity scores; however, further research is needed to assess whether this could be a part of future treatment plans.

Severity of coronary artery disease and major cardiovascular outcome in diabetic patients with history of severe hypoglycemia: A matched case-control study

Severity of coronary artery disease and major cardiovascular outcome in diabetic patients with history of severe hypoglycemia: A matched case-control study

Neurovascular Hypoxia Trajectories Assessed by Photoacoustic Imaging in a Murine Model of Cardiac Arrest and Resuscitation.

Cardiac arrest is a common cause of death annually mainly due to postcardiac arrest syndrome that leads to multiple organ global hypoxia and dysfunction after resuscitation. The ability to quantify vasculature changes and tissue oxygenation is crucial to adapt patient treatment in order to minimize major outcomes after resuscitation. For the first time, we applied high-resolution ultrasound associated with photoacoustic imaging (PAI) to track neurovascular oxygenation and cardiac function trajectories in a murine model of cardiac arrest and resuscitation. We report the preservation of brain oxygenation is greater compared to that in peripheral tissues during the arrest. Furthermore, distinct patterns of cerebral oxygen decay may relate to the support of vital brain functions. In addition, we followed trajectories of cerebral perfusion and cardiac function longitudinally after induced cardiac arrest and resuscitation. Volumetric cerebral oxygen saturation (sO2) decreased 24 h postarrest, but these levels rebounded at one week. However, systolic and diastolic cardiac dysfunction persisted throughout and correlated with cerebral hypoxia. Pathophysiologic biomarker trends, identified via cerebral PAI in preclinical models, could provide new insights into understanding the pathophysiology of cardiac arrest and resuscitation.

Low- versus standard-dose post-transplant cyclophosphamide as GVHD prophylaxis for haploidentical transplantation.

Haploidentical haematopoietic cell transplantation (haplo-HCT) using post-transplant cyclophosphamide (PTCY) as graft-versus-host disease (GVHD) prophylaxis is the standard of care for various haematological malignancies. The original PTCY dose after haplo-HCT was 100 mg/kg, but no dose-finding studies have been performed to identify the optimal dose. We performed a retrospective analysis to compare standard-dose PTCY (100 mg/kg) with reduced-dose PTCY (80 mg/kg): 969 in the standard-dose group and 538 in the reduced-dose group. As there was a significant difference between the two groups regarding patient and transplant characteristics, we performed propensity score (PS) matching. After PS matching, 425 patients in each group were included. The probabilities of 2-year OS were 55.9% in the standard-dose group and 47.0% in the reduced-dose group (p = 0.36). The cumulative incidences of 2-year non-relapse mortality were 21.3% in the standard-dose group and 20.5% in the reduced-dose group (p = 0.55). There was no significant difference in the incidence of acute (grade II-IV 29.2% [95% CI, 24.9-33.6] vs. 25.3% [95% CI, 21.3-29.6]; grade III-IV 7.3% [95% CI, 5.1-10.0] vs. 6.6% [95% CI, 4.5-9.3]) or chronic GVHD. In conclusion, reduced- and standard-dose PTCY were comparable in terms of major clinical outcomes.

Predictors of Outcome in Management of Ruptured Arteriovenous Fistula in Hemodialysis Patients: A Cross-Sectional Study at a Tertiary Care Hospital, Karachi

