Retrospective Observational Study Research Articles

Occurrence of Plasmid-Mediated Quinolone Resistance and Carbapenemase-Encoding Genes in Pseudomonas aeruginosa Isolates from Nosocomial Patients in Aguascalientes, Mexico

Pseudomonas aeruginosa is a leading cause of healthcare-associated infections, which are related to substantial morbidity and mortality. The incidence of Plasmid-Mediated Quinolone Resistance (PMQR) determinants has been previously reported in this bacterium. However, there is limited information regarding the presence of PMQR and carbapenemase-encoding genes simultaneously. This study aims to analyze the prevalence of these determinants on P. aeruginosa strain isolated from clinical patients in the State of Aguascalientes, Mexico. Fifty-two P. aeruginosa isolates from nosocomial patients were collected from Centenario Hospital Miguel Hidalgo. This is a retrospective observational study conducted at a single center. Antibiotic susceptibility was tested using the Vitek-2 system. Only carbapenem-resistant isolates were included in this study. Carbapenemase-encoding genes and PMQR determinants were screened by polymerase chain reaction (PCR). Resistance rates of 100% were found on tigecycline and ceftriaxone. Of the 52 isolates, 34.6% were positive for the qnr genes, 46.2% for the oqxA gene, and 25% for the aac-(6′)-lb gene. The most frequent carbapenemase genes found in the samples were blaOXA-51 (42.3%), blaOXA-1 (15.4%), and blaVIM (15.4%). blaOXA-51 co-carrying oqxA was detected in 21.1% of the isolates, blaOXA-51 co-carrying aac-(6’)-lb in 11.5%, blaVIM co-carrying aac-(6′)-lb in 3.8%, and blaKPC co-carrying oqxA in 5.8%. Systematic surveillance to detect carbapenemase-encoding genes and PMQR determinants, and rational prescription using the last-line drugs could help in preventing the dissemination of multidrug-resistant determinants.

HPB SO70 - Evaluating the Outcome of Laparoscopic Common Bile Duct Exploration Against Key Performance Indicator (KPI) of the British Benign Upper GI Surgical Society (BBUGSS)

Abstract Background Treatment of common bile duct (CBD) stone(s) can be challenging with a risk of significant complications. Laparoscopic common bile duct exploration (LCBDE) displays superior outcomes when compared to endoscopic retrograde cholangiopancreatography (ERCP). Acknowledging the impact of patient variables and surgical proficiency, the British Benign Upper GI Surgical Society (BBUGSS) developed Key Performance Indicators (KPIs) to optimize LCBDE outcomes. The present study comprises an audit of LCBDE outcomes with respect to the BBUGSS KPIs and aims to determine the feasibility and quality of LCBDE that can be achieved in a district general hospital (DGH) with a recently developed LCBDE service. Method This retrospective observational study examined all adult patients who underwent LCBDE between August 2022 and June 2024 by two specialized biliary surgeons at a single surgical unit within a DGH. This DGH also serves as a referral center for biliary cases from affiliated hospitals. The preference in our surgical unit is single stage management (laparoscopic cholecystectomy and simultaneous LCBDE) of CBD stones in surgically fit patients. The analysis included preoperative assessments, intraoperative observations, and postoperative outcomes, with respect to the published BBUGSS KPIs for LCBDE. Results 60 patients were eligible for inclusion; median age was 56 years (IQR 40-67) and 40 (66.7%) were female. 33 (55%) were emergency cases. 52 (86.7%) were transcystic exploration; of these 8 (15.4%) utilised basket-in-catheter and 44 (84.6%) utilised choledochoscopes. Median post-operative stay for transcystic exploration was 1 day (IQR 0-2) and for cholechodotomy 8 days (IQR 5-9). Key Performance IndicatorBBUGSS StandardOur outcomeConversion rates<10%0%Bile duct clearance rates>85%91.7%Bile Leak Rates<5%0%Returns to theatre<5%0%Readmission rates (within 30 days)<15%6.7%Overall Morbidity<15%3.3%Overall Mortality<1%0% Conclusion This study indicates that the BBUGSS KPIs for LCBDE are satisfactorily achieved in our centre. Adequate ductal clearance with minimal morbidity was achieved. Our outcomes are likely attributed to the recent commencement of a specialist biliary service and utilisation of predominantly transcystic approach, with the aid of electrohydraulic lithotripsy where needed, as opposed to choledochotomy. Furthermore, the present study suggests a high quality LCBDE service is feasible in a DGH setting if there is sufficient clinical and managerial motivation. We suggest that single stage management of bile duct stones model should be considered in other similar centres.

A real-life clinical application of cardiac magnetic resonance imaging in patients with acute myocarditis - one-center observational retrospective study.

