Tertiary Academic Medical Center Research Articles

Quantifying neuronal biomarkers in aqueous humor in individuals undergoing routine cataract surgery and correlating with age and cognition

AbstractBackgroundPlasma and cerebrospinal fluid (CSF) levels of neuronal biomarkers have been associated with Alzheimer’s disease (AD). The aqueous humor, which can be collected during routine cataract surgery, may have similar concentrations of neuronal biomarkers to CSF.MethodThis proof‐of‐concept study prospectively enrolled adults without a diagnosis of cognitive impairment undergoing cataract surgery at a tertiary academic medical center. Participants underwent Montreal Cognitive Assessment (MoCA blind version 7.1, “abnormal” < 18) at the time of study enrollment. Aqueous samples were collected during cataract surgery through a surgical paracentesis. Samples were analyzed using an ultrasensitive single‐molecule array (SiMoA). Assessed biomarkers included phosphorylated tau (pTau)‐181, amyloid‐beta (Aß)‐42, Aß‐40, neurofilament light chain (NfL), and glial fibrillary acidic protein (GFAP). Correlations were assessed using Spearman’s rank correlation (rho).ResultSixteen eyes of 16 patients (average MoCA 19.2) underwent aqueous sampling to assess pTau‐181 and 7 eyes of 7 separate patients (average MoCA 20.0) underwent aqueous and plasma sampling to assess Aß‐42, Aß‐40, NfL, and GFAP. Aqueous pTau‐181 increased with increasing age (rho = 0.67, p = 0.0046). No aqueous or plasma biomarkers were significantly correlated with MoCA scores (all p > 0.05). Aqueous and plasma levels of biomarkers were not significantly correlated.ConclusionNeuronal biomarkers are measurable in aqueous humor using SiMoA analysis; however, these biomarkers did not significantly correlate with MoCA scores in a cognitively normal population. Further study in individuals with a known diagnosis of Alzheimer’s disease or mild cognitive impairment is indicated.

0919 EMR-Integrated Clinical Pathway Improves Familiarity with Obesity Hypoventilation Syndrome Among Inpatient Clinicians

Abstract Introduction Obesity hypoventilation syndrome (OHS) is an underrecognized chronic respiratory condition characterized by obesity (BMI > 30kg/m2) and hypoventilation (PaCO2 > 45mmHg) in the absence of other causes of hypoventilation. In OHS, obesity causes mass loading on the respiratory system, leading to CO2 retention, diminished ventilatory response, progressive hypoxia/hypercapnia, and eventual cardiopulmonary arrest. OHS is typically diagnosed while inpatient, wherein 18-month mortality approaches 23%. Non-invasive ventilation (NIV) improves OHS symptoms & prognosis which subsequently decreases healthcare utilization and mortality. With the proper tools and training, inpatient providers can facilitate accurate diagnosis and prompt treatment of OHS. Our team developed an EMR-integrated clinical pathway to increase recognition and facilitate treatment of OHS in hospitalized patients on the general medicine service. Methods The OHS Pathway was implemented among a large group of hospitalists at a tertiary academic medical center. A multi-disciplinary team of physicians, respiratory therapists, and care coordinators designed the pathway structure and content. Prior to integrating the OHS pathway into the EMR, hospitalists were surveyed to assess existing knowledge and experiences caring for patients with OHS. Hospitalists then participated in an educational series on OHS with orientation to the pathway. 12-months into the intervention, hospitalists were re-surveyed. Results Survey data analysis revealed that providers were significantly more familiar with the diagnostic criteria for OHS after (n=40) the introduction of the clinical pathway rather than before the introduction (n=24) of the pathway (t (62) = 2.88, p = .0027). Subjective success rates for prescribing NIV to patients upon discharge did not significantly improve Conclusion OHS diagnosed in the inpatient setting carries significant morbidity and mortality. Proper detection and prompt treatment of OHS are essential to improving the care and prognosis of this high-risk population. We demonstrate that our multi-disciplinary based, EMR-integrated clinical pathway increased provider familiarity with the diagnostic criteria for OHS. While treatment success did not significantly improve, numerous systems factors were at play, and further investigations are needed to address access to treatment. Support (if any)

