Retrospective Cohort Chart Review Research Articles

Cancer patterns in Arua district, Uganda: a hospital-based retrospective study.

Cancer is the second leading cause of mortality with over 19 million cases and 10 million deaths worldwide. Available data on cancer patterns in Uganda are through modelling of data from two population-based cancer registries (PBCRs) representing only about 10% of the cancer situation in Uganda. This study sought to determine the common types of cancer among adults and children in Arua District over a 5-year period (2017-2021). Retrospective cohort chart review and 'catchment population approach' were employed. All newly diagnosed cancer patients from Arua between 2017 and 2021 were included in this study. Data were collected using Redcap whereas management and analysis were conducted using Stata 17. Cancer patterns were computed as frequencies and percentages and the interest was in finding out the common cancers among adults (above 19 years) and children (0-19 years). Over the 5-year study period, a total of 1,118 new cancer cases were registered, with slightly more females (52.1%). The top five common cancers irrespective of sex and age were: liver cancer (13.7%), cervical (11.8%), breast (10.7%), oesophagus (10.5%) and Burkitt's lymphoma (BL) (6.4%). In this study, 15.3% (n = 171) of the study participants were children. The top five common childhood cancers included BL (42%), leukemia (10.5%), other lymphomas (9.4%), osteosarcoma (4.7%) and nephroblastoma (3%). There is a high incidence of liver cancer in Arua district. The high levels of cervical, breast and oesophagus cancer were consistent with what is reported by the two PBCRs in Uganda. However, BL could be due to the presence of a BL treatment centre at Kuluva hospital in Arua. Cancer interventions in Arua should therefore be targeted towards liver, cervix, breast, and oesophagus cancer and furthering research on the reason for the high incidence of liver cancer.

Association Between High Sensitivity Troponin Levels Following Pediatric Orthotopic Heart Transplantation and Intensive Care Unit Resource Utilization.

The utility of troponin levels, including high sensitivity troponin T (hs-TnT), after orthotopic heart transplant (OHT) is controversial. Conflicting data exist regarding its use as a marker of acute rejection. Few studies have examined possible associations of hs-TnT levels immediately after OHT with metrics of intensive care unit (ICU) resource utilization or risk of acute rejection. We performed a retrospective cohort chart review including all OHT recipients < 20years of age at our center between June 2019 and December 2022. Patients were divided into two groups based on supra- or sub-median initial hs-TnT levels (median 3462.5ng/L). Primary outcome was days requiring ICU-level care, secondary outcomes included days intubated, days requiring positive pressure ventilation (PPV), days on inotropic medications, actual ICU length of stay, Vasoactive Inotrope Scores (VIS) on postoperative days (POD) 0 through 7, and acute rejection at 30days and one year after OHT. Patients with higher hs-TnT required ICU level care for longer [13.5 (10-17.5) vs. 9.5 (8-12) days, p = 0.01] and spent more days intubated [6 (4-7) vs. 3 (3-5) days, p < 0.001], on PPV [9 (6-15) vs. 6 (5-8.5) days, p = 0.02], and on inotropes [11 (9-14) vs. 8 (7-11) days, p = 0.025]. VIS was only different between groups on POD7 [5 (3-7) vs. 3 (0-5), p = 0.04]. There was no difference in rejection between the groups. Higher hs-TnT immediately following pediatric OHT may predict higher ICU resource utilization, despite no difference in VIS, although it does not predict acute rejection in the first year after OHT.

Pericapsular Nerve Group (PENG) Block Results in Significant Opioid Reduction in Total Hip Arthroplasty: A Retrospective Analysis

PurposeThe purpose of this retrospective study was to determine the effectiveness of pericapsular nerve group (PENG) block for pain control intraoperatively in patients undergoing total hip arthroplasty (primary-27130) (THA), compared to opioid based analgesia. The PENG block is an emerging regional anesthesia technique that aims to provide hip analgesia with preservation of motor function offering benefit over existing regional techniques while reducing overall opioid requirements. DesignA retrospective cohort chart review and analysis. MethodsA single-site, retrospective chart review was performed for individuals undergoing THAs at a community hospital from 2019 to 2022 (N = 123). Anesthesia records were collected and observed for multiple data points including peripheral nerve block provided, micrograms of fentanyl administered before and during the case, additional medications given, and additional nerve blocks performed. The demographic data included birth date, sex, and procedure date. FindingsFor statistical analysis only, patients receiving PENG (59) were compared to those receiving only intravenous analgesia (No Block-57). Statistically and clinically significant reductions in fentanyl administration and morphine equivalents were found in the population receiving PENG blocks. The mean intraoperative fentanyl given to the No Block group was 292.98 mcg versus 50.42 mcg in the PENG group (P < .05). Mean morphine equivalents given in the No Block group was 23.51 mg versus 11.21 mg in the PENG group (P < .05). ConclusionsReceiving a PENG block preoperatively resulted in clinically and statistically significant opioid reduction during the perioperative period when compared with patients who did not receive a regional block.

