Penn State Hershey Medical Center Research Articles

Demographics and Reported Symptoms Associated With Marijuana Use Among Adolescents and Young Adults.

Purpose Marijuana use has been increasing in the adolescent population. Our objective was to examine the prevalence of marijuana use among a sample of adolescents and young adults, determine an association with risk-taking behaviors, identify reported medical symptoms, and delineate common beliefs about marijuana use. Methods A questionnaire was administered to a sample of patients aged between 12 and 23 years old presenting to the emergency department of Penn State Hershey Medical Center, Hershey, Pennsylvania. Data were stratified by marijuana users and non-users, and further stratified by traditional (vape, pipe, edibles) and non-traditional (oils/concentrates, topical creams) use. Results The analysis was based on 200 questionnaires. Thirty-nine percent (n=78) reported marijuana use. Marijuana users were more likely to report previous sexual intercourse (79.5% vs. 32.8%; p=<0.0001), as well as the use of alcohol (50.0% vs. 10.7%; p=<0.0001), cigarettes (41% vs. 8.2%; p=<0.0001), prescription pain medications (20.5% vs. 4.1%; p=0.002), and cocaine (14.1% vs. 0.8%; p=0.0017). Users more likely reported texting while driving (41.0% vs. 13.1%; p=0.005) and experienced physical or electronic victimization due to bullying (43.6% vs. 19.7%; p=0.002). Users were more likely to report gastroesophageal reflux disease (GERD), attention deficit disorder (ADD), anxiety, and depression. The most common symptoms associated with marijuana use were anxiety (65.4%), headache (61.6%), nausea/vomiting (53.8%), cough (51.3%), and abdominal pain (47.4%). Sixty-nine percent of respondents believed marijuana was "safer than other drugs". Conclusion Based on our sample, we identified risk-taking behaviors, medical symptoms, and beliefs associated with marijuana use. Healthcare professionals may use these data to provide screening and anticipatory guidance to adolescents who use marijuana and consider marijuana use in their differential diagnosis.

Mind the gap: Recurrence of ventricular pre-excitation after accessory pathway effective refractory period with short coupled paced stimuli.

Journal of Cardiovascular ElectrophysiologyEarly View EP ROUNDS Mind the gap: Recurrence of ventricular pre-excitation after accessory pathway effective refractory period with short coupled paced stimuli Nathan McConkey DO, Nathan McConkey DO Division of Cardiology, Penn State Hershey Medical Center, Heart and Vascular Institute, Hershey, Pennsylvania, USASearch for more papers by this authorAnkit Maheshwari MD, Corresponding Author Ankit Maheshwari MD [email protected] orcid.org/0000-0002-3096-3372 Division of Cardiology, Penn State Hershey Medical Center, Heart and Vascular Institute, Hershey, Pennsylvania, USA Correspondence Ankit Maheshwari, MD, Division of CardiologyPenn State Hershey Medical Center, Heart and Vascular Institute, 500 University Dr, Hershey, PA 17033, USA. Email: [email protected]Search for more papers by this author Nathan McConkey DO, Nathan McConkey DO Division of Cardiology, Penn State Hershey Medical Center, Heart and Vascular Institute, Hershey, Pennsylvania, USASearch for more papers by this authorAnkit Maheshwari MD, Corresponding Author Ankit Maheshwari MD [email protected] orcid.org/0000-0002-3096-3372 Division of Cardiology, Penn State Hershey Medical Center, Heart and Vascular Institute, Hershey, Pennsylvania, USA Correspondence Ankit Maheshwari, MD, Division of CardiologyPenn State Hershey Medical Center, Heart and Vascular Institute, 500 University Dr, Hershey, PA 17033, USA. Email: [email protected]Search for more papers by this author First published: 14 June 2023 https://doi.org/10.1111/jce.15971 Disclosures: None. Read the full textAboutPDF ToolsRequest permissionExport citationAdd to favoritesTrack citation ShareShare Give accessShare full text accessShare full-text accessPlease review our Terms and Conditions of Use and check box below to share full-text version of article.I have read and accept the Wiley Online Library Terms and Conditions of UseShareable LinkUse the link below to share a full-text version of this article with your friends and colleagues. Learn more.Copy URL No abstract is available for this article. REFERENCE 1Josephson ME. Josephson's Clinical Cardiac Electrophysiology: Techniques and Interpretations. 5th ed. Wolters Kluwer; 2016. Early ViewOnline Version of Record before inclusion in an issue ReferencesRelatedInformation

The Cost Does Not Outweigh the Benefit: Pathologic Evaluation of Wrist Ganglion Cysts Should Not Be Routine.

As health care costs in the United States continue to rise, there is increasing attention on cost-saving measures. One area of investigation is the utility of pathologic examination of specimens from routine procedures with a suspected benign pathology. We assessed the utility and cost of routine pathologic analysis for wrist ganglion cyst excision. A retrospective cohort study of all wrist ganglion cyst excisions performed by seven hand surgeons was conducted from 2015 to 2019 at Penn State Hershey Medical Center. Preoperative and intraoperative diagnoses, pathologic diagnosis, and pathology cost were assessed. A total of 407 patients underwent ganglion cyst excision, with 318 (78.1%) specimens sent for pathologic review. Of the 318, 317 (99.6%) specimens were concordant with the preoperative or intraoperative diagnosis of ganglion cyst. One specimen (0.3%) resulted as a benign cystic vascular malformation. The charge per specimen was $258, totaling $81,786 spent confirming benign pathology that was clinically correctly diagnosed by the operating surgeon in 99.6% of cases. Routine pathologic analysis is not indicated in cases in which surgeons have a high clinical suspicion for ganglion cyst based on preoperative and intraoperative findings. Pathologic review should be reserved for cases with atypical presentations or intraoperative findings.