Bleeding from ruptured arteriovenous fistulae (AVF) is a distressing complication resulting from multiple factors and can lead to life-threatening hemorrhage. Objective: To analyze factors that contribute to the development of a bleeding ruptured AVF which could enable us to make decision regarding line of management for saving these AVFs. Methods: This cross-sectional study was conducted at Department of Vascular Surgery, Sindh Institute of Urology and Transplant (SIUT), including 52 patients presenting with burst arteriovenous fistula during the time period of six months. Data collection was carried out using a pretested questionnaire which comprised of detailed history regarding pre-operative and per-operative factors related to burst fistula. Results: The mean age of the patients was 35.7 ± 19.6 years with gender distribution identified as male (51.9%) and female (48.1%). The major outcome of the study was salvageability of AVF which was observed to be 36.5% among the study cohort. We also analyzed association of AVF salvageavility with pre-operative and intraoperative factors which showed its significant association with risk factors such as fistula age (&lt;40 or &gt; 40 days), area of surrounding inflammation, overlying skin, bleeding AVF before initiation of hemodialysis from fistula, type of cannulation, site of bleeding from AVF and ligation/repair status of fistula. Conclusions: Understanding these significantly associated factors could contribute to the early detection and allow measures aimed at averting adverse outcomes, which can span from the loss of vascular access to severe health problems and even, in some cases, prove fatal.

Norm-Violating Behavior in Organizations: A Comprehensive Conceptual Review and Model of Constructive and Destructive Norm-Violating Behavior

Norm violations can not only cause harm but also contribute to the well-being of organizations. During the last several decades, two different foci of research on workplace norm violations have generated a host of empirical studies on both constructive and destructive norm-violating behavior (NVB). However, the two closely related bodies of literature have remained in almost complete isolation from each other. Our conceptual review seeks to kindle a new perspective to better understand the general concept of NVB in organizations by combining the bifurcated silos of both constructive and destructive NVB. By conducting a systematic literature review of research on workplace NVBs over the past 30 years, we synthesize the major research findings on both constructive and destructive deviance into a general framework and examine the major antecedents, moderators, mediators, and outcomes as they fit within the major theoretical perspectives. Moreover, we study the commonalities of constructive and destructive NVB, focusing especially on the overlapping and dynamic relationships between the two concepts. To conclude, we propose new lines of inquiry for future research to assist academics and practitioners in understanding and managing different forms of organizational norm violations.

Groundwater potential delineation using geodetector based convolutional neural network in the Gunabay watershed of Ethiopia

Groundwater potential delineation is essential for efficient water resource utilization and long-term development. The scarcity of potable and irrigation water has become a critical issue due to natural and anthropogenic activities in meeting the demands of human survival and productivity. With these constraints, groundwater resource is now being used extensively in Ethiopia. Therefore, an innovative convolutional neural network (CNN) is successfully applied in the Gunabay watershed to delineate groundwater potential based on the selected major influencing factors. Groundwater recharge, lithology, drainage density, lineament density, transmissivity, and geomorphology were selected as major influencing factors during the groundwater potential of the study area. For dataset training, 70% of samples were selected and 30% were used for serving out of the total 128 samples. The spatial distribution of groundwater potential has been classified into five groups: very low (10.72%), low (25.67%), moderate (31.62%), high (19.93%), and very high (12.06%). The area obtains high rainfall but has a very low amount of recharge due to lack of proper soil and water conservation structures. The major outcome of the study showed that moderate and low potential is dominant. Geodetoctor results revealed that the magnitude influences on groundwater potential have been ranked as transmissivity (0.48), recharge (0.26), lineament density (0.26), lithology (0.13), drainage density (0.12), and geomorphology (0.06). The model results showed that using a convolutional neural network (CNN), groundwater potentiality can be delineated with higher predictive capability and accuracy. CNN based AUC validation platform showed that, 81.58% and 86.84% were accrued from the accuracy of training and testing values, respectively. Based on the findings, the local government can receive technical assistance for groundwater exploration, and sustainable water resource development in the Gunabay watershed. Finally, the use of a detector-based deep learning algorithm can provide a new platform for industrial sectors, groundwater experts, scholars, and decision-makers.