The diagnosis of acute myocarditis is complex, with cardiac magnetic resonance (CMR) being a recommended diagnostic method. This study aimed to evaluate the real-life use of CMR in the diagnosis of acute myocarditis and to correlate CMR results with the degree of myocardial damage. This is a retrospective, observational tertiary single-center study of 90 consecutive patients (F/M:18/72, mean age:39 ± 14 years) hospitalized between 2015-2022 with a clinical diagnosis of acute myocarditis. The study population was divided into two groups: patients who underwent CMR+ and those who did not undergo CMR - In the CMR+ group, various sequences, including T1/T2-weighted imaging, late gadolinium enhancement (LGE), and mapping techniques, were used to assess myocardial inflammation and damage. CMR was performed in 39 patients (43.3%, F/M:10/29, mean age:41 ± 16 years). In this group, myocardial edema (increased T2 signal intensity) was detected in 29 patients, and LGE (signal intensity 2 standard deviations cabove normal on T1 images) was found in 39 patients. Diagnosis based on Lake Louise Criteria was possible in 29 cases. Edema negatively correlated with TnT levels (r = -0.412, p < 0.05) and positively with the number of LGE segments (r = 0.372, p < 0.05). Significant correlations were found between LVEF and LGE mass (r = -0.360, p < 0.05), and maximal TnT levels (r = -0.38, p < 0.05). CMR+ patients had lower myocardial damage markers and CRP concentrations compared to CMR- patients. CMR is underused in diagnosing acute myocarditis. Myocardial damage markers correlate with CMR-detected edema and volumetric measures, but not LGE extent. More research is needed to enhance risk assessment and treatment.

Clinical and Biochemical Outcomes in Transgender Individuals Undergoing Hormone Therapy: Protocol for a Systematic Review.

Monitoring of various clinical outcomes and parameters, such as lipid levels, is recommended in transgender individuals undergoing hormone therapies. However, comprehensive data to inform these recommendations is scarce. This study aims to conduct a systematic review and meta-analysis to synthesize evidence from existing literature on the effect of exogenous hormone therapy on clinical and biochemical outcomes for transgender adolescents and adults. We will search multiple electronic databases and will include prospective and retrospective observational studies with and without a control group. The study population will include transgender individuals undergoing hormone therapy with testosterone or estrogen. Comparisons will include age-matched, cisgender individuals and changes from baseline. Primary outcomes include changes in or the development of abnormal lipid parameters. Secondary outcomes include BMI, weight, height, and blood pressure for age, serum testosterone or estrogen levels, and development of disease including hypertension, diabetes, fatty liver disease, obesity, adverse cardiac events, as well as all-cause mortality. The meta-analysis will pool the studies where applicable, and meta-regressions will be conducted to evaluate effect modifiers. The GRADE (Grading of Recommendations Assessment, Development, and Evaluation) approach will be used to evaluate the overall certainty of evidence. We will summarize the selection of the eligible studies using a PRISMA (Preferred Reporting Items for Systematic Reviews and Meta-Analyses) flowchart. The results will be presented in a table summarizing the evidence. Data collection is ongoing, and the paper is expected to be published in Spring 2025. This systematic review will summarize and evaluate the evidence of the clinical and biochemical outcomes associated with hormone therapies for transgender individuals. PROSPERO CRD42024483138; https://tinyurl.com/yc4sfvnb. PRR1-10.2196/57931.

Abstract 4135211: Children with the D801N Variant of the ATP1A3- Encoded Sodium-Potassium ATPase Alpha-3 Subunit Demonstrate Paradoxical QT Response to Bradycardia and Increased Ventricular Arrhythmia Risk

Introduction: Alternating hemiplegia of childhood (AHC) is a rare condition most frequently caused by mutations in ATP1A3, encoding for the alpha-3 subunit of Na + /K + -ATPase, and D801N is the most common variant. Individuals with ATP1A3-D801N have shorter corrected QT (QTc) than those with other variants and can experience ventricular arrhythmias following bradycardia; however, the mechanism of why this occurs is unknown. Goals: To analyze how QT and QTc change with heart rate in ATP1A3-D801N compared to healthy individuals. Hypothesis: Individuals with ATP1A3-D801N have increased shortening of QT and QTc at lower heart rate. Methods: In this retrospective observational study, patients seen for evaluation of AHC at Duke University Medical Center were categorized by genotype: ATP1A3-D801N, ATP1A3 non-D801N single nucleotide variant, ATP1A3 loss-of-function variant, and genotype negative. A cohort of matched healthy children was also compiled. We collected average heart rate, QT, and QTc measurements over 5-minute intervals from Holter recordings using HScribe TM software and conducted manual blinded validation to ensure accuracy. We then used linear regression to investigate the relationship between heart rate, QT, and QTc. Results: The cohort consisted of 44 patients with ATP1A3 -related phenotypes with 81 total Holter recordings (52.27% female; mean age at first Holter 8.04 years), compared to 36 healthy individuals with 57 total Holter recordings (52.78% female; mean age at first Holter 9.84 years). Patients with ATP1A3-D801N showed diminished prolongation of QT with decreasing heart rate, manifested as a reduced mean slope for heart rate vs QT compared to healthy (-0.85 ± 0.46 vs -1.52 ± 0.42, p&lt;0.0001). This blunted QT response resulted in paradoxical shortening of QTc at lower heart rate, demonstrated by an increased mean slope for heart rate vs QTc compared to healthy (0.80 ± 0.51 vs 0.22 ± 0.43, p&lt;0.0001). Further, patients with ATP1A3- related phenotypes and very short baseline QTc showed increased shortening of QT and QTc at lower heart rate compared to those with normal QTc (p=0.0025 and p=0.0013, respectively). Conclusions: Children with AHC and ATP1A3-D801N demonstrate a paradoxical shortening of QT and QTc with slowing of heart rate. The impaired prolongation of QT and resultant further shortening of QTc increase the risk of arrhythmia. We put this forward as a novel mechanism of sudden cardiac arrest in patients with ATP1A3 mutations.

