Stanford Hospital Research Articles

ED observation unit-based delayed comfort care pathway for ED patients on life support.

Critically ill ED patients on life support may undergo transition to comfort care as decided by the surrogate decision maker. When several hours are needed for loved ones to arrive and say farewell before initiating comfort care ("delayed comfort care"), these patients require prolonged ED stays or costly intensive care unit (ICU) admissions. A novel ED observation unit (EDOU)-based delayed comfort care pathway for ED patients on invasive mechanical ventilation and/or vasopressors was created in 2013 at Stanford Hospital. Inclusion criteria are: agreement by the surrogate decision maker to no titration of life support and initiation of comfort care within 18h of EDOU admission. Exclusion criteria are: potential for organ donation and lack of a private room or nursing resources in the EDOU. Feasibility was assessed by analyzing the electronic health record for all patients who utilized the pathway between 8/2013 and 2/2023. The primary outcome was the proportion of patients who had initiation of comfort care after all expected loved ones arrived to the bedside. We also analyzed patient characteristics, clinical operation data, and safety data. 23 patients were identified in the study cohort. The average patient age was 76, and 48% were female. Three ED diagnoses for the cohort were intracranial hemorrhage (57%), cardiac arrest (26%), and respiratory failure (17%). All patients were intubated, and six were also on vasopressors on arrival to the EDOU. 100% of patients had all expected family members arrive to bedside prior to initiation of comfort care. All patients had initiation of comfort care within 18h of EDOU admission (median time from EDOU arrival to extubation 1.1h (IQR 0.2-3.2)). No patients had adverse events in the EDOU, died before comfort care initiation, or were transferred to ICU. The EDOU-based delayed comfort care pathway is a feasible way to deliver compassionate end of life care for patients on life support. It can be considered in hospitals with an EDOU especially if their private ED beds and ICU resources are scarce.

A prospective, observational study of a pediatric affect and cooperation scale (HRAD±) for vascular access procedures.

Anxiety is common in pediatric patients, especially during vascular access procedures. Most well-studied affect and anxiety scales, including the Observation Scale of Behavioral Distress-Revised (OSBD-r), the modified Yale Preoperative Anxiety Scale (mYPAS), and the modified Induction Compliance Checklist (mICC), are too cumbersome for clinical use outside of research settings. HRAD± (Happy, Relaxed, Anxious, Distressed with yes/no to cooperation) is a clinically-efficient observational scale that evaluates pediatric procedural affect and cooperation. This study examined the clinical utility of HRAD± during vascular access procedures in children. The aims were to investigate the correlation of HRAD± to highly reliable, research-based affect and cooperation scales and to assess inter-rater reliability (IRR) between observers in this setting. This was a prospective, observational study conducted at Lucile Packard Children's Hospital Stanford. Inpatient participants were 1 month to 25 years old and undergoing a peripheral intravenous insertion or phlebotomy. Two trained research assistants (RAs) scored each patient independently during the vascular access procedure using HRAD±, OSBD-r, mYPAS, and mICC. Correlation analyses computed the associations between HRAD± and reference scales. IRR between RAs and vascular access providers was calculated using Fleiss' Kappa. A total of 234 patients were included. HRAD± scores strongly correlated with OSBD-r and mYPAS (p < 0.0001, p < 0.0001, respectively). The cooperation assessment of HRAD± demonstrated strong correlation to mICC (p < 0.0001). IRR of HRAD± between research assistants and vascular access providers showed moderate agreement (p < 0.0001). HRAD± demonstrated strong correlation to the reference affect and cooperation scales. This study supports the utility of HRAD± for rapid assessment of pediatric procedural anxiety and cooperation during vascular access procedures. HRAD± can serve as a practical tool for facilitating clinical decisions, and its wider incorporation into healthcare settings would importantly guide targeted interventions to reduce patient anxiety.

The influence of desynchronised circadian rhythm on emotional contagion and reactivity: A comparative study

Objectives: The objective of this study was to assess the impact of acute sleep deprivation (12 h) on emotional and autonomic reactivity and processing in nursing shift workers at KLE’s Prabhakar Kore Hospital and MRC. The impact of acute sleep deprivation on emotional behaviour in health-care personnel, especially nurses, is a topic of significant interest in the scientific community. Despite this, the existing body of literature on this topic remains relatively scarce. This is particularly important in the field of nursing, where socioemotional behaviour, irritability and volatilities are compulsory evil and an occupational hazard. This study aims to delve into the effects of acute sleep deprivation on emotional behaviour among shift-working nurses. It explores the correlation between desynchronised circadian rhythms, emotional processing, and reactivity, with a specific focus on their interaction with declarative memory. The impact of sleep deprivation on associative memory is also touched on. Materials and Methods: Seventy-two nursing students (III year) who were posted for night duties (8 p.m.–8 a.m.) and age- and gender-matched day-time working nurses were recruited. Following their respective shifts, they were made to fill Pittsburgh Sleep Quality Index (PSQI), Stanford Sleepiness Score and Hospital Anxiety and Depression Scale (HADS) questionnaires. To assess emotional contagion, the nurses underwent a facial affective recognition task, and to assess autonomic reactivity, heart rate variability (HRV) in the form of the root mean square of the successive difference (RMSSD) was recorded using an HRV phone tracker. Results: The results of our study prove that sleep deprived group (SD) nurses had poor PSQI global score (females [12 ± 7.6] and males [12.34 ± 5.4]) as compared to daytime controls (female [7 ± 4.8] and male [7.2 ± 6]). Sleep-deprived female nurses showed a tendency toward sleepiness (3.66 ± 0.24) as compared to SD male nurses, who showed greater anxiety (8 ± 1.1) on the HADS questionnaire as compared to daytime controls. During the affective facial recognition task (AFRT) for emotional contagion, the SD female nurses showed hyperarousal to negative valence emotions such as anger (4 ± 11.12) and fear (4.2 ± 9.0) as compared to controls. There was blunting toward positive valence emotions (happy) in SD (1.5 ± 11) as compared to daytime controls (2.5 ± 10.2), but no statistical change among the male SD and controls. HRV in relation to negative valence emotion to assess reactivity (anger) was associated with sympathetic activity characterised by reduced RMSSD (39 ± 7.0) in SD female nurses as compared to controls (51 ± 12.46); no statistically significant change was observed in male counterparts. There was no notable change in emotions such as surprise and disgust among SD and controls in both genders. Conclusion: Results obtained from our study suggest fragmented sleep quality as well as a higher incidence of morning sleepiness in night-shift workers. The AFRT showed heightened hyperarousal following a negative valence (anger and fear) Stimuli but a blunted response toward happy and sad pictures. The vagal dominance in the form of RMSSD showed a blunted response during negative valence emotions, suggesting increased sympathetic preponderance during viewing those during sleep-deprived states.

