Ohio State University Wexner Medical Research Articles

The Impact of Faculty Gender on Resident Evaluations of Faculty Performance in Emergency Medicine.

Gender bias impacts the promotion and tenure of female emergency medicine (EM) physicians and limits their ability to advance in academic rank.Many factors influence the promotion and tenure process including research, evaluations, opportunities for leadership, sponsorship, and mentorship. The goal of this study is to determine if resident evaluations of EM faculty differ by faculty gender. A quantitative analysis was used to examine 14,613 teaching evaluations of faculty by residents at a single academic center (The Ohio State University Wexner Medical Center, Columbus) in the years 2017-2019.Anonymized ratings of male and female faculty on a five-point Likert scale were compared using Fischer's exact test and adjusting for multiple comparisons. Male faculty were more likely to hold the rank of Associate Professor or Professor. When taking both faculty gender and rank into account, male Clinical Instructors and Assistant Professors had significantly higher evaluation scores by residents in the domain of resident autonomy than their female counterparts. Regardless of gender or faculty rank, the majority of faculty received scores greater than four. A significant gender difference was found in resident evaluation scores of faculty in the domain ofresident autonomyat the level of Clinical Instructor and Assistant Professor.Resident autonomy refers to the degree of supervision by faculty which evolves over time and is primarily based on level of training.This is important as it demonstrates a gender difference in scores that could be used to determine faculty compensation and promotion. Evaluation tools used for promotion and tenure of academic faculty should be evaluated for implicit bias and appropriate statistical analysis.

Prevalence of Electrographic Seizures in Hospitalized Patients With Altered Mental Status With No Significant Seizure Risk Factors Who Underwent Continuous EEG Monitoring: A Retrospective Study.

The objective of this study is to evaluate the prevalence of electrographic seizures in hospitalized patients with altered mental status and no significant risk factors for seizures. We retrospectively reviewed over a six-year period (2013-2019) the medical records of all adults admitted at Ohio State University Wexner Medical Center (OSUWMC), who underwent continuous electroencephalography (cEEG) monitoring for > 48 hours. Our primary objective was to identify the prevalence of electrographic seizures in patients with altered mental status and no significant acute or remote risk factors for seizures. A total of 1966 patients were screened for the study, 1892 were excluded (96.2%) and 74 patients met inclusion criteria. Electrographic seizures were identified in seven of 74 patients (9.45%). We found a significant correlation between electrographic seizures and a history of hepatic cirrhosis, n= 4 (57%), (p=0.035), acute chronic hepatic failure during admission, 71% (n=5), (p=0.027), and hyperammonemia (p =0.009). In this retrospective study of patients with altered mental status and no significant acute or remote risk factors for seizures who underwent cEEG monitoring for > 48 hours, electrographic seizures were identified in 9.45%. Electrographic seizures were associated with hepatic dysfunction and hyperammonemia. Based on our results, cEEG monitoring should be considered in patients with altered mental status and hepatic dysfunction even in the absence of other seizure risk factors.

Measuring Chief Resident Skill and Entrustment Progression in An Operative Coaching Program: Four Years’ Experience

Operative coaching (OC) may facilitate improvement of surgery residents' competencies by optimizing learning and teaching. We investigated how residents' operative skills and prospective entrustment (PE) progress throughout the chief year in our OC program, how OC is perceived by participants, and how OC may facilitate learning and teaching. This is a mixed-methods study conducted within the Ohio State University Wexner Medical Center General Surgery residency. Validated performance evaluations with procedural-specific skill, general skill (GS), step-specific guidance required (SSG) (an autonomy measure), and PE measures completed by chiefs, faculty coaches, and attending surgeons from 7/2018 to 6/2022 were reviewed. We also interviewed OC participants to understand their experience. Descriptive statistical and qualitative content analysis were applied. 441 evaluations from 147 OC cases completed by 22 chiefs, 5 faculty coaches, and 24 attendings were included. Overall, resident GS (p = 0.036), SSG (p = 0.023), and PE (p = 0.002) significantly improved throughout the year. PE significantly correlated (all p < 0.0001) with SSG (r = 0.73), followed by procedural-specific skill (r = 0.59), then GS (r = 0.57). On average, chiefs underestimated their surgical skills while attendings overestimated autonomy they permitted to residents. Chiefs, coaches, and attendings reached consensus on chiefs' PE upon graduation. Five graduated chiefs and 5 attendings were interviewed. Chiefs described OC as effective in improving their self-regulated learning and particularly valued 3 OC elements: neutral authentic feedback, third-party real-time observation, and actionable feedback. Attendings noted OC promoted their engagement in skills assessment and teaching. Our findings suggest chief residents' skills, autonomy, and PE progress steadily along their OC journey. Despite differences in residents', coaches', and attendings' perceptions of skill, measures of autonomy reliably correlate with entrustment. OC promotes resident learning, faculty teaching, and assessment of resident skills, autonomy, and PE in the OR.

