Penn State Health Research Articles

Abstract 4135113: Referral to a Heart Failure Clinic Substantially Increases the Use of Angiotensin Receptor Neprilysin Inhibitor (ARNi) and Sodium-glucose cotransporter-2 Inhibitor (SGLT2i) in Heart Failure Patients.

Introduction: Addressing access to life-saving therapy is crucial in influencing health outcomes. The stark reality of limited access to pharmacological therapy for heart failure with reduced ejection fraction (HFrEF), particularly novel drugs such as angiotensin receptor neprilysin inhibitors (ARNi) and sodium-glucose cotransporter-2 inhibitors (SGLT2i) for patients with heart failure (HF), underscores the challenges we face. Hypothesis: We analyze the impact of referring patients diagnosed with HF to our HF clinic by evaluating access to the 4 pillars of HFrEF, emphasizing cost-prohibiting pharmacological therapy, and assessing the efficacy of these medications when applied. Methods: This study compared 314 patients who live in counties within and outside the Penn State Health System. The data collected included healthcare insurance coverage, HF etiology, comorbidities, onset, initial and within six months post titration of guideline-directed medical therapy (GDMT) echocardiogram, and medication dose. Results: Among patients referred to our HF clinic, 184 live in counties within, and 130 live outside the Penn State Health System. The average age was 64, 69.4% were male, and a significant number of patients had HFrEF (92.7%). The prevailing comorbidities between the 2 groups were hypertension, hyperlipidemia, and diabetes. Upon completion, there was a significant increase in ARNi (83.1%) and SGLT2i (65.3%) use in both groups. They both (within vs. outside) reached almost similar percentages of triple therapy (77.9% vs. 79.2%; p-value=0.78), except for quadruple therapy (36.4% vs. 44.6%; p-value=0.16) and maximum tolerated dose (83.3% vs. 75%; p-value=0.11). The overall mean ejection fraction (EF) in both groups demonstrated significant improvement from pre-EF (30.5%) to post-EF (45.9%). Conclusion: Despite their location, patients referred to the HF clinic experienced intensified use of cost-prohibiting medications such as ARNi and SGLT2i, compared to the current gap in GDMT use. After optimizing GDMT, both groups had markedly improved EF. These findings suggest that referral to a HF clinic is a promising strategy for addressing the use of life-saving therapy and potentially reducing adverse health outcomes.

BIOM-08. LEVERAGING CSF PROTEOMICS TO OPTIMIZE CNS LYMPHOMA MANAGEMENT

Abstract INTRODUCTION Despite exquisite responses to initial therapy for CNS lymphoma (CNSL), relapse is common and overall responses are disappointing compared to other non-CNS diffuse large B-cell lymphomas. Incorporation of multi-agent intraventricular chemotherapy (MAIVC) alongside systemic therapy is novel. Identification of minimally-invasive biomarkers of response to MAIVC are necessary but lacking. The objectives of this study were to 1) identify baseline cerebrospinal fluid (CSF)-based proteomic predictive biomarkers of MAIVC treatment response and 2) identify tumor burden markers for longitudinal monitoring of MAIVC treatment response in CNSL. METHODS A cohort of patients with primary or secondary CNSL that were treated with MAIVC at Penn State Health (2015-2021) was included. Each MAIVC cycle was administered via Ommaya reservoir and included a 2-drug combination comprised of methotrexate, rituximab, cytarabine, etoposide, topotecan, gemcitabine, or thiotepa. Patient-matched CSF was sampled at pre- and post-therapeutic endpoints and profiled using shotgun proteomics. Patients were grouped by treatment response status. Early responders were defined as patients that achieved malignant cell-free CSF within 6 MAIVC cycles, whereas never responders were those patients that i) did not achieve malignant cell-free CSF by endpoint or ii) required salvage surgery or radiation during MAIVC. RESULTS 59 patients were included (21 primary; 38 secondary CNSL) with a median age of 66 years (range 25-90) and median number of MAIVC cycles of 8 (range 2-23). A proteomic-based classifier, comprised of SGCE, LCP1 and AGRN, discriminated between early and never responders with an AUROC of 0.95. Comparison of CSF at baseline (<3 cycles MAIVC) vs. post-treatment (>12 cycles MAIVC) identified H3F3A, YWHAE, LCP1, CA1 and GAPDH as tumor burden biomarkers. CONCLUSION Here we developed a proteomic signature capable of predicting CNSL patient response to MAIVC, with potential to improve clinical decision making. Furthermore, the biomarkers associated with tumor burden represent important indicators of treatment response. Ongoing efforts are underway to evaluate these candidates as actionable therapeutic targets.