Closing the loop: Utilizing advanced practice providers for a 7-day post hospital discharge follow-up of GI oncology patients at an academic cancer center.

304 Background: Acute care visits for oncology patients may be preventable, especially for high-risk patients with a recent hospitalization. During our 2023 Fiscal Year, we observed an approximate 22% rate for 30 day readmissions for oncology patients, with our gastrointestinal (GI) oncology patients having the most readmissions, at Stanford Cancer Center. Readmission review through clinician surveys suggested that about 28% of unplanned admissions may have been preventable, with root cause analysis identifying timely access to ambulatory symptom management as a major driver. Methods: We established a cancer transitional care (CTC) clinic to provide consistent and timely post-discharge follow-up for oncology patients. We initiated a pilot program for GI oncology patients (chosen due to high acuity and readmission rate) who had an unplanned admission to Stanford Hospital. We aimed to schedule a visit with an advanced practice provider (APPs) within 7 days of discharge. The A3 problem solving process was implemented weekly by a multidisciplinary team. We created a referral in our electronic medical record. Inpatient oncology teams were instructed to place this referral within 3 days before discharge, allowing for adequate patient and family education regarding the goals of CTC visits and ample time for the post-discharge CTC visit to be scheduled prior to patient discharge. Prior to CTC visits, pharmacists performed outreach to reconcile medications to reduce medication errors. Eight oncology APPs were trained regarding the focused nature of a CTC visit, including symptom management, medication reconciliation, and goals of care discussions. Results: At baseline, from June 1 and November 30th, 2023, 61% of patients had follow-up within 7 days of discharge and 12% of patients with none. Between December 13, 2023 and April 19, 2024, CTC implementation resulted in a total of 220 referrals for GI oncology discharges, yielding 144 CTC clinic visits. Resulting in 66.1% of patients having follow up within 7 days of discharge and 9% of patients had no follow up scheduled. 79% of visits were within 7 days of discharge, representing a 29% increase in our goal scheduling timeline. The average time between discharge date and CTC visit was 6.2 days. Sixty six patients also received detailed pharmacy reviews with medication reconciliation and addressing medication access issues. Conclusions: Through our CTC clinic, we standardized post-discharge follow-up access for GI oncology patients, reducing variability in follow up. We plan to disseminate this model across medical oncology subspecialty clinics. Barriers included standardization of follow up with clinical team and expectations for the visit for both patients and clinicians. Future directions include integrating same day symptom management and urgent care access.

Discordant High Activated Partial Thromboplastin Time Relative to Anti-Xa Values in Hospitalized Patients is an Independent Risk Factor for Increased 30-day Mortality.

The activated partial thromboplastin time (aPTT) and anti-factor-Xa levels (anti-Xa) are both used to monitor patients on unfractionated heparin. Our previous study demonstrated that patients with discordant high aPTT relative to anti-Xa had higher rates of mortality and bleeding events. To determine if underlying patient characteristics drive both discordance and adverse outcomes or if discordance is an independent risk factor to adverse outcomes. We analyzed all patients hospitalized at the Stanford Hospital between January 2011 and December 2019 who had simultaneous aPTT and anti-Xa levels performed. From the electronic medical record, we extracted and analyzed 51 patient features including baseline coagulation laboratory results, demographics, values of other common laboratories (basic metabolic panel, complete blood count, etc.), diagnostic procedures, medications, and death. A total of 17,728 patients had 78,701 paired aPTT and anti-Xa levels. Patients with discordant aPTT and anti-Xa where aPTT (seconds) was elevated beyond the expected therapeutic range had a higher 30-day mortality (odds ratio [OR]: 2.16, 95% confidence interval [CI]: 1.78-2.63, p < 0.001). Sectioning the patients based on the degree of discordance and whether aPTT or anti-Xa were signaling excess anticoagulation, we found those with an elevated aPTT discordant to their anti-Xa level had the highest odds of death (OR: 2.46, 95% CI: 1.99-3.10) compared with the concordant group. This finding was still present after controlling for patient comorbidity and other laboratory results at hospital admission. After controlling for patient features strongly associated with increased mortality in heparinized patients, we identified that the discordant pattern of high aPTT to anti-Xa served as an independent predictor of 30-day all-cause mortality, with a higher degree of discordance associated with increased odds of 30-day mortality.