Evaluating Different Strategies to Screen for Depression in Sickle Cell Disease

Introduction Sickle Cell Disease (SCD) is an inherited blood disorder affecting approximately 100,000 Americans, most from socially disadvantaged groups. Adults with SCD have a significant burden of depression, which can adversely affect their quality of life, the clinical course of their SCD, and mortality. National guidelines recommend screening for depression in adults annually. Also, adults with SCD may not report symptoms routinely in the clinic since they can be stigmatized. Therefore, screening for depression is critical in managing adults with SCD. A standard tool to screen for depression is the nine-item Patient Health Questionnaire (PHQ-9). This measure can be self-administered on paper or a tablet or administered by healthcare providers or staff in the clinic by asking them questions. There is a gap in our knowledge of the optimal strategy to screen for depression in SCD. Objective To close this knowledge gap, we tested the hypothesis that the strategy of a self-administered depression screening questionnaire PHQ-9 on a tablet during clinic would have more positive screenings for depression than the strategy of asking the PHQ-9 questions by nurses. Methods This study was part of a prospective cohort of adults with SCD in a patient-centered medical home with an integrated primary care provider at the Ohio State University Wexner Medical Center Comprehensive Sickle Cell Clinic. Adults with any type of SCD were recruited between January 1, 2021, and March 31, 2023. These participants were given tablets to self-administer the PHQ-9 and were also asked the PHQ-9 questions by the nursing staff. The total score determined positive screening and severity of depression. Scores ≥5, ≥10, ≥15, and ≥20 represent mild, moderate, moderately severe, and severe depression, respectively. We used a proportions test for differences among the proportion who screened positive for depression between the two strategies and a Welch's t-test of independence to determine differences in PHQ-9 scores. The Ohio State University IRB approved this study. Results A total of 50 adults with SCD, aged 18 to 67, were recruited after meeting the inclusion criteria. Of these 50 adults, 60% were female. The categorization of the severity of depression varied between the two strategies, with more participants in the self-administered group having higher categories of depression (Table 1). Only 24% of the nurse-administered scores screened positive for depression, while 48% of the self-administered scores positively screened for depression (p = 0.02). The mean PHQ-9 score was higher with self-administered PHQ-9 (mean: 5.60; standard deviation (SD): 5.72) compared to clinic-administered PHQ-9 by nurses (mean: 3.32; SD: 4.62, p = 0.03). Conclusions Our study is the first to demonstrate the importance of the strategy of screening for depression in adults with SCD. Lower levels of depression were reported when nurses screened for depression compared to when adults with SCD completed the questionnaire independently. The PHQ-9 is commonly used to screen for depression, but depending on the clinic, the administration of the questionnaire may differ, which may lead to suboptimal screening for depression. Identifying the optimal strategy for screening for depression is crucial in this population with a high burden of depression, as depression can ultimately affect their outcomes. This study was limited by being at a single center and the selection bias of only including those who presented in the SCD clinic. Future multi-center studies for optimal strategies to screen, diagnose, and manage depression among adults with SCD are needed.

Targeting EBV Encoded Viral Kinases with GCV, AZT, Rituximab and Dexamethasone (GARD) Results in Durable Responses in Patients with CNS Lymphoproliferative Disease

Introduction: Epstein-Barr virus positive (EBV+) central nervous system lymphoproliferative diseases (CNS-LPD) are aggressive clinical conditions with poor prognosis. EBV+ CNS-LPD often occurs in the setting of immune suppression and comorbidities (solid organ transplant, autoimmunity). Treatment with high-dose methotrexate has increased survival but is not a viable option for all patients, highlighting the need for alternative treatments. Previous research has reported EBV+ CNS-LPD exhibits unique genetic and immunobiological signatures, however, few studies have reported on the epigenetic landscape. We have previously reported use of ganciclovir (GCV), zidovudine (AZT), rituximab and dexamethasone (GARD) regimen induced complete and durable responses in a cohort of 13 patients with primary CNS post-transplant lymphoproliferative disease (PCNS-PTLD). Here we present 24 patients (10 from prior cohort and 14 new) with EBV+ CNS-LPD treated with GARD. We extend follow-up time for the previous cohort and add molecular context to clinical observations. We performed DNA methylation and expression analysis of EBV viral kinases in available tumor samples and revealed unique viral epigenetic states leading to expression of antiviral drug targets in an array of EBV+ CNS-LPD. Methods: We conducted an IRB-approved, retrospective review of patients with EBV+ CNS-LPD treated with GARD at The Ohio State University Wexner Medical Center between 1998-2022. Patient information was extracted from the electronic medical record. Treatment consisted of two-week induction of twice daily IV GCV/AZT (5mg/kg and 1,500 mg) IV dexamethasone (10-40mg), and weekly rituximab (375mg/m 2). After induction, dexamethasone was tapered, and GCV/AZT was switched to maintenance oral dosing of 450mg valganciclovir twice daily and 300mg of AZT twice daily. Rituximab was administered on days 1, 8, 15, and 22. Two-year overall survival (OS), five-year OS, and overall response rate were assessed. Available CNS-LPD biopsy samples were obtained, and expression of EBV lytic genes BZLF1, BXLF1 (thymidine kinase), and BGLF4 (protein kinase) were measured via qRT-PCR. Mass spectrometry based EpiTYPER assay was used to report the percentage of DNA CpG methylation in the gene promoters for viral BZLF1, BXLF1, BGLF4 and LMP1 genes . Biopsies from 17 patients with systemic PTLD with no CNS involvement were used for comparison. Results: 24 patients with EBV+ CNS-LPD were identified. 21 (87.5%) patients were diagnosed with a primary CNS-LPD (PCNS-LPD). Of the PCNS-LPD, 14 patients were PCNS-PTLD, 4 were receiving immunosuppression for autoimmune conditions, 1 patient had type 2 diabetes and two had no known history of immunosuppression. The remaining three patients had systemic PTLD with secondary CNS involvement. Diffuse large B-cell lymphoma was the most common histology (11; 45.8%) followed by grade 3 lymphomatoid granulomatosis (5; 20.8%), B-cell LPD (5;20.8%), polymorphic PTLD (2;8.3%) and one large cell lymphoma of ambiguous lineage. All patients were HIV negative. EBER was positive in all biopsies and EBV PCR of cerebrospinal fluid was positive in patients without biopsy. Sixteen patients (66.7%) achieved a completed response, with an overall response rate of 83%. Two-year OS was 62.5% (95% CI, 45.8-85.2%) and five-year OS was 52.8% (95% CI, 35.7%-77.9%). Five CNS-LPD brain biopsies were available for analysis. qRT-PCR of biopsy specimens showed expression of LMP1, BXLF1, and BGLF4, but not BZLF1. Expression of BGLF4 was significantly higher (p=1.35e-5) in CNS-LPD when compared to systemic EBV+ PTLD. EpiTYPER data showed significantly decreased promoter methylation for viral kinases BXLF1 and BGLF4 (p=0.0281 p=0.0089). Conclusions: We have shown that GARD regimen shows efficacy in the treatment of EBV+ CNS-LPD, with 62.5% two-year OS and 52.8% five-year OS. Our results provide the molecular basis for expression of lytic viral kinases BXLF1 and BGLF4 in CNS-LPD by showing that both genes exhibit decreased promotor methylation. This expression of viral kinases in CNS-LPD supports the mechanistic rationale of this antiviral approach and could be further investigated as a predictive biomarker. Overall, this research highlights unique epigenetic features of EBV in CNS-LPD that support the use of antiviral, specifically the GARD regimen, in EBV+ CNS-LPD.