Lack of Access to Primary Care Reduces Survival Following Aortic Dissection

Optimal medical management is critical for the long-term treatment of aortic dissections (AD) to prevent complications and improve survival. Medical management is known to be influenced by various social determinants of health (SDOH), including health insurance, social support, distance to the hospital, and primary care provider (PCP) access. This study was designed to determine the relative impact of these different geographic and SDOH factors on the long-term survival of patients after diagnosis and treatment for acute AD. We retrospectively analyzed patients presenting to a single academic tertiary medical center for surgical and medical management of acute AD (types A and B) from January 2010 to December 2020. Data were collected regarding patient demographics, perioperative hospital course, and SDOH factors such as home/social status, primary and secondary insurance status, PCP access following surgery, distance to the hospital, and 2020 Area Deprivation Ondex scores. Cox proportional hazards regression models were used to estimate the risk-adjusted association between SDOH variables and mortality following acute AD. We identified 124 patients who presented with an acute AD during the study period (25% type A, 25% type B, and 50% with both type A and B components), who were predominantly male (68%) with a mean age of 60 years. Patients resided a median distance of 30.2 miles from the medical center, 18% lived alone, and 9% were uninsured. Roughly one-half of the cohort (52%) was documented to have access to a PCP, and patients with a PCP were significantly more likely to be maintained on antihypertensive (anti-HTN) medication therapy during follow-up (Fig 1). The most common anti-HTN agents were angiotensin-converting enzyme inhibitors or angiotensin receptor blockers (56%), followed by beta-blockers (44%), and calcium channel blockers (26%). Over a median follow-up of 14.6 months, 43 patients (35%) died, with reduced survival observed among patients with no PCP access (Fig 2). In risk-adjusted models, increasing age, no PCP access, and lack of insurance were all found to be independent predictors of mortality following acute AD. Further, uninsured patients with no-PCP access or medication use had the highest risk for mortality (hazard ratio, 27.6; 95% confidence interval, 8.95-85.23; P < .001). Lack of access to a PCP and anti-HTN therapy following acute AD significantly increases the risk of short- and long-term mortality. These findings are independent of how far patients live from the hospital or other SDOH factors, highlighting the importance of community outreach programs to maintain medical management for uninsured AD patients.Fig 2Kaplan-Meier survival curves following acute aortic dissection, stratified by whether patients had access to a primary care provider (PCP).View Large Image Figure ViewerDownload Hi-res image Download (PPT)

Automated methods indicate specialty disparities in follow-up time for cancer screening tests within one system

IntroductionA study utilizing automated algorithms was used determine if abnormal results for cancer screening tests could be identified and if appropriate follow-up took place. We examined our system in order to determine whether follow-up varied by sociodemographic characteristics and/or clinical specialty. MethodsA retrospective, observational study was conducted to assess the time to follow-up for each abnormal cancer screening test result at Brigham and Women's Hospital, a tertiary academic medical center, from June 30, 2008 to June 29, 2010. Time to follow-up was evaluated using cumulative distribution function curves for mammograms, Pap smears, and prostate-specific antigen (PSA) tests. ResultsOut of 110,000 total cancer screening tests, we identified 4,378 abnormal mammograms, 1,066 abnormal pap smears, and 1,114 abnormal PSA tests. Mammograms were followed-up at the fastest speed, followed by PSA tests, then Pap smears. Mammograms ordered by OB/GYN (HR=1.154, p<0.001) or Hematology/Oncology (HR=1.400, p<0.001) were followed-up faster than those ordered by General Internal Medicine. Pap smears ordered by OB/GYN were followed-up slower compared to General Internal Medicine (HR=0.685, p=0.001). PSA test orders by Hematology/Oncology were followed-up at twice the speed of tests ordered by General Internal Medicine (HR=2.213, p=0.003); tests ordered by other specialties were followed-up at half the speed of General Internal Medicine (HR=0.465, p<0.001). ConclusionsThe disparities in time to follow-up for cancer screening tests within one health system indicate that best practices are not employed uniformly. Health IT methods may be a viable option to help bridge this gap.

Upper Airway Surgery or Weight Control? Modified Drug-Induced Sleep Endoscopy for Obstructive Sleep Apnea.