Factor Eight Inhibitor Bypass Activity Use in Cardiac Surgery: A Propensity-matched Analysis of Safety Outcomes.

Bleeding during cardiac surgery may be refractory to standard interventions. Off-label use of factor eight inhibitor bypass activity (FEIBA) has been described to treat such bleeding. However, reports of safety, particularly thromboembolic outcomes, show mixed results, and reported cohorts have been small. Adult patients undergoing cardiac surgery on cardiopulmonary bypass between July 1, 2018, and June 30, 2023, at Stanford Hospital (Stanford, California) were reviewed (n = 3,335). Patients who received FEIBA to treat postcardiopulmonary bypass bleeding were matched with those who did not by propensity scores in a 1:1 ratio using nearest neighbor matching (n = 352 per group). The primary outcome was a composite outcome of thromboembolic complications including any one of deep vein thrombosis, pulmonary embolism, unplanned coronary artery intervention, ischemic stroke, and acute limb ischemia, in the postoperative period. Secondary outcomes included renal failure, reoperation, postoperative transfusion, intensive care unit length of stay, and 30-day mortality. A total of 704 encounters was included in this propensity-matched analysis. The mean dose of FEIBA administered was 7.3 ± 5.5 U/kg. In propensity-matched multivariate logistic regression models, there was no statistically significant difference in odds ratios for thromboembolic outcomes, intensive care unit length of stay, or mortality. Patients who received more than 750 U FEIBA had an increased odds ratio for acute renal failure (odds ratio, 4.14; 95% CI, 1.61 to 10.36; P < 0.001). In multivariate linear regression, patients receiving FEIBA were transfused more plasma and cryoprecipitate postoperatively. However, only the dose range of 501 to 750 U was associated with an increase in transfusion of erythrocytes (β, 2.73; 95% CI, 0.68 to 4.78; P = 0.009) and platelets (β, 1.74; 95% CI, 0.85 to 2.63; P < 0.001). Low-dose FEIBA administration during cardiac surgery does not increase risk of thromboembolic events, intensive care unit length of stay, or mortality in a propensity-matched cohort. Higher doses were associated with increased acute renal failure and postoperative transfusion. Further studies are required to establish the efficacy of activated factor concentrates to treat refractory bleeding during cardiac surgery.

Scaling performance frontiers across multiple perioperative services

BackgroundOne of the primary principles governing operating room management includes maximizing clinical efficiency and optimizing the time used in the high-cost, high-revenue environments represented by operating rooms. Under-utilized and over-utilized times are elementary metrics that describe the operating room performance. Performance frontiers, the graphical representation of a hypothetical maximum performance of a manufacturing unit given a set of operating choices, visualize the maximal efficiency of systems and their existing constraints. MethodsMonthly aggregated operating room metrics from services at the University of Vermont Medical Center (UVM), Stanford Hospital, and the University of Alabama (UAB) at Birmingham Hospital were extracted. Paired under- and over-utilized times were plotted against each other. Performance frontiers representing the optimal performance of each service were overlaid. ResultsThe Kolmogorov-Smirnov test for goodness-of-fit at 95 % level of significance confirms that the performance frontiers representing UVM and Stanford (K-S = 0.9507, p < 0.0001), UVM and UAB (K-S = 0.9989, p < 0.0001), and Stanford and UAB (K-S = 0.9773, p < 0.0001), indicating each service is represented by a different performance frontier. ConclusionsOur analysis shows that the performance frontier defining the optimal efficiency of UVM is more efficient than that of Stanford and UAB. Differences in efficiency may be the result of a collection of factors that must be the subject of future research, including but not limited to organizational differences limited in scale of institutions. Choices in operating room management must be made in relation to the existing organizational structures of each institution and their specific capacity to make changes in tactical decisions. Systemic interventions should be implemented via qualitative analysis of more efficient services, defined by the relative positioning of relevant performance frontiers.

Abstract PO5-06-01: Loss of hormone receptor expression in breast cancer is associated with increased brain tropism and accelerated progression of leptomeningeal disease