Abstract 17764: Clinical Outcomes and Predictors of Vasoplegia in Patients Undergoing Orthotopic Cardiac Transplantation at a High-Volume Single-Center

Background: Patients undergoing heart transplantation are at significant risk of the developing post-operative vasoplegia, which is associated with poor outcomes. Despite significant burden to these patients, risk factors for development of vasoplegia are poorly understood. We assess these risk factors and outcomes in patients undergoing orthotopic heart transplant at our high-volume academic center. Methods: 173 patients underwent cardiac transplantation between January 1 st , 2015 and February 28 th 2022 at the Ohio State University Wexner Medical Center. Baseline demographics, operative characteristics, peri-operative management, and long-term follow-up data were obtained. Vasoplegia was defined as provider documentation of vasoplegia for patients with persistent hypotension requiring the use of one or more vasopressors to maintain mean arterial pressures &gt;65 mmHg in the absence of other explainable causes (cardiogenic shock, sepsis, etc.) The two primary endpoints assessed were development of vasoplegia in the 48 hours post-transplant and all-cause mortality. Statistical significance was assessed using Chi-squared, analysis of variance, or Kruskal-Wallis where appropriate. Results: In total, 173 patients underwent cardiac transplantation. 89 (51.4%) developed vasoplegia in the post-operative period. 130 (75.1%) were males. The average age at transplant was 56 years. Patients with vasoplegia were more likely to have history of atrial fibrillation (p=0.01) and had higher BMI (p&lt;0.01) compared to those without. There were otherwise no significant differences in demographic data such as past medical history and medication history in those with and without vasoplegia. Patients with vasoplegia had significantly higher cardiopulmonary bypass times (p=0.01), aortic cross-clamp times (p&lt;0.01) and need for red blood cell transfusion peri-operatively (p=0.02). Patients with vasoplegia had higher 30-day mortality (p=0.03), however there was no significant difference in 1-year mortality for those with and without vasoplegia. Conclusions: Vasoplegia is common following orthotopic heart transplant, and short-term mortality is high. Appropriate risk-stratification is paramount in caring for these high-risk patients.

Building a national brand: The experience of The Ohio State University Wexner Medical Center Department of Surgery

People have an abundance of choices relative to health care choices. Patients can easily access personal reviews, third-party rankings, and other information from a computer or mobile phone. In turn, health care organizations can have difficulty setting themselves apart from others. A brand can refer to an organization’s image and design elements; the messaging and values it conveys to consumers, staff, and the public; and its reputation in the community. A strong brand evokes trust, reliability, and value among other competitors. The foundation of any health care organization’s brand is built on these key elements: mission, vision, and values; logo, colors, typography, and imagery; brand voice; brand consistency; brand experience. The Ohio State University Wexner Medical Center has positioned itself nationally as a leading academic health center. The Department of Surgery has built upon this strong brand to create an equally strong reputation among other departments nationwide. Marketing efforts for the department have focused on promoting its nationally ranked general surgery residency program, world-renowned clinical programs and faculty, and robust research portfolio. We herein highlight some of the tactics that go into building a strong, vibrant brand for a department of surgery.

Describing the monthly variability of hospital-onset Clostridioides difficile during early coronavirus disease 2019 (COVID-19) using electronic health record data.

To assess the relative risk of hospital-onset Clostridioides difficile (HO-CDI) during each month of the early coronavirus disease 2019 (COVID-19) pandemic and to compare it with historical expectation based on patient characteristics. This study used a retrospective cohort design. We collected secondary data from the institution's electronic health record (EHR). The Ohio State University Wexner Medical Center, Ohio, a large tertiary healthcare system in the Midwest. All adult patients admitted to the inpatient setting between January 2018 and May 2021 were eligible for the study. Prisoners, children, individuals presenting with Clostridioides difficile on admission, and patients with <4 days of inpatient stay were excluded from the study. After controlling for patient characteristics, the observed numbers of HO-CDI cases were not significantly different than expected. However, during 3 months of the pandemic period, the observed numbers of cases were significantly different from what would be expected based on patient characteristics. Of these 3 months, 2 months had more cases than expected and 1 month had fewer. Variations in HO-CDI incidence seemed to trend with COVID-19 incidence but were not fully explained by our case mix. Other factors contributing to the variability in HO-CDI incidence beyond listed patient characteristics need to be explored.