Abstract 4124323: Extensive atrial cardiomyopathy indicated by left atrial low-voltage areas predicts subsequent stroke after atrial fibrillation ablation

Background: Atrial fibrillation (AF) is a leading cause of stroke. However, predictors of stroke after AF ablation have not been well clarified, therefore, evidences of anticoagulation therapy after the procedure have been limited. Although left atrial low-voltage areas (LVAs) reflects atrial cardiomyopathy, which is a potential cause of thromboembolism, there are few reports of an association between LVAs and stroke. The purpose of this study was to investigate the association between atrial cardiomyopathy assessed by LVAs and stroke in patients undergoing AF ablation. Methods: The study design was a single center, retrospective observational study. This study included 1,486 (age, 68 ± 10 years; female, 501 [34%]; persistent AF, 905 [61%]) consecutive patients who underwent initial AF ablation from December 2014 to March 2022. The definition of LVAs were areas with a bipolar voltage of &lt;0.5 mV in the left atrium. The area of LVAs in the whole left atrium was divided into 3 groups, namely &lt;5cm 2 , 5-20 cm 2 and ≥20 cm 2 . Stroke after AF ablation was followed for 60 months. Results: Of 1,486 patients, LVAs were found in 352 (24%) patients, and 25 (1.7%) patients developed stroke (hemorrhagic stroke, 4 [16%] patients; ischemic stroke 21 [84%] patients). Freedom from stroke was significantly lower in patients with LVAs than in those without (&lt;5cm 2 : 98.3%, 5-20 cm 2 : 95.4%, ≥20 cm 2 : 88.8%, p&lt;0.001). Additionally, LVAs ≥20 cm 2 was an independent predictor of the development of stroke after AF ablation (hazard ratio 4.9, 95% confidence interval: 2.0-12; p=0.001, adjusted by estimated glomerular filtration rate and AF recurrence after ablation). Conclusion: In patients with initial AF ablation, freedom from stroke after AF ablation was significantly lower in patients with LVAs ≥20 cm 2 than in patients with LVAs 5-20 cm 2 and in patients with LVAs &lt;5cm 2 . Particularly, LVAs ≥20 cm 2 was an independent predictor of the development of stroke after AF ablation.

Abstract 4117310: Alcohol-Related Cardiomyopathy - Exploration of Recent Mortality Trends in the United States

Introduction: Data is accumulating regarding the contemporary trends of mortality rates in patients with alcohol-related cardiomyopathy across the United States. Hypothesis: We hypothesized that with increased awareness about the adverse effects of alcohol on the cardiovascular system and the advancement of echocardiography in the early diagnosis of alcoholic cardiomyopathy, mortality rates may show a downward trend. Methods: This is a retrospective observational study that retrieved death certificates from the CDC WONDER (Center for Disease Control and Prevention’s Wide-ranging ONline Data for Epidemiological Research) database from 2001-2020. The mortality rate of alcohol-related cardiomyopathy using ICD code I42.6 (Alcoholic cardiomyopathy) was studied from 2001-2020. This study duration was further subdivided into five-year periods. We calculated the crude mortality rate and age-adjusted mortality rate per 100,000 for four U.S census regions (CR-1 Northeast, CR-2 Midwest, CR-3 South, CR-4 West). Results: The overall age-adjusted mortality rate remained at 0.1/100,000 deaths in four U.S census regions until 2015; however, in the last five years of the study period, AAMR(age-related mortality rate) increased from 0.1 to 0.2/100,000 deaths. Conclusions: The mortality trends associated with alcohol-related cardiomyopathy have not changed significantly over the past two decades. This can be explained by the larger number of people developing alcoholic cardiomyopathy due to the increase in global alcohol use in addition to the fact that more diagnosed patients are receiving earlier treatment with goal-directed medical therapy for cardiomyopathy. Limitations of this study include intrinsic weakness of the WONDER dataset (changes with ICD-9 to ICD-10 codes, and potentially miscoding) which needs further research. Discussion: This suggests that while mortality rates associated with alcohol-related cardiomyopathy remained relatively steady for most of the study period, there was a concerning uptick in the latter years. This could prompt further investigation into potential factors contributing to this increase, despite advancements in awareness and diagnostic techniques.

