Ochsner Health Research Articles

Prognosis of first-line tumor directed therapy for hepatocellular carcinoma using a combination of AFP, AFP-L3, and DCP

Presenter: Paul Thevenot PhD | Ochsner Health System Background: The expanded biomarker panel consisting of α-fetoprotein (AFP), AFP-L3%, and des-γ-carboxy prothrombin (DCP) has improved surveillance and early detection of hepatocellular carcinoma (HCC). The biomarkers individually, when elevated, have also been linked to aggressive tumor biology including vascular invasion and advanced staging. With increased clinical utilization on the horizon, we investigated the role of using biomarker combinations at the time of diagnosis and correlating the outcomes at the time of liver transplantation. Methods: This prospective study was conducted at a single-center in HCC patients presenting to a multi-disciplinary tumor board for liver-directed therapy (LDT) and evaluation for bridge to liver transplantation (8/30/16 – 10/16/20). AFP, AFP-L3%, and DCP were assayed on the day of first line LDT using the μTASWako i30 instrument. Additional analyzed parameters were also obtained prior to first-line LDT and monitored for bridge to transplant outcome as the primary study endpoint. Results: Consented for analysis were 140 treatment naïve HCC patients undergoing first line LDT with transarterial chemoembolization, Ytrrium-90, or microwave ablation. The median cohort age was 61 years with majority demographics of male (74%) and hepatitis C etiology (59%). Tumor burden was 82% within Milan with a median MELD-Na prioritization score of 11. Study endpoint breakdown was 29% transplanted, 29% dropout due to tumor progression, 24% censored from study endpoint, and 18% remaining waitlist active at the time of analysis. Median biomarker values were 10 ng/mL AFP, 7% AFP-L3, and 3.1 ng/mL DCP. Forty-four percent of cohort was negative for all three biomarkers while 14% were triple positive. Univariate analysis for each biomarker at threshold were associated with tumor progression (OR 5.6 – AFP > 20 ng/mL, 4.8 – AFP-L3 >10%, 8.8 – DCP >7.5 ng/mL). Analysis of cohort based on biomarker status (triple negative, AFP only, or positive for AFP-L3% and/or DCP) revealed an association between biomarker positivity and largest lesion size (P < 0.001). Univariate analysis showed largest lesion, and each individual biomarker, along with 2 positive biomarkers was associated with bridge to transplant survival. Controlling for tumor burden in separate multivariate analyses, AFP (HR 4.8), and DCP (HR 2.2), or having 2 positive biomarkers (HR 6.0) remained associated with bridge to transplant survival. In endpoint analysis, patients with more than 2 positive biomarkers had significant lower bridge to transplant survival. Biomarker positivity was also associated with response to first line LDT (OR 3.2). Conclusion: The expanded biomarker panel (AFP, AFP-L3%, and DCP) prior to LDT in bridge to transplant HCC can identify patients at high risk of tumor progression following LDT. The expanded biomarker panel may provide an opportunity to optimize treatment modality with outcome based on profile independent of radiographic tumor burden.

Abstract 13544: Cardiologist Underutilization of New Antihyperglycemic Medications in Diabetic Patients With Cardiovascular Disease

Introduction: Sodium Glucose Cotransporter-2 inhibitors (SGLT2i) and Glucose-Like Peptide-1 receptor agonists (GLP-1ra) showed significant reduction in cardiovascular (CV) events in type 2 diabetes (T2DM) patients (pts). The ADA and ACC recommend using SGLT2i/GLP-1ra in CV patients with T2DM (T2DM-CV). This study evaluated prescribing patterns in T2DM-CV to distinguish characteristics between those pts receiving SGLT2i/GLP-1ra from those not receiving SGLT2i/GLP-1ra. Hypothesis: SGLT2i/GLP-1ra are underutilized in T2DM-CV pts. Methods: Ochsner Health’s EPIC database was queried for T2DM-CV pts treated between Jan 2016 - Dec 2018. Baseline demographics and clinical characteristics were compared using ANOVA for numerical covariates, χ-square test for categorical covariates and multivariate logistic regression. Results: A total of 4,741 T2DM-CV pts were identified with approved indication for SGLT2i/GLP-1ra. Only 686 received a prescription for one of the approved SGLT2i/GLP-1ra with CV indication at the time of the study (empagliflozin, canagliflozin, liraglutide). Pts receiving SGLT2i/GLP1-ra were younger, had higher BMI, A1c, hypertension, hypercholesteremia, and/or commercial insurance or self-pay. Pts with CAD, atrial fibrillation, prior TIA or stroke, or heart failure were less likely to receive these drugs. (Table) Cardiologists rarely prescribed SGLT2i/GLP-1ra (2.2%) compared with primary care physicians (PCP) (45.6%) or endocrinologists (44.6%) (p&lt;0.001). Conclusions: T2DM-CV pts rarely received guideline directed SGLT2i/GLP-1ra, and cardiologists rarely prescribed them. Younger pts with higher A1c, CV risk factors, and commercial insurance were more likely to be prescribed SGLT2i/GLP-1ra than pts with CV disease, despite reduction in CV events in randomized trials and societal guidelines. Cardiologists need to work with endocrinologists and PCPs to drive use of these medications to improve outcomes in T2DM-CV pts.

