Orlando Health Research Articles

Impact of early palliative care referral in patients with locally advanced and metastatic GI/lung cancer.

201 Background: Early palliative care improves quality of life and survival in patients with metastatic NSCLC. As a result, ASCO recommends early palliative care integration in patients with metastatic cancer. However, generalizing the benefits outside of a clinical trial may be difficult due to selection bias of patients that opt into palliative care due to advanced symptom burden and real-world resource constraints. Therefore, the benefits of this in real-world practice may not be realized. We aimed to evaluate early vs late palliative care referral impact on unplanned hospital visits and survival among GI and lung cancer patients at a large health system cancer center. Methods: The study design was a retrospective, single health system, review of patients treated at Orlando Health from 2021-2022.156 patients of all stage GI and Lung cancers were included. For these patients, early referral was defined as receiving a palliative referral within 8 weeks of cancer diagnosis. Any referral later than this was considered late and it was possible for patients to opt out of referral. Our main outcomes were unplanned hospital visits and survival. To compare the rates of these between palliative care referral groups, a multivariable negative binomial regression model was fitted. To assess any differences in survival, a multivariable cox hazard regression model was fitted. These were adjusted for age, sex, diagnosis, stage, ECOG, race, and insurance. Results: Patients with any palliative care referral had increased unplanned hospital visits and shorter survival than patients who did not have referrals. Specifically, patients with no palliative care referrals had a 62% lower relative rate of unplanned hospital visits compared to patients with early referral (RR = 0.38 [0.22-0.66], p<0.001). And patients with any time referral had approximately 8 months lower restricted mean survival times (RMST) when followed for 2 years for stage 1-3 cancers than patients receiving no palliative care (14 vs 22 month RMST; stage x palliative care interaction, p <0.05). In contrast, stage 4 patients had similar survival of ~14-month RMST when followed for 2 years regardless of referral. Conclusions: In real world practice palliative care referral was associated with increased unplanned hospital visits. Additionally, in this retrospective review, palliative care referral was not found to confer a survival advantage in gastrointestinal and Lung cancer patients. We postulate that this is related to selection bias in the opt in approach to palliative care referral biasing towards a sicker population with higher symptom burden and comorbidities. Our future prospective study will build upon this work through expansion of palliative care services and to better evaluate patient co-morbidities. Our goal is to increase utilization of palliative care for patients with GI and lung malignancies as part of a multidisciplinary integrative approach.

Comparing Air Medical Personnel Intubation Success Rates Using Direct, Channeled Video-Assisted, and Unchanneled Video-Assisted Laryngoscopy

ObjectiveThe aim of this study was to determine the first-pass intubation success rates of air medical providers using direct laryngoscopy, channeled blade video laryngoscopy, and nonchanneled blade video laryngoscopy. MethodsThis was a retrospective cohort study of the Orlando Health Air Care Team (ACT) airway quality registry over a 5-year period. The ACT had 3 approved approaches for endotracheal intubation: direct laryngoscopy, the King Vision (Ambu, Ballerup Denmark) channeled blade laryngoscope, or the C-MAC (Karl-Storz, Tuttlingen Germany) (nonchanneled) laryngoscope. The main outcome was the first-pass success rate. The secondary outcomes included the number of attempts, the overall success rate, and complications. ResultsOf 517 intubations, 312 were performed with direct laryngoscopy, 126 with a channeled video laryngoscope, and 79 with a nonchanneled laryngoscope. The mean number of attempts was 1.26, and the overall success rate was 93%. Use of the nonchanneled video laryngoscope had a higher first-pass success rate than direct or channeled laryngoscopy (92% vs. 76% and 78%, P = .006), required fewer attempts (1.09 [95% confidence interval (CI), 1.01-1.17] vs. 1.29 [95% CI, 1.23-1.35] and 1.28 [95% CI, 1.18-1.38], P < .001), and a higher overall success rate for intubation (99% vs. 90% and 95%, P = .018). ConclusionThe use of a nonchanneled video laryngoscope provided higher first-pass success rates, fewer total attempts, and higher overall success rates.

Independent validation of 30-day emergency department visit after initial chemotherapy A-PROACCT model.

