Tertiary Care Medical Center Research Articles

Most adults with severe HbSC disease are not treated with hydroxyurea.

Sickle cell hemoglobin SC (HbSC) disease is the second most frequent sickle cell disease (SCD) genotype after sickle cell anemia (HbSS). Globally, ∼55 000 newborns with HbSC are delivered annually, with the highest HbC gene frequency in West Africa. In Ghana, 40% of adults visiting the Ghana Institute of Clinical Genetics SCD clinic have HbSC. Unlike HbSS, hydroxyurea use is not routinely recommended for individuals with HbSC because of the perceived high-risk to benefit ratio. To test the hypothesis that at least 5% of adults with HbSC will meet the American Society of Hematology criteria for severe disease, we conducted a retrospective descriptive cohort study of all individuals with HbSC (≥18 years) who visited the clinic in 2019. Adults with HbSC aged from 18 to 45 years were selected. We identified a comparison group of 639 individuals with HbSS and matched the frequency based on the age and sex of individuals with HbSC. Severe disease was defined as a history of ≥3 SCD-associated moderate or severe pain episodes per year, history of acute chest syndrome, and severe symptomatic chronic anemia that interferes with daily activities or quality of life. The study end points were the proportion of individuals with SCD who met the definition of severe disease and were eligible for hydroxyurea. In total, 64 of 639 (10.0%) individuals with HbSC met the eligibility criteria for hydroxyurea therapy compared with 154 of 639 (24.1%) individuals with HbSS. Less than 1% and 3% of individuals with severe HbSC and HbSS, respectively, were routinely prescribed with hydroxyurea in this tertiary care medical center.

Quantifying Intubation Forces on Incisors and Tongue Base Across Exposure Difficulty and Experience in a Simulator.

Laryngoscopy simulators quantifying forces on critical structures in progressively challenging airways and operator expertise are lacking. We aimed to quantify laryngoscopy forces across expertise and exposure difficulty. Prospective observational study Setting: Tertiary care medical center Methods: Force gauges were affixed to a difficult airway mannequin to quantify teeth and tongue forces across increasingly challenging airway exposure. Medical students (n=10), residents (n=11), and otolaryngology staff (n=10) performed direct laryngoscopy using a Miller size 3 laryngoscope with 1) normal neck/jaw mobility, 2) restricted neck extension, 3) restricted jaw opening, and 4) restricted neck/jaw mobility. Incisor and tongue pounds of force (lbf) were continuously measured. As the difficulty setting increased, forces exerted by the students, residents, and staff on the incisors and tongue base increased (p=0.01). Between normal and maximally restricted settings, force delivered to the incisors increased by 6.95 lbf (standard error (SE) 1.29), 5.93 lbf (SE 0.98), and 5.94 lbf (SE 0.70) for the students, residents, and staff, respectively. At the tongue base, force increased by 0.37 lbf (SE 0.18), 0.46 lbf (SE 0.14), and 0.73 lbf (SE 0.15) for the students, residents, and staff, respectively. Esophageal intubations occurred in 50% of the students, 23% of the residents, and 45% of the otolaryngology staff at maximal difficulty, with none at the easiest setting (p=0.33). Compared to the residents, the staff applied significantly increased pressure on the tongue base during laryngoscopy (p=0.02). Forces exerted on the incisors and tongue base varied across exposure difficulty and expertise levels, suggesting that they may be useful markers for training and competence assessment.

Factors Associated With Neuroradiologic Diagnostic Errors at a Large Tertiary-Care Academic Medical Center: A Case-Control Study.