Multivariate mortality analyses in COVID-19: Comparing patients with cancer and patients without cancer in Louisiana.

This is the largest and only multivariate study evaluating the difference in mortality from coronavirus disease 2019 (COVID-19) between patients with cancer and patients without cancer in the United States. The objective was to assess COVID-19 mortality rates in patients with cancer versus patients without cancer and uncover possible statistically significant characteristics contributing to mortality. This retrospective study analyzed patients with cancer and patients without cancer who tested positive for severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2) from March 1 through April 30, 2020. This was a multicenter study in the state of Louisiana throughout the Ochsner Health System in both tertiary and nontertiary centers. Patients older than 18 years were eligible. Three hundred twelve patients with cancer were compared with 4833 patients without cancer. Mortality was found to be higher in the cancer group. Patients of advanced age with cancer had a significant increase in mortality (odds ratio [OR], 5.96; P < .001). Other significant risk factors for increased mortality were male sex (OR, 2.15), a history of chronic kidney disease (OR, 3.84), and obesity (OR, 1.30). In hospitalized patients with cancer, adverse vital signs on admission, decreased absolute lymphocyte counts, thrombocytopenia, elevated creatinine, lactic acidosis, and elevated procalcitonin all seemed to increase the risk of death. Among patients with cancer, active or progressive disease (P < .001) and recent therapy (OR, 2.34; 95% confidence interval, 1.08-5.08) were shown to increase mortality. Patients with cancer have increased mortality in the setting of infection with SARS-CoV-2 in comparison with patients without cancer. Patients with cancer who are 65 years of age or older and those with certain comorbidities have the greatest risk of death. Recent cancer-directed therapy and disease status also seem to play roles in mortality. This is the largest study of patients with cancer versus patients without cancer to date and is the first multivariate analysis study comparing these 2 patient populations. This study confirms the hypothesis that patients with cancer are at increased risk for mortality and that there are multiple characteristics posing the potential to risk-stratify these patients in the setting of a future outbreak.

Frequency of Symptoms and Asymptomatic SARS-CoV-2 Infection in Louisiana, USA

Background: While many surveillance studies of seroprevalence to SARS-CoV-2 rely on remnant blood samples obtained as medical waste, representative, prospective collection allows for analysis of a representative cross-section of symptomatic and asymptomatic presentation of infection in the community. Louisiana, and particularly New Orleans, were hard-hit in the early phase of the pandemic, and an ongoing outbreak was occurring in Baton Rouge throughout July.Methods: A representative, cross-sectional sample of subjects from two cities in Louisiana were sent to testing sites to complete a verbal consent, survey, nasopharyngeal swab, and blood draw. Swabs were tested for active viral shedding (PCR) and blood was tested for immunoglobulin G (IgG) specific to SARS-CoV-2.Findings: Anosmia was extremely predictive for a positive test (40·6% of those with anosmia tested positive, OR: 13·6; CI 10·1, 18·3) and 47·3% of the sample experienced no symptoms at all. A lower quantity of virus was noted during the contagious phase of infection in asymptomatic compared to symptomatic individuals. Symptom presentation clustered into three groups; low/no symptoms (0·4±0·9 symptoms on average), highly symptomatic (7·5±1·9) or moderately symptomatic (4·0±1·5). The probability of reporting symptoms changed with age; those under age 60 had a >50% probability of reporting symptoms while those 60 years and older had Interpretation: Anosmia should be used as a screening criterion to differentiate from other illnesses, and, given the high ratio of asymptomatic individuals, mask mandates should be enforced. Asymptomatic individuals should be tested with cause.Funding: This study was funded by ReNOLA, Ochsner Health, the Baton Rouge Area Foundation, Louisiana COVID-19 Health Equity Task Force, and The Humana Foundation, the Blue Cross and Blue Shield of Louisiana Foundation, Healthy Blue, the Huey and Angelina Wilson Foundation, and the Irene W. and C.B. Pennington Foundation.Declaration of Interests: The authors have no other conflicts of interest to report.Ethics Approval Statement: This study was approved by the Ochsner Clinic Foundation Institutional Review Board #2020·163.