Abstract The four breast cancer subtypes—luminal A, luminal B, HER2-overexpressing, and triple-negative breast cancer (TNBC) – are classified based on gene expression profiles of hormone receptors (HRs) (estrogen receptor (ER) and progesterone receptor (PR)) and human epidermal growth factor receptor 2 (HER2/ERBB2). Negative hormone receptor status is known to be associated with more aggressive breast cancer. Compared to other breast cancer subtypes, the HR-negative TNBC and HER2-overexpressing subtypes are characterized by high rates of recurrence and a notable increase in brain metastases and in particular, leptomeningeal disease (LMD). LMD – the most aggressive form of central nervous system (CNS) metastasis, in which cancer cells infiltrate leptomeninges of the brain and spine – carries a dismal prognosis due to a rapid progression, poor detection, and no effective treatment. Several studies that investigated the link between HR status and LMD suggest that HR-negative breast cancers have a shorter time to LMD diagnosis. This shortened timeline is consistent with higher migratory capabilities reported for TNBC and HER2 breast cancer cells. However, as it is known that breast cancers exhibit subtype-specific metastatic tropism (i.e., luminal subtypes tend to metastasize to bone and liver, while TNBCs metastasize to the CNS), the longer time between primary breast cancer diagnosis and LMD diagnosis for HR-positive breast cancers may also reflect a longer metastatic route that first includes a non-CNS location. In this study, we performed a retrospective analysis on 141 breast cancer patients with LMD treated at Stanford Hospital between 2008-2020. The Stanford LMD cohort was analyzed using linear regression analysis, Cox regression analysis, and Chi-squared analysis. HR status was recorded (when available) for local recurrences and distant metastases, and was included in our regression models as a time-dependent HR covariate. We tested if: (1) HR-negative breast cancers had shorter time between primary and LMD diagnosis as well as worse survival after LMD diagnosis versus HR-positive breast cancers, and if (2) HR loss (i.e., HR status changing from positive to negative) increased likelihood of the metastasis to CNS. In agreement with published studies, the Stanford LMD cohort showed that HR-negative cancers had shorter time to development of LMD (p = 0.0004 for ER, p = 0.0001 for PR) and increased mortality following LMD (p = 0.010 for ER, p = 0.009 for PR). We found that HR-negative status at primary breast cancer diagnosis increased risk of first metastasis to CNS versus non-CNS locations (p = 0.021 for ER, p = 0.043 for PR). HR status switch (also known as hormone discordance) between primary diagnosis and metastasis occurred in 15% of patients in Stanford cohort, consistent with other studies. Importantly, accounting for HR status switch strengthened the association between HR-negative status and the risk of CNS metastasis [Hazard Ratio = 2.506 (1.395 - 4.500) for “baseline ER status” versus Hazard Ratio = 3.509 (1.890 - 6.515) for “time-dependent ER status”, Hazard Ratio = 2.420 (1.310 - 4.471) for “baseline PR status” versus Hazard Ratio = 3.407 (1.815 - 6.395) for “time-dependent PR status”]. In conclusion, HR-negative status was associated with shorter time to development of LMD, higher CNS tropism, and shorter survival following LMD diagnosis. Taking into consideration hormone discordance between the primary tumor and metastatic sites strengthened this association. Our results suggest a potential value in testing HR status at all recurrences and advanced CNS monitoring following HR loss. Citation Format: Sophia Pribus, Maxine C. Umeh-Garcia, Bo Gu, Bryanna Godfrey, Summer Han, Sophia Chernikova, Melanie Hayden Gephart. Loss of hormone receptor expression in breast cancer is associated with increased brain tropism and accelerated progression of leptomeningeal disease [abstract]. In: Proceedings of the 2023 San Antonio Breast Cancer Symposium; 2023 Dec 5-9; San Antonio, TX. Philadelphia (PA): AACR; Cancer Res 2024;84(9 Suppl):Abstract nr PO5-06-01.

Identifying consistent echocardiographic thresholds for risk stratification in pulmonary arterial hypertension.

Several indices of right heart remodeling and function have been associated with survival in pulmonary arterial hypertension (PAH). Outcome analysis and physiological relationships between variables may help develop a consistent grading system. Patients with Group 1 PAH followed at Stanford Hospital who underwent right heart catheterization and echocardiography within 2 weeks were considered for inclusion. Echocardiographic variables included tricuspid annular plane systolic excursion (TAPSE), right ventricular (RV) fractional area change (RVFAC), free wall strain (RVFWS), RV dimensions, and right atrial volumes. The main outcome consisted of death or lung transplantation at 5 years. Mathematical relationships between variables were determined using weighted linear regression and severity thresholds for were calibrated to a 20% 1-year mortality risk. PAH patients (n = 223) had mean (SD) age of 48.1 (14.1) years, most were female (78%), with a mean pulmonary arterial pressure of 51.6 (13.8) mmHg and pulmonary vascular resistance index of 22.5(6.3) WU/m2. Measures of right heart size and function were strongly related to each other particularly RVFWS and RVFAC (R 2 = 0.82, p < 0.001), whereas the relationship between TAPSE and RVFWS was weaker (R 2 = 0.28, p < 0.001). Death or lung transplantation at 5 years occurred in 78 patients (35%). Guided by outcome analysis, we ascertained a uniform set of parameter thresholds for grading the severity of right heart adaptation in PAH. Using these quantitative thresholds, we, then, validated the recently reported REVEAL-echo score (AUC 0.68, p < 0.001). This study proposes a consistent echocardiographic grading system for right heart adaptation in PAH guided by outcome analysis.

Abstract 3532: Transforming genomic data into images for enhanced deep learning in precision oncology

