Tertiary Care Academic Center Research Articles

Piloting total perioperative telemedicine for elective cholecystectomies for symptomatic cholelithiasis.

Telemedicine has the potential to increase healthcare access while decreasing the environmental impact associated with providing care. We piloted total perioperative telemedicine (TPT) visits for evaluating patients with symptomatic cholelithiasis. We aimed to evaluate the feasibility and environmental impact of TPT by comparing the perioperative and environmental outcomes of patients participating in TPT to those undergoing traditional in-person preoperative evaluations. During a six-month period in 2022, patients referred to a single provider at an academic tertiary care center for uncomplicated cholelithiasis were offered a preoperative telemedicine visit. Adverse events, number of perioperative clinical visits, and patient demographics were then collected retrospectively for elective cholecystectomies performed between 1/1/2022 and 12/31/2022. Perioperative outcomes were compared between patients who underwent TPT versus those evaluated in-person. Life cycle assessment was utilized to compare greenhouse gas (GHG) emissions (measured in kilograms of carbon dioxide equivalents, kgCO2-eq) between both groups. During the study period, 12 patients proceeded with elective cholecystectomy for symptomatic cholelithiasis after a preoperative telemedicine evaluation while 31 patients did so after an in-person evaluation. Patients participating in TPT had a similar adverse event rate (8.3% vs. 12.9%, p = 0.67, chi-squared test). Patients participating in TPT had more perioperative clinic visits on average compared to patients undergoing in-person preoperative evaluation (1.42 vs. 1.06, p = 0.004). Of the TPT group, 8 patients (67%) patients proceeded with surgery after initial telemedicine evaluation. TPT resulted in a 51% decrease in perioperative GHG emissions compared to patients who underwent in-person evaluation (60.2-60.9 kgCO2-eq vs. 123.4-123.5 kgCO2-eq, p = 0.0271). This pilot study suggests that TPT is feasible for patients undergoing elective cholecystectomy for symptomatic gallstones. Additionally, TPT significantly reduces GHG emissions associated with caring for a patient through an elective procedure by reducing the average number of required trips to the medical facility.

Audiologic Outcomes After Cochlear Implantation in Prelingually Deaf Children Who Have Combined Anomalies or Disabilities.

To evaluate the audiologic outcomes after cochlear implantation (CI) in prelingually deaf children with comorbid disorders. Retrospective study. Tertiary care academic center. We enrolled 85 deaf children (111 ears) with comorbid disorders who underwent CI surgery. We selected the most common comorbid disorder and compared the categories of auditory performance (CAP) scores of each comorbidity group with those of the control group. Combined cochlear anomalies were also evaluated using temporal bone computed tomography. The most common comorbid disorder was CHARGE syndrome (n = 17), followed by developmental delay (n = 13), valvular heart disease (including septal defect) (n = 13), Waardenburg syndrome (n = 8), Down syndrome (n = 6), cerebral palsy (n = 5), and cryptorchidism (n = 5). The CAP scores differed significantly between all the groups and the control group after 6 months (p < 0.001). The differences in the CHARGE syndrome (p = 0.004), cerebral palsy (p = 0.001), and Down syndrome (p = 0.004) groups remained significant 2 years after CI. When comparing the presence or absence of anomalies within the syndromic and nonsyndromic groups, significantly poorer outcomes exist when cochlear anomalies with absent modiolus or cochlear nerve deficits were observed, regardless of the presence of syndromic disorders. Compared with those in the control group, the CAP scores in the group with coexisting disabilities increased over time, but their final scores were relatively lower. Combined disabilities as well as the absent modiolus and cochlear nerve deficit may be clinical markers for poor CAP scores.

PET/CT for perforator identification in deep inferior epigastric perforator flap harvest.

CT angiography (CTA) is used for preoperative localization in deep inferior epigastric perforator (DIEP) flaps, but is an additional costly study that involves contrast and radiation exposure. Many patients with head and neck cancer already undergo PET/CT. We investigated if PET/CT could be used to preoperatively localize perforators and if this corresponded with the intraoperative location. This was a prospective cohort study at an academic tertiary care center between 2017 and 2022. Participants were adults with head and neck cancer who had undergone PET/CT and were scheduled to undergo reconstruction with DIEP flaps. The mean difference between the preoperative and intraoperative horizontal and vertical distance of perforators from the umbilicus was determined. Preoperative and intraoperative measurements were obtained from 42 perforators (30 patients). The mean difference between preoperative and intraoperative measurements was not statistically significant for HDU (-0.05 with 95% CI [-0.11, 0.01], p=0.13) or VDU (-0.02 with 95% CI [-0.06, 0.03] p=0.41). Bland-Altman analysis demonstrated limits of agreement of -0.42 (95% CI [-0.52, -0.31]) to 0.33 (95% CI [0.23, 0.43]) for HDU and -0.31 (95% CI [-0.39, -0.23]) to 0.27 (95% CI [0.19, 0.35]) for VDU. This was within our chosen limit of agreement of 1cm. Preoperative identification of DIEP perforators on PET/CT can be used to locate perforators intraoperatively. Utilizing this method facilitates efficient flap harvesting and does not require an additional imaging study since many patients undergo PET/CT.

