Tertiary Care Academic Center Research Articles

Survey on the Perceptions of Pregnancy and Parenthood in Trainees: Advances, Obstacles, and Growth Opportunities

IntroductionDespite national policy changes, perspective changes on pregnancy and parenting in training are often lacking. We evaluated current viewpoints regarding pregnancy, parenthood, leave needs, and perceptions of support across trainees at our institution. MethodsA cross-sectional survey was sent to all residents and fellows at a tertiary care academic center with >700 trainees. Demographic information, opinions on maternity and paternity leave, and opinions on institutional support and career goals were collected. The survey was sent via the Graduate Medical Education Office listserv -- 66 Accreditation Council for Graduate Medical Education (ACGME) programs and 40 non-ACGME programs. ResultsSeven hundred and forty-seven house officers received the survey with a response rate of 21.9% (n = 164). Of respondents, 81% were residents and 99 respondents were female (representing 31% of female trainees at our institution). Thirty-seven point two percent of respondents reported being parents. Twenty-five point three percent of respondents had been pregnant while a trainee with no statistical difference by specialty type (P = 0.0817). Statistically significant difference was noted in having children based on sex with men becoming parents at twice the rate of women (56% vs 26%, P < 0.001). No difference was noted between specialties on perceived support while pregnant and peripartum. Thirty percent of parent respondents reported thinking about leaving medical training after having children given family stressors. Statistical difference in thoughts of leaving medicine overall between females (46%) and males (17.6%; P = 0.0238). ConclusionsMen and women need support as they navigate becoming parents at a naturally stressful transition period. Females consider leaving medicine at twice the rate of males after becoming parents. Our institution and other ACGME programs need greater transparency and consistent leave practices that reflect changing times.

Only as Strong as the Weakest Link: Resident Perspectives on Entrustable Professional Activities and Their Impact on Learning.

Background Core to competency-based medical education (CBME) is the use of frequent low-stakes workplace-based assessments. In the Canadian context, these observations of performance are framed around entrustable professional activities (EPAs). Objective We aimed to explore residents' real-world perspectives of EPAs and their perceived impact on learning, because assessments perceived to be "inauthentic," or not truly reflective of their lived experiences, may interfere with learning. Methods Using constructivist grounded theory, we conducted 18 semistructured interviews in 2021 with residents from all programs that had implemented CBME at one tertiary care academic center in Canada. Participants were recruited via email through respective program administrators. Data collection and analysis occurred iteratively, and categories were identified using constant comparative analysis. Results Residents were strikingly polarized, perceiving EPAs as either a valuable opportunity for professional growth or as an onerous requirement that interfered with learning. Regardless of what view participants held, all perspectives were informed by: (1) the program administration and the perceived messaging from program to residents; (2) faculty assessors and their perceived degree of engagement, or "buy-in" with the EPA system; and ultimately (3) learner behavior. We theorized from these findings that all 3 aspects must be working in tandem for the assessment system to function as intended. Conclusions From the learners' perspective, there exists a dynamic, interdependent relationship between the 3 CBME stakeholders. As such, the perceived value of the EPA assessment system can only be as strong as the weakest link in the chain.

Trial in Progress: Patient-Reported Outcome Measures in the Prospective Observational Cohort Study of Patients at Risk for Chronic Graft-Versus-Host Disease in the United States (THRIVE)

Background and Significance: Allogeneic hematopoietic cell transplantation (alloHCT) is a curative immunotherapy for patients with hematologic disorders. However, graft-versus-host-disease (GVHD) is a major limitation to the success of alloHCT, with chronic GVHD (cGVHD) as the leading cause of morbidity and mortality. The pleomorphic nature of cGVHD makes the diagnosis and patient management challenging for clinicians; thus, patient-reported symptoms often guide in diagnosing and determining the severity of cGVHD. Our current understanding of cGVHD is largely based on data from registries, single-institution prospective studies, and the cGVHD Consortium with representation from tertiary care academic centers. Prospective studies including patient-reported outcomes and a focus on a more representative and generalizable sample of patients with cGVHD are needed to better understand cGVHD symptoms, disease burden, and practice patterns for management. This trial in progress focuses on broad patient-centered assessment of post-alloHCT medical and psychosocial complications and patient-reported caregiver involvement in a diverse and contemporary patient population. This study uses multiple organ- or system-directed patient-reported outcome measures (PROMs) to help identify cGVHD symptoms, severity, and impact on patient quality of life including financial impact. The primary objective of THRIVE is to assess the clinical course and burden of cGVHD, including diagnosis and severity recorded in electronic case report forms (eCRFs) and PROMs. Secondary objectives include measuring healthcare resource utilization and patient economic and employment impact associated with cGVHD management, as well as patient-reported organ-specific symptoms. Study Design and Methods: THRIVE is a prospective, longitudinal, observational study (NCT05919511) of alloHCT recipients in the United States that uses a hybrid model designed to work with HCT centers and a virtual platform. Eligible patients are ≥18 years old, received alloHCT 90-180 days before enrollment, and are able to complete patient-assessment questionnaires provided in their preferred language either alone or with minimal caregiver assistance. Up to 1500 alloHCT recipients will be recruited at HCT sites (with the expectation that ~500 will have cGVHD symptoms at enrollment; ~500 are estimated to develop cGVHD during the course of the study; ~500 are estimated not to develop cGVHD during the study; Figure). Patients have the option to participate on a virtual platform. Patients will be followed for 36 months from date of enrollment or until the earliest of study termination, withdrawal, or death. Data from 13 PROMs (Table) divided into 3 groups will be collected every 3 months using a decentralized virtual platform. To reduce survey burden, patients will be randomized into 1 of 6 sequence groups to capture 4-5 PROMs per month in year 1 and every 2 months in years 2 and 3. Clinical data, including medications and adverse events, will be collected and abstracted into eCRFs every 3 months. In general, reporting of results will be descriptive for variables of interest. Summary statistics for continuous variables and for categorical variables will be calculated for all patients as well as for subgroups of interest. Whenever applicable, 95% confidence intervals will be calculated for endpoint estimates. Univariate, multivariate, or repeated-measurement analyses will be performed to assess factors associated with evolution of clinical manifestations of and complications from cGVHD. Recruitment for this study is ongoing.

Coping in Patients with Hematologic Malignancies Undergoing Hematopoietic Cell Transplantation

Background Patients undergoing hematopoietic cell transplantation (HCT) must cope with immense physical and psychological symptoms during HCT hospitalization, which contribute to a dramatic deterioration in quality of life (QOL). Yet, studies examining pre-HCT coping strategies are limited. We aimed to characterize use of pre-HCT coping strategies, to identify sociodemographic and clinical factors associated with coping strategy use, and to investigate the association of coping strategy use with pre-HCT QOL and psychological distress. Methods We conducted a secondary analysis of baseline data from a multi-site randomized controlled trial evaluating a supportive care intervention for patients with hematologic malignancies undergoing allogeneic or autologous HCT (NCT#03641378). From 10/2018 - 07/2022, the trial enrolled consecutive adults (age ≥ 18) with hematologic cancers undergoing HCT at three tertiary care academic centers. Prior to HCT, we assessed QOL (Functional Assessment of Cancer Therapy - Bone Marrow Transplant), psychological symptoms (Hospital Anxiety and Depression Scale and Post Traumatic Stress Disorder (PTSD) - Civilian Version), and coping (Brief COPE). We categorized coping as either “approach-oriented” (active coping, use of emotional support, positive reframing, acceptance) or “avoidant” (behavioral disengagement, denial, and self-blame). We used the median split method to categorize high and low use of approach-oriented and avoidant coping. Univariate logistic regression was used to identify sociodemographic and clinical factors associated with high use of coping strategies. Multivariate linear regression was used to measure associations of coping strategy use with QOL and psychological distress. Results Of pre-HCT patients (n=360), the majority were male (62.8%), identified as White (77.5%), were younger than 65 (73.6%), and had received at least some college education (78.9%). A minority were unemployed due to disability from illness (29.2%). Approximately half received autologous HCT (n=178, 49.4%). Figure 1 displays the proportion of patients scoring as high utilizers of individual coping strategies. While 31.3% were high utilizers of avoidant coping, 43.5% were high utilizers of approach-oriented coping. Notably, 43 (11.9%) patients identified as high utilizers of both approach-oriented and avoidant coping. No sociodemographic or clinical factors were associated with use of approach-oriented coping. Older age (&amp;gt;65 years, OR=0.9, p=0.01) and higher income (&amp;gt;$100K, OR=0.90, p=0.04) were associated with less frequent use of avoidant coping. Female gender (OR=1.11, p=0.03) and disabled employment status (OR=1.11, p=0.05) were associated with increased likelihood of high use of avoidant coping. Table 1 displays adjusted associations between approach-oriented and avoidant coping strategies and patient-reported outcomes. High use of approach-oriented coping was associated with better pre-HCT QOL (B=6.4, p&amp;lt;0.001) and lower depression (B=-1.1, p=0.001) and anxiety (B=-0.9, p=0.02) symptoms. High use of avoidant coping was associated with worse pre-HCT QOL (B=-11.7, p&amp;lt;0.001) and symptoms of depression (B=1.9, p&amp;lt;0.001), anxiety (B=3.1, p&amp;lt;0.001), and PTSD (B=8.1, p&amp;lt;0.001). Conclusions Prior to HCT, patients frequently employ approach-oriented and avoidant coping strategies. Key sociodemographic factors including age, gender, income level, and employment status were associated with avoidant coping. Patients with high use of approach-oriented coping reported higher baseline QOL and lower psychological distress, while those with high use of avoidant coping strategies reported worse QOL and psychological distress. These data suggest that supportive care interventions which enhance approach-oriented coping and mitigate avoidant coping in pre-HCT populations may improve QOL and reduce psychological distress

Obstetrical Use of Intravenous Immunoglobulin at a Tertiary Care Canadian Center: A 14-Year Retrospective Study

Introduction: Intravenous immunoglobulin (IVIG) has gained widespread acceptance for the treatment of various medical conditions. However, its availability is limited, it incurs substantial costs, and reports of shortages have raised concerns regarding patient access. Additionally, adverse events with IVIG use underscore the need for prudent administration. While IVIG is approved for specific indications, its off-label use remains significant. Prior studies have addressed the general use of IVIG use and called for measures to ensure its appropriate application, research specific to the obstetrical use of IVIG is lacking. Understanding how IVIG is used in pregnancy could guide future research endeavours and shape policies aimed at optimizing patient care, minimizing unwarranted exposure, and containing healthcare costs. The objectives of this study are three-fold: (1) to assess the frequency, volume, and indications of IVIG use in pregnancy, (2) to assess the congruent use of IVIG with the approved Canadian indications and the approved conditions by the Ontario Immunoglobulin Utilization Management Guidelines, and (3) to compare the volume of IVIG used in pregnancy to the total volumes of IVIG use. Methods: This retrospective cohort study used administrative data and chart reviews to analyze all pregnant individuals between 2007 and 2020 who received IVIG during their pregnancy and delivered at a large tertiary care academic center with high-risk obstetrical care in Ontario, Canada. Data were collected on IVIG volumes, administration regimens, indications, and timing of administration during pregnancy. A descriptive analysis was performed to present the findings. Results: The study cohort comprised 122 pregnant patients, accounting for 136 deliveries. The cumulative volume of IVIG used across all obstetrical patients amounted to 41,107.50 grams, representing 1.6% of the total consumption of IVIG (2,575,766.50 grams) at our center. Among the indications for IVIG administration during pregnancy (Table 1), the most prevalent were maternal thrombocytopenia (77/136 deliveries, 56.6%) and antenatal therapy for Fetal/Neonatal Alloimmune Thrombocytopenia (F/NAIT) (22/136 deliveries, 16.2%). The highest IVIG consumption was observed in F/NAIT, with a total of 26,435 grams (64.3%) used in all pregnancies and a median of 1015 grams per pregnancy (IQR = 542.5, 1938.75). Maternal thrombocytopenia followed, accounting for a total of 6,952.50 grams (16.9%) used in all pregnancies and a median of 70 grams per pregnancy (IQR = 40, 90). We observed an overall increase in the trend of IVIG use in pregnancy and average volumes per delivery, but this remains a small proportion of total IVIG use (Figure 1). In terms of congruent use of IVIG, 38.2% of deliveries (52/136) did not meet the Canadian licensed indications for IVIG use, accounting for a large amount (33,025 grams, 80.3% of total volume used). However, 17.6% of deliveries (24 out of 136) did not adhere to the Ontario guidelines' indications for IVIG use, which constituted a total of 5,475 grams (13% of total volume used). Conclusions: The obstetrical use of IVIG represents a minor proportion of the total volume used at a large Canadian tertiary care center. Hematologic conditions, particularly F/NAIT and maternal thrombocytopenia, are the predominant drivers of IVIG administration during pregnancy. Recent reports on IVIG use in the general population demonstrated similarly high prescribing patterns of IVIG among hematologists, but also neurologists. Rational prescribing and dose minimization are important strategies to improve judicious and cost-effective use of IVIG. However, implementation of such strategies for obstetrical use of IVIG may be limited as evidence generally stems from small, retrospective, observational studies, and reaching a consensus among various specialists may sometimes prove difficult. There is a pressing need for prospective multicenter studies in pregnant individuals, particularly for conditions with high IVIG consumption. These studies would help to examine the efficacy and safety of IVIG during pregnancy and provide essential guidance for appropriate IVIG use in this unique patient population.

Neuraxial Analgesia in Pregnant Individuals with Bleeding Disorders: A Comprehensive Examination of Obstetric Anesthesia Practices and Outcomes

Introduction: Neuraxial analgesia in obstetric anesthesia offers multiple advantages when compared with general anesthesia, including better pain relief and patient satisfaction, reduced opioid-related side effects, and decreased maternal morbidity and mortality. However, neuraxial analgesia carries a risk of hematoma, which can lead to permanent neurological complications, and is considered contraindicated in patients with uncorrected bleeding disorders. Hemostatic thresholds for safe neuraxial analgesia remain undetermined. Current evidence for neuraxial analgesia in pregnant individuals with bleeding disorders is limited to a few case reports or small case series, leaving significant gaps in clinical practices based on expert opinions. We sought to examine obstetric analgesia practices and outcomes in pregnant individuals with bleeding disorders. Specifically, we aimed to determine the methods used at the time of labor and delivery, the concordance with antenatal recommendations, and the outcomes in relation to the bleeding disorder, hemostatic thresholds, and hemostatic therapy support. Methods: A retrospective cohort study was conducted on all pregnant individuals with bleeding disorders who delivered between 2010-2020 at our institution, a large tertiary academic care center with high-risk obstetrical care in Ontario, Canada. We collected data on patient and disease characteristics, delivery mode, hemostatic laboratory values, hemostatic support, obstetric analgesia method, antenatal anesthesia and hematology recommendations, and post-procedure outcomes. A descriptive analysis was performed to present the findings. Results: The study cohort comprised of 56 pregnant patients, resulting in 82 deliveries. The median maternal age was 31.5 years (interquartile range (IQR): 28-34), and the median gestational age was 39 weeks (IQR: 38-40). Most patients delivered vaginally (60/82, 73.2%). von Willebrand disease type 1 (VWD-1) (28/82, 34.1%) and hemophilia A (24/82, 29.3%) were the most prevalent bleeding disorders. Neuraxial analgesia was used in most deliveries (59/82, 72.0%), followed by opioids (25/82, 30.5%), and nitrous oxide (15/82, 18.3%). Antenatal neuraxial anesthesia recommendations were documented by anesthesiology in 59.8% (50/82) and by hematology in 82.9% (68/82) of deliveries. The concordance rate between the two specialties was high at 95.7%. In two cases with discordant recommendations, neuraxial anesthesia was performed without hemostatic therapy, and no adverse events were reported. A diagnosis of bleeding disorder was established prior to the pregnancy in 79 deliveries (96.3%). Three patients were diagnosed after pregnancy: one with VWD-1 and baseline von Willebrand factor (VWF) activity at 0.34 IU/mL, one with VWD-1 and baseline VWF activity at 0.44 IU/mL, and one with Factor XIII deficiency and baseline levels at 0.42 IU/mL. They had neuraxial anesthesia administered without bleeding complications. Hemostasis laboratory values in the third trimester were considered adequate for neuraxial analgesia in 68.4% (54/79) of deliveries. Those who did not reach adequate levels received hemostatic therapy support prior to neuraxial analgesia, except for three patients (one with VWD-1 with VWF activity &amp;lt; 0.50 IU/mL, one with VWD type 2 with VWF activity &amp;lt; 0.50 IU/mL, one with factor XI deficiency and levels &amp;lt; 0.40 IU/mL) who fortunately did not develop post-procedural hematomas. We observed no bleeding events following neuraxial analgesia, but there were two adverse events (pain at epidural site) necessitating emergency room visits. Conclusions: Our study represents the largest cohort of pregnant individuals with bleeding disorders receiving neuraxial anesthesia and provides evidence supporting the safe administration of neuraxial analgesia, with high level of adherence to antenatal recommendations. In most cases, hemostatic laboratory values were deemed adequate, obviating the need for additional hemostatic therapy support. These findings contribute to our understanding of obstetric anesthesia practices in this population, thereby facilitating the provision of safe and effective analgesia during labor and delivery. Future prospective and multicenter studies focusing on the obstetrical management of pregnant persons with bleeding disorders, with specific emphasis on neuraxial analgesia, are warranted.

1869. Knowledge about and Perceptions of Latent Tuberculosis Infection (LTBI) among Physicians and Advanced Practice Providers at Tufts Medical Center

Abstract Background Mycobacterium Tuberculosis (TB) is a leading cause of infectious disease mortality worldwide. Most active TB cases result from reactivation of latent tuberculosis infection (LTBI). A large reservoir of latent TB is a major public health problem worldwide and in the United States. A better understanding of provider perspectives on LTBI could improve a sub-optimal LTBI care cascade. Methods A 13-question survey was fielded to attending physicians, fellows, and advanced practice providers working in the infectious disease, pulmonary/critical care, and general medicine departments at Tufts Medical Center (TMC), an academic tertiary care center in Boston, Massachusetts. Results The response rate of the survey was 33% (62/186). Only 17 (30.9%) providers were able to correctly identify all indications for screening. When asked how they decide who to treat, 26.8% (15/56) of providers selected that they would refer their patient to another specialist. Overall, provider confidence in LTBI management decreased along the care cascade (Figure 1). Infectious disease providers expressed more confidence in management than general medicine and pulmonary/critical care providers. The two most observed issues/barriers to care for patients were language, reported by 39 (76.5%) providers, and lack of knowledge or understanding about TB, reported by 39 (76.5%) providers. The two most selected interventions to improve LTBI care at TMC were use of in-person language interpreters, chosen by 37 (71.2%) providers, and information pamphlets available in patients’ preferred languages, chosen by 36 (69.2%) providers. Providers were asked “On a scale of 1-5, (“1” = not at all, and “5” = perfectly) “How confident are you in your ability to do the following” for the listed management tasks. Conclusion Results suggest that providers believe the largest barriers to patient LTBI treatment completion are due to a lack of patient comprehension about their infection. Improving patient understanding could be accomplished through in-person interpreters, information pamphlets about LTBI in patients’ preferred languages, and forming community partnerships to improve awareness and understanding of the risks of LTBI. Additionally, ensuring that providers feel confident in their ability to manage LTBI, are updated on screening guidelines, and have referral resources when needed, could help close the gaps in the LTBI care cascade. Disclosures All Authors: No reported disclosures

2437. The Impact of Healthcare Associated Infections on Costs and Lengths of Stay 2019-2023

Abstract Background As 85% of hospitals in the U.S. face unsustainable operating margins, extraordinary labor costs (LC) from nursing shortages, and have under resourced infection prevention departments, updated assessments of the costs of healthcare associated infections (HAI) are needed. However, most published cost analyses are either more than a decade old, or did not adjust for timing of infection. We sought to determine excess lengths of stay (LOS) and LC associated with HAI during the COVID-19 era, while adjusting for timing of infection. Timing of Infection Onset In Patients with an HAI Legend: dark orange = days before infection; light orange = days after infection; yellow bar = geometric mean national average length of stay of uninfected patients with the same diagnosis code; green circle = mean length of stay of local uninfected controls Methods All inpatients in an academic tertiary care center and 4 community hospitals in Western NY from 01-01-19 to 12-31-22 were included. Using nationally standardized definitions of catheter-associated urinary tract (CAUTI), central line associated bloodstream (CLABSI), and surgical site infections (SSI), 728 HAIs were identified and compared to patients during the same encounter with the same diagnosis codes (DRG) without an HAI (n= 90,046). Only days after infection onset were used to calculate excess LOS and cost. Results The mean yearly standardized infection ratios (SIRs), as defined by the National Healthcare Safety Network, were 0.89, 0.98, and 1.14 for CLABSI, CAUTI and SSI, respectively. Patients with an HAI had significantly higher LC and longer post-infection LOS (all p-values &amp;lt; 0.005) compared to a national benchmark and their DRG-matched HAI-negative counterparts. Per admission, the average excess labor cost and excess LOS were $43,975, 13.4 days for CLABSI; $31,253, 8.9 days for CAUTI; and $5,985, 1.4 days for SSI (Table). The 4-year total was $23.4 M, and 4810 excess days. 100% of CLABSI and CAUTI occurred after the 13th day, and the pre and post-infection LOS were similar. SSI occurred early in admission, and the post-infection LOS was longer than the pre-infection LOS (Figure). Re-admission occurred for 83% of SSI. For CLABSI and CAUTI excess LOS and costs increased 178% over the study period. Conclusion These findings suggest that for CLABSI and CAUTI, minimizing pre-infection LOS can provide a greater economic and safety impact than focusing entirely on preventing the infection. However, for SSI, focusing on preventing the infection may provide the greatest benefit. Other hospitals can adjust these data based on their individual SIRs. Disclosures All Authors: No reported disclosures

Big Data Analysis of Inflammatory Conditions Associated With Optic Neuritis.

Previous studies in the United States established multiple sclerosis (MS) as the most common cause of optic neuritis (ON). ON can be associated with other systemic inflammatory conditions including sarcoidosis, neuromyelitis optica spectrum disorder (NMOSD), myelin oligodendrocyte glycoprotein antibody-associated disease (MOGAD), and lupus; however, prospective studies to establish risk of ON associated with these diseases are lacking. Furthermore, appropriate workup for ON is still debated. A deidentified electronic medical record of a tertiary care academic center was searched for ON and rheumatologic/neuro-inflammatory diseases in the medical history, diagnoses, and laboratory results; followed by the intersection of ON with each condition. We calculated frequency of systemic conditions among patients with ON and prevalence of ON in those conditions. We also calculated relative risk (RR) of underlying systemic conditions among patients with ON compared with the study patient population. In 6.7 million charts, 5,344 cases of ON were identified. Among those, MS occurred most commonly (20.6%), followed by NMOSD (10.5%). Conversely, ON occurred in 98.4% of NMOSD cases, 53.3% of MOGAD, and 10.0% of MS. NMOSD (RR = 1,233), MOGAD (RR = 688), and MS (RR = 126) had the highest RR among the conditions we evaluated. The subset analysis showed similar findings. The high RR for ON among patients with NMOSD and MOGAD suggests that clinical suspicion for ON should be high among patients with these conditions presenting with vision changes. Conversely, MS and NMOSD should initially be high on the differential diagnosis for any patient presenting with optic neuritis.

Nanoparticle Concentration in Surgical Plume During Tonsillectomy: A Comparison of Four Techniques.

Surgical plume has known potential occupational health hazards. This study compares nanoparticle concentrations in surgical plumes generated between different pediatric tonsillectomy surgical techniques and assesses the efficacy of mitigation measures. This is a cross-sectional study performed at a tertiary care academic center. Extracapsular or intracapsular tonsillectomy was performed in 60 patients using four techniques and in 10 additional patients using mitigation measures. Two nanoparticle counters were used to measure particulate concentrations: CPC™ and DiSCmini™. Tonsillectomy techniques included: (1) microdebrider (MD), (2) Bovie with manual suctioning by an assistant (B), (3) Bovie with built-in smoke evacuation system (BS), and (4) Coblator™ (CB). An additional Yankauer suction was used in the mitigation groups (BSY) and (CBY). Comparative analysis was performed using one-way ANOVA on ranks and pairwise comparisons between the groups. The mean concentrations (particles/cm3) and coefficient of variants for the DiSCmini particulate counter were MD: 5140 (1.6), B: 30700 (1.5), BS: 25001 (0.8), CB: 54814 (1.7), CBY: 2395 (1.3) and BSY: 11552 (1.0). Mean concentrations for the CPC particulate counter were MD: 1223 (1.4), B: 3405 (0.7), BS: 5002 (0.9), CB: 13273 (1.0), CBY: 1048 (1.2) and BSY: 3046 (0.6). The lowest mean concentrations were noted in cases using MD and the highest in cases using CB. However, after mitigation, CBY had the lowest overall levels. Tonsillectomy technique does impact the levels of nanoparticles emitted within the surgical plume, which may present an occupational hazard for operating room personnel. 3 Laryngoscope, 134:2444-2448, 2024.

Functional neurological disorder in Saudi Arabia: A retrospective study.

To describe the clinical profile of a sample of Saudi patients with Functional Neurological Disorder (FND). A retrospective review of charts of FND patients seen from 2021-2023 at a neuropsychiatry clinic at an academic tertiary care center in Jeddah, Saudi Arabia. Out of 473 patients seen in the clinic, 52 (11%) had FND. Their mean age was 34 (standard deviation = 10.7), and 77% were female. Family disputes (39%) were the most reported risk factor, followed by sexual abuse (15%). The most common FND symptoms were nonepileptic seizures (61.5%) and abnormal movements (30.8%). Pain was reported by 57.7% and cognitive symptoms by 36.5%. FND symptoms were frequently attributed to supernatural causes (67.3%). During the last follow up visit, 53.9% of patients reported FND symptom improvement, whereas 21.2% reported no change, 10.2% reported worsening, and 15% were lost to follow-up. The proportion of patients without symptom improvement was higher among patients with cognitive symptoms (45.5% vs 18% respectively, X2 = 10.08, df = 3, P = .018). The mean number of visits was highest in patients reporting worsening and lowest among patients reporting no change (F = 4.21, P = .017). The role of family disputes in FND in the Middle East, the role of supernatural concepts in how FND is perceived, and the relatively high rate of subjective improvement within this sample of Saudi FND patients merit exploration. Cognitive symptoms may be a prognostic indicator. Prospective multicenter research using standardized assessment scales is needed.