Length of Disease More than Therapy Impacts Anxiety and Depression in Multiple Sclerosis

Persons with multiple sclerosis (PwMS) often report a reduced quality of life related to their anxiety and depression associated with the biological unknowns of MS. The COVID-19 pandemic increased the risk of anxiety due to the uncertainties related to vaccine efficacy and immune-suppressing disease-modifying therapies. PwMS were recruited from the Neurology Clinic of the Penn State Hershey Medical Center and asked to complete a demographic questionnaire and surveys on depression (MS-Beck Depression Inventory, MS-BDI) and the Hospital Anxiety and Depression Scale (HADS). The rationale for the study is to determine whether treatment modalities, age, and length of disease impacted anxiety and/or depression in PwMS. Data from 150 participants were included in the analyses. The overall mean age was 54.6 years with a 3.7:1 female:male ratio and mean length of disease of approximately 17 years. Mean scores of the HADS-D, and high scores (&gt; 8) were 4.68 ± 0.3 and 10.0 ± 0.32, respectively, with no differences between males and females. The mean HADS-A score was 6.15 ± 0.36 with significant differences recorded between male and females. The mean high HADS-A score was 10.77 ± 0.40, with no differences between sexes. The mean MS-BDI score was 4.15 ± 0.7 with no differences between males and females. Analyses of anxiety scores in relationship to length of disease revealed no differences between males and females. Anxiety scores did not differ for PwMS on different disease-modifying therapies. In conclusion, the number of years that PwMS had the disease impacted anxiety levels more than the age or treatment regimen..

Trends in characteristics of the recipients of new prescription stimulants between years 2010 and 2020 in the United States: An observational cohort study.

SummaryBackgroundStimulant prescriptions increased by 250% in the United States from 2006-2016 while diagnoses for ADHD minimally increased. There is insufficient data regarding who may be the recipients of these new stimulant prescriptions and safety of stimulants have come under scrutiny in some populations. We aim to describe trends in stimulant prescriptions across biopsychosocial patient level factors between 2010 and 2020.MethodsWe applied a retrospective observational cohort design utilizing electronic health records from 52 healthcare organizations sourced from the TriNetX research network database in the United States. We assessed new stimulant prescriptions across biopsychosocial variables for recipients of prescriptions. We utilized linear regression to assess longitudinal trends of all participants and also conducted an age stratified logistic regression analysis.FindingsThere was an increase in stimulants to people categorized as white (OR 1.24 CI 1.20-1.28), female (OR 1.28 CI 1.23-1.31), and to those with diagnosed anxiety disorders (OR 1.39 CI 1.35-1.44) as well as obesity (OR 1.34 CI 1.28-1.41). The average age of recipients increased throughout the study, and among people sixty-five and older, there was an increase in prescriptions to people with multiple cardiovascular risk factors.InterpretationPrescription stimulant dispensing may have liberalized during the study period in some demographics as a greater number of new prescriptions were dispensed to individuals with risk of adverse outcomes (i.e. older individuals, obese individuals, and geriatric patients with CV risk factors) between 2010 and 2020. Similar trends in prescription medications were witnessed through the opioid epidemic and warrant attention given concerning trends with illicit stimulants. Additional research that investigates patient and provider motivation for stimulant prescriptions, as well as risk perception of stimulants, may be warranted.FundingThis study was made possible by institutional resources at Penn State Hershey Medical Center.

Smooth Versus Textured Tissue Expander Breast Reconstruction: Complications and Efficacy.

Ongoing recognition of breast implant-associated anaplastic large cell lymphoma (BIA-ALCL) and its link with textured devices has brought a paradigm shift in prosthetic-based breast reconstruction. Many institutions no longer offer textured expansion devices for staged reconstruction. However, there is a paucity of data regarding the efficacy of smooth tissue expanders (TE). We hypothesized that the time to final reconstruction and complication profile between smooth and textured TEs would be similar in breast reconstruction patients. A retrospective chart review was performed of all patients who underwent TE breast reconstruction during a 6-year period at the Penn State Hershey Medical Center. Rates of complications treated nonoperatively and those requiring reoperation were assessed. Mechanical complications, including expander malposition and rupture, were evaluated. Time to final breast reconstruction was quantified. Mixed-effects logistic regression and linear regression models, as appropriate, were used to compare textured to smooth TEs. Patient characteristics and anatomic plane placement were adjusted for in all analyses of outcomes. Data were collected on 389 patients, encompassing 140 smooth and 604 textured TEs. Textured devices had an increased incidence of complications treated nonsurgically (16.7% vs 10.7%; P = 0.14). However, smooth TEs had an increased incidence of reoperation (12.1% vs 7.6%; P = 0.06). Most noteworthy was that although smooth TEs had a 40-fold increase in malposition (13.6% vs 0.3%; P < 0.001), no reoperation for this complication was warranted. Further, the time to final reconstruction was comparable between the 2 devices (textured expanders: 221 days and smooth expanders: 234 days; P = 0.15). Staged, implant-based reconstruction is the most common surgical approach to recreate the breast mound following mastectomy. Textured TEs were the cornerstone to this approach. Unfortunately, the association between textured devices and BIA-ALCL now mandates an alternative. We postulated that smooth expanders would compare favorably for breast reconstruction. Although our study suggests that smooth TEs suffer more malposition, this has a negligible impact on the reconstructive timeline. Thus, smooth TEs may prove beneficial when considering the risk of BIA-ALCL associated with textured devices.