A framework to classify gestational diabetes diagnosed by routine antenatal 75g glucose tolerance testing

Objective To create an objective framework to classify gestational diabetes mellitus diagnosed by routine antenatal 75 g diabetes testing results to provide an alternative to current treatment-based classification. Methods A framework was created to classify gestational diabetes according to the severity of glycemic abnormalities after routine antenatal 75 g GTT (classes 1 through 4, determined by fasting and post-test glycemic abnormalities). A retrospective cohort chart review was used to correlate clinically how often diet therapy alone maintained glycemic targets throughout pregnancy in each class. Chi-square analysis was used to assess inter-class differences in the success of diet therapy alone maintaining glycemic targets throughout pregnancy. Results Seventy-four of 228 (33%), 35/228 (15%), 76/228 (33%), and 43/228 (19%) of the study population were classified as Class 1, 2, 3, or 4, respectively. Of eighty-nine patients who maintained glycemic targets throughout pregnancy with diet alone 51/89 (57%) were Class 1, 20/89 (22.5%) were Class 2, 11/89 (12.5%) were Class 3, and 7/89 (8%) were Class 4. Chi-square analysis showed statistically significant inter-class differences in the likelihood of diet therapy alone maintaining glycemic targets throughout pregnancy. Conclusion In this framework classifying gestational diabetes according to the severity of glycemic abnormalities after routine antenatal 75 g GTT (an objective proxy for disease severity), the higher the assigned class, the less likely that diet therapy alone maintained glycemic targets throughout pregnancy (a clinical proxy for disease severity).

SAT397 A Low Dose Cyproterone Acetate In Feminizing Hormone Treatment

Abstract Disclosure: S. Korpaisarn: None. J. Arunakul: None. K. Chaisuksombat: None. T. Rattananukrom: None. Background: A feminizing hormone therapy (FHT) for transgender women (TW) who have not undergone gonadectomy consists of estrogens and antiandrogens. Cyproterone acetate (CPA) is the most common antiandrogen used in Thailand. A standard dose of CPA is 25-50 mg/day. Recent data showed that a low-dose CPA might be effective in testosterone suppression. However, the result was limited due to the small number of subjects. Our recent survey showed that CPA 12.5 mg/day was commonly used among Thai TW. This study aimed to evaluate the effectiveness of CPA 12.5 mg/day in testosterone suppression. Methods: The retrospective cohort chart review was done on all TW receiving FHT in a transgender clinic at Ramathibodi Hospital between January 2014-July 2022. Among the TW who initiated FHT during the study period, the effectiveness and safety of CPA 12.5 mg/day were compared with the standard dose of CPA. Only TW with information at 3-month follow-up were analyzed for a median time of achieving the T level at the goal (&amp;lt;50 ng/dL) using a Cox regression analysis and a proportion of TW achieving T level at goal at 3 months using risk ratio regression model. All TW who initiated CPA were analyzed for changes in laboratory measurements using a generalized estimating equation (GEE). Results: A total of 89 transwomen were initially reviewed. Forty-one TW initiated CPA, and 37 TW had information at the 3-month follow-up visit. Among the latter, 22 TW (59.5%) started with CPA 12.5 mg. The median age of FHT initiation were 19 years (IQR 15-23) in CPA 12.5 mg group and 20 years (IQR 17-27) in the standard CPA dose group (p-value=0.504). Median follow-up time was 7.5 months (IQR 3-12) and 9 months (IQR 6-12), respectively (p-value=0.402). Baseline T levels were not different, with the median level at 518 ng/dL (IQR 173-787) in CPA 12.5 mg and 752 ng/dL (IQR 56-957) in control (p-value =0.653). In terms of effectiveness, the median time when T levels were suppressed at goal (&amp;lt;50 ng/dL) was 3 months in both groups. The proportion of TW who achieved targeted testosterone level within 3 months was 72.7% in CPA 12.5 mg and 86.7% in control with the risk ratio (RR) of 0.84 (95%CI 0.60-1.17, p-value= 0.295) for univariable analysis. The multivariable analysis showed an adjusted RR of 0.85 (95% CI 0.46-1.57, p-value=0.606). The multivariable GEE showed no difference between testosterone level changes. Only the LDL levels was significantly lower in the CPA 12.5 mg dose group with the difference of -13.72 mg/dL (95%CI (-25.86) – (-1.58), p-value=0.027). Other laboratories were not different among the 2 groups. There was no report of cardiovascular disease or new-onset depression in both groups.Conclusion: A CPA of 12.5 mg/day is effective in testosterone suppression as the standard dose of CPA in a FHT for TW with a comparable safety profile. This low-dose CPA regimen could be used as a FHT since it has a 50% cost reduction with equivalent effectiveness. Presentation: Saturday, June 17, 2023