“Transplant Changes Your Life”: Communication Strategies of Transplant Hematologists in High Risk Decision Making Conversations

Introduction: Allogeneic hematopoietic cell transplantation (alloHCT) offers a chance of cure for many patients with blood cancers including higher risk myelodysplastic syndromes (MDS) but carries many risks. In this high risk, high reward situation, shared decision making is essential to empower patients to make goal-concordant decisions. We detail communication strategies hematologists use to discuss treatment options including alloHCT and to facilitate shared decision making with patients. Methods: Our research team recruited hematologists who routinely perform alloHCT in the United States through email. Participants conducted a video-recorded virtual encounter lasting up to one hour with an actor portraying a 67-year-old man with recently diagnosed high risk MDS referred for specialty hematology consultation to discuss treatment options including alloHCT. We transcribed and qualitatively analyzed hematologists' communication approaches. Results: Participants (n=37) from 25 institutions were a median age of 44 years (range 33-73 years) and mostly male (65%) and white (65%). More than half spent &amp;gt;50% of their clinical time in managing alloHCT patients. Hematologists followed a similar conversation structure, though varied in the amount of detail they provided within each of the main sections (Figure 1). Their conversation routinely included an assessment of the patient's perception of his condition, information about MDS, and discussion of treatment options including transplant and chemotherapy and less commonly supportive care or a clinical trial. Many repeatedly highlighted that transplant was the only option with the potential for cure. Their discussion about transplant frequently followed a chronological approach from pretransplant considerations including donor issues, formal fitness testing, and disease control; to the peri-transplant period and hospital experience; and through the posttransplant course including need for dedicated caregiver support. Hematologists discussed risks, complications, and major outcomes at varying lengths. Decision making talk occurred at different points in the visit though was often concentrated in the latter part of the conversation. Hematologists referred to several elements that formed the basis of treatment decision making (Figure 2). While hematologists indicated that multiple factors should inform the patient's and hematologist's decision making, many honed in on transplant's position as the only chance for long-term survival. Although most hematologists acknowledged on a general level the importance of patients' goals and preferences in decision making, they elicited and incorporated the individual patient's specific goals into the discussion to varying degrees. Instead, in several conversations, hematologists' assessment of the patient's fitness and candidacy for transplant was prominent in their discussion about whether the patient could and should consider pursuing the curative option. Hematologists frequently recommended that the patient take time to think and talk with his family about the treatment decision in the immediate future. The strength of their longer-term recommendations ranged from strong recommendations for transplant or chemotherapy to conditional recommendations for transplant or deferral pending further information. These recommendations reflected a range of decision-making strategies, from a physician-led approach to a primarily patient-guided effort. In the middle, some hematologists described a collaborative effort with the patient, in which the patient and hematologist would work together to reach a shared decision. Within a single encounter, many hematologists expressed various statements suggesting that their approach to decision making did not fit tightly within a single domain but rather fell along a continuum which evolved as the encounter proceeded. Conclusions: The transplant decision making discussion is complex. The ways in which hematologists frame information and engage patients affect how they make decisions together. Hematologists consistently discuss similar major content areas as they navigate from beginning to end; identification of these key components can be used as the basis for creation of a communication tool to help hematologists discuss alloHCT with patients.

Chronic Myeloid Leukemia and Myocardial Infarction: A Nationwide Readmission Database Analysis