Abstract PO-083: Prostate cancer and COVID-19: Impact of hormonal therapy on severe outcomes

Abstract Background: Early reports on cancer patients infected with COVID-19 have suggested a high risk of hospitalization and death compared to the general population. Limited data are available on outcomes in specific cancer types. We aim to identify whether hormonal treatment impacts severe outcomes (rate of hospitalization, ICU admission, intubation, and death) in prostate cancer patients. Methods: We conducted a multicenter study in the state of Louisiana, throughout the Ochsner Health System, in both tertiary and nontertiary centers. Patients must carry a diagnosis of prostate cancer and have a completed SARS-CoV-2 test between March 1st and April 30th, 2020. Chi-squared and Fisher’s exact tests were performed to compare the proportion of patients experiencing severe outcomes between treatment groups. Results: As of April 30, 2020, a total of 56 patients with prostate cancer who had a positive SARS-COV-2 test were identified. Median age 69, median BMI 28.8, 78.6% (n=44) black, 58.9% (n=33) current/former smokers, HTN, DM2, and CKD were the most common comorbidities, and 12.5% (n=7) of patients had stage IV disease. Of these patients, 26.8% (n=15) were on hormonal treatment (received within 90 days of COVID+ test). In terms of severe outcomes, 58.9% (n=33) of patients required hospitalization, 17.9% (n=10) required ICU admission with 14.3% (n=8) patients requiring intubation, and 23.2% (n=13) of patients died. There was no statistical difference in rate of severe outcomes (rate of hospitalization, ICU admission, intubation, and death) among prostate cancer patients receiving hormonal therapy vs. those receiving no hormonal therapy. Conclusion: With an ongoing global pandemic of COVID-19, it is important to identify characteristics leading to increased risk of severe events in cohorts of cancer patients. This small cohort does not identify hormonal therapy as a risk factor for increased rate of severe outcomes in patients with prostate cancer. Further analyses describing impact of specific hormonal regimens on risk of hospitalization and death will be completed by time of presentation. Citation Format: Karine Tawagi, Jeff Burton, Diana Maslov, Michael Lunski, Marc Matrana, Daniel Johnson. Prostate cancer and COVID-19: Impact of hormonal therapy on severe outcomes [abstract]. In: Proceedings of the AACR Virtual Meeting: COVID-19 and Cancer; 2020 Jul 20-22. Philadelphia (PA): AACR; Clin Cancer Res 2020;26(18_Suppl):Abstract nr PO-083.

Urinary Sediment Microscopy in Acute Kidney Injury Associated with COVID-19.

AKI has been observed in patients infected with the novel coronavirus severe acute respiratory syndrome coronavirus 2 that causes coronavirus disease 2019 (COVID-19). Recent studies in the United States have reported an incidence of AKI in the context of COVID-19 around 25%–50% of cases requiring hospitalization (1,2; L. Chan, et al, unpublished observations). Nevertheless, data remain scarce about specific characteristics of coronavirus disease 2019–associated AKI (CoV-AKI). Microscopic examination of the urinary sediment (MicrExUrSed) is a reliable clinical tool of diagnostic and prognostic value in the assessment of AKI (3⇓⇓⇓–7). To date, there has been no report comprehensively describing findings of MicrExUrSed in specimens from patients with CoV-AKI. We hypothesized that MicrExUrSed may provide diagnostic information that could help in elucidating the pathogenic mechanisms of kidney injury in CoV-AKI. We conducted a prospective observational study in patients seen in the inpatient nephrology consultation service with a diagnosis of Kidney Disease Improving Global Outcomes AKI stage ≥1 and positive nasopharyngeal swab test for severe acute respiratory syndrome coronavirus 2 RNA over a 1-month period. This study was an ancillary study of a previously reported larger cohort of 161 patients with CoV-AKI (1). Because of concerns of health care worker exposure to infected patients and rationale use of personal protective equipment (PPE), MicrExUrSed was not systematically pursued as it is routinely done outside the context of COVID-19. Nevertheless, MicrExUrSed was attempted whenever there was a suspicion for an intrinsic cause of AKI that could affect medical management and/or in clinical scenarios that were confounded by more than one possible etiology of AKI. Thus, in selected cases, urine specimens were collected and handled with PPE to perform MicrExUrSed under bright-field, dark-field, and phase contrast microscopy. At least three operators inspected each slide. Slides were assessed for …