BACKGROUND. Numerous studies have explored factors associated with diagnostic errors in neuroradiology; however, large-scale multivariable analyses are lacking. OBJECTIVE. The purpose of this study was to evaluate associations of interpretation time, shift volume, care setting, day of week, and trainee participation with diagnostic errors by neuroradiologists at a large academic medical center. METHODS. This retrospective case-control study using a large tertiary-care academic medical center's neuroradiology quality assurance database evaluated CT and MRI examinations for which neuroradiologists had assigned RADPEER scores. The database was searched from January 2014 through March 2020 for examinations without (RADPEER score of 1) or with (RADPEER scores of 2a, 2b, 3a, 3b, or 4) diagnostic error. For each examination with error, two examinations without error were randomly selected (unless only one examination could be identified) and matched by interpreting radiologist and examination type to form case and control groups. Marginal mixed-effects logistic regression models were used to assess associations of diagnostic error with interpretation time (number of minutes since the immediately preceding report's completion), shift volume (number of examinations interpreted during the shift), emergency/inpatient setting, weekend interpretation, and trainee participation in interpretation. RESULTS. The case group included 564 examinations in 564 patients (mean age, 50.0 ± 25.0 [SD] years; 309 men, 255 women); the control group included 1019 examinations in 1019 patients (mean age, 52.5 ± 23.2 years; 540 men, 479 women). In the case versus control group, mean interpretation time was 16.3 ± 17.2 [SD] minutes versus 14.8 ± 16.7 minutes; mean shift volume was 50.0 ± 22.1 [SD] examinations versus 45.4 ± 22.9 examinations. In univariable models, diagnostic error was associated with shift volume (OR = 1.22, p < .001) and weekend interpretation (OR = 1.60, p < .001) but not interpretation time, emergency/inpatient setting, or trainee participation (p > .05). However, in multivariable models, diagnostic error was independently associated with interpretation time (OR = 1.18, p = .003), shift volume (OR = 1.27, p < .001), and weekend interpretation (OR = 1.69, p = .02). In subanalysis, diagnostic error showed independent associations on weekdays with interpretation time (OR = 1.18, p = .003) and shift volume (OR = 1.27, p < .001); such associations were not observed on weekends (interpretation time: p = .62; shift volume: p = .58). CONCLUSION. Diagnostic errors in neuroradiology were associated with longer interpretation times, higher shift volumes, and weekend interpretation. CLINICAL IMPACT. These findings should be considered when designing work-flow-related interventions seeking to reduce neuroradiology interpretation errors.

SUSCEPTIBILITY WEIGHTED IMAGING TECHNIQUE UTILITY IN DIVERSE NEUROLOGICAL ENTITIES

Background: Susceptibility Weighted Imaging (SWI) is a novel modality based upon GE (Gradient Echo) sequences that employ differences in susceptibility of various paramagnetic as well as diamagnetic substances that aid in the better diagnosis of various neurological entities such as intracranial tumors, vascular malformations, arterial stroke, venous hemorrhagic infarcts. Objective:To assess utility of SWI in various neurological diseases. Methods: The retrospective observational study was held in a tertiary care medical center in India in 2021. Multiple neurological diseases on SWI were analyzed in 100 patients with neurological complaints. The inclusion criteria included patient of all age group who presented with neurological signs and symptoms. The exclusion criteria included presence of post-operative non-compatible orthopedic hardware and patients with cardiac pacemakers, cochlear implants in situ. Results: The majority were males and &gt; 60 years (23%) in age. Among 100 patients, most had tumors (18%), followed by trauma (16%), arterial stroke (15%), and hemorrhage (14%). Most of 14 patients with hemorrhage have intraparenchymal hemorrhage 9 (64.29%). There were10 patients with venous sinuses thrombosis and 15 cases with arterial stroke amongst whom most had middle cerebral artery thrombosis (46.66%). Most 13 patients with vascular pathologies had amyloid angiopathy 4 (30.77%). The majority of tumors were primary 15 (83.33%) with 10 (66.67%) newly diagnosed tumors, 11 (61.11%) tumors had a hemorrhage, 3 (16.67%) presented with calcification, and 4 (22.22%) had both hemorrhage and calcification. According to SWI grading of the tumor by intratumoral susceptibility score (ITSS), the majority were in grade III. On the correlation of SWI grading with MR Spectroscopy (MRS) and MR perfusion (MRP) study, 6 (100%) grade III patients showed hyperperfusion on MRP with raised choline/Creatinine ratio. SWI was better than CT (P&lt;0.05) in detecting trauma, hemorrhage, cerebral venous sinus thrombosis, vascular pathologies, and tumors. Conclusion: SWI is a helpful imaging tool in neuroradiological practice and should be incorporated into standard procedures. It is beneficial in identifying hemorrhages, low-flow vascular abnormalities, diffuse axonal injury, and neurodegenerative illnesses. In addition, it is a supplementary sequence in the stroke by distinguishing calcium from hemorrhage in the brain and categorizing brain tumors.