Introduction Chronic myeloid leukemia (CML) is a hematological malignancy with an excellent outcome. After advancements in CML treatment and the introduction of different Tyrosine kinase inhibitors (TKI), their life expectancy is equivalent to the normal population. As a result of that, coronary artery disease is anticipated to be the leading cause of death among CML patients. It was particularly noted that TKI use is associated with the risk of endothelial dysfunction and it associated risk of cardiovascular events, including myocardial infarction. In this study, we compare the outcome of PCI in patients with CML to their matched non-CML group. Method The National readmission database (NRD) was searched from January 2016 to December 2020 for the study population. Adults above (age ≥ 18 years) with chronic myeloid leukemia hospitalized with a primary diagnosis of myocardial infarction, ST Elevation Myocardial Infarction (STEMI), and Non-ST-elevation myocardial infarction (NSTEMI) were identified using ICD 10 code. The primary outcomes were in-hospital mortality and 30-day readmission, and the secondary outcome was to compare the complications. The weighting of patient-level observations was implemented to obtain national estimates. Multivariate regression analysis models were built by including all confounders significantly associated with the outcome on univariable analysis with a cutoff P-value of 0.2. Variables deemed important determinants of the outcomes based on literature were forced into the models. For readmission comparison, we used the time-to-event Cox regression analysis. Propensity matching was done by the Greedy method. Proportions were compared using the Mantel-Haenszel Chi-square test or Fisher exact test, and continuous variables were compared using the Student t-test. All P values were two-sided, with .05 as the threshold for statistical significance. Results Out of 2727619 patients with myocardial infarction, 2124 CML patients were identified, and 888 CML patients had Percutaneous Coronary Intervention (PCI). Patients' baseline characteristics and major outcomes were compared (table 1). The mean age of CML patients was 68.34 ± 11.14 (P&amp;lt;0.001). The analysis showed no significant difference between CML and non-CML patients after PCI for the primary outcome of death 0.93 (CI 0.49-1.80) P value 0.527 and 30 days readmission rate 1.41 (0.99-2.01) P value 0.056. Also, there was no statistical significance in developing major complications, including cardiac arrest, coronary artery dissection, cardiac tamponade, stroke, thrombosis, major bleeding, AKI, and dialysis. Discussion and Conclusion Patients with hematologic malignancies, including chronic myeloid leukemia, are at increased risk of thrombosis. In CML, thrombosis can be venous or arterial (myocardial infarction, cerebrovascular accidents, and peripheral artery disease). Arterial thrombosis in CML is primarily linked to using different TKIs, and thrombotic events were reported with the second-generation TKIs like nilotinib, dasatinib, and ponatinib more often than with first-generation TKIs. The mechanism of TKI use-associated thrombosis is likely related to TKI-associated endothelial dysfunction and vascular toxicity that lead to accelerated atherosclerosis and subsequent vascular thrombosis. This increased risk might lead to an assumption of an increased risk of complications with vascular intervention like PCI. Some studies showed that PCI for hematological cancer patients with STEMI have no significant difference regarding in-hospital mortality. This analysis of patients with CML with myocardial infarction ( STEMI and NSTEMI ) showed no statistically significant difference in outcome after PCI between the two groups. There were no significant differences in mortality, 30 days readmission rate, and other complications post PCI. Therefore, diagnosis of chronic myeloid leukemia shouldn't prevent patients from receiving routine therapy and intervention because of the theoretical risk of thrombosis. This information aid in patient counseling and achieving the objective of maintaining a normal quality of life for chronic myeloid leukemia patients.

Safety and Efficacy of Direct Oral Anticoagulants in Patients with Liver Cirrhosis: A Systematic Review and Meta-Analysis