Abstract Purpose: In the realm of cancer treatment and research, the analysis of genomic data stands as a cornerstone for diagnosis and therapy. Recognizing this, our study embarks on an ambitious journey to revolutionize how we interpret such data. By converting complex genomic data into a two-dimensional (2D) image format leveraging feature correlations, we pave the way for more profound insights and applications in clinical decision-making. This innovative approach utilizes 2D convolutional neural networks (CNNs) to analyze these structured images, promising a leap forward in the accuracy and utility of such data. Methodology: The core of our method involves a novel transformation of tabular genomic data into an image format. We start with m patient samples, each characterized by n genes, and calculate a pairwise correlation matrix to capture the intricate relationships between these genes. Concurrently, we generate an Euclidean distance matrix that represents the distances between n points in a 2D grid. The next step involves the optimization of the Gromov-Wasserstein discrepancy to align these two matrices, resulting in a transformation matrix, T. When applied to the tabular data, T transforms it into m distinct, informative images. These images are then processed using a 10-layer CNN, comprising a convolutional layer (3 × 3 kernel), three dense layers, two relu layers, and a dropout layer. Data Sources: We created images, termed 'genomaps', from genomic data collected from three diverse patient groups: 130 individuals (cancerous and normal) from Stanford Hospital, 230 breast cancer patients from The Cancer Genome Atlas (TCGA), and a larger group of 1572 patients from the Memorial Sloan Kettering (MSK) Cancer Center. The created genomaps are visually interpretable, offering clear differentiation between cancerous and non-cancerous samples, which is pivotal for accurate analysis. Outcomes: Our method demonstrates a remarkable 8% improvement in survival prediction accuracy in comparison to the existing methods. The employment of DeepSHAP in our analysis has allowed us to identify critical genes with greater precision than conventional methods. The p53 gene family, notably TP53 and TP63, was identified as significantly mutated in over 50% of all cancer types analyzed. Another critical discovery was the ERBB gene family, encompassing EGFR, ERBB2, ERBB3, ERBB4, which plays a dual role in tumor proliferation and influencing the immune response against tumors, a factor critical for immunotherapy strategies. Conclusion: This research introduces a transformative approach to represent genomic data, utilizing 2D CNNs for in-depth analysis. It sets a new benchmark in classification and regression accuracy, offering a more interpretable pathway for biomarker discovery, significantly contributing to the field of personalized medicine and cancer research. Citation Format: Md Tauhidul Islam, Lei Xing. Transforming genomic data into images for enhanced deep learning in precision oncology [abstract]. In: Proceedings of the American Association for Cancer Research Annual Meeting 2024; Part 1 (Regular Abstracts); 2024 Apr 5-10; San Diego, CA. Philadelphia (PA): AACR; Cancer Res 2024;84(6_Suppl):Abstract nr 3532.

Cloud-Based Machine Learning Platform to Predict Clinical Outcomes at Home for Patients With Cardiovascular Conditions Discharged From Hospital: Clinical Trial.

Hospitalizations account for almost one-third of the US $4.1 trillion health care cost in the United States. A substantial portion of these hospitalizations are attributed to readmissions, which led to the establishment of the Hospital Readmissions Reduction Program (HRRP) in 2012. The HRRP reduces payments to hospitals with excess readmissions. In 2018, >US $700 million was withheld; this is expected to exceed US $1 billion by 2022. More importantly, there is nothing more physically and emotionally taxing for readmitted patients and demoralizing for hospital physicians, nurses, and administrators. Given this high uncertainty of proper home recovery, intelligent monitoring is needed to predict the outcome of discharged patients to reduce readmissions. Physical activity (PA) is one of the major determinants for overall clinical outcomes in diabetes, hypertension, hyperlipidemia, heart failure, cancer, and mental health issues. These are the exact comorbidities that increase readmission rates, underlining the importance of PA in assessing the recovery of patients by quantitative measurement beyond the questionnaire and survey methods. This study aims to develop a remote, low-cost, and cloud-based machine learning (ML) platform to enable the precision health monitoring of PA, which may fundamentally alter the delivery of home health care. To validate this technology, we conducted a clinical trial to test the ability of our platform to predict clinical outcomes in discharged patients. Our platform consists of a wearable device, which includes an accelerometer and a Bluetooth sensor, and an iPhone connected to our cloud-based ML interface to analyze PA remotely and predict clinical outcomes. This system was deployed at a skilled nursing facility where we collected >17,000 person-day data points over 2 years, generating a solid training database. We used these data to train our extreme gradient boosting (XGBoost)-based ML environment to conduct a clinical trial, Activity Assessment of Patients Discharged from Hospital-I, to test the hypothesis that a comprehensive profile of PA would predict clinical outcome. We developed an advanced data-driven analytic platform that predicts the clinical outcome based on accurate measurements of PA. Artificial intelligence or an ML algorithm was used to analyze the data to predict short-term health outcome. We enrolled 52 patients discharged from Stanford Hospital. Our data demonstrated a robust predictive system to forecast health outcome in the enrolled patients based on their PA data. We achieved precise prediction of the patients' clinical outcomes with a sensitivity of 87%, a specificity of 79%, and an accuracy of 85%. To date, there are no reliable clinical data, using a wearable device, regarding monitoring discharged patients to predict their recovery. We conducted a clinical trial to assess outcome data rigorously to be used reliably for remote home care by patients, health care professionals, and caretakers.

Predicting rapid progression and overall survival in stage II-III pancreatic cancer using a CT-based radiomic signature.