Physical development of infants born to patients with COVID-19 during pregnancy: 2 years of age

Background SARS-CoV-2 infection during pregnancy and pandemic circumstances could negatively impact infant development. This study aimed to investigate the physical development, common pediatric illness incidence, and healthcare utilization over the first 2 years of life of infants born to COVID+ and COVID- patients. Comparisons were also made with infants born pre-pandemic. Methods This is a retrospective observational study at a major academic health system in New York City. Participants include all infants born to birthing persons with SARS-CoV-2 infection during pregnancy (N = 758) and without (N = 9,345) from 03/01/2020 to 08/17/2022, infants born pre-pandemic (N = 3,221) from 03/01/2017 to 08/17/2019, and birthing persons of all infants. Results There were no differences in weight, length, or head circumference curves between pandemic infants born to COVID+ and COVID- patients over the first 2 years of life (p &gt; 0.05, repeated ANOVA). Annualized incidence of illness occurrence and healthcare utilization were similar between groups. Compared to pre-pandemic infants, the length of pandemic (COVID-) infants was lower from birth to 9 months (p &lt; 0.0001). Pandemic infants additionally had more adverse perinatal outcomes including increased stillbirth (0.75% vs. 0.12%, p = 0.0001) and decreased gestational age (38.41 ± 2.71 vs. 38.68 ± 2.55 weeks, Cohen’s d = −0.10, p &lt; 0.0001), birthweight (2,597 ± 335 vs. 3,142 ± 643 g, Cohen’s d = −1.06, p &lt; 0.0001), and birth length (48.08 ± 4.61 vs. 49.09 ± 3.93 cm, Cohen’s d = −0.24, p &lt; 0.0001). Conclusions Birthing persons’ SARS-CoV-2 infection status, birthing persons’ profiles, and pandemic circumstances negatively affected perinatal outcomes, newborn physical development, and healthcare utilization. These findings draw clinical attention to the need to follow infants closely and implement enrichment to ensure optimal developmental outcomes.

Abstract 4136085: The Prognostic Impact of Thrombocytopenia at 6 months after Transcatheter Aortic Valve Replacement: A Retrospective Multicenter Study

Background: Transient thrombocytopenia after transcatheter aortic valve replacement (TAVR) is a common phenomenon. Thrombocytopenia after TAVR during the perioperative period has been reported to impact prognosis. However, the impact of thrombocytopenia in the mid-term post-TAVR period is currently unknown. Methods: A retrospective observational study was conducted on 1405 patients who underwent TAVR from May 2016 to February 2023 at four institutions. Of these, 850 patients were analyzed. Patients who underwent dialysis (67), converted to an open chest surgery (8), had a Valve-in-Valve procedure (30), underwent a direct aortic approach (16), had a malignant tumor (66), and patients whose platelet levels could not be measured at 6 months after TAVR due to death or dropout were excluded from the analysis. The clinical follow-up occurred at 1, 6, and 12 months after the procedure. Laboratory testing was conducted before TAVR, during the perioperative period, 1 month post-procedure, and 6 months later. The decrease in platelet count (DPC) 6 months after TAVR was calculated by the following formula: [(Baseline platelet – 6 months platelet)/baseline platelet *100]. A receiver operating characteristics curve was plotted for all-cause mortality at 1 year and DPC at 6 months. The calculated cutoff value for the DPC at 6 months (28.68%) was utilized to classify and compare the two groups. Multivariate logistic regression models were also used to examine the association between the DPC at 6 months and all-cause mortality at 1 year. Adjusted for propensity score matching, the DPC was compared at 6 months in self-expandable and balloon-expandable prosthetic valves. Result: Of the 850 eligible patients (age: 85.5 ± 4.9 years), 31 (3.4%) died between 6 months and 1 year after TAVR. The DPC at 6 months after TAVR was 11.9 ± 22.5%. Multivariate logistic regression analysis including the DPC at 6 months, age, gender, and STS score showed that the DPC at 6 months was independently associated with all-cause mortality at 1 year (odds ratio: 1.03, 95% confidence interval: 1.005-1.046, p=0.01). After adjustment for propensity score matching, the balloon-expandable prosthetic valve had a higher rate of thrombocytopenia at 6 months (15.0% vs. 9.6%, p=0.04). Conclusion: The DPC at 6 months after TAVR may predict all-cause mortality at 1 year.

