Obtaining Institutional Review Board Approval Research Articles

Unveiling nurses’ end-of-life care experiences: Moral distress and impacts

Background Nurses providing care to patients with end-of-life or terminal illnesses often encounter ethically challenging situations leading to moral distress. However, existing quantitative studies have examined moral distress using instruments that address general clinical situations rather than those specific to end-of-life care. Furthermore, qualitative studies have often been limited to participants from a single unit or those experiencing moral distress-induced circumstances. A comprehensive and integrated understanding of the overarching process of moral distress is vital to discern the unique circumstances surrounding end-of-life care and its consequential impacts. Research objectives To explore the moral distress experiences of nurses who are frequently involved in caring for patients with end-of-life or terminal illnesses and apply it to two existing theories: the model of moral distress and the ecological model. Research design A qualitative descriptive approach was employed. Participants and research context Seven focus group interviews involving 30 nurses were performed. The subsequent transcriptions underwent rigorous content analysis. Ethical considerations We obtained Institutional Review Board approval from a university. Focus group interviews were conducted with nurses who agreed to participate and signed the consent form. Findings The moral distress-inducing factors and nurses’ perceived impact of moral distress were identified and categorized based on moral distress theories and ecological models. A total of 15 categories and 30 subcategories across the following 4 domains were derived: (1) intrapersonal, (2) interpersonal, (3) organizational, and (4) structural factors. Conclusions End-of-life-specific circumstances induced moral distress among nurses, with both negative and positive impacts identified. Effective organizational and policy support is essential to manage conflicts, form a healthy organizational culture, provide training, and prevent unnecessary expenses due to the negative consequences of moral distress.

Glucose Lability and Complications in Diabetic Ankle Fractures

Introduction/Purpose: Rotational ankle fractures in diabetics have long posed difficult clinical challenges, with several observational studies noting increased risk of complications and amputation following treatment of unstable ankle fractures in diabetics. Several treatment options exist, including non-operative management, external fixation, open reduction internal fixation, staged fixation, and fusion. Hemoglobin A1C produces a mean blood glucose level over a three-month period. There is mounting evidence that glucose variability may be an alternative predictor of complication profile in non-orthopedic procedures, as well as in the total joint arthroplasty literature. The purpose of this investigation is to retrospectively analyze complication rates for diabetics with rotational ankle fractures at a single institution and assess their association with both the hemoglobin A1C and glucose variability. Methods: After obtaining Institutional Review Board approval, all patients from 2015-2022 with a diagnosis of diabetes and ankle fracture were retrospectively identified based on ICD-9/ICD-10 codes. These charts were manually reviewed to determine fracture classification and treatment. For operatively and non-operatively managed ankle fractures, the patient’s hemoglobin A1C was recorded when available within 3 months of the date of injury. Glucose variability was calculated using a coefficient of variation. Results: Two-hundred patients were included for analysis, of which 29% (n=58) were treated non-operatively. The majority of surgically treated patients underwent acute ORIF (58%, n=116). 8.5% were treated with staged fixation, 3.5% with acute hindfoot fusion, and 1% with external fixation alone. The overall complication rate was 27.5% (n=55). There were no statistically significant differences in both A1C (7.81 +/- 1.89 vs 7.73 +/- 1.96) and glucose variability, as measured by the covariance of variation (0.23 +/- 0.15 vs 0.20 +/- 0.13) in patients who did and did not experience postoperative complications. Higher glucose variability did trend towards predicting complications, though not in a statistically significant fashion (OR=1.57, p=0.35). Conclusion: Ankle fractures in patients with diabetes pose a challenge for orthopedic surgeons, as evidenced by the high medical and surgical complication rate observed in this study and others. No statistical significance was found between higher A1C and complication rate or between glucose variability and complication rate. Further investigation on the impact of glucose variability on complication rates in a larger cohort of this patient population is warranted. Univariable logistic Regression Results for the association of the odds of post-operative complication with patient characteristics.

Poster 200: Earlier Evaluation by an Orthopaedic Surgeon Is Associated with Higher Return to Work Among Workers’ Compensation Patients Undergoing Shoulder Arthroscopy