Introduction Direct oral anticoagulants (DOACs) are widely used for treatment of venous thromboembolism (VTE) and stroke prophylaxis in patients with atrial fibrillation. Liver cirrhosis increases the risk of conditions necessitating anticoagulation, but also increases the risk of bleeding, complicating anticoagulation use. Traditionally, low molecular weight heparin (LMWH) or Vitamin K Antagonists (VKA) have been used in this patient population. However, VKA use can be complicated due to difficulty monitoring in the context of synthetic dysfunction and baseline INR abnormalities. DOACs have emerged as alternative agents, with less proposed reliance on hepatic elimination. Apixaban, rivaroxaban, edoxaban and dabigatran are eliminated by the liver at 75%, 65%, 50% and 20% respectively. However, safety data on DOACs in cirrhosis patients is limited due to historic exclusion from larger trials. Patients with severe Child-Pugh (CP) classes are notably underrepresented in major trials. Various guidelines currently classify CP class C (and sometimes B) as contraindications to DOACs. Methods A literature search of MEDLINE and Embase from inception to Jan 2023 identified randomized controlled trials (RCTs) and cohort studies comparing DOACs to LMWH/VKA in cirrhosis patients. Two independent reviewers screened and extracted data at title, abstract, and full-text. Patient characteristics, CP class, and anticoagulation regimens were extracted. The primary outcome was major bleeding per ISTH criteria. Secondary outcomes include clinically relevant non-major bleeding (CRNMB) and minor bleeding per ISTH criteria as a composite outcome, VTE incidence, and arterial thromboembolism (ATE) incidence. Results were stratified into two subgroups: CP B&amp;C Exclusive, and CP Unspecified (primary study did not report or stratify by CP class). A meta-analysis was conducted using the Mantel-Haenszel random-effects model and presented as odds ratios (OR) with corresponding 95% confidence intervals (CI). Results Of 794 articles screened, 21 articles (2 RCTs, 1 prospective cohort, 13 retrospective cohorts, 5 abstracts) were included for analysis (n = 5738). Overall, DOACs were associated with a lower risk of major bleeding compared to controls (OR=0.63 [0.45, 0.89], p&amp;lt;0.01). This result was consistent in the CP B&amp;C Exclusive subgroup (OR=0.42 [0.29, 0.62], p&amp;lt;0.01, 5 studies) but not in the CP Unspecified subgroup (OR=0.71 [0.48, 1.08], p=0.11, 13 studies). One large study (n=3213), Lawal 2023, weighed 20.1% in the CP B&amp;C Exclusive group, favoured DOACs in reduction of major bleeding (OR=0.37, 95%CI [0.24,0.57]). Removal of this study in a post-hoc sensitivity analysis led to no differences in major bleeding in the CP B&amp;C subgroup (OR=0.79, 95%CI [0.31,1.97]), CP Unspecified subgroup (OR=0.71, 95%CI [0.48,1.08]), or overall bleeding (OR=0.75, 95%CI [0.55,1.03]). For CRNMB and minor bleeding, DOACs did not differ from control overall or in any subgroups. DOACs significantly reduced the risk of VTE in the CP Unspecified subgroup and overall. The difference in VTE incidence was non-significant in the CP B&amp;C Exclusive subgroup, however the analysis only had two studies. The difference in ATE incidence in the overall sample and all subgroups was non-significant. Conclusion In this analysis comparing DOACs to LMWH/VKAs in patients with liver cirrhosis, DOACs were associated with a statistically significant reduction in the risk of major bleeding overall and in the more advanced subgroups (CP B&amp;C). The association between DOACs and the risk of CRNMB and minor bleeding was non-significant. Patients using DOACs had lower VTE incidence compared to those using LMWH/VKA, with no difference in ATE incidence. Limitations include the inability to stratify CP class B and C due to limited CP class C evidence, reducing confidence in our ability to differentiate a differing effect in these two groups. Furthermore, a single large study (Lawal 2023), heavily influenced the major bleeding outcome; its removal shifted the conclusion from favouring DOACs to non-significant differences. Nevertheless, these results provide reassurance on the safety profile of DOACs in comparison to LMWH/VKA in patients with cirrhosis, particularly in those with moderate to severe liver cirrhosis, a population of clinical uncertainty. There is no concerning evidence for future trials, which are much needed, to include this population.

The State and Direction of Treatment of Heart Failure with Reduced Ejection Fraction in Papua New Guinea

The pharmacological treatment of heart failure has evolved over the last three decades since the demonstration of the effect of angiotensin-converting enzyme inhibitors on major cardiovascular events in patients with heart failure with reduced ejection fraction. Composite analysis of heart failure with reduced ejection fraction trials and the recent identification of newer drug treatments show early benefits on the major cardiovascular outcomes, ushering in a change of the treatment strategy; from a ‘sequential’ initiation of the treatments to a ‘simultaneous’ initiation to harness the early benefits. The adoption and implementation of these changes at the bedside have been dismal in many healthcare settings. Papua New Guinea, like many other lower-to-middle-income countries, is facing many barriers that impact on the care of heart failure patients. It needs to adopt and implement these changes to provide evidence-based treatment for its people with heart failure with reduced ejection fraction.