Enhancing Sepsis prognosis: Integrating social determinants and demographic variables into a comprehensive model for critically ill patients

BackgroundThe Sequential Organ Failure Assessment (SOFA) score monitors organ failure and defines sepsis but may not fully capture factors influencing sepsis mortality. Socioeconomic and demographic impacts on sepsis outcomes have been highlighted recently. ObjectiveTo evaluate the prognostic value of SOFA scores against demographic and social health determinants for predicting sepsis mortality in critically ill patients, and to assess if a combined model increases predictive accuracy. MethodsThe study utilized retrospective data from the MIMIC-IV database and prospective external validation from the Penn State Health cohort. A Random Forest model incorporating SOFA scores, demographic/social data, and the Charlson Comorbidity Index was trained and validated. FindingsIn the MIMIC-IV dataset of 32,970 sepsis patients, 6,824 (20.7%) died within 30 days. A model including demographic, socioeconomic, and comorbidity data with SOFA scores improved predictive accuracy beyond SOFA scores alone. Day 2 SOFA, age, weight, and comorbidities were significant predictors. External validation showed consistent performance, highlighting the importance of delta SOFA between days 1 and 3. ConclusionAdding patient-specific demographic and socioeconomic information to clinical metrics significantly improves sepsis mortality prediction. This suggests a more comprehensive, multidimensional prognostic approach is needed for accurate sepsis outcome predictions.

Air pollution and incident sarcoidosis in central Pennsylvania

ABSTRACT Sarcoidosis is a chronic granulomatous disease predominantly affecting the lungs and inducing significant morbidity and elevated mortality rate. The etiology of the disease is unknown but may involve exposure to an antigenic agent and subsequent inflammatory response resulting in granuloma formation. Various environmental and occupational risk factors have been suggested by previous observations, such as moldy environments, insecticides, and bird breeding. Our study investigated the association of air pollution with diagnosis of sarcoidosis using a case-control design. Penn State Health electronic medical records from 2005 to 2018 were examined for adult patients with (cases) and without (controls) an International Classification of Disease (ICD)-9 or −10 code for sarcoidosis. Patient addresses were geocoded and 24-hr residential-level air pollution concentrations were estimated using spatio-temporal models of particulate matter <2.5 μm (PM2.5), ozone, and PM2.5 elemental carbon (EC) and moving averages calculated. In total, 877 cases and 34,510 controls were identified. Logistic regression analysis did not identify significant associations between sarcoidosis incidence and air pollution exposure estimates. However, the odds ratio (OR) for EC for exposures occurring 7–10 years prior did approach statistical significance, and ORs exhibited an increasing trend for longer averaging periods. Data suggested a latency period of more than 6 years for PM2.5 and EC for reasons that are unclear. Overall, results for PM2.5 and EC suggest that long-term exposure to traffic-related air pollution may contribute to the development of sarcoidosis and emphasize the need for additional research and, if the present findings are substantiated, for public health interventions addressing air quality as well as increasing disease surveillance in areas with a large burden of PM2.5 and EC.

Identifying diversity of patient anatomy through automated image analysis of clinical ultrasounds.