Diffusion-Weighted Imaging Does Not Differentiate Between Bacterial and Fungal Skull Base Osteomyelitis.

Apparent diffusion coefficient (ADC) value helps in differentiating infections from neoplasms on magnetic resonance imaging (MRI). We investigate the diffusion-weighted images in skull base osteomyelitis (SBO) to evaluate if ADC values can differentiate fungal and bacterial SBO and to analyse the microbiology of all SBO patients. Retrospective observational study. Quaternary care referral centre. A retrospective review of 142 patients diagnosed and treated for SBO patients from January 2010 to May 2023 was done. Chi-square or Fisher's exact test was used to compare ADC values of bacterial and fungal SBO. The most common pathogens isolated were Pseudomonas (42.2%), Aspergillus (30.98%), and S. aureus (23.94%). The average ADC value of affected soft tissues among patients was 1.13 ± 0.26 × 10-3 mm2/s compared to the average ADC value of normal soft tissue, 1.34 ± 0.31 × 10-3 mm2/s. There was no statistical significance when comparing the average ADC values of bacterial and fungal SBO patients (p value = 0.142). This study suggests that though infection due to Pseudomonas was the commonest, it was detected only in 42.2% of patients. More than half of the cases had organisms other than Pseudomonas, demanding the clinician to obtain deeper biopsies early in the course of the disease for microbiological analysis. DWI does not help differentiate bacterial and fungal SBO, again emphasising the need for deeper tissue biopsies in all these patients to assist in the early identification of the pathogen.

Association between mammographic breast density and outcome in patients with unilateral invasive breast cancer receiving neoadjuvant chemotherapy.

To analyze the relationship between mammographic breast density and tumor response and outcome at follow-up, in terms of overall survival (OS) and disease-free survival (DFS), in patients with unilateral invasive breast cancer receiving neoadjuvant chemotherapy (NACT). A total of 228 women (mean age, 47.6years ± 10 [SD]; range: 24-74years) with invasive breast cancer who underwent NACT were included in this observational retrospective study. Clinical, radiological and histopatological data were retrieved. Categorization of breast density was performed by two radiologists in consensus on mammography acquired at the time of diagnosis according to BI-RADS categories. Association between density categories and tumor response was analyzed in the overall population and in subgroups defined by menopausal status, tumor phenotype and stage at diagnosis. Kaplan-Meier (KM) curves were used to estimate the OS and DFS probabilities. Subgroup analyses based on menopausal status and tumor phenotype were performed. A total of 30 patients (13.2%) achieved pathological complete response (pCR). No association between density categories and pCR was found (P = 0.973), even at subgroups analysis. The median follow-up time was 92months. Patients with dense breast showed the longest DFS (P = 0.0094), results confirmed in premenopausal patients (P = 0.0024) and in triple negative breast cancers (P = 0.0292). Density category did not show a statistically significant association with OS. Breast cancer patients receiving NACT with extremely dense breasts showed better DFS. No evidence of breast density as a predictive marker for complete pathological response or as a prognostic factor in terms of OS was found.

Abstract Su502: Is 80% a Reasonable Minimal Goal for Defibrillation Efficacy of Out-of-Hospital Cardiac Arrest ?

Introduction: There is no clear goal defined by standards or learned societies on clinical performance related to defibrillation efficacy. In literature, monophasic shocks defibrillation efficacy is mainly &gt;70% whereas biphasic is &gt;80%. Resuscitation guidelines define efficient defibrillation as cessation of shockable rhythm at 5s post-shock and proceed to state that beyond 5s, shock outcomes are biased by known confounders (call to AED connection time (CallAEDTime), bystander, cardio-pulmonary resuscitation (CPR), drugs…). Thus, it is consistent that automated external defibrillator (AED) performance should be assessed in terms of defibrillation efficacy right after the shock rather than in terms of restoration of a spontaneous circulation or survival to hospital discharge. This study aimed to define an acceptable goal for validation of defibrillation efficacy. Method: In this observational retrospective study, we included AED tracings of adult non-traumatic out-of-hospital cardiac arrest (OHCA) patients with initial ventricular fibrillation (VF) rescued by basic life support teams (Paris Fire Brigade) from 01/2017 to 02/2022. Cardiac rhythm was examined during the 10 first minutes of connection of the AED (DGT7, Schiller Médical, France). Shockable rhythm is defined as coarse-VF with at least 200µV peak-to-peak amplitude (ptpA). Efficient defibrillation was defined as cessation of shockable rhythm at 5s post-shock. We fitted a linear mixed model to predict defibrillation efficacy using the 4s ptpA of pre-shock VF. The model included the patient as random effect and a p-value &lt;0.05 was considered statistically significant. Results: We analyzed 1333 shocks from 547 patients, with: median age of 59 (interquartile range, IQR[49-71]), 78% male, 36% in public places, 72% with bystander CPR and median[IQR] CallAEDTime of 13min [10-15]min. The effect of the pre-shock ptpA of VF on the defibrillation efficacy is statistically significant: OR=1.023, 95% Confidence Interval (CI) [1.010,1.036], p&lt;0.001. That means that for each 100µv increment in VF amplitude pre-shock, the probability of success at 5s post-shock increases by 2.3%. Adjusting for age, sex, location, CPR and CallAEDTime does not change the results. The logistic regression of Figure1, shows a defibrillation efficacy at 200µV ptpA of 79%, CI [75,82]%. Conclusion: Based on 1333 OHCA biphasic shocks, this study suggests defining 80% as a reasonable minimal goal for validation of the AED defibrillation efficacy.