Social Determinants of Health Affecting Retinopathy of Prematurity Follow-up Attendance.

To identify social determinants of health (SDOH) associated with follow-up attendance of pre-term infants with retinopathy of prematurity (ROP) after neonatal intensive care unit (NICU) discharge. This retrospective cohort study, conducted at a single academic tertiary care center, included preterm infants screened for ROP from July 2018 to December 2022. Sociodemographic and clinical data were collected from a preexisting NICU database. Residential ZIP code was used to derive community-level SDOH indices. Multivariable logistic regression was used to determine factors associated with ophthalmology follow-up attendance within 8 weeks to 1 year after NICU discharge. Forty-two percent (303 of 723) of patients attended follow-up in the designated interval. Infants with private insurance (odds ratio [OR]: 4.47, 95% CI: 1.98 to 10.1, P < .001), maternal non-Hispanic White identity (OR: 1.80, 95% CI: 1.15 to 2.81, P = .01), ROP treatment history (OR: 3.67, 95% CI: 2.05 to 6.57, P < .001), and longer NICU stay (weeks) (OR: 1.06, 95% CI: 1.03 to 1.08, P < .001) had higher odds of attending follow-up. In an interaction effect, privately insured patients had lower odds of follow-up with each higher quartile of Social Vulnerability Index Racial and Ethnic Minority Status (OR: 0.61, 95% CI: 0.44 to 0.84, P = .002). Social determinants of health, including individual and community-level factors, significantly impact access to ROP follow-up. The identified disparities and overall inadequate follow-up rate suggest a need for targeted interventions to improve vision health equity and follow-up adherence. [J Pediatr Ophthalmol Strabismus. 20XX;X(X):XXX-XXX.].

Predictors of biochemical remission after transsphenoidal surgery in a large cohort of acromegaly patients.

The objective of this study was to characterize the clinical characteristics and factors predictive of biochemical remission in patients with symptomatic acromegaly undergoing transsphenoidal surgery (TSS) at an academic tertiary care center, as defined by the 2022 Acromegaly Consensus Conference guidelines. In this single institution, longitudinal, retrospective study, a large cohort of 158 patients with a preoperative diagnosis of acromegaly undergoing surgery at a large, academic, tertiary care center were examined. We excluded 38 patients as IGF-1 testing was performed less than 12 weeks postoperatively. The majority of tumors were intrasellar macroadenomas (75%), receiving endoscopic surgery (98.3%). Patients who failed remission appeared to have higher raw IGF-1 levels preoperatively (732 ± 313 ng/mL) compared to those who attained remission (278 ± 313 ng/mL), and trended towards higher rates of GH hypersecretion (93.1% vs. 78.4%). Patients failing remission had higher GH levels and IGF-1 levels postoperatively and experienced a lower percentage reduction in raw IGF-1 levels. Multivariable logistic regression demonstrated that the magnitude of preoperative IGF-1 (OR: 1.001, 95% CI: 1.00, 1.003) and the percentage change in IGF-1 (OR: 1.021, 95% CI: 1.01, 1.04) were predictive of remission failure. Radiographic characteristics such as tumor size, suprasellar extension, and location were not necessarily predictive of worse postoperative outcomes. Lesions which failed to achieve biochemical remission appeared to display distinctive preoperative endocrinological characteristics, with preoperative IGF-1 levels and percentage changes in IGF-1 levels being predictive of biochemical remission status.

Neutrophil-to-Lymphocyte Ratio and Pembrolizumab Outcomes in Oral Cavity Squamous Cell Carcinoma.