Central venous catheterization (CVC) carries inherent risks which can be mitigated through the use of appropriate ultrasound-guidance during needle insertion. This study aims to comprehensively understand patient anatomy as it is visualized during CVC by employing a semi-automated image analysis method to track the internal jugular vein and carotid artery throughout recorded ultrasound videos. The ultrasound visualization of 50 CVC procedures were recorded at Penn State Health Milton S. Hershey Medical Center. The developed algorithm was used to detect the vessel edges, calculating metrics such as area, position, and eccentricity. Results show typical anatomical variations of the vein and artery, with the artery being more circular and posterior to the vein in most cases. Notably, two cases revealed atypical artery positions, emphasizing the algorithm's precision in detecting anomalies. Additionally, dynamic vessel properties were analyzed, with the vein compressing on average to 13.4%of its original size and the artery expanding by 13.2%. This study provides valuable insights which can be used to increase the accuracy of training simulations, thus enhancing medical education and procedural expertise. Furthermore, the novel approach of employing automated data analysis techniques to clinical recordings showcases the potential for continual assessment of patient anatomy, which could be useful in future advancements.

Improving and Sustaining Resident Physician Handover.

Background Handoffs serve a critical patient safety function in the transition between caregivers. In 2006, the Joint Commission on Accreditation of Healthcare Organizations strongly recommended the implementation of "a standardized approach to 'handoff' communications, including an opportunity to ask and respond to questions."Numerous studies have investigated the quality and efficacy of patient handoffs and the utility of structured handoff curriculums, particularly in the context of patient safety and outcomes. Objective The pediatric residents at Penn State Health (PSH) did not utilize a formal written or verbal handoff tool. Our study facilitated the design of a comprehensive handoff curriculum, including verbal and written components, and the implementationof faculty and multidisciplinary care team involvement coupled with resident training and observations.We investigate the impact of this curriculum longitudinally utilizing validated tools completed by external observers as well as the residents themselves. Methods Prior to SAFETIPS being implemented, residents at a mid-sized Pediatric program were observed giving handovers at various intervals to understand baseline habits.Residents were then educated with the SAFETIPS curriculum and again observed.Trained observers of the handover process completed a validated evaluation form concentrating onseven key domains necessary for effective handover and communication; residents involved in the handover also completed a validated evaluation form.Consent for the project was implied with the observer's presence during the process and our study was exempt from full IRB consideration given its quality improvement design.A mix of summary statistics, stacked dot plots, mixed effects regression, and joint F tests were used to analyze data. Results Mean values on all sections of the handover evaluation Likert scale completed by trained observers tended to increase over time; the variance in responses was likewise much smaller at later time periods.Similarly, all sections of the evaluation tools completed by the resident physicians themselves showed significantly increased scores from pre- to post-implementation of our curriculum.Data revealed a plateauing of results towardlater time points suggestive of skills mastery and sustained improvements. Conclusion Our findings suggest that the introduction of a structured handoff curriculum correlated with improved communication among residents, and such improvements were sustained over time.

Characterizing Tobacco Usage in Otolaryngology Patients to Target Smoking Cessation Efforts.

Smoking cessation is critical in reducing incidence of head and neck cancers (HNC) and improving postoperative outcomes. Accurate documentation of tobacco usage is necessary to understand prevalence in patients to target smoking cessation. This study aims to characterize tobacco usage documentation, including electronic nicotine delivery systems (ENDS) use, among otolaryngology patients. Retrospective chart review. Penn State Health Milton S. Hershey Medical Center (PSHMC). A retrospective chart review was conducted on adult otolaryngology patients seen from January 1, 2020 - December 31, 2020. Patient demographics, details of alcohol and tobacco usage, including type of tobacco, and subspecialty seen were collected. Associations were evaluated using chi-square tests and a multivariable logistic regression model. Patients (n = 2137) were an average of 58.4years old ±18.0, 59.3% female, and 78.0% white. Of participants with documented tobacco history (n = 944), 56.7% were never users, 28.9% were former users, and 14.4% were current users. Among current users (n = 308), 86.4% used cigarettes, and 5.2% used ENDS. The remainder used chew (4.9%) and cigars (3.25%). Odds of tobacco use were 1.5x greater for males (95% CI 1.19-2.00), 1.6x greater for unmarried patients (95% CI 1.24-2.09), 2.1x greater for those with no insurance vs government (95% CI 1.43-3.18), and 2.4x greater for those diagnosed with HNC (95% CI 1.64-3.49). Most patients report cigarette smoking when asked about tobacco use. Taking into consideration the rise of ENDS use, our sample showed ENDS use that was higher than the national average. There is significant opportunity for improved history taking, especially within general and head and neck oncology subspecialties for more comprehensive treatment.