Racial Disparities in COVID-19: Present from Diagnosis to Death

Many have reported that Black people have been disproportionately affected by COVID-19. Investigators at Ochsner Health System in Louisiana have now

Hospitalization and Mortality among Black Patients and White Patients with Covid-19

BackgroundMany reports on coronavirus disease 2019 (Covid-19) have highlighted age- and sex-related differences in health outcomes. More information is needed about racial and ethnic differences in outcomes from Covid-19.MethodsIn this retrospective cohort study, we analyzed data from patients seen within an integrated-delivery health system (Ochsner Health) in Louisiana between March 1 and April 11, 2020, who tested positive for severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2, the virus that causes Covid-19) on qualitative polymerase-chain-reaction assay. The Ochsner Health population is 31% black non-Hispanic and 65% white non-Hispanic. The primary outcomes were hospitalization and in-hospital death.ResultsA total of 3626 patients tested positive, of whom 145 were excluded (84 had missing data on race or ethnic group, 9 were Hispanic, and 52 were Asian or of another race or ethnic group). Of the 3481 Covid-19–positive patients included in our analyses, 60.0% were female, 70.4% were black non-Hispanic, and 29.6% were white non-Hispanic. Black patients had higher prevalences of obesity, diabetes, hypertension, and chronic kidney disease than white patients. A total of 39.7% of Covid-19–positive patients (1382 patients) were hospitalized, 76.9% of whom were black. In multivariable analyses, black race, increasing age, a higher score on the Charlson Comorbidity Index (indicating a greater burden of illness), public insurance (Medicare or Medicaid), residence in a low-income area, and obesity were associated with increased odds of hospital admission. Among the 326 patients who died from Covid-19, 70.6% were black. In adjusted time-to-event analyses, variables that were associated with higher in-hospital mortality were increasing age and presentation with an elevated respiratory rate; elevated levels of venous lactate, creatinine, or procalcitonin; or low platelet or lymphocyte counts. However, black race was not independently associated with higher mortality (hazard ratio for death vs. white race, 0.89; 95% confidence interval, 0.68 to 1.17).ConclusionsIn a large cohort in Louisiana, 76.9% of the patients who were hospitalized with Covid-19 and 70.6% of those who died were black, whereas blacks comprise only 31% of the Ochsner Health population. Black race was not associated with higher in-hospital mortality than white race, after adjustment for differences in sociodemographic and clinical characteristics on admission.

Can automating surgical processes reduce operating room supply costs? A pilot study of a novel OR based technology.

Introduction In the struggling economic post covid era, there will be greater cost containment, efficiency, and quality pressures. How does novel technology to dynamically digitize and automate surgical processes, as an adjunct to existing static workflows, impact surgical supply costs in knee replacement surgeries compared to traditional non automated knee replacement surgeries? Materials/Methods A novel innovative patented technology (SIGHT Medical, Alexandria LA) was created to digitize surgical processes and interface with hospital data systems (EMR- EPIC and ERP- Lawson) within Ochsner health system. Medical Surgical supplies and billable medical supplies were captured by the OR staff using standard hospital EMR and materials management workflows. Outcome measures included costs of surgical supplies, length of stay and number of cases captured using the Ochsner Health system data analytics platform (Tableau, Seattle, WA). Results 1023 knee replacement surgeries were reviewed over 3 years by 3 surgeons at 3 different hospitals within the Ochsner Health system. There was an average of $479/surgery in medical surgical supply costs for automated surgeries and $557/surgery for traditional surgeries. There was an average of $2,444/surgery in billable medical supply costs for automated surgeries and $4,660/surgery for traditional surgeries. Discussion Deploying innovative technology to create a real time dynamic communication and transparency platform can create significant supply cost savings. An average of $78 in medical surgical supply cost savings and $2216 in billable medical supply cost savings can be achieved by automating many of the surgical workflows and processes.

