Prior Attempts Research Articles

The impact of music therapy on opioid use in cancer survivors with chronic pain.

e24124 Background: Chronic pain and persistent opioid use are significant problems for many cancer survivors. Opioid tapering comes with major challenges. It is therefore recommended that cancer survivors learn non-pharmacological techniques to support opioid tapering. Methods: The purpose of this pilot study ( N = 26) was to examine the benefits of interactive music therapy (IMT) for opioid tapering in cancer survivors with chronic pain who are persistent opioid users. Those with a history of polysubstance abuse/substance use disorder or who were receiving maintenance methadone or suboxone were excluded. Participants were randomized to 10 weekly, individual IMT ( n = 14) or social attention control ( n = 12) sessions. We measured daily opioid use and chronic pain outcomes (pain interference, pain-related self-efficacy, and pain intensity) at baseline, post-intervention (week 10) and 3-month follow-up (FU). We also conducted semi-structured interviews to gain understanding of participants’ perspectives on the usefulness of IMT for opioid tapering. We modeled the pattern of mean daily opioid dose change over time using multilevel models. The cross-level interaction between time and treatment was used to determine the effect of treatment condition on the pattern of change in the target outcomes. We used restricted maximum likelihood to estimate model parameters and to test the significance of random effects. Given the small sample size, we relied on effect sizes for interpretation. Interview transcripts were analyzed using thematic analysis. Results: Participants were 58±13 years old. Most participants identified as female (58%), not Hispanic or Latino (92%), and white (58%) or Black (38%), and reported to have had breast (23%), cervical (8%), lung (8%), or melanoma skin cancer (8%). A total of 85% of participants said that they were quite to very motivated to taper their opioid use. About one third had had prior opioid tapering attempts and 31% stated that they had concerns related to opioid tapering. We found a large effect of IMT on mean daily opioid use at week 10 ( η2p = 0.36) and at 3-month FU ( η2p = 0.27). There was a medium effect of IMT on pain interference at week 10 ( η2p = 0.18) and a large effect at 3-month FU ( η2p = 0.30). For pain-related self-efficacy, we found a medium effect at week 10 ( η2p = 0.21) and small effect at 3-month FU ( η2p = 0.09). IMT resulted in a small treatment effect for pain intensity at week 10 and at 3-month FU (week 10: η2p = 0.05; 3 month: η2p = 0.09). The quantitative results were congruent with the qualitative findings as many IMT participants reported feeling more “in control” of their pain and being able to apply the music-based self-management strategies outside of the sessions to help with pain management and improve their functioning. Conclusions: These promising findings warrant further research on the effects of IMT on opioid tapering and chronic pain management in cancer survivors. Clinical trial information: NCT03782506 .

Revision for instability following reverse total shoulder arthroplasty: outcomes and risk factors for failure.

Revision of unstable reverse shoulder arthroplasty (RSA) is significantly challenging with recurrence rates ranging 20-40%. The purpose of this study was to identify factors associated with recurrent instability. The factors studied included 1) indication for the revision RSA (failed primary RSA vs failed revision RSA), 2) previous attempts at stabilization, 3) mechanisms of instability, 4) clinical history of instability, and 5) surgical technique. Outcomes were reported in patients with 2-year follow-up. All patients undergoing RSA for instability were identified at our institution. A total of 43 surgeries in 36 patients were included. Arthroplasty indication prior to instability (14 failed primary RSA vs 22 failed revision RSA), instances of prior attempts at stabilization (14 patients treated outside), mechanism of instability classification, clinical history of instability (17 recurrent, 26 chronic), and surgical technique were collected. Stability at final follow-up (min.12 months), and clinical outcomes at 2-year follow-up were assessed. Overall, 32/36 patients (89%) required 38 revisions to achieve stability at final follow-up (average 53±47 months; range: 12-210 months). When comparing stability to indication, 13/14 (93%) patients in the failed primary group were stable (average 65±59 months; range 12-210 months compared to 19/22 (86%) in the failed revision group (45±36 months; range: 12-148 months, p=0.365). Average number of procedures per patient was 3 in the failed primary group (range: 2-10) compared to 4.5 in the failed revision group (range: 3-7; p = 0.008). Stability was achieved in 12/14 (86%) patients with history of failed stabilization procedures. The mechanism leading to persistent instability was loss of compression. Stability was achieved in 14/16 patients treated for recurrent instability compared to 18/20 treated for chronic/locked dislocation (p = 0.813). Continued instability occurred in 33% of patients managed glenoid-sided only, 33% humeral-sided only, and 10% of bipolar revision tactics performed. At 2-year follow-up, 18/21 patients evaluated were found to be stable with improvements in ASES, FF, ABD, ER, and SST (p=0.016, <0.01, 0.01, <0.01, and 0.247 respectively). Patients who had multiple revisions after failed previous arthroplasty will require more surgical attempts to achieve stability compared to patients who had a revision after a failed primary RSA. Loss of compression was the most common mechanism for persistent instability. Recurrent instability was more reliably stabilized than chronic/locked dislocations. Continued instability was noted in 1/3 of patients with humeral-sided only or glenoid-sided only revisions and in 10% of patients undergoing bipolar revisions. Successfully stabilized patients had improved clinical outcomes.

Assessing and measuring leadership identity.

This article explores numerous complexities involved in assessing and measuring leadership identity development. It also reviews leader and leadership identity as well as prior attempts to assess leader and leadership identity development. Recommendations for effective assessment and measurement practices when diagnosing development in leader and leadership identity are offered.