Quality Improvement (QI) Framework to Examine Health Care Disparities in Behavioral Emergency Management in the Inpatient Medical Setting: A Consultation-Liaison (CL) Psychiatry Health Equity Project.

De-escalation of behavioral emergencies in the inpatient medical setting may involve restrictive clinical interventions that directly challenge patient autonomy. We describe a quality improvement framework used to examine associations between patient characteristics and behavioral emergency de-escalation strategies. This project may inform other Consultation-Liaison Psychiatry teams seeking to promote equity in care. We examined behavioral emergency response team (BERT) management at an urban, tertiary-care medical center in the United States over a 3-year period. BERT data from an existing dataset were combined with demographic information from the hospital's electronic medical record. Race and ethnic identities were categorized as Black, Hispanic, Asian, White, and unknown. BERT events were coded based on the most restrictive intervention utilized per unique patient. Cross-tabulations and adjusted odds ratios from multivariate logistic regression were used to identify quality improvement targets in this exploratory project. The sample included N= 902 patients and 1532 BERT events. The most frequent intervention reached was verbal de-escalation (n= 419 patients, 46.45%) and the least frequent was 4-point restraints (n= 29 patients, 3.2%). Half of BERT activations for Asian and a third for Hispanic patients required interpreter services. Anxiety and cognitive disorders and 2 BERT interventions, verbal de-escalation, and intramuscular/intravenous/ medications, were significantly associated with race/ethnic category. The most restrictive intervention for BERTs involving Black and Asian patients were verbal de-escalation (60.1%) and intramuscular/intravenous(53.7%), respectively. These proportions were higher compared with other race/ethnic groups. There was a greater percentage of patients from the unknown (6.3%) and Black (5.9%) race/ethnic groups placed in 4-point restraints compared with other groups (3.2%) that did not reach statistical significance. A logistic regression model predicting 4-point restraints indicated that younger age, multiple BERTs, and violent behavior as a reason for BERT activation, but not race/ethnic group, resulted in significantly higher odds. This project illustrates that a quality improvement framework utilizing existing clinical data can be used to engage in organizational introspection and identify potential areas of bias in BERT management. Our findings suggest opportunities for further exploration, enhanced education, and programmatic improvements regarding BERT intervention; 4-point restraints; interpreter services; and the influence of race on perception of psychopathology.

Healthcare Burden Associated with Malnutrition Diagnoses in Hospitalized Children with Critical Illnesses.

Our primary study objectives were to (i) determine the proportion of children admitted to the Pediatric Intensive Care Unit (PICU) with malnutrition diagnoses, (ii) compare healthcare utilization by malnourished and non-malnourished PICU patients, and (iii) examine the impact of implementing malnutrition screening and coding practices at a major academic urban tertiary care medical center. Using patient records, we conducted a retrospective analysis of 4106 children admitted to the PICU for severe illnesses between 2011 and 2019. Patients were identified as malnourished if records showed an ICD-9 or ICD-10 code for malnutrition. We compared malnourished and non-malnourished patients by age, admitting diagnoses, number of comorbid conditions, and clinical outcomes (length of stay, hospital readmission). About 1 of every 5 PICU-admitted patients (783/4106) had a malnutrition diagnosis. Patients with malnutrition were younger (mean age 6.2 vs. 6.9 years, p < 0.01) and had more comorbid conditions (14.3 vs. 7.9, p < 0.01) than those without. Malnourished patients had longer hospital stays (26.1 vs. 10.0 days, p < 0.01) and higher 30-day readmission rates (10% vs. 7%, p = 0.03). Implementation of malnutrition screening and coding practices was associated with an increase in malnutrition diagnosis. In this study of children admitted to the PICU, malnourished patients had more comorbid diagnoses and used more healthcare resources (prolonged hospitalizations and higher 30-day readmission rates), leading to higher healthcare costs. Such findings underscore the need for policies, training, and programs emphasizing identification and treatment of malnutrition at hospitals caring for critically ill children.