To identify the value of head rotation in the supine position and oral appliance (OA) use in drug-induced sleep endoscopy (DISE). Eighty-three sleep apnea adults undergoing target-controlled infusion-DISE (TCI-DISE) were recruited from a tertiary academic medical center. During DISE, 4 positions were utilized: supine position (position 1), head rotation (position 2), mandibular advancement using an OA (position 3), and head rotation with an OA (position 4). Polysomnography (PSG) data and anthropometric variables during DISE were analyzed. Eighty-three patients (65 men and 18 women; mean [standard deviation, SD], 48.5 [11.0] years) who underwent PSG and TCI-DISE were included. The mean (SD) apnea-hypopnea index (AHI) was 35.5 (22.4) events/h. Twenty-three patients had persistent complete concentric velopharyngeal collapse in the supine position, even with concurrent head rotation and OA (position 4). Their mean (SD) AHI was 54.7 (24.6) events/h, significantly higher than that of the 60 patients without such collapse in position 4 (p < .001). Their mean (SD) body mass index (BMI) was 29.0 (4.1) kg/m2 , also significantly higher (p = .005). After adjustment for age, BMI, tonsil size, and tongue position, the degree of velum and tongue base obstruction was significantly associated with sleep apnea severity in positions 2, 3, and 4. We showed the feasibility, safety, and usefulness of using simple edge-to-edge, reusable OA in DISE. Patients who are not responsive to head rotation and OA during TCI-DISE may need upper airway surgery and/or weight control.

Pivotal Role of Genetic Counselors in the Uptake of Germline Genetic Testing in Non-Metastatic Breast Cancer and the Impact of Testing on Surgical Decision Making.

Genetic testing is increasingly utilized in breast cancer patients; however, testing rates remain low. We aimed to evaluate the rate of genetic testing at a tertiary academic medical center utilizing a multidisciplinary clinic model including genetic counselor. A single-center retrospective chart review was performed on a cohort of newly diagnosed breast cancer patients from January 2018 through February 2019. Patients were reviewed for genetic screening eligibility, consultation with a genetic counselor, and test results. Final analysis included 426 patients. 261 (61.3%) were found to meet National Comprehensive Cancer Network guidelines for genetic testing, of which 178 patient (68.2%) underwent testing and 32 patients (12.3%) declined testing. Of the 165 not eligible for testing, 5 patients were tested. A total of 183 patients underwent testing and 116 (63.4%) had a negative result, 17 (9.3%) were positive for at least one gene mutation and 50 (27.3%) were identified to have a variant of unknown significance (VUS). There was a positive association between those patients who met with a genetic counselor and eligibility for testing (OR 31.1, 95% CI 16.0-60.5). Genetic testing result has become an increasingly important factor when defining optimal surgical treatment for breast cancer patients. Increasing the availability of genetic consultation for breast cancer patients can improve testing rates and patient selection.

Rates of Recurrent Marginal Ulcer in Gastric Bypass Patients Undergoing Revisional Surgery.

The rate of marginal ulcer (MU) following primary Roux-en-Y Gastric Bypass (RYGB) is approximately .6-16%. Few studies have evaluated recurrence rates following surgical revision for MU. The primary aim of this study was to determine the rate of MU recurrence following revision. The secondary aim was to evaluate the impact of truncal vagotomy (TV) on the recurrence rates and analyze potential risk factors associated with the recurrence of MU after revision. We conducted a retrospective cohort study examining data at a single tertiary academic medical center. Adult patients with a history of RYGB who underwent gastrojejunostomy revision for recurrent MU between the years of 2003-2020 were included. We sought to determine our overall rate of MU following revision, with and without TV. Additionally, we examined the association of risk factors with MU recurrence. Fisher's exact test was used to determine the statistical significance of recurrence rates between the groups. We included 90 patients in the study. The overall recurrence rate for MU was 16.7%. Of the 90 patients, 35 (35.4%) patients underwent TV at the time of revision. The recurrence rate of MU after GJ revision with TV was 14.3% in comparison to those without TV, 18.2% (P = .775). Smoking, steroid, alcohol use, history of cardiac surgery/intervention, and helicobacter pylori were not significantly associated with recurrent MU following revision. The rate of recurrence after revision for MU is high. Adding TV trended towards decreased MU recurrence after revisional surgery, however not significant. Larger studies are needed to evaluate risk factors associated with recurrent MU after revision.

Continuous IV infusion of anakinra.