A genomic score to predict local control among patients with brain metastases managed with radiation.

2011 Background: Clinical predictors of local recurrence following radiation among patients with brain metastases (BrM) provide limited explanatory power. As a result, radiation doses and fractionation schemes are prescribed with a “one-size-fits-all” approach. We sought to develop a DNA-based signature of radiation-based efficacy among patients with BrM, utilizing readily testable genes, to identify subpopulations at greater vs. lesser risk of recurrence. Methods: We retrospectively identified 570 patients with 1,487 distinct BrM managed with whole-brain (WBRT) or stereotactic radiation therapy (SRS/SRT) at a tertiary cancer center (2013-2020) for whom next-generation sequencing panel data (OncoPanel, 239 genes) were available on at least one tumor specimen. Local recurrence was assessed in a manner consistent with Response Assessment in Neuro-Oncology – Brain Metastases guidelines (i.e., radiographic enlargement of &gt;20% in maximal cross-sectional diameter). Enlarging lesions managed with salvage treatment prior to &gt;20% enlargement were considered to have recurred on the date of salvage therapy. Fine/Gray’s competing risks regression was utilized to compare local recurrence on a per-metastasis level among patients with vs. without somatic alterations of likely biological significance across 84 OncoPanel genes with a mutational frequency &gt;0.5%. Genes with a q-value&lt;0.10 were utilized to develop a numeric “Brain-Radiation Prediction Score” (“Brain-RPS”) to quantify local recurrence risk. Results: Genomic alterations of potential biological relevance in 11 ( ATM, MYCL, PALB2, FAS, PRDM1, PAX5, CDKN1B, EZH2, NBN, DIS3, MDM4) and two genes ( FBXW 7 and AURKA) were associated with a decreased or increased risk of local recurrence, respectively (q-value&lt;0.10). Weighted scores corresponding to the strength of association with local failure for each gene were summed to calculate a patient-level RPS. On multivariable Fine/Gray’s competing risks regression, RPS [1.66 (1.44-1.92, p&lt;0.001)], metastasis-associated edema [1.89 (1.38-2.59), p&lt;0.001] and receipt of WBRT without SRS/SRT or neurosurgical resection [2.73 (1.78-4.20), p&lt;0.001] were independent predictors of local failure. Conclusions: We developed a genomic score that can be calculated from an extracranial or intracranial site to quantify local recurrence risk following brain-directed radiation. Prior attempts to develop a biomarker-based radiation response signature have not been BrM-specific and have primarily relied on RNA-based measures of radiosensitivity, limiting their utility in clinical practice. To our knowledge, this represents the first study to systemically correlate DNA-based alterations with radiation-based outcomes among patients with BrM. If validated, Brain-RPS has potential to facilitate clinical trials aimed at genomic personalization of radiation treatment among patients with BrM.

Phase 1b multicenter study to evaluate CHM 1101 in patients with recurrent or progressive glioblastoma.

TPS2086 Background: Glioblastoma multiforme (GBM) is the most common and most aggressive primary brain tumor. More than 300,000 new cases are diagnosed globally with over 250,000 deaths each year (Sung H, et al. CA Cancer J Clin. 2021). Patients with recurrent GBM have a poor prognosis, with limited treatment options and a median survival of less than 1 year (Gallego. Curr Oncol, 2015). While prior attempts to treat GBM with chimeric antigen receptor (CAR) T-cells have been limited by tumor heterogeneity, chlorotoxin (CLTX)-directed CAR T-cells in mice demonstrated broad anti-tumor activity and prolonged survival with no off-tumor toxicity or antigen escape (Wang, et al. Sci Transl Med, 2020). CLTX, a 36–amino acid peptide identified in scorpion venom, selectively binds to malignant glioma cells through matrix metalloproteinase-2 (MMP2) and clinical administration of CLTX-based biologics has been well tolerated in patients (Mamelak, et al. J Clin Oncol, 2005, Patil, et al. Neurosurgery, 2019). CHM 1101 is the first CAR T to utilize CLTX as its tumor targeting domain for autologous CAR T-cell therapy. A single-center first-in-human phase 1 study of CHM 1101 in patients with recurrent GBM is ongoing. Methods: Clinical Trial NCT05627323 is a phase 1b, multi-center study of CHM 1101 in adult subjects with MMP2+ recurrent or progressive GBM after standard therapy. After leukapheresis and tumor resection, pts will receive CHM 1101 at Dose Level 1 (240 × 106 CAR T cells) or Dose Level 2 (440 x 106d CAR T-cells), divided across 3 once-weekly intracranial (intracavitary and intraventricular) administrations; after disease assessment at 28 days, additional doses of CHM 1101 can be administered on a weekly schedule. Eligible subjects have a prior histologically confirmed diagnosis of a grade 4 GBM, a grade 2 or 3 malignant glioma with radiographic progression consistent with a grade 4 GBM (IDH wild type), grade 4 diffuse astrocytoma (IDH mutant), or a unifocal relapse of GBM. MMP2+ tumor expression is confirmed by IHC (≥20% moderate/high MMP2 score [2+ or 3+]). The primary endpoint is safety; key secondary endpoints include feasibility, progression-free survival, overall survival, response rate (RANO criteria), and cellular kinetics. Recruitment is ongoing. Clinical trial information: NCT05627323 .

Outcomes of Surgical Treatment of Malar Mounds and Festoons.