Outcomes of posterior component separation with transversus abdominis release for repair of abdominally based breast reconstruction donor site hernias.

Abdominally based autologous breast reconstruction (ABABR) is common after mastectomy, but carries a risk of complex abdominal wall hernias. We report experience with posterior component separation (PCS) and transversus abdominis release (TAR) with permanent synthetic mesh repair of ABABR-related hernias. Patients at Cleveland Clinic Foundation and Penn State Health were identified retrospectively. Outcomes included postoperative complications, hernia recurrence, and patient-reported outcomes (PROs): Hernia Recurrence Inventory, HerQLes Summary Score, Patient-Reported Outcome Measurement Information System (PROMIS) Pain Intensity 3a Survey, and the Decision Regret Scale (DRS). Forty patients underwent PCS/TAR repair of hernias resulting from pedicled (35%), free (5%), muscle-sparing TRAMs (15%), and DIEPs (28%) from August 2014 to March 2021. Following PCS, 30-day complications included superficial surgical site infection (13%), seroma (8%), and superficial wound breakdown (5%). Five patients (20%) developed clinical hernia recurrence. At a minimum of 1year, 17 (63%) reported a bulge, 12 (44%) reported pain, median HerQLes Quality Of Life Scores improved from 33 to 63/100 (p value < 0.01), PROMIS 3a Pain Intensity Scores improved from 52 to 38 (p value < 0.05), and DRS scores were consistent with low regret (20/100). ABABR-related hernias are complex and technically challenging due to missing abdominal wall components and denervation injury. After repair with PCS/TAR, patients had high rates of recurrence and bulge, but reported improved quality of life and pain and low regret. Surgeons should set realistic expectations regarding postoperative bulge and risk of hernia recurrence.

The relationship between perceptions of electronic health record usability and clinical importance of social and environmental determinants of health on provider documentation.

Social and environmental determinants of health (SEDH) data in the electronic health record (EHR) can be inaccurate and incomplete. Providers are in a unique position to impact this issue as they both obtain and enter this data, however, the variability in screening and documentation practices currently limits the ability to mobilize SEDH data for secondary uses. This study explores whether providers' perceptions of clinical importance of SEDH or EHR usability influenced data entry by analyzing two relationships: (1) provider charting behavior and clinical consideration of SEDH and (2) provider charting behavior and ease of EHR use in charting. We performed a cross-sectional study using an 11-question electronic survey to assess self-reported practices related to clinical consideration of SEDH elements, EHR usability and SEDH documentation of all staff physicians, identified using administrative listserves, at Penn State Health Hershey Medical Center during September to October 2021. A total of 201 physicians responded to and completed the survey out of a possible 2,478 identified staff physicians (8.1% response rate). A five-point Likert scale from "never" to "always" assessed charting behavior and clinical consideration. Responses were dichotomized as consistent/inconsistent and vital/not vital respectively. EHR usability was assessed as "yes" or "no" responses. Fisher's exact tests assessed the relationship between charting behavior and clinical consideration and to compare charting practices between different SEDHs. Cumulative measures were constructed for consistent charting and ease of charting. A generalized linear mixed model (GLMM) compared SDH and EDH with respect to each cumulative measure and was quantified using odds ratios (OR) and 95% confidence intervals (CI). Our results show that provider documentation frequency of an SEDH is associated with perceived clinical utility as well as ease of charting and that providers were more likely to consistently chart on SDH versus EDH. Nuances in these relationships did exist with one notable example comparing the results of smoking (SDH) to infectious disease outbreaks (EDH). Despite similar percentages of physicians reporting that both smoking and infectious disease outbreaks are vital to care, differences in charting consistency and ease of charting between these two were seen. Taken as a whole, our results suggest that SEDH quality optimization efforts cannot consider physician perceptions and EHR usability as siloed entities and that EHR design should not be the only target for intervention. The associations found in this study provide a starting point to understand the complexity in how clinical utility and EHR usability influence charting consistency of each SEDH element, however, further research is needed to understand how these relationships intersect at various levels in the SEDH data optimization process.