Deterioration in ankle reflex is associated with a reduced estimated glomerular filtration rate in patients with type 2 diabetes: A retrospective observational cohort study.

We investigated the association between the ankle reflex and the estimated glomerular filtration rate (eGFR) in patients with type 2 diabetes. This was a single-center, retrospective, observational cohort study. A total of 1,387 patients who underwent an ankle reflex examination between January 2005 and December 2015 were included in the analysis for the primary outcome. The findings of the ankle reflex examination were classified into three groups: normal, decreased, or absent. The primary outcome was defined as the incidence of a 40% loss of eGFR from baseline. A survival time analysis using the Kaplan-Meier method and a regression analysis using a Cox proportional hazards model were conducted to evaluate the association between the ankle reflex test results and loss of eGFR. The ankle reflex test results were as follows: normal, n = 678 (48.9%); decreased, n = 270 (19.5%); and absent, n = 439 (31.6%) patients. The median follow-up period was 5.6 years in the observational period. In the univariate regression analysis, decreased and absent ankle reflexes were significantly associated with loss of eGFR. Moreover, decreased ankle reflex (hazard ratio: 1.83, 95% confidence interval: 1.16-2.87) and absent ankle reflex (hazard ratio: 2.57, 95% confidence interval: 1.76-3.76) were independently associated with loss of eGFR after adjusting for prognostic risk factors. Decreased and absent ankle reflexes are closely and independently associated with loss of eGFR in patients with type 2 diabetes.

Real-world use of androgen-deprivation therapy intensification for metastatic hormone-sensitive prostate cancer: a systematic review.

To conduct a systematic literature review of real-world data (RWD) studies to summarise treatment patterns among men with metastatic hormone-sensitive prostate cancer (mHSPC).While androgen-deprivation therapy (ADT) is a primary treatment strategy for mHSPC, ADT intensification with androgen receptor pathway inhibitors (ARPIs) and/or chemotherapy is recommended by current guidelines and has improved clinical outcomes in the last decade. We searched electronic databases (PubMed; Excerpta Medica dataBASE [EMBASE]) for eligible studies (retrospective or prospective observational RWD studies examining mHSPC treatment patterns) between database inception and July 2023, and manually screened the past 2 years of relevant conference proceedings. Of 2336 retrieved citations, 29 studies met the inclusion criteria, covering North America (United States, n = 21; Canada, n = 2), Europe (n = 8), and Asia (n = 6). Most studies utilised retrospective cohorts (n = 26) and included men with a median age of ≥70 years (n = 20). ADT monotherapy was predominantly used across geographies, followed by ADT + ARPI and ADT + docetaxel in the United States and Europe but not in Asia, where use of each combination remained low. Studies with recent electronic medical record data from cancer centres/registries showed >40% use of ADT + ARPI in the United States and Europe. Abiraterone was the most frequently used ARPI, followed by enzalutamide. Quantitative factors associated with ADT intensification were high disease burden, younger age, Eastern Cooperative Oncology Group performance status score of 0 to 1, fewer comorbidities, and oncologist physician specialty; qualitative factors were patient preference, unsatisfactory response to ADT, ability to tolerate adverse events, and absence of cost barriers. While there was an increasing trend in ADT intensification for mHSPC over the study period across geographies, use remained suboptimal considering the high proportion of patients who were still receiving ADT monotherapy only. These findings highlight the need for interventions to further optimise current mHSPC therapies with high guideline concordance.

Total hip arthroplasty in patients under 35 years: a systematic review of the last 2 decades studies.