Ten years of riluzole use in a tertiary ALS clinic.

Riluzole is a glutamate inhibitor approved for the treatment of amyotrophic lateral sclerosis (ALS). There are scant data on factors associated with riluzole initiation and adherence. The goal of this study was to describe the use of riluzole at the Penn State Hershey Medical Center (PSHMC) ALS clinic. A retrospective medical record review of ALS patients seen at the PSHMC from January 2007 to December 2016. A timeline of riluzole use was established for each patient. Factors contributing to dose changes or discontinuations were recorded. Riluzole adherence was assessed using the proportion of days covered (PDC) calculated by the patient-reported length of riluzole use divided by total time from prescription to death/censor. Multivariable analysis was performed to evaluate the association of demography and clinical course with adherence. Seven hundred twenty-three records were screened, with 508 (307 men, 201 women) meeting the criteria for inclusion. The median duration of riluzole use was 435 (range, 0-3773) days. The median PDC for the group was 64%. Those with higher initial overall function and slower rate of decline were more likely to have a larger PDC. No trends in patients' demographics, riluzole use, and tracheostomy-free survival were found over time. A high rate of riluzole initiation and adherence was found in this sample. The most common reasons for dose modification were related to adverse effects, yet social-, economic-, and patient-related factors were also common. The characteristics of riluzole prescription and use have remained relatively unchanged in a single tertiary ALS center over the past 10 years.

Computational Modeling of the Penn State Fontan Circulation Assist Device.

To address the increasing number of failing Fontan patients, Penn State University and the Penn State Hershey Medical Center are developing a centrifugal blood pump for long-term mechanical support. Computational fluid dynamics (CFD) modeling of the Penn State Fontan Circulatory Assist Device (FCAD) was performed to understand hemodynamics within the pump and its potential for hemolysis and thrombosis. CFD velocity and pressure results were first validated against experimental data and found to be within the standard deviations of the velocities and within 5% of the pressures. Further simulations performed with a human blood model found that most of the fluid domain was subjected to low shear stress (<50 Pa), with areas of highest stress around the rotor blade tips that increased with pump flow rate and rotor speed (138-178 Pa). However, the stresses compared well to previous CFD studies of commercial blood pumps and remained mostly below common thresholds of hemolysis and platelet activation. Additionally, few regions of low shear rate were observed within the FCAD, signifying minimal potential for platelet adhesion. These results further emphasize the FCAD's potential that has been observed previously in experimental and animal studies.

Hemodynamic Optimization Of Left Ventricular Assist Devices During Right Heart Catheterization Ramp Studies

Background : Studies have shown that the hemodynamic measurements taken during a Left Ventricular Assist Device (LVAD) ramp study can be used to optimize LVAD speed and improve clinical outcomes, yet these studies lack external validation. Methods : 470 patients, including 3 LVAD subtypes, were retrospectively analyzed at Penn State Hershey Medical Center from January 2015 to September 2020 and 53 ramp studies were identified. Measurements (RA, mean PA, PCWP, and CI) were taken at speeds +/- 20% of manufacturer recommended set speed for HM2, HM3, and HVAD devices. Primary outcomes were all-cause and heart failure (HF) hospitalizations in the 6-month period pre- and post-ramp study. Secondary outcomes included final LVAD speed and hemodynamic measurements following ramp study. Subgroup analysis was performed on LVAD type and subjects who underwent LVAD speed change. Time to first hospitalization and cumulative incidence rate of all-cause and HF hospitalization were reported. Results : 53 ramp studies were analyzed. Baseline characteristics included: mean age of 60.1 (+/- 10.9), 84.9% male, 56.6% ischemic etiology, 71.7% destination therapy, and average NYHA class and INTERMACS of 2.5 (+/- 0.7) and 5.9 (+/- 1), respectively. 38 of 53 studies (71.7%) showed PCWP decompression >20%, with average PCWP decompression of 51.2% (+/- 21.0%), and CI increase of 22.5% (+/- 18.7%). Optimal LVAD speeds were chosen to maintain CI > 2.2, PCWP < 15 and minimize RAP, in the absence of suction events. 31 (58.5%) of studies resulted in an LVAD speed change and 16 (30.2%) of studies resulted in diuretic change. All-cause and HF hospitalizations were significantly decreased in the 6-months following ramp studies compared the 6-months pre-ramp (total days hospitalized for all causes: 12.0 vs 26.6, p=0.0002; total days hospitalized for HF, 4.8 vs 22.1, p=0.00003). Time to first hospitalization was decreased in the subgroup of studies who underwent a speed change during ramp procedure, yet these differences were not statistically significant. Conclusion : This data externally validates previous work showing that LVAD hemodynamic ramp studies decrease hospitalizations. Future, prospective studies with a larger patient cohort and longer follow up time may elucidate specific hemodynamic targets to improve mortality and further reduce rehospitalizations. : Studies have shown that the hemodynamic measurements taken during a Left Ventricular Assist Device (LVAD) ramp study can be used to optimize LVAD speed and improve clinical outcomes, yet these studies lack external validation. : 470 patients, including 3 LVAD subtypes, were retrospectively analyzed at Penn State Hershey Medical Center from January 2015 to September 2020 and 53 ramp studies were identified. Measurements (RA, mean PA, PCWP, and CI) were taken at speeds +/- 20% of manufacturer recommended set speed for HM2, HM3, and HVAD devices. Primary outcomes were all-cause and heart failure (HF) hospitalizations in the 6-month period pre- and post-ramp study. Secondary outcomes included final LVAD speed and hemodynamic measurements following ramp study. Subgroup analysis was performed on LVAD type and subjects who underwent LVAD speed change. Time to first hospitalization and cumulative incidence rate of all-cause and HF hospitalization were reported. : 53 ramp studies were analyzed. Baseline characteristics included: mean age of 60.1 (+/- 10.9), 84.9% male, 56.6% ischemic etiology, 71.7% destination therapy, and average NYHA class and INTERMACS of 2.5 (+/- 0.7) and 5.9 (+/- 1), respectively. 38 of 53 studies (71.7%) showed PCWP decompression >20%, with average PCWP decompression of 51.2% (+/- 21.0%), and CI increase of 22.5% (+/- 18.7%). Optimal LVAD speeds were chosen to maintain CI > 2.2, PCWP < 15 and minimize RAP, in the absence of suction events. 31 (58.5%) of studies resulted in an LVAD speed change and 16 (30.2%) of studies resulted in diuretic change. All-cause and HF hospitalizations were significantly decreased in the 6-months following ramp studies compared the 6-months pre-ramp (total days hospitalized for all causes: 12.0 vs 26.6, p=0.0002; total days hospitalized for HF, 4.8 vs 22.1, p=0.00003). Time to first hospitalization was decreased in the subgroup of studies who underwent a speed change during ramp procedure, yet these differences were not statistically significant. : This data externally validates previous work showing that LVAD hemodynamic ramp studies decrease hospitalizations. Future, prospective studies with a larger patient cohort and longer follow up time may elucidate specific hemodynamic targets to improve mortality and further reduce rehospitalizations.