Utility of a bone health clinic in bridging the osteoporosis care gap: Prescribing habit review at an academic institution.

To analyze osteoporosis medication prescribing trends across specialties in the context of a Bone Health Clinic. Osteoporosis affects over 10 million adults in the US, taking a significant toll on patients and the healthcare system. Although screening methods and treatments are improving, the disease remains underdiagnosed and undertreated. This study aims to evaluate the prescribing trends of osteoporosis medication among department specialties to delineate the benefits of a bone health clinic. Retrospective data collection identified and analyzed patients within the Penn State Health system prescribed one of the following osteoporosis medications: Bisphosphonate, denosumab, romosozumab, teriparatide, abaloparatide, or raloxifene. Date range: 4/18/2016 to 4/14/2021. Data collection identified the specialty origin of prescriptions for osteoporosis medications across various medical specialties (e.g., orthopaedics, family medicine, and internal medicine). 10,736 prescription orders were issued to patients with an average age of 68 years. Non-Hispanic Caucasian patients received 88.6% of prescriptions, followed by Asian (3.4%) and African American (2.2%). Female patients accounted for 87.8% of all prescriptions. The Bone Health Clinic under two orthopaedic providers wrote 3,619 prescriptions, averaging 361.9 prescriptions per provider per year-marking the highest rate among specialties. The clinic prescriptions constituted 33.7% of all prescriptions across specialties. Orthopaedic surgery prescribed the most denosumab, romosozumab, teriparatide, and abaloparatide prescriptions, and had the highest number of male osteoporosis patients compared to other specialties (15.6%), consequently prescribing the most male prescriptions (578). Establishing a bone health clinic dedicated to osteoporosis management leads to significantly higher prescription rates per provider, increased utilization of anabolic therapies compared to other specialties, and more male patients being treated-an often-neglected population in osteoporosis.

BIOM-63. PROTEOMIC BASED PROFILING OF CSF FOR CNSL MANAGEMENT

Abstract Central nervous system lymphoma (CNSL) is a rare subtype of non-Hodgkin lymphoma, primarily affecting the brain and spinal cord. CNSL exhibits a dismal prognosis, as reflected by a low 5-year survival rate of 30%, with the current standard of care. The advent of multi-agent intrathecal chemotherapy (MAITC) in conjunction with systemic therapy has demonstrated encouraging outcomes, enhancing both progression-free survival and overall survival in patients with CNSL. Given the potential morbidity associated with MAITC, identification of minimally-invasive biomarkers for guiding patient management are necessary. Leveraging the longitudinal, large volume of Cerebrospinal fluid (CSF) afforded through our MAITC program, the objective of this study is to identify CSF-based proteomic biomarkers that can serve as reliable indicators of MAITC treatment response and CNSL management. Patient-matched CSF samples from the Penn State Health Neuroscience biorepository were banked at pre- and post-therapeutic endpoint in 22 primary and 36 secondary CNSL patients. The samples were profiled using high-throughput fluid sample protocol coupled with mass-spectrometry that only requires 30 μl of CSF. More than 1000 unique proteins were detected using shotgun proteomics, and 797 proteins were present in 70% of the analyzed samples, which were used for downstream analysis. We were able to effectively discriminate between primary and secondary CNSL based on protein abundance. Furthermore, the findings suggest significant changes in the cellular processes related to glycoprotein metabolism and redox signalling in response to the treatment, indicating a potential impact on protein modification and the cellular response to oxidative stress. Our comprehensive, pathway-level analysis uncovered significant molecular alterations, shedding light on their potential prognostic significance in the context of CNS lymphoma. Future work is underway to identify biomarker signatures that would predict optimal response to MAITC therapy, exhibiting potential to improve clinical decision making.

SDPS-39 AN UPDATED VALIDATION OF PREDICTIVE ALGORITHMS FOR BRAIN METASTASES IN NON-SMALL CELL LUNG CANCER: SYSTEMATIC REVIEW AND INDEPENDENT COHORTVALIDATION ANALYSIS

Abstract INTRODUCTION Many non-small cell lung cancer (NSCLC) patients eventually develop brain metastases (BM). Reliable risk stratification with predictive algorithms can lead to early intervention. Here, we evaluated the performance of published BM risk-stratification algorithms using an independent cohort of NSCLC patients. METHODS We evaluated statistical models predicting BM in NSCLC by systematically reviewing relevant studies and testing them on an independent cohort of NSCLC patients in electronic medical records (2011-2020) from Penn State Health. Patient data was randomly split into 70% training and 30% testing for modeling using L1-regularized logistic regression, and we assessed the models' performance using ROC analyses. RESULTS Out of 1,643 publications, 22 met our criteria, and 12 of those studies (527,258 patients) included variables consistently available in patient charts. Our validation cohort included 1,699 NSCLC patients, with a median age at diagnosis of 68 and 20.4% developing BM. Among feasible models, Zhang 2021 had the highest performance in our cohort (AUROC [95% CI]: 0.89 [0.85-0.93]) and was comprised of the following predictors: age at diagnosis; surgical, chemotherapy, and radiation status; T and N stage; histological grade; and number of organs with metastases. Within our independent cohort, logistic regression revealed that the most informative predictors were the number of organs with metastases (OR [95% CI]: 3.25 [2.70, 3.92]), age at NSCLC diagnosis (OR [95% CI]: 0.98 [0.96, 0.99]), N-stage 1 at diagnosis (OR [95% CI]: 1.83 [1.08, 3.11]), and non-carcinoid or -carcinoma histology (OR [95% CI]: 0.29 [0.10, 0.84]). CONCLUSION Our robust approach, including systematic review and one of the largest-to-date independent institutional datasets, proposes a clinically feasible, novel algorithm for stratifying NSCLC patients based on risk of developing BM. This work can inform pragmatic screening and surveillance guidelines to facilitate early detection of BM in NSCLC patients.

0376 Long-Term Effectiveness of Cognitive-Behavioral Therapy for Insomnia: A Patient-Reported Outcomes Post-Treatment Study

Abstract Introduction Insomnia is the most prevalent sleep disorder, with 10% of adults meeting criteria for a chronic insomnia disorder (CID). Cognitive-behavioral therapy for insomnia (CBT-I) is the first-line recommended treatment given the strong evidence supporting its efficacy in the short-term and mid-term. Less is known about the effectiveness of CBT-I in routine clinical practice on patient-reported outcomes beyond 3y post-treatment. Methods Participants included 68 adults (48±15 years old, 63% female, and 11% minority) who received CBT-I for CID at the Behavioral Sleep Medicine (BSM) program of Penn State Health Sleep Research &amp; Treatment Center3 to 7y prior to the present study. Participants completed Insomnia Severity Index (ISI) and Flinders Fatigue Scale (FFS) at baseline and follow up. Results After a median of 5y follow-up, 50% of patients didn’t meet insomnia case definition (ISI&amp;lt; 11), and 60% had experienced a meaningful improvement in insomnia severity (change in ISI score of -6 points or more). Only 35% of patients continued to experience moderate-to-severe insomnia (ISI&amp;gt;14) at follow-up. These effects were similar in patients who had a history of a medical (n=42) or psychiatric (n=38) disorder at pre-treatment when compared to those without prior medical or psychiatric disorders (p=0.380 and p=0.467 for insomnia caseness, respectively). The percent of patients absent of clinically significant daytime fatigue (FFS&amp;lt; 13) increased from 29% to 50 after the same period of long-term follow-up, and those with moderate-to-severe daytime fatigue (FFS&amp;gt;15) fell from 62% to 38%. Hypnotic use (i.e., prescription or over-the-counter) decreased from 66% at baseline, though this varied by insomnia status at follow-up: while 56% of insomnia cases (n=34) at follow-up reported still taking medications at bedtime, only 17% of remitted cases (n=34) did (p&amp;lt; 0.001). Conclusion This long-term evidence is consistent with prior clinical trials, national trends, and further supports that insomnia is a disorder, not a symptom, comorbid with medical and psychiatric conditions that should be treated independently. The effectiveness outcomes show improved sleep, daytime functioning, and discontinuation of sleep medications, a goal of clinical practice guidelines. Importantly, treatment gains remained after the onset of the COVID-19 pandemic. Support (if any) Penn State Health Department of Psychiatry Trainee Award

Use of Complementary and Alternative Medicine in Children with Neuromuscular Disorders Followed at Penn State Health Pediatric Muscular Dystrophy Association Care Center Clinic.

The exact prevalence of complementary and alternative medicine (CAM) use is not known in pediatric patients with neuromuscular diseases followed by any of the 150 Muscular Dystrophy Association (MDA) Care Center Clinics nationwide. This study describes the prevalence and variety of CAM usage in this population, while also assessing the prevalence of caregiver disclosure of CAM use and caregiver perception of provider support for CAM. Fifty-two caregivers of pediatric patients seen at Penn State Health's Pediatric MDA Care Center Clinic completed our online survey. Overall, 19.2% of caregivers reported CAM use by their child. Less than half of caregivers reported discussing CAM use with their child's neurologist (41.5%); however, a majority of respondents reported interest in using CAM for their child in the future (52.8%). Understanding the prevalence of CAM usage and disclosure in pediatric MDA clinics may facilitate safer use of CAM in this community.

The Opaque Language of Sexuality: Medical Students' and Providers' Beliefs About Virginity.

Although virginity is not a medical term and is instead socially constructed, it remains unknown what medical providers believe about the biological basis of virginity. This study explored providers' and medical students' beliefs about virginity and the potential impact of such beliefs on healthcare. This was a concurrent mixed-method survey study of 124 medical students and 216 healthcare providers (Registered Nurse, Physician Assistant, Nurse Practitioner, and Doctor of Medicine) at Penn State Health and The Pennsylvania State University College of Medicine. Participants rated their level of agreement with common misconceptions about virginity on a six-point Likert scale. Open-ended questions gave respondents the opportunity to define virginity and to describe terms like virgin and virginal in the context of sexual experience and the medical lexicon. We identified common themes in the qualitative data using thematic analysis. Frequencies of misconceptions and statistically significant demographic associations were identified in the quantitative data. Definitions of virginity were varied and vague, most with negative connotations. A majority of respondents said that virginity has no biological basis. Many participants identified downsides to use of terms like virgin, virginity, and virginal in medicine. The most prevalent misconceptions about virginity were related to the hymen. Seventeen percent of students and 26% of providers at least somewhat agreed that it was possible to determine whether a person has engaged in vaginal intercourse through a gynecological exam. Misconceptions about virginity persist in medicine and bias, even if unintended, may impact the quality-of-care people with vaginas receive. Language around sexual health should be specific, inclusive, clinically relevant, and free from judgment. Medical education must continue to work to eliminate the concept of a biological basis to virginity.

A Brief History of Transcranial Magnetic Stimulation

A Brief History of Transcranial Magnetic Stimulation

Alcohol, nicotine, and COVID-19: A retrospective study of health outcomes in central Pennsylvania

Individuals with substance abuse disorder are at increased risk for the development of severe disease following COVID-19 infection. Furthermore, individuals in rural populations where access to healthcare is limited and rates of substance abuse tend to be higher are at increased risk compared to other regions. The Penn State Health Network serves 29 counties in central Pennsylvania that are largely rural. The current study assessed the electronic medical records for individuals in this population that were reported as having alcohol dependence, nicotine dependence or both (co-users) in addition to individuals with no history of drug use and the rate of developing primary and secondary health outcomes following COVID-19 infection. All patients in this study were determined to be COVID+ while in care. We found that overall, risk for requiring ventilation, developing pneumonia, and mortality within 30 days of diagnosis all increased with any substance use history, across both males and females and across all age groups. Moreover, rates of these outcomes were considerably higher in patients that were both alcohol and nicotine dependent suggesting additive effects of co-use. Rates of secondary effects also increased substantially across all use categories with these patients showing greater risk of developing liver, kidney, and pancreas maladies compared to patients with no history of substance use. Taken together, these findings reinforce previous studies showing that substance use increases the risks of significant disease following COVID-19 infection, giving insights into the health disparities that exist in rural populations.