Ethnicity Is Associated With Differing Presentation and Outcomes of Patients Undergoing Aortic Valve Replacement for Calcific Aortic Stenosis in Aotearoa New Zealand

Surgical aortic valve replacement (SAVR) has been the gold standard for treatment of severe symptomatic aortic stenosis (AS) for decades. We examined whether ethnic differences exist in the presentation and outcomes of patients undergoing aortic valve replacement (AVR) for AS in New Zealand. Patients of New Zealand European, Māori, and Pacific Island ethnicities undergoing SAVR with or without other procedures in New Zealand public hospitals from 2017 to 2019 were included. Major postoperative outcomes were compared between ethnic groups, with 30-day mortality being the primary outcome. A total of 1,175 patients were included: 1,085 European, 50 Māori, and 40 Pacific. The mean age was 71.1±9.4 years, and men accounted for more than half of all patients (69.9%). Māori (64.7±9.4 years) and Pacific (65.4±10.1 years) patients were younger when undergoing SAVR compared with European patients (71.7±9.2; analysis of variance p<0.001). Māori and Pacific patients had a higher prevalence of diabetes, poorer renal function, and worse left ventricular function; 30-day mortality was higher in Māori and Pacific compared with European patients (6% and 10% vs 2.4%, respectively; Fisher's exact test p=0.011), with odds ratio of 3.06 (95% confidence interval [CI] 0.88-10.66) for Māori patients after adjustment for EuroSCORE II and odds ratio of 5.23 (95% CI 1.79-16.07) for Pacific patients. There are significant differences in presentation and outcomes of patients undergoing AVR in New Zealand. Māori and Pacific patients undergo SAVR at a younger age, have more preoperative comorbidities, and have higher rates of 30-day mortality than European patients.

772. Learning from our patients: An exploratory study to inform the development of a case tracking dashboard for subspecialty fellows

Abstract Background Educators identify case tracking (following-up prior patient encounters) as a valued practice to cultivate physician expertise. Much of the existing research has focused on the practices of general medicine providers, where challenges include insufficient time and difficulty tracking patients in the electronic health record (EHR). Subspecialty fellows constitute a group of advanced learners who see a high volume of patients and need to quickly become subject matter experts, yet little is known about their particular needs and motivations around case tracking. In this study, we performed a needs assessment with fellows to inform the design of an EHR-based case tracking dashboard that can facilitate learning from prior patient encounters. Methods We conducted semi-structured interviews with 22 medicine subspecialty fellows (including 4 Infectious Diseases [ID] fellows) at a single academic medical center that explored participants’ motivations, preferences, and practices around case tracking. Interview transcripts were coded and analyzed with directed qualitative content analysis. Results of this analysis will be used to inform the design of a subspecialist EHR-based case tracking dashboard. Results Participants were motivated to engage in case tracking, with curiosity regarding patient outcomes as a strong motivator. Although some attempted to track all consults, most focused on subsets of patients, feeling that not all encounters were of equal educational value. Participants highlighted particular results, specialty-specific notes, and major outcomes as the most useful information. ID fellows specifically were interested in post-discharge ID clinic encounters, send-out tests, and outcomes of their management decisions. Despite widespread motivation to engage in case tracking, manually adding patients to lists and remembering to follow up poses logistical and time barriers. Conclusion An ideal EHR case-tracking dashboard would automatically keep a list of patients cared for by fellows and provide easy access to own-specialty notes, specific results of interest, and information on the global clinical course. The ability to highlight specific cases anticipated to have more educational value would also be of benefit. Disclosures All Authors: No reported disclosures