Malar mounds (congenital) and festoons (acquired) are persistent puffiness in the prezygomatic space between the orbicularis retaining ligament (ORL) and zygomatico-cutaneous ligament (ZCL). Non-surgical treatments often yield unsatisfactory results. This paper aims to demonstrate a surgical approach for the treatment of malar bags by outlining the author's surgical technique of treating malar mounds and festoons and reviewing outcomes in 89 cases. Correction of malar mounds and festoons was achieved with subciliary skin-muscle flap, release of the ORL and ZCL, midface lift, canthopexy, and muscle suspension. We performed a retrospective study of 89 patients, all of whom had surgical correction of malar mounds or festoons in the past 10 years and a follow-up period of at least 6 months. This study was conducted over the course of the past year and involved reviewing patient charts in the office. Specifically, patient data spanning 2012 to 2022 were analyzed. The predictor variable in this study is the specific class of malar bags the patient has, as determined by the underlying pathophysiology. Outcome variables include the presence or absence of prolonged lid or malar edema, necessary re-excision of excess orbicularis oculi of the subciliary area, lid malposition, permanent visual changes, the need for additional non-operative treatment, and recurrence requiring reoperation. The majority of patients presented with acquired festoons (81/89) with prior attempts of correction (49/89). The mean follow-up is 11.2 months. Persistent malar edema (> 6 weeks) was documented in 14 patients and mainly resolved with Medrol Dosepak (methylprednisolone) and hydrochlorothiazide. A two-proportion Z-test was conducted, comparing the proportion of patients with poor protoplasm who experienced postoperative malar edema to the proportion of those with excellent protoplasm who experienced postoperative malar edema. A p-value of 3.414e-7 was obtained, indicating a statistically significant difference of proportions between the two groups. Five patients received additional injections of deoxycholic acid and two needed fillers for smoother contour of the lower eyelids. Two patients with severe malar mounds required multiple reoperations including direct excision in one patient. One incidence of transient lid retraction was reported in a patient with previous facelift and facial nerve injury. Malar mounds and festoons present a unique challenge to plastic surgeons. They are persistent in nature and require close-interval, long-term follow-up as additional injections and reoperations are warranted. Our approach to malar mound and festoon correction is safe and effective and provides long-lasting results. This journal requires that authors assign a level of evidence to each article. For a full description of these Evidence-Based Medicine ratings, please refer to the Table of Contents or the online Instructions to Authors www.springer.com/00266 .

0655 Whose Mind after Midnight? Demographic and Clinical Variation in Nocturnal Suicide Risk

Abstract Introduction Although suicides are more prevalent during the day, the risk of suicide is highest at night when adjusted for population wakefulness. It is unclear how nighttime patterns of suicide risk vary by demographic and clinical subgroups. Methods Population wakefulness data were combined with time of fatal injury data for 78,647 suicides from 2003-2017. The primary outcome was number of suicides per hour with wakefulness as an offset/exposure term. Subgroups included sex, race, ethnicity, military service, blood alcohol category and marijuana positive on autopsy, current depressed mood or partner conflict, and prior suicidal ideation or suicide attempts. Formal interaction tests identified significant subgroup variations adjusted for age, sex, race, and ethnicity where appropriate. Groups with significant interactions were subsequently examined using robust Poisson regression models to measure incident risk ratios (IRRs). Results There were subgroup interactions for age (p &amp;lt; 0.001), ethnicity (p = 0.014), blood alcohol level on autopsy (p &amp;lt; 0.001), and current partner conflict at time of fatal injury (p &amp;lt; 0.001). There was a sharp peak in risk around 4AM for individuals aged 15 to 24 (aIRR: 3.11 [2.39, 4.05]) and 25-34 (aIRR 2.15 [1.63, 2.86]), and at 6AM for individuals aged 65 to 74 (aIRR: 1.78 [1.40, 2.25]) and 75+ (aIRR: 2.25 [1.69, 3.00]). Hispanic individuals had an elevated risk between 10PM and 3AM with a maximal 232% increase at 2am (aIRR: 2.32 [1.67, 3.23]). Current partner conflict increased risk from 8PM to11PM and from 1AM to 3AM with a peak risk at 11PM (aIRR: 1.53 [1.24, 1.89]). Individuals with a BAL &amp;lt; 0.08 mg/dL showed a sustained increased risk for suicide between 8PM and 4AM; individuals with a BAL of 0.08 mg/dL or more showed greater risk (aIRR 2.33 [1.88, 2.89] at 1AM) than those with a BAL &amp;lt; 0.08 mg/dL (aIRR: 1.68 [1.40, 2.01] at 12AM). Conclusion Nighttime suicide risk varied significantly by age, ethnicity, blood alcohol level on autopsy, and current partner conflict. Military service was not associated with greater nighttime risk, which contrasts with prior findings. Support (if any)

Factors associated with surgeon recognition of mental health care opportunities and inclination to attend to mental health

PurposeA notable percentage of people that die by suicide have had a medical visit within a few months of their death. In a survey-based experiment, we evaluated: 1) whether there are any surgeon, setting, or patient factors associated with surgeon rating of mental health care opportunities, and 2) if there are any surgeon, setting, or patient factors associated with likelihood of mental health referrals. MethodsOne hundred and twenty-four upper extremity surgeons of the Science of Variation Group viewed five scenarios of a person with one orthopedic condition. The following aspects of the scenarios were independently randomized: Social worker or psychologist available, office workload, socioeconomic status, gender, age, mental health factors, mental health clues, and diagnosis. ResultsAccounting for potential confounders, surgeon likelihood of discussing mental health was associated with cancer, disadvantaged socioeconomic status, mental health factors other than being shy, prior suicide attempt, history of physical or emotional abuse, isolation, and when the office is not busy. Factors independently associated with higher likelihood of referring a patient for mental health care included cancer, disadvantaged socioeconomic status, mental health cues, mental health risk factors, and a social worker or psychologist available in the office. ConclusionUsing random elements in fictitious scenarios we documented that specialist surgeons are aware of and attuned to mental health care opportunities, are motivated to discuss notable cues, and will make mental health referrals, in part influenced by convenience.