A feasibility study of urinary catheter removal protocol following transurethral prostatectomy procedure in older patients

AbstractWe hypothesized that older patients who underwent a urinary catheter removal protocol would not have an increased risk of postoperative complications. We further hypothesized that the revised protocol would be more suitable for clinical application. This study aimed to develop a urinary catheter removal protocol after Transurethral Resection of the Prostate and to assess the feasibility of the protocol to support catheter removal and promote recovery of self‐voiding function. Delayed catheter removal after Transurethral Resection of the Prostate was associated with urinary tract infection and longer hospital stays. However, no strategy has been described to promote recovery of self‐voiding function after catheter removal after Transurethral Resection of the Prostate. The urinary catheter removal protocol was developed through expert consensus, including strategies for caring for urinary catheters, assessment of urinary catheter removal, and strategies after urinary catheter removal. Moreover, a quasi‐experimental design was adopted in the urology ward of a tertiary care medical centre in southern Taiwan. Patients aged ≥65 years who underwent Transurethral Resection of the Prostate were included. A total of 13 patients (intervention = 5; control = 8) were included in the feasibility evaluation. A urinary catheter removal protocol after Transurethral Resection of the Prostate was developed and the consensus among experts on the urinary catheter removal protocol was 99%. There were no significant differences in terms of bleeding, urine retention, urinary tract infection, or re‐catheterization between the two groups. However, in the intervention group, the pain score decreased significantly on the second day after Transurethral Resection of the Prostate. This revised urinary catheter removal protocol after Transurethral Resection of the Prostate may be suitable for clinical applications. However, small size reduces the statistical power of the findings and further studies are needed to examine the current protocol does not have an increased risk of postoperative complications.

Timing of Transport of Patients with COVID-19.

The objective of this study was to evaluate the risk of mortality or ECMO cannulation for patients with confirmed or suspected COVID-19 transferred from sending hospitals to receiving tertiary care centers as a function of the duration of time at the sending hospital. To determine outcomes of critically ill patients with COVID-19 who were transferred to tertiary or quarternary care medical centers. Retrospective cohort study of critical care transports of patients to one of seven consortium tertiary care centers from March 1, 2020, through September 4, 2020. Age 14 years and older with confirmed or suspected COVID-19 transported from a sending hospital to a receiving tertiary care center by the critical care transport organization. Patients transported with confirmed or suspected COVID-19 to tertiary care centers had a mortality rate of 38.0%. Neither the number of days admitted, nor the number of days intubated at the sending hospital correlated with mortality (correlation coefficient 0.051 and -0.007, respectively). Similarly, neither the number of days admitted, nor number of days intubated at the sending hospital correlated with ECMO cannulation (correlation coefficient 0.008 and -0.036, respectively). It may be reasonable to transfer a critically ill COVID-19 patient to a tertiary care center even if they have been admitted at the sending hospital for several days.

The current status of emergency departments in secondary emergency medical institutions in Japan: a questionnaire survey

BackgroundWhile emergency medicine (ER)-based emergency care is prevalent in many countries, in Japan, the “department-specific emergency care model” and the “emergency center model” are mainstream. We hypothesized that many secondary emergency medical institutions in Japan have inadequate systems. Using a questionnaire, we investigated the status of and problems in the emergency medical services system in secondary emergency medical institutions in Japan. Until date, there has not been an exhaustive survey of emergency facilities on a countrywide scale. The main objective of this study was to investigate problems in the Japanese emergency medical services system and thereby improve optimal care for emergency patients.ResultsA nationwide questionnaire survey involving 4063 facilities (all government-approved emergency medical facilities certified by prefectural governors) in Japan was conducted. Of the facilities that responded, all secondary emergency facilities were included in the analysis. Responses from 1289 facilities without a tertiary emergency medical care center were analyzed. Among them, 61% (792/1289) had ≤ 199 beds, and 8% were emergency department specialty training program core facilities. Moreover, 42% had an annual patient acceptance number of ≤ 500, 19% did not calculate the number of acceptances, 29% had an acceptance rate of ≥ 81%, and 25% had an acceptance rate of 61–80%. Pregnant women (63%) and children (56%) were the major types of patients that affected the acceptance rate. Factors affecting facilities with a response rate of 81% or higher were “hospitals designated for residency training” and “facilities making some efforts to improve the quality of emergency care and the emergency medical system” (logistic analysis, P < .001).ConclusionRelevant authorities and core regional facilities should consider and implement specific measures for regions and hospitals with a shortage of emergency medicine specialists and physicians (e.g., development of ER-based emergency medicine and provision of education). This study may lead to further improvement in the optimal care of emergency patients through the nationwide establishment of the proposed measures as well as through grouping and integrating the structures and systems in emergency and other medical facilities.

P-758 Impact of serum estradiol levels prior to progesterone administration in artificial frozen embryo transfer cycles:a retrospective study over 26,000 cycles

Abstract Study question To investigate whether serum estradiol (E2) levels prior to progesterone administration in the FET-cycle affect the Clinical pregnancy rate (CPR) and live birth rate (LBR). Summary answer High serum E2 levels prior to progesterone administration in Artificial endometrial preparation are associated with a decreased live birth rate and clinical pregnancy rate . What is known already Although the use of FET has progressively increased, it is still unknown whether a specific endometrial preparation protocol should be favored over another. Owing to their minimal need for clinic visits and a larger scheduling flexibility, artificial cycles for FET are widely used. Additional to the ultrasonographic endometrial thickness check prior to FET, the need for endocrine monitoring in artificial cycles remains unclear. Specifically, the value of proliferative phase serum hormone measurements remains a point of discussion. Study design, size, duration A total of 26,194 artificial FETs performed in a Tertiary-care academic medical centre between 2016 and 2021 were subdivided into 3 groups according to the following late-proliferative serum E2 level percentiles: ≤p33.3 (E2 ≤118 pg/ml; n = 8784), p33.4–p66.6 (E2 from 118.1 to 231.9 pg/ml; n = 8662) and ≥p66.7 (E2 ≥232 pg/ml; n = 8748). Participants/materials, setting, methods A retrospective study over 26,194 cycles,from 2016 to 2021 were included.Univariable and multivariable logistic regression analysis was performed. Main results and the role of chance In 26,194 cycles, there were significant differences in CPR and LBR among the tri-sectional quantiles groups with E2 levels. After stratifying the analysis by age, BMI, infertility diagnosis, type of embryo transferred, number of transferred embryos, infertility factors, method of fertilization, and endometrial thickness on transfer day, there were still significant differences in CPR and LBR among the tri-sectional quantiles group with E2 levels. Multivariate regression analysis showed that female age, thin endometrium, high serum E2 level, tubal factor infertility were risk factors for CPR and LBR, ICSI fertilization, blastocyst transfer, the number of transferred embryos, ovulation disorder infertility and male factor infertility were protective factors for CPR and LBR, BMI was only a risk factor for LBR. Limitations, reasons for caution •Different routes of administration affect serum estrogen levels,and the relationship of serum estrogen levels and endometrial estrogen concentrations is unclear Wider implications of the findings High miscarriage rate following FET has been a point of debate in literature.Future research should definitely focus on the the usefulness of serum E2 evaluation to optimize the success rate. Trial registration number Not applicable

431 Assessment of racial and ethnic differences of atopic dermatitis severity and treatment patterns in a diverse outpatient cohort in the United States

Abstract Previous population-based studies in the USA found racial and ethnic differences of atopic dermatitis (AD) severity and treatment patterns. It is unclear whether these differences are from differences of disease characteristics or disparities. This study aims to examine racial and ethnic differences in severity and treatment patterns in a diverse outpatient patient cohort of patients with AD (n = 833). A retrospective observational study was performed of patients with physician-diagnosed atopic AD from a large metropolitan tertiary care medical center. Medical records were reviewed for race, ethnicity, disease severity and use of therapies from 10/01/2015-10/1/2021. Atopic dermatitis cases were identified using Hanifin–Rajka criteria. Chi-square or Fisher’s exact tests or were used to assess associations of race and ethnicity with AD severity. Generalized linear models were used to assess interactions of race or ethnicity with gender or age as predictors of individual treatments. There were no significant associations of body surface area (BSA; Fisher’s exact test, P = 0.19 and P = 0.44) or physician’s global assessment (PGA; P = 0.63 and P = 0.57) with race or ethnicity; nor interactions of race/ethnicity with gender or age as predictors of BSA or PGA. Asian and multiracial/other patients were more likely than White or Black patients to use topical calcineurin inhibitors (Chi-square, P = 0.01). Dupilumab use differed by race (Multiracial/other = 35.0%; White = 20.1%; Asian = 15.7%; Black = 13.6%; Chi-square, P = 0.03), but not ethnicity (P = 0.88). Use of oral corticosteroids (Chi-square, P = 0.74), immunosuppressants (P = 0.98) or GABAergics (P = 0.16), or NBUVB (P = 0.42) did not differ by race. There were no statistical interactions of race or ethnicity with gender or age as predictors of treatment use. This study demonstrates that AD severity and specific treatments did not differ overall between racial and ethnic groups in this diverse urban academic cohort.

432 Comparative treatment persistence of different advanced-therapies in patients with atopic dermatitis

Abstract Multiple advanced therapies are used to treat atopic dermatitis (AD), each with different efficacy, safety, tolerability, accessibility and treatment success that can affect treatment persistence. Little is known about how treatment persistence rates compare between different therapies. We compared treatment persistence for subcutaneous dupilumab, oral cyclosporine, mycophenolate, and upadacitinib, and narrowband ultraviolet B (NB-UVB) treatment of AD. A retrospective observational study was performed of patients with physician-diagnosed atopic AD from a large metropolitan tertiary care medical center. Medical records were reviewed for race, ethnicity, disease severity and use of therapies from 10/01/2015 to 10/1/2021. The AD cases were identified using Hanifin–Rajka criteria. Drug persistence was assessed using proportion of patients who discontinued therapy and median time to discontinuation. Chi-square tests were used to assess if there were differences in drug discontinuation rates by advanced therapy. Overall, 766 patients with AD were identified, including 139 (18.1%) prescribed dupilumab, 10 (1.3%) cyclosporine, 21 (2.7%) mycophenolate, 5 (0.7%) upadacitinib and 64 (8.4%) NB-UVB; no patients were treated with methotrexate. Drug persistence was highest for upadacitinib (100%), followed by dupilumab (86.3%), mycophenolate (38.1%), cyclosporine (30.0%) and NB-UVB (12.5%) (Chi-square, P &amp;lt; 0.0001). Highest median (days) time to discontinuation was observed with dupilumab (638), followed by cyclosporine (539), mycophenolate (274) and NB-UVB (167). Lack of efficacy was the most common reason for discontinuation of dupilumab, cyclosporine, mycophenolate and NB-UVB alike. Discontinuation due to adverse-events was highest for cyclosporine (42.9%), followed by dupilumab (31.6%), mycophenolate (30.8%) and NB-UVB (16.1%). Dupilumab had the most patients who discontinued due to disease improvement and no longer requiring advanced-therapy (21.1%). Our data suggest that drug persistence varies substantially across different advanced therapies for AD. Recently approved advanced therapies, including dupilumab and upadacitinib, showed the highest proportion of drug persistence.

Mental wellbeing of frontline health workers post-pandemic: lessons learned and a way forward.

To assess the state of mental wellbeing among medical and dental frontline health workers as the COVID-19 pandemic transitions to an endemic phase and to determine what employer-provided intervention strategies these workers perceive as effective and desirable to improve their mental wellbeing. An anonymous online survey distributed to frontline health workers in a hospitalist program of a tertiary care medical center and a university dental school in Minnesota in September 2022. The survey contained validated tools to measure depression severity, levels of perceived stress, and mental health status as well as questions to determine effective strategies to improve emotional wellbeing among these health workers. Data was evaluated on an aggregate level as well as stratified by level (e.g., physician, staff) and field (e.g., medicine, dentistry). On average, all groups of health workers suffered from moderate to moderately severe depression, had a much higher perceived stress level than average, and had a fair mental health status. There were no significant differences in depression severity, stress level, or mental health status among physicians, dentists, medical staff, and dental staff. The majority of the respondents perceived adjusted work hours, rewards and incentives, and teamwork as the most effective and desirable strategies to improve their mental wellbeing. The current mental wellbeing of frontline health workers is poor. Many are dissatisfied with healthcare and consider leaving the industry. To improve their employees' mental wellbeing, healthcare employers might want to consider adjusted work hours, rewards, and teamwork as these intervention strategies are perceived as most effective and desirable by the intended recipients.

Resting abnormalities encountered in stress echocardiography predict long-term outcomes among patients admitted for chest pain

Abstract Funding Acknowledgements Type of funding sources: None. Background Patients hospitalized with chest pain frequently undergo stress echocardiography for detecting inducible ischemia, but other cardiac pathology is often noted on rest imaging. The long term significance of these findings is not well studied. We hypothesized that such findings indicative of cardiovascular pathology on the resting portion of a stress echocardiogram have prognostic significance for patients admitted with chest pain. Methods We examined patients admitted with chest pain at an academic tertiary care medical center over a 2-year period who had stress echocardiography as the primary diagnostic test. Patients admitted with heart failure symptoms or syncope or patients referred for presurgical/prerehabilitation clearance were excluded. Resting and stress echocardiograms were evaluated by cardiologists with board-certification in echocardiography, and resting abnormalities were analyzed for any effect on cardiovascular outcomes, assessed over 3 years of follow up. Survival of patients with echocardiographic abnormalities on the resting study (resting wall motion abnormalities) was compared with an age- and sex-matched cohort of admitted chest pain patients without resting abnormalities. Results A total of 587 patients met inclusion criteria, and 198 (34%) had resting echocardiographic abnormalities. The most common abnormality involved the left ventricle. Left ventricular hypertrophy (LVH) was seen in 16% (96), and resting wall abnormalities were seen in 15% (90); among the 90 patients with resting wall motion abnormalities, segmental wall motion abnormality was seen in 57 (9.7% of total sample), and global LV dysfunction was seen in 33 (5.6% of total sample). LVH in the absence of hypertension was found in 5% (28), raising the diagnostic possibility of hypertrophic cardiomyopathy. Moderate or greater left heart valvular abnormalities were found in 3% (18). Abnormal pericardial effusions greater than mild (excluding trivial effusion) were found in 3 patients (0.5%), and pulmonary hypertension was detected in 13 patients (2%). At 3-year follow-up, patients with resting wall motion abnormalities were found to have a higher mortality than an age and sex-matched cohort of chest pain patients without these abnormalities at rest; 85% vs. 97%, p&amp;lt;0.015. Conclusions In patients hospitalized for chest pain, cardiac diagnoses with prognostic significance are often detected on the resting echocardiographic examination. These abnormalities offer insight into outcomes, given their propensity to determine mortality three years post admission, and an opportunity to institute adequate therapy that alters adverse outcomes.

Preimplantation genetic testing for sickle cell disease: a cost-effectiveness analysis

To evaluate the cost-effectiveness of invitro fertilization with preimplantation genetic testing for monogenic disease (IVF + PGT-M) in the conception of a nonsickle cell disease (non-SCD) individual compared with standard of care treatment for a naturally conceived, sickle cell disease (SCD)-affected individual. A Markov simulation model was constructed to evaluate a one-time IVF + PGT-M treatment compared with the lifetime standard of care costs of treatment for an individual potentially born with SCD. Using an annual discount rate of 3% for cost and outcome measures, quality-adjusted life years were constructed from utility weights and life expectancy values and then used as the effectiveness measurement. An incremental cost-effectiveness ratio was calculated for both treatment arms, and a willingness-to-pay threshold of $50,000 per quality-adjusted life year was assumed. Tertiary care or university medical center. A hypothetical cohort of 10,000 patients was analzyed over a lifetime horizon using yearly cycles. Invitro fertilization with preimplantation genetic testing for monogenic disease use in conception of a non-SCD individual. The primary outcomes of interest were the incremental cost and effectiveness of an IVF+PGT-M conception compared with the SOC treatment of an SCD-affected individual. Invitro fertilization with preimplantation genetic testing for monogenic disease was the optimal strategy in 93.17% of the iterations. An incremental savings of $137,594 was demonstