Study Time Frame Research Articles

From early development to maturity: a phenotypic analysis of the Townes sickle cell disease mice.

Well-characterised mouse models of disease may provide valuable insights into pathophysiology. This study characterises the Townes mouse model of sickle cell disease (SCD) and establishes a time window in which the disease is present but does not progress significantly in terms of severity. We examined Townes mice with the HbAA, HbAS, and HbSS genotypes from young (4 weeks) to mature (5 months) stages of life to assess the disease state at different ages and any progression. We conducted blood tests, histological organ damage evaluations, and metabolic assessments to identify a suitable time frame for study based on welfare considerations. Townes HbSS mice displayed key SCD features such as anaemia, haemolysis, thromboinflammation and organ pathology. Notably, these manifestations remained relatively stable over the study period, indicating a stable phase suitable for conducting intervention studies. Mice with HbAS and HbAA genotypes served as comparative controls, showing minimal to no pathology throughout. These findings are valuable for future research on SCD and may ultimately lead to the development of more effective treatments for this debilitating disease.

Virtual Interviews Correlate with Home and In-State Match Rates at One Emergency Medicine Program

Introduction: Incorporating virtual interviews into residency recruitment may help diversify access to residency programs while reducing the cost involved with travel and lodging. Programs may be more likely to rank students they have met in person at an interview when compared to unknown virtual applicants. Our objective was to characterize home institution, in-state, and in-region match rates to emergency medicine (EM) residency programs for fourth-year medical students. Methods: We used National Residency Matching Program data available to the program director to identify medical school and match location of fourth-year medical students who interviewed at a large EM residency program in the Midwest from 2018–2023. Students’ medical schools and ultimately matched programs were mapped to Electronic Residency Application Service geographic regions; subgroup analyses evaluated allopathic and osteopathic medical students separately. We used chi-square tests to compare proportions of students matching to home, in-state, or in-region programs across years. Results: There were 1,401 applicants with match information available. The percentage of students matching to a home institution remained stable over the course of the study. The percentage of students matching to an in-state institution increased over the first two years of virtual interviews rising from 23.2%in the 2020 match to 30.8% in-state matches for the 2022 match. Chi-square tests did not reveal any significant differences among groups for all applicants. Allopathic medical students demonstrated a significant increase in matches to home institutions. In-region matches stayed relatively stable over the study time frame regardless of subgroup. Conclusion: Virtual interviews changed the landscape of residency interviews. Home institution and in-state matches may be more likely for applicants from allopathic schools who participated in a virtual interview as both programs and applicants are more familiar with each other; however, our study did not find convincing evidence of this possibility among all applicants. Additional study is needed to determine ongoing effects of the transition to virtual interviews.

Safety and Tolerability of Initiating Sacubitril-Valsartan With Spironolactone During Hospitalization for Acute Decompensated Heart Failure

Background: Initiation of sacubitril-valsartan and mineralocorticoid receptor antagonists (MRA) during hospitalization for acute decompensated heart failure (ADHF) may be an ideal time to optimize guideline-directed medical therapy. However, there is limited research assessing the safety of combining these agents in the hospital. Methods: This was a multi-center, retrospective, propensity-score matched cohort study performed at 7 acute-care hospitals within a large health care system. All adult patients admitted with ADHF between January 1, 2019 to December 31, 2021 who received sacubitril-valsartan with MRA (MRA group) or without MRA (non-MRA group) and had a left ventricular ejection fraction (LVEF) < 40% were included in the study. Results: 220 patients were screened during the study time frame with 179 meeting inclusion criteria. Following propensity-score matching, 50 patients in the MRA group were matched to 50 patients in the non-MRA group. The overall incidence of adverse drug reactions (ADRs) was 24% in the non-MRA group compared to 20% in the MRA group (P = .629). There was a significantly greater incidence of hyperkalemia in the MRA group (0% vs 10%; P = .022). None of the patients in the non-MRA group were readmitted within 30 days due to an ADR compared to 6% in the MRA group (P = .079). Conclusion: The addition of spironolactone to sacubitril-valsartan in the hospital setting following stabilization of ADHF did not lead to a significantly greater incidence of overall ADRs, but patients were more likely to develop hyperkalemia and there was a numerically higher incidence of 30-day readmissions due to ADRs.

Disparities in Utilization of Outpatient Telemedicine for Neurologic Care.

To characterize outpatient telemedicine utilization for neurologic conditions and identify potential disparities. All outpatient visits conducted by neurology clinicians at an academic medical health care system for patients aged 18 years or older from January 2019 to July 2022 were included. All telemedicine visits were synchronous audio-visual. Patients completing in-person visits alone were compared with patients completing telemedicine visits. Utilization of telemedicine was compared across 3 time frames: prepandemic (before March 2020), early-pandemic (March-June 2020), and late-pandemic (July 2020-July 2022). Generalized linear mixed-effects models were used to evaluate whether the odds of a visit being telemedicine vs in-person differed based on the time frame and to predict likelihood of telemedicine vs in-person visit in late pandemic time frame. In total, 242,273 patients (mean age 55.9 years, 58.2% female, 81.9% White, 12.5% Black, 3.4% Hispanic, 39.2% Medicare) completed 752,174 visits during the study time frame. There was a significant difference in telemedicine utilization between the time frames, with the highest utilization being in the early pandemic (p 0.01). In the late pandemic time frame, odds of a telemedicine visit were significantly lower for individuals who were older (odds ratio [OR] 0.97), Black (OR 0.84), Hispanic (OR 0.70), a higher Area Deprivation Index (20%-40%: OR 0.85, 40%-60%: OR 0.80, 60%-80%: OR 0.78, ≥80%: OR 0.65), with nonprivate insurance (Medicaid OR 0.78; Medicare OR 0.84; self-pay OR 0.60), and non-English preferred language (OR 0.61) (p < 0.01 for all). Odds of a telemedicine visit were significantly higher for individuals who were female (OR 1.25) and lived outside of the greater Cleveland area (other Ohio OR 2.33; out of state OR 3.32) (p < 0.01). Visits completed by rural patients did not differ significantly from metropolitan patients (OR 0.95, p = 0.09). Disparities in telemedicine persist with lower use in individuals who were older, Black, Hispanic, non-English preferred language, and lower socioeconomic status. These disparities improved initially but were accentuated later in the pandemic. The equal utilization of telemedicine by rural and urban patients in this study suggests the potential of telemedicine to improve access disparities for rural patients. The implementation of equitable health care delivery will require a better understanding of barriers, preferences, and legislation needed to support equitable telemedicine access.

P-716. Epidemiology and patient burden of human parainfluenza virus in adults: a systematic review

Abstract Background The objective of this systematic review was to evaluate the scope of published epidemiological and patient outcomes data available for parainfluenza virus (PIV) in adults worldwide and to identify data gaps for this patient population. Methods PubMed was searched for original articles on epidemiology or patient outcome of PIV (any strain) published from January 1, 2014, to August 26, 2023. This identified 549 publications. Studies were screened for relevant data in adults and in those at high risk for respiratory infections (severe pulmonary diseases, malignancies, transplants, cystic fibrosis, or those who were unhoused). Based on an initial screen, 390 articles were excluded, yielding 166 articles for full text review (Figure). This included 7 studies identified by screening bibliographies of excluded review articles that were not captured by the initial search. Upon review, 103 further articles were excluded (eg, study time frame was before 2014 or during the COVID-19 pandemic, lack of PIV or target data reported in adults). Collectively, this process identified a database of 63 articles for final analysis with any epidemiological or outcome data. Results The prevalence of PIV reported in the literature varied widely based on geography and patient population. The population was broad including hospitalized adults, healthy volunteers, and those presenting with respiratory infections. Patients were defined as “otherwise healthy” if they were not considered high risk. Preliminary results indicate the overall prevalence of PIV (PIV1-4 or PIV unspecified) ranges from 0-15.2% [median 2%] in otherwise healthy adults, with PIV3 as the most prevalent (0.6-15.2% [2.9]) followed by PIV4 (0.4-5.9% [0.5]), PIV1 (0.5-2.8% [1.1]), and PIV2 (0-2.9% [1.1]). The prevalence of PIV was higher in at-risk adults (up to 52%). Patient outcome data was scarce, with mortality rates being the most frequently reported topic. Hematopoietic stem cell transplant patients were found to be the most at risk for PIV-associated mortality, though there was no clear strain-specific pattern of mortality given the limited data on patient outcomes. Conclusion Significant data gaps remain on the burden of PIV on adults, particularly in otherwise healthy adults. Disclosures Oliver Martyn, MPH, Sanofi: Employee of Sanofi|Sanofi: Stocks/Bonds (Public Company) Peter Openshaw, PhD, AstraZeneca: Advisor/Consultant|AstraZeneca: Honoraria|AstraZeneca: Speaker bureau participation|CSL Seqirus: Advisor/Consultant|CSL Seqirus: Honoraria|GSK: Advisor/Consultant|GSK: Honoraria|Icosavax: Advisor/Consultant|Janssen: Advisor/Consultant|Janssen: Honoraria|Medical Research Council UK: Grant/Research Support|Medscape: Speaker bureau participation|Moderna: Advisor/Consultant|Moderna: Honoraria|Pfizer: Advisor/Consultant|Pfizer: Honoraria|Sanofi: Advisor/Consultant|Sanofi: Grant/Research Support|Sanofi: Speaker bureau participation Clemens Vlasich, MD, MSc, Sanofi: Employee of Sanofi|Sanofi: Stocks/Bonds (Public Company) Rolf Kramer, PhD, Sanofi: Employee of Sanofi|Sanofi: Stocks/Bonds (Public Company)

P-1355. Trends in Carbapenemase and Co-carbapenemase Production among Enterobacterales in Latin America: SMART 2018-2022

Abstract Background The proliferation of carbapenemases in many geographies has compromised the effectiveness of the carbapenem class of antimicrobials and constitutes a major clinical problem. However, carbapenems paired with β-lactamase inhibitors, like imipenem/relebactam (IMR), can restore their activity against isolates carrying some types of carbapenemases. We evaluated trends in carbapenemase and co-carbapenemase production among Enterobacterales collected as part of the SMART surveillance program in Latin America. Methods In 2018-2022, 47 clinical labs in 11 countries in Latin America (Argentina, Brazil, Chile, Colombia, Ecuador, Guatemala, Mexico, Panama, Peru, Puerto Rico, Venezuela) each collected up to 250 consecutive Gram-negative pathogens per year from patients with bloodstream, intraabdominal, respiratory tract, and urinary tract infections. MICs were determined using CLSI broth microdilution and interpreted with 2024 CLSI breakpoints. Most imipenem (IPM) nonsusceptible non-Morganellaceae Enterobacterales and ceftolozane/tazobactam (C/T) nonsusceptible Enterobacterales were screened for β-lactamases genes. Results Of the 29,419 Enterobacterales collected, 6669 tested non-susceptible to IPM or C/T; of these, 4474 (67.1%) were characterized molecularly. KPC was the most frequently observed carbapenemase each year, ranging from 40.8% of the characterized isolates in 2021 to 31.1% in 2022, exhibiting an overall slight decreasing trend (Fig. 1). In contrast, the rate of NDM detection increased annually, ranging from 2.0% of the characterized isolates in 2018 to 20.8% in 2022. Rates of detection of other carbapenemases, including OXA-48-like, VIM, IMP and GES remained low and relatively stable over the studied time frame. Detection of carbapenemase co-carriers peaked in 2021 (3.5%), with isolates harboring NDM &amp; KPC the most common genotype (Fig. 2). Conclusion KPC was the most commonly encountered carbapenemase among Enterobacterales in Latin America from 2018-2022, suggesting agents that retain potency against KPC-carrying Enterobacterales, like IMR, remain appropriate therapies. However, the increasing trend of NDM detection in this region is of concern as it severely limits treatment options. Disclosures Daniel F. Sahm, PhD, Pfizer, Inc.: Advisor/Consultant

Guideline adherence to echocardiographic monitoring of aortic stenosis

Abstract Background/Introduction Close monitoring of aortic stenosis (AS) by follow-up echocardiography is recommended by all Cardiology and Imaging Societies’ guidelines. Whether these guidelines are strictly followed is unknown. Purpose We aimed to describe our institution’s practice patterns for echocardiographic monitoring in patients with aortic sclerosis (AScl) and AS of any severity. Methods Adult patients residing in our institution’s county with an echocardiographic diagnosis of AScl or AS between 01/2005-01/2022 were identified and classified into 4 groups: AScl, mild AS, moderate AS, or severe AS, at each echocardiogram during the study timeframe. Kaplan Meier analyses were used to evaluate the composite outcome, the occurrence of follow-up echocardiogram or death. Patients were censored at the time of aortic valve replacement/repair, heart transplant, or last clinical follow-up. Guideline follow-up was considered appropriate when the primary outcome occurred by 5 years (AScl/mild AS), 2 years (moderate AS), and 1 year (severe AS). Results A total of 23,726 echocardiograms from 9,578 unique patients were included. At index echocardiogram, median patient age was 74 years (IQR 65-82) and 4,806 (50.2%) were women. AScl was observed in 7,358 (76.8%) cases, mild AS in 1,442 (15.1%) cases, moderate AS in 479 (5%), and severe AS in 301 (3.1%) cases. Rates of composite outcome achievement by the end of the guideline-recommended interval were 81%, 90%, 80%, and 72% in AScl, mild, moderate, and severe AS, respectively. Rates for men were 83%, 92%, 82%, and 75% in these groups, while rates for women were 78%, 88%, 78%, and 68%, respectively (Figure 1). Follow-up rates were similar before and after 2012 (when transcatheter aortic valve replacement was approved for treatment of severe AS in high-risk surgical patients in the USA). Follow-up rates were higher in patients managed by cardiovascular providers compared to non-cardiovascular providers (Figure 2). Conclusion Depending on disease severity, between one fourth and one tenth of patients remained alive and unfollowed at the end of their guideline-recommended surveillance interval. There is significant variability in echocardiogram monitoring based on sex and referring provider specialty. Figure 1 Figure 2

P-941. Short- and Long-term Mortality of Infective Endocarditis in the Veteran Population

Abstract Background The aim of this study was to evaluate the short- and long-term mortality of infective endocarditis within the veteran population. Methods This study was a retrospective, national study of veterans &amp;gt; 18 years old between 1/1/2010-3/1/2023 diagnosed with endocarditis. Endocarditis was defined by ICD coding, patients having at least one positive blood culture and having an echocardiogram performed. during admission. The primary objective was to evaluate the rate of 30-day and one-year mortality of the study population. Secondary endpoints looked at correlation between mortality and other factors such as comorbidities, causative organism, drug/alcohol disorders, smoking status, septic emboli, fever, and the use cardio-protective medications. Charlson Comorbidity Scores Results 4,241 hospitalized patients who received care at a Veterans Affairs Hospital and were diagnosed with bacterial endocarditis during the study timeframe were included. The primary outcome of short- and long-term mortality was seen in 658/4,241 patients (15.5%) and 1775/4,241 patients (41.9%) respectively. Enterococcus faecalis endocarditis was the most prevalent organism (17.2% of infections). MRSA endocarditis was associated with a clinically significant increase in mortality at both 30-days and one-year (p &amp;lt; 0.001). The diagnosis of septic emboli showed a statistically significant increase in short-term mortality with 106/427 patients diagnosed experiencing mortality within 30-days (p &amp;lt; 0.001) Fever during admission showed a statistically significant increase in mortality for both short- and long-term mortality rates (p &amp;lt; 0.001). Conclusion Mortality within one-year was found to be 41.9% amongst our patient population. Identifying possible risk factors for increased mortality in this population may assist in decreasing both the short- and long-term mortality of those with infective endocarditis. Future directions for research could include assessing cardio-protective medications in this population on a larger scale to assess potential benefit. Disclosures All Authors: No reported disclosures

P-1477. In vitro efficacy of Minocycline on Skin, Soft Tissue and Musculoskeletal Gram Negative bacterial isolates

Abstract Background Minocycline is a second-generation tetracycline with a broad antimicrobial spectrum. It is often used in chronic suppression of musculoskeletal infections, given activity against gram positive organisms. Efficacy of Minocycline against gram negative skin and soft tissue infection has not previously been defined. In this study, we review in vitro minocycline efficacy against isolates from skin, muscle, and bone sources.Fig 1.Organisms isolated Methods We conducted a retrospective review of all minocycline susceptibility testing performed on musculoskeletal GNB isolates performed at the Mayo Clinic reference lab between 2013-2022. We describe the isolates broken down by site of culture and organism isolated. Then, we calculated the overall susceptibility of these isolates to Minocycline and susceptibility of the most common 6 organisms isolated.Fig 2.Sites of gram negative isolation Results During the study timeframe, we identified 13,567 gram negative isolates from musculoskeletal sites. Of 330 species identified, 19 were identified in at least 100 isolates (fig 1). Of 36 unique sites, 19 sites were each identified in at least 100 isolates (fig 2). 1920 isolates were tested for susceptibility to minocycline. Of these, 1584 (82.5%) were susceptible to minocycline. Of the most common organisms identified and tested for minocycline susceptibility, 99% of Stenotrophomonas maltophilia, 83% of Enterobacter cloacae, 80% of Escherichia coli, 68% of Acinetobacter baumanii, 1% of Proteus mirabilis, 53% of Klebsiella pneumoniae, 65% of Serratia marcescens isolates were susceptible to minocycline (fig 3). Pseudomonas aeruginosa isolates were not tested, due to innate resistance.Fig 3.Minocycline susceptibility compared to key organisms Conclusion A majority of skin and soft tissue cultures positive for Gram negative isolates were below the waist line. Of these, we reported organisms most commonly found. Minocycline showed in vitro activity against some commonly isolated gram negative organisms, especially E.coli, Acinetobacter, and Stenotrophomonas. Further research is needed into the efficacy of minocycline in gram negative skin and soft tissue infections, but it may represent a viable oral option, especially in the end of life. Disclosures All Authors: No reported disclosures

Mucinous tubular and spindle cell carcinoma of the kidney: Clinical, imaging and pathological features

Background: Mucinous Tubular and Spindle Cell Carcinoma (MTSCC) is a rare variant of Renal Cell Carcinoma (RCC). MTSCC has been regarded as an indolent subtype of RCC conveying a good prognosis. However, recently some cases of MTSCC have been described presenting or evolving with metastasis, showing an aggressive behaviour. We aim to describe MTSCC clinical characteristics, treatment, prognosis and survival. Methods: We retrospectively reviewed all cases of MTSCC diagnosed at our institution from 1 January 2008 to 31 December 2022. Electronic health records were reviewed, and data were retrieved and analysed. This study was approved by our institution’s ethics committee. Data confidentiality was assured. Results: We identified eight cases of MTSCC among the 15 years of the study timeframe diagnosed in our hospital. The median age at diagnosis was 59 years (range = 32–80 years), and half of the patients were women (n = 4; 50%). In six (75%) of the patients, presentation was incidental, while the remaining two presented with flank pain. One patient had metastasis at presentation, while the remaining cases were localised at the time of diagnosis. Six patients were submitted to radical nephrectomy: four by open approach and two by transperitoneal laparoscopic approach. Two patients were submitted to a partial nephrectomy by an open approach. Mean (SD) postoperative haemoglobin drop was 2.18 (1.12) g/dL. Median follow-up was 36.5 months (range = 2–157). During the study timeframe, no other patients were diagnosed with local recurrence or distant metastasis. Two patients died during follow-up: the one that was metastatic at diagnosis died due to disease progression 2 months after surgery and another died due to a competitive disease (acute lower limb ischaemia). Conclusion: MTSCC is a rare variant of RCC that, despite being initially regarded as an indolent disease with good prognosis, might harbour an aggressive behaviour and grim prognosis. Level of evidence: 2b

P1068 Preventable hospitalisations for patients with IBD are relatively uncommon in a modern multidisciplinary IBD service, and due to non-adherence or non-engagement in a significant proportion

Abstract Background Despite tighter treatment targets and an expanding array of therapeutics, hospitalisations for patients with inflammatory bowel disease (IBD) continue to occur, resulting in significant healthcare expense. This study aimed to identify factors associated with hospitalisation. Methods Patients seen at specialist IBD clinics at a tertiary health service and those hospitalised over a 13-month period from September 2022 to September 2023 were identified, and medical records interrogated for demographic and disease characteristics. Data including indication for admission, length of stay and cost was recorded. Results 1082 patients with IBD (median age 48 [IQR 34-63] years, 495 [48.2%] female) were seen in specialist IBD outpatients clinics during the study time frame. Of these, 468 (43.3%) had Crohn’s disease (CD), 464 (42.9%) ulcerative colitis (UC), 13 (1.2%) IBD-unclassified, and 143 (13.2%) had other/uncertain diagnoses. During the same period, 115 patients (48 [41.7%] female, median age 35 [IQR 27-51] years), with either new or pre-existing diagnosis of IBD, were admitted to hospital for a total of 138 admissions. 18 patients had multiple admissions (twice, n=14; thrice, n=3; four times, n=1). 64 (55.7%) had CD, and 48 (41.7%) UC. The main reasons for presentation for UC-related admissions included active disease (55.2%, n=32) and acute severe ulcerative colitis (36.2%, n=21). For Crohn’s-related admissions, main reasons for presentation were active disease without obstructive symptoms (53.9%, n=42) and small bowel obstruction (19.2%, n=15). 31 (27%) were unknown to the health service prior to their admission, and a further 23 (20%) patients (12 with CD and 11 UC) were newly diagnosed with IBD as the index hospitalisation. Of the remaining 61 patients who were known to the IBD service (5.6% of total), non-adherence and/or non-engagement was a contributing factor in 20 (32.8%) patients. Progressive, treatment refractory disease or loss of response to medications was noted in 43 (70.5%), with Clostridium difficile infection in 5 (8.2%) patients. Across all admissions, median length of stay was 3 (IQR 2-6) days. 5 patients were readmitted within 30 days (UC, n=3; Crohn’s, n=2) and 13 patients were readmitted within 90 days (UC, n=6; Crohn’s, n=7). Cost of hospitalisation as per DRG codes was available from September 2022 to June 2023, with median cost being $13,308 AUD (IQR $9,464-$21,058 AUD). Conclusion The proportion of patients requiring hospitalisation in a 12-month period seen at a modern IBD service is small, and accounted for by non-adherence and/or non-engagement in a third. Measures to reduce non-adherence and non-engagement may result in further reduction in hospitalisation.