e23243 Background: This study assessed model performance and, more importantly, the clinical usefulness of the PROACCT model created by Grant et al. (JAMA, 2019), refined as A-PROACCT by Stein et al. (JOP, 2023) with data from Orlando Health. The predictive performance of models anticipating acute care events within thirty days (ACE30) of initial chemotherapy administration (ICA) were evaluated. Methods: Stein et al. models classified high-risk patients as those whose model output risk score was at or above the 90th percentile. They studied 5153 ICAs between July and November of 2021, of which 559 (10.8%) had an ACE30. Their first model used drug category, age group, ED visits and hospitalizations in the prior year, and cancer type, and had sensitivity (Sen), specificity, (Spec), C-Statistic (C-Stat), and positive predictive value (PPV) of 0.28, 0.93, 0.79 and 0.18 respectively. Their second model added insurance category, number of anti-cancer agents, race, and BMI category and reported Sen, Spec, C-Stat, and PPV of 0.30, 0.94, 0.80 and 0.23 respectively. Of the high-risk patients, 33.6% and 34.1% had an ACE30 respectively. Of the low-risk patients, 8.3% and 8.1% had an ACE30 respectively. Our data were propagated through the two models. Results: Between February of 2012 and April 2021, Orlando Health had 15,483 distinct patient visits with ICAs. Overall, 2046 (13.2%) had an ACE30. Model one had Sen, Spec, C-Stat, and PPV of 0.19, 0.92, 0.65 and 0.27 respectively. Model two had Sen, Spec, C-Stat, and PPV of 0.19, 0.91, 0.65 and 0.25 respectively. Both models had an accuracy of 0.82. This demonstrated our data fit the Stein model. Of the 1460 ICAs identified as high-risk by model one, 387 (26.5%) had an ACE30, and of the 14,023 ICAs identified as low-risk, 1659 (11.8%) had an ACE30. Of the 1549 ICAs identified as high-risk by model two, 393 (25.4%) had an ACE30, and of the 13,934 ICAs identified as low-risk, 1653 (11.9%) had an ACE30. The difference of ACE30 rates between high risk and low risk groups were statistically significant (p &lt; 0.0001) in both models. This demonstrated both models were clinically useful in identifying chemotherapy patients at high risk of acute care events. Conclusions: These models allowed for clinically relevant stratification of patients into meaningful high-risk and low-risk groups (26.5% vs 11.8% with our data) for risk of acute care events within 30 days of initial chemotherapy administration. Nevertheless, only 26.5% of these high-risk patients actually had an acute care event within thirty days of initial chemotherapy administration. Further research is needed to improve the precision of identifying high-risk patients, by potentially adding more clinical variables, using alternative sampling methods, and employing nonlinear and more complex machine learning methodologies.

Refining the 30-day emergency department visit after initial chemotherapy administration A-PROACCT model.

e23253 Background: This study attempted to address limitations in the A-PROACCT model developed by Stein et al. (JOP, 2023) to predict the rate of acute care events within 30 days (ACE30) of initial chemotherapy administration (ICA). The four most important predictors were drug category (immunotherapy), cancer type (gastrointestinal), age group ( &lt; 40), and BMI category (underweight). Only linear relationships were considered. For patients for whom an ACE30 was predicted by their first and second models, only 0.18 and 0.23 actually had an ACE30, a low positive predictive value (PPV). We attempted to improve the PPV with advanced modeling techniques. Methods: Using Orlando Health data between February of 2012 and April 2021, random sampling was used to split the dataset into training (10,838) and validation (4645). For the training data, resampling was employed to obtain a balanced quota, equal observations followed by an ACE30 and not followed by an ACE30. We included only variables used in Stein (drug category, age group, ED visits and hospitalizations in the prior year, cancer type, insurance category, number of anti-cancer agents, race, and BMI category). Logistic regression with L1-penalty, XGBoost (a non-linear nonparametric tree-based algorithm to account for nonlinear relationships), and artificial neural networks were used to develop and evaluate predictive models. Different sampling methods (bootstrap and SMOTE) as well as cuff-off thresholds for high-risk groups were tested. Results: Based on evaluation with validation data set, the best performing approach was an XGBoost model with SMOTE resampling in the training data. The four most important predictors were ED visits in the prior year, payor category (self-insured), cancer type (genitourinary) and hospitalization in past year. This model reported a PPV of 0.27. Many other combinations of methodologies described above were performed, and the PPV varied between 0.19 to 0.27. Of the 282 ICAs identified as high-risk by the best model, 76 (27.0%) had an ACE30. Of the 4346 ICAs identified as low-risk, 533 (12.3%) had an ACE30. The differences between high risk and low risk ACE30 rates were statistically significant (p &lt; 0.0001). In comparison, using Stein et al. models with our data reported a PPV of 0.27 and 0.25 which are basically at the same level of our best trained model. Conclusions: Using the variables included in A-PROACCT and a variety of machine learning models, advanced sampling methodologies and threshold cut-off limits, the best results were similar to those obtained using basic logistic regression. This suggests improvement in predicting acute care events following chemotherapy administration need to incorporate more extensive multimodal data, such as vital signs, performance status, patient reported outcomes, socioeconomic factors, laboratory and radiology results, remote patient monitoring and wearable device data.

Educational Intervention for Pediatricians on Research and Resources for Moms with Postpartum Depression

Postpartum depression (PPD) is a serious condition that affects 13-19% of mothers who previously had postpartum blues. The American Academy of Pediatrics recommends that mothers receive screening for PPD at their infant’s well-child visits during months 1, 2, 4, and 6. The purpose of this intervention was to host an informational session for pediatric residents regarding current research and local/national resources for women with postpartum depression. We hypothesize that by doing this session, there will be a notable increase in the knowledge learned. The session was held at the Orlando Health Arnold Palmer Hospital for Children. Residents were given a pre-survey, a presentation, and then a post-survey immediately after. All surveys were online and given via Qualtrics. The presentation consisted of background information on postpartum depression, local specialists on maternal mental health, research supporting telemedicine, exercise, social interactions, and expressive writing as evidence-based methods to improve symptoms, and local/national resources for each respective field. Descriptive statistical analysis was used to analyze the differences in our pre-survey data versus. post-survey data. In comparing the pre to post-survey responses, an overall average of an 87% increase in knowledge occurred. Overall it was noted that all residents gained a better understanding of resources nationally and in the local community. Although limited by our sample size, N&lt;14, our study concluded that the residents who attended our session were able to screen and diagnose postpartum depression and were able to provide local resources to mothers. We were able to accept our hypothesis that creating an educational intervention where current research and resources regarding support for women with PPD is synthesized and presented to pediatricians, their knowledge on available tools accessible to mothers will increase.