A-390 Implementation of the New GEM Hemochron 100 Point-of-care Coagulation System for Heparin Monitoring During Cardiopulmonary Bypass Procedures

Abstract Background The Ohio State University Wexner Medical Center has monitored the administration of unfractionated heparin (UFH) during cardiopulmonary bypass (CPB) procedures with the activated coagulation time test, using the Hemochron Signature Elite (Elite) instrument (Werfen) with the ACT+ cartridge. An assessment was conducted to evaluate the performance of the newest Hemochron model, the GEM Hemochron 100 (Werfen), to upgrade current instruments. Methods Precision and Methods Comparison studies were conducted with nine GEM Hemochron 100 systems. Each GEM Hemochron 100 instrument was analyzed with two levels of directCHECK liquid quality control, five replicates, over four days. The Method Comparison study compared the results from one Elite system's result, against the average result reported from one to three GEM Hemochron 100 systems. This methodology was repeated in multiple groups, using different Elite and GEM Hemochron 100 systems. All tests were performed with the ACT+ assay, which is sensitive to UFH from 1–6 IU/mL. Results Precision: All nine GEM Hemochron 100 instruments yielded: Level 1 CV ≤ 9.5%, and Level 2 CV ≤ 2.5%. Method Comparison: Total datasets 66; range 94–902 seconds; estimated bias at the 300, 420, and 480 second ACT+ clinical decision points were 1.6, 3.2, 4.1 seconds respectively; correlation (r) 0.97; slope 1.01; average CV across GEM Hemochron 100 systems 6.0%. Conclusion The performance of the new GEM Hemochron 100 system demonstrated acceptable agreement compared to the Elite system during CPB, maintaining existing ACT+ procedural target times. Results of system performance were consistent with the manufacturer's package insert, as well as previously published data. Based on the clinical performance, GEM Hemochron 100 systems have been implemented into our surgical suites.

First international meeting towards eliminating paralysis after aortic aneurysm surgery

First international meeting towards eliminating paralysis after aortic aneurysm surgery Professor Hamdy Awad, MD, FASA, from the Ohio State University Wexner Medical Center, examines the dangers of aortic aneurysm surgery and the importance of continued research towards eliminating paralysis. Aortic aneurysmal disease is a rapidly growing problem in the United States. Ruptured aortic aneurysm is the 12th leading cause of death in the U.S. with 43,000–47,000 deaths per year (1). Risk factors associated with aneurysmal disease include old age, smoking, male sex, and a family history of aortic aneurysm. Aortic aneurysms inevitably rupture due to their thin and weakened walls, resulting in massive internal bleeding, which is usually fatal. This necessitates timely surgical intervention.

Adapting Compassionate Conversations for Virtual Mediated Communication

The Covid-19 pandemic resulted in a shift in communication of difficult, emotionally charged topics from almost entirely in-person to virtual mediated communication (VMC) methods due to restrictions on visitation for safety. The objective was to train residents in VMC and assess performance across multiple specialties and institutions. The authors designed a teaching program including asynchronous preparation with videos, case simulation experiences with standardized patients (SPs), and coaching from a trained faculty member. Three topics were included - breaking bad news (BBN), goals of care / health care decision making (GOC), and disclosure of medical error (DOME). A performance evaluation was created and used by the coaches and standardized patients to assess the learners. Trends in performance between simulations and sessions were assessed. Four academic university hospitals - Virginia Commonwealth University Medical Center in Richmond, Virginia, The Ohio State University Wexner Medical Center in Columbus, Ohio, Baylor University Medical Center in Dallas, Texas and The University of Cincinnati in Cincinnati, Ohio- participated. Learners totaled 34 including 21 emergency medicine interns, 9 general surgery interns and 4 medical students entering surgical training. Learner participation was voluntary. Recruitment was done via emails sent by program directors and study coordinators. A statistically significant improvement in mean performance on the second compared to the first simulation was observed for teaching communication skills for BBN using VMC. There was also a small but statistically significant mean improvement in performance from the first to the second simulation for the training overall. This work suggests that a deliberate practice model can be effective for teaching VMC and that a performance evaluation can be used to measure improvement. Further study is needed to optimize the teaching and evaluation of these skills as well as to define minimal acceptable levels of competency.

Weight Gain in People with HIV: The role of demographics, antiretroviral therapy, and lifestyle factors on weight.

We explored factors associated with weight gain among people with HIV (PWH) on antiretroviral therapy (ART) at The Ohio State University Wexner Medical Center (OSUWMC). This was a retrospective cohort study of adult PWH on ART for ≥3 months. Patients with CD4+ T cell count <200 cells/mm3, viral load >200 copies/mL, history of malignancy, or pregnancy were excluded. 870 patients met criteria. The primary outcome was percent weight change over the follow up period (Δ = relative effects). The secondary outcome was the odds of ≥5kg weight gain over the study period. The effects of concurrent medications, medical comorbidities, ART combinations, and lifestyle behaviors on these outcomes were modeled using mixed effect regression analyses. Over a mean follow-up of 1.86 years, the study population gained a mean percent weight of 2.12 ± 0.21% (p<0.001) with an odds of ≥5kg weight gain of 0.293 (p<0.001). Men gained an average of 1.88 ± 0.22% over follow up, while women gained an average of 3.37 ± 0.51% over follow up (p=0.008 for the difference). Improvement in diet was associated with a decrease in weight change (Δ = -1.99 ± 0.47%, p= < 0.001) and a reduced odds of ≥5kg of weight gain (OR= 0.70, 95% CI = 0.50 - 0.97, p=0.03). In regression models, combination therapy with tenofovir alafenamide (TAF) and integrase strand transfer inhibitor (INSTI) containing regimens was associated with an increase in weight over the study period (Δ = 2.14 ± 0.45%, p< 0.001 and Δ = 1.09 ± 0.39%, p=0.005, respectively). Increasing age was significantly associated with a decrease in percent weight change over the study period (Δ = -0.68 ± 0.18% per year, p<0.001). Factors associated with weight gain include therapy with TAF and INSTI. Diet plays an influential role in attenuating weight gain in PWH.