Implementation of Transitional Care Planning is Associated with Reduced Readmission Rates in Patients Undergoing Lower Extremity Bypass Surgery for Peripheral Arterial Disease

Patients undergoing lower extremity bypasses (LEB) are at a high risk of developing post-discharge complications requiring readmission. Health systems have developed several strategies to mitigate this risk. One such measure is developing comprehensive Transitional Care Program (TCP), which includes phone calls to patients after being discharged from the hospital. Our study aimed to assess short-term readmission, mortality, and amputation rates of patients who participated in TCP by completing at least one post-discharge follow-up phone call after undergoing LEB for revascularization of peripheral arterial disease (PAD). A retrospective review was completed for patients who underwent LEB surgery between January 2010 and January 2020 to treat PAD at Penn State Hershey Medical Center. Immediate discharge follow-up was done via telephone calls using a standardized script. Patients were then divided into two groups, those who did not have a successful follow-up call (Group I) and those who had at least one successful follow-up call within seven days after discharge (Group II). Univariate analysis was used to compare preoperative demographics, intraoperative variables, and postoperative outcomes. The probability of readmission and risk factors contributing to it were computed using multiple stepwise forward regression analyses. Epidemiological analysis was done to evaluate the risk of readmission in the group receiving post-discharge follow-up calls. A total of 457 patients underwent LEB from 2010 to 2020 and qualified for inclusion in the study. Among these patients, 126 (27.6%) did not have a successful post-discharge follow-up call (Group I), whereas, 331 (72.4%) patients did complete a successful call (Group II). The mean age of patients was 66.7years. There were no significant differences in preoperative baseline patient characteristics or intraoperative factors. Patients who completed a successful call had lower readmission rates within thirty days of the operation (8.8 vs. 17.5%, P=0.008), and this was sustained in multivariate analysis (adjusted odds ratio AOR: 0.18, [confidence interval CI: 0.05-0.66], P=0.009). However, no differences were observed for thirty-day mortality (Group-I: 3.2% versus Group-II: 1.2%, P=0.152) or amputation (Group-I: 9.6% versus Group II 5.9%, P=0.162). Among those who had a successful call, patients with a history of smoking (AOR: 4.05 [CI: 1.21, 17.12] P=0.025), diabetes mellitus (AOR: 3.42 [CI: 1.35, 8.7] P=0.01) and myocardial infarction (AOR: 7.15 [CI: 1.76, 20.1] P=0.006) had a much higher chances of readmission. Risk analysis using epidemiological methods showed that by receiving a call, the risk of readmission could be dropped to half (RR: 0.50 [CI: 0.30, 0.84]), with an attributable risk reduction of -8.7% (CI: -15.9%, -1.4%). This single-institution retrospective study demonstrates the importance of immediate discharge follow-up phone calls in patients who undergo open lower extremity revascularization to reduce thirty-day readmissions. Our analysis showed patients who received immediate follow-up phone calls were less likely to be readmitted to the hospital. The development of reliable and efficient systems to enhance immediate discharge follow-up in vascular surgery patients is pivotal to improving quality of care, preventing readmissions, and reducing healthcare costs.

P070 Next Generation Wearable Technology for IBD Patients: A Feasibility Study.