Horizontal mattress uterine closure compared to single layered lock suture in cesarean section - A retrospective cohort study

ObjectiveThe objective of this study is to compare the outcomes of standard cesarean section uterine closure, single-layered running lock sutures, versus using primary horizontal mattress sutures (the K uterine closure technique). MethodThis study used a retrospective cohort chart review of patients undergoing elective primary and repeat cesarean section between January 2016 and August 2020 at a South Florida hospital. From 613 included patients, 176 received the K uterine closure technique completed by a triple board-certified physician. Remaining 437 patients received single-layered lock uterine closure completed by other physicians in the same hospital. Clinical, demographic, and post-operative outcomes were collected using patients’ operative, post-operative, and progress notes. ResultsUsing the data gathered, the experimental group demonstrated a greater difference between pre- and post-cesarean section hemoglobin (p < 0.027) and hematocrit (p < 0.014) compared to single-layered lock closure methods. There was a significantly lower estimated blood loss (p < 0.001), however, there was no significant difference in the average quantitative blood loss (p < 0.374). There was also a significant reduction in the length of total and postoperative hospital stay (p < 0.001), but the total operation time was significantly increased (p < 0.016). No significant difference was found in the percentage of patients using opioids as pain management during hospital stay (p < 0.431). There was no need for blood transfusion nor an increase in infectious morbidity using this method. ConclusionsUsing the K uterine closure technique for post-cesarean section uterine closure was a reasonable alternative for closure of hysterotomy. It led to decreased duration of hospital stay and no significant difference in quantitative blood loss. The greater difference in hemoglobin and hematocrit for the K uterine closure technique group could be explained due to the significantly greater total operation time. Although the single-layered running lock suture closure is what has been more historically performed by obstetricians for cesarean sections, this data supports the viability and efficacy of the K uterine closure technique as an equally safe, non-inferior alternative. The value of this technique for uterine closure can be confirmed with future prospective studies and potential research in reduction of uterine scar defects. SynopsisPrimary horizontal mattress closure at cesarean section provides a safe alternative to single-layered lock closure and may reduce blood loss, hospital stay, and opioid use.

Changes in clinical markers observed from pharmacist-managed cardiovascular risk reduction clinics in federally qualified health centers: A retrospective cohort study.

Reductions in hemoglobin A1c (HbA1C) have been associated with improved cardiovascular outcomes and savings in medical expenditures. One public health approach has involved pharmacists within primary care settings. The objective was to assess change in HbA1C from baseline after 3-5 months of follow up in pharmacist-managed cardiovascular risk reduction (CVRR) clinics. This retrospective cohort chart review occurred in eight pharmacist-managed CVRR federally qualified health clinics (FQHC) in Indiana, United States. Data were collected from patients seen by a CVRR pharmacist within the timeframe of January 1, 2015 through February 28, 2020. Data collected include: demographic characteristics and clinical markers between baseline and follow-up. HbA1C from baseline after 3 to 5 months was assessed with pared t-tests analysis. Other clinical variables were assessed and additional analysis were performed at 6-8 months. Additional results are reported between 9 months and 36 months of follow up. The primary outcome evaluation included 445 patients. Over 36 months of evaluation, 3,803 encounters were described. Compared to baseline, HbA1C was reduced by 1.6% (95%CI -1.8, -1.4, p<0.01) after 3-5 months of CVRR care. Reductions in HbA1C persisted at 6-8 months with a reduction of 1.8% ([95%CI -2.0, -1.5] p<0.01). The follow-up losses were 29.5% at 3-5 months and 93.2% at 33-36 months. Our study augments the existing literature by demonstrating the health improvement of pharmacist-managed CVRR clinics. The great proportion of loss to follow-up is a limitation of this study to be considered. Additional studies exploring the expansion of similar models may amplify the public health impact of pharmacist-managed CVRR services in primary care sites.

Characterization of a late-onset multiple sclerosis Portuguese cohort.