Letter from the Editor

Bariatric Surgical Practice and Patient CareVol. 18, No. 2 EditorialFree AccessLetter from the EditorDean J. MikamiDean J. MikamiDean J. Mikami, MD, FACS, Editor-in-Chief, Bariatric Surgical Practice and Patient Care, Professor of Surgery, Associate Chair of Clinical Affairs, Division Chief, General Surgery, Associate Program Director, John A. Burns School of Medicine, University of Hawaii, Honolulu, HI 96813, USA E-mail Address: dmikami2@hawaii.eduDepartment of General Surgery, John A. Burns School of Medicine, University of Hawaii, Honolulu, Hawaii, USA.Search for more papers by this authorPublished Online:15 Jun 2023https://doi.org/10.1089/bari.2023.29034.djmAboutSectionsPDF/EPUB Permissions & CitationsPermissionsDownload CitationsTrack CitationsAdd to favorites Back To Publication ShareShare onFacebookTwitterLinked InRedditEmail Since our last issue, we have continued to receive high-quality articles from around the world. I again want to thank our dedicated peer review physicians, surgeons, and allied health professionals for their many hours of work. I also want to thank William F. Gourash, CRNP, PhD, Chih-Kun Huang, MD, and Melissa A. Kalarchian, PhD who will be rotating off our editorial board. Their many years of dedication to Bariatric Surgical Practice and Patient Care has moved the journal forward and we wish them the best in their future endeavors. I want to welcome two new members to the board at this time. Dr. Jennifer Schwartz is an assistant professor of surgery in the division of bariatric and minimally invasive surgery at the Yale School of Medicine. Dr. Schwartz earned her BS from Vanderbilt University and MD from SUNY Upstate Medical University.She then completed her general surgical residency and minimally invasive surgical fellowship at The Ohio State University Wexner Medical Center in Columbus, Ohio. Dr. Sara Martin del Campo who most recently received the 2022 Bariatric Surgery Top Doc designation. Sara E. Martin del Campo, MD, is a metabolic and bariatric surgeon with Swedish Weight Loss Services at First Hill and Issaquah. Dr. Martin del Campo is a board-certified general surgeon and fellowship-trained bariatric surgeon. She has studied clinical outcomes in surgery and has authored multiple peer-reviewed publications in the field, and she continues to participate on committees of many national societies, including the American Society for Metabolic and Bariatric Surgery and The Society of American Gastrointestinal and Endoscopic Surgeons.In this issue, we have a wide variety of articles from around the world. Our lead study is from Dr. Andrew Strong titled “Use of Acid Suppression Therapy Following Gastric Bypass and Sleeve Gastrectomy a Long-Term Follow up.” Bariatric Surgical Practice and Patient Care continues to hold a strong international presence as we have publications from six different countries represented in this issue.In closing, I hope you consider publishing your next study in Bariatric Surgical Practice and Patient Care. The journal is always open to innovative ways of improving the reader's experience. Please feel free to contact me if you have any suggestions that could improve our journal.Sincerely,FiguresReferencesRelatedDetails Volume 18Issue 2Jun 2023 InformationCopyright 2023, Mary Ann Liebert, Inc., publishersTo cite this article:Dean J. Mikami.Letter from the Editor.Bariatric Surgical Practice and Patient Care.Jun 2023.65-65.http://doi.org/10.1089/bari.2023.29034.djmPublished in Volume: 18 Issue 2: June 15, 2023PDF download

AB1855 SUSAC SYNDROME: CASE SERIES FROM ADULT &amp; PEDIATRIC TERTIARY ACADEMIC MEDICAL CENTERS

BackgroundSusac Syndrome (SS) is a rare autoimmune endotheliopathy that affects the brain, retina, and inner ear, characterized by a clinical triad of encephalopathy, branch retinal artery occlusion (BRAO), and sensorineural hearing loss (SNHL)[1]. Brain MRI, fluorescein angiogram (FA), and audiometry help to establish a diagnosis[2]. The clinical presentation of SS is often variable leading to a delay in the diagnosis.ObjectivesThis study aims to compare clinical features and therapeutic strategies in adult and pediatric populations with Susac Syndrome.MethodsThis was a retrospective chart review of cases with a diagnosis of SS from December 2010 to December 2020 at The Ohio State University Wexner Medical Center (OSUWMC) and Nationwide Children’s Hospital in Columbus, Ohio, USA (tertiary care centers). We analyzed the following: age, gender, ethnicity, symptoms at the time of presentation, diagnostic studies, autoimmune serologies, brain MRI, FA, audiometry, treatment approaches, and outcomes.ResultsAll the patients (seven adult- patients and two pediatric-onset patients) identified as females, and the majority (78%) were Caucasian. The age at presentation ranged from 10 to 45 years old with a mean age of 38 years. The time to diagnosis ranged from 3 to 17 months with a mean of 7.8 months. The most common symptoms at onset included dizziness, hearing loss, and visual change. ESR was elevated in 50% with a range of 23 to 52 mm/hr (normal&lt;30 mm/hr). CRP was elevated in 22% of patients with a range of 11 to 22 mg/dl (normal &lt;10 mg/dL). Low to medium titer ANA was positive in 30%. FA detected unilateral or bilateral BRAO in seven patients (78%). Sensorineural hearing loss was confirmed on audiogram testing in 7 of 9 patients, and 44% of patients had bilateral hearing loss. 88% of our patient population had evidence of corpus callosal involvement (“snowball lesions”) in the brain MRI. CSF study was done in 5 patients - 4/5 had elevated CSF protein at 77 mg/dL (range 15-45 mg/dL) and the mean cell count was &lt;3 (normal), without any oligoclonal bands. One patient had a brain biopsy.The most common initial treatment was high-dose steroids followed by a taper. Oral immunosuppressive therapy with mycophenolate mofetil (MMF) was initiated in 78% and was maintained in 56% of patients, who remained stable. Intravenous immunoglobulin (IVIG) was initially used in 56% of patients. Two patients transitioned from MMF to azathioprine due to pregnancy. Due to the severity of the disease, one patient transitioned from MMF to tacrolimus and Rituximab. 20% had a disease flare after the initial therapy requiring additional immunosuppression.ConclusionOur series highlights the rarity of SS. A neurologic exam, brain MRI, fluorescein angiogram, and audiogram should be performed in every case. A brain biopsy is not necessary for the diagnosis, unless for exclusion. BRAO was detected in 75% of our patients, highlighting the importance of an ophthalmology evaluation with FA, even in the absence of visual symptoms. In our series, only 20% presented with the full clinical triad of visual, auditory, and central nervous system symptoms, indicating that presentation of SS is often incomplete and diagnosis relies on a high index of suspicion[3]. Treatment depends on the severity of the presentation and involves the use of high-dose corticosteroids along with immunosuppression including mycophenolate, IVIG, tacrolimus, rituximab, and cyclophosphamide[4].