706 Background: We sought to assess the ability of a computed tomography (CT)-derived radiomic signature (RS) feature set to predict rapid tumor progression and overall survival (OS) in patients diagnosed with stage II-III pancreatic cancer undergoing stereotactic body radiation therapy (SBRT) in sequence with chemotherapy. Methods: We conducted a retrospective study on a cohort of 240 stage II-III pancreatic cancer patients who underwent SBRT in sequence with chemotherapy at a single institution (Stanford Hospital and Clinics). Among them, 83 had pre-SBRT contrast-enhanced CT images with segmented tumors, forming the imaging set, from which we extracted 900 radiomic (quantitative pixel-level imaging characteristic) features from delineated tumor regions-of-interest. For RS development, we divided the imaging set into a training set (n = 53) for model development and a test set (n = 30) for evaluation. We built a binary prediction model on the training set to identify patients at risk of rapid tumor progression within three months after SBRT. We utilized logistic regression with the Least Absolute Shrinkage and Selection Operator algorithm for feature selection and classification. To fine-tune parameters, we performed five-fold cross-validation on the training set, repeating each set of parameters five times. Finally, we assessed the model's performance on the test set (n = 30) using the area under the curve (AUC) value. We selected the model with the best AUC, while also generating the predictive radiomic feature set. For OS prognostication, we conducted both univariate and multivariate Cox proportional-hazards analyses using RS and clinical features (age, sex, stage, vessel involvement, tumor location, performance status, body mass index, biological equivalent dose of radiation) as potential predictors. Results: The enrolled cohort consisted of 127 men (mean age, 69 years ± 12 [SD]) and 113 women (mean age, 69 years ± 13 [SD]). Seventeen textural radiomic features were identified as the RS, which demonstrated a high AUC in the test set for the prediction of rapid progression (AUC 0.850; 95% CI: 0.725, 0.975). Age was associated with OS in the multivariate model while high RS (&gt;0.5) was independently associated with OS in both univariate and multivariate models. Conclusions: CT-derived RS, combined with age, represent the most prognostic factors for stage II-III pancreatic cancer. RS, which likely reflects underlying biology or molecular alterations, contributes to the highest HR of poor OS and provide the strongest indicator of outcome following commonly used treatments in this patient population. [Table: see text]

Race, Sex, and Age Disparities in the Performance of ECG Deep Learning Models Predicting Heart Failure.

Deep learning models may combat widening racial disparities in heart failure outcomes through early identification of individuals at high risk. However, demographic biases in the performance of these models have not been well-studied. This retrospective analysis used 12-lead ECGs taken between 2008 and 2018 from 326 518 patient encounters referred for standard clinical indications to Stanford Hospital. The primary model was a convolutional neural network model trained to predict incident heart failure within 5 years. Biases were evaluated on the testing set (160 312 ECGs) using the area under the receiver operating characteristic curve, stratified across the protected attributes of race, ethnicity, age, and sex. There were 59 817 cases of incident heart failure observed within 5 years of ECG collection. The performance of the primary model declined with age. There were no significant differences observed between racial groups overall. However, the primary model performed significantly worse in Black patients aged 0 to 40 years compared with all other racial groups in this age group, with differences most pronounced among young Black women. Disparities in model performance did not improve with the integration of race, ethnicity, sex, and age into model architecture, by training separate models for each racial group, or by providing the model with a data set of equal racial representation. Using probability thresholds individualized for race, age, and sex offered substantial improvements in F1 scores. The biases found in this study warrant caution against perpetuating disparities through the development of machine learning tools for the prognosis and management of heart failure. Customizing the application of these models by using probability thresholds individualized by race, ethnicity, age, and sex may offer an avenue to mitigate existing algorithmic disparities.

2422. Relative Risk of Patients Having a Catheter-Associated Urinary Tract Infection Within 7 days of Having an Indwelling Urinary Catheter Reinserted Within 24 Hours of Indwelling Urinary Catheter Removal

Abstract Background Indwelling urinary catheters (IUC) are reinserted in patients who should initially be managed with intermittent straight catheterization for urinary retention. We hypothesize patients who have an IUC reinserted within 24 hours will be at higher risk of catheter-associated urinary tract infections (CAUTI) within 7 days compared to patients who were straight catheterized or did not have an IUC reinserted. Methods A retrospective review of electronic health records (EHR) using Epic Systems (Verona, Wisconsin) was conducted for all inpatients at Stanford Hospital, Palo Alto, CA who had an IUC removed and a CAUTI defined by the National Healthcare Safety Network (NHSN) between January 1, 2020 to March 31, 2023. Patients with an IUC reinserted within 24 hours from initial removal of an IUC were compared to patients who had an IUC removed and did not have a reinsertion of an IUC within 24 hours. Relative risk of a CAUTI was the primary outcome metric. Results Between January 1, 2020 and March 31, 2023 there were 30,161 IUCs removed and 204 NHSN defined CAUTI identified within 7 days of removal that were included in the study. Patients who had an IUC reinserted within 24 hours had significant risk (RR: 7.96, p&amp;lt; 0.05) of having a CAUTI within 7 days post IUC removal compared to patients who did not have an IUC reinserted within 24 hours.Figure 1.Relative Risk of CAUTI with Indwelling Catheter Reinsertion Conclusion Reinsertion of IUCs in patients with urinary retention following IUC removal should be managed with intermitted straight catheterization or more conversative methods if possible. Patients who are re-catheterized with an IUC within 24 hours of removal are at significantly higher risk of developing a CAUTI within 7 days compared to patients who are straight catheterized or do not have a Foley catheter reinserted. Healthcare providers should use alternative methods of bladder management to improve patient outcomes. Disclosures All Authors: No reported disclosures

TMIC-75. SPATIALLY-RESOLVED TRANSCRIPTOME ANALYSIS OF BRAIN METASTATIC BREAST CANCER REVEAL KEY MEDIATORS OF BRAIN-TROPIC METASTATIC POTENTIAL

Abstract BACKGROUND In women with metastatic breast cancer, 30% (HER2+) to 50% (triple negative) develop brain metastases. Breast-to-brain metastasis carries a poor median survival of only 10 months and is accompanied by severe neurologic decline. Halting the progression of breast cancer brain metastases requires modulation of the tumor microenvironment (TME), yet little is known about how the primary breast TME affects brain tropism, or how, once there, metastatic cancer cells interact with normal brain cells (e.g., neurons, astrocytes, microglia). METHODS We constructed a large (n = 253 cores), diverse, clinically-annotated tissue microarray (TMA) of breast cancer brain metastases with surrounding brain (n = 127), associated primary breast tumors (n = 67, with 30 matched), normal brain (n = 23), and staining control (n = 18) tissue samples, from patients (n = 140) treated at Stanford Hospital between 2008 – 2018. We then leveraged a combination of genome-wide transcriptome analysis and high resolution spatial imaging (using GeoMx Digital Spatial Profiling) to interrogate the distinct, spatially-driven gene signatures of tumor, immune, and normal brain cells within the breast cancer brain metastasis TME. RESULTS We revealed novel gene regulatory programs that are associated with metastatic potential from the primary breast to the brain. We also identified not only diverging features of the breast and brain TMEs, but equivalent features which may contribute to preferential honing and outgrowth of metastatic breast cells in the brain microniche. Additionally, we uncovered significant cellular crosstalk between tumor, immune, and brain cell populations, including putative cell-cell interactions and intercellular signaling pathways. CONCLUSION These results served as a starting point for identifying key tumor-immune-brain interactions responsible for priming immune and brain tolerance of malignant cells, allowing outgrowth and progression of breast cancer brain metastases. Further investigation focused on tumor-brain crosstalk, specifically tumor-microglia interactions, will provide promising targets for therapeutic advancements.

Chronic Rhinosinusitis After Maxillary Advancement Orthognathic Surgery.

Maxillomandibular advancement (MMA) remains an effective procedure for the management of obstructive sleep apnea (OSA). Maxillary advancement may lead to anatomical changes that impair paranasal sinus drainage, leading to chronic sinus inflammation. The aim of this study was to describe the clinical features and outcomes of patients suffering from chronic rhinosinusitis (CRS) following MMA. This is a retrospective case series study. Our study included subjects diagnosed with CRS following MMA from January 1992 to October 2018 at Stanford Hospital. We screened 730 patients undergoing MMA and identified a total of 57 with CRS after MMA. A descriptive analysis was performed using clinical data including patient demographics, comorbidities, prior surgical history, physical exam manifestations, CT findings, and quality of life outcomes (SNOT-22). Out of 730 patients undergoing MMA, 57(7.8%) were found to have CRS after orthognathic surgery. Presenting symptoms included facial pain (92.5%), nasal drainage (75%), nasal obstruction (67.5%), and hyposmia (20%). Endoscopic examination revealed recirculation (30.5%), purulent discharge (27.7%), polypoid changes (22.2%), and scarring (13.8%). Preoperative CT prior to undergoing endoscopic sinus surgery (ESS) demonstrated mucosal thickening in maxillary (64.2%), anterior ethmoid (39.2%), frontal (14.2%), posterior ethmoid (10.7%), sphenoid sinus (14.2%), and ostiomeatal complex (55.3%). Average Lund-Mackay score was 5.5(±3.8). Additional CT findings included secondary ostium in the inferior meatus (42.8%). Forty patients (70.1%) underwent ESS at a mean of 4.6 years after MMA. Patients undergoing ESS experienced significant improvement in SNOT-22 scores at 12-months post-surgery (P = .018). Patients undergoing maxillary advancement surgery are at risk of developing CRS postoperatively and should be advised of the risk of CRS associated with this procedure. Surgical treatment can be an option for medically refractory CRS related to MMA surgery.

Virtual reality facilitated exercise improves pain perception: A crossover study

Study objectiveBoth virtual reality (VR) and exercise are recognized for their analgesic and anxiolytic properties. The purpose of this study is to evaluate the ability of VR-facilitated exercise to modulate pain. DesignWithin-subject cross-over clinical trial. SettingThe Stanford Chariot Program conducted this study at Lucile Packard Children's Hospital Stanford (LCPHS). PatientsHealthy participants meeting inclusion criteria were recruited by volunteer solicitation from LCPHS. InterventionsParticipants were randomized by hand dominance and subjected to a standardized cold pressor test with no VR or exercise. After a 5-min wash-out period, participants repeated the test on their other hand while experiencing a VR-facilitated exercise condition. Pain sensitivity, pain tolerance, and sympathetic activation data were collected during both conditions. MeasurementsPain sensitivity was scored 0–10 and collected every 30 s. Pain tolerance was recorded as the duration a participant could endure the painful stimuli. Sympathetic activation was measured by skin conductance response density (SCRD) and recorded in 30 s epochs by a biosensor. In all analyses, data were nested by participant. Main resultsForty-one participants completed both interventions. Pain sensitivity was reduced in the VR-facilitated exercise condition (p < 0.0001). There was no difference in pain tolerance between conditions. While both conditions resulted in an increase in sympathetic activity, SCRD was higher at all time points in the VR-facilitated exercise condition. ConclusionsThe reduction in pain sensitivity indicates VR-facilitated exercise results in improved pain perception. VR-facilitated exercise may be especially useful for patients with chronic pain or other conditions requiring physical therapy, where pain may be exacerbated by exercise.