Uncovering energetic mechanisms that link work stressors to sleep

ABSTRACT In this study we examine whether and why daily work stressors are associated with sleep quality and sleep quantity. We draw on the effort-recovery model to test daily relationships between challenge and hindrance work stressors and sleep through physical and psychological fatigue, and vigor. We analyze daily diary data from 98 working sole mothers collected over seven days. The within-person daily hypotheses linking challenge and hindrance stressors to sleep via energetic mediators in our model were not supported. Exploratory analysis revealed several of our hypotheses were supported at the between-person level. Challenge and hindrance stressors were differentially related to psychological fatigue and physical fatigue such that hindrance stressors were positively associated, and challenge stressors were negatively associated. Challenge and hindrance stressors were differentially related to vigor such that hindrance stressors were negatively associated, and challenge stressors were positively associated. Across individuals, challenge and hindrance stressors were indirectly related to sleep quantity through these energetic mediators. This study answers calls for more investigations into mechanisms linking work stressors and sleep, and emphasises the importance of examining phenomena at multiple levels of analysis. Theoretical and practical implications for the challenge-hindrance framework and effort-recovery model, including the appropriate timeframe for study, are discussed.

Vascular Quality Initiative Assessment of Compliance with Society for Vascular Surgery Practice Guidelines for the Endovascular Management of Claudication.

In 2015, Society for Vascular Surgery guidelines on claudication management were released spanning optimal medical management, procedural, and post-procedure recommendations. Uptake of guidelines and changes to clinical practice over time remain unknown. This study hypothesized that guideline aligned practice increased after guideline release. The Vascular Quality Initiative Peripheral Vascular Intervention (VQI PVI) dataset was queried for years 2010-2021 for cases of claudication from occlusive disease. Only the initial procedure was considered, and subsequent interventions were excluded. The primary endpoint was care aligned with the 2015 SVS claudication treatment guidelines that were possible to evaluate in the VQI PVI dataset. Guideline aligned practice before 2016 was compared to after 2016. A hierarchical regression was used to control for hospital level variation introduced by changing VQI membership during the study timeframe. A majority of the 2015 SVS guideline GRADE 1-A recommendations can be assessed using the VQI PVI dataset. Overall, 93,654 cases were included, 30.9% before 2016 and 69.1% after guideline release. After controlling for hospital level variation, guideline aligned care improved for preoperative smoking cessation, aspirin, clopidogrel, and statin use, and post operative medical therapy with antiplatelet, dual antiplatelet and statin therapy. Guideline aligned care did not change over time for aorto-iliac stent use, covered stent use in calcified aortoiliac disease, or superficial femoral artery stenting for 5-15cm lesions. Guideline aligned care worsened for isolated infrapopliteal treatments and use of bare metal stents for 5-15 cm SFA occlusions. Secondary analysis identified an association between area deprivation index and increased odds of smoking and decreased odds of meeting post-discharge optimal medical therapy. While guideline aligned care improved after guideline release for medical management of claudication, procedural elements did not improve. Those with social deprivation were less likely to receive guideline aligned care for medical management representing a future area of study and improvement. High GRADE recommendations can be tracked using the VQI PVI dataset and should be monitored to help improve care.

Keep Moving: Sustainability of an Early Mobility Protocol in an Academic Pediatric ICU.

Mobilization protocols are safe and feasible for critically ill pediatric patients in the intensive care unit (ICU), but barriers exist to sustainability. This study described a focused early mobility protocol, sustained over 5 years, which is on time for therapy consults and patient mobilization at a single institution. A formal ICU mobility protocol was implemented as part of a unit-wide ICU liberation bundle. As part of the ongoing program assessment, over a specific 3-month timeframe annually from 2017 to 2023, the number of physical and occupational therapy (PT/OT) consults, mobilization rate, and time to PT/OT consult were analyzed. In addition, in 2023, we assessed specific barriers to early PT/OT consultation. Annually, for each study timeframe, there was a sustained decrease in time to therapy consult from a mean of 3.8 days for PT and 7 days for OT in 2017 to 1.9 and 1.6 days, respectively, in 2023. Similarly, the mobilization rate increased from 20.3 sessions per 100 patient days in 2017 to 48.2 in 2023. There was a trend toward missed or delayed therapy consults at times of higher ICU census. No adverse events were associated with mobilization. An ICU early mobility protocol leads to a sustained decrease in the time to therapy consultation, an increase in the number of therapy consults, and an increase in the mobilization rate. Future interventions should focus on mitigating barriers to timely consultation, specifically at times of higher ICU census.

Cryptorchidism: A 20-Year Journey of Patient Outcomes and Family Concerns – A Cohort Study at a Single Center