To determine the relationship between pretreatment neutrophil-to-lymphocyte ratio (NLR) and 6-month progression-free survival (PFS)/2-year overall survival (OS) among patients with recurrent or metastatic (R/M) oral cavity cancer on pembrolizumab. This study was a retrospective, observational study performed at a tertiary care academic center. Participants included patients with oral cavity squamous cell carcinoma (OCSCC) who began pembrolizumab treatment at the University of California, San Francisco between May 2016 and May 2022. The primary outcome was a 6-month PFS. The secondary outcome was a 2-year OS. NLR was treated as a continuous variable. Disease progression was determined using radiographic criteria, adopted from the Response Evaluation Criteria in Solid Tumors. Fifty-two patients with OCSCC were included. Immune checkpoint inhibitor (ICI) indication was recurrence/metastasis for all patients. The median pretreatment NLR was 5.7 (interquartile range: 3.6-7.6). Twenty-seven (55%) patients received pembrolizumab alone. Of those receiving treatment for R/M prior to ICI, 9 (18%) received salvage surgery and adjuvant therapy, 2 (4%) received chemotherapy alone, 1 (2%) received chemoradiation, and 10 (20%) received salvage surgery. Nineteen (36.5%) patients had distant metastases at the start of ICI. Six-month PFS was 46%. Two-year OS was 44%. NLR was independently associated with 6-month PFS [hazard ratio, HR: 1.05 (95% confidence interval, CI: 1.01-1.11), P = .028] and 2-year OS [HR: 1.12 (95% CI: 1.05-1.20), P < .001]. Higher pretreatment NLR was associated with poorer 6-month PFS and 2-year OS in OCSCC patients treated with pembrolizumab.

Emergency Department Healthcare Providers’ Knowledge and Attitudes regarding Appropriate Indications for Indwelling Urinary Catheter Use

Abstract Introduction: Indwelling urinary catheters (IUCs) are frequently used in emergency departments (EDs), but many insertions lack clear indications, leading to potential overuse. This overuse contributes to catheter-associated urinary tract infections (CAUTIs), costing billions in preventable healthcare expenses. Campaigns such as Choosing Wisely and Centers for Disease Control and Prevention guidelines aim to reduce unnecessary IUC use, improve patient outcomes and prevent CAUTIs. Materials and Methods: A cross-sectional survey and retrospective chart review were conducted at an academic tertiary care centre. The survey targeted ED providers, including physicians and nurses, while the chart review encompassed all adult ED patients in 2022. The survey covered demographic information, self-reported understanding and attitudes towards urinary catheters, including clinical scenarios, to evaluate the knowledge of appropriate indications for IUC insertion. The data analysis was performed using NCSS software and involved t-tests or one-way analysis of variance to explore associations between sample characteristics and knowledge scores. The significance level for all analyses was set at P &lt; 0.05. Results: A total of 96 of the 198 ED staff members participated in the survey. The confidence rate for knowledge of appropriate indications for IUC insertion was 100% among physicians and 97.8% among nurses. However, the results from the clinical scenarios in the survey showed that participants incorrectly answered in a range of 8%–75%. The mean scores of correct answers among consultants, residents and nurses were 65%, 67% and 66%, respectively. Conclusion: There is a considerable gap between ED healthcare providers’ subjective knowledge and attitudes and objective knowledge of appropriate IUC placement, which serves as a basis for an intervention to reduce the potential for inappropriate IUC insertion.

Chimeric Versus Multiple Simultaneous Free Flaps for Head and Neck Reconstruction.

To describe our experience with chimeric flaps and to assess the surgical outcomes and postoperative complications associated with chimeric flaps compared to multiple flaps. Patients undergoing chimeric and multiple simultaneous free tissue transfer between June 2016 and October 2023 were retrospectively reviewed. The primary outcome of interest was the complication rate. Major complications required takeback to the operating room, hospital readmission, or transfer to the intensive care unit. Minor complications were managed conservatively. Secondary outcomes included operative time, length of hospitalization, and flap survival. Academic tertiary care center. Our analysis included 113 patients (chimeric n = 38, multiple n = 75). We found no significant difference in operative times or minor complications. Chimeric flaps were associated with a shorter length of hospitalization. The major complication rate was higher for chimeric flaps (42.1% vs 22.7%, P = .03), but each cohort only had 1 instance of total flap loss. The complexity of large head and neck defects poses a reconstructive challenge for microvascular surgeons. Our findings suggest that chimeric and multiple flaps both produce acceptable complication rates when used appropriately. Differences in complication rates may reflect differences in utilization. The chimeric flap remains a valuable option for those with prior radiation or radical resection, but it remains unclear the degree to which they lessen the inherent risk of postoperative complications within this population. Each technique must be weighed in context of the patient's reconstructive profile and the institution's surgical capabilities to optimize long-term outcomes.