PO-02-195 ADJUNCTIVE VEIN OF MARSHALL ETHANOL ABLATION FOR ATRIAL FIBRILLATION: SINGLE CENTER EXPERIENCE AND PROCEDURAL LEARNING CURVE

Retrograde ethanol infusion into the vein of Marshall (EI-VOM) has been demonstrated to be an effective adjunct to pulmonary vein isolation (PVI) for ablation of atrial fibrillation (AF). This study sought to assess the temporal change in procedural volume and associated success rate of VOM ethanol ablation. All patients undergoing PVI with EI-VOM at The Ohio State University Wexner Medical Center from January 2021 to November 2022 were included. Procedural success was defined as successful retrograde infusion of ethanol into the vein of Marshall followed the development of a characteristic distribution of low voltage scar in a semicircular pattern around the left inferior pulmonary vein on high-density electroanatomical mapping. The scar was adjudicated by two blinded high-volume operators. The primary endpoint was procedural success over 6-month intervals. Statistical significance was assessed via Fisher's exact test. 201 patients underwent attempted EI-VOM. Patient characteristics were notable for age 65.2 ± 9.0 years, 56 (28%) females, body mass index 33.1 ± 7.3 kg/m2, left ventricular ejection fraction 52.3 ± 11.3%, and CHA2DS2-VASc 2.9 ± 1.5. 113 (56%) patients had non-paroxysmal AF. 173 (86%) patients had failed antiarrhythmic drugs, 113 (56%) patients had a prior cardioversion, and 105 (52%) patients had a prior catheter ablation for AF. Over 23 months, procedural volume increased from an average of 2 cases/month to 12 cases/month, and the procedural success rate increased from 33% to 68% (p=0.020). Figure 1 demonstrates the case volume and procedural learning curve over time. Notable complications included 1 (0.5%) case of cardiac tamponade requiring pericardiocentesis. VOM ethanol ablation is associated with a significant learning curve, and procedural success rate significantly improves with increased case volume.

PO-03-139 HIGH-RESOLUTION CARDIAC MAGNETIC RESONANCE IMAGING FOR LEFT ATRIAL APPENDAGE SIZING AND THROMBUS EXCLUSION PRIOR TO DEVICE CLOSURE

Transesophageal echocardiography and cardiac computed tomography angiography are currently utilized for left atrial appendage closure (LAAC) planning. The advent of high-resolution cardiac magnetic resonance imaging (HR-CMR) now potentially allows for adequate spatial resolution for LAAC planning. This study sought to assess preoperative HR-CMR with software-based sizing vs intraoperative TEE for LAA sizing and thrombus exclusion prior to LAAC. This retrospective study conducted at The Ohio State University Wexner Medical Center included all patients who underwent preoperative HR-CMR and intraoperative TEE for LAAC with Watchman FLX (Boston Scientific, Marlborough, MA) from May to September 2022. For HR-CMR, magnetic resonance angiography (MRA) and late gadolinium enhancement (LGE) sequences were obtained for LAA sizing and thrombus exclusion respectively. A proprietary sizing software (TruPlan, Boston Scientific) was utilized to analyze the MRA sequence to characterize LAA anatomy, predict closure device size, and estimate device compression ratio. HR-CMR was compared to TEE for assessing accuracy of LAA thrombus exclusion, maximum ostial diameter, depth, lobe count, morphology, and accuracy of predicted device size. 16 patients were included, with baseline characteristics notable for 8 (50%) females, age 73 ± 6 years, 30 ± 7 kg/m2 body mass index, 54 ± 8% left ventricular ejection fraction, and 4 ± 2 CHA2DS2-VASc. 15 (94%) cases were successfully completed. There was no significant difference in LAA thrombus exclusion (CMR 14 (88%) vs TEE 16 (100%) cases, p=0.48), maximum ostial diameter (CMR 20.9 ± 4.2 vs TEE 20.6 ± 4.2 mm, p=0.99), depth (CMR 31.1 ± 7.8 vs TEE 26.8 ± 5.6 mm, p=0.09), lobe count (CMR 1.8 ± 0.8 vs TEE 1.4 ± 0.6 lobes, p=0.25), and morphology features (p=0.44). LAA assessments are summarized in Table I. The mean devices deployed per case was 1.1 ± 0.3. In 2 (13%) cases a device downsize was required. 1 case was aborted due to inability to access a very small LAA ostium. On 45-day TEE or CCTA, no peri-device leak ≥5 mm or device-related thrombus were noted. A comparison of standard vs high-resolution contrast-enhanced (CE)-MRA of the LAA is demonstrated in Figure 1. HR-CMR is a viable modality for preoperative LAA sizing and thrombus exclusion with promising results. HR-CMR may provide utility in cases where TEE or CCTA are contraindicated or unavailable.Tabled 1Table IMeasureHR-CMR (N=16)TEE (N=16)P-valueLAA thrombus accurately excluded14 (88%)16 (100%)0.484Minimum LAA ostial diameter (mm)18.0 ± 4.216.6 ± 3.40.335Target LAA ostial diameter (mm)*20.9 ± 4.220.6 ± 4.20.987LAA depth (mm)31.1 ± 7.826.8 ± 5.60.093Number of lobes1.8 ± 0.81.4 ± 0.60.250Morphology0.437Cactus4 (25%)3 (19%)Cauliflower0 (0%)2 (13%)Chicken wing5 (31%)2 (13%)Windsock7 (44%)8 (50%)Other0 (0%)1 (6%)LAA closure device size accurately predicted12 (75%)12 (75%)1.000Values presented as mean ± 1 standard deviation for continuous variables and n (%) for categorical variables. Abbreviations: HR-CMR = high resolution cardiac magnetic resonance imaging, LAA = left atrial appendage, TEE = transesophageal echocardiography. *Based on maximum diameter measured on TEE vs area-derived diameter on HR-CMR. Open table in a new tab