PCN226 LUNG CANCER PATIENT CHARACTERISTICS FROM A DATA LINKAGE STUDY

This research analyzed the clinical pathway of patients from a diagnosis of solitary pulmonary nodule including demographics, diagnostic procedures and lung cancer diagnosis through data linkage. REACHnet is one of 9 clinical research networks (CRNs) in PCORnet®, the National Patient-Centered Clinical Research Network and includes electronic health record for over 8 million patients from multiple partner health systems. Data from Ochsner Health System and Tulane Medical Center were linked to Louisiana Tumor Registry (LTR), a statewide population-based cancer registry, for analysis of patient’s clinical pathways. Index date was diagnosis of solitary pulmonary nodule (SPN), low-dose computer tomography (LDCT) or chest computer tomography (CT) between July 2013 and 2017. Patients with lung biopsy and without SPN diagnosis, SPN with pleural biopsy as first biopsy, secondary lung cancer diagnosis, residence outside of Louisiana, Death Certificate diagnosis, and diagnosis on autopsy were excluded. A total of 30,561 patients with SPN, LDCT or qualifying biopsy were identified and 2,929 (9.58%) had primary lung cancer. 1,496 (51.1%) were documented in LTR. When linking REACHnet and LTR, 94% of 1,496 patients had diagnosis of SPN, 84% had CTs capturing portions of the lung and 89% had 1 or more biopsies. Biopsy distribution was 2.4% surgical, 50.1% bronchoscopy and 47.5% CT guided. Median interval and interquartile from index date to biopsy was 11 days and 28 days respectively. AJCC stage among these patients was Stage 0 (0.53%), Stage I (20.66%), Stage II (7.22%), Stage III (21.86%) Stage IV (47.26%), and Unknown (2.47%). Despite clinical workup, 70% of patients were diagnosed as having stage III or IV disease. Approximately half of lung cancer patients receiving care at Ochsner or Tulane healthcare systems do not appear in the LTR. Reasons for this are not clear but are presumed to be attributable to residence.

Locally Informed Modeling to Predict Hospital and Intensive Care Unit Capacity During the COVID-19 Epidemic.

Background: In the early phases of the 2019 novel coronavirus (COVID-19) pandemic, health system leaders faced the urgent task of translating the unknown into forecasting models for hospital capacity. Our study objective was to demonstrate the application of a practical, locally informed model to estimate the hospital capacity needed even though the community COVID-19 caseload was unknown.Methods: We developed a susceptible-infected-recovered (SIR) model that was adopted from the University of Pennsylvania COVID-19 Hospital Impact Model for Epidemics and employed at 8 hospitals within Ochsner Health, the largest integrated delivery system in Louisiana, between March 16 and April 15, 2020. Intensive care unit (ICU) admissions of cases in the New Orleans area were used to estimate the community case load when testing was delayed.Results: Initially, the observed ICU census trended near R0=2.0, whereas the ventilator census trended between R0=2.0 and 3.0. After implementing social distancing, both the ICU and ventilator capacity trended toward R0=1.3, while non-ICU medical/surgical beds trended toward R0=1.5. The model accurately predicted peak ICU (n=250) and hospital bed (n=487) usage by April 6, 2020. In response to model trends, Ochsner added 130 ICU beds across its hospitals by opening a new ICU and converting operating rooms and parts of emergency departments to ICU beds.Conclusion: When disease testing is limited or results are delayed, ICU admissions data can inform SIR models of the rate of spread of COVID-19 in a community. Our model used various R0 plots to demonstrate an array of scenarios to guide planning for hospital and political leaders.

Biomarkers Afp In Combination With Afp-L3 And Dcp Predicts Tumor Progression In Treatment Naïve Hcc Patients