DISP-07. SURVIVAL ANALYSIS OF GLIOBLASTOMA PATIENTS IN PENNSYLVANIA ACCORDING TO AREA DEPRIVATION INDEX AND IDH STATUS

Abstract INTRODUCTION Glioblastoma (GBM) is the most aggressive primary brain tumor with a universally poor prognosis. Living in disadvantaged neighborhoods is associated with poor health outcomes, including increased cancer incidence. This study was designed to elucidate the relationship between GBM patients’ survival, isocitrate dehydrogenase (IDH) mutation status, and residential areas of deprivation in the state of Pennsylvania. METHODS Patients from Pennsylvania with a pathological diagnosis of GBM WHO Grade IV between January 2007 and December 2018 were retrospectively reviewed in the Penn State Health database. Demographic variables and molecular features were assessed. Area Deprivation Index (ADI) is a validated measure of regional socioeconomic deprivation that indexes neighborhoods by percentile, with low ADI scores representing less deprivation. Patients were assigned to low ( &amp;lt; 50) or high ( ≥ 51) ADI groups. Survival was measured against IDH status and ADI score; log-rank tests were performed. RESULTS 121 GBM WHO Grade IV patients were identified (median age at diagnosis: 63, 39.7% female, 60.3% male, 93.4% of white race). Among those, 64 (52.9%) had low ADI, and 57 (47.1%) had high ADI. Patients with high ADI had similar overall survival (OS) rates and progression free survival (PFS) at 18 months (56% OS, 95% confidence interval [CI]: 48-64%; 37.4% PFS, 95%CI: 30-44%; P=0.27) compared to patients with low ADI (50% OS, 95%CI: 43-57%; 32.4% PFS, 95%CI: 26-39%; P = 0.27). Further classification by IDH status resulted in 17 (14%) IDH mutant (IDHm) and 104 (86%) IDH wildtype (IDHwt) patients. Survival analysis demonstrated no significant difference in OS between IDHwt and IDHm patients, regardless of ADI score. CONCLUSION The aggressive nature of GBM requires early diagnostic approaches to impact survival. Living in socioeconomic disadvantaged areas may diminish survival outcomes; however, our data indicate that GBM may be too aggressive for ADI to have a significant impact on prognosis.

Commentary: Microsurgical Obliteration of Craniocervical Junction Dural Arteriovenous Fistulas: Multicenter Experience.

Department of Neurosurgery, Penn State Health, Hershey, Pennsylvania, USA Correspondence: Varun Padmanaban, MD, Department of Neurosurgery, Penn State Health, 30 Hope Drive, Hershey, PA17036, USA. Email: [email protected] Twitter: @v_padmanaban

No difference in subsequent trainee satisfaction associated with in-person exposure prior to remote interviews

ABSTRACT Background In 2020–2021, residency and fellowship applicants participated in virtual interviews. There was concern that trainees who had not been to the area before would potentially have different satisfaction with their new workplace and community. Objective To compare satisfaction and likelihood to recommend work and community among new trainees with or without prior exposure to a single academic center or its environs. Methods We conducted an IRB-approved cross-sectional survey of new trainees. An electronic survey included demographic items, self-report of prior exposure to the area, satisfaction with the program and area, and likelihood to recommend the program and area. Descriptive statistics were used for responses and Chi square tests for comparisons. Results In September 2021 and May 2022 electronic surveys were sent to all 173 trainees who started residency or fellowship in July 2021, which had 87 responses (50.3% response rate) and 31 (18.0% response rate) responses, respectively. At both times, most respondents were interns. The majority of the September group (55.6%), while 38.7% of the May group had prior exposure to the area. Overall, the majority were satisfied with Penn State Health and would recommend their workplace. The majority also agreed they were satisfied with their new community and would recommend it to others. There were no significant differences in the proportions of satisfied trainees for any of the four outcomes at either timepoint. Conclusions Satisfaction with training and the community were not significantly different for trainees with or without prior in-person exposure to the institution or surrounding area.