Objective: A review of the use of continuous IV infusion of anakinra; a description of the protocol for continuous IV infusion of anakinra in the treatment of cytokine storm developed over the past 4years at a tertiary level academic medical center in the United States. Methods: We reviewed published reports of continuous IV infusion of anakinra in cytokine storm and summarize this method of treatment in other diseases. As well, over the past 4 years, continuous IV infusions of anakinra were administered at our tertiary level academic medical center in the United States (Regions Hospital, St. Paul, Minnesota) for approximately 400 patient days of treatment primarily for the cytokine storm associated with macrophage activation syndrome (MAS) in adults. This updated protocol is presented. While this a single center protocol, it may serve as an initial guide for further refinement of protocols in MAS and other conditions. Conclusion:Continuous IV infusion of anakinra has advantages over subcutaneous infusions and may be important in controlling severe life-threatening cytokine storm as seen in macrophage activation syndrome. This has the potential to be an important therapy for other syndromes including Cytokine Release Syndrome related to CAR T-cell therapy. Close collaboration between Rheumatology, Pharmacy and Nursing allows this treatment to be delivered rapidly and efficiently.

Association between community-level political affiliation and peripartum vaccination

Political affiliation has been associated with vaccine uptake, but whether this association holds in pregnancy, when individuals are recommended to receive multiple vaccinations, remains to be studied. This study aimed to examine the association between community-level political affiliation and vaccinations for tetanus, diphtheria, and pertussis; influenza; and COVID-19 in pregnant and postpartum individuals. A survey was conducted about tetanus, diphtheria, and pertussis and influenza vaccinations in early 2021, with a follow-up survey of COVID-19 vaccination among the same individuals at a tertiary care academic medical center in the Midwest. Geocoded residential addresses were linked at the census tract to the Environmental Systems Research Institute 2021 Market Potential Index, which ranks a community in comparison to the US national average. The exposure for this analysis was community-level political affiliation, defined by the Market Potential Index as very conservative, somewhat conservative, centrist, somewhat liberal, and very liberal (reference). The outcomes were self-reported vaccinations for tetanus, diphtheria, and pertussis; influenza; and COVID-19 in the peripartum period. Modified Poisson regression was used and adjusted for age, employment, trimester at assessment, and medical comorbidities. Of 438 assessed individuals, 37% lived in a community characterized by very liberal political affiliation, 11% as somewhat liberal, 18% as centrist, 12% as somewhat conservative, and 21% as very conservative. Overall, 72% and 58% of individuals reported receiving tetanus, diphtheria, and pertussis and influenza vaccinations, respectively. Of the 279 individuals who responded to the follow-up survey, 53% reported receiving COVID-19 vaccination. Individuals living in a community characterized by very conservative political affiliation were less likely to report vaccinations for tetanus, diphtheria, and pertussis (64% vs 72%; adjusted risk ratio, 0.83; 95% confidence interval, 0.69-0.99); influenza (49% vs 58%; adjusted risk ratio, 0.79; 95% confidence interval, 0.62-1.00); and COVID-19 (35% vs 53%; adjusted risk ratio, 0.65; 95% confidence interval, 0.44-0.96) than those in a community characterized by very liberal political affiliation. Individuals living in a community characterized by centrist political affiliation were less likely to report vaccinations for tetanus, diphtheria, and pertussis (63% vs 72%; adjusted risk ratio, 0.82; 95% confidence interval, 0.68-0.99) and influenza (44% vs 58%; adjusted risk ratio, 0.70; 95% confidence interval, 0.54-0.92) than those in a community characterized by very liberal political affiliation. Compared with pregnant and postpartum individuals living in communities characterized by very liberal political beliefs, those living in communities characterized by very conservative political beliefs were less likely to report vaccinations for tetanus, diphtheria, and pertussis; influenza; and COVID-19, and those in communities characterized by centrist political beliefs were less likely to report vaccinations for tetanus, diphtheria, and pertussis and influenza. Increasing vaccine uptake in the peripartum period may need to consider engaging an individual's broader sociopolitical milieu.

Germline Genetic Testing in Unselected Squamous and Non-Squamous Head and Neck Cancers.