Biliopancreatic Diversion with Duodenal Switch (BPD/DS) Results in Superior Weight Loss and Diabetes Remission in Patients with Baseline BMI≥50 kg/m2

BackgroundPatients with Body Mass Index (BMI) ≥ 50 kg/m2 have more obesity-associated medical problems and often require more aggressive surgical management. Few single-institution comparative studies have been published examining this specific population. ObjectivesThe study aims to compare the weight loss and diabetes remission effects of Sleeve Gastrectomy (SG), Roux-en-Y Gastric Bypass (RYGB), and Biliopancreatic Diversion with Duodenal Switch (BPD/DS). SettingRural academic tertiary care center. MethodsWe conducted a retrospective cohort study using prospectively collected data. All patients with a BMI ≥ 50 kg/m2 who underwent a SG, RYGB, and BPD/DS were included. Comparative analysis was performed for complications, readmission rates, weight loss, and diabetes remission. ResultsExcess weight loss at 3 years was 40.1% for SG, 54.1% for RYGB, and 67.4% for BPD/DS, with BPD/DS performing significantly better (p<0.001). Complete diabetes remission at 5 years was 29% for SG, 61% for RYGB, and 79% for BPD/DS. BPD/DS had significantly longer operative times (p<0.001) and rates of minor complications (p=0.02). ConclusionsBPD/DS achieved superior sustained weight loss and diabetes remission compared to RYGB and SG.

Epidemiology and Gender Variation in Thyroid Malignancies: A Retrospective Study of a Tertiary Care Center

Abstract Background: Thyroid malignancies are among the most common endocrine cancers, ranking ninth in incidence. In Saudi Arabia, thyroid cancer rates have significantly increased in both genders. Despite the rising incidence, mortality rates have declined. The evolving epidemiology of thyroid malignancies in Saudi Arabia reflects changes in demographics, culture, and clinical practices. This study aims to update the epidemiological data and examine gender variations in thyroid malignancies. Materials and Methods: This retrospective study included cases admitted to an academic tertiary care center from January 2023 to June 2024. Data on demographic variables (gender, age, and nationality) and clinical diagnosis categories (ranging from nondiagnostic to malignant) were collected. Histopathological details of thyroid lesions were also recorded. Clinical, cytological, and histopathological data were as per the Bethesda system, and they were analyzed accordingly. Results: The average age of 300 patients in our study cohort was 45.56 years, with 81.3% of them being female. The majority of patients were Saudi nationals (87.7%). According to the Bethesda system, the most common findings for lesions were benign (category II), followed by malignant (category VI) and atypia of undetermined significance (AUS; category III). Histopathologically, 52.7% showed benign features, with hyperplastic thyroid lesions (20.7%) and follicular adenomas (14.3%) being the most common. The most common malignancy was papillary carcinoma (42.7%). Age-specific analysis revealed differences, with younger patients more likely to have follicular neoplasm/suspicious for follicular neoplasm (category IV) and older patients having a higher risk of malignancy. Other variables including colloid cyst, subacute granulomatous thyroiditis, follicular carcinoma, Hürthle cell type, and medullary carcinoma were not statistically associated with any age group. Conclusion: Our findings are consistent with global trends indicating a significant increase in thyroid cancers, particularly among women. In our cohort, female patients were diagnosed with thyroid cancer nearly four times more frequently than male patients, which is double the commonly reported gender gap. There were statistically significant differences between genders in age groups, malignancies, and histopathological findings, with hyperplastic thyroid lesions and papillary carcinoma being more common in women. We also observed age-related differences in thyroid findings, with younger patients having more follicular neoplasms and older patients having more AUS.

Detection of enoxaparin and argatroban by use of the novel viscoelastic coagulometer ClotPro

Owing to the simultaneous increase in the risk of thrombosis and bleeding in critically ill patients, point-of-care-available diagnostic tests to guide parenteral anticoagulation are warranted. We evaluated the detection of enoxaparin and argatroban, two commonly used parenteral anticoagulants, using the novel ClotPro viscoelastic coagulometer. For this experimental in vitro study at a tertiary care academic center, blood samples were drawn from twelve (six female, six male) healthy volunteers without intake of antithrombotic medication and no history of hemostatic disorders. Blood samples were spiked with enoxaparin (IU.ml− 1) and argatroban (µg.ml− 1) at increasing concentrations ranging from 0 to 1. The ClotPro Russell’s viper venom (RVV)-test and the ClotPro ecarin (ECA)-test clotting time were performed in parallel with conventional coagulation tests (anti-Xa activity, activated partial thromboplastin time, and diluted thrombin time). We observed a strong correlation between anti-Xa activity and the RVV-test clotting time (r = 0.88 (95% confidence interval (CI) 0.8–0.92; p < 0.001)). Although clotting time cutoff values of 71 and 145 s provided high sensitivity and specificity for detecting anti-Xa activity of ≤ 0.1 and ≥0.6 IU.ml− 1, we found a poor performance at both high and low concentrations. The ECA-test clotting time revealed a very strong correlation with activated partial thromboplastin time (r = 0.96 (95% CI 0.93–0.97; p < 0.001)) and diluted thrombin time (r = 0.97 (95% CI 0.96–0.98; p < 0.001)). The clotting time cutoff values of 86 and 298–431 s provided high sensitivity and specificity for detecting diluted thrombin time values ≤ 0.1 and 0.5-1 µg.ml− 1. Our results suggest that the RVV test is an unreliable method for monitoring enoxaparin treatment, whereas the ECA-test might be an accurate point-of-care alternative for detecting argatroban concentration with potential advantages over standard coagulation tests in terms of point-of-care applicability and turnaround time.