Late-onset multiple sclerosis (LOMS) is defined as the onset of symptoms above 50 years, corresponding to an increasingly recognized subset of MS. This study aimed at comparing demographic and clinical data of patients with LOMS to those of early-onset MS (EOMS) from a Portuguese cohort. Retrospective chart review of an MS cohort from a Portuguese tertiary center. From 746 patients with MS (61.7% female), we identified 39 cases with presentation after 50 years of age (22 males and 17 females), corresponding to 5.3%. The mean age at onset was 55.4 (±5.0) for LOMS and 29.5 (±8.9) for EOMS. There was no significant difference in disease duration. The most common type was relapsing-remitting MS, accounting for 51.5% and 83.9% of LOMS and EOMS patients, respectively. Primary-progressive MS (PPMS) was significantly more represented in the LOMS group (41.0%) (p<0.01). The median EDSS was significantly higher in the LOMS group (4.75, 0.0-7.5) when compared to the EOMS group (2.0, 0.0-9,0). The most frequent presenting feature was myelitis in both LOMS (48.7%) and EOMS patients (47.4%), resulting in significantly higher EDSS (p=0.003). LOMS is associated with higher EDSS when considering the same disease duration, translating into increased disability.

Surgical management of acute life-threatening events affecting esophageal atresia and/or tracheoesophageal fistula patients

BackgroundFollowing surgical correction, many patients with esophageal atresia with or without tracheoesophageal fistula (EA/TEF) present to the emergency department (ED) with acute airway complications. We sought to determine the incidence and risk factors for severe acute life-threatening events (ALTEs) in pediatric patients with repaired congenital EA/TEF and the outcomes of operative interventions. MethodsA retrospective cohort chart review was performed on patients with EA/TEF with surgical repair and follow-up at a single centre from 2000 to 2018. Primary outcomes included 5-year ED visits and/or hospitalizations for ALTEs. Demographic, operative, and outcome data were collected. Chi-square tests and univariate analyses were performed. ResultsIn total, 266 EA/TEF patients met inclusion criteria. Of these, 59 (22.2%) had experienced ALTEs. Patients with low birth weight, low gestational age, documented tracheomalacia, and clinically significant esophageal strictures were more likely to experience ALTEs (p < 0.05). ALTEs occurred prior to 1 year of age in 76.3% (45/59) of patients with a median age at presentation of 8 months (range 0–51 months). Recurrence of ALTEs after esophageal dilatation was 45.5% (10/22), mostly due to stricture recurrence. Patients experiencing ALTEs received anti-reflux procedures (8/59, 13.6%), airway pexy procedures (7/59, 11.9%), or both (5/59, 8.5%) within a median age of 6 months of life. The resolution and recurrence of ALTEs after operative interventions are described. ConclusionSignificant respiratory morbidity is common among patients with EA/TEF. Understanding the multifactorial etiology and operative management of ALTEs have an important role in their resolution. Type of StudyOriginal Research, Clinical Research. Level of EvidenceLevel III Retrospective Comparative Study.

Effect of the hospital transfer of STEMI patients through the remote emergency consultation system on the emergency department length of stay and survival at hospital discharge: a single center retrospective cohort study

This study aimed to analyze and determine the effects of emergency department (ED) length of stay (LOS) and survival at hospital discharge (SHD) on patients with ST-segment elevation myocardial infarction (STEMI) treated by the Remote Emergency Consultation System (RECS), a government-led teleconsultation project. This was a retrospective cohort chart review performed at a single center. The study period was from 01 May 2015, to 31 December 2020. The RECS group was set as the intervention group among the total transferred STEMI patients, and the No-RECS group was set as the control group. Ninety-eight patients with STEMI were collectively included in the No-RECS (n = 56) and RECS (n = 42) groups. The median value of ED LOS was 31 (21, 46.5) min in the No-RECS group and 21.5 (13.25, 37.25) min in the RECS group (p = 0.0329). The variables (odds ratio (95% confidence interval (CI)); p-value) predictive of SHD in the patients with STEMI were systolic blood pressure (SBP) (1.09 (1.003, 1.19); p = 0.0413) and total hospital days (2.95 (1.05, 8.26); p = 0.0399). The optimal cut-off points (sensitivity and specificity) of the receiver operating characteristic (ROC) curve of the SBP and total hospital days to predict SHD in the patients with STEMI were (0.742, 1) 105 and (0.753, 1) 3.5, respectively. RECS was associated with a decrease in EDLOS in patients with STEMI, but showed no association with SHD. SBP at the time of the ED visit and total hospital days were positively correlated with SHD.

Recurrent Urinary Tract Infection in Living Donor Renal Transplant Recipients and the Role of Behavioral Education Program in Management: A Single-Center Experience

Urinary tract infections (UTIs) are the most prevalent type of kidney transplant (KT) recipients. We aimed to investigate the incidence, causes, and clinical impact of early recurrent UTI post-living donor KT and to examine the role of behavioral education program in management. This retrospective cohort chart-review study included all KT recipients with recurrent UTI necessitating hospital admission between September 2017 and August 2021. All patients with recurrent UTI were subjected to behavioral education for a month. UTI was found in 14 of 145 patients (9.6%), with recurrent UTI in 11 (7.6%). A total of 93% of UTIs occurred during the first 6 months post-transplant and represented 52% of KT readmissions during the same period. A total of 64.3% of patients were older than 50 years. The mean (SD) length of hospital stay was 5 (2.5) days, with an equal incidence in both sexes. The most common bacterial isolates in early recurrent UTI were Escherichia coli in 80.9%. Both Extended-spectrum beta-lactamases and multidrug-resistant organisms (resistance in ≥3 drugs) were seen in 82.4% of isolates. Furthermore, the most effective antibiotic was meropenem, with 86.7% effectiveness. A total of 65% of UTIs were managed with a single antibacterial course. A total of 64.3% of patients were older than 50 years. In patients who developed UTI, the mean (SD) serum creatinine was 1.31 (0.52) mg/dL, with a mean increase in serum creatinine of 0.19 mg/dL on having the episodes; at 1 year post-transplant, serum creatinine declined to 1.23 (0.43) mg/dL. Four patients (36%) had no recurrence of UTI after behavioral education. The multidrug-resistant bacterial isolates account for 82.4% of the UTIs. Therefore, antibiotic prescription should follow the antimicrobial stewardship guidelines. Behavioral education significantly reduced the incidence of recurrent UTI.

Nonfulfillment of desired postpartum permanent contraception and resultant maternal and pregnancy health outcomes

Up to half of the patients requesting postpartum permanent contraception do not undergo the desired procedure. Although nonfulfillment of desired postpartum permanent contraception is associated with increased risk of pregnancy within 12 months of delivery, its long-term reproductive and maternal health outcomes are less clear. This study aimed to determine the association of fulfillment of postpartum permanent contraception with number and timing of subsequent pregnancies and maternal health outcomes. This was a retrospective single-center cohort chart review study of health outcomes in the 4 years following delivery (2016-2018) for 1331 patients with a documented contraceptive plan of female permanent contraception at time of postpartum discharge from 2012 to 2014. Rates of permanent contraception fulfillment within 90 days of delivery and clinical and demographic characteristics associated with permanent contraception were calculated. We determined number of and time to subsequent pregnancies, and diagnoses of medical comorbidities (hypertension, diabetes mellitus, depression, anxiety, asthma, anemia), sexually transmitted infection, and pregnancy comorbidities (preterm birth, gestational diabetes mellitus, gestational hypertension, preeclampsia, postpartum hemorrhage, low birthweight, intrauterine fetal demise) in the 4 years following delivery. Of the 1331 patients desiring permanent contraception postpartum, 588 (44.1%) had their requests fulfilled within 90 days of delivery and 743 (55.8%) did not. Patients who achieved permanent contraception fulfillment tended to have attended more outpatient prenatal visits, delivered via cesarean delivery, and were older, married, college-educated, and privately insured. Patients who received their desired postpartum permanent contraception were less likely to have subsequent intrauterine pregnancies (P<.001). In those who did not achieve permanent contraception, 22 (9.0%) subsequent pregnancies occurred within 6 months of previous deliveries, and 223 (91.0%) occurred after short interpregnancy intervals (within 18 months). Of 178 continued pregnancies, 26 (14.6%) were delivered preterm. There were no differences between the 2 groups in terms of ever attending an outpatient, preventive, or emergency room visit, or in most nonreproductive health outcomes investigated. Nonfulfillment of desired postpartum permanent contraception is associated with subsequent maternal reproductive and nonreproductive health ramifications. Given the barriers to permanent contraception, alternative plans for contraception should be discussed proactively if permanent contraception is not provided.