Objectives: Workers’ compensation (WC) patients represent a large expenditure to the health care system and account for a large number of missed work days. Studies have shown that WC patients are less likely to return to work after injury or surgery. The purpose of our study was to determine if there was a higher return to full duty among WC patients who underwent arthroscopic shoulder surgery when they were seen by an orthopaedic surgeon within 100 days of injury. Methods: After obtaining Institutional Review Board approval, a retrospective chart review was conducted of WC patients treated with arthroscopic shoulder surgery by 2 senior authors at a community hospital between 2011 and 2018. WC patients that were treated with arthroscopic shoulder surgery were identified using Current Procedural Terminology (CPT) codes 29806, 29807, 29819, 29820, 29821, 29822, 29823, 29824, 29825, 29826, 29827, and 29828. Patients were excluded if they were polytrauma patients who had undergone surgical procedures in other locations, patients who had a fracture, and patients being treated with revision shoulder surgery. A total of 59 WC patients were included in the study and were followed up to 2 years post-operatively. WC patients who identified as laborers were divided into 2 groups. The first group was evaluated by an orthopaedic surgeon within 100 days of injury (early orthopaedic evaluation) and the second group was evaluated by an orthopaedic surgeon more than 100 days after injury (late orthopaedic evaluation). The primary outcomes included the length of time from injury to evaluation by an orthopaedic surgeon and from surgery to return to work in some form. Results: Early orthopaedic evaluation was associated with a higher rate of return to full duty (p=0.02). The early orthopaedic evaluation group had a 69% (25 out of 36) return to full duty while the late orthopaedic evaluation group had a return to full duty of 39% (9 out of 23). There was no significant difference in the rate of return to work in some form with the early orthopaedic evaluation group returning at 94% (34 out of 36) and the late orthopaedic evaluation group returning at 83% (19 out of 23). There was a moderate association between time to evaluation by an orthopaedic surgeon following injury and time to return to work in some form (r=.22). There was no significant difference between the groups with respect to the type of laborer (p=.128). Conclusions: WC patients who were evaluated by an orthopaedic surgeon within 100 days of injury had a higher likelihood of return to full duty as well as return to work in some form compared to WC patients who were evaluated by an orthopaedic surgeon more than 100 days after injury. [Table: see text]

The General Population's Perspectives on Implementation of Artificial Intelligence in Radiology in the Western Region of Saudi Arabia.

Background Artificial intelligence (AI) is a broad spectrum of computer-executed operations that mimics the human intellect. It is expected to improve healthcare practice in general and radiology in particular by enhancing image acquisition, image analysis, and processing speed. Despite the rapid development of AI systems, successful application in radiology requires analysis of social factors such as the public's perspectives toward the technology. Objectives The current study aims to investigate the general population's perspectives on AI implementation in radiology in the Western region of Saudi Arabia. Methods A cross-sectional study was conducted from November 2022 and July 2023 utilizing a self-administrative online survey distributed via social media platforms. A convenience sampling technique was used to recruit the study participants. After obtaining Institutional Review Board approval, data were collected from citizens and residents of the western region of Saudi Arabia aged 18 years or older. Results A total of 1,024 participants were included in the present study, with the mean age of respondents being 29.6 ± 11.3. Of them, 49.9% (511) were men, and 50.1% (513) were women. The comprehensive mean score of the first four domains among our participants was 3.93 out of 5.00. Higher mean scores suggest being more negative regarding AI in radiology, except for the fifth domain. Respondents had less trust in AI utilization in radiology, as evidenced by their overall distrust and accountability domain mean score of 3.52 out of 5. The majority of respondents agreed that it is essential to understand every step of the diagnostic process, and the mean score for the procedural knowledge domain was 4.34 out of 5. The mean score for the personal interaction domain was 4.31 out of 5, indicating that the participants agreed on the value of direct communication between the patient and the radiologist for discussing test results and asking questions. Our data show that people think AI is more effective than human doctors in making accurate diagnoses and decreasing patient wait times, with an overall mean score of the efficiency domain of 3.56 out of 5. Finally, the fifth domain, "being informed," had a mean score of 3.91 out of 5. Conclusion The application of AI in radiologic assessment and interpretation is generally viewed negatively. Even though people think AI is more efficient and accurate at diagnosing than humans, they still think that computers will never be able to match a specialist doctor's years of training.

Hyalomatrix coverage in scalp wounds with exposed cranium and dura

The armamentarium of options available for soft tissue reconstruction of the scalp spans the reconstructive ladder. The purpose of this paper is to describe a case series of patients with exposed cranium and dura who were successfully reconstructed using esterified hyalomatrix (eHAM, Hyalomatrix, Medline Industries Inc., US). After obtaining Institutional Review Board approval, a retrospective review of the senior author's (ALF) patient database was completed. Patients who underwent scalp reconstruction using eHAM were identified. Each patient's chart was reviewed and data collected on demographics, days to skin graft, duration of follow-up, pathology, comorbidities and complications. This case series consisted of five patients aged ≥18 years, with scalp wounds exposing dura or cranium, who were treated with eHAM as a bridge to definitive coverage with a skin graft. Each wound successfully granulated the exposed critical structure with the use of the eHAM. The mean time to skin graft coverage was 41 days, with a range of 13-79 days. Of the series of five patients, four had a follow-up of ≥12 weeks. The mean defect size was 90.2cm2. Complex scalp reconstruction can be accomplished using healing by secondary intention, skin grafts, local flaps, tissue expansion and free tissue transfer. As shown in this case series, another option available in select patients is using a dermal substitute such as eHAM. This is one treatment option available to reconstructive surgeons in multiple specialties.