This study describes the prevalence of pathogenic germline variants (PGVs) in head and neck cancer patients, the incremental yield compared to a guideline-based approach to genetic evaluation, and the uptake of family variant testing. Prospective cohort study. Three tertiary academic medical centers. Germline sequencing using an 84-gene screening platform among unselected head and neck cancer patients who received care at Mayo Clinic Cancer Centers between April 2018 and March 2020. Amongst 200 patients, the median age was 62.0 years (Q1, Q3: 55, 71), 23.0% were female, 89.0% white/non-Hispanic, 5.0% Hispanic/Latinx, 6% of another race, and 42.0% had prognostic stage IV disease. The most common subsites were the oropharyngeal (45.0%) and salivary glands (12.0%). The most common histology was squamous cell carcinoma (74.5%). Twenty-one patients (10.5%) had a total of 22 PGVs; 20 of the 21 patients (95.2%) did not meet criteria for testing by current guidelines. Regarding penetrance of the 22 PGVs, 11 were high or moderate (most common PMS2 or HOXB13), and 11 were low or recessive (most common MUTYH, WNR, or RECQL4). One patient had a change in care based on an identified PGV. Family variant testing was completed at a rate of 4.8%. Universal gene panel testing identified a PGV in 10.5% of head and neck cancer patients; almost all would have been missed by current guideline-based testing. One of 21 patients had a treatment change due to their PGV, indicating that head and neck cancer treatment decisions are not yet widely informed by germline alterations. 3 Laryngoscope, 133:3378-3388, 2023.

Difficult Airway Response Team (DART) and Airway Emergency Outcomes: A Retrospective Quality Improvement Study.

Difficult airways can be associated with significant morbidity and mortality, particularly in the event of a delay in securing the airway. To improve the airway metrics at our institution, we implemented a multidisciplinary team of airway providers to respond to difficult and emergent airways, or the Difficult Airway Response Team (DART). The purpose of the present study is to assess the feasibility of a DART program at a tertiary care center. A retrospective study evaluating the outcomes of emergent airway cases using the DART protocol. Single tertiary academic care center. In August 2019, a DART program was implemented at a tertiary academic medical center. In order to assess the feasibility and effectiveness of this system, data were collected to assess DART outcomes through chart review and surveys following each event, and analyzed in Microsoft Excel. A total of 161 DART events (average 4.6/month) took place from August 2019 to June 2022. Anesthesiologists secured the airway in 71 events (51%), otolaryngologists in 38 (27%), and pulmonary/critical care in 12 (9%). Seventy-three activations were not labeled as a difficult airway. Pre-DART, 19 cases required more than 3 attempts to secure the airway compared to 11 cases after DART. Transoral intubation was the most common intervention. Thirteen cases required surgical intervention. Implementing a multidisciplinary team-based approach for managing emergent difficult airways at a tertiary care institution was feasible and resulted in a decreased number of airway attempts in difficult airway patients. Continuous process improvement is essential for the ongoing enhancement of DART systems.

Auditory and Vestibular Symptom Improvement With Surgery for Superior Canal Dehiscence Syndrome.

(1) To measure the change in auditory and vestibular symptoms following superior canal dehiscence (SCD) surgery, and (2) to determine differences in clinical features and surgical outcomes between superior canal dehiscence syndrome (SCDS) patients with primarily auditory or vestibular complaints. Retrospective cohort study. Single surgeon series at the tertiary academic medical center from 2002 to 2021. Retrospective review of SCDS patients who underwent surgical repair. (1) Patients were administered a standardized symptom questionnaire at preoperative and follow-up visits, and results were compared with paired statistical testing. (2) Patients were divided into 2 cohorts based on either auditory or vestibular chief complaint and differences in demographic, clinical, and outcome variables were examined. Our study included 113 patients with 118 operated ears. Twenty-seven patients (24%) had radiographic bilateral dehiscence. 10/11 auditory symptoms (91%) and 5/8 vestibular symptoms (63%) solicited on the questionnaire improved significantly with surgery, except for nonpulsatile tinnitus, sense of imbalance, positional dizziness, and oscillopsia. Analyses stratified by chief complaint (auditory vs vestibular) revealed overall similar characteristics and surgical outcomes. Patients with chief vestibular complaints underwent surgery at an earlier age (45.5 vs 53.9 years, p < 0.05). SCD surgery alleviates a wide range of auditory and vestibular symptoms. Overall, we did not find significant differences between patients with chief auditory versus vestibular complaints, and both groups benefited from surgery. Symptoms are not directly linked to third-window physiology and certain vestibular symptoms may be more likely to persist. Bilateral dehiscence may play an important role in persistent symptoms as well.