Inflammatory Bowel Disease (IBD) prevalence is rising. Quality of life (QOL) in chronic illness is affected by various physical and psychosocial factors. Recent studies in other chronic illnesses have used remote physiologic monitoring (RPM) to help predict changes in disease activity and provide opportunities for patient self-management. It has been proposed that bowel inflammation can lead to suboptimal sleep, circadian rhythm disruption and even additional immune system activation. Heart rate variability (HRV) is a validated metric that has been used to predict outcomes and help manage other disease states. To date, there is limited data on the benefit of RPM in IBD care. We wish to explore the potential benefit of the Whoop Strap (new wearable technology device) as a method of RPM for IBD patients. We recruited patients with Ulcerative Colitis from our tertiary care IBD center 18 years and older willing to wear the Whoop Strap 3.0 for 12 months with support from the Penn State Hershey Medical Center, 2020 Department of Medicine House Staff Grant; Clinical Trial Identifier is NCT04333810. During this time, participants were encouraged to use the Whoop mobile application to record symptoms. Physiologic metrics of interest included sleep, resting heart rate (RHR), and HRV; each were correlated to IBD related symptoms. Additionally, we performed monthly "check-ins" to collect disease activity (SCCAI), mood (HADS) and stress (PSS4) questionnaire data. Descriptive statistics were utilized along with correlation coefficient testing to explore potential relationships between Whoop metrics, disease activity scores and patient reported outcomes. Enrollment is ongoing with 7 participants, one of which was lost to follow up. Of note, 2 patients proactively reached out to communicate concern for an underlying disease flare as they noticed significant change in their Whoop metrics in conjunction with worrying symptoms. Patient 1 subsequently had serologic testing after having increased HRV and elevated RHR several days prior to symptoms; results were consistent with active inflammation exhibiting a rise in C-reactive protein from 0.25 mg/dL in 2020 to 2.82 mg/dL. Fecal calprotectin was also elevated at 566 ug/g. Colonoscopy is scheduled for the near future. Patient 2 also had noticeable HRV and RHR changes alongside significant sleep disturbances, which has prompted additional testing. Remote physiologic monitoring is a feasible way to give patients ownership of their medical care and involve them in the diagnostic and treatment process of their underlying IBD. As exhibited with our preliminary results, the Whoop device appears easy to use and may empower patients to reach out to providers even before symptoms occur, leading to an expedited evaluation for increased disease activity. Our feasibility study will hopefully lead to larger prospective efforts utilizing wearable technology devices such as the Whoop in IBD patients.

Implementing an Electronic Medical Record Osteoporosis Self-Assessment Tool Score Which Identifies Patients at Risk for Osteoporosis Promotes Osteoporosis Evaluation.

Introduction:Osteoporosis affects nearly half of the U.S. population. Screening methods are improving but remain inadequate, leaving the disease underdiagnosed and undertreated. The purpose of this study is to determine the effectiveness of an EMR implemented system that identifies patients at risk for osteoporosis via an OST (osteoporosis screening tool) score in prompting patients toward osteoporosis evaluation.Methods:OST scores are generated on every patient 50 years of age and older that is admitted to the Penn State Hershey Medical Center (PSHMC) and recorded in their electronic medical record. An OST score < 2 indicates that a patient has a potential risk for osteoporosis. Information Technology (IT) implemented the EMR OST calculation, which currently generates a daily filtered list of all patients with an OST score <2; patients with an OST score < 2 are then mailed letters approximately 3 months after their admission informing them of their risk for osteoporosis and suggesting that they schedule a follow-up appointment with a physician for further evaluation. To test the effectiveness of this system in prompting patients toward osteoporosis evaluation, approximately 3 months after letters were mailed, the patients were contacted via telephone and asked a series of questions to determine if the patients had sought osteoporosis evaluation.Results:In the intervention group, 67 (58.26%) of 115 did not schedule a follow-up, while the remaining 48 (41.74%) did seek a follow-up. Thus, the patient follow-up response rate improved with letter intervention using the OST score as an indicator (P < .0001) compared to historical controls (14.29%).Conclusion:Implementing an EMR OST score which identifies patients at risk for osteoporosis, which generates an automatic letter to the patient, significantly promotes patient driven osteoporosis evaluation compared to historical controls.

Abstract 17187: Misinterpretation of Q-waves in Ventricular Septal Defect and Tetralogy of Fallot Patients by Non-Adult Congenital Heart Disease Specialists

Introduction: Tetralogy of Fallot (TOF) and Ventricular Septal Defect (VSD) patients have non-diagnostic Q-waves within inferior (II, III, aVF) or septal (V1-V2) leads on ECG, perhaps due to incomplete conduction through septal defects. Non-diagnostic Q-waves tend to either be wide within a single lead, or deep (3-4mm) in contiguous leads, but do not meet diagnostic criteria for infarct. Hypothesis: Non-Adult Congenital Heart Disease (ACHD) physicians may inaccurately characterize non-diagnostic Q-waves as pathologic opposed to expert interpretation by ACHD-trained physicians in VSD and TOF patients. Thus, misinterpreting ECGs to suggest prior infarct and decreasing their positive predictive value (PPV). Methods: With application of pre-specified inclusion and exclusion criteria, we retrospectively reviewed 72 ECGs from TOF or VSD patients at Penn State Hershey Medical Center from 2002-2020 that were separately read by ACHD and non-ACHD specialists. Primary outcomes were ECGs with diagnosed Q-waves in two separate distributions, inferior or septal leads, by both groups using standard criteria for Q-wave infarct. Reported measures were sensitivity, specificity, PPV, and negative predictive value (NPV). Results: The 72 subjects with isolated TOF or VSD had a mean age of 39 years and 63% were male. Total disease prevalence (presence of Q-waves) was 4.6%. Q-wave infarct diagnosed by non-ACHD physicians had a sensitivity and specificity of 33% and 74% respectively. Their PPV was 5.87% and NPV was 95.85%. Conclusions: This retrospective cohort analysis of TOF and VSD patient ECGs showed the low PPV of non-ACHD physician diagnosis of Q-waves in this respective population. Misinterpretation and misdiagnosis of infarct based off ECG, has ramifications for both the patient and medical system as a whole. Sequelae include, but are not limited to, increasing patient risk for unwarranted medical treatment and affecting hospital billing and insurance coverage.