Effectiveness, safety, and patient reported outcomes of a planned investment procedure in higher-risk chronic total occlusion percutaneous coronary intervention:Rationale and design of the invest-CTO study.

The anatomical complexity of a chronic total occlusion (CTO) correlates with procedural failure and complication rates. CTO modification after unsuccessful crossing has been associated with subsequent higher technical success rates, but complication rates remain high with this approach. While successful CTO percutaneous coronary intervention (PCI) has been associated with improved angina and quality of life (QOL) this has not been demonstrated in anatomically high-risk CTOs. Whether a planned CTO modification procedure, hereafter named Investment procedure, could improve patient outcomes has never been investigated. Invest-CTO is a prospective, single-arm, international, multicenter study, evaluating the effectiveness and safety of a planned investment procedure, with a subsequent completion CTO PCI (at 8-12 weeks), in anatomically high-risk CTOs. We will enroll 200 patients with CTOs defined as high-risk according to our Invest CTO criteria at centers in Norway and United Kingdom.Patients with aorto-ostial lesions, occlusion within a previous stent, or a prior attempt at target vessel CTO PCI within 6 months will be excluded. The co-primary endpoints are cumulative procedural success (%) after both procedures, and a composite safety endpoint at 30 days after completion CTO PCI. Patient reported outcomes (PROs), treatment satisfaction, and clinical endpoints will be reported. This study will prospectively evaluate the effectiveness and safety of a planned two staged PCI procedure in the treatment of high-risk CTOs and may have the potential to change current clinical practice.

Osteochondral Autograft Transplantation for Proximal Pole Scaphoid Nonunions

Osteochondral autograft transplantation (OAT) is a technique to reconstruct the proximal pole scaphoid nonunion associated with an intact dorsal and volar scapholunate ligament. This study aimed to report the clinical and radiographic outcomes in patients who underwent OAT for this indication. A retrospective review of patients who underwent proximal pole scaphoid nonunion reconstruction with a femoral trochlea OAT was undertaken between 2018 and 2022. Patient demographics, scaphoid nonunion characteristics, surgery details, and clinical and radiographic outcomes were obtained. Eight patients underwent the procedure at an average of 18.2 months from injury. Four patients failed prior attempts at scaphoid union surgery, one of whom failed two prior surgeries. Four had no prior surgery. The average follow-up was 11.8 months. The postoperative wrist flexion-extension arc of motion was 125° or 87% of the contralateral wrist. Grip strength averaged 30.0 kg or 86% of the contralateral side. Adjusted grip strength for hand dominance was 81% of the contralateral side. All OATs healed. Computed tomography scan confirmed the union in 6 patients between 6 and 10 weeks. Two patients whose radiographs demonstrated OAT incorporation at the time of follow-up did not undergo advanced imaging. Osteochondral autograft transplantation is an attractive surgical reconstructive procedure for patients with proximal pole scaphoid nonunions associated with an intact scapholunate ligament. Osteochondral autograft transplantation mitigates the need for vascularized bone grafting, has a rapid time to osseous incorporation, and has a simple postoperative course in which patients can expect early union, near-full range of motion, and grip strength. Therapeutic V.

Computer vision quantitation of erythrocyte shape abnormalities provides diagnostic, prognostic, and mechanistic insight

AbstractExamination of red blood cell (RBC) morphology in peripheral blood smears can help diagnose hematologic diseases, even in resource-limited settings, but this analysis remains subjective and semiquantitative with low throughput. Prior attempts to develop automated tools have been hampered by their poor reproducibility and limited clinical validation. Here, we present a novel, open-source machine-learning approach (denoted as RBC-diff) to quantify abnormal RBCs in peripheral smear images and generate an RBC morphology differential. RBC-diff cell counts showed high accuracy for single-cell classification (mean AUC, 0.93) and quantitation across smears (mean R2, 0.76 compared with experts, interexperts R2, 0.75). RBC-diff counts were concordant with the clinical morphology grading for 300 000+ images and recovered the expected pathophysiologic signals in diverse clinical cohorts. Criteria using RBC-diff counts distinguished thrombotic thrombocytopenic purpura and hemolytic uremic syndrome from other thrombotic microangiopathies, providing greater specificity than clinical morphology grading (72% vs 41%; P < .001) while maintaining high sensitivity (94% to 100%). Elevated RBC-diff schistocyte counts were associated with increased 6-month all-cause mortality in a cohort of 58 950 inpatients (9.5% mortality for schist. >1%, vs 4.7% for schist; <0.5%; P < .001) after controlling for comorbidities, demographics, clinical morphology grading, and blood count indices. RBC-diff also enabled the estimation of single-cell volume-morphology distributions, providing insight into the influence of morphology on routine blood count measures. Our codebase and expert-annotated images are included here to spur further advancement. These results illustrate that computer vision can enable rapid and accurate quantitation of RBC morphology, which may provide value in both clinical and research contexts.

Impact of Dental Treatment on Oral Health-Related Quality of Life of Patients.