A Multidisciplinary Approach to Outpatient Parenteral Antimicrobial Therapy Care

From the Division of Infectious Disease, Orlando Health Infectious Disease, Orlando, FL. Correspondence to: Aixa Curbelo-Irizarry, MD, FIDSA, Division of Infectious Disease, Orlando Health Infectious Disease, 1012 Lucerne Terrace, Orlando, FL 32806. E-mail: [email protected]. The author has no funding or conflicts of interest to disclose.

Is Sentinel Lymph Node Biopsy Necessary in Patients who Undergo Prophylactic Mastectomy?

BackgroundOver the last decade, rates of risk-reducing prophylactic mastectomy (PM) have risen dramatically. A topic of debate regarding the procedure is whether to use sentinel lymph node biopsy (SLNB) at the time of PM and what factors might predict for such need. In order to assess the rate of identifying presence of occult invasive breast cancer in the PM specimen, we performed a retrospective review of the pathology findings from a single-surgeon case-series of PM. MethodsPatients undergoing PM between January 2013 and June 2019 at Orlando Health Cancer Institute were identified for a retrospective chart review. Demographic, clinical, and histopathological data from the surgical procedure were collected and analyzed for the incidence of occult invasive breast cancer in the PM specimen. ResultsA total of 146 consecutive patients with PM were identified; 120 (82.2%) underwent contralateral PM (CPM) and 26 (17.8%) underwent bilateral PM (BPM). Final pathology of the 172 PM specimens identified 4 (3.3%) with lobular carcinoma in situ, 3 (2.5%) with atypical ductal hyperplasia, and 2 (1.7%) with atypical lobular hyperplasia and 2 (1.7%) with intraductal papilloma. No invasive malignancy was detected in any of the 172 PM specimens.Conclusions: The absence of occult invasive carcinoma in 172 consecutive PM specimens suggests a limited clinical utility in routinely performing SLNB in this setting. This study also suggests that use of preoperative breast MRI imaging could offer a potential non-invasive tool to detect occult malignancy and select patients who can safely undergo omission of SLNB at the time of PM.

Mandatory Caprini Score Documentation and Incidence of Hospital VTE

ASH Abstract Submission: Background: Hospital acquired VTE continues to be a source of morbidity and mortality for patients. The Caprini risk score is a risk assessment tool for the occurrence of venous thromboembolism. Though initially developed for use among surgical patients, it is now being applied to many hospitalized patients. It involves 20 variables and it is derived from a prospective study of general surgery patients published in 1991. After adding Caprini score documentation to internal medicine admission order sets and general surgery pre-procedural order sets, the 90 day incidence of hospital acquired VTE went from 67 to 0. Prior to the change, documentation of Caprini score was poor and ordered VTE prophylaxis did not align with the documented Caprini score, ultimately effecting compliance to prophylaxis and affecting patient safety. Methods: In order to decrease the rate of VTE throughout the Orlando Health hospital system, changes were made to the electronic medical record (EMR) to better improve selection of proper VTE prophylaxis. Because VTE prophylaxis was frequently not ordered appropriately, the ability to personalize order sets for VTE was removed 5/3/2022. We implemented a mandatory order set requiring documentation of Caprini score in two admission order sets. Subsequent VTE prophylaxis was ordered depending on the calculated score. The EMR changes were implemented 6/8/2022 as a pilot program within both internal medicine admission order sets and general surgery pre-procedure admission order sets. Incidence of hospital acquired VTE as well as re-admission rates were monitored over the subsequent period. Results: In the period immediately prior to implementation of this program, there were 67 hospital acquired DVT/PE events. After the pilot program went live 6/8/22, there were 0 preventable hospital acquired VTE for the subsequent period. VTE prophylaxis was ordered within 24hrs of admission 81% of the time. During the whole study phase there were 95 total readmissions due to DVT/PE, 35 from DVT, 29 from PE, and 25 from DVT/PE. Of these, only 3 occurred after implementation of pilot program. Conclusions: Addition of Caprini score documentation to internal medicine admission order set and pre-procedural general surgery order set prevented hospital acquired VTE across the hospital system over a 30 day period, and dramatically decreased readmission rate due to VTE/PE. These results have a direct effect on patient safety and quality of patient care.