Background: Undescended testis (UDT), or cryptorchidism, is a prevalent pediatric condition with significant implications for fertility and malignancy risk if untreated. Affecting 1–5% of male infants, UDT is influenced by genetic, hormonal, and environmental factors. Methods: This retrospective cohort study examines 470 pediatric UDT cases treated at a single center over two decades (2004–2024) at a single pediatric surgery center - The Maternity and Child Teaching Hospital, Al Qadisiya, Iraq, focusing on surgical outcomes, fertility, long-term testicular health, and family concerns. Inclusion criteria; Patients were identified from hospital records and outpatient clinic registries confirmed diagnosis of UDT (unilateral or bilateral), availability of complete medical records, patients who underwent chromosomal analysis as part of their diagnostic workup, and underwent surgical intervention within the study timeframe at our center with at least three years of follow-up. Results: The mean age at diagnosis was 18 months, with 45% diagnosed within the first year. Unilateral UDT predominated (60%), and testicular position influenced size and outcomes. Surgical success was achieved in 90% of cases, with minor complications including wound infections (5%) and reoperations (5%). Earlier diagnosis correlated with improved fertility outcomes, with normal spermatogenesis observed in 75% of early cases but declining significantly with delayed treatment (P &lt; 0.05). Chromosomal abnormalities, present in 9% of patients, heightened family concerns, particularly regarding fertility and psychosocial impacts. Conclusion: Family concerns evolved through stages of care, initially focusing on fertility and malignancy risks, then shifting to surgical safety and postoperative recovery. Tailored counseling and psychosocial support were integral to family satisfaction. This study underscores the importance of early diagnosis, multidisciplinary care, and culturally sensitive family engagement to optimize outcomes and enhance the quality of life for patients with UDT. Future recommendations include routine genetic screening and targeted educational initiatives to address community-specific challenges.

Qualitative Content Analysis of Unplanned Readmissions in Patients With Acute Heart Failure

Unplanned readmissions in patients with acute heart failure generate a substantial burden on healthcare systems and are associated with significant morbidity and mortality. Heart failure admissions are projected to increase over time with the ageing population. Understanding the factors contributing to readmissions after an index admission for heart failure is important, in order to develop strategies to address this phenomenon. To understand the patient and organisational factors that contribute to readmissions in patients who are admitted with acute heart failure. Qualitative content analysis was performed on clinical notes from electronic medical records of all patients readmitted within 30 days after admission with acute heart failure at a single tertiary referral centre, between June 2022 and January 2023. Text related to patient and system-related factors contributing to readmissions were coded and organised into categories and sub-categories. The frequency of codes per patient was generated as a surrogate marker of the relative importance of codes within the dataset. Overall, 64 patients were readmitted within the study timeframe. Three main categories emerged from the analysis, including patient-related medical factors contributing to readmission, patient-related psychosocial factors, and system-related factors. Patient-related medical factors were the most dominant category, with sub-categories of "non-heart failure causes of readmission", "frailty or functional decline", or "severe underlying cardiac pathology" occurring most frequently within the cohort (60.9%, 48.4%, 42.2%, respectively). This study explores the patient-related medical, psychosocial, and system-related factors as significant contributors to readmissions in acute heart failure patients. It underscores the need for comprehensive and multi-faceted interventions to improve patient outcomes in this population and reduce healthcare burdens.

The association of HIV status with triple-negative breast cancer in patients with breast cancer in South Africa: a cross-sectional analysis of case-only data from a prospective cohort study

Breast cancer is the most common malignancy diagnosed among women in South Africa, with the aggressive triple-negative subtype comprising approximately 15% of breast cancers in this population. South Africa has the largest population of people with HIV in the world. This study aims to evaluate the association between HIV status and the proportion of patients with breast cancer with the triple-negative subtype. We did a cross-sectional analysis of case-only data from the South African Breast Cancer and HIV Outcomes (SABCHO) study, a prospective cohort study recruiting patients with newly diagnosed breast cancer at six public hospitals in South Africa. We analysed data from patients who enrolled in SABCHO between Jan 1, 2015, and Jan 18, 2022. Women aged 18 years or older with newly diagnosed and histologically confirmed invasive breast cancer were eligible. Participants were classified as HIV-positive or HIV-negative by use of an ELISA-based HIV test done at the time of enrolment. We developed multivariable logistic regression models to test for an association between HIV status and the proportion of triple-negative relative to non-triple-negative breast cancers while adjusting for demographic and reproductive risk factors. Of the 4122 patients enrolled in the SABCHO cohort within our study timeframe, 239 patients were excluded due to unknown breast cancer subtype (n=141), HIV status (n=97), or race (n=1). 3883 women with breast cancer were included in the study, of whom 637 (16·4%) had triple-negative breast cancer, 894 (23·0%) were HIV-positive, and 186 (4·8%) had triple-negative breast cancer and HIV. Triple-negative breast cancer accounted for 186 (20·8%) of 894 breast cancers among women who were HIV-positive and 451 (15·1%) of 2989 breast cancers among women who were HIV-negative (p<0·0001). In the fully adjusted logistic regression model, HIV-positive status was associated with an increased proportion of triple-negative breast cancer (adjusted odds ratio [OR] 1·39, 95% CI 1·12-1·74, compared with women who were HIV-negative). When compared with women who were HIV-negative, the association between HIV-positive status and the proportion of triple-negative breast cancer was strongest among the subgroup of women with a duration of HIV infection of 2 years or longer (1·57, 1·23-2·00) and those on antiretroviral therapy (ART; 1·47, 1·16-1·87). Patients with breast cancer and chronic HIV who are on ART are more likely to have triple-negative breast cancer than patients with breast cancer without HIV. This association is independent of age, race, and reproductive factors. US National Institutes of Health, University of the Witwatersrand, South Africa Medical Research Council Common Epithelial Cancers Research Center, Conquer Cancer Foundation, and Varmus Global Scholars Fund.