It is crucial to understand how individuals perceive the impact of oral disorders and the treatment associated with or received for those disorders on their quality of life. A relatively new but quickly spreading concept of oral health-related quality of life (OHRQoL) that notably affects three fields, clinical dental practice, dental research, and dental education makes it feasible to figure out the relationship between oral health and its impact on the quality of life of an individual. OHRQoL can be measured in various ways; the most well-liked method uses a multiple-item questionnaire. There haven't been any prior attempts to compare the effects of various invasive and non-invasive dental therapies on OHRQoL, even though few studies have been conducted to evaluate the OHRQoL among patients undergoing independent dental procedures. Such a comparison would aid in our understanding of not only how various dental conditions affect OHRQoL, but also whether or not a patient's OHRQoL has improved as a result of various therapies for these diseases. A longitudinal study was conducted on patients receiving invasive and non-invasive dental treatment at Teerthanker Mahaveer Dental College and Research Centre, Moradabad. A two-part questionnaire, the first part of which consists of questions related to the demographic details of the patient and the second part consisting of a set of 14 questions of the oral health impact profile (OHIP)-14 for assessing the OHRQoL, was used in the study. Patients' baseline OHRQoL was assessed before the commencement of any treatment by the interview method and follow-up OHRQoL was assessed three days, sevendays, one month, and six months post-treatment telephonically. The OHIP-14 contains 14 items on the frequency of adverse impacts caused by oral conditions and the patients were asked to rate each item on a 5-point Likert scale as 0=never; 1=hardly ever; 2=occasionally; 3=fairly often; 4=very often. The results obtained after compiling and analyzing the data from a total sample of 400 indicate that the mean difference in the OHIP score at different time intervals between the groups who undertook invasive and non-invasive treatment was significant as the p-value was less than 0.05. In addition, it was observed that the mean difference at baseline was statistically significant in the invasive and non-invasive groups as the p-value is less than 0.05. At the domain level, the mean score at each domain was higher in the invasive group as compared to the non-invasive treatment group after three days and seven days of treatment. The mean difference between the group treated with invasive treatment on day three and the group treated with non-invasive treatment on day seven was statistically significant as the p-value is less than 0.05. The mean score was high in the invasive group as compared to the non-invasive group after one month and six months of treatment. The present study was conducted to assess dental treatment's impact on oral health-related quality of life in patients attending Teerthanker Mahaveer Dental College and Research Centre, Moradabad. Results from this study indicated that both types of treatments either invasive or non-invasive have significantly influenced the OHRQoL. Post-treatment OHRQoL improved at different intervals after receiving either treatment.

Abstract #1404823: Too Much of a Good Thing: A Case of Levothyroxine Overdose

Levothyroxine is the most prescribed medication in the last decade in the United States and used commonly for treatment of hypothyroidism. Despite this, overdoses with levothyroxine are rare. Patient presentations can range from asymptomatic with a benign course to severe thyrotoxicosis. Here we present a case of an elderly woman with depression and prior suicide attempts who ingested an estimated 3000 mcg of levothyroxine in a suicide attempt. An 86-year-old female with history of hypothyroidism, major depression, bipolar disorder, mild cognitive impairment, multiple prior suicide attempts presented to the hospital 3 hours after intentional ingestion of 3000 mcg of levothyroxine. She denied co-ingestion of other medications. On physical examination, she had blood pressure of 139/76 mmHg, heart rate of 67 beats per minute (bpm), temperature 98.6 °C, respiratory rate 18 breaths/min, and oxygen saturation of 100% on room air. She denied palpitations, shortness of breath, light-headedness, or chest pain. Her neck was supple without a palpable goiter or nodules. She did not have a tremor. She was alert and oriented to time, place. She endorsed feeling depressed and hopeless which had led to the attempted suicide but now felt remorseful for the attempt. Laboratory workup was notable for lithium level 0.24 mEq/L (0.50 – 1.20 mEq/L), potassium 3.3 mEq/L (3.6 – 5.1 mEq/L), and a negative urine toxicology screen. Electrocardiogram showed normal sinus rhythm without evidence of T-wave abnormalities. Thyroid function tests revealed a thyroid stimulating hormone (TSH) of 1.087 μIU/mL (0.350 – 5.500 uIU/mL), total T3 of 360 ng/dL (80 – 180 ng/dL), and free T4 of 11.76 ng/dL (0.8 – 1.80 ng/dL). She was admitted with suicide precautions and initially treated with lorazepam as needed for anxiety. She developed tachycardia of 101 bpm on day 3 and atenolol 25 mg daily was started. Her heart rate remained in the 80 – 100 bpm range until discharge. Her free T4 trended down into the normal range on day 15 of admission and levothyroxine 50 mcg daily was restarted. She was transferred to the inpatient psychiatric unit for further management of her depression. Prior reports have described a benign course after overdose however symptoms may present in a small subset of patients. These symptoms can be mild (tremors, tachycardia, restlessness, headaches, vomiting) or severe (transient hemiparesis, coma). More severe symptoms have been described with higher doses ingested (levothyroxine 75000- 125000 mcg). Therefore, obtaining history and collateral information about the total dose ingested is important. Free thyroxine levels are trended for biochemical follow up and commonly return to normal after two weeks. TSH levels may remain suppressed well beyond the two-week period and therefore are of limited use in an acute setting. Treatment options include close clinical follow up with symptomatic treatment for tachycardia with beta-blockers. Development of severe symptoms may require levothyroxine extraction through hemodialysis or plasmapheresis.