Evaluation and Treatment of Acute Facial Palsy: Opportunities for Optimization at a Single Institution.

Introduction: Most patients with acute facial palsy initially present to emergency departments (EDs), where clinical practice guidelines (CPGs) recommend steroids, eye care, and follow-up with facial nerve specialists. Objective: To evaluate adherence to the American Academy of Otolaryngology-Head and Neck Surgery (AAO-HNS) Bell's palsy (BP) CPGs within EDs at a single academic institution. Method: We conducted a retrospective review of all patients diagnosed with acute facial palsy in the EDs of an academic tertiary care center between June 1, 2021, and June 1, 2022. Results: A total of 270 patients met inclusion criteria; most were male (n = 150, 55.9%), diagnosed with BP (n = 243, 90.0%), and presented to community-based emergency rooms (n = 170, 62.96). Although most patients received steroid treatment (n = 243, 90.0%), only 61.5% (n = 166) received the AAO-HNS-recommended course. Older patients and those who received steroids were more likely to receive imaging (p < 0.001, p = 0.03). Treatment with the AAO-HNS-recommended steroid regimen was associated with a higher likelihood of receiving laboratory evaluation (p = 0.02). Providers often advised follow-up; however, only 12.2% of patients were discharged with an electronic referral order. Conclusion: There are opportunities to standardize the treatment of patients in the ED presenting with acute facial palsy according to AAO-HNS CPGs.

Preoperative Multivariable Model for Risk Stratification of Hypoxemia During One-Lung Ventilation.

Hypoxemia occurs with relative frequency during one-lung ventilation (OLV) despite advances in airway management. Lung perfusion scans are thought to be one of the most accurate methods to predict hypoxemia during OLV, but their complexity and costs are well-known limitations. There is a lack of preoperative stratification models to estimate the risk of intraoperative hypoxemia among patients undergoing thoracic surgery. Our primary objective was to develop a risk stratification model for hypoxemia during OLV based on preoperative clinical variables. This is a single-center, retrospective cohort study including 3228 patients who underwent lung resections with OLV from 2017 to 2022, at a tertiary academic health care center in the United States. Vital signs and ventilator settings were retrieved minute by minute. Intraoperative hypoxemia was defined as an episode of oxygen desaturation (Spo2 <90%) for at least 5 minutes. Demographic and clinical characteristics were included in a stepwise logistic regression, which was used for the selection of predictors of the risk score model. All patients included in this cohort underwent elective lung surgery in lateral decubitus position, with double lumen tube and placement confirmation with fiberoptic bronchoscopy. Our model was validated internally using area under the receiver operating curves (AUC) with bootstrapping correction. The incidence of hypoxemia during OLV was 8.9% (95% confidence interval [CI], 8.0-10.0). Multivariable logistic regression identified 9 risk factors with their corresponding scoring: preoperative Spo2 <92% (15 points), hemoglobin <10 g/dL (6 points), age >60 years old (4 points), male sex (4 points), body mass index >30 kg/m2 (8 points), diabetes mellitus (4 points), congestive heart failure (7 points), hypertension (3 points), and right-sided surgery (3 points). The AUC of the model after bootstrap correction was 0.708 (95% CI, 0.676-0.74). Based on the highest Youden index, the optimal score for predicting intraoperative hypoxemia was 13. The risk of hypoxemia increased from 4.7% in the first quartile of scores (0-13 points), to 32% in the third quartile (27-39 points), and 83.3% in the fourth quartile (>39 points). At scores of 20 or greater, the specificity of the model exceeded 90% and reached a positive predictive value of 80%. The risk of hypoxemia during OLV can be stratified preoperatively using accessible clinical variables. Our risk model is well calibrated but showed moderate discrimination for predicting intraoperative hypoxemia. The accuracy of preoperative models for risk stratification of hypoxemia during OLV should be explored in prospective studies.

A Retrospective Review of Revision and Re-revision Patella Osteosynthesis Performed for Failure of Fixation of Initial Comminuted Fracture Patterns: Very High Complication Rates.