Defining Primary Vs Secondary AML: Correlation between Pathology and NGS/FISH

Introduction: The treatment of acute myelogenous leukemia (AML) is often determined by factors that include an antecedent dysplasia. At presentation it is often unknown whether a patient has had dysplastic bone marrow features or not. We opted to look back at our leukemia patients to determine the frequency of antecedent dysplasia and to determine if next generation sequencing (NGS) or Florescent in situ hybridization (FISH) findings correlate with the pathologic review. Methods: We chart reviewed 43 charts from a period of 9/21/2021 to current from Orlando Health records. We focused on 29 charts that we could gather complete information from. We reviewed initial bone marrow biopsies and NGS/ FISH findings. We determined if a patient had a known history of myelodysplasia from previous records. If there was no known history of myelodysplastic syndrome (MDS) but dysplasia was seen on the bone marrow biopsy, we looked at NGS/FISH. While there can be overlap with AML, findings that suggest MDS are as follows: NGS: TET2, NRAS, U2AF1, RUNX1, TP53, SF3B1 FISH: 5q-, -5 (5p15, 5q31, 5q33), 7q-, -7 (Cen 7, 7q22, 7q31), Trisomy 8 (Cen 8), MLL (11q23), 20q- (20q12, 20qter) We then examined what treatments were used based on these findings. Results: Overall: 11/29 patients had dysplasia mentioned in their initial pathology report. 4/11 had a known preexistent dysplasia. Of the 7 who didn't have known dysplasia, 6/7 had an NGS or FISH suggesting MDS. Age: Of the patient who had dysplastic findings as well as NGS/FISH to support those findings, the patients had an average age of 57. The one patient without MDS/FISH findings has an age of 69. The average age of all patients with dysplastic findings on their bone marrow was 60. Of the patients who did not have any dysplastic findings on the bone marrow, the average age was 58. Treatment: Vyexos (liposomal daunorubicin and cytarabine), a therapy generally used for secondary leukemias was only used in two patients. Age and performance status was cited as a reason to use alternative therapy. Although one patient did receive 7+3 (idarubicin and cytarabine) instead of Vyxeos. One patient also had severe COVID pneumonia at diagnosis as the reason for not getting induction with Vyexos and instead getting venetoclax/azacitidine. Four patients were either treated with hypomethylating agent of either azacitidine or decitabine, again this was normally chosen due to performance status, age, or active COVID pneumonia as above. Conclusion: These results show that pathology findings of underlying dysplastic changes seem to correlate with NGS or FISH findings. Of the 7 patients with these bone marrow changes but no known MDS, 6 of them had NGS or FISH to support an underlying disease. Factors such as age did not help to predict antecedent MDS. Based on this information it may be appropriate to start with induction therapies such as Vyxeos when dysplastic changes are seen on the bone marrow while FISH and NGS are still pending, if their performance status and age allow to do so. Further larger retrospective studies to compare underlying dysplastic findings versus FISH/NGS findings should be done to further support this concept.

COVID-19 admissions among patients with cancer, characterization, and at-home monoclonal antibody treatment.

414 Background: Cancer patients are at risk for severe Covid-19 infection. We characterized Covid-related hospitalizations across a large health system in Central Florida. We then used this analysis to target at home treatment for Covid-19. Methods: Retrospective chart review was conducted for all Covid-related admissions in cancer patients 1/2021-7/2021 at Orlando Health. Cancer type, discharge, vaccination and treatment status were collected. Distribution of cancer type among patients admitted was compared to the population treated at the cancer institute using chi-square test. Casirivimab and imdevimab monoclonal antibody (intravenous or subcutaneous) was provided at home through partnership with a home health agency. All patients received follow-up for patient satisfaction and resolution of symptoms. Results: 104 patients with Covid-related admissions were identified. 83% were diagnosed with solid and 17% with hematologic malignancy. The most common cancers were breast, genitourinary, lung, head and neck and upper gastrointestinal cancers. Proportion of patients with hematologic malignancies (lymphoma, leukemia, myeloma) were significantly higher among Covid admissions compared to the population of patients treated at the cancer institute (19/104 versus 320/4127, p &lt; 0.01). 9% of patients died in hospital. 91% were discharged alive, 72% to home. 78% were unvaccinated (15% two, 7% one dose). 30% were on active treatment within 90 days, 52% received cytotoxic agents, 48% received targeted therapy or immunotherapy. Oncology clinics caring for hematologic malignancy patients were then targeted to offer Covid treatment at home.18 patients requested treatment from 8/17/21-10/25/21. 13 patients were treated at home, 1 went to the emergency room before receiving therapy and 4 were denied by insurance. Patients and providers were highly satisfied, with net promoter scores of 85 (n = 13) and 100 (n = 7) respectively. No infusion reactions occurred. Follow-up with all patients indicated resolution of symptoms, no patients were hospitalized for Covid after 7 days. Conclusions: Covid admissions among cancer patients at a large health system were consistent with published reports noting increased risk for patients with hematologic malignancies. Identification of this population translated to a targeted approach to offering monoclonal antibody treatment at home. In this small cohort, at home treatment was safe and associated with high patient and provider satisfaction.

A Retrospective Health Economic Analysis of a Stable Hypochlorous Acid Preserved Wound Cleanser Versus 0.9% Saline Solution as Instillation for Negative-Pressure Wound Therapy in Severe and Infected Wounds.