PO-01-189 IMPACT OF CORONARY SINUS BALLOON UTILIZATION ON IDENTIFICATION OF THE VEIN OF MARSHALL FOR ADJUNCTIVE ETHANOL ABLATION FOR ATRIAL FIBRILLATION

Retrograde ethanol infusion into the vein of Marshall (EI-VOM) as an adjunct to pulmonary vein isolation (PVI) has been reported to improve success of atrial fibrillation (AF) ablation. However, identification and cannulation of the VOM remains technically challenging. It has been proposed that balloon occlusion of the coronary sinus (CS) allows for improved contrast opacification and facilitates identification of the VOM as well as differentiation of other branching veins. This study sought to assess the impact of CS balloon use on the success rate of VOM identification and time to VOM identification during adjunctive VOM ethanol ablation for AF. All patients undergoing PVI with EI-VOM at The Ohio State University Wexner Medical Center from January 2021 to November 2022 with known use or non-use of CS balloon were included. The primary endpoint was success rate of VOM identification and time to identification of VOM. The secondary endpoints were fluoroscopy time, procedure time, successful VOM cannulation, successful scar formation as defined by development of a characteristic low voltage area around the left inferior pulmonary vein on high-density electroanatomical mapping after ethanol infusion, and procedural complications. 106 patients underwent VOM ethanol ablation, 36 (34%) with and 68 (66%) without CS balloon use respectively. There was a significantly increased success rate in identification of VOM with CS balloon use (balloon 32 (89%) vs no balloon 50 (71%) patients, p=0.042). There was no significant difference in time to VOM identification. Notably, overall procedure time was significantly longer with CS balloon use (balloon 210.4 ± 51.7 vs no balloon 181.4 ± 37.1 minutes, p=0.004). There was no significant difference with balloon use in terms of fluoroscopy time, successful VOM cannulation, or successful scar formation (Table I). Notably, there were 3 (4%) cases of CS or VOM dissection in patients without balloon use as compared to 0 (0%) cases with balloon use, but this difference did not meet statistical significance. Figure 1 demonstrates the use of CS balloon during EI-VOM to facilitate identification of the VOM as well as atrial branches. CS balloon use is associated with significantly improved success in identification of the VOM during adjunctive ethanol ablation for AF. However, this is balanced by an associated increased procedure time.Tabled 1Table I: Procedural characteristicsProcedural characteristicsCoronary Sinus Balloon Used (N=36)Coronary Sinus Balloon Not Used (N=70)Total (N=106)P valueTimingTime to VOM identification, mins43.2 ± 15.546.1 ± 14.445.1 ± 14.80.419Fluoroscopy time, mins33.4 ± 10.031.4 ± 11.532.1 ± 11.00.374Procedure time, mins210.4 ± 51.7181.4 ± 37.1191.3 ± 44.60.004Key Procedural StepsCS cannulated36 (100%)68 (97%)104 (98%)0.547VOM identified32 (89%)50 (71%)82 (77%)0.042VOM cannulated29 (81%)46 (66%)75 (71%)0.112Able to advance balloon to VOM29 (81%)46 (66%)75 (71%)0.112Ethanol infused into VOM29 (81%)46 (66%)75 (71%)0.112OutcomeSuccessful formation of characteristic scar / low voltage area on high-density EAM15 (42%)35 (50%)50 (47%)0.853ComplicationsCS or VOM dissection0 (0%)3 (4%)3 (3%)0.549Values presented as mean ± 1 standard deviation for continuous variables and n (%) for categorical variables. Abbreviations: CS = coronary sinus, EAM = electroanatomical map, VOM = Vein of Marshall. Open table in a new tab

PO-03-140 CARDIAC MAGNETIC RESONANCE IMAGING VERSUS CARDIAC COMPUTED TOMOGRAPHY ANGIOGRAPHY FOR LEFT ATRIAL APPENDAGE SIZING AND THROMBUS ASSESSMENT PRIOR TO DEVICE CLOSURE

Preoperative imaging for left atrial appendage closure (LAAC) is essential for LAA sizing and thrombus assessment. Transesophageal echocardiography (TEE) and cardiac computed tomography angiography (CCTA) have been utilized to date for this purpose. During the recent global iodine contrast shortage, cardiac magnetic resonance imaging (CMR) was utilized as an alternative imaging modality. The purpose of this study was to assess CMR vs CCTA for preoperative LAA sizing and thrombus assessment prior to LAAC. This retrospective study conducted at The Ohio State University Wexner Medical Center included all patients who underwent preoperative CMR or CCTA for LAAC with Watchman FLX or Amplatzer Amulet between May 2022 and October 2022. Primary measures were accuracy of predicted device size, accuracy of thrombus detection/exclusion, and mean difference in maximum LAA ostial diameter and depth as compared to intraoperative TEE. An area-derived diameter approach was utilized with CMR and CCTA to obtain the maximum diameter in order to prevent oversizing highly elliptical ostial shapes. The radius (r) was calculated based on device design. For the octadecagonal Watchman FLX, area = r2 x 3.0782. For the circular Amulet, area = r2 x 3.1416. 75 patients underwent LAAC, and 25 (33%) vs 50 (67%) underwent preoperative CMR vs CCTA respectively. Demographics were notable for age 75 ± 7 years, 32 (43%) females, 31 ± 7 kg/m2 body mass index, 53 ± 9% left ventricular ejection fraction, and 4 ± 1 CHA2DS2-VASc. 64 (88%) and 9 (12%) patients underwent Watchman FLX and Amplatzer Amulet implantation respectively. There was no significant difference with CMR vs CCTA in accuracy of predicted device size (CMR: 16 (64%) vs CCTA: 26 (70%) patients, p=0.604) and accuracy of thrombus assessment (CMR: 22 (88%) vs CCTA: 46 (92%) patients, p=0.680). Among the 57 (76%) cases completed with intraoperative TEE guidance where LAA measurements were obtained, there was no significant difference with CMR vs CCTA in the mean difference in maximum LAA ostial diameter (CMR: 2.9 ± 2.0 vs CCTA: 2.6 ± 2.5 mm, p=0.699) and mean difference in maximum LAA depth (CMR: 9.5 ± 8.5 vs CCTA: 10.8 ± 7.5 mm, p=0.620) as compared to intraoperative TEE. Figure 1 demonstrates LAAC device sizing using multiplanar reconstruction with oblique views of the LAA on CCTA (A-C) and CMR (D-F). CMR and CCTA were comparable for LAA sizing and thrombus assessment prior to LAAC.