Literature on revision osteosynthesis for failed patella fracture fixation is extremely limited. This study reviews the treatment options and outcomes for revision and re-revision osteosynthesis at a Level 1 trauma center. All patella revision osteosynthesis cases between January 2021 and March 2024 were identified using Current Procedural Terminology codes at a single tertiary care academic center. Medical records, operative reports, and radiographs were reviewed to collect details regarding patient demographics, initial injury and fracture management, indications for revision surgery, revision construct, postoperative weight bearing and range-of-motion restrictions, and outcomes. The primary outcome was major failure defined as loss of fixation or further surgery for nonunion or infection. Ten patients underwent revision osteosynthesis for failed fixation. All fractures were initially comminuted fracture patterns (AO/OTA 34-C3), with nine (90%) initially treated with a 2.7-mm patella-specific variable angle locking plate (Synthes, Paoli, PA). Half (n = 5) of the patients were revised with the same patella-specific plate and half with an all suture transosseous fibertape tension band (Arthrex, Naples, FL). Additional fixation in the form of bony augmentation was performed in 20% (n = 2) of cases and soft tissue augmentation in 70% (n = 7). There was a 70% (n = 7) major failure rate, mostly due to loss of inferior pole fixation. There were four re-revision procedures performed with surgical fixation. Two of these subsequently developed infection, one united and the other had no radiographic signs of union and was lost to follow-up, but was without complication. Regardless of the chosen fixation construct, revision osteosynthesis for failed fixation of initial comminuted fracture patterns has an extremely high rate of failure. Complications increase with further revision surgery. Level of evidence: therapeutic level 3.

Impact of moderate or severe mitral and tricuspid valves regurgitation after transcatheter aortic valve replacement

BackgroundTricuspid regurgitation (TR) and mitral regurgitation (MR) are common valvular conditions encountered in patients undergoing transcatheter aortic valve replacement (TAVR). This retrospective study investigates the impact of moderate or severe TR and MR on all-cause mortality in one-year post-TAVR patients. MethodsConsecutive patients who underwent TAVR at the 3 academic tertiary care centers in our health system between 2012 and 2018 were identified. Patients were stratified into 2 groups based on valvular regurgitation severity: moderate/severe MR vs. no/mild MR, and moderate/severe TR vs. no/mild TR. Primary outcome was all-cause mortality at 1-year and 5-year follow up, and secondary outcome was in-hospital death. Logistic regression analysis was conducted to assess the relationship between moderate/severe MR or TR and all-cause mortality at 1-year and 5-year follow-up. ResultsWe included a total of 1,071 patients who underwent TAVR with mean age 80.9 ± 8.6 years, 97% white, and 58.3% males. Moderate or severe MR group included 52 (4.88%) patients while mild or no MR group included 1,015 (95.12%) patients. There was no significant difference between both groups in TAVR procedure success rate (100% vs. 97.83%, p=0.283), in-hospital mortality (0 vs. 1.08%, p=0.450), or mortality at 1-year follow up (15.38% vs. 14.09%, p=0.794). At 5-year follow up, moderate/severe MR group had higher mortality (61.4% vs. 49.5%, p=0.046). In multivariable logistic regression analysis, moderate or severe MR did not show significant correlation with all-cause mortality at 1-year and 5-year follow up. Moderate or severe TR group included 86 (8.03%) patients while mild or no TR group included 985 (91.97%) patients. There was no difference between both groups in TAVR procedure success (98.8% vs. 97.9%, p=0.54) or in-hospital mortality (0% vs. 1.1%, p=0.33). At 1-year follow up, patients with moderate or severe TR had higher mortality (26.7% vs. 13.2%, p=0.001) compared to patients with mild or no TR. Same finding was noted with extended follow up at 5-years (68.3% vs. 48.7%, p<0.001). In multivariable cox regression analysis, moderate/severe TR was associated with higher all-cause mortality at 1-year (OR 1.94, 95% CI [01.09, 3.44], p=0.0.023) and at 5-year (OR 1.46, 95% CI [1.092, 1.952], p=0.0.011) follow up. Patients with combined moderate/severe MR and TR have even higher mortality compared to either moderate/severe valve regurgitation alone or mild/no valve regurgitation at 5-year follow up. ConclusionAt long term follow up, moderate/severe TR, but not MR, is associated with higher mortality in patients underwent TAVR. Combined moderate/severe TR and MR had even worse mortality. Careful assessment of multi-valvular heart disease prior to the procedure is warranted.