Healthcare Disparities in Early Childhood Brain Injury

<h3>Research Objectives</h3> While healthcare and educational disparities are known to impact minoritized groups, few research studies have been conducted to examine disparities after childhood acquired brain injury (ABI). The purpose of this study was to explore child factors associated with referral (i.e., race, socioeconomic status, type and time since injury, length of hospital stay), parent education, and long-term need for children who experienced an early childhood ABI. <h3>Design</h3> Secondary-analysis of data collected through retrospective cohort chart review and prospective caregiver phone surveys. <h3>Setting</h3> Large, urban Trauma 1 pediatric hospital in the Midwestern US. <h3>Participants</h3> 29 caregivers of children who experienced an ABI before five years of age and currently in elementary or middle school. <h3>Interventions</h3> Not applicable. <h3>Main Outcome Measures</h3> Medical records and a 10-min phone survey that included a series of yes/no and short open-ended questions. <h3>Results</h3> Logistic regressions indicated a significant association between child factors and 1) referral to services at hospital discharge (p = .004) and 2) caregiver-reported long-term need for special education services (met and unmet; p = .009). The models for caregiver-reported receipt of education on ABI and caregiver-reported unmet need for special education were not significant. For both significant models, there were no significant individual predictors, but some factors appear to have stronger associations than others. <h3>Conclusions</h3> Differences in acute and long-term service provision and need after childhood ABI are likely influenced by a complex interaction of individual, injury, and social-environmental factors. Future research should consider how healthcare and education practice and policy might account for these interactions to support more equitable access to and utilization of services to improve long-term outcomes for all children with ABI. <h3>Author(s) Disclosures</h3> Jessica Salley Riccardi and Jennifer Lundine have no financial or non-financial relationships to disclose.

S462 Impact of Esophageal Biopsies During Index Endoscopy for Food Bolus Impaction on Rates of Patient Outpatient Follow-Up and Recurrence of Food Bolus Impaction: A Retrospective Study

Introduction: Food bolus impaction (FBI) is a gastroenterological emergency requiring urgent upper endoscopy, of which up to half of cases may be due to eosinophilic esophagitis (EoE). EoE is defined by eosinophilic infiltration in the esophageal mucosa without secondary causes, which can lead to inflammatory and structural complications. Patients with EoE should have outpatient follow up as it can be effectively managed with proton pump inhibitors, swallowed topical steroids, and food elimination diets. This study aims to determine baseline rate of esophageal biopsy during index endoscopy for FBI, as recommended by American College of Gastroenterology clinical guidelines, and evaluate the impact of biopsies on rate of outpatient follow-up and repeat FBI presentations. Methods: This retrospective cohort chart review study evaluated patients over age 18 who presented with acute FBI at Dartmouth-Hitchcock Medical Center from 2015 to 2020. Patients with incidentally found food boluses and with non-food foreign body impactions were excluded. Simple count and chi-squared analyses were performed, with a p-value < 0.05 indicating significance. Results: 122 patients met inclusion criteria, with a mean age of 64 years old and 65% being male. Approximately half had a prior FBI though only 20% had a previous outpatient gastroenterology appointment. Baseline rate of esophageal biopsy during index endoscopy was 16%, of which 10% revealed a new diagnosis of EoE. After index endoscopy, 55% presented for outpatient follow-up and 51% underwent repeat endoscopy. 11% presented again to the emergency department for a recurrent FBI, with 31% of those patients having previously declined an outpatient visit. A greater percentage (65%) of patients with index biopsy completed an outpatient follow-up compared to those without a biopsy (53%) (p=0.32). There was minimal difference between those who had a biopsy and presented again with emergent FBI (15%) compared to those without a biopsy who re-presented (10%) (p=0.49). Conclusion: The baseline rate of esophageal biopsy during initial endoscopy was low, suggesting missed opportunities to diagnose EoE early. A greater number of index biopsy cases followed up in outpatient clinic, though was not statistically significant. Findings could be affected by low volume of index biopsies. Further research is needed to identify barriers to outpatient follow-up and treatment adherence for patients diagnosed with EoE on index biopsy.

An Exploratory Study on Disparities in Service Provision and Long-Term Need After Early Childhood Acquired Brain Injury.

While health care and educational disparities are known to impact minoritized groups, few research studies have been conducted to examine disparities after childhood acquired brain injury (ABI). The purpose of this study was to explore child and injury factors (i.e., race, socioeconomic status, and length of hospital stay) associated with referral, parent education, and long-term need for children who experienced an early childhood ABI. This study was a secondary analysis of data collected through retrospective cohort chart review and prospective caregiver phone surveys. Exploratory logistic regressions indicated a statistically significant association between child and injury factors and (a) referral to rehabilitation or educational services at hospital discharge (p < .001) and (b) caregiver-reported long-term needs (including both met and unmet needs) for special education services (p = .009). The models for caregiver-reported receipt of education on ABI and caregiver-reported unmet need for special education were not significant. For both significant models, there were no significant individual predictors. Differences in acute and long-term service provision and need after childhood ABI are likely influenced by a complex interaction of individual, injury, and social-environmental factors. Future research should consider how health care and education practice and policy might account for these interactions to support more equitable access to and utilization of services to improve long-term outcomes for all children with ABI. https://doi.org/10.23641/asha.21158878.