Re-evaluating the Timing of Surgery after Isolated Orbital Floor Fracture

Background: Orbital floor fractures are among the most common facial injuries. Although urgent surgical repair may be indicated, most patients require interval follow-up to assess for symptom onset and need for definitive operative intervention. This study aimed to evaluate the time to operative indication after these injuries. Methods: A retrospective review was conducted of all patients with isolated orbital floor fractures at a tertiary academic medical center from June 2015 to April 2019. Patient demographic and clinical data were recorded from the medical record. Time until operative indication was evaluated by the Kaplan-Meier product limit method. Results: Of 307 patients meeting inclusion criteria, 9.8% (30/307) developed indications for repair. Among these, 60% (18/30) were recommended surgery on the day of initial evaluation. Of 137 follow-up patients, 8.8% (12/137) developed operative indications based on clinical evaluation. The median period to decision for surgery was 5 days (range, 1–9). No patients developed symptoms suggesting the need for surgery beyond 9 days after trauma. Conclusions: Our investigation demonstrates that only about 10% of patients presenting with isolated orbital floor fracture develop an indication for surgery. For patients undergoing interval clinical follow-up, we found that patients demonstrated symptoms within 9 days of trauma. No patients demonstrated need for surgery beyond 2 weeks of injury. We believe these findings will assist to establish standards of care and inform clinicians on the appropriate length of follow-up for these injuries.

Neurocheck Frequency: Determining Perceptions and Barriers to Implementation of Evidence-Based Practice.

Following acute brain injury, patients in the intensive care unit often undergo hourly or every-other-hour exams ("neurochecks") to monitor for neurodeterioration. We assessed health care provider attitudes towards neurocheck frequency and evaluated providers' ideal neurocheck frequency. This was a cross-sectional, online survey distributed in Spring 2021 at a tertiary care academic medical center. Providers from multiple intensive care unit and neuroscience clinical specialties including attending faculty, medical trainees, advanced practice providers, and bedside nurses were invited to participate. Among 177 participants, 61 (34%) and 116 (66%) were self-identified as ordering and performing providers, respectively. The survey response rate was 58% among physicians and 51% among bedside nurses with neurological expertise. The most common medical and non-medical reasons for ordering hourly neurochecks were "a specific diagnosis with anticipated course" and "standard of care", respectively. Compared with ordering providers, performing providers felt guidelines regarding neurocheck frequency (P<0.01) and duration (P<0.01) should be proscriptive. Conversely, ordering providers felt hourly neurochecks were detrimental to patients with acute brain injury (P=0.02) and believed they would not utilize hourly neurochecks if there was another mode of monitoring available (P=0.03). Performing providers identified multiple patient-related factors impacting the difficulty of and their willingness to perform frequent neurochecks, and only 70% of neurochecks were perceived to be performed as ordered. Both ordering and performing providers preferred every-other-hour neurochecks following acute brain injury. This survey revealed clinically relevant differences in ordering versus performing provider attitudes about frequent neurochecks. Providers preferred every-other-hour rather than hourly neurochecks.

Validation of an Automated Symptom-Based Triage Tool in Ophthalmology.

Acute care ophthalmic clinics often suffer from inefficient triage, leading to suboptimal patient access and resource utilization. This study reports the preliminary results of a novel, symptom-based, patient-directed, online triage tool developed to address the most common acute ophthalmic diagnoses and associated presenting symptoms. A retrospective chart review of patients who presented to a tertiary academic medical center's urgent eye clinic after being referred for an urgent, semi-urgent, or nonurgent visit by the ophthalmic triage tool between January 1, 2021 and January 1, 2022 was performed. Concordance between triage category and severity of diagnosis on the subsequent clinic visit was assessed. The online triage tool was utilized 1,370 and 95 times, by the call center administrators (phone triage group) and patients directly (web triage group), respectively. Of all patients triaged with the tool, 8.50% were deemed urgent, 59.2% semi-urgent, and 32.3% nonurgent. At the subsequent clinic visit, the history of present illness had significant agreement with symptoms reported to the triage tool (99.3% agreement, weighted kappa = 0.980, p < 0.001). The triage algorithm also had significant agreement with the severity of the physician diagnosis (97.0% agreement, weighted kappa = 0.912, p < 0.001). Zero patients were found to have a diagnosis on exam that should have corresponded to a higher urgency level on the triage tool. The automated ophthalmic triage algorithm was able to safely and effectively triage patients based on symptoms. Future work should focus on the utility of this tool to reduce nonurgent patient load in urgent clinical settings and to improve access for patients who require urgent medical care.