Abstract 4138604: Impact of GLP-1 Agonist on the Incidence of Atrial Fibrillation in Obese Patients Following Heart Failure Hospitalization

Introduction: Atrial fibrillation (AF) in patients with heart failure (HF) is associated with increased morbidity and mortality. Glucagon-like peptide-1 (GLP-1) agonists have been shown to reduce cardiovascular risk in patients with obesity and diabetes, respectively. Meta-analysis of prospective trials looking at GLP-1 agonist use on the incidence of AF suggest benefit in patients with diabetes but is of unclear benefit in this regard for patients with obesity. Hypothesis: GLP-1 agonists reduce atrial fibrillation incidence in patients with diabetes and obesity. Aims: The goal of the study is to assess the effects of GLP-1 agonist on incidence of new AF in patients with obesity and diabetes following heart failure hospitalization. Methods: The study included consecutive patients who were admitted to an academic tertiary care center over three years with a primary diagnosis of heart failure exacerbation and no prior diagnosis of AF. The primary outcome was incidence of AF within 12 months after hospitalization. Demographic, comorbidity, echocardiography, and medications were obtained. Cox-regression analysis was performed to identify the predictors of new-onset AF following HF hospitalization. Results: Of the patients included in our study, 1668 (42.9%) have a BMI greater than or equal to 30, 574 (14.5%) have BMI greater than or equal to 40, and 2300 (58.2%) have diabetes mellitus. GLP-1 use is associated with a significantly lower incidence of AF at one year in obese patients (p=0.042; RR 0.73; 95% CI: 0.54-.99) (Figure), while in non-obese individuals, GLP-1 receptor agonist was not associated with a decreased incidence of AF (p=0.674; RR 1.08; 95% CI: 0.76-1.53). In patients with diabetes, GLP-1 receptor agonist use did not reach statistical significance for reduced AF incidence following heart failure hospitalization ( p=0.091; RR 0.80; 95% CI 0.62-1.04 ). Conclusion: GLP-1 receptor agonist use is associated with a statistically significant reduction of incidence of new atrial fibrillation at one year following hospitalization for heart failure in obese patients.

Abstract 4138611: Impact of SGLT-2 Inhibitor Use on Atrial Fibrillation Incidence Following Heart Failure Hospitalization

Introduction: The development of atrial fibrillation (AF) in patients with heart failure (HF) is associated with increased morbidity and mortality. Sodium-glucose cotransporter-2 (SGLT-2) inhibitors have demonstrated cardiovascular benefit in patients with both preserved and reduced ejection fractions. Meta analysis of prospective trials suggest reduced incidence and burden of atrial fibrillation in patients taking SGLT-2 inhibitors, though this has not been specifically addressed in prospective trials. Hypothesis: SGLT-2 inhibitors reduce the incidence of atrial fibrillation in patients with heart failure. Aim: The goal of the study is to assess the impact of SGLT-2 inhibitor on the incidence of atrial fibrillation following heart failure hospitalization. Methods: The study included consecutive patients who were admitted to an academic tertiary care center over a 3 year time period with a primary diagnosis of heart failure exacerbation and no prior diagnosis of AF. The primary outcome was development of AF within 12 months after hospitalization. Demographic, comorbidity, echocardiographic data, and medications were obtained. Cox-regression analysis was performed to identify the predictors of new-onset AF after HF hospitalization. Results: Among the 3,953 patients included in our study, 704 (17.8%) patients were prescribed SGLT-2 inhibitors. Of those taking SGLT-2 inhibitors, 559 (79.4%) patients had diabetes. SGLT-2 inhibitor use is associated with significant reduction of AF at one year ( p&lt;0.001; RR 0.65; 95% CI: 0.51-.81 ). This finding was consistent across patients with reduced ejection fractions (EF&lt;50%) ( p=0.001; RR 0.56; 95% CI: 0.40-.80 ) and preserved ejection fraction (EF&gt;50%)( p=0.001; RR 0.58; 95% CI: 0.42-0.80 ). Conclusion: In patients with reduced ejection fraction and preserved ejection fraction heart failure, use of an SGLT-2 inhibitor is associated with a statistically significant lower risk of new-onset atrial fibrillation at one year following HF hospitalization.

Increased individual workload for nuclear medicine physicians over the past years: 2008-2023 data from The Netherlands.