Suppressed paraoxonase-1 activity associates with elevated oxylipins and the presence of small airways disease in patients with rheumatoid arthritis

BackgroundRheumatoid arthritis (RA)-associated lung disease (LD) associates with significantly increased morbidity and mortality. Although oxidative stress plays an important role in the inflammatory responses in other forms of lung disease, minimal work has evaluated its role in RA-LD. The current work examines the relationship between the anti-oxidant HDL-associated enzyme paraoxonase-1 (PON1), the PON1 Q192R polymorphism, and a targeted oxylipin panel with RA-LD.MethodsThis study was conducted as a retrospective chart review of a longitudinal single-center cohort of 250 RA patients. CT scans of the chest were reviewed by the interpreting radiologist and classified as small airways disease (SAD), interstitial lung disease (ILD), and bronchiectasis. PON1 activity was measured by its lactonase, arylesterase, and paraoxonase functions. The PON1 Q192R polymorphism and a targeted lipidomics panel were performed as previously reported.Results43.2% of the 250 RA patient cohort (n = 108) had available CT scans, including 48 patients (44.4%) with SAD, 27 patients (25.0%) with bronchiectasis, and 16 patients (14.8%) with ILD. Patients with SAD had significantly lower baseline PON1 activity by its arylesterase, and lactonase functions, as well as higher 15-HETE, LTB4, and PGE2 levels compared to those without SAD. These predictors of SAD remained significant after multivariate analysis including known risk factors for RA-LD. Suppressed PON1 activity also correlated with higher levels of 15-HETE and 12-HETE.ConclusionIn a single-center RA cohort, suppressed baseline PON1 activity and elevation in the oxylipins 15-HETE, LTB4, and PGE2 predicted the presence of RA-SAD in longitudinal follow-up.Key Points• Small airways disease (SAD) was present in 44.4% of this rheumatoid arthritis (RA) cohort.• Patients with SAD had significantly lower baseline PON1 activity, as well as higher levels of the oxylipins 15-HETE, LTB4, and PGE2 levels compared to those without SAD.• Further work is warranted to confirm these findings and further define the role of PON1 and lipid oxidation in RA lung disease.

Clinical, Economic, and Humanistic Impact of Short-Bowel Syndrome/Chronic Intestinal Failure in Portugal (PARENTERAL Study)

Introduction: This study aimed to assess the clinical, economic, and humanistic impact of short-bowel syndrome/chronic intestinal failure (SBS/CIF) in Portugal. Methods: This is a retrospective multicenter cohort chart review study, with a cross-sectional component for quality-of-life (QoL) evaluation. Inclusion criteria comprised patients with SBS/CIF, aged ≥1 year, with stable parenteral nutrition (PN). Data collection included patient chart review over a 12-month period and patient/caregiver self-report and SF-36/PedsQL™ questionnaires. Main endpoints comprised clinical and PN characterization, healthcare resource use (HRU), direct costs, and patient QoL. Results: Thirty-one patients were included (11 adults and 20 children). Patients’ mean age (standard deviation [SD]) was 57.9 (14.3) years in adults and 7.5 (5.0) years in children, with a mean time since diagnosis of 10.2 (5.9) and 6.6 (4.2) years, respectively. PN was administered for a mean of 5.2 and 6.6 days/week in adults and children, respectively; home PN occurred in 81.8% of adults and 90.0% of children for a mean of 9.6 and 10.8 months/year, respectively. The mean annual number of hospitalizations was 1.9 and 2.0 which lasted for a mean of 34.0 and 29.4 days in adults and children, respectively. Twenty-one and forty hospitalization episodes were reported in adults and children, respectively, of which 71.4% and 85.0% were due to catheter-related complications. Mean annual direct costs per patient amounted to 47,857.53 EUR in adults and 74,734.50 EUR in children, with PN and hospitalizations as the main cost-drivers. QoL assessment showed a clinically significant impaired physical component in adults and a notable deterioration in the school functioning domain in children. Conclusion: In Portugal, SBS/CIF patient management is characterized by a substantial therapeutic burden and HRU, translating into high direct costs and a substantial impairment of the adults’ physical function and children’s school functioning.

Code Status Blues: Do Legal Nudges Discourage Doctors From Ordering Do-Not-Resuscitate?