Patients with total hip arthroplasty (THA) under the age of 35 represent a small and heterogeneous group of 1% of all THA performed. This systematic review aims to analyse the diagnosis, implant type, complications, and long-term results in these patients. A search was performed on PubMed, Scopus, and Cochrane Library up to 31 July 2023. We included observational prospective and retrospective studies published in the last 20 years, which evaluated diagnosis, implant types, long-term results, and return to sports in patients ⩽35 years who underwent THA. We excluded case reports, case series, and studies with <35 patients. We extracted age, diagnosis, surgical information, follow-up, complications, revision rate, implant survival, and clinical outcomes for each study. The methodology of the included studies was evaluated using the MINORS score. 18 studies with 1955 patients and 2383 THAs were included. Osteonecrosis (40.6%), posterior approach (81%), the uncemented press-fit implants (73.4%), metal-polyethylene bearings (31.3%) were the most frequently found items. All the clinical outcomes reported improvement from the preoperative to postoperative. The most frequent complication was aseptic loosening (4.3%). The survival rate was 92.4% at a mean follow-up of 10 years. THA is a good option for specific hip diseases in the young, but aseptic loosening still is the major point of concern.

Abstract 4133324: Socioeconomic status, race, and ethnicity in management of pediatric SVT

Introduction: Electrophysiology study and ablation (EPS) is often the preferred approach to management of supraventricular tachycardia (SVT) and/or ventricular pre-excitation (WPW) in older children/adolescents. There are inequities in arrhythmia management in adults, and in other areas of pediatric cardiology, but little is known about disparities in management of SVT in children. Research question: Do racial/ethnic and socioeconomic inequities affect referral for EPS in patients with SVT and/or WPW? Methods: This retrospective observational study utilized the Pediatric Health Information System of 49 children’s hospitals’ administrative data from 2016-2022. We included patients with SVT or WPW seen in the emergency department, admitted for observation, or inpatient. We excluded patients with congenital heart disease. The outcome was having a procedure code for EPS. The childhood opportunity index (COI, scale 1-100) based on zip code was used to measure socioeconomic status (SES). Results: Among 37,818 patients with primary diagnosis of SVT (27620, 73%) or WPW (10198, 27%), 9840 (26%) underwent EPS (Table 1). COI was higher in patients who underwent EPS than those who did not (median 59 [IQR 34,82] vs 57 [IQR 30,81]). In addition, time from initial visit with diagnosis of SVT/WPW to EPS was longer in patients with lower COI (beta= -0.026, p=0.007). Black (21.2%), Hispanic (23.8%), and American Indian (19.8%) patients were less likely to undergo EPS than White (26.5%) and Asian (28.31%) patients and those with other (28.4%) or unknown/missing (35.7%) race (p&lt;0.001, Figure 1). In both subgroups of patients with SVT and WPW, EPS differed by race and COI, and higher COI predicted shorter time to EPS. Conclusions: In this hospital database of pediatric patients, we found disparities in use of EPS for the management of SVT and/or WPW. Patients of minoritized race/ethnicity and lower SES were less likely to undergo EPS.

Prognostic Value of Serum D-dimer in Predicting Outcomes in COVID-19 Positive Pregnant Women

Background: Combined effects of pregnancy induced hypercoagulability and SARS-CoV-2 infection place pregnant women with COVID-19 disease at high risk of severe outcome. COVID-19 severity has also been associated with serum D-dimer, a biomarker reflecting coagulation and fibrin degradation, in general populations. Despite its prognostic value in pregnant women, the prognostic value of this finding particularly in maternal outcomes remains less understood. The aim of this study was to determine whether elevated serum D-dimer levels in pregnant COVID-19 positive women are of prognostic significance for severe maternal outcomes. Methods: This retrospective observational study included 62 third trimester COVID 19 positive pregnant women admitted to the Department of Obstetrics and Gynecology, BSMMU, Dhaka from March 2019 to February 2020. Serum D-dimer were measured at admission and day 7, 14. D-dimer levels were related to clinical outcomes and statistically evaluated using chi square tests and logistic regression at p &lt; 0.05. Results: Significantly associated with higher risk of severe outcomes, all of which included ICU admission, respiratory complications and adverse pregnancy events is elevated D-dimer levels (≥1.5 mg/L). In logistic regression analysis, patients with D-dimer levels of ≥1.5 mg/L had 3.5-fold greater odds of severe outcomes (OR 3.486; 95% CI, 1.184 to 10.263; p = 0.023). D-dimer had a sensitivity of 64.29%, 67.55% specificity in predicting severe outcomes. Conclusion: Serum D-dimer is valuable prognostic marker of disease severity in pregnant COVID-19 positive women and may be used for early risk assessment and clinical decision making. Routine measurement may help identify early high risk cases in order to improve maternal outcomes.