Epitope Tag Conjugation System Provides Versatility for Multiplex Assay Design

Abstract With the ever-growing use of multiplex assays in research, therapeutics, and diagnostics, the need to conjugate antibodies to dyes, enzymes, and other materials is increasing. While there are many challenges to overcome regarding conjugation, the largest hurdle is maintaining antibody activity after conjugation. To combat these conjugation challenges, Alpha Thera developed a conjugation system that utilizes a small adapter protein to label antibodies quickly and site-specifically, resulting in antibodies that maintain their activity post conjugation. The adapter protein contains a customizable C-terminal region that can be modified to contain diverse labels including fluorescent dyes, click-chemistry, drugs, and epitope tags. Incorporating the epitope tag conjugation system with Fortis Life Sciences anti-epitope tag detection antibodies, we developed an easy and adaptable system for generating conjugated antibodies to use in multiplex assays. We used this system to detect staining of multiple makers including CD3, TIM3, PCNA, and actin via flow cytometry, IHC, ICC, and western blot. One of the tested antibodies retained normal activity post-conjugation even though prior attempts with metal tagging via sulfhydryl groups resulted in lost activity. The vast array of conjugated anti-epitope tag antibodies allows for the selection of specific dyes/materials that are optimized to your desired assays. Additionally, since the secondary antibody is detecting the epitope tag, multiplexing is simplified, and antibody host is rendered irrelevant. This epitope tag system provides a simple, site-specific conjugation method that has incredible adaptability for any multiplex assay.

Morpho-mechanistic screening criteria for the echocardiographic detection of rheumatic heart disease

IntroductionScreening echocardiography, guided by the current World Heart Federation (WHF) criteria, has important limitations that impede the establishment of large-scale rheumatic heart disease (RHD) control programmes in endemic regions. The...

Heterogeneity in the Course of Suicidal Ideation and its Relation to Suicide Attempts in First-Episode Psychosis: A 5-Year Prospective Study.

Although the risk of suicide is high in first-episode psychosis (FEP), little is known about the course of suicidal ideation and its relation to suicide attempts. Therefore, we aimed to identify 5-year trajectories of suicidal ideation and associated factors in FEP and compare how suicide attempts were distributed across these identified trajectories. This 5-year prospective study assessed suicidal ideation, suicide attempts and potentially associated factors through research interviews, chart review and coroners' reports in 382 FEP patients [mean age = 23.53 (SD = 3.61)] admitted to 2 5-year early psychosis services in Montreal, Canada. Trajectories were identified using a semiparametric mixture model, and associated factors with multinomial logistic regression. Three suicidal ideation trajectories were identified: low and decreasing (n = 325, 85.08%); early decline, then increasing (n = 30, 7.85%), and persistent suicidal ideation (n = 27, 7.07%). Suicidal ideation prior to admission (OR = 2.85, 95% CI, 1.23 to 6.63, P < 0.05) and cocaine use disorder (OR = 6.78, 95% CI, 1.08 to 42.75, P < 0.05) were associated with the early decline, then increasing suicidal ideation trajectory. Persons with prior suicide ideation (OR = 4.33, 95% CI, 1.66 to 11.29, P < 0.05) and attempts (OR = 8.18, 95% CI, 2.39 to 27.97, P < 0.001) and alcohol use disorder (OR = 3.63, 95% CI, 1.4 to 9.42, P < 0.05) were more likely to belong to the persistent suicidal ideation trajectory, and to attempt suicide during follow-up. Our study highlights heterogeneity in the course of suicidal ideation over 5 years and the importance of ongoing assessment of suicidal risk in FEP patients, particularly for patients who persistently report suicidal ideation, as they are likelier to engage in suicide attempts. Patients with factors associated with increasing or persistent suicidal ideation trajectories should be targeted for suicide prevention interventions from the early phase of follow-up. Given the small number of persons in these trajectories and the wide CIs for some factors, larger studies are however needed to further characterize who belongs in each group.

Management of pediatric aural foreign bodies: Towards a universal Otolaryngology referral algorithm

Children with aural foreign bodies (AFB) frequently present to the Emergency Department (ED). Our objective was to analyze patterns of pediatric AFB management at our center to characterize children who are commonly referred to Otolaryngology. A retrospective chart review of all children (ages 0-18 years) presenting with AFB to the tertiary care Pediatric ED over a three-year period was performed. Demographics, symptoms, type of AFB, retrieval strategy, complications, need for Otolaryngology referral, and, use of sedation, were evaluated with respect to outcomes. Univariable logistic regression models were conducted to determine which patient characteristics were predictive of AFB removal success. One hundred and fifty-nine patients seen at the Pediatric ED met the inclusion criteria. Average age at presentation was 6 years (2-18 years). Otalgia was the most common presenting symptom (18.0%). However, only 27.0% of children were symptomatic. ED physicians primarily flushed AFBs out of the external auditory canal with water, whereas Otolaryngologists exclusively used direct visualization. Otolaryngology-Head & Neck Surgery (OHNS) was consulted for 29.6% of children. Of these, 68.1% had complications associated with prior retrieval attempts. Sedation was administered in 40.4% of referred children, with 21.2% in an operative setting. Patients experiencing multiple retrieval methods by ED, and, age less than 3 years, were more likely to be referred to OHNS. Patient's age should be strongly considered as a factor for early OHNS referral. By synthesizing our conclusions with previously published results, we propose a referral algorithm.