Prevalence of Surgical Site Infections Following Coronectomy: A Systematic Review and Meta-Analysis.

Background/Objectives: This systematic review and meta-analysis aimed to investigate the prevalence of surgical site infections (SSIs) following coronectomy of mandibular third molars. Methods: A comprehensive literature search was conducted in Medline, Scopus, Web of Science, and Google Scholar databases up to 30 July 2024. Two independent reviewers performed study selection, data extraction, and quality assessment using the Newcastle-Ottawa Scale. Observational studies assessing SSI prevalence following coronectomy were included. The pooled prevalence of SSI with 95% confidence intervals (CI) was calculated using a random-effects model. Heterogeneity was assessed using the I2 statistic, and meta-regression was conducted to explore the influence of continuous variables. Results: A total of 22 studies involving 2173 coronectomy procedures were included. The overall pooled prevalence of SSI was 2.4% (95% CI: 1-4.3%), with substantial heterogeneity (I2 = 81%). Meta-regression showed no significant effect of the examined variables on SSI prevalence. No study was identified as a significant outlier. Quality assessments revealed that all studies had moderate methodological quality. Conclusions: Considerable heterogeneity was observed, likely due to variations in study settings, geographical regions, and timeframes, among other factors. Therefore, this study underscores the need for further rigorous research to better understand SSI risk factors and enhance management strategies for this postoperative complication.

The Granulomas of Orbital Sarcoidosis Often Show Foci of Necrosis: A Retrospective Observational Study.

To characterize the frequency and extent of necrosis within granulomas among patients diagnosed with orbital sarcoidosis on biopsy. A retrospective review was conducted of patients diagnosed with orbital sarcoidosis at a single institution from 2018 to 2024. Histopathology slides were re-reviewed for evidence of any necrosis or infection. Demographic, laboratory, histopathologic, and radiographic data were gathered for these patients. All findings were presented using descriptive statistics. There were 19 total cases of orbital sarcoidosis in the study timeframe. The majority were female (15, 78.9%) with a median age of 49 (range: 11-85) presenting with a unilateral, mass-occupying orbital lesion (n = 16, 84.2%). The lacrimal gland and orbital fibroadipose tissue were the most frequently involved and biopsied. Biopsies from 13 patients (68.4%) had granulomas containing varying amounts of necrosis on histopathology on retrospective review. No fungal or acid-fast microorganisms were detected with special stains; a subset of patients had additional molecular genetic-based microbiologic studies which were also unrevealing. Although the histopathology of sarcoidosis is classically described as a "non-necrotizing (noncaseating) granulomas," granulomas with varying extents of necrosis are more frequently seen in orbital sarcoidosis than previously recognized, or than reported in biopsies from patients with sarcoidosis at other anatomic sites. The presence of necrosis within sarcoidal granulomas should not exclude a diagnosis of sarcoidosis at this site, given that infection is adequately excluded.

The scientific value of medical student research: The experience at the Arrow Program for Medical Research Education.

This study presents a comparative analysis of the publications of students participating in the Arrow Research Program in comparison to those of attending physicians and researchers at the same tertiary medical center in order to assess the impact of the Arrow Research Program on the students' scientific achievements. The study encompassed 90 Arrow Research Program students who were involved in the program at the Sheba Medical Center between 2019 and 2021. As a comparison group, 2082 attending physicians and researchers affiliated with the same center during the same period of time were considered. Publications were collected from The Web of Science Database, and the publication data parameters of each group were compared to assess scientific outcomes. The Arrow Research Program students collectively published 67 articles, and the 2082 physicians and researchers in the comparison group produced 4283 papers during the study timeframe. Similarly, the average impact factor of the journals in which the Arrow Research Program papers were published was 4.16 ± 2.68, similar to the average impact factor of 4.74 ± 6.26 in the comparison group (p = 0.388). Likewise, the average quartile of the journals in which the Arrow Research Program articles were published was 1.39 ± 0.59, which is similar to the comparison group's average quartile of 1.39 ± 0.63 (p = 0.997). In conclusion, the Arrow Research Program demonstrates its effectiveness in empowering young students to execute successful research projects. This study may help develop educational programs worldwide.