Abstract 15865: Analysis of Left Ventricular Assist Device Hemodynamics During Right Heart Catheterization Ramp Studies

Background: Although hemodynamic-driven Left Ventricular Assist Device (LVAD) speed changes have been shown to improve patient outcomes, there is no standardized algorithm for how to best adjust LVAD speed for optimization of cardiac output (CO) and decompression of left sided filling pressures as measured by pulmonary capillary wedge (PCW). Methods: We performed a retrospective study of LVAD patients at Penn State Hershey Medical Center from 2015 to present, to identify those that ramp studies during right heart catheterizations. 470 patients were identified, of which 60 had ramp studies. Only studies with at least 4 of 5 standard ramp speeds were included. Any study that did not exhibit at least a 20% decrease in PCW, suggesting improper LVAD function or recovered heart function, was also excluded. 32 studies were included in final analysis: 11 HVAD, 12 HMIII, and 9 HMII. CO measured by thermodilution was reported. Standard ramp speeds, in rpm, were as follows: HVAD (2100, 2400, 2700, 3000, 3300), HMIII (4500, 5000, 5500, 6000, 6500), and HMII (8000, 9000, 10,000, 11,000, 12,000). Results: Combined data showed an average CO improvement of 22.3% and average PCW decrease of 89.7%. HMII and HMIII had similar improvements in CO, 44.4% and 43.8%, respectively; much greater than HVAD (17.2%). HMIII had the largest magnitude of decompression 141.5% versus 106.4% for HMII and 56.1% for HVAD. Suction events occurred at an overall rate of 9.4%, and were greatest in HVADs. Conclusion: We report the ramp study hemodynamics for three separate LVADs. Overall, our results suggest the HMIII is most responsive to changes in speed in terms of improvement of CO and decreased PCW. Addition of samples to this analysis may allow for algorithm development to provide clinical guidance regarding LVAD speed settings.

391 Adverse Effects Associated With the Use of Electronic Vaping Products on Adolescents and Young Adults

Despite the increasing prevalence of the use of electronic vaping products (vapes) among adolescents and young adults, few studies have examined the clinical symptoms associated with vaping. The goal of this study was to examine the prevalence of vaping, to identify symptoms that may be associated with vaping, and to understand beliefs about vaping that may contribute to its growing prevalence. A questionnaire was administered to a convenience sample of subjects aged 12-23 years presenting for medical care to Penn State Hershey Medical Center in central Pennsylvania. The questionnaire focused on use of vapes, presence of clinical symptoms during the previous six months, and perceived beliefs associated with vaping. Stratification was performed to compare subjects who used vapes frequently (at least once a month) and those who were infrequent/non-users (never tried or tried one time). Data analysis was performed on 498 completed questionnaires. The mean age of subjects was 17 years old and 56% were female. 80% (n=396) of subjects were considered infrequent/non-users and 20% (n=102) were considered frequent users. When stratified by frequency of use, frequent users were more likely to report the following symptoms in the last six months compared to infrequent/non-users: headache [67% (95% CI: 57-76) vs. 55% (95% CI: 50-60), P=.04], nausea [61% (95% CI: 51-70) vs. 42% (95% CI: 38-47), P=.0009], cough [54% (95% CI: 44-64) vs. 38% (95% CI: 33-43), P=.004], sleep disturbances [53% (95% CI: 43-63) vs. 38% (95% CI: 33-43), P=.006], dehydration [51% (95% CI: 41-61) vs. 35% (95% CI: 30-40), P=.003], weakness [47% (95% CI: 37-57) vs. 28% (95% CI: 23-32), P=.0002], racing heart [46% (95% CI: 57-76) vs. 27% (95% CI: 23-32), P=.0002], chest pain [40% (95% CI: 31-50) vs. 28% (95% CI: 24-33, P=.02], tremors/shakiness [27% (95% CI: 19-37) vs. 15% (95% CI: 11-19), P=.002]. There were no significant differences in reported dizziness and abdominal discomfort between the two groups. In respect to perceived beliefs about electronic vaping products, 53% of respondents believed that they “can help someone quit smoking,” 36% believed that they “are safer than cigarettes,” 30% believed that they “are less addictive than cigarettes,” and 27% believed that they “are just for fun.” Based on our preliminary data, 20% of respondents use electronic vaping products at least once a month. Frequent users were more likely to report headache, nausea, cough, sleep disturbances, dehydration, weakness, racing heart, chest pain, and tremors/shakiness. The perceived beliefs about vapes could be related to their growing use among a younger population.

Changes in the Plantarflexion Moment Arm of the Achilles Tendon Following Total Ankle Arthroplasty

Category:Ankle; Ankle ArthritisIntroduction/Purpose:Deficits in ankle joint kinetics following total ankle arthroplasty (TAA) may be attributed to a reduction in the force-generating capacity of ankle joint muscles, but it is also important to consider the alterations to joint structure that may accompany this procedure. One key parameter indicative of joint structure with the potential to be influenced by TAA is the plantarflexion moment arm of the Achilles tendon (ATma). ATma is an indicator of the potential for the tendon force to produce plantarflexion moment that is determined by the three-dimensional line of action of the tendon relative to the ankle joint axis. The purpose of this study was to assess pre-to-post TAA changes in ATma; we hypothesized that pre- and post-TAA moment arms would not be different.Methods:We tested 10 TAA patients (age at surgery: 62.86 +- 9.72 y; height: 1.72 +- 0.08 m; body mass: 97.81 +- 20.89 kg) at pre-operative (˜ 1 mo pre) and post-operative (˜6 mo post) visits. All procedures involving testing of human subjects were approved by the Penn State Hershey Medical Center Institutional Review Board. ATma were measured using a method that combined ultrasound imaging of the tendon with 3D motion tracking of both the ultrasound probe and the ankle joint. The tendon and joint axis were located during trials in which the patients were seated with the knee extended while the ankle joint was voluntarily rotated in the sagittal plane. We also examined sagittal-plane weightbearing radiographs (pre- and post-op) to determine the AP distance from the center of the talar dome to the posterior margin of the calcaneus. Pre- and post-op ATma were compared using a paired t-test and regression.Results:No significant mean differences were found between post-op ATma and pre-op ATma (p = 0.360). Despite this, some patients were found to have large differences between pre- and postoperative ATma. For example, participants 1, 3, and 8 exhibited changes of -54.22%, +64.14% and +123.98% (pre-to-post) respectively (Figure 1). A moderate correlation between pre- and post-op ATma was found (r2 = 0.461, p = 0.031), indicating that only 46.1% of the variance in post-op ATma was explained by pre-op ATma (Figure 1). The normalized AP distance measured from the radiographs did not significantly change on average pre- to post-TAA (p = 0.561), and we found the change in this distance to correlate with the change in ATma (r2 = 0.370, p = 0.062).Conclusion:This is the first investigation of whether TAA alters ATma. Our results supported our hypothesis that pre-operative ATma predicts post-operative ATma. However, our hypothesis is supported only when the mean differences are considered, as there were sizeable differences for individuals. Despite a non-significant average change in ATma following TAA, at the individual level substantial changes in ATma were observed in seven of the 10 patients. Change in ATma was only partly explained by change in the AP position of the talar dome. Change in ATma has potential consequences for function in terms of ankle plantarflexor strength and walking velocity.

Sa2062 TRANSANAL ENDOSCOPIC SUBMUCOSAL DISSECTION USING THE FLEX® ROBOTIC SYSTEM (MEDROBOTICS) BY A GASTROENTEROLOGIST: A CASE SERIES

Precancerous rectal lesions not amenable to standard mucosal resection and early T1a cancers are effectively treated with endoscopic submucosal dissection. Recently, a robotic endoscope with potential to expand and improve efficiency of transanal procedures has been approved by the FDA for transanal use. This scope provides access for two accessories capable of multiple freedoms of movement allowing effective dissection of tissue. The endoscopic surgeon uses both his hands, divorced from the scope controls for the dissection. We present the first case series of a gastroenterologist using the Flex® Robotic System for endoscopic submucosal resection of advanced rectal lesions. A retrospective review of patients was approved by the Institutional Review Board at Penn State Hershey Medical Center. Clinical data for the 7 consecutive patients was collected including length of the procedure, length of stay, location of mass, size of mass, and details of the procedure. Data on patient demographics including BMI, age, and ASA score were also collected. Procedural notes from prior to the robotic resection, the robotic resection itself, and follow-up endoscopic evaluation after robotic resection were all reviewed. Of the 7 patients listed for procedure, 2 cases were abandoned; one due to evidence of T2 cancer and another due to anal stenosis. Among the rest, 3 used the robotic device alone while 2 of the cases used traditional ESD in addition to the robotic device. Reasons for needing to use conventional methods included equipment issues with suctioning using the robotic device and need for improved visualization of a bleed occurring in a difficult location. Average age of the patients was 62, BMI was 30, and ASA score was 3. Average size of the lesions resected was 4.4cm x 5.0cm. Final pathology included one tubulovillous adenoma, one tubular adenoma with high grade dysplasia, one tubulovillous adenoma with high grade dysplasia, and two with adenocarcinoma. The robotic scope represents a true advancement in the endoscopic surgical platform. Advantages of the robotic system include the ability to use traction and counter-traction which allow for precise control and ease of dissection as well as stabilization of the resection field, allowing for faster dissection with seemingly less bleeding. In addition, the 3D vision of the robotic system allows for excellent sense of tissue planes, even without the use of submucosal elevation. Disadvantages include the need for anal dilation and general anesthesia. The current robot lacks suction and submucosal injection capabilities. Additional weaknesses include limited length reached within the rectum and maneuverability of the device. With improvement of technique and technology, endoscopists skilled in both conventional and robotic ESD could minimize the need for proctectomy.Figue 2Endoscopic robotic suturing after dissection of the rectal mass lesionView Large Image Figure ViewerDownload Hi-res image Download (PPT)

Use of Complementary and Alternative Medicine in Children With Tourette Syndrome.

