Tertiary Academic Institution Research Articles

Quality of Life for Patients with Sporadic Small Vestibular Schwannomas Following Middle Fossa Craniotomy.

To evaluate quality-of-life outcomes for patients with vestibular schwannomas (VS) undergoing a middle cranial fossa (MCF) approach. Prospective study from 2018 to 2023. Tertiary academic institution. Adults with sporadic VS. MCF. The primary outcome measure was the change in preoperative and 1-year postoperative Penn Acoustic Neuroma Quality-of-life (PANQOL) scores. Secondary outcome measures included hearing preservation and facial nerve function. Of the 164 patients who underwent MCF for sporadic VS, 78 patients elected to voluntarily complete preoperative PANQOL assessments prior to surgery. Seventy-one (91%) of those 78 patients completed postoperative PANQOL surveys. Fifty (70%) of the respondents were female and the median age was 48 years (range, 27-71 years). Overall, at 1-year postsurgery, a minimal clinically important difference (MCID) was obtained in the hearing (mean difference, 10.5; 95% confidence interval [CI], 4.3-16.7) and anxiety (mean difference, 18.8; 95% CI, 11.7-25.9) domains. For patients with hearing preservation (n = 48, 68%), MCIDs were reached in the hearing (mean difference, 13.4; 95% CI, 6.3-20.6), anxiety (mean difference, 20.8; 95% CI, 11.8-29.9), energy (mean difference, 13.7; 95% CI, 3.6-23.8), pain (mean difference, 13.7; 95% CI, 3.6-23.8) domains, and overall PANQOL scores (mean difference, 12.7; 95% CI, 7.1-18.3). Postoperatively, 64 (90%) patients maintained a House-Brackmann I. To our knowledge, this is the largest study examining disease-specific QOL for VS patients undergoing MCF. Based on our institution's experience, MCF approach for small VS is associated with clinically meaningful improvements in QOL, hearing preservation, and excellent facial nerve outcomes.

Abstract PO1-10-07: A Video Intervention to Improve Patient Understanding of Tumor Genomic Testing in Patients with Metastatic Breast Cancer: Primary Results of a Prospective Intervention Trial

Abstract Background: Tumor genomic testing (TGT) has become standard-of-care for all patients with metastatic breast cancer (MBC). American Society of Clinical Oncology (ASCO) and American College of Medical Genetics (ACMG) guidelines for patient education prior to TGT are not widely followed. We have previously demonstrated disparities in general genomic knowledge across race and income. The purpose of this study was to develop a concise (3-4 minute) video for patient education prior to TGT and evaluate the video’s impact in a prospective interventional trial. We report the results of the primary endpoint of the MBC cohort (ClinicalTrials.gov NCT05215769). Methods: We previously published our internal quality improvement cycle involving provider surveys, patient focus groups, and adult learning theory-based content development for TGT educational videos. An animated video incorporating culturally diverse images available in English and Spanish was created to be applicable to any cancer type, with MBC-specific content included for patients with breast cancer. A total of 150 participants were enrolled at a single tertiary academic institution, of whom 53 were diagnosed with MBC. Participants completed validated survey instruments immediately prior to video viewing (T1), immediately post-viewing (T2) and 60-90 days later, after TGT results were documented (T3). Instruments included: 1) 10-question objective genomic knowledge/understanding (GKU); 2) 10-question video message-specific knowledge/recall (VMSK); 3) 11-question Trust in Physician/Provider (TIPP); 4) attitudes regarding TGT. The primary objective was to assess change in VMSK between T1 and T2 and a cohort of 50 participants provided 90% power to detect an effect size of 0.47 from pre- to post-video using two-sided Wilcoxon signed-rank test with alpha of 0.05. Associations of VMSK, GKU, and TIPP with categorical demographic variables were explored with Kruskal-Wallis test. Results: From April 2022 to May2023, a total of 150 participants were enrolled (MBC n=53, lung cancer n=38, metastatic cancer of any type n=59). The MBC cohort analysis is presented. The MBC cohort had a median age of 59; all were female; majority Caucasian (48/53, 91%); most were married/in domestic partnership (35/53, 66%). For the primary endpoint, there was a significant increase in video message-specific knowledge (Wilcoxon signed rank p< 0.0001) but there was no significant change in general genomic knowledge (p=0.89) or trust in provider (p=0.59). Improvement of video message-specific knowledge was consistent across demographic groups, including age, income, and education. Of the 10-questions in the VMSK survey, results for four questions significantly improved after viewing the video, including questions informing the likelihood of TGT impact on treatment decision, incidental germline findings, and cost of testing (Table 1). Baseline genomic knowledge was significantly associated with income (nominal p=0.028), with higher income associated with higher baseline knowledge. Conclusions: A concise, 3-4 minute, broadly applicable video incorporating culturally diverse images administered prior to TGT significantly improved video message-specific knowledge across all demographic groups. Ongoing work includes analysis of additional cohorts (lung, any type) and evaluation in community oncology setting with a goal to provide a paradigm to efficiently educate and empower patients while addressing ASCO/ACMG guidelines within the flow of clinical practice. Table 1. Response to video message-specific questions before versus after tumor genomic testing educational video intervention Citation Format: Daniel Stover, Deloris Veney, Lai Wei, Amanda Toland, Carolyn Presley, Tasleem Padamsee, Clara Lee, Heather Hampel, William Irvin, Jawad Francis, Michael Bishop, Shelly Hovick, Leigha Senter. A Video Intervention to Improve Patient Understanding of Tumor Genomic Testing in Patients with Metastatic Breast Cancer: Primary Results of a Prospective Intervention Trial [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 PO1-10-07.