Presenter: Kelley Nunez PhD | Ochsner Health System Background: Hepatocellular carcinoma (HCC) treatment with locoregional therapy (LRT) is standard process to downstage or maintain lesions within Milan Criteria. In this study, we retrospectively analyzed early-stage HCC patients undergoing de novo LRT and monitored both recurrence-free survival and intention-to-treat (ITT) survival. We also prospectively monitored a subset of early-stage HCC patients to determine whether additional HCC biomarkers would aid in predicting ITT survival compared to α—fetoprotein (AFP) alone. Methods: All studies were IRB-approved at our institution. A retrospective review of HCC patients transplanted from June 2011 – Feb 2019 that underwent DEB-TACE was performed with patients monitored for 5 year recurrence. In the ITT cohort, HCC patients undergoing de novo DEB-TACE from Aug 2015 – May 2019 were reviewed. Blood was collected from a subset of the ITT cohort (n=52) immediately prior to LRT. Plasma was used to measure HCC biomarkers (AFP, des-λ-carboxy prothrombin (DCP), and Lens culinaris agglutinin-reactive α-fetoprotein (AFP-L3)) in samples with the μTASWako i30 autoanalyzer. ITT endpoint included patients that received liver transplantation or dropout due to tumor progression. Results: In the retrospective transplanted cohort, 268 treatment-naïve patients were analyzed with 75% male and main etiology of Hepatitis C (58%). Recurrence free survival was significantly lower in patients that presented with AFP > 100 (P=0.01). In the ITT cohort, 160 treatment-naïve HCC patients were analyzed with 71% male and 65% Hepatitis C. Milan Criteria and AFP elevation alone was not predicitive ITT survival, however patients with AFP > 100 had significantly lower ITT survival. A subset of the ITT cohort was prospectively monitored with blood collections. Demographic comparsions between two revealed only significant differenecs in sodium and bilirubin levels. Univariate analysis revealed patients with tumor progression had larger lesions (P < 0.0001), cumulative lesion size (P < 0.0001), and higher HCC biomarkers AFP (P=0.39), AFP-L3 (P=0.002), and DCP (P=0.005). ITT survival was significantly lower in patients presenting with elevated single biomarkers [AFP >100 (P < 0.0001), AFP-L3 (P < 0.0001), and DCP (P < 0.0001)], primary lesion >3cm (P < 0.0001), and cumulative lesion size >3cm (P < 0.001). Analysis of patients stratified by HCC biomarkers revealed patients presenting with AFP elevation and an additional biomarker had worse ITT survival and were at greater risk of waitlist dropout. Conclusion: AFP alone can identity patients at risk of waitlist dropout with higher risk of recurrence post transplant. However, the addition of AFP-L3 and DCP biomarkers can identify a patient population prior to LRT intervention at risk of tumor progression from the waitlist.

Effects of donor macrosteatosis and post transplant and post transplant complement activation on early allograft dysfunction in liver transplant patients

Presenter: Kelley Nunez PhD | Ochsner Health System Background: Liver transplantation provides a curative option for patients with underlying cirrhosis. However, organ shortage continues to increase waitlist mortality. To combat this, less than optimal organs have been used for transplantation. These extended criteria donor grafts are accompanied by increased risk of both graft failure and decreased patient survival. In this study, we investigated the impact of donor Macrosteatosis on early allograft dysfunction, complement activation, and inflammatory mediators in recipients. Methods: Cohort consisted of patients who received a liver transplant at Ochsner Medical Center from November 2011 – April 2019. Clinical variables and donor macrosteatosis percentages were retrospectively extracted from the electronic medical record. Recipient blood samples were collected immediately following liver transplantation in a subset of cohort. Multiple indices to determine early allograft dysfunction were calculated, and ELISA’s were performed on the blood samples for complement activation measurements and damage associated molecular proteins. Results: Cohort consisted of 1322 patients with median Donor age of 44, 58% male. Increases in donor Macrosteatosis led to significant increases in liver enzymes, INR, and bilirubin, all measures of liver damage. Higher levels of early allograft dysfunction were also found in patients receiving donor grafts with > 20% macrosteatosis. These patients had increased complement activation of both C3a and C5a, and significantly higher levels of the alarmin IL-33. Conclusion: Recipients that receive donor grafts with > 20% macrosteatosis have higher levels of liver damage, complement activation, and alarmin release. Proactive measures of lower complement activation may decrease presence of early allograft dysfunction.

Using Technology to Improve Women's Health Care.

Background: Technology is being integrated into all aspects of health care. While many applications offer novel experiences, the evidence supporting translation to improved education or care is evolving.Methods: We review ways that technology is affecting a variety of fields pertinent to women's health, including patient communication, physician education, and health care performance.Results: In the Ochsner Health Department of Obstetrics and Gynecology, we have developed a platform known as Connected Maternity Online Monitoring—Connected MOM—to encourage remote monitoring during the prenatal course. We are also assessing improvements in quality and safety through a centralized fetal heart rate monitoring bunker known as TeleStork.Conclusion: Through systematic integration of technology into the delivery of women's health care at Ochsner, we hope to demonstrate sustainable improvements in physician skills, patient access, and quality and safety.

Getting Ahead of the Curve: How Ochsner Became a Leader in SARS-CoV-2 Diagnostic Testing.