IntroductionNegative-pressure wound therapy (NPWT) with instillation and dwell time is an accepted adjunct therapy for infected wounds. A study was conducted to assess whether the use of hypochlorous acid preserved wound cleanser (HAPWOC) (Vashe, Urgo Medical North America, Fort Worth, TX, USA) as the irrigant would reduce the cost of care in comparison to 0.9% saline (NaCl).MethodA comparative, observational, retrospective analysis assessed 27 serious and infected wounds in 24 patients. The lesions were of different and complex etiologies, including necrotizing fasciitis and stage IV diabetic foot ulcers. NPWT was used as part of the overall multimodal treatment regimen. The only variance in the treatment protocol was the use of saline (N=8) or HAPWOC (N=19) as the irrigant.ResultsWhen compared to NaCl, wounds treated with HAPWOC trended toward fewer operating room (OR) visits versus NaCl (3.3 versus 4.1) and a shorter length of hospital stay (LOS) (24.3 days versus 37.9 days).The Orlando Health Transparency guide shows the cost of OR debridement as $2,525. Thus, debridement for HAPWOC-treated wounds ($8,332) costs $2,020 (24%) less than for NaCl-treated wounds ($10,352).Using the 2016 Kaiser Health data (average daily hospital cost, excludingall interventions: $2,052), the cost of HAPWOC and NaCl instill translates to $49,864 and $77,771, respectively, a difference of $27,906 (56%) more for NaCl treatment. The Agency for Healthcare Research and Quality (AHRQ) 2012 data indicate an average daily cost of hospital stay, including all interventions, of $10,400. Thus, HAPWOC treatment cost translates to $252,720 versus NaCl-related costs of $394,160; in these calculations, using NaCl costs $141.440 (+56%) more per patient than HAPWOC.ConclusionThe use of NPWT with HAPWOC versus NaCl as instillation in NPWT reduces the number of visits to the operating room and LOS. This has a significant impact on lowering the cost of care when HAPWOC is used.

Pediatric Popliteal Artery Pseudo-Aneurysm: A Case Report and Literature Review

<h3>Introduction/Objectives</h3> Osteochondroma is the most common benign, skeletal tumor occurring in 1% of the population and is most prevalent in males.¹ Rarely, they can be associated with vascular complications, in the lower extremity most commonly affecting the popliteal artery.² We describe a case of a young male who presented with right knee pain and a history significant forprevious removal of bilateral tibial osteochondromas that were symptomatic. He was found to have a large popliteal pseudo-aneurysm associated with a posterior right distal femur osteochondroma. <h3>Case Report</h3> A 16-year-old male with a past medical history of multiple hereditary exostoses was seenas an outpatient due to sudden right knee pain and tightness over his popliteal fossa that started occurring over the last several days. Three years prior he underwent removal of bilateral medial proximal tibial osteochondromas that were symptomatic. He was found to have a large popliteal pseudo-aneurysm on CT measuring 3.5 × 5.6 × 6.6cm with thrombus visualized with the aneurysm (Fig. 1Figure 1CT image demonstrating a large popliteal artery pseudo-aneurysm in association with an osteochondroma spike. Orlando Health, Department of General Surgery, Orlando, FloridaFigure 1). An arterial duplex was also obtained (Fig. 2Figure 2Proximal, mid, and distal representations of popliteal pseudo-aneurysm on arterialduplex. Orlando Health, Department of General Surgery, Orlando, FloridaFigure 2). There was no evidence of neurological compromise and distal pulses were palpable. In the operating room, the right thigh greater saphenous vein was harvested endoscopically with the patient in the supine position. Concerned about our ability to obtain proximal control from the prone position, our attention was turned to the above-knee popliteal fossa and proximal control of the popliteal artery was obtained. The patient was then placed in the prone position. We created a "Lazy S" incision and deepened the incision over the popliteal fossa. We dissected over the large pseudo-aneurysm, continuing our dissection distally until normal popliteal artery was encountered, obtaining distal control. Although the pseudo-aneurysmextended approximately 20cm, the diseased portion of the artery was only approximately 0.5cm (Fig. 3Figure 30.5cm segment of diseased portion of popliteal artery, anterior surface (left) andposterior surface (right). Video link below.Figure 3). We were able to separate the underlying pseudo-aneurysm from the normalized artery and again ensured proximal and distal control. We entered the sac and encountered a large amount of clot, this was evacuated (Fig. 4Figure 4Clot evacuated from pseudo-aneurysm sac.Figure 4). We then began to resect the pseudo-aneurysm wall distally, this allowed us to encounter the spike coming off of the osteochondroma which was essentially a sharp, pointed segment (Fig. 5Figure 5Osteochondroma spike.Figure 5). At this point the orthopedist took over resecting thissegment, we then resected the diseased portion of the artery and performed our repair of the popliteal artery with reversed greater saphenous vein in an end-end fashion (Fig. 6Figure 6Repair of popliteal artery with greater saphenous vein.Figure 6). The patient was discharged the following day with strongly palpable pulses and no in-hospital complications. Unfortunately, the patient was lost to follow up. <h3>Discussion</h3> Osteochondromas develop from skeletal elements that have undergone endochondral ossification and can occur at any time of the human skeletal growth phase. They are ‘protected' by a soft hyaline cartilaginous cap that is identical to the epiphyseal plate and undergoes ossification following cessation of growth.³ They are often solitary (90% of cases) although when multiple represent a hereditary autosomal dominant condition as in our patient's case. Thepopliteal artery is particularly susceptible to pseudo-aneurysmal changes as it is fixed between Hunter's canal superiorly and popliteus muscle inferiorly, preventing displacement from any underlying lesion. There have been multiple studies suggesting that following the cessation of growth, the cartilaginous cap undergoes ossification resulting in a sharp bone spur. As the vesselbecomes tethered, the resulting constant compression and pulsatile friction against the ‘non- protected' osteochondroma causes continuous injury to the vessel wall, resulting in pseudo- aneurysm formation.^4-6 Early surgical repair is mandatory, conservative management has been shown to increasethe risk of secondary complications including venous thrombosis, and distal emboli.^7-9 Posterior and medial surgical approaches have both been described, venous patch angioplasty, vein/prosthetic bypass and ligation. We adopted a posterior approach to the lesion, utilizing a greater saphenous vein bypass. <h3>Conclusion</h3> Popliteal pseudo-aneurysms are the most common vascular sequela of femur osteochondromas due to the superior and inferior fixation of the vessel. Post-operative imaging investigations should be considered due to multiple osteochondromas occurring in about 10% ofpatients as evidenced in our case.