Total Tau Level in Cerebrospinal Fluid as a Predictor of Survival in Creutzfeldt-Jakob Disease: A Retrospective Analysis.

Creutzfeldt-Jakob disease (CJD) is a rapidly progressive and universally fatal neurodegenerative disorder with highly variable survival times, ranging from weeks to years. However, there are currently no tools for prognosticating a patient's survival time. This study aims to fill this gap by examining the relationship between CSF total tau (t-tau) levels and time to death in patients with CJD. We use cases with CJD recorded in the electronic health record of a tertiary academic medical center from 2010 to 2022. We identified 29 cases with diagnosis of CJD. Using a Cox proportional hazards model, we find that elevated t-tau levels (>4,000 pg/mL) are associated with 9.62 (95% confidence interval: 1.93-47.92) times the hazard of death compared with CJD patients with t-tau less than 4,000 pg/mL. This finding supports the use of CSF t-tau as a prognostic biomarker for CJD.

A Multi-Institutional Experience Utilizing Boari Flap in Robotic Urinary Reconstruction.

Objectives: There is presently scarce literature describing the outcomes of patients undergoing robotic ureteral reconstruction (RUR) using the Boari flap (BF) technique. Herein, we report our prospective, multi-institutional experience using BF in patients undergoing robotic urinary reconstruction. Patients and Methods: We reviewed our prospective, multicenter database for all patients undergoing RUR between September 2013 and September 2021 in which a BF was utilized. Preoperative, perioperative, and follow-up data were collected and analyzed. Major complications were defined as a Clavien-Dindo classification grade >2. Surgical failure was defined as recurrent symptoms, obstruction on imaging, or the need for additional surgical interventions. Results: We identified 50 patients who underwent RUR using a BF. Four (8%) underwent the Single Port approach. Twenty-four patients (48%) were active or former tobacco users. Thirty-four patients (68%) had previously undergone abdominal surgery, 17 (34%) had prior ureteral stricture interventions, and 9 (18%) had prior abdominopelvic radiation. The most common stricture etiology was malignancy (34.4%). The median follow-up was 15.0 months with a 90% (45/50) success rate. The five documented cases of failure occurred at a median of 1.8 months following the procedure. Conclusion: In the largest prospective, multi-institutional study of patients undergoing RUR with BF in the literature to date, we demonstrate a low rate of complications and a high rate of surgical success in three tertiary academic medical centers. All observed failures occurred within 2 months of surgical intervention.

D77. In-fracture and Out-fracture: Novel Conceptions of Nasoorbitoethmoid Injury

PURPOSE: Nasoorbitoethmoid (NOE) fractures are commonly categorized by the Markowitz-Manson classification system, which grades severity of injury by degree of comminution and involvement of the medial canthal tendon. However, this system does not account for directionality of bony injury, which may impact clinical findings. We propose these fractures may be conceived as either in-fractured, resulting in nasal airway obstruction, or out-fractured, resulting in traumatic telecanthus. METHODS: A retrospective review was conducted of all patients with NOE fractures referred to plastic surgery at a tertiary academic medical center from 2017—2022. Radiographic data (CT) were evaluated to assess for directionality of NOE segment involvement. Frequencies of in-fracture and out-fracture across NOE type were compared by chi-squared test. RESULTS: Among 57 adults, 73 NOE fractures were identified with 39.7% (29) as Type 0 (non-displaced), 43.8% (32) as Type I, 12.3% (9) as Type II, and 4.1% (3) as Type III. Type I fractures were significantly associated with in-fracture (p < 0.0001), whereas Type III fractures were more likely out-fractured (p = 0.02). Type II fractures were not significantly associated with either presentation (p = 0.32). CONCLUSION: We discover that Type I NOE fractures more frequently present with in-fracture, whereas comminuted injuries such as Type III are typically out-fractured. Further study will validate these findings in a larger cohort and correlate radiography with clinical symptoms.