Relationships Among Physician Vendor-Derived Proficiency Score, Gender, and Time in the Electronic Health Record

Background and Objectives: Electronic health record (EHR) customization is proposed to mitigate EHR-related burnout. Gender disparities in EHR usage are established, though less is known regarding differences in customization and its impact on EHR time. This study examined gender differences in vendor-derived proficiency score (PS) and its relationship to EHR time. Methods: This was a retrospective observational study of ambulatory EHR use for adult primary care and medical subspecialty physicians at an academic safety-net health care system. The EHR vendor provided a physician PS (0–10), derived from customization and efficiency tool utilization. Primary outcomes were PS, time in system per day, and time in system per appointment stratified by gender. We used multiple variable linear regression to determine whether gender differences persisted with the inclusion of other factors. Results: A total of 228 physicians were included in the study; 122 were women, and 106 were men. Women had higher median PS (7.6 vs 6.6, P=.021) and EHR time per day (150.5 vs 119.9 minutes, P=.013), but no difference in time per appointment (24.7 vs 26.1 minutes, P=.665). After adjusting for potential confounders, gender remained a significant predictor of PS, but not time in EHR. Higher PS was significantly associated with greater time in the system per appointment, but not per day. Conclusions: While women had higher PS than men, gender was not significantly associated with measures of EHR time after adjusting for potential confounders. Higher PS was associated with greater time in the EHR per appointment, suggesting factors that influence EHR time are complex and varied.

Abstract 4137534: Troponin Can Predict Late Gadolinium Enhancement on Cardiac MRI in COVID-19 Vaccine-Associated Myocarditis

Background/Aim: We previously reported that late gadolinium enhancement (LGE) on cardiac MRI (CMR) was as high as 82% in pediatric patients with COVID-19 vaccine-associated myocarditis (C-VAM) despite mild clinical symptoms and normal left ventricular function. As LGE can be a harbinger for future adverse events including arrhythmias, heart failure or sudden cardiac death, we sought to identify predictors for LGE in C-VAM, specifically assessing troponin as a screening marker for C-VAM patients at risk for myocardial scarring who could then be referred for a confirmatory CMR with LGE. Methods: In this longitudinal multicenter retrospective observational study across 38 U.S. member institutions of the M yocarditis A fter C OVID V accination (MACiV) study network, 333 patients with C-VAM based on CDC criteria were included from April 2021 to November 2022. Data collected included demographics, laboratory values, clinical and cardiac imaging characteristics and outcomes. Using logistic regression, troponin levels at presentation were assessed as a log transformed continuous variable and categorized into tertiles. Results: The C-VAM patients were predominantly white (67%) adolescent males (91%, 15.7± 2.8 years). There were 216/333 (65%) patients who had both a reported troponin value and had a CMR. On univariate analysis, elevated troponin increased the probability of having LGE (OR=1.29, 95% CI: 1.06, 1.58, p=0.012). Even after controlling for age, race, sex, number of vaccine doses and left ventricular ejection fraction (OR=1.32, 95% CI: 1.06, 1.65, p=0.013). Patients &gt;15 years compared to those ≤15 years of age were 2.94 (95% CI: 1.28, 6.75, p=0.011) times more likely to have LGE at presentation. Patients with troponin levels in the highest tertile compared to lowest tertile were 2.66 times (95% CI: 1.04, 6.83, p=0.042) more likely to have LGE along with a greater involvement &gt; 4 AHA myocardial segments with LGE (p=0.004) Conclusions: Higher troponin values are associated with presence of late gadolinium enhancement on cardiac MRI in patients with COVID-19 vaccine-associated myocarditis. Troponin levels at presentation may facilitate risk stratification and function as a screening tool to identify those C-VAM patients with the greatest likelihood of myocardial scarring, who may benefit from undergoing CMR for tissue characterization.

A Novel Preoperative Classification System for Selecting Suitable Surgeries in Liver Transplant Patients with Portal Vein Cavernous Transformation

Background To evaluate the new preoperative Changgung classification (CC) system of portal vein thrombosis (PVT) in choosing suitable operative procedures to reconstruct portal veins during liver transplantation (LT) in patients with portal vein cavernous transformation (PVCT). Methods This retrospective observational study analyzed data from allograft LTs performed for various liver diseases Results The study included 22 males and 4 females with LT indications comprising cirrhosis (n = 9), hepatocellular carcinoma (n = 12), PVCT (n = 2), liver failure from fulminant hepatitis B (n = 1), dysfunction of transplanted liver (n = 1), and chronic rejection of transplanted liver (n = 1). Patients were classified according to Yerdel (21 Yerdel II and 5 Yerdel III) and CC (C1–C5). In total 16 simple operations were performed on C1–C3 cases and 9 complex operations on C4–C5 cases, with one additional simple operation. The distribution according to the Yerdel classification was 16 simple and 5 complex operations in Yerdel II cases and 1 simple and 4 complex operations in Yerdel III cases. The median follow-up time was 27.5 months with overall one-year and three-year OS rates of 88.1% and 83.9% for the cohort. Specifically, the one-year OS rates for patients classified as C1-3 vs. C4-5 were 93.3% and 80.0%, while the three-year OS rates were 86.7% and 80.0%, respectively (p = 0.526). Conclusion The CC proposed in this study shows comparable potential to the Yerdel classification in preoperatively identifying the need for complex surgical techniques in LT patients with PVCT and may also have predictive power for the survival benefits following LT.