Compliance with Expert Recommendations of Sickle Cell Pain Management—a Single Institution Review

Introduction:Sickle cell disease in a lifelong disorder associates with the occurrence of recurrent painful vasoocclusive crisis that often result in frequent emergency room trips and inpatient hospital stays. There are several goals in the management of sickle cell disease including early resolution of painful crisis and reduction of end stage events such as pulmonary hypertension and stroke. Unfortunately, the painful crisis leads to frequent ER visits and sometimes results in lengthy hospital stays. In 2014, The US Department of Health and Human Services came out with an expert report panel dictating recommendations on care for patient with sickle cell disease recommending pain medicine in the emergency room within one hour of triage and use of personal controlled analgesia (PCA) pumps. We opted to look at patient records within Orlando Health, a center with a large sickle cell patient population, to determine if we are following these recommendations.Methods: We reviewed emergency room and inpatient records of 158 patients. We documented if pain medications were started within two hours of arrival to the emergency room (we allowed additional time to account for registration and triage) and we reviewed inpatient records for PCA use. We also looked for trends in PCA use in terms of complexity of hospital stays and length of stay.Results:For sickle cell patients coming into the emergency room, 107/158 (68%) were given pain medication within 2 hours of registration.Of patients admitted to the hospital, only 10/158 (6%) were given a PCA pump. The patients given a PCA pump had an average length of stay of 16 days compared to the general population of 6.1 days. PCA use increased during lengthy hospitalizations rather than being started immediately.The patients who were given a PCA pump were assigned an ER acuity score of 3 compared to the general population of 2.1.Discussion:In caring for patients with sickle cell disease, we often aim to provide quick and effective management of pain crisis. In terms of emergency room management, triage to pain medication time is ideally within one hour. By looking at an extended window to account for registration time, we were able to provide pain medication on time 68% of the time. Per pharmacy staff, the pain medications are kept in the emergency room pharmacy system and should be immediately available upon request. Emergency room physicians identify overcrowding of the ER and the prospect of patient addiction as potential barriers to more immediate access. This thought process can lead to unnecessary suffering from patients.Inpatient PCA use was very infrequently started. Currently the hospitalist service is starting most of the inpatient pain medication. When asked about PCA use, the hospitalist physicians mostly stated that their experience hasn't shown a trend toward shorter length of stay. Additionally, patients frequently state that they prefer push medication to PCA use. Data does exist that the opposite is true, PCA use is associated with shorter length of stay. Education on this data and encouragement of PCA use with patients should be encouraged per expert recommendations. It does appear that PCA use is reserved for patients who are deemed “sicker” or have longer length of stay.We believe these trends are reflective of other institutions and broad education on best management of sickle cell pain crisis may be required. DisclosuresLandau:celgene: Speakers Bureau; sanofi: Speakers Bureau; alexion: Speakers Bureau; novartis: Speakers Bureau; BMS: Speakers Bureau.

Characteristics, Comorbidities, Complications, and Outcomes Among 802 Patients With Severe Acute Respiratory Syndrome Coronavirus 2 in a Community Hospital in Florida.

Coronavirus disease 2019 continues to increase throughout the United States. Despite the rapid progression of the disease, there is limited information of the factors associated with mortality in Florida. This study aims to review the demographics, characteristics, comorbidities, complications, and outcomes of hospitalized patients, and their association with mortality. Cohort study. A community-based tertiary-care hospital of Orlando Health, Orlando Regional Medical Center. Data of hospitalized patients who tested positive for severe acute respiratory syndrome coronavirus 2 between March 1, 2020, and August 31, 2020, at the Orlando Regional Medical Center. None. Main data assessed included patient demographics, clinical characteristics, comorbidities, complications, outcomes, and inhospital mortality. The median age for hospitalized patients was 61 years; among them, 56% were males. Most were of African American (n = 288, 35.9%), Hispanic (n = 237, 29.6%), and Caucasian (n = 217, 27.1%) descent. More patients presented with symptoms developing at home (n = 589, 75.9%) than from skilled nursing and long-term acute care facilities. The most common comorbidities were diabetes mellitus (42.8%), obesity (39.2%), lung disease (23.3%), coronary artery disease (20.2%), and congestive heart failure (18.3%). Complications with higher odds of mortality were mechanical ventilation (odds ratio, 148.00, p < 0.001), coinfections (odds ratio, 56.42, p < 0.001), acute kidney injury (odds ratio, 84.01, p < 0.001), atrial fibrillation (odds ratio, 28.30, p < 0.001), acute myocardial infarction (odds ratio, 23.29, p < 0.001), and acute venous thromboembolism (odds ratio, 26.43, p < 0.001). We identified an increase of severity of coronavirus disease 2019 within older patients of African American and Hispanic descent with comorbidities such as diabetes, coronary artery disease, congestive heart failure, chronic kidney disease, cancer, liver disease, or cerebrovascular disease. Noninvasive positive-pressure ventilation and high-flow nasal cannula oxygen may have helped avert mechanical ventilation, and this may have improved patient outcomes over the course of the study period.