Transition-of-care program from emergency department to gastroenterology clinics improves follow-up

ObjectivesPatients discharged from the emergency department (ED) with gastrointestinal (GI) symptoms need to appropriately transition their care to a GI outpatient clinic in a timely manner to have their health needs met and avoid significant morbidity. When this transition isn't optimal, patients are lost to follow-up, potentially placing them at risk for adverse events. We sought to study the effectiveness of implementing an electronic medical record (EMR) based transition-of-care (TOC) program from the ED to outpatient GI clinics. MethodsWe performed a retrospective single center cohort study of patients discharged from the ED of a tertiary care academic medical center referred to outpatient GI clinic before (Pre-TOC patients) and after implementation of an EMR based TOC program (TOC patients). We further stratified patients based on the Distressed Communities Index (DCI), which is a composite measure of economic well-being. We compared rates of appointment scheduling and appointment attendance between the two groups, as well as 30-day readmission rates to the ED. We also performed a subgroup analysis to determine if socioeconomic status would affect patient follow-up rates. ResultsWe included 380 Pre-TOC and 399 TOC patients in our analysis. TOC patients were found to both schedule appointments (50% vs 27% p-value <0.01) as well as show up to appointments (34% vs 24% p-value <0.01) at significantly higher rates compared to Pre-TOC patients. There was no significant difference between 30-day readmission rates between the two groups. In addition, TOC patients from At-Risk and Distressed Communities were over 22 times more likely to schedule an appointment compared to Pre-TOC patients from similar neighborhoods (OR 22.18, 95% CI 4.23–116.32). ConclusionOur study shows that patients who are discharged from the ED with outpatient GI follow-up are more likely to both schedule and show up to appointments with implementation of an EMR-based direct referral program compared to no patient navigation, particularly among patients of lower socioeconomic status.

Integration of palliative care consultation into the management of patients with chronic limb-threatening ischemia

ObjectiveWe assessed the feasibility of integrating palliative care consultation into the routine management of patients with chronic limb-threatening ischemia (CLTI). Additionally, we sought to describe patient-reported outcomes from the palliative care and vascular literature in patients with CLTI receiving a palliative care consultation at our institution. MethodsThis was a single-institution, prospective, observational study that aimed to assess feasibility of incorporating palliative care consultation into the management of patients admitted to our tertiary academic medical center with CLTI by looking at utilization of palliative care before and after implementation of a protocol-based palliative care referral system. A survey comprised of patient-reported outcomes from the palliative care literature was administered to patients before and after palliative consultation. Length of stay and mortality were compared between our study cohort and a historic cohort of patients admitted with CLTI. ResultsOver a 14-month enrollment period, 44% of patients (n = 39) with CLTI (rest pain, 36%; tissue loss, 64%) admitted to the vascular service received palliative care consultation, compared with 5% of patients (n = 4) who would have met criteria over the preceding 14 months before our protocol was instituted. The mean age was 69 years, 23% were female, 92% were white, and 49% were able to ambulate independently. Revascularization included bypass (46%), peripheral vascular intervention (23%), and femoral endarterectomy (21%). Additional procedures included minor amputation or wound debridement (26%) and major amputation (15%). No patients received medical management alone. After receiving palliative care consultation, patients reported experiencing less emotional distress than before consultation (P = .03). They also reported being less bothered by uncertainty regarding what to expect from the course of their illness (P = .002). Fewer patients reported being unsure of the purpose of their medical care after palliative care consultation (8%) vs before (18%), although this was not statistically significant (P = .10). Median length of stay was longer in the study group compared with the historic cohort (8 vs 7 days; P = .02). There was no difference in 30-day mortality (3% vs 8%; P = .42) between the study group and the historic cohort (n = 77). ConclusionsIntegrating inpatient palliative care consultation into the routine management of patients with CLTI is feasible and may improve emotional domains of health-related quality of life. This study laid the foundation for future studies on longer term outcomes of patients with CLTI undergoing palliative care consultation as well as the benefit of outpatient palliative care consultation in patients with CLTI.