Exploring Subordinates' Perceptions and Experiences with Abusive Leaders in Higher Education: A Qualitative Study

Exploring Subordinates' Perceptions and Experiences with Abusive Leaders in Higher Education: A Qualitative Study

The Development of an Artificial Intelligence Model Based Solely on Computer Tomography Successfully Predicts Which Patients Will Pass Obstructing Ureteral Calculi

To improve upon prior attempts to predict which patients will pass their obstructing ureteral stones, we developed a machine learning algorithm to predict the passage of obstructing ureteral stones using only the CT scan at a patient's initial presentation. We obtained Institutional Review Board approval to conduct a retrospective study by extracting data from all patients with an obstructing 3-10mm ureteral stone. We included patients with sufficient data to be categorized as having either passed or failed to pass an obstructing ureteral stone. We developed a 3D-Convolutional Neural Network (CNN) model using a dynamic learning rate, the Adam optimizer, and early stopping with 10-fold cross-validation. Using this model, we calculated the area under the curve (AUC) and developed a model confusion matrix, which we compared with a model based only on the largest dimension of the stone. 138 patients met inclusion criteria and had adequate images that could be preprocessed and included in the study. 70 patients failed to pass their ureteral stones, and 68 patients passed their stones. For the 3D-CNN model, the mean AUC was 0.95 with an overall mean sensitivity of 95% and mean specificity of 77%, which outperformed the model based on stone-size. The 3D-CNN model predicts which patients will pass their obstructing ureteral stones based on CT scan alone and does not require any further measurements. This can provide useful clinical information which may help obviate the need for a delay in care for patients who inevitably require surgical intervention.

Medication safety in the perioperative setting: A comparison of methods for detecting medication errors and adverse medication events.

The purpose of this study was to evaluate perioperative medication-related incidents (medication errors (MEs) and/or adverse medication events (AMEs)) identified by 2 different reporting methods (self-report and direct observation), and to compare the types and severity of incidents identified by each method. We compared perioperative medication-related incidents identified by direct observation in Nanji et al's 2016 study[1] to those identified by self-report via a facilitated incident reporting system at the same 1046-bed tertiary care academic medical center during the same 8-month period. Incidents, including MEs and AMEs were classified by type and severity. In 277 operations involving 3671 medication administrations, 193 MEs and/or AMEs were observed (5.3% incident rate). While none of the observed incidents were self-reported, 10 separate medication-related incidents were self-reported from different (unobserved) operations that occurred during the same time period, which involved a total of 21,576 operations and approximately 280,488 medication administrations (0.004% self-reported incident rate). The distribution of incidents (ME, AME, or both) did not differ by direct observation versus self-report methodology. The types of MEs identified by direct observation differed from those identified by self-report (P = .005). Specifically, the most frequent types of MEs identified by direct observation were labeling errors (N = 37; 24.2%), wrong dose errors (N = 35; 22.9%) and errors of omission (N = 27; 17.6%). The most frequent types of MEs identified by self-report were wrong dose (N = 5; 50%) and wrong medication (N = 4; 40%). The severity of incidents identified by direct observation and self-report differed, with self-reported incidents having a higher average severity (P < .001). The procedure types associated with medication-related incidents did not differ by direct observation versus self-report methodology. Direct observation captured many more perioperative medication-related incidents than self-report. The ME types identified and their severity differed between the 2 methods, with a higher average incident severity in the self-reported data.

Severity of traumatic adrenal injury does not meaningfully affect clinical outcomes.

There are limited data comparing the severity of traumatic adrenal injury (TAI) and the need for interventions, such as transfusions, hospitalization, or incidence of adrenal insufficiency (AI) and other clinical outcomes. The aim of this study was to analyze the relationship between the grade of TAI and the need for subsequent intervention and clinical outcomes following the injury. After obtaining Institutional Review Board approval, our trauma registry was queried for patients with TAI between 2009 and 2017. Contrast-enhanced computed tomography (CT) examinations of the abdomen and pelvis were evaluated by a board-certified radiologist with subspecialty expertise in abdominal and trauma imaging, and adrenal injuries were classified as either low grade (American Association for the Surgery of Trauma (AAST) grade I-III) or high grade (AAST grade IV-V). Patients without initial contrast-enhanced CT imaging and those with indeterminate imaging findings on initial CT were excluded. A total of 129 patients with 149 TAI were included. Eight-six patients demonstrated low-grade injuries and 43 high grade. Age, gender, and Injury Severity Score (ISS) were not statistically different between the groups. There was an increased number of major vascular injuries in the low-grade vs. high-grade group (23% vs. 5%, p < 0.01). No patient required transfusions or laparotomy for control of adrenal hemorrhage. There was no statistical difference in hospital length of stay (LOS), ventilator days, or mortality. Low-grade adrenal injuries were, however, associated with shorter ICU LOS (10days vs. 16days, p = 0.03). The need for interventions and clinical outcomes between the low-grade and high-grade groups was similar. These results suggest that, regardless of the TAI grade, treatment should be based on a holistic clinical assessment and less focused on specific interventions directed at addressing the adrenal injury.