TAILORx Update

TAILORx Update

Tumors With Neuroectodermal Differentiation of the Uterus and Ovary: A Series of 12 Cases and Review of the Literature

Abstract Objectives Primitive neuroectodermal tumors (PNETs) are a group of small round cell tumors most commonly found in the central nervous system, soft tissue, or bone. Such tumors arising in the uterus or ovary are rare. In this study, we describe the clinicopathologic features from a series of gynecological tumors with neuroectodermal differentiation. Methods In a retrospective review, 5 years of departmental archives were searched for gynecological tumors diagnosed at Orlando Health’s Department of Pathology. Clinicopathological information was analyzed, including age at diagnosis, tumor size, depth of invasion, other component, pathologic stage, FIGO stage, immunohistochemical stains, months of follow-up, and current disease status. Results Twelve fully staged tumors with neuroectodermal differentiation were identified. Eleven were of uterine origin and one was of ovarian origin. Ages at diagnosis ranged from 38 to 78 years (median 65). Neuroectodermal component was variable in morphology, including lymphocyte-like small cells in sheets, perivascular pseudorosettes, or cords; larger cells with prominent nucleoli with or without cystic change; and giant cells resembling megakaryocytes. Components other than neuroectodermal differentiation included carcinosarcoma, dedifferentiated endometrioid carcinoma, and high-grade serous carcinoma. Membranous and/or paranuclear dot-like CD99 immunoreactivity were in all cases. Ten patients were deceased due to disease at 1 to 33 months follow-up, while one patient was alive without evidence of disease after 61 months follow-up, possibly due to being able to tolerate a different therapeutic protocol for peripheral PNET. Conclusion Neuroectodermal differentiation may be found as components of other gynecological tumors, especially those with an aggressive phenotype and high-stage disease. The neuroectodermal component comprises a spectrum of cytohistological features. Because of its presentation in the shadow of other components, it may be more common than is generally assumed. Mortality remains high, but recognition of neuroectodermal differentiation in gynecologic tumors might introduce a different therapeutic approach and potentially improve clinical outcomes.

Enrollment disparities in cancer clinical trials: A single institution experience.

e18128 Background: The importance of population heterogeneity in clinical cancer research is universally recognized. This study aims to identify possible disparities in trial participation at UF Health Cancer Center at Orlando Health. Methods: Data on patients’ enrollment, during the period from 01/01/2016 to 12/31/2016, was obtained from our research C-base. We utilized descriptive statistics to characterize the main demographic variables. Pearson's Chi-squared and Z-tests were utilized to compare percentages of enrolled versus not enrolled patients by ethnicity, race and gender. Results: A total of 3704 cases were established as new patients during the study period, of which 369 (10%) were enrolled in cancer research studies (Table). Our analysis showed statistically significant differences in enrollment by racial category (χ2= 95.09, df = 3, p &lt; 0.0000). American Indian (n = 6) and Native Hawaiian (n = 4), were excluded from the analysis due to small sample sizes and no enrollments. In addition we tested with the Z-stat whether the enrollment in each group was different from the population average (p = 0.10). The Caucasian group did not differ from the average (z = 0.3944; p &lt; 0.6933), whereas both the African American (z = -4.2286; p &lt; 0.0001) and the Asian group (z = -2.3102; p &lt; 0.0209) were under enrolled. The Others group was above the average (z = 8.4632; p &lt; 0.0001). There were also differences in enrollment by gender and ethnicity. Females were under enrolled as compared to Males (z = -7.0716; p &lt; 0.0001). The Hispanic group enrollment was significantly below the population average (z = -4.17; p &lt; 0.0001). Conclusions: We found significant differences in the enrollment of minorities in cancer trials in our institution. African Americans, Asians, Hispanics and Females were all under represented. The group labeled as Others requires further attention. [Table: see text]

Abstract P4-09-13: A prognostic predictive model based on the correlation of standard clinicopathologic characteristics with oncotype Dx 21-gene recurrence score for node-negative and ER positive breast cancer