1382. The Lesser Known Treponemal Infections: A Review Of Non-Syphilitic Cases

Abstract Background Nonvenereal treponemal (NVT) infections (Bejel, Yaws, and Pinta) are historically a major health concern in developing countries1 (Figure 1), but they are increasingly ignored. NVTs can lead to severe complications. Our aim was to highlight disease characteristics, treatments, and outcomes, and to identify drug repurposing by curating all cases of NVTs in the literature in CURE ID4, a platform that catalogs real-world data on drug repurposing for difficult-to-treat infectious diseases. Geographical distribution of Contracted Nonvenereal Treponemal Infection Yaws caused by Treponema pallidum subsp pertenue was primarily prevalent in Southeast Asia, particularly Indonesia, and Papua New Guinea. In contrast, Treponema pallidum subsp endemicum, which causes Bejel, was commonly found in Japan. Treponema carateum, the causative agent of Pinta, was limited to Cuba. Geographical distribution of treated Nonvenereal Treponemal Infection Treponema Pallidum Subsp Pertenue (Yaws) was mainly treated in Southeast Asia, Indonesia, and Papua New Guinea, as well as in England following identification after migration. Treponema pallidum subsp endemicum (Bejel), was typically treated in Japan. Treponema Carateum (Pinta), was managed in South America. Methods We identified all case reports on NVTs from PubMed and Embase databases using relevant keywords, MeSH, and Emtree terms. Rayyan.ai3 was used to screen articles following a PRISMA protocol (Figure 3). All included articles were uploaded using the CURE ID case report form. De-identified, standardized data on NVTs from CURE ID was then analyzed. PRISMA protocol for Nonvenereal Treponemal Infections Out of 251 cases, identified on Pubmed and Embase, 53 cases met the inclusion criteria and were included in the analysis. We included cases published in English and those where antibiotics were used. All the case reports were added to CURE ID, organized, and analyzed. The CURE ID Home Page CURE ID captures treatment outcomes when drugs are used to treat new diseases or are used in other new ways. Through CURE ID’s ability to obtain and organize this information received directly from healthcare providers, patients, caregivers, electronic health records, and published case reports, promising new therapeutic uses can be identified for formal study by institutions involved in drug development, and unhelpful or harmful uses can potentially be avoided. Results 53 cases of NVTs were included: Yaws (37), Bejel (13), and Pinta (3). Most originated in developing countries (Figure 1), but many were treated in OECD countries (figure 2). Yaws predominantly occurred in children (1-10 years), while Bejel and Pinta were evenly distributed across age groups. Table 1 breaks down the NVTs according to gender and common sites of infection and Table 2 according to gender and symptoms. Diagnosis was often by clinical assessment (49/53) and serology (46/53) (Table 3). Penicillin was the most frequently used antibiotic, followed by azithromycin (Table 4). Common sites of infection caused by Nonvenereal Treponemal infections The presentations of Bejel and Yaws varied. In Bejel, men (4/10) primarily experienced genital involvement, and women (3/3) exhibited frequent facial involvement. In Yaws, both genders commonly experienced leg involvement. Meanwhile, Pinta usually presented with skin rashes/lesions all over the body in women and was not reported in men. Common symptoms caused by Nonvenereal Treponemal infections In the 37 cases of Yaws, skin rash/lesion (19/37) was the predominant presentation, followed by bone involvement (15/37) and ulcer (10/37). Bejel, on the other hand, commonly manifested with ulcers (7/13) and skin rash/lesion (6/13). In Pinta all three cases presented with skin rash/lesion. Investigations leading to the diagnosis Clinical assessment (49/53) and serology (46/53 cases) were commonly used diagnostic methods for Nonvenereal Treponemal infections. Conclusion Most cases originated in developing countries such as Indonesia (Figure 1), but many were only treated when patients emigrated to OECD countries (Figure 2). Interestingly, all cases of Bejel in females (3/3) had face or eye involvement, while symptoms were more varied for males (Table 2). This may be coincidental, but further investigation could identify gender-based differences in disease presentation. Most cases of NVT (52/53) either improved or were cured when treated (Table 5). Penicillin is FDA approved for NVTs and was the most often used drug (44/53). The successful use of azithromycin in some cases (7) indicates its potential as a second-line agent if resistance to penicillin arises. This project highlights the utility of CURE ID in using real-world data to identify signals of drug repurposing where traditional efficacy trials cannot be conducted. Antibiotics used to treat Nonvenereal Treponemal infections Penicillin was the most frequently used antibiotic class in 11/13 (84.61%), 30/37 (81.08%), and 3/3 (100%) of Bejel, Yaws, and Pinta respectively. Among other antibiotics, azithromycin was prescribed in 1/11 in Bejel and 6/37 in Yaws. Outcomes of Nonvenereal Treponemal infections The majority of Nonvenereal Treponemal infections (52/53) either showed improvement or were cured. Disclosures All Authors: No reported disclosures