Risk Factors for Radiotherapy Failure in the Treatment of Spinal Metastases.

Retrospective cohort study. To build a predictive model for risk factors for failure of radiation therapy, hypothesizing a higher SINS would correlate with failure. Patients with spinal metastasis being treated with radiation at a tertiary care academic center between September 2014 and October 2018 were identified. The primary outcome measure was radiation therapy failure as defined by persistent pain, need for re-irradiation, or surgical intervention. Risk factors were primary tumor type, Karnofsky and ECOG scores, time to treatment, biologically effective dose (BED) calculations using α/β ratio = 10, and radiation modality. A logistic regression was used to construct a prediction model for radiation therapy failure. One hundred and seventy patients were included. Median follow up was 91.5days. Forty-three patients failed radiation therapy. Of those patients, 10 required repeat radiation and 7 underwent surgery. Thirty-six patients reported no pain relief, including some that required re-irradiation and surgery. Total SINS score for those who failed reduction therapy was <7 for 27 patients (62.8%), between 7-12 for 14 patients (32.6%), and >12 for 2 patients (4.6%). In the final prediction model, BED (OR .451 for BED > 43 compared to BED ≤ 43; P = .174), Karnofksy score (OR .736 for every 10 unit increase in Karnofksy score; P = .008), and gender (OR 2.147 for male compared to female; P = .053) are associated with risk of radiation failure (AUC .695). A statistically significant association between SINS score and radiation therapy failure was not found. In the multivariable model, BED ≤ 43, lower Karnofksy score, and male gender are predictive for radiotherapy failure. SINS score was among the candidate risk factors included in multivariable model building procedure, but it was not selected in the final model. Prognostic level III.

Abstract 16930: Patient Perceptions of Multilevel Nudges About Cardiovascular Medication Refills: A Qualitative Analysis

Introduction: Nudges are simple messages designed to elicit behavior change. In a multi-center pragmatic clinical trial, we embedded nudge messages into short message service texts (SMS) to encourage patients to refill medications to improve medication adherence. In this study, we assessed patient perceptions of the nudge messages. Methods: We conducted in-depth, open-ended interviews with a sample of English and Spanish speaking patients with cardiovascular disease and documented medication refill gaps enrolled in the clinical trial from a tertiary care academic center, UCHealth, and an urban safety-net hospital, Denver Health. We transcribed interviews and performed content analysis to identify themes. Patients were interviewed about their experiences over the phone using interview guides and perceptions of the nudge messages. Content analysis was done by a trained reviewer to identify themes. Results: Among 12 interviews (4 in Spanish), all appreciated the nudge messages, even though some had successful systems to remind them of medications already. All patients interviewed had no concerns about the messages because they were discreet and respected patient privacy. Some patients felt the health system was caring for them by sending messages. Suggestions for improvement included: 1) medications instructions, such as whether to take them with food; 2) dietary education; and 3) reminders for taking medication in the middle of the day, the doses that were more likely to be missed. Despite liking the messages, most self-reported no change in their medication taking behavior due to reminders they had set up themselves. They did, however, appreciate the nudge messages, and a few patients stated that the messages helped them ‘stay on track’ with refills. Conclusions: Patients appreciated the nudge messages that encouraged them to pick up medication, and generally felt supported by the healthcare system in receiving them. Most patients had no suggestions for improving the nudges. Self-reported behavior change in taking medications was low, though patients’ statements suggested the messages were still helpful with refills. True behavior change will be revealed in the final quantitative analysis of the trial.

Abstract 17255: Local Gunfire Exposure is Associated With Acutely Increased Blood Pressure on the South Side of Chicago

Hypertension is a leading risk factor for cardiovascular disease, which is especially prevalent among minority urban patients. Our group and others have previously shown that socio-environmental factors such as crime and poverty raise cardiovascular risk. However, the acute effects of local urban gunfire on patients’ blood pressure are unknown. We hypothesized that local gunfire in our South Side Chicago community was temporally associated with an acute rise in blood pressure for nearby patients. We performed a retrospective cohort study including 7,564 patients aged 18-104 who completed two or more outpatient clinic visits within 1 year at our academic tertiary-care center on the South Side of Chicago. We included 41,554 pre-pandemic clinic visits and recorded the blood pressure for each visit. Local gunfire was measured using ShotSpotter®, a network of microphones installed throughout the South Side of Chicago, which locates gunshots using auditory triangulation. Datasets of gunfire incidents are publically available from ShotSpotter® including date/time and geolocation of incidents. We focused on incidents that occurred within 1 km of each patient’s address and between two clinic visit dates (33 days, on average). Our primary outcome was the change in systolic blood pressure between the two clinic appointments. We excluded patients whose antihypertensive regimen was changed at the first appointment. Next, we utilized a multivariate regression model to assess the relationship between incidents of gunfire and seasonally-adjusted changes in blood pressure. Between-visit gunshot exposure ranged from 1 to 1,793 per patient. We found that each incident of gunfire was associated with a statistically significant acute increase in systolic blood pressure (0.0033 mmHg increase per gunfire incident [0.0022, 0.0044], p&lt;0.0001). Results were similar regardless of whether total round count or total gunfire incidents were considered. In this study of urban patients, incidence of gunfire within 1 km of a patient’s address was associated with an acute rise in blood pressure over approximately 1 month. These findings implicate the adverse impact of local gunfire exposure and environmental stress on blood pressure in adults on the South Side of Chicago.