Abstract BACKGROUND: The Oncotype Dx Breast Cancer Assay (21-gene recurrence assay) is a prognostic tool that produces a recurrence score, which estimates the probability of distant recurrence within 10 years, given 5 years of adjuvant endocrine therapy as well as predicts benefit from adjuvant chemotherapy. The primary objective of this study was to explore if standard clinicopathologic variables independently correlate to the recurrence score. As a secondary objective, we explored if a model based on the clinicopathologic variables can accurately predict recurrence score. METHODS: We conducted a retrospective chart review of 507 patients with node-negative, estrogen receptor (ER) positive breast cancer from the UF Health Cancer Center at Orlando Health. Of the 507 patients, 84 did not meet inclusion criteria (n = 423). The following factors were correlated with recurrence score (RS): age, tumor size, ER, PR, ki67, HER2 (IHC), HER2 (FISH), and tumor grade. Although the RS is a continuous variable, scores are also used to categorize patients into three risk groups: low (RS&amp;lt;18), intermediate (18≤RS&amp;lt;31), and high (RS≥31). This study evaluated variation of the HER2 levels within this subset of HER2 negative patients. RESULTS: In univariate analysis, there were no significant correlations between age, ER, tumor size, Ki67 and RS. There were statistically significant correlations between PR (r=-.42, p&amp;lt;.001), HER2 (IHC) (r=.097, p&amp;lt;.05), HER2 (FISH) (r=0.40, p&amp;lt;.001), and tumor grade (r=0.37, p&amp;lt;.001) and RS. As a second step, we used these results and clinical expertise to guide a predictive model. As expected, independently, PR and tumor grade were significant predictors of RS (βs= -.096, .37, respectively; p&amp;lt;.05). However, HER2 (IHC) was not, β=.097, p = .054. As a final step, three pathologic factors (PR, HER2 by IHC, and tumor grade) were used to predict recurrence score. In the multivariate analysis, we found a statistically significant model, (R = 0.54, RAdj = .30; F (3, 399) = 57.17, p &amp;lt; .001), where, PR (β= -.096), HER2 (IHC) (β= 2.007), and tumor grade (β= 4.778). Concordance with the 21-gene assay was as follows: 76.0%, 54.5%, and 66.7% for low, intermediate, and high-risk groups, respectively. As clinical guidelines are not firmly established for the use of chemotherapy in the intermediate risk group it is also valuable to estimate the two-step discordance, an estimated RS that is high, when the 21-Gene recurrence score is low and vice versa. The two-step discordance was 2.2% and 0.0% for the low and high risk groups, respectively. CONCLUSION: The data presented here suggests that it may be possible to create a model based on standard clinicopathologic parameters to predict the 21-gene recurrence score in node-negative, ER positive breast cancer patients. In practice, a 21-gene recurrence score assay is not always possible. We present an option to identify patients whose risk category can be confidently determined from the standard clinicopathologic variables alone, thereby reducing medical cost. Admittedly, this model has not undergone validation nonetheless, the data suggest the potential for a novel; low-cost; high reach diagnostic tool. Citation Format: Mankbadi MR, Luo Y, Yasin M, Ben Khallouq B, Moroose R. A prognostic predictive model based on the correlation of standard clinicopathologic characteristics with oncotype Dx 21-gene recurrence score for node-negative and ER positive breast cancer [abstract]. In: Proceedings of the 2017 San Antonio Breast Cancer Symposium; 2017 Dec 5-9; San Antonio, TX. Philadelphia (PA): AACR; Cancer Res 2018;78(4 Suppl):Abstract nr P4-09-13.

Orlando Health Nurse Leaders Reflect on the Pulse Tragedy

In the predawn hours of Sunday, June 12, 2016, dozens of people hit by gunfire poured into Orlando Regional Medical Center's (ORMC) emergency department (ED) in Orlando, Florida. The largest mass-casualty shooting in American history happened just a few blocks from ORMC, Orlando Health's flagship hospital and the region's only level one trauma center. The gunman had opened fire at Pulse, a popular gay nightclub, during a crowded Latin night. Due to the close proximity of the nightclub to ORMC, first responders loaded victims into police cars and the backs of trucks, and transported them to the ED. The shooting resulted in the treatment of 44 total victims in just a few hours’ time, testing the effectiveness of the disaster planning preparedness and the resiliency of team members. Nurse leaders played an important coordinating role during the unfolding disaster, and interprofessional collaboration became crucial to ensure that patients received optimal care. In the time that has elapsed since the 2016 tragedy, the Orlando Health team has been applauded on the national and international stages for their heroic initial response and for the care provided in the days and months that ensued. As nurse leaders reflect on lessons learned, successes can be attributed to 3 major themes: preparedness, teamwork, and a culture of resiliency. In the predawn hours of Sunday, June 12, 2016, dozens of people hit by gunfire poured into Orlando Regional Medical Center's (ORMC) emergency department (ED) in Orlando, Florida. The largest mass-casualty shooting in American history happened just a few blocks from ORMC, Orlando Health's flagship hospital and the region's only level one trauma center. The gunman had opened fire at Pulse, a popular gay nightclub, during a crowded Latin night. Due to the close proximity of the nightclub to ORMC, first responders loaded victims into police cars and the backs of trucks, and transported them to the ED. The shooting resulted in the treatment of 44 total victims in just a few hours’ time, testing the effectiveness of the disaster planning preparedness and the resiliency of team members. Nurse leaders played an important coordinating role during the unfolding disaster, and interprofessional collaboration became crucial to ensure that patients received optimal care. In the time that has elapsed since the 2016 tragedy, the Orlando Health team has been applauded on the national and international stages for their heroic initial response and for the care provided in the days and months that ensued. As nurse leaders reflect on lessons learned, successes can be attributed to 3 major themes: preparedness, teamwork, and a culture of resiliency.

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