On March 9, 2020, Ochsner Health admitted its first COVID-19 patient. Less than 2 weeks later, Ochsner became the first hospital in Louisiana to insource diagnostic testing for severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2), the virus responsible for COVID-19. While Ochsner soon became

Cirrhosis-Drive Immune Dysfunction Associates With Poor Response To Deb-Tace And Waitlist Dropout In Hepatocellular Carcinoma Patients

Presenter: Kelley Nunez PhD | Ochsner Health System Background: Hepatocellular carcinoma (HCC) recurrence after transplantation is associated with higher tumor grade on explant, failure to respond to DEB-TACE, and pretreatment lymphopenia. We prospectively monitored HCC patients in transplant evaluation to investigate associations between lymphopenia and tolerance with treatment response and waitlist outcomes. Methods: HCC patients undergoing DEB-TACE were prospectively enrolled. Blood was collected before and after DEB-TACE (100-300μm LC Beads with 100mg doxorubicin). Peripheral blood mononuclear cells were analyzed by flow cytometry. Tumor response to DEB-TACE was determined using mRECIST imaging criteria. Intention-to-treat (ITT) endpoint included transplantation or tumor progression. Results: Analyzed were 91 patients with a median age 61, predominantly Caucasian (73%) with Hepatitis C (80%). Prior to DEB-TACE, 47% of patients were lymphopenic (absolute lymphocyte count, ALC≤1.2k/μL). Tumor response was scored using mRECIST and available in 82 patients. Pre-treatment ALC and lymphopenia status were associated with failure to respond to DEB-TACE (P=0.028, P=0.004). Overall, 69% of patients that did not respond to treatment were lymphopenic. These patients also exhibited significantly lower albumin (P=0.0017) and higher bilirubin (P=0.02) at the time of treatment. Interestingly, no significant changes were observed in lymphocyte count, albumin, and bilirubin levels between 3 years prior to HCC development, at the time of diagnosis, and day of treatment. Tolerogenic immune populations, myeloid derived suppressor cells (MDSC) and regulatory T cells were significantly elevated in lymphopenic patients (P=0.02 and P=0.001). MDSCs isolated from HCC patients exhibited immune suppressive activity. To investigate whether bilirubin could impact T cells, isolated human T cells were incubated with unconjugated bilirubin; Results showed no effect on proliferation. Sixty patients (66%) reached ITT endpoint with 30/60 transplanted and 30/60 waitlist dropout due to tumor progression. In the ITT cohort, 61% of patients that did not respond to treatment experienced tumor progression. Conclusion: Lymphopenic status remains stable prior to HCC development and may be cirrhosis-driven. Patients presenting with lymphopenia and poor liver synthetic function can identify patients with immune dysfunction both at risk of tumor progression prior to transplantation.

PCV92 IMPROVING MEMBERS HYPERTENSION AT BLUE CROSS BLUE SHIELD OF LOUISIANA: THE EFFECTIVENESS OF OCHSNER'S DIGITAL MEDICINE HYPERTENSION (DMH) PROGRAM

Hypertension, a controllable chronic condition through lifestyle changes and/or medication management, affects millions of Americans. Ochsner Health System introduced a digital medicine hypertension (DMH) program that combined in-depth education, lifestyle management, and remote blood pressure monitoring and individualized pharmacist medication management. This study evaluated whether Ochsner Health System’s DMH program improved enrollee blood-pressure, utilization and health care spending. Beginning February 2016, hypertensive patients could enroll in Ochsner’s DMH during their visit with an Ochsner primary care physician (PCP). Additional requirements for patient enrollment included: patients had to be a resident of Louisiana and not have had a heart or kidney transplant. The treatment group included all patients who enrolled in the DMH program and were continuously enrolled in BCBSLA at least 6 months prior to and after the DMH participation date. Treatment cohort via propensity scoring was matched to a control population with the same inclusion criteria, patient characteristics and comorbid conditions but were not being managed by Ochsner PCPs. Blood pressure readings are the primary clinical health outcome. Controlled blood pressure was defined as < 140/90 mmHg in the baseline period. Healthcare utilization and expenditures were analyzed at the per member per month level (PMPM). After matching, 386 patients were included in the analysis (193 in each cohort). The treatment group had significantly improved blood pressure with 18% higher of members that were ‘uncontrolled’ at baseline gained controlled blood pressure readings within the study period; hypertension related medication adherence also increased 7.5%. Healthcare utilization was lower with less ER visits and Inpatient Admissions; however, study participants had more PCP, specialist visits and Rx scripts. The Ochsner Health System’s DMH program improved enrollee blood-pressure, medication adherence and health care utilization.

Smoking history and PD-1/PDL-1 pathway blockade: Predicting response to treatment in metastatic cancer.

95 Background: Identifying patients who will benefit from immune-checkpoint inhibitor therapy is a challenge as proven predicative indicators remain to be elucidated. High tumor mutational burden (TMB) represents a possible biomarker for response to PD1 blockade such as in nivolumab or pembrolizumab. Genomic analyses have shown that patients with heavy smoking history are more likely to have high TMB. However smoking status alone has not been examined independently in relation to treatment response. We sought to determine whether a relationship existed between smoking history and response to treatment in metastatic non-small cell lung cancer (NSCLC), metastatic renal cell carcinoma (mRCC) and metastatic melanoma (mMelanoma). Methods: A retrospective analysis was conducted of Ochsner Health System patients with mRCC, mMelanoma, and NSCLC receiving a minimum of two cycles of nivolumab or pembrolizumab between 12/2014 and 01/2018. Pre- and post-treatment target lesions were analyzed using RECIST criteria to calculate best response to treatment. Patient demographic information was gathered including age, sex, smoking history, and performance status pre and post treatment. Kaplan-Meier method was used to estimate progression free survival (PFS) and overall survival (OS) outcomes. Results: Heavy smokers (&gt;10 pack-years) had a higher response to immunotherapy than light (&lt; 10 years) and never smokers (p = 0.0500). Heavy smokers with NSCLC treated with immuno-therapy also had significantly improved OS compared to light smokers with NSCLC (p=0.003). mRCC immuno-therapy patients with heavy smoking history showed increased PFS compared to light/never smokers (p=0.026). Conclusions: In summary, in response to PD-1 blockade heavy smokers showed improved survival compared to light and never smokers suggesting smoking history may represent a potential predictor of treatment response to PD-1 inhibitor therapy.[Table: see text]

Standardising practice in cardiology: reducing clinical variation and cost at Ochsner Health System

ObjectiveLow quality and unwarranted clinical variation harm patients and increase unnecessary costs. Effective approaches to improve clinical and economic value have been difficult. The Ochsner Health System looked to improve...

Factors Associated With Discussions of Human Immunodeficiency Virus Pre-Exposure Prophylaxis in Men Who Have Sex With Men.

Background: Pre-exposure prophylaxis (PrEP) with emtricitabine/tenofovir disoproxil fumarate (Truvada) is highly effective at preventing human immunodeficiency virus (HIV) transmission in high-risk populations, including in men who have sex with men (MSM). In 2019, the US Preventive Services Task Force released an A recommendation to offer PrEP to persons at high risk of HIV acquisition. Despite the demonstrated efficacy of PrEP, areas with high HIV incidence, such as Louisiana, have historically had low PrEP prescription rates. The objective of this study was to determine the factors associated with whether providers in the Ochsner Health System (OHS) discussed PrEP with HIV-negative MSM patients. Methods: Investigators extracted electronic medical record data on all HIV-negative MSM patients who had at least one outpatient visit at OHS between July 1, 2012 and July 1, 2016 and manually reviewed a random sample of 115 charts. Results: Subjects were predominantly Caucasian (75.7%) with a mean age of 37.6 years. A PrEP discussion was documented for 34 (29.6%) patients. Multivariate modeling showed that having a PrEP discussion was associated with 3 factors: being assigned to a primary care provider known to specialize in MSM care (odds ratio [OR] 5.05, 95% confidence interval [CI] 1.81-14.10; P=0.002), having a documented history (positive or negative) of sexually transmitted infection vs no documentation (OR 5.41, 95% CI 1.80-16.23; P=0.003), and having documentation of condom use (consistent or inconsistent) vs no documentation (OR 3.32, 95% CI 1.27-8.74; P=0.015). Conclusion: Despite evidence that PrEP significantly reduces sexual transmission of HIV in MSM, PrEP discussions with MSM across OHS were undesirably low. Additional resources need to be aimed at increasing PrEP uptake and should focus on providing skills-based training and education in PrEP and MSM care to healthcare providers. With increased knowledge of and familiarity with PrEP prescribing guidelines, more providers will be better equipped to identify at-risk patients and to discuss prevention options such as PrEP.