Systolic Blood Pressure Variability When Transitioning From Intravenous to Enteral Antihypertensive Agents in Patients With Hemorrhagic Strokes.

Background/ObjectiveSystolic blood pressure variability (SBPV) in patients with intracranial hemorrhage (ICH) and subarachnoid hemorrhage (SAH) is associated with an increased risk of acute kidney injury (AKI) and mortality. SBPV is a strong predictor of poor functional outcomes in patients with ICH. Intravenous (IV) antihypertensive agents are commonly used to achieve sustained target blood pressure goals; however, this is not a feasible long-term option. The transition from IV to enteral antihypertensives is not yet well established in patients with ICH and SAH. This study aimed to assess the effect of the number of antihypertensive agents and overlap time during the transition period from IV to enteral route on SBPV in patients with ICH and SAH.MethodsThis retrospective single-center study was conducted at a tertiary teaching hospital in Riyadh, Saudi Arabia. Data were extracted from electronic medical records after obtaining Institutional Review Board approval. Patients were included if they were >18 years old, admitted with spontaneous ICH or SAH, and received continuous infusion antihypertensives prior to transitioning to the enteral route. The major outcome was the effect of the number of antihypertensive agents and overlap time on SBPV during the transition process. Minor outcomes included the effect of the number of antihypertensive agents and overlap time on heart rate variability and the incidence of AKI on day 7.ResultsAfter the screening, we included 102 patients. Based on our regression model, the number of enteral antihypertensive agents upon transitioning from IV to enteral antihypertensive therapy had no effect on SBPV in the intensive care unit (ICU) among our patients (p-value = 0.274). However, the prolonged overlap was associated with reduced SBPV in the ICU (p-value = 0.012). No differences were observed between the groups in heart rate variation or AKI rate.ConclusionsIn patients with ICH and SAH, prolonged overlap of enteral antihypertensive agents to overlap with intravenous antihypertensive therapy may result in lower SBPV. This finding needs to be confirmed on a larger scale with more robust study designs for patients with ICH and SAH.

A Grounded Theory Approach to Navigating Infertility Care During U.S. Military Service.

In this study, we aimed to understand how active duty service members and their partners navigate the infertility care process within the Military Health System (MHS) while managing a military career. We obtained Institutional Review Board approval to employ a qualitative design using grounded theory methods. We recruited participants using purposive sampling, followed by theoretical sampling. We derived data from demographic questionnaires and semi-structured interviews. Consistent with grounded theory methods, we began analysis with line-by-line coding and moved to focused coding. We employed constant comparative analysis throughout the process to name, categorize, and conceptualize data and relationships. The participants included 28 patients, five partners, nine health care providers, and two military leaders. The infertility care process began with active duty service members and their partners recognizing the desire to have a child and discovering infertility, followed by deciding to seek infertility care. The experience was temporally bound within the context of the military environment. We identified the following themes, which described facilitators and barriers to accessing care: Duty station location, career stage, military versus the civilian cost of services, command climate, and policy. These facilitators and barriers varied widely across the Department of Defense (DoD), which resulted in fragmented and inconsistent care cycles, contributed to emotional and physical stress, and created tension between career progression and family formation. Understanding how military couples perceive and manage demands of infertility care may enhance access to care, decrease patient costs, improve outcomes, result in better support for military couples who experience infertility, and ultimately improve the health and military readiness of our armed forces. The results support the need for action by providers, policy makers, and military leaders to develop effective infertility treatment programs and policies in the DoD.

Abstract P4-11-14: Importance of work and work-related needs among survivors living with metastatic breast cancer