PD35-12 MULTI-INSTITUTIONAL ANALYSIS OF SURGERY FOR LICHEN SCLEROSUS INDUCED PENILE URETHRAL STRICTURES: CONFIRMING SINGLE-STAGE URETHROPLASTY AS THE TREATMENT STANDARD

You have accessJournal of UrologyCME1 Apr 2023PD35-12 MULTI-INSTITUTIONAL ANALYSIS OF SURGERY FOR LICHEN SCLEROSUS INDUCED PENILE URETHRAL STRICTURES: CONFIRMING SINGLE-STAGE URETHROPLASTY AS THE TREATMENT STANDARD Ross Hengel, Alex Vanni, Bradley A Erickson, Sean Elliott, Benjamin Breyer, Jill C Buckley, Joshua Broghammer, Bryan Voelzke, Jeremy B Myers, Nathan Hoy, and Keith Rourke Ross HengelRoss Hengel More articles by this author , Alex VanniAlex Vanni More articles by this author , Bradley A EricksonBradley A Erickson More articles by this author , Sean ElliottSean Elliott More articles by this author , Benjamin BreyerBenjamin Breyer More articles by this author , Jill C BuckleyJill C Buckley More articles by this author , Joshua BroghammerJoshua Broghammer More articles by this author , Bryan VoelzkeBryan Voelzke More articles by this author , Jeremy B MyersJeremy B Myers More articles by this author , Nathan HoyNathan Hoy More articles by this author , and Keith RourkeKeith Rourke More articles by this author View All Author Informationhttps://doi.org/10.1097/JU.0000000000003333.12AboutPDF ToolsAdd to favoritesDownload CitationsTrack CitationsPermissionsReprints ShareFacebookLinked InTwitterEmail Abstract INTRODUCTION AND OBJECTIVE: The optimal treatment of penile urethral strictures related to lichen sclerosus (LS) is controversial. At the heart of the debate lies the issue of whether or not a single-stage reconstruction should be employed over a 2-stage repair to minimize the number of surgeries performed. Additionally, depending on patient preference, a urethrostomy is a viable option. The objective of this study is to compare single-stage urethroplasty, staged urethroplasty and perineal urethrostomy for the treatment of LS related penile urethral strictures in a multi-institutional analysis. METHODS: A retrospective analysis was performed on patients undergoing urethroplasty for LS induced isolated penile urethral strictures (LSE S2b/S2c) at 9 different institutions. Meatal strictures <2 cm in length and panurethral strictures (>10 cm) involving the bulbar urethra were excluded from study. Patients were reconstructed using either a single-stage approach, a staged technique or perineal urethrostomy. The primary outcome measure was urethral patency at routine follow-up cystoscopy without stricture intervention thereafter and secondary outcomes were 90-day complications, and adverse change in sexual dysfunction, chordee or urethrocutaneous fistula. Outcomes were compared using a Cox regression or a two-tailed Chi-square test when appropriate. RESULTS: 231 patients were analyzed with an average age of 51.6 years and mean stricture length of 5.5 cm. Prior endoscopic treatments were performed in 197 patients (85.3%) with a mean of 3.0 prior endoscopic treatment attempts. Overall, 127 (55.0%) were managed with single-stage BMG urethroplasty, 44 (19.0%) with staged BMG, and 60 (26.0%) with perineal urethrostomy. At a mean follow-up of 68.6 months, overall stricture free rate was 81.0% (n=187). Clavien ≥2 90-day complications occurred in 17 patients (9.8%). de novo erectile dysfunction occurred in 13 patients (5.6%), chordee in 7 (4.8%), and urethrocutaneous fistula in 3 (3.4%). On Mantel-Cox testing, there was no difference in stricture recurrence between techniques (15.7% vs. 27.3% vs. 20.0%; p=0.60) and no difference in 90-day complications (8.0% vs. 15.6% vs. 9.8%; p=0.45), erectile dysfunction (7.1% vs. 4.5% vs. 3.3%; p=0.55), chordee (6.7% vs. 0.0% vs. 3.6%; p=0.33), and urethrocutaneous fistula (2.2% vs. 9.1% vs. 0.0%; p=0. 0.17). On Cox regression analysis, obesity (BMI>35) was associated with a higher rate of stricture recurrence (Hazard Ratio 2.31, 95%CI 1.28-4.17, p=0.006, 30.1% vs. 13.9%) but not 90-day complications (Odds Ratio 1.00, 95% CI 0.33-2.99, p=0.99, 9.8% vs. 9.8%). No other clinical variable was associated with stricture recurrence or 90-day complications. CONCLUSIONS: Favorable outcomes of single-stage techniques for the treatment of lichen sclerosus induced penile urethral strictures, confirm single-stage urethroplasty as the treatment standard for LS induced penile urethral strictures especially when considering the decreased number of surgeries the patient is exposed to. Source of Funding: None © 2023 by American Urological Association Education and Research, Inc.FiguresReferencesRelatedDetails Volume 209Issue Supplement 4April 2023Page: e979 Advertisement Copyright & Permissions© 2023 by American Urological Association Education and Research, Inc.MetricsAuthor Information Ross Hengel More articles by this author Alex Vanni More articles by this author Bradley A Erickson More articles by this author Sean Elliott More articles by this author Benjamin Breyer More articles by this author Jill C Buckley More articles by this author Joshua Broghammer More articles by this author Bryan Voelzke More articles by this author Jeremy B Myers More articles by this author Nathan Hoy More articles by this author Keith Rourke More articles by this author Expand All Advertisement PDF downloadLoading ...