The Utility of Ultrasound in Evaluating Joint Pain in Systemic Lupus Erythematosus: Looking beyond Fibromyalgia.

Systemic lupus erythematosus (SLE) is a complex autoimmune condition with varied clinical presentations, and musculoskeletal pain is one of the most commonly associated symptoms. However, fibromyalgia (FM) is a prevalent co-existing condition in SLE patients that can also cause widespread pain, and in patients with both conditions, it is often difficult to distinguish the underlying cause of musculoskeletal pain and provide optimal therapy. A retrospective cohort study was conducted including all adult SLE patients who received musculoskeletal ultrasound (US) examinations for joint pain at the Ohio State University Wexner Medical Center between 1 July 2012, and 30 June 2022. Binary and multiple logistic regression analyses were performed to determine predictors of US-detected inflammatory arthritis as well as improved musculoskeletal pain. A total of 31 of 72 SLE patients (43.1%) had a co-existing diagnosis of FM. In binary logistic regression, a co-existing diagnosis of FM was not significantly associated with US-detected inflammatory arthritis. In multiple logistic regression analysis, clinically detected synovitis was significantly associated with US-detected inflammatory arthritis (aOR, 142.35, p < 0.01), and there was also a weak association with erythrocyte sedimentation rate (ESR) (aOR 1.04, p = 0.05). In separate multiple logistic regression analysis, US-guided intra-articular steroid injection was the only predictor of improved joint pain at follow-up visit (aOR 18.43, p < 0.001). Musculoskeletal US can be an effective modality to detect inflammatory arthritis as well as to guide targeted intra-articular steroid injection to alleviate joint pain in SLE patients with or without FM.

Careers in Telestroke: Toward a Virtual and Tangible Purpose.

HomeStrokeAhead of PrintCareers in Telestroke: Toward a Virtual and Tangible Purpose No AccessResearch ArticleRequest AccessAboutView PDFSections ToolsAdd to favoritesDownload citationsTrack citationsPermissions ShareShare onFacebookTwitterLinked InMendeleyReddit Jump toNo AccessResearch ArticleRequest AccessCareers in Telestroke: Toward a Virtual and Tangible Purpose Amanda L. Jagolino-Cole, Alicia M. Zha, Navdeep Sangha, Shlee S. Song and Jennifer J. Majersik Amanda L. Jagolino-ColeAmanda L. Jagolino-Cole Correspondence to: Amanda L. Jagolino-Cole, MD, McGovern Medical School at The University of Texas Health Science Center at Houston, 6431 Fannin St, MSB 7.125, Houston, TX, 77030. Email E-mail Address: [email protected] https://orcid.org/0000-0001-8504-6224 Department of Neurology, McGovern Medical School at The University of Texas Health Science Center at Houston (A.L.J.-C.). *A.L. Jagolino-Cole and A.M. Zha contributed equally. Search for more papers by this author , Alicia M. ZhaAlicia M. Zha https://orcid.org/0000-0002-3647-4158 Department of Neurology, The Ohio State University Wexner Medical Center, Columbus (A.M.Z.). *A.L. Jagolino-Cole and A.M. Zha contributed equally. Search for more papers by this author , Navdeep SanghaNavdeep Sangha https://orcid.org/0000-0001-9650-0488 Department of Neurology, Kaiser Permanente, Los Angeles, CA (N.S.). Search for more papers by this author , Shlee S. SongShlee S. Song https://orcid.org/0000-0002-7838-0205 Department of Neurology, Cedar Sinai Medical Center, Los Angeles CA (S.S.S.). Search for more papers by this author and Jennifer J. MajersikJennifer J. Majersik https://orcid.org/0000-0003-3191-262X Department of Neurology, University of Utah, Salt Lake City (J.J.M.). Search for more papers by this author Originally published3 Apr 2023https://doi.org/10.1161/STROKEAHA.122.039149Stroke. 2023;0Footnotes*A.L. Jagolino-Cole and A.M. Zha contributed equally.The opinions expressed in this article are not necessarily those of the editors or of the American Heart Association.For Sources of Funding and Disclosures, see page XXX.Correspondence to: Amanda L. Jagolino-Cole, MD, McGovern Medical School at The University of Texas Health Science Center at Houston, 6431 Fannin St, MSB 7.125, Houston, TX, 77030. Email amanda.l.[email protected]tmc.edu Previous Back to top Next FiguresReferencesRelatedDetails Advertisement Article InformationMetrics © 2023 American Heart Association, Inc.https://doi.org/10.1161/STROKEAHA.122.039149PMID: 37009743 Originally publishedApril 3, 2023 Keywordsleadershiphospitalquality improvementtelemedicineneurologistPDF download Advertisement SubjectsCerebrovascular Disease/Stroke