Abstract Background: Survivors living with metastatic cancer may continue to work. Up to 35% report working at least part-time. 1 There is a knowledge gap regarding the reasons and priorities driving the decisions about continuing to work while living with metastatic cancer. By 2020, the US population of individuals living with metastatic breast cancer (MBC) was projected to exceed 165,000. 2 Thus, it is necessary to understand and to explore the importance of work and information needs, in order to develop interventions to address MBC survivors’ employment-related needs. Objective: To explore the importance of work and characterize the information needs among survivors living with MBC. Methods: We conducted an online survey assessing work-related needs and motivations, between November 2014 and February 2015, using a MBC listserv and clinic flyers. Respondents who worked at the time of MBC diagnosis were divided into “stably-working” and “no-longer-working” based on employment status at the time of the survey. Comparisons between the two groups were made with chi-square or two-tailed t-test. A p-value &amp;lt;0.05 was considered statistically significant. The study obtained Institutional Review Board approval. Results: Respondents (n=133) were predominantly non-Hispanic White (93.2%), with a college degree (72.7%). The majority of stably-working women (80.5%) considered work to be important due to financial and/or insurance reasons (80.4%), the importance of staying busy (67.9%), and the desire to support themselves and family (64.3%). Among those no-longer-working who stated that work was unimportant (47,6%), the work became less important since the diagnosis of MBC. The stably-working group valued information on how to talk with employers or co-workers about diagnosis, legal rights in the workplace, when to think about stopping work, and applying for disability. Among those no-longer-working, information on Medicare and/or Medicaid and spirituality were deemed important. Conclusion: Assessing the employment needs of survivors with MBC is important. It can be a continuous process as the disease progresses, and maintenance of employment and priorities may change. Thus, offering resources to empower survivors living with MBC to manage their employment issues earlier in the disease trajectory is needed, particularly considering that unemployment and financial burden can adversely affect health-related quality of life and increase distress. 3 Table 1.Sociodemographic and importance of work among women with MBCStably-workingNo-longer-working(n=72)(n=61)Age, Mean (SD) **49.5 (8.3)54.0 (8.1)Time from MBC diagnosis (yr), Mean (SD) **3.3 (3.4)4.6 (4.0)Highest level of education, %Less than college23.931.2College graduate29.637.7Post-graduate or professional degree46.531.2Household income, %≤$75,00047.242.6$75,001-150,00029.237.7≥ $150,00118.19.8Unknown or prefer not to answer5.69.8RaceWhite98.693.4Black03.3Asian00Other1.43.3Prefer not to answer1.41.6Ethnicity (Spanish/Hispanic/Latino origin) %Yes03.3No97.296.7Prefer not to answer2.80Current importance of work, %**Extremely important33.31.6Very important47.227.9Neither important nor unimportant5.623Somewhat unimportant8.314.8Not at all important5.632.8Reasons why work is important %(n=56)(n=18)Success is important to me30.438.9It means a lot for me to be able to support myself/my family64.350It is important that I have a worthwhile job60.772.2It is necessary for financial and/or insurance reasons80.461.1Work is an important part of my social life48.266.7Staying busy is important to me67.972.2Other14.316.7Reasons why work is unimportant %(n=10)(n=29)Work has never been very important to me03.5Work is less important to me since being diagnosed with metastatic breast cancer*10055.2Work is not important because I do not need to work for financial reasons1037.9Work is not important because I do not need to work for insurance reasons3034.5Work is not important because it does not provide social support06.9Other5041.4Comparison between stably-working and no-longer-working groups using t-test for continuous variables and chi-square test for categorical variables; *p&amp;lt;0.05; **p&amp;lt;0.01. Citation Format: Cibele B. Carroll, Mary E. Sesto, Xiao Zhang, Karen B. Chen, Abigail Terhaar, Athena S. Wilson, Amye J. Tevaarwerk. Importance of work and work-related needs among survivors living with metastatic breast cancer [abstract]. In: Proceedings of the 2021 San Antonio Breast Cancer Symposium; 2021 Dec 7-10; San Antonio, TX. Philadelphia (PA): AACR; Cancer Res 2022;82(4 Suppl):Abstract nr P4-11-14.

Cerebral perfusion in posterior reversible encephalopathy syndrome measured with arterial spin labeling MRI

Background and purposeThe pathophysiologic basis of posterior reversible encephalopathy syndrome (PRES) remains controversial. Hypertension (HTN)-induced autoregulatory failure with subsequent hyperperfusion is the leading hypothesis, whereas alternative theories suggest vasoconstriction-induced hypoperfusion as the underlying mechanism. Studies using contrast-based CT and MR perfusion imaging have yielded contradictory results supporting both ideas. This work represents one of the first applications of arterial spin labeling (ASL) to evaluate cerebral blood flow (CBF) changes in PRES. Materials and methodsAfter obtaining Institutional Review Board approval, MRI reports at our institution from 07/2015 to 09/2020 were retrospectively searched and reviewed for mention of “PRES” and “posterior reversible encephalopathy syndrome.” Of the resulting 103 MRIs (performed on GE 1.5 Tesla or 3 Tesla scanners), 20 MRIs in 18 patients who met the inclusion criteria of clinical and imaging diagnosis of PRES and had diagnostic-quality pseudocontinuous ASL scans were included. Patients with a more likely alternative diagnosis, technically non-diagnostic ASL, or other intracranial abnormalities limiting assessment of underlying PRES features were excluded. Perfusion in FLAIR-affected brain regions was qualitatively assessed using ASL and characterized as hyperperfusion, normal, or hypoperfusion. Additional quantitative analysis was performed by measuring average gray matter CBF in abnormal versus normal brain regions. ResultsHTN was the most common PRES etiology (65%). ASL showed hyperperfusion in 13 cases and normal perfusion in 7 cases. A hypoperfusion pattern was not identified. Quantitative analysis of gray matter CBF among patients with visually apparent hyperperfusion showed statistically higher perfusion in affected versus normal appearing brain regions (median CBF 100.4 ml/100 g-min vs. 61.0 ml/ 100 g-min, p < 0.001). ConclusionElevated ASL CBF was seen in the majority (65%) of patients with PRES, favoring the autoregulatory failure hypothesis as a predominant mechanism. Our data support ASL as a practical way to assess and noninvasively monitor cerebral perfusion in PRES that could potentially alter management strategies.