Abstract 15442: Street Gang Territories and Hypertension in Chicago

Hypertension is a major cardiovascular risk factor. Gang violence is an unfortunately common reality in urban communities and violence is associated with worse cardiovascular outcomes. However, the relationship between street gang territories and cardiovascular risk is unknown. We conducted a retrospective cohort study to determine if residence within a street gang territory is associated with higher blood pressure compared with demographically similar patients who resided outside of gang territories within Chicago. A balanced dataset of 1,016 unique-but-demographically-similar patients with at least 3 available pre-pandemic ambulatory blood pressure measurements at our urban, academic tertiary-care center were sampled from over 70,561 available patients. Patients were matched for the number of BP measurements, age, race, sex, and other sociodemographic variables. Patients were geo-coded and mapped, and known street gang territories were similarly geo-coded and mapped using publicly available data from the Chicago Police Department data portal. Out of 66 known street gangs in Chicago, our institution served patients from 28 unique gang territories. Patients residing within a known street gang territory had on average 6.2 mmHg higher BP than those living outside any known street gang territory (median = 133.2 vs 127.0, respectively,p&lt;0.001). SBP control in each unique street gang territory was highly variable with medians ranging between 108.8 to 165.0 mmHg (Figure). In conclusion, we find that residence within a street gang territory is associated with significantly higher systolic blood pressure compared with demographically similar patients who do not live in a gang territory. While poverty and other social determinants of health are known to affect hypertension and cardiovascular risk, residence within a gang territory may represent a new social risk factor for cardiovascular disease.

Abstract 18766: Optimizing Stroke Prophylaxis in the Emergency Department With an Electronic Clinical Decision Support Tool: A Preliminary Analysis of a Multi-Stage Multi-Center Stepped-Wedge Cluster Randomized Trial

BACKGROUND: Atrial fibrillation (AF) is a common arrhythmia that is often first diagnosed in the Emergency Department (ED). AF is associated with an increased risk of stroke that can be reduced by 64% if an oral anticoagulant (OAC) is prescribed appropriately. RESEARCH QUESTION: Will education and implementation of a clinical decision support (CDS) tool in the ED increase OAC prescription for appropriate candidates diagnosed with new-onset or paroxysmal AF (pAF)? METHODS: This is the first phase of a multi-stage multi-center stepped-wedge cluster-randomized clinical trial implementing a CDS tool into the electronic health record (EHR). Step one implements an external browser link to the CDS tool in the EHR with targeted provider education, whereas steps 2 and 3 will motivate provider engagement with triggers. Data were collected from an urban academic tertiary care center and a community hospital. Patients aged greater than 17 years were selected if they had a primary diagnosis of AF/pAF during ED visits from Jan 2020-Apr 2023. The academic and community sites transitioned from the retrospective phase to Step 1 in Jan 2022 and Apr 2022, respectively. Appropriate OAC prescription was determined based on elevated stroke risk and low-moderate bleed risk. A logistic GEE model was used to study the effect of the proposed intervention on OAC prescription. ED providers were treated as a random effect to capture clustering. The model includes the CDS intervention, site, and patient characteristics sex, race, ethnicity, and age. RESULTS: Of 2031 patients, 312 met inclusion criteria and 150 were selected as appropriate OAC candidates, with 72 (52% male, median age 74) in the retrospective step and 78 (52% male, median age 76) in Step 1. Below are odds ratio estimates with corresponding 95% CI’s: CDS intervention 3.12 [1.57, 6.21] and sex female vs male 2.04 [1.04, 4.00]. Non-significant variables site, race, ethnicity, and age were included as adjusting covariates. CONCLUSIONS: Limited CDS tool education and integration is associated with improved OAC prescribing for appropriate AF/pAF patients. Future studies should assess the impact of additional CDS integration on OAC prescribing and patient outcomes.

Abstract 14117: Home Operated Ultrasound Exam for Detection of Worsening Heart Failure

Introduction: Acute Decompensated Heart Failure (ADHF) is associated with a high degree of morbidity and mortality. Dynamic lung ultrasound artifact called B-lines directly correlate with pulmonary vascular congestion (PVC) and can be seen on a limited lung ultrasound. Hypothesis: We assessed the ability of a recently hospitalized patient with ADHF to self-perform a lung ultrasound using a hand-held ultrasound and store images for physician interpretation. Methods: This was a prospective observational convenience sample of patients with known chronic heart failure admitted to an urban academic tertiary care center. The patient was educated on a 6 lung-zone image protocol, how to use the cloud archival system, and given a hand-held ultrasound transducer and iPad. The patients were asked to upload images three times a week, for 3 weeks. A B-line score for each interpretable lung zone was calculated. Results: Fifteen patients were enrolled, all of whom completed 7 or more scans. Average patient age was 60 years (range: 28- 86 years), 73% male, 60% white, and 47% obese. Five patients had ejection fraction &gt;50%, and average length of hospital stay was 6.3 days. Of the 792 potential images, 784 were obtained (99%) and 637 (81%) were interpretable. The right upper zone was most often interpretable (97%), whereas the left lateral zone was least (70%). Median patient B line score when indexed to 6 interpretable scans was 3.00. Indexed B line scores are shown for all 15 patients (Figure 1). Patient survey data identified the left lateral zone as the most challenging to obtain. Conclusions: This pilot study shows that patients with ADHF can be taught how to use a hand-held portable ultrasound device and obtain and upload lung ultrasound images to a cloud. Compliance with the study protocol was excellent. Further studies are needed to determine if patient-performed lung ultrasound can be useful to clinicians to detect and manage PVC in this patient population.