457 Assessment of Mental Health Needs of Transgender Adults Seen at a Midwest Transgender Center

OBJECTIVES/GOALS: Prior studies suggest that transgender individuals are at greater risk of mental health problems. This study aims to determine the mental health care needs of the adult transgender population seen at a tertiary referral hospital in the Midwest region of the United States and assess necessary resources to provide optimal care. METHODS/STUDY POPULATION: This descriptive, retrospective, cross-sectional study included all new transgender patients &gt; 18 years old, seen at the Washington University Transgender Center since December 2019 through May 2022. Electronic medical record data obtained from their initial and subsequent follow-up visits include 1) Demographics: date of birth, age, race, ethnicity, sex assigned at birth, gender identity, zip code of residency 2) Mental health diagnosis: Previous mental health diagnosis, mental health history 3) Mental health care access: mental health providers, mental health treatment, previous mental health admission, resources provided in clinic. RESULTS/ANTICIPATED RESULTS: 487 patient records were reviewed. Median age at initial visit was 24 years (18 - 75 yr), with 46% identify as woman, 37% as man. Predominantly white (84%), 11% were black. 93% had primary health insurance At the first visit, 81% reported having some mental health diagnosis: depression (88%), anxiety (71%), attention deficit disorder (21%). Prior suicide attempt reported on 12% and 5% with self-harm behavior. Only 48% had a therapist and 22% had an established psychiatrist First follow up occurred with a median of 4 months (1-22 months). 4 patients reported new suicide attempt, 3 reported new self-harm behavior. 9 patients required a hospital admission due to a psychiatric condition. 4% reported a new mental health diagnosis (most common: depression and anxiety). No changes noted on access to therapist or psychiatrist DISCUSSION/SIGNIFICANCE: Our study shows that adult transgender individuals have high rates of depression, anxiety, and overall psychological distress which is exacerbated by poor access to mental healthcare. This indicates a critical need to include mental healthcare professionals during the evaluation of adult transgender individuals

MP42-13 ROBOTIC NON-TRANSECTING URETERAL REIMPLANTATION: A MULTI-INSTITUTIONAL EXPERIENCE

You have accessJournal of UrologyCME1 Apr 2023MP42-13 ROBOTIC NON-TRANSECTING URETERAL REIMPLANTATION: A MULTI-INSTITUTIONAL EXPERIENCE Brian Chao, David Strauss, Matthew Lee, Teona Iarajuli, Jennifer Nguyen, Ashley Alford, Michael Stifelman, Daniel Eun, and Lee Zhao Brian ChaoBrian Chao More articles by this author , David StraussDavid Strauss More articles by this author , Matthew LeeMatthew Lee More articles by this author , Teona IarajuliTeona Iarajuli More articles by this author , Jennifer NguyenJennifer Nguyen More articles by this author , Ashley AlfordAshley Alford More articles by this author , Michael StifelmanMichael Stifelman More articles by this author , Daniel EunDaniel Eun More articles by this author , and Lee ZhaoLee Zhao More articles by this author View All Author Informationhttps://doi.org/10.1097/JU.0000000000003280.13AboutPDF ToolsAdd to favoritesDownload CitationsTrack CitationsPermissionsReprints ShareFacebookLinked InTwitterEmail Abstract INTRODUCTION AND OBJECTIVE: Robotic non-transecting ureteroneocystostomy (reimplantation) is an efficacious alternative to conventional reimplantation for mid- to distal ureteral strictures. We sought to update our multi-institutional experience with this technique and analyze intermediate-term outcomes. METHODS: We retrospectively reviewed a multi-institutional database of robotic ureteral reconstruction (CORRUS, or Collaborative of Reconstructive Robotic Ureteral Surgery) for patients undergoing robotic non-transecting reimplantation. Demographic, perioperative, and postoperative data were captured and reported using descriptive statistics. The primary outcome of interest was freedom from recurrent ureteral stenosis, defined as the absence of obstructive findings on follow-up imaging. Minimum follow-up duration for inclusion was three months. RESULTS: We identified 50 patients (comprising 55 ureters) who underwent robotic non-transecting ureteroneocystostomy between 2016 and 2022. Demographic, perioperative, and postoperative data are shown in the accompanying Table 1. Median stricture length was 2.8 cm (IQR 1–4). 17 patients (34%) had a history of radiation and 28 (56%) had prior abdominal or pelvic surgeries. 15 patients (30%) failed endoscopic stricture management; three (6%) failed prior reconstructive attempts. There was one intraoperative complication, a gastric injury repaired primarily by general surgery without subsequent sequelae. There were no immediate (≤30 days) postoperative complications. Over a median follow-up of 17.1 months (7.2–32.0), 47 patients (94%) comprising 52 ureters (95%) remained free from recurrent stricture disease. CONCLUSIONS: Our updated experience reaffirms the safety and efficacy of robotic non-transecting ureteral reimplantation. Despite a high proportion of patients with complex stricture disease, reimplantation was accomplished with minimal morbidity, satisfactory patency rates, and durable outcomes. Source of Funding: None © 2023 by American Urological Association Education and Research, Inc.FiguresReferencesRelatedDetails Volume 209Issue Supplement 4April 2023Page: e572 Advertisement Copyright & Permissions© 2023 by American Urological Association Education and Research, Inc.MetricsAuthor Information Brian Chao More articles by this author David Strauss More articles by this author Matthew Lee More articles by this author Teona Iarajuli More articles by this author Jennifer Nguyen More articles by this author Ashley Alford More articles by this author Michael Stifelman More articles by this author Daniel Eun More articles by this author Lee Zhao More articles by this author Expand All Advertisement PDF downloadLoading ...