Clinical Outcomes of Post-Transplant Lymphoproliferative Disease (PTLD): Role of Radiation Therapy in Improvement of Disease Response

Post-transplant lymphoproliferative disease (PTLD) is a rare disease complicating solid organ transplantation (SOT) and hematopoietic cell transplantation (HCT). Management of PTLD includes immunosuppression reduction, systemic therapy, surgery and radiation therapy (RT). Data regarding the efficacy and outcomes of radiation therapy in treatment of PTLD is limited. Here, we report our institution's experience with the treatment of PTLD including RT outcomes.We retrospectively reviewed patients with biopsy proven PTLD who were treated at our institution. After obtaining Institutional Review Board approval, patient demographics, disease characteristics, treatment modalities and follow-up data were recorded. Disease response before and after RT use was assessed per response evaluation criteria in solid tumors (RECIST) 1.1 including complete response (CR), partial response (PR), stable disease (SD) and progressive disease (PD). Progression-free survival (PFS) and overall survival (OS) were estimated using the Kaplan Meier method. Cox Proportional Hazards models were utilized to determine variables associated with OS.We identified and reviewed medical records of 48 patients with PTLD. Median follow up was 38 months. The median age was 58 (range:10-81). The majority were white (79%) and male (56%). 50% of the cohort were SOT recipients, 44% were HCT recipients and 6% underwent combined transplants. The most common site of PTLD was CNS (29%). Monomorphic PTLD was the most common histological type with EBV positivity in 75% of patients. Median time from SOT-to-PTLD was 77 months (range:5-322) and HCT-to-PTLD was 5 months (range: 2-46). Systemic therapy was the most commonly used modality in 92% of patients. The most commonly used regimen was Rituximab monotherapy. Surgery was employed in 10% of patients. RT was utilized after induction therapy in 37.5%. The most common treated site was the brain (61%). Overall response of the entire cohort was 87% (58% CR and 29% PR), 6% achieved SD and 7% had PD. Among the RT cohort, 55% achieved CR, 33% achieved PR and 12% had SD. Local control rate was 100%. Of 21 patients who did not respond completely to induction therapy, 6 patients with initial PR achieved CR, 1 patient with initial SD achieved CR, 1 patient with initial PD achieved CR, and 2 patients with initial PD achieved PR and SD, respectively, after RT receipt. The median RT dose was 3,600 cGy (range: 2400-4600). 3- and 5-year PFS were 90% and 85%, respectively, while 3- and 5-year OS were 70% and 55%, respectively. Cox hazards modeling confirmed that HCT receipt was associated with better OS on multivariate analysis (HR 0.26, 95% CI 0.008- 0.671, P = 0.007).RT provides excellent local control and improves overall disease response of PTLD. Further optimization and standardization of combined modality paradigms are needed to improve clinical outcomes of this rare entity.

Early initiation of breastfeeding and factors associated with its delay among mothers at discharge from a single hospital.

Background According to the National Family Health Survey–4, in India, 78.9% of deliveries occur in institutions, although only 42.6% of new mothers initiate breastfeeding within 1 hour of delivery.Purpose To estimate the proportion of early initiation of breastfeeding (EIBF) among new mothers at discharge from a tertiary care hospital and identify the determinants of delayed initiation of breastfeeding among them.Methods This was a hospital-based analytical cross-sectional study of 108 new mothers. After obtaining Institutional Review Board approval and informed consent, we interviewed the new mothers on the day of discharge. Multivariate logistic regression was performed using IBM SPSS Statistics ver. 24.Results The median breastfeeding initiation time was 90 minutes (interquartile range, 30–180 minutes). Overall, 43.5% of the mothers practiced EIBF, 77.4% practiced exclusive breastfeeding, and 43.5% were rooming in at discharge. Reasons for breastfeeding delays included extended recovery time from spinal anesthesia, maternal lassitude, and uncomfortable breastfeeding position due to post-cesarean pain. In the multivariate analysis, a birth weight less than 2,500 g (adjusted odds ratio [aOR], 4.33; 95% confidence interval [CI], 1.12–16.82; P=0.03), cesarean section delivery (aOR, 4.68; 95% CI, 1.57–13.92; P=0.005), and mother’s poor knowledge of breastfeeding (aOR, 4.61; 95% CI, 1.44–14.72; P=0.010) were more likely to delay the initiation of breastfeeding.Conclusion EIBF was practiced by less than half of the new mothers as determined by the cesarean section, baby’s birth weight, and mothers’ awareness of breastfeeding. Thus, it is vital to improve breastfeeding and nutritional counseling among mothers during the antenatal period and improve healthcare professionals’ training to facilitate EIBF, even in circumstances such as cesarean section.