BackgroundLaws influence human behavior, including practitioners' behavior, and legal nudges may affect bedside patient care practices. Do-not-resuscitate (DNR) practices are one such example. Ensuring that practitioners order DNR for patients who request it is a crucial part of providing quality end-of-life care. On April 1, 2018, in the state of Texas, Senate Bill 11 (SB 11) took effect. This law did not make DNR orders illegal, but it constrained and complicated the process for issuing them. This study aimed to determine if DNR order utilization decreased after the law's implementation. MethodsThe authors conducted a retrospective cohort chart review of all adult patients admitted to a single academic urban tertiary care hospital in Texas before and after the state's DNR law went into effect. The authors reviewed code status orders for the 5426 sickest patients. The primary outcome is the proportion of patients who had DNR orders in effect at the end of their hospitalizations. ResultsImplementation of the DNR law's cumbersome documentation and witnessing requirements correlated with a substantial decline in DNR orders for patients at the highest risk of dying from chronic or severe illness. ConclusionThis is the first study the authors know of that examines whether DNR usage declined after implementation of a DNR law. A troubling implication of this study is that the Texas law has had a chilling effect on doctors' willingness and ability to place medically and ethically appropriate DNR orders and has threatened the right of patients with serious illness to forgo cardiopulmonary resuscitation.

Prenatal Buprenorphine/Naloxone or Methadone Use on Neonatal Outcomes in Michigan.

BackgroundMaternal opioid exposure during pregnancy has various effects on neonatal health. Buprenorphine/naloxone and methadone are examples of medications for opioid use disorder (MOUD) used for the treatment of opioid use disorder (OUD). Research comparing the impacts of these MOUD modalities on neonatal outcomes when used to treat pregnant people with OUD remains limited. We evaluated the differences in outcomes between neonates with in-utero exposure to buprenorphine/naloxone versus methadone.MethodologyWe performed a retrospective cohort chart review between October 15, 2008, and October 15, 2019, evaluating mother/neonate dyads at two medical centers in Michigan. The charts of female patients, aged 18+, with OUD and buprenorphine/naloxone or methadone treatment, were examined. The charts of the corresponding neonates were also examined. Multiple regression analysis was performed.ResultsIn total, 343 mother/infant dyads were included: 99 patients were treated with buprenorphine/naloxone and 232 patients were treated with methadone. The buprenorphine/naloxone group had significant differences in maternal age, hepatitis status, asthma, gestational age in weeks, neonatal intensive care unit (NICU) length of stay (LOS), neonatal opioid withdrawal syndrome (NOWS) peak score, birth head circumference, and birth weight compared to the methadone group at baseline. Adjusted multivariable regression analysis demonstrated neonates with exposure to buprenorphine/naloxone had a NOWS peak score 3.079 points less (95% confidence interval (CI): -4.525, 1.633; p = 0.001) and NICU LOS 8.955 days less (95% CI: -14.399, -3.511; p = 0.001) than neonates exposed to methadone.ConclusionsNeonates with in-utero exposure to buprenorphine/naloxone had significantly lower NOWS scores and shorter NICU LOS compared to neonates with in-utero exposure to methadone. These findings demonstrate that buprenorphine/naloxone is potentially a more favorable treatment for the reduction in metrics representing adverse neonatal outcomes in pregnant people with OUD than methadone.

The clinical effectiveness of the STUMBL score for the management of ED patients with blunt chest trauma compared to clinical evaluation alone

The STUMBL (STUdy of the Management of BLunt chest wall trauma) score is a new prognostic score to assist ED (Emergency Department) decision making in the management of blunt chest trauma. This is a retrospective cohort chart review study conducted in a UK University Hospital ED seeing 120,000 patients a year, comparing its performance characteristics to ED clinician judgement. All blunt chest trauma patients that presented to our ED over a 6-month period were included. Patients were excluded if age < 18, if they had immediate life-threatening injury, required critical care admission for other injuries or in case of missing identification data. Primary endpoint was complication defined as any of lower respiratory tract infection, pulmonary consolidation, empyema, pneumothorax, haemothorax, splenic or hepatic injury and 30-day mortality. Clinician judgement (clinician decision to admit) and STUMBL score were compared using the receiver-operating curve (ROC) and sensitivity analysis. Three hundred and sixty-nine patients were included. ED clinicians admitted 95 of 369 patients. ED clinician decision to admit had a sensitivity of 83.9% and specificity of 86.0% for predicting complications. STUMBL score ≥ 11 had a sensitivity of 79.0% and specificity of 77.9% for the same and would have led to 117 of 369 patients being admitted. Area under the curve (AUC) of STUMBL score and ED clinician decision to admit was 0.84 (95% CI 0.78–0.90) and 0.85 (95% CI 0.79–0.91), respectively. Our findings show that a STUMBL score ≥ 11 performs no better than ED clinician judgement and leads to more patients being admitted to hospital.