Short- and Mid-Term Results of Pulmonary Valve Replacement with the Inspiris Valve

BackgroundVarious bioprosthetic valves are used off-label for pulmonary valve replacement (PVR), but there is no consensus on whether a particular valve is best for this application. Recently, the Inspiris Resilia valve (Edwards Lifesciences Inc) was approved for aortic valve replacement, and surgeons have begun using it for PVR. There is limited evidence on the performance of the Inspiris valve compared with other valves in the pulmonary position. MethodsThis study reviewed all patients who underwent PVR with a size 19- to 29-mm Inspiris valve or Mosaic valve (Medtronic Inc) from 2007 to 2022 at Lucile Packard Children's Hospital Stanford (Palo Alto, CA). Midterm outcomes included freedom from moderate or severe pulmonary regurgitation (PR), a maximum Doppler gradient ≥36 mm Hg, and freedom from reintervention. ResultsA total of 225 consecutive patients who underwent PVR with a size 19- to 29-mm Mosaic (n = 163) or Inspiris (n = 62) valve were included. There was no difference in baseline characteristics. Early postoperative gradients were low in both groups but higher in the Mosaic cohort, and neither group had more than mild PR on discharge. On univariable and multivariable analysis, Inspiris valves were significantly more likely to develop moderate or greater PR over time. There was no significant difference between the valves in freedom from reintervention or from a maximum gradient ≥36 mm Hg. ConclusionsEarly and short-term gradients were similar in patients undergoing PVR with Inspiris and Mosaic valves, but significant PR was more common in patients who received an Inspiris valve. These preliminary findings suggest that the durability of the Inspiris valve in the pulmonary position may not be superior to that of other bioprosthetic valves used for PVR.

Preoperative Versus Perioperative Risk Factors for Delayed Pain and Opioid Cessation After Total Joint Arthroplasty: A Prospective Cohort Study.

The evolution of pre- versus postoperative risk factors remains unknown in the development of persistent postoperative pain and opioid use. We identified preoperative versus comprehensive perioperative models of delayed pain and opioid cessation after total joint arthroplasty including time-varying postoperative changes in emotional distress. We hypothesized that time-varying longitudinal measures of postoperative psychological distress, as well as pre- and postoperative use of opioids would be the most significant risk factors for both outcomes. A prospective cohort of 188 patients undergoing total hip or knee arthroplasty at Stanford Hospital completed baseline pain, opioid use, and emotional distress assessments. After surgery, a modified Brief Pain Inventory was assessed daily for 3months, weekly thereafter up to 6months, and monthly thereafter up to 1year. Emotional distress and pain catastrophizing were assessed weekly to 6months, then monthly thereafter. Stepwise multivariate time-varying Cox regression modeled preoperative variables alone, followed by all perioperative variables (before and after surgery) with time to postoperative opioid and pain cessation. The median time to opioid and pain cessation was 54 and 152days, respectively. Preoperative total daily oral morphine equivalent use (hazard ratio-HR 0.97; 95% confidence interval-CI 0.96-0.98) was significantly associated with delayed postoperative opioid cessation in the perioperative model. In contrast, time-varying postoperative factors: elevated PROMIS (Patient-Reported Outcomes Measurement Information System) depression scores (HR 0.92; 95% CI 0.87-0.98), and higher Pain Catastrophizing Scale scores (HR 0.85; 95% CI 0.75-0.97) were independently associated with delayed postoperative pain resolution in the perioperative model. These findings highlight preoperative opioid use as a key determinant of delayed postoperative opioid cessation, while postoperative elevations in depressive symptoms and pain catastrophizing are associated with persistent pain after total joint arthroplasty providing the rationale for continued risk stratification before and after surgery to identify patients at highest risk for these distinct outcomes. Interventions targeting these perioperative risk factors may prevent prolonged postoperative pain and opioid use.

Results following implementation of a cardiac surgery ERAS protocol.

Adequate peri-operative care is essential to ensuring a satisfactory outcome in cardiac surgery. In this study, we look at the impact of evidence-based protocols implemented at Stanford Hospital. This study is a single-center, retrospective analysis. Enhanced recovery after surgery (ERAS) protocols were implemented for CABG/Valve and open Aortic operations on 11/1/2017 and 6/1/2018, respectively. Propensity-score matched analysis was used to compare 30-day mortality and morbidity of patients from the pre- and post-implementation cohorts. Secondary endpoints included the following: total hospital length of stay (LOS), ICU LOS, time until extubation, and time until urinary catheter removal. After the implementation of the ERAS protocols for CABG/Valve operations, the median post-op LOS decreased from 7.0 days to 6.1 days (p<0.001), and median ICU LOS decreased from 69.9 hours to 54.0 (p = 0.098). There was no significant decrease in 30-day mortality (4% to 3.3%, p = 0.47). However, the incidence of post-op ventilator associated pneumonia (VAP) decreased from 5.0% to 2.1% (p = 0.003) and post-op urinary tract infections (UTIs) from 8.3% to 3.6% (p<0.001). Patients who underwent open aortic procedures experienced an improvement in 30-day mortality (7% to 3.5%, p = 0.012), decrease in median ICU LOS (91.7 hours to 69.6 hours, p<0.001), and a decrease in duration of mechanical ventilation (79.3 hours to 46.3 hours, p = 0.003). There was a decrease in post-op LOS, post-op VAP, and post-op UTI, although statistical significance was not attained. At Stanford Hospital, ERAS pathways have led to decreased morbidity and LOS while simultaneously improving mortality amongst our critically ill patient population.