ADVANCED LUNG CANCER INFLAMMATORY INDEX AS A PROGNOSTIC MARKER FOR OXYGEN REQUIREMENT IN PATIENTS ADMITTED WITH SARS-COV-2 INFECTION

TOPIC: Chest Infections TYPE: Original Investigations PURPOSE: Severe acute respiratory syndrome coronavirus (SARS-COV-2) infection continues to spread at exponential rates globally with more than 145 million confirmed cases worldwide and over 3 million deaths. SARS-COV-2 presents with different clinical manifestations ranging from asymptomatic to severe infection, requiring various levels of O2 support, facing high rates of mortality. Systemic inflammatory response to the viral infection contributes to a variety of clinical manifestations and to the degree of severity of illness. Limited evidence exists on potential biomarkers to quantify severity and outcomes of SARS-COV-2 infection. Our objective is to see if Advanced lung cancer inflammation index (ALI) calculated at the time of admission to the hospital can be used as a prognostic marker for oxygen requirements and adverse clinical outcomes. METHODS: We conducted a retrospective chart review of all patients ages 18 and above admitted to Memorial Hermann Hospitals between March 1, 2020 to June 30, 2020 who tested positive for SARS-COV-2 by RT-PCR. The ALI was calculated using patients Body mass index (BMI), serum albumin and neutrophil/lymphocyte ratio (NLR) from the admission labs using the formula ALI= BMI (kg/m2) × albumin (g/dL)/NLR. Patient related information was obtained by reviewing medical records after obtaining Institutional review board approval. RESULTS: A total of 700 patients were identified out of which 417 patients had complete medical records for analysis. Patients were stratified into group A (high inflammation (ALI < 18) n = 205) and group B (low inflammation (ALI ≥ 18) n = 218). 67% of the patients were aged 45 or older. 52.5% of the patients had a BMI < 30. 22.3% of patients in group A, 22.3% and 16.7% patients in group B, 16.7% were of white race. ALI < 18 was associated with higher oxygen requirements (73% vs 52%, p ≥ 0.0001), higher mechanical ventilation requirements (16.59% vs 9.91%, p = 0.04) and higher mortality rates (14.15% vs 7.08%, p = 0.02). In multi-variate analysis, ALI < 18 was significantly associated with oxygen requirements, (OR 2.62 (1.64 - 4.17), p ≤ 0.0001). CONCLUSIONS: In patients diagnosed with SARS-CoV-2 infection, an ALI < 18, representing high systemic inflammation, calculated at the time of admission is associated with significantly increased oxygen requirements, severe disease and mortality. CLINICAL IMPLICATIONS: Advanced lung cancer inflammation index can be easily calculated from basic clinical parameters available in most clinical settings. It can be used as a tool in early identification of patients who are likely to have more severe respiratory disease and poorer outcomes in patients with SARS-COV-2 infections. Early use of steroids can be considered in this population of patients with an ALI <18. DISCLOSURES: No relevant relationships by Shailesh Advani, source=Web Response No relevant relationships by Syed Jafri, source=Web Response No relevant relationships by Pushan Jani, source=Web Response No relevant relationships by Arthi Sridhar, source=Web Response No relevant relationships by Wei Yang, source=Web Response

NUMERICAL RATING SCALE AS A PREDICTOR OF AN UNDERLYING PATHOLOGY IN PEDIATRIC BACK PAIN USING MAGNETIC RESONANCE IMAGE AS DIAGNOSTIC TOOL

Background & Objectives:Recently, constant and night pain has been discarded as adequate clinical markers to predict the presence of an underlying pathology in pediatric back pain. The pain intensity has been recognized as an important domain in the pain assessment. Numerical Rating Scale (NRS) is one of the most common validated tools to assess pediatric pain intensity in children above 8 years of age. The aim of this study is to assess NRS as a predictor of underlying pathologies found by magnetic resonance image (MRI) in pediatric back pain. We hypothesize that a higher NRS score is associated with a high sensitivity, specificity and likelihood ratio to identify the present of organic pathology in pediatric chronic back pain.Methodology: After obtaining Institutional Review Board approval, a retrospective electronical medical record review was conducted. All pediatric patients who reported back pain lasting > 4 weeks between 2009 to 2018 were enrolled in the study. As per regular protocol, a pediatric orthopedic surgeon evaluated all patients who presented with back pain. After a non-diagnostic history, physical examination and spinal x-ray; spine MRI was order. Pain was graded with the use of NRS from 0 to 10. Patients were divided in two groups: NRS (1-5) & NRS (6-10). Variables such as gender, age, pain frequency, night pain, neurological exam, and the presence of an underlying pathology were compared between both groups. Patients that presented with injury due to trauma, previous diagnosis of back pain or cervical pain were excluded.Results: A total of 467 patients were evaluated in the study. Mean age of subjects was 15 years; 69% being female. An underlying pathology was identified in 131/315 (41.6%) patients with NRS (6-10), and 55/152 (36.2%) patients with NRS (1-5) (P=0.27). Patients with NRS (6-10) had two times more probability of suffering constant pain (P<0.03) and three times more likely of having an abnormal neurological examination (P<0.05). See table 1.Conclusion: Evaluation and treatment of children and adolescent with chronic back pain is challenging. Our study shows a strong association between NRS high (6-10) and constant pain and/or abnormal neurological exam. However, the use of NRS of (6-10) was not found as adequate predictor for the presence of an underlying organic pathology in children and adolescent patients. Therefore, physicians should not rely only high NRS score to recommend advance imaging study to assess chronic back pain in children and adolescent patients.Summary