To investigate temporal trends in the individual workload of nuclear medicine physicians at a large tertiary care academic center between 2008 and 2023. This study analyzed the reporting workload of nuclear medicine physicians in a large tertiary care academic center in The Netherlands on 36 unique (randomly sampled) calendar days, for each year between 2008 and 2023. The average daily departmental workload (measured with relative value units) was calculated for each year between 2008 and 2023. The individual workload was calculated by dividing the average daily departmental workload in each year by the available full-time equivalent nuclear medicine physicians in each year. Mann-Kendall tests were used to assess for any temporal monotonic trends in individual workload and types of nuclear medicine procedures performed. Individual workload increased significantly between 2008 and 2023 (Mann-Kendall tau of 0.611, P = 0.001). Individual workload in 2023 was 86% higher than in 2008. The use of positron emission tomography (PET) increased significantly (Mann-Kendall tau of 0.912, P < 0.001) between 2008 and 2023. The use of diagnostic scintigraphy decreased significantly in the same period (Mann-Kendall tau of -0.817, P < 0.001). The use of DEXA also showed a significant decrease (Mann-Kendall tau of -0.467, P = 0.013), but this decrease was negligible on a relative scale. The number of therapeutic procedures (Mann-Kendall tau of -0.100, P = 0.626) remained statistically stable in this period. Our single-center study showed that the individual workload of nuclear medicine physicians has increased significantly between 2008 and 2023, driven by the rise in PET scans. The demand for both diagnostic and therapeutic nuclear medicine procedures and associated workload is expected to keep on increasing in the foreseeable future. This workload trend should be taken into account by policymakers involved in nuclear medicine staffing planning. A healthy balance between the nuclear medicine workforce and workload is necessary to maintain the quality of care, to be able to perform other important (academic) tasks such as research, educating and training medical students and residents, and management, and to prevent physician burnout and dropout.

Incidence of venous thromboembolic disease and risk of bleeding in critically ill patients with hematologic malignancies: A retrospective study

ObjectiveOur objectives were to describe the use of thromboprophylaxis and the incidence of VTE/bleeding in critically ill patients with hematologic malignancies (HM). DesignRetrospective cohort study (2014–2022). SettingMedic-Surgical Intensive Care Unit (ICU) in a tertiary care academic center. PatientsAdult patients admitted to ICU with a concomitant diagnosis of a hematological malignancy. InterventionsNone. Main variables of interestWe analyzed demographic data, use of thromboprophylaxis and secondary outcomes that included incidence of VTE (venous thromboembolism), bleeding, mortality, severity scores and organ support. We applied a multivariable logistic regression model to examine the risk of thrombosis in the ICU. ResultsWe included 862 ICU admissions (813 unique patients). Thromboprophylaxis was given during 65% of admissions (LMWH 14%, UFH 8%, and SCDs 43%); in 21% it was contraindicated due to thrombocytopenia; 14% of cases lacked documentation on prophylaxis. There were 38 unique incident cases of VTE (27 DVT, 11 PE), constituting 4.4% of ICU episodes. Most of VTE cases happened in patients with various degrees of thrombocytopenia. In the multivariable analysis, SOFA score on the first ICU day was independently associated (OR 0.85, 95% CI 0.76−0.96) with the risk of VTE. Bleeding occurred in 7.2% (minor) and 14.4% (major) of episodes; most frequent sites being CNS, abdomen/GI and pulmonary. ConclusionsIn this cohort of critically ill patients with HM, there was considerable variability in the utilization of DVT prophylaxis, with predominant use of SCDs. The incidence of VTE was 4.4% and major bleeding 14%. Clinical Trial RegistrationNCT05396157. Venous Thromboembolism in Hematologic Malignancy and Hematopoietic Cell Transplant Patients: a Retrospective Study (https://clinicaltrials.gov/).

National Liver Cancer Screening Trial (TRACER) study protocol.

Professional guidelines recommend HCC screening in at-risk patients using semi-annual ultrasound with or without alpha-fetoprotein (AFP); however, this strategy has limited effectiveness due to low adherence and sensitivity. Increasing data support the potential role of blood-based biomarker panels, which could improve both aspects. The biomarker panel GALAD, comprised of sex, age, and 3 blood biomarkers (AFP, AFP-L3, and des-carboxy prothrombin des-carboxy prothrombin), has shown high sensitivity and specificity in biomarker phase II (case-control) and phase III (retrospective cohort) validation studies. However, prospective validation in a large phase IV biomarker clinical utility trial is necessary before its adoption in practice. The National Liver Cancer Screening Trial is an adaptive pragmatic randomized phase IV trial, which began enrollment in January 2024, comparing ultrasound-based versus biomarker-based screening in 5500 patients with chronic hepatitis B infection or cirrhosis from any etiology. Eligible patients are randomly assigned in a 1:1 ratio to semi-annual screening with ultrasound ± alpha-fetoprotein (arm A) or semi-annual screening with GALAD (arm B). Randomization is stratified by enrollment site, liver disease severity (per Child-Pugh class), liver disease etiology (viral, nonviral, and noncirrhotic HBV), and sex. Patients are being recruited from 15 sites (a mix of tertiary care academic referral centers, safety-net health systems, and large community health systems) over a 3-year period, and the primary endpoint, reduction in late-stage HCC, will be assessed at the end of year 5.5. The results of this trial will inform the best strategy for HCC screening and early-stage detection in patients with chronic liver diseases. If GALAD shows superiority, HCC screening would primarily shift from an ultrasound-based strategy to the adoption of the biomarker panel. NCT06084234. The TRACER Study is actively enrolling.