Correlating area deprivation index with initial stage at presentation and with follow up and recurrence within an advanced practice provider-led survivorship clinic

IntroductionLiving in disadvantaged neighborhoods has been shown to result in worse healthcare outcomes. The Area Deprivation Index (ADI) is a metric that ranks neighborhoods by socioeconomic disadvantage utilizing numerous factors including income, education, employment, and housing quality. MethodsA retrospective review of all patients who underwent surveillance in an APP-led head and neck cancer survivorship clinic from Dec 2016 to Oct 2020 at an academic tertiary care center were included. Tumor characteristics, visit frequency, recurrence, number of missed appointments, loss of follow up, and ADI scores were collected. Results543 patients were included in the study. A majority were male (69.9 %) and white race (84.9 %) with an average age of 64.6 years old. Average ADI national percentile score was 71.6(range: 17 to 100). ADI national percentile score was not predictive of tumor characteristics at initial presentation: lymphovascular invasion (p = 0.940; OR 1.0 [95 % CI: 0.9 to 1.1]), extranodal extension (p = 0.576; OR 1.0 [95 % CI: 0.9 to 1.2]), positive margins (p = 0.069; OR 0.9 [95 % CI: 0.9 to 1.0]). ADI national percentile score was not significantly correlated with loss to follow up (p = 0.153; OR 1.2 [95 % CI: 0.9 to 1.7] or cancer recurrence (p = 0.594; OR 1.0 [95 % CI: 0.9 to 1.1]). Missing one or more clinic visits was correlated with loss to follow up (p = 0.029; OR 13.1 [95 % CI: 1.3 to 131.7]. ConclusionLiving in a disadvantaged neighborhood did not correlate with negative tumor characteristics, loss to follow up, or recurrence within an APP-led survivorship head and neck cancer clinic.

Primary Total Laryngectomy for Endolaryngeal cT3-4M0 Squamous Cell Carcinoma: A STROBE Analysis.

To document 10-year oncologic outcome of primary total laryngectomy (TL) for patients with cT3-4M0 endolaryngeal squamous cell carcinoma (SCC). Observational inception cohort of 531 patients with isolated untreated endolaryngeal cT3-4M0 SCC review over 40 years using STROBE guideline. 94% of patients were followed until death or for a minimum of 10 years. Academic tertiary referral care center. All patients underwent primary TL. Prior tracheotomy, induction chemotherapy, thyroid gland resection, level II-IV neck dissection, level VI dissection, and postoperative radiation therapy were associated in 6%, 40%, 43%, 89%, 47%, and 74% of cases, respectively: The main objective was to determine the 10-year actuarial local control estimate. Accessory objectives comprised screening for clinical variables increasing the risk of local recurrence, and analysis of long-term oncologic consequences of local recurrence. The 10-year actuarial local control estimate was 89.7%. Local recurrence was salvaged in 11% of cases, resulting in 92% overall local control. On multivariate analysis, none of the study variables correlated with local recurrence. Local recurrence resulted in significantly reduced nodal control, distant metastasis control, and survival. Postoperative complications, persistent index SCC, intercurrent disease, and metachronous second primary cancer accounted for respectively 3%, 37%, 33%, and 28% of the 334 deaths noted during the 10 years following TL. The present study underscored the long-term oncologic efficacy of primary TL, the dangers of local recurrence, the key role of local control for survival, and the importance of a long-term oncologic watch policy. 3 Laryngoscope, 134:2288-2294, 2024.

Endogenous Endophthalmitis Associated with Injection Drug Use Compared with Other Etiologies.

To compare features of endogenous endophthalmitis associated with injection drug use (IDU) to endogenous endophthalmitis from other etiologies. We retrospectively collected data on patients with endogenous endophthalmitis due to IDU or other causes from three academic tertiary care centers over a six-year period. Differences in presenting characteristics, culture results, treatment, and visual acuity (VA) were compared between groups. Thirty-eight (34%) patients had IDU-associated endogenous endophthalmitis, while 75 (67%) had endogenous endophthalmitis from other causes. Compared to patients in the non-IDU group, IDU patients were significantly younger, more frequently male, had longer duration of symptoms at diagnosis, and were less likely to have bilateral disease (p<0.05 for all). IDU patients were less likely to have a systemic infection source identified (29% vs 71%, p<0.001) or have positive cultures (47% vs 80%, p<0.001). The IDU group was less likely to be admitted to the hospital (71% vs 92%, p=0.005) and less likely to receive treatment with intravenous antimicrobials (55% vs 83%, p=0.003). VA did not significantly differ between groups. Endophthalmitis related to IDU presents in younger patients with less comorbidities and frequently without positive cultures or an identifiable systemic source; therefore, a high index of suspicion is needed to identify this disease.