Classification and management strategy of spontaneous carotid artery dissection

ObjectiveSpontaneous carotid artery dissections (sCAD) are the common cause of stroke in middle-aged and young people. There is still a lack of clinical classification to guide the management of sCAD. We reviewed our experience with 179 sCAD patients and proposed a new classification for sCAD with prognostic and therapeutic significance. MethodsThis is a retrospective review of prospectively collected data from June 2018 to June 2023 of sCAD patients treated at a large tertiary academic institution in an urban city in China. Based on imaging results, we categorize sCAD into four types. Type Ⅰ: intramural hematoma or dissection with < 70% luminal narrowing; type Ⅱ: intramural hematoma or dissection with ≥ 70% luminal narrowing; type Ⅲ: dissecting aneurysm; type ⅣA: extracranial carotid artery occlusion; type ⅣB: tandem occlusion. We compared the clinical data and prognostic outcomes among various types of sCAD. ResultsA total of 179 patients and 197 dissected arteries met the inclusion criteria. The mean age of the 179 sCAD patients was 49.5 years, 78% were male, 18 patients (10%) had bilateral sCAD. According to our classification, there were 56 (28.4%) type Ⅰ, 50 (25.4%) type Ⅱ, 60 (30.5%) type Ⅲ, and 31 (15.7%) type Ⅳ dissections. During a mean hospitalization length of 11.4±47.0 days, there were 9 recurrent strokes (4.6%) after medical treatment, 2 (1.0%) type Ⅲ dissections, 7 (3.6%) type Ⅳ dissections, all ipsilateral, and 1 death. Overall, there were 7 (3.6%, 1 type Ⅰ dissection, 3 type Ⅱ dissections, 2 type Ⅲ dissections, and 1 type Ⅳ dissection) recurrent stroke and 3 (1.5%, all type Ⅲ dissections) recurrent TIA in patients treated with just medical therapy during the follow-up period, all ipsilateral, with a mean follow-up of 26 months (3-59 months). These patients did not undergo further intervention due to the high difficulty associated with endovascular treatment or the mild nature of recurrent cerebral ischemic symptoms. Twenty-nine (51.8%) type I dissections were completely recanalized after antithrombotic therapy. A total of 19 (38 %) of type II dissections and 44 (73%) of type III dissections received endovascular treatment (EVT) for persistent flow-limited dissections, enlargement of dissecting aneurysms, or aggravation of neurological symptoms despite antithrombotic therapy. Type Ⅳ dissections are more likely to lead to the occurrence of ischemic stroke and presented with more severe symptoms. Eight (33%) type IVB dissections received acute phase intervention due to distal thromboembolism or aggravation of neurological symptoms after medical treatment. In terms of cerebral ischemic events and mortality, there were no statistically significant differences among the four types of sCAD (all p > .05). Favorable outcome was achieved in 168 (93.9%) patients. ConclusionsThis study proposed a novel and more comprehensive classification method and the modern management strategy for sCAD. Antithrombotic therapy is beneficial to reduce the risk of recurrent stroke for stable sCAD. Non-emergent EVT can be an alternative therapeutic approach for patients who meet indications as in type II to IVA dissections. Urgent procedure with neurovascular intervention is necessary for some type IVB dissections. The short-term results of EVT for sCAD are encouraging, and long-term device-related and functional outcome should undergo further research.

Preoperative Circulating Tumor HPV DNA and Oropharyngeal Squamous Cell Disease

The utility of preoperative circulating tumor tissue-modified viral human papillomavirus DNA (TTMV-HPV DNA) levels in predicting human papillomavirus (HPV)-associated oropharyngeal squamous cell carcinoma (HPV+ OPSCC) disease burden is unknown. To determine if preoperative circulating tumor HPV DNA (ctHPVDNA) is associated with disease burden in patients with HPV+ OPSCC who have undergone transoral robotic surgery (TORS). This cross-sectional study comprised patients with HPV+ OPSCC who underwent primary TORS between September 2021 and April 2023 at one tertiary academic institution. Patients with treatment-naive HPV+ OPSCC (p16-positive) and preoperative ctHPVDNA levels were included, and those who underwent neck mass excision before ctHPVDNA collection were excluded. The main outcome was the association of increasing preoperative ctHPVDNA levels with tumor size and lymph node involvement in surgical pathology. The secondary outcome was the association between preoperative ctHPVDNA levels and adverse pathology, which included lymphovascular invasion, perineural invasion, or extranodal extension. A total of 70 patients were included in the study (65 men [93%]; mean [SD] age, 61 [8] years). Baseline ctHPVDNA levels ranged from 0 fragments/milliliter of plasma (frag/mL) to 49 452 frag/mL (median [IQR], 272 [30-811] frag/mL). Overall, 58 patients (83%) had positive results for ctHPVDNA, 1 (1.4%) had indeterminate results, and 11 (15.6%) had negative results. The sensitivity of detectable ctHPVDNA for identifying patients with pathology-confirmed HPV+ OPSCC was 84%. Twenty-seven patients (39%) had pathologic tumor (pT) staging of pT0 or pT1, 34 (49%) had pT2 staging, and 9 patients (13%) had pT3 or pT4 staging. No clinically meaningful difference between detectable and undetectable preoperative ctHPVDNA cohorts was found for tumor size or adverse pathology. Although the median preoperative ctHPVDNA appeared to be higher in pT2 through pT4 stages and pN1 or pN2 stages, effect sizes were small (pT stage: η2, 0.002 [95% CI, -1.188 to 0.827]; pN stage: η2, 0.043 [95% CI, -0.188 to 2.600]). Median preoperative log(TTMV-HPV DNA) was higher in active smokers (8.79 [95% CI, 3.55-5.76]), compared with never smokers (5.92 [95% CI, -0.97 to 1.81]) and former smokers (4.99 [95% CI, 0.92-6.23]). Regression analysis did not show an association between tumor dimension or metastatic lymph node deposit size and preoperative log(TTMV-HPV DNA). After univariate analysis, no association was found between higher log(TTMV-HPV DNA) levels and adverse pathology. In this cross-sectional study, preoperative ctHPVDNA levels were not associated with disease burden in patients with HPV+ OPSCC who underwent TORS.

The Ribbon Sign as a Radiological Indicator of Intramedullary Spinal Cord Subependymomas

INTRODUCTION: Intramedullary spinal cord (IMSC) subependymomas are rare World Health Organization grade 1 ependymal tumors. The potential presence of functional neural tissue within the tumor and poorly demarcated planes presents a risk to resection. Recognition of an intramedullary subependymoma on preoperative imaging can assist in operative planning and factor into the decision-making for gross- or sub-total resection. However, no definitive pathognomonic features have been reported on magnetic resonance imaging (MRI). METHODS: We retrospectively reviewed preoperative MRIs of patients presenting with IMSC tumors at a large tertiary academic institution between April 2005 and January 2022. The diagnosis was confirmed histologically. The “ribbon sign” was defined as a ribbon-like structure of T2 isointense spinal cord tissue interwoven between regions of T2 hyperintense tumor. The ribbon sign was confirmed by an expert neuroradiologist. RESULTS: MRIs from 151 patients were reviewed, including 42 (28%) astrocytomas, 82 (54%) ependymomas, 8 (5.3%) gangliogliomas, and 19 (13%) hemangioblastomas. Of the 82 ependymomas, ten patients (12%) presented with intramedullary subependymomas. The ribbon sign was demonstrated on nine (90%) patients with histologically proven subependymomas. No other tumor types displayed the ribbon sign. CONCLUSIONS: The ribbon sign is a distinctive imaging feature of IMSC subependymomas and indicates the presence of spinal cord tissue between eccentrically located tumor. Recognition of the sign should prompt clinicians to consider a diagnosis of subependymoma. Unlike their intracranial counterparts, resection of these lesions can be technically difficult, particularly in cases with poor demarcation between cord and tumor. Therefore, the risks and benefits of gross- vs. sub-total resection should be carefully considered and discussed with patients.

MRI, clinical, and radiomic models for differentiation of uterine leiomyosarcoma and leiomyoma.

To assess the predictive ability of conventional MRI features and MRI texture features in differentiating uterine leiomyoma (LM) from uterine leiomyosarcoma (LMS). This single-center, IRB-approved, HIPAA-compliant retrospective study included 108 patients (69 LM, 39 LMS) who had pathology, preoperative MRI, and clinical data available at our tertiary academic institution. Two radiologists independently evaluated 14 features on preoperative MRI. Texture features based on 3D segmentation were extracted from T2W-weighted MRI (T2WI) using commercially available texture software (TexRAD™, Feedback Medical Ltd., Great Britain). MRI conventional features, and clinical and MRI texture features were compared between LM and LMS groups. Dataset was randomly divided into training (86 cases) and testing (22 cases) cohorts (8:2 ratio); training cohort was further subdivided into training and validation sets using ten-fold cross-validation. Optimal radiomics model was selected out of 90 different machine learning pipelines and five models containing different combinations of MRI, clinical, and radiomics variables. 12/14 MRI conventional features and 2/2 clinical features were significantly different between LM and LMS groups. MRI conventional features had moderate to excellent inter-reader agreement for all but two features. Models combining MRI conventional and clinical features (AUC 0.956) and MRI conventional, clinical, and radiomics features (AUC 0.989) had better performance compared to models containing MRI conventional features alone (AUC 0.846 and 0.890) or radiomics features alone (0.929). While multiple MRI and clinical features differed between LM and LMS groups, the model combining MRI, clinical, and radiomic features had the best predictive ability but was only marginally better than a model utilizing conventional MRI and clinical data alone.

Electromyography findings in radiation-induced unilateral tongue immobility.

We used electromyography to characterize hypoglossal nerve function among radiation-treated head and neck cancer survivors with later onset unilateral tongue immobility. Patients with unilateral tongue immobility without evidence of recurrent cancer were seen at a tertiary academic institution between February and September 2021. All patients were at least 2 years post-treatment with radiation therapy for head and neck squamous cell carcinoma. Participants were under annual surveillance and displayed no evidence of operative injury to the hypoglossal nerve. The median symptom-free interval for the 10 patients included in this study was 13.2 years (range 2-25 years). Myokymia alone was present in 3 of 10 patients, fibrillation potentials alone were present in 3 of 10 patients, and 1 subject displayed both fibrillation and myokymia. Three out of 10 patients had normal hypoglossal nerve function. These findings highlight how disparate mechanisms may underlie similar clinical presentations of radiation-induced neuromuscular dysfunction.

Evaluating Trends in Screening Mammography Volumes at a Tertiary Academic Institution During the COVID-19 Pandemic

Evaluating Trends in Screening Mammography Volumes at a Tertiary Academic Institution During the COVID-19 Pandemic

Referred molecular testing as a barrier to optimal treatment decision making in metastatic non-small cell lung cancer: Experience at a tertiary academic institution in Canada.

Molecular testing is critical to guiding treatment approaches in patients with metastatic non-small cell lung cancer (mNSCLC), with testing delays adversely impacting the timeliness of treatment decisions. Here, we aimed to evaluate the time from initial mNSCLC diagnosis to treatment decision (TTD) following implementation of in-house EGFR, ALK, and PD-L1 testing at our institution. We conducted a retrospective chart review of 165 patients (send-out testing, n = 92; in-house testing, n = 73) with newly diagnosed mNSCLC treated at our institution. Data were compared during the send-out (March 2017-May 2019) and in-house (July 2019-March 2021) testing periods. We performed a detailed workflow analysis to provide insight on the pre-analytic, analytic, and post-analytic intervals that constituted the total TTD. TTD was significantly shorter with in-house testing (10 days vs. 18 days, p < 0.0001), driven largely by decreased internal handling and specimen transit times (2 days vs. 3 days, p < 0.0001) and laboratory turnaround times (TAT, 3 days vs. 8 days, p < 0.0001), with 96% of in-house cases meeting the international guideline of a ≤ 10-day intra-laboratory TAT (vs. 74% send-out, p < 0.001). Eighty-eight percent of patients with in-house testing had results available at their first oncology consultation (vs. 52% send-out, p < 0.0001), and all patients with in-house testing had results available at the time of treatment decision (vs. 86% send-out, p = 0.57). Our results demonstrate the advantages of in-house biomarker testing for mNSCLC at a tertiary oncology center. Incorporation of in-house testing may reduce barriers to offering personalized medicine by improving the time to optimal systemic therapy decision.

Knowledge gaps and confidence in counseling about aneuploidy screening and testing: A survey of prenatal care clinicians.

Comprehensive counseling on prenatal genetic screening and diagnostic testing is challenging for clinicians. We sought to identify baseline clinician knowledge of prenatal genetic screening and diagnostic testing and needs to promote counseling aligned with ACOG recommendations. We performed an anonymous, cross-sectional survey of clinicians at two unaffiliated, tertiary academic institutions to assess the knowledge of, confidence in, and time spent counseling on prenatal genetic screening and diagnostic testing. Stata (Version 17, College Station, TX) was used to perform descriptive statistics. Deductive and inductive coding was used to analyze responses regarding ideal education resources. The survey response rate was 78% (100/129). Only 36% of respondents correctly answered knowledge questions about prenatal genetic screening and diagnostic testing. A majority, 59% (16/39), of those confident or extremely confident in counseling were unable to answer all questions accurately. Respondents reported a median of 5.6min (95% CI 4.9-6.4min) spent counseling. Thematic analysis of free responses revealed desire for visual tools that discuss financial costs and patient values. Surveyed clinicians demonstrated deficiencies in knowledge about prenatal genetic counseling. To provide better and more comprehensive care, we noted a desire for the development of formalized resources for clinician and patient education.

Internal hemipelvectomy: A single institution's learning curve and longitudinal experience.

Wide margin resection for pelvic tumors via internal hemipelvectomy is among the most technically challenging procedures in orthopedic oncology. As such, surgeon experience and technique invariably affect patient outcomes. The aim of this clinical study was to assess how an individual surgeon's experiences and advancements in technology and techniques in the treatment of internal hemipelvectomy have impacted patient outcomes at our institution. This study retrospectively examined a single tertiary academic institution's consecutive longitudinal experience with internal hemipelvectomy for primary sarcoma or pelvic metastases over a 26-year period between the years 1994 and 2020. Outcomes were assessed using two separate techniques. The first stratified patients into cohorts based on the date of surgery with three distinct "eras" ("early," "middle," and "modern"), which reflect the implementation of new techniques, including three-dimensional (3D) computer navigation and cutting guide technology into our clinical practice. The second method of cohort selection grouped patients based on each surgeon's case experience with internal hemipelvectomy ("inexperienced," "developing," and "experienced"). Primary endpoints included margin status, complication profiles, and long-term oncologic outcomes. Whole group multivariate analysis was used to evaluate variables predicting blood loss, operative time, tumor-free survival, and mortality. A total of 72 patients who underwent internal hemipelvectomy were identified. Of these patients, 24 had surgery between 1994 and 2007 (early), 28 between 2007 and 2015 (middle), and 20 between 2016 and 2020 (modern). Twenty-eight patients had surgery while the surgeon was still inexperienced, 24 while developing, and 20 when experienced. Evaluation by era demonstrated that a greater proportion of patients were indicated for surgery for oligometastatic disease in the modern era (0% vs. 14.3% vs. 35%, p = 0.022). Fewer modern cases utilized freehand resection (100% vs. 75% vs. 55%, p = 0.012), while instead opting for more frequent utilization of computer navigation (0% vs. 25% vs. 20%, p = 0.012), and customized 3D-printed cutting guides (0% vs. 0% vs. 25%, p = 0.002). Similarly, there was a decline in the rate of massive blood loss observed (72.2% vs. 30.8% vs. 35%, p = 0.016), and interdisciplinary collaboration with a general surgeon for pelvic dissection became more common (4.2% vs. 32.1% vs. 85%, p < 0.001). Local recurrence was less prevalent in patients treated in middle and modern eras (50% vs. 15.4% vs. 25%, p = 0.045). When stratifying by case experience, surgeries performed by experienced surgeons were less frequently complicated by massive blood loss (66.7% vs. 40% vs. 20%, p = 0.007) and more often involved a general surgeon for pelvic dissection (17.9% vs. 37.5% vs. 65%, p = 0.004). Whole group multivariate analysis demonstrated that the use of patient-specific instrumentation (PSI) predicted lower intraoperative blood loss (p = 0.040). However, surgeon experience had no significant effect on operative time (p = 0.125), tumor-free survival (p = 0.501), or overall patient survival (p = 0.735). While our institution continues to utilize neoadjuvant and adjuvant therapies following current guideline-based care, we have noticed changing trends from early to modern periods. With the advent of new technologies, we have seen a decline in freehand resections for hemipelvectomy procedures, and a transition to utilizing more 3D navigation and customized 3D cutting guides. Furthermore, we have employed the use of an interdisciplinary team approach more regularly for these complicated cases. Although our results do not demonstrate a significant change in perioperative outcomes over the years, our institution's willingness to treat more complex cases likely obscures the benefits of surgeon experience and recent technological advances for patient outcomes.

Body Surface Area-Based Dosing of Mycophenolate Mofetil in Pediatric Hematopoietic Stem Cell Transplant Recipients: A Prospective Population Pharmacokinetic Study.

Mycophenolate mofetil (MMF) is commonly used for acute graft-versus-host disease (aGVHD) after allogeneic hematopoietic stem cell transplantation (HSCT). However, limited population pharmacokinetic (PPK) data are available for pediatric HSCT patients. This study aimed to develop a PPK model and recommend optimal oral MMF dosage in pediatric HSCT patients. This prospective study involved pediatric HSCT patients at a tertiary academic institution. Patients received oral MMF 15-20 mg/kg twice daily for aGVHD prophylaxis and treatment. The PPK analysis was conducted using a nonlinear mixed-effects modeling method. Simulation was performed considering different body surface areas (BSAs) (0.5 m2, 1.0 m2, 1.5 m2) and dosing (400 mg/m2, 600 mg/m2, 900 mg/m2 twice daily). Based on the simulation, an optimal dosage of oral MMF was suggested. A total of 20 patients and 80 samples were included in the PPK model development. A one-compartment model with first-order absorption adequately described the pharmacokinetics of mycophenolic acid (MPA). BSA was a statistically significant covariate on Vd/F. Simulation suggested the optimal dosage of oral MMF as 900 mg/m2 twice daily, respectively. A reliable PPK model was developed with good predictive performance. This model-informed optimal MMF dosage in pediatric HSCT patients can provide valuable dosing guidance in real-world clinical practice.

Utilization and Barriers to Stem Cell Transplantation in Relapsed/Refractory Hodgkin Lymphoma: A ‘Real-World’ Study of Treatment Patterns and Outcomes at a Safety-Net Versus a Tertiary Academic Hospital

Background About 20-30% of patients with classical Hodgkin Lymphoma (cHL) develop relapsed or refractory disease (R/R) after initial induction therapy. The standard of care for R/R cHL involves salvage chemo- and/or immuno-therapy followed by autologous hematopoietic stem cell transplantation (ASCT), with which up to 50% of patients achieve durable remission. However, ASCT is not readily available for all patients. Safety-net hospitals disproportionately take care of minority patients who face significant barriers to care due to lack of insurance or prohibitive medical costs. With novel therapies like brentuximab vedotin (BV) and immune checkpoint inhibitors increasingly used in treating cHL, the optimal timing and role of ASCT in R/R cHL requires ongoing investigation. This study compares the demographics, treatment patterns, and survival outcomes among R/R cHL patients treated at a safety-net versus a tertiary academic institution. Methods We conducted an IRB approved, retrospective review of adult patients with cHL treated within our healthcare system between 2009 and 2023. Hypothesis testing was performed using Chi-square test or Fisher's exact test for categorical variables and t-test or Wilcoxon rank sum test for continuous variables, with a 2-tailed P value ≤ .05. Survival analysis for progression-free (PFS) and overall survival (OS) was performed using Kaplan-Meier method and evaluated by log-rank test. Univariate Cox proportional hazard regression was used to assess the relationship between pre-specified variables and the primary endpoints of PFS and OS. All statistical testing was done using R version 4.3.1. Results There was a total of 230 adult patients with cHL between the two hospital systems. Seventy-one patients (31%) in the study cohort had R/R cHL (safety-net hospital, n=30 [42%] and tertiary academic medical center, n=41 [58%]). Patients treated at the safety-net hospital were predominantly male (p=0.033), Hispanic (p=0.014) and uninsured (p&amp;lt;0.001) and had higher rates of HIV/AIDS (p&amp;lt;0.001). They also had more advanced stage disease (p=0.015), higher IPS score (p&amp;lt;0.001), and bone marrow involvement (p=0.031) (Table 1). Primary refractory cHL constituted 17/30 (57%) at the safety-net hospital and 22/41 (54%) at the academic medical center. Only 7/30 (23%) patients treated at the safety-net hospital received ASCT compared to 30/41 (73%) at the academic medical center (p&amp;lt;0.001). The main barriers to ASCT for the former were predominantly financial and social barriers (&amp;gt;50%) while those at the latter were based on patient/physician choice due to anticipated adverse effects and comorbid conditions. Following ASCT, 2/7 (29%) safety-net patients received BV maintenance therapy compared to 11/30 (37%) academic center patients. Rates of relapse post-ASCT were 29% (2/7) and 53% (16/30) respectively. Five patients (31%) at the academic center received allogeneic SCT at relapse post-ASCT. Univariate Cox regression analysis showed that advanced age at diagnosis and EBER positivity were associated with inferior OS (HR=1.043, p=0.004; HR=4.205, p=0.014) but not PFS (HR=1.004, p=0.699; HR=1.317, p=0.352). Higher IPS score and high ECOG performance status adversely impacted OS (HR=1.578, p=0.011; HR=10.280, p=0.025) and PFS (HR=1.261, p=0.016; HR=1.930, p=0.05). Receipt of SCT significantly improved OS (HR=0.211, p=0.016) and PFS (HR=0.333, p&amp;lt;0.001). This was reflected in the five-year OS of 90.2% versus 57.8% in patients receiving SCT versus those who did not. Notably, safety-net patients receiving ASCT (n=7) had a 5-year OS comparable to SCT recipients at the academic center (100.0% vs 87.7%) (Figure 1). Conclusions Our results show significant differences in treatment patterns and outcomes for R/R cHL patients at a safety-net versus a tertiary academic hospital. Even in the era of novel agents, ASCT significantly improves survival outcomes in R/R cHL. Thus, all eligible patients should be offered this curative treatment. In practice, however, socioeconomic barriers still pose significant barriers to optimal care, with less than 25% of safety-net patients having access to ASCT. Cost effectiveness may be another consideration as eligible patients barred from ASCT may need further treatment with expensive immunotherapies. Urgent policy measures are needed to mitigate these disparities experienced by safety-net hospitals.

Abstract 18561: Trends Among Patients Undergoing Transvenous Lead Extraction: A Single Center Experience

Background: In recent years there has been an increase in cardiac device-related infections and the need for transvenous lead extraction (TLE). Limited data exist on secular trends in baseline characteristics and outcome measures among patients undergoing this high-risk procedure. Objective: To examine secular trends in baseline characteristics and outcomes for patients undergoing lead extraction procedure at our institution. Methods: We conducted a retrospective chart review of patients undergoing TLE from 2010 to 2021, at a tertiary academic institution. Patients were divided into three epochs (2010-2013, 2014-2017 and 2018-2021). Baseline characteristics in hospital length of stay (LOS) and survival were compared between groups. Results: A total of 794 patients, with a mean age of 64±16 years, were analyzed. 481 (60%) patients had infection as the indication for TLE. On average, 2 ± 1 leads were extracted per patient. The longest lead dwell time was 6.5 ± 4.8 years. Significant progressive increase in baseline comorbidity over time is noted (Table 1). A concomitant increase in infection indication versus lead management was also noted. There was a significant increase in the median hospital LOS across epochs; 3.88 IQR (1.26-10.06) for epoch 1 vs 7.34 IQR (2.25-13.35) for epoch 2, vs 9.06 IQR (5.78-14.05) for epoch 3 (P &lt; 0.0001). While there was no difference in long term survival curves (log rank p =0.4), between group analysis showed higher risk for 30 day [RR 2.24(1.08-4.66) p=0.0306] and 1 year mortality [RR 1.44 (1.004-2.05) p=0.0478] between epoch 3 vs epoch 1. Conclusion: Across epochs, the number of TLE procedures performed decreased while patient morbidity increased with a notable increase in infection indication for the procedure. This corresponded to a progressive increase in hospital LOS and an emergent signal toward increased near-term mortality.

Deformity, etiology, solution, sequence (DESS): Facial analysis in rhinoplasty

PurposeRhinoplasty is amongst the most challenging surgeries to perfect and can take decades. This process begins during residency; however, residents often have limited exposure to rhinoplasty during their training and lack a standardized method for systematically analyzing and formulating a surgical plan. The DESS (Deformity, Etiology, Solution, Sequence) is a novel educational format for residents that serves to increase their pre-operative comfort with the surgical evaluation and intraoperative planning for a rhinoplasty. Materials and methodsA qualitative study performed at a tertiary academic institution with an otolaryngology residency program evaluating three consecutive residency classes comprised of four residents per class. A 9-item questionnaire was distributed to measure change in resident comfort after utilizing the DESS during their facial plastics rotation. Questionnaire responses highlighted resident comfort with facial nasal analysis, identifying deformities, suggesting surgical maneuvers, and synthesizing a comprehensive surgical plan. ResultsTen of the twelve residents surveyed responded. Of those that responded, comfort in facial nasal analysis, identification of common nasal deformities, surgical planning, and development of an overall surgical plan were significantly improved after completion of the facial plastic rotation. These residents largely attributed their success to the systematic educational format, with an average score of 4.8/5.0 (SD 0.42). ConclusionWhile rhinoplasty is a challenging artform to master, systematic approaches to analysis and operative planning are vital for teaching and guiding residents. Through this novel methodology, residents display significant improvement in their comfort with facial nasal analysis and overall surgical preparation.

Evaluation of an Advanced Practice Provider Onboarding and Development Program.

To evaluate the impact of implementing a comprehensive secondary onboarding and development program within a hospital medicine group at a large tertiary academic medical institution. This was a mixed-methods study with physician and advanced practice providers (APPs) at an academic medical institution. For quantitative methods, improvement in competencies was determined using a pre-and posttest for APPs and pre- and postevaluation scores from collaborating physicians. APPs also participated in a pre- and post-self-assessment. For qualitative methods, experiences in the secondary onbo.arding and development program were assessed using semistructured interviews. For quantitative results, there were a total of 25 APPs who completed the pre- and posttest and were evaluated by at least 9 physicians. The average pretest score for APPs was 71.7% and the average posttest score was 83.0%. The average score for physicians' evaluations of APPs was 4.24/5 and increased to 4.38/5 in the postprogram evaluations. The average score for APP self-assessment pretraining was 3.52/5 and after the 12-month onboarding training, average scores increased to 3.84/5. For qualitative results, 4 APPs and 6 physicians were interviewed. Three of the APPs reported having more confidence in treating patients, whereas 1 APP viewed the program as a refresher course. All of the APPs mentioned that they would recommend the program to other APPs. Physicians reported that the program was beneficial in standardizing the care provided among the different types of APPs (physician assistants and nurse practitioners). All of the physicians also would recommend the program to other physicians and APPs.

Relationship between the Ratio of Red Cell Distribution Width to Albumin and 28-Day Mortality among Chinese Patients over 80 Years with Atrial Fibrillation

Introduction: Atrial fibrillation (AF) is a prevalent heart arrhythmia in elderly adults aged 80 years or older. The red cell distribution width (RDW) to albumin ratio has been acknowledged as a reliable prognostic marker for poor outcomes in a variety of disorders. However, there exists limited scientific evidence on the association of RDW to albumin (RAR) with mortality in geriatric individuals with AF. Methods: From January 2015 to June 2020, a retrospective study was conducted in a tertiary academic institution that diagnosed 1,141 elderly adults with AF. The RAR value was calculated as the ratio of RDW (%) to albumin (g/dL). The potential association between RAR and cardiovascular mortality and the risk of all-cause mortality within 28 days was evaluated by means of multivariable Cox regression analysis. Results: The 28-day all-cause and cardiovascular mortality rates were 8.7% and 3.3%, respectively. Increased RAR tertiles were found to be significantly associated with greater all-cause mortality (T1: 1.6%; T2: 6.2%; T3: 18.1%, p < 0.001) and cardiovascular mortality (T1: 0.8%; T2: 2.9%; T3: 6.3%, p < 0.001) using Kaplan-Meier analysis. Continuous RAR had a positive association with all-cause mortality (hazard ratios [HR] = 1.42, 95% confidence interval [CI] 1.23–1.65) and cardiovascular mortality (HR = 1.31, 95% CI: 1.05–1.64), even after accounting for numerous confounding variables. In comparison to the T1 group, individuals with the highest RAR levels displayed a greater risk of all-cause mortality (HR = 2.73, 95% CI: 1.11–6.74) and cardiovascular mortality (HR = 2.59, 95% CI: 0.69–9.78). Increased RAR levels were related to higher rates of cardiovascular and all-cause mortality across almost all subgroups. Conclusion: RAR is independently correlated with 28-day all-cause mortality and cardiovascular mortality in AF-affected individuals aged ≥80.

“We must help them despite who they are…”: healthcare providers’ attitudes and perspectives on care for young gay, bisexual and other men who have sex with men in Nairobi, Kenya

BackgroundCompared to young heterosexual men, young gay, bisexual and other men who have sex with men (YMSM) face a disproportionate burden of sexual health conditions. This disparity is occasioned by factors such as criminalization and stigmatization of same-sex practices, YMSM’s limited access to non-judgmental and non-discriminatory health services, and challenges associated with healthcare delivery. We explored the attitudes and perspectives of tertiary academic institution-based healthcare providers (HCPs) toward provision of services to YMSM in Nairobi, Kenya.MethodsIn September 2021, six in-person focus group discussions (FGDs) were held with 36 HCPs drawn from six public tertiary academic institutions within the Nairobi metropolis. HCPs were drawn from six cadres: front office staff, nurses, clinicians, counsellors, laboratory technologists, and pharmaceutical technologists. Discussions were conducted in English, transcribed verbatim and analyzed thematically using NVivo version 12.ResultsAnalysis showed that despite expressing disapproval of same-sex practices, HCPs recognized their professional duty to provide care to YMSM, voiced challenges they experienced when providing care to YMSM, and suggested possible strategies for improving care for YMSM. Disapproval of same-sex practices mainly stemmed from HCPs’ personal values, societal norms and religious beliefs, though some HCPs identified religious principles such as the golden rule of “treating others as one would want to be treated” as motivation to providing care to YMSM. HCPs did not perceive criminalization of same-sex practices as a barrier to providing care to YMSM. Healthcare delivery challenges included inadequate knowledge and skills, a desire to “convert” YMSM’s perceived deviant homosexual to the normative heterosexual orientation, secondary stigma from other HCPs, and healthcare settings that did not support YMSM to disclose same-sex practices. Suggestions for improving care comprised sensitization and training of HCPs, encouraging more HCP-YMSM interaction, providing YMSM-friendly and inclusive services, and advocacy for YMSM services.ConclusionThere is need for interventions to improve HCPs’ knowledge of YMSM’s health needs, build skills to respond to these needs, and foster affirming attitudes toward same-sex practices. By so doing, YMSM can hopefully be able to access services that meet their needs, and are non-discriminatory, non-stigmatizing and non-judgmental.

Automated classification of fat-infiltrated axillary lymph nodes on screening mammograms.

Fat-infiltrated axillary lymph nodes (LNs) are unique sites for ectopic fat deposition. Early studies showed a strong correlation between fatty LNs and obesity-related diseases. Confirming this correlation requires large-scale studies, hindered by scarce labeled data. With the long-term goal of developing a rapid and generalizable tool to aid data labeling, we developed an automated deep learning (DL)-based pipeline to classify the status of fatty LNs on screening mammograms. Our internal data set included 886 mammograms from a tertiary academic medical institution, with a binary status of the fat-infiltrated LNs based on the size and morphology of the largest visible axillary LN. A two-stage DL model training and fine-tuning pipeline was developed to classify the fat-infiltrated LN status using the internal training and development data set. The model was evaluated on a held-out internal test set and a subset of the Digital Database for Screening Mammography. Our model achieved 0.97 (95% CI: 0.94-0.99) accuracy and 1.00 (95% CI: 1.00-1.00) area under the receiver operator characteristic curve on 264 internal testing mammograms, and 0.82 (95% CI: 0.77-0.86) accuracy and 0.87 (95% CI: 0.82-0.91) area under the receiver operator characteristic curve on 70 external testing mammograms. This study confirmed the feasibility of using a DL model for fat-infiltrated LN classification. The model provides a practical tool to identify fatty LNs on mammograms and to allow for future large-scale studies to evaluate the role of fatty LNs as an imaging biomarker of obesity-associated pathologies. Our study is the first to classify fatty LNs using an automated DL approach.

The Relationship Between Patient-Reported Outcomes and Patient Satisfaction With Ligament Reconstruction Tendon Interposition

Achieving the minimal clinically important difference (MCID) on an outcomes instrument and reporting satisfaction with surgical outcomes are not equivalent. We hypothesized that improvement exceeding the QuickDASH and PROMIS UE CAT MCID is associated with a greater likelihood of reporting satisfaction with ligament reconstruction tendon interposition (LRTI) treatment. Our secondary hypothesis was that a subset of patients failing to meet MCID would still be satisfied. Patients ≥1 year after LRTI at one academic tertiary institution were included. QuickDASH and UE CAT v1.2 scores were obtained before and after surgery. Postoperative satisfaction and levels of improvement in pain and function were also obtained. A total of 93 patients completed the QuickDASH, and of those, 90 also completed the UE CAT. At a mean of 2.6 ± 1.0 years after surgery, QuickDASH and UE CAT score improvement exceeded the previously published MCID estimates of 8.8 and 4.8. Although 90% (84/93) of the patients reported satisfaction, only 85% (72/93) and 72% (59/90) achieved MCID on the QuickDASH and UE CAT, respectively. Using the MCID estimate of 8.8, 96% (72/75) of the patients meeting the MCID were satisfied with their treatment. Those failing to achieve MCID reported significantly less physical function and pain improvement; however, most were satisfied nonetheless (68% [13/19] for QuickDASH, 77% [23/30] for UE CAT). Achieving published MCID thresholds on the QuickDASH and PROMIS UE CAT v1.2 was predictive of patients reporting general satisfaction with their LRTI outcome ≥1 year after surgery. Most patients failing to achieve MCID still reported satisfaction with their LRTI. Achieving MCID thresholds alone should not be used as a surrogate for patient satisfaction with their treatment. Patient satisfaction is a complicated construct that is potentially very different from that of high-quality care. Prognostic IV.