Outcomes of Head and Neck Microvascular Free Tissue Transfer for Advanced Cutaneous Squamous Cell Carcinoma: A Comparison of Solid Organ Transplant Recipients to Nontransplant Patients

BackgroundPatients with solid organ transplant (SOT) are at increased risk of developing aggressive cutaneous malignancies due to their immunosuppression, particularly cutaneous squamous cell carcinoma PurposeThere is limited data regarding solid organ transplant patients with locally advanced cutaneous squamous cell carcinoma (cSCC) requiring radical surgery and microvascular free tissue transfer (MVFTT). Our objectives were to characterize outcomes in SOT patients and compare them with a non-SOT cohort. Study DesignThis is a retrospective cohort study of patients undergoing MVFTT for advanced cSCC of the head and neck between January 2016 and May 2020 at a tertiary referral center. Patients who underwent MVFTT as part of curative intent surgery for advanced cSCC during the study were considered for inclusion. Exclusion criteria included distant metastasis, palliative intent treatment, age less than 18 years, and lip primaries. PredictorThe predictor variable was SOT status. A cohort of non-SOT patients was matched to the SOT cohort based on age, smoking status, tumor stage, and defect size. Main outcome variablesThe primary reconstructive outcome was the major surgical complications and secondary outcome measures included major medical complications and minor surgical complications. The primary oncologic outcome was overall survival and the secondary outcome was disease-specific survival. The primary predictor was transplant status. CovariatesCovariates included patient comorbidities, prior treatment, tumor stage, type of reconstruction, pathologic findings, and adjuvant therapy. AnalysisContinuous and categorical variables were compared using Student’s T test and Fisher’s exact test. Survival was calculated using the Kaplan-Meier method and differences in survival between groups were calculated using the log-rank test. Statistical significance was set a priori at p ≤ 0.05 ResultsFourteen SOT and 14 matched non-SOT patients met inclusion criteria. There was not a statistically significant difference in the rate of major surgical complications (7% vs 7%, p = 0.74) between the SOT and non-SOT cohorts. Rates of minor (21% vs 43%, p = 0.26) wound complications and medical complications (0% vs 14%, p =0.24) were also similar between the SOT and non-SOT cohorts. Locoregional recurrences and distant metastasis were more common for SOT patients, though this was not statistically significant. Overall survival was significantly worse for SOT patients (21.7 vs 31.0 months, p = 0.04), though there was not a significant difference in disease-free survival (9.8 vs 31.0 months, p = 0.17). Conclusions and RelevanceMVFTT in the management of SOT patients with locally advanced head and neck cSCC demonstrates similar complication rates with non-SOT patients. While survival and oncologic outcomes are worse in the SOT cohort, aggressive surgical intervention with MVFTT can be performed with comparable complication rates to patients without a history of SOT.