Tourette syndrome is a neuropsychiatric condition defined by motor and phonic tics with onset in childhood. Many families have concerns regarding potential side effects of pharmacologic treatments, and often have difficulty accessing comprehensive behavioral intervention for tics. Patients and caregivers may turn to complementary and alternative medicine (CAM) as they perceive these as "natural" and therefore "safe." Although there are anecdotal reports of an increased use of CAM in Tourette syndrome patients, the exact prevalence is unknown. The purpose of this study was to identify commonly used CAM therapies for children with Tourette syndrome at Penn State Hershey Medical Center. A questionnaire was administered to the caregivers of children (<18 years old) via telephone. The data pertaining to demographics, type of CAM use, duration of use, adverse effects, and caregiver's perception of the effectiveness were collected. A total of 110 patients participated in this survey. When inquired about the different CAM methods, 69.1% of the participants reported using 1 or more CAM therapies, and 58% of those who used CAM informed the doctor about their use. Ninety-three percent of those who used CAM therapy reported a decrease in tic frequency. The most commonly used CAM therapies were stress management (44.6%), herbal medicine (18.2%), homeopathy (12.7%), and meditation (9.1%). In total, 46% of the participants said that CAM helped more than medication. The majority of patients interviewed were using CAM therapies, and a significant portion reported benefit greater than medication. More than half of all participants discussed CAM therapies with their physicians, and 63% of participants felt that their physicians would support their use of CAM therapies.

Noninferior Outcomes between Central versus Percutaneous Right Ventricular Assist Device Support Immediately after LVAD Placement

Postoperatively, left ventricular assist device (LVAD) implantation can be complicated by right ventricular failure in up to 40% of patients. Typically, temporary right side mechanical circulatory support (MCS) necessitates re-sternotomy and central placement of pulmonary artery and right atrial cannulas. However, percutaneous right ventricular assist device (pRVAD) can be placed without need for reoperation. Minimal literature exists comparing pRVAD with surgical RVAD (sRVAD) in patients in right heart failure that underwent LVAD placement. We believe that these two techniques are equally efficacious and can produce similar outcomes. Data from Penn State Hershey Medical Center was retrospectively reviewed. Characteristics and outcomes of patients receiving RVAD support during the same hospitalization as LVAD implant were evaluated. Between 2013 and 2019, 22 patients were identified who underwent LVAD implant and subsequent RVAD MCS. 14 patients required sRVAD (mean age 56), and 8 required pRVAD (mean age 54). 85% of sRVAD patients had support initiated intraoperatively at the time of LVAD insertion, while only 25 % of pRVAD patients had intraoperative support (range 0 to 9 days following LVAD implant). Despite later initiation of support in pRVAD patients, hospital mortality was similar between groups (57% vs 62% with sRVAD & pRVAD, respectively). Duration of RVAD MCS was similar between those who survived to RVAD explant (mean 16.7 days vs 17.8 days in 11 sSVR and 5 pSVR patients, respectively). Those who survived had similar total LOS (70 vs 69 days) and ICU LOS (54.0 vs 57.4 days). Interestingly, maximum CVP in the 24 hours following RVAD implant was found to be lower in only 21% of sRVAD patients, while it was reduced in 89% of pRVAD patients. In addition, among those who survived and did not receive a tracheostomy (6 surgical and 5 percutaneous), pRVAD patients had shorter mean duration of ventilation (13.2 days v 30.8 days). Rates of CRRT were similar (64% vs 62%), and average decrease in creatinine by postoperative day 3 was also similar (-0.02 vs 0.25). Percutaneous RVAD is an effective method of right heart MCS that can avoid the morbidity of reintubation and general anesthesia in the operating room, and achieve comparable outcomes to surgically placed RVAD while avoiding return to the operating room.

Long-term outcomes in the treatment of acquired hemophilia A: a 16-year single institution prospective cohort experience.

: Acquired hemophilia A (AHA) is a rare bleeding disorder caused by autoantibodies against coagulation factor VIII. We conducted a single institution prospective cohort study to assess treatment strategies and long-term outcomes in AHA patients and provide further evidence for effective treatment and relapse timing. A total of 25 patients diagnosed with AHA between 2001 and 2017 at Penn State Hershey Medical Center were prospectively followed. Information was collected on factor VIII activity and inhibitor titer at diagnosis, treatment regimen(s), complete remission, and relapse time. For immunosuppressive therapy (IST), 19 patients were treated initially with prednisone and cyclophosphamide, four were treated with prednisone, one with prednisone and rituximab, and one with prednisone and second-line rituximab. 13/17 (76%) evaluable patients treated with prednisone and cyclophosphamide achieved complete remission. Four patients received rituximab as second-line therapy (inhibitor titers 34, 122, 416, and 768 BU); three achieved complete remission and one died from sepsis. Both evaluable patients receiving initial prednisone alone achieved complete remission. Five relapses occurred from 17 days to 7 years; all were treated with prednisone and cyclophosphamide and achieved complete remission. IST with prednisone and cyclophosphamide is highly effective in achieving and maintaining complete remission, even for relapsed patients. Despite dual IST with prednisone and cyclophosphamide, some patients, particularly with extremely high inhibitor titers, required addition of second-line rituximab to achieve complete remission. This supports rituximab as effective salvage treatment, including for patients with inhibitor titers at least 100-200 BU. Those who experienced relapse often did so years after complete remission, signifying importance of continued monitoring and vigilance.