Effect of BIS monitoring on sevoflurane consumption in patients undergoing breast cancer surgeries under general anesthesia\u2014a prospective observational study

BackgroundThe bispectoral index (BIS), a parameter derived from electroencephalogram, has been used to assess the depth of anesthesia. The objectives of this study were to evaluate the effect of BIS monitoring on sevoflurane consumption and recovery profile at the end of anesthesia. After obtaining Institutional Review Board approval and written informed consent, 25 American Society of Anesthesiologists (ASA) physical status classification 1 and 2 patients undergoing breast cancer surgeries who had BIS monitoring in addition to standard ASA monitoring (BIS GROUP) were compared against 25 controls (control group). In the control group, adequate depth of anesthesia was maintained using routine clinical parameters like heart rate (HR), mean arterial pressure (MAP), and minimum alveolar concentration (MAC) of sevoflurane, while in the BIS group, it was maintained by keeping the BIS score between 40 and 60 (mean 50). Data including demographics, sevoflurane consumption, hemodynamic variables, and recovery profile at the end of anesthesia was assessed in terms of time for eye opening (TEO), time for motor response (TMR), time for extubation (TE), and modified Aldrete scoring (MAS).ResultsThe mean sevoflurane consumption was lower (P = 0.019) in the BIS group. TEO (P = 0.001), TMR (P = 0.0001), and TE (0.003) were shorter in the BIS group. Difference in MAS between the 2 groups was not statistically significant (P = 0.085).ConclusionsBIS monitoring during anesthesia resulted in significant reduction in the sevoflurane consumption. Patients who had BIS monitoring awoke earlier and had better recovery profile at the end of anesthesia.

Patient satisfaction scores with telemedicine in the neurosurgical population

BackgroundThe benefits of telemedicine in neurosurgery have been widely studied, especially as its implementation into clinical practice boomed at the start of the COVID-19 pandemic. However, few studies have investigated telemedicine from the perspective of the patient experience. ObjectiveTo evaluate patient satisfaction scores of telemedicine outpatient clinic visits in neurosurgery in comparison with in-person visits. MethodsAfter obtaining Institutional Review Board approval, Press Ganey surveys from 3/1/2019 to 9/15/2020 were evaluated retrospectively from single-institution, academic neurosurgical clinics. Due to the non-normality of our data, stratified Wilcoxon tests were performed with correction for care provider differences. Domain score probability values were corrected for multiple comparisons. Average scores (range 20–100) are documented as mean ± standard deviation. ResultsThe response rates were 20% (97 responders) for telemedicine visits and 19% (589 responders) for in-person visits. Patient overall satisfaction score was slightly higher with telemedicine visits compared to in-person corrected for care provider differences (94.2 ± 12.2 vs 93.1 ± 13.4, p = 0.085). The care provider domain demonstrated no statistically significant difference in telemedicine compared to in-person (94.7 ± 14.4 vs 92.4 ± 16.5, p = 0.096). The access domain (93.7 ± 12.3 vs 93.4 ± 12.4, p = 0.999) and overall domains (94.1 ± 12.1 vs 94.4 ± 13.4, p = 1.000) were not found to be different between visit types. ConclusionTelemedicine appears to be a valuable option for neurosurgical patients and is not significantly different to in-person visits in all domains. This study demonstrates that telemedicine visits result in comparable satisfaction scores by neurosurgical patients, and providers should continue offering this option to their patients as we approach the post-COVID era.

Do Health Programs Contribute to Keeping the Peace? A Scientific Analysis

The role of health problems and programs to address problems in keeping the peace has not been scientifically analyzed. We sought to mitigate this gap in knowledge. We examined hundreds of conflicts in a robust international database (NAVCO 2.0) for the presence of health programs by conflict parties and were unable to demonstrate a significant statistical correlation between the presence of a health program and peace. Using this analysis and a comprehensive international database of health conditions (the Global Burden of Disease), we obtained Institutional Review Board approval and undertook a matched case-control analysis. We identified 14 countries with new-onset conflict as our cases and 52 similar countries without conflict during the same year as our controls. We calculated the association between conflict status and the prevalence of 254 different health conditions among the case and control nations. None of the 254 health conditions had changes in prevalence that correlated with the conflict status of that nation. None of those common health conditions is therefore a predictive "leading indicator" of conflict in this study. Without such an association or causal link, the role of health programs in peacekeeping and "stability operations" remains ambiguous. Negative findings do not mean that there is no connection between health programs and peace, and further study should be done. Our results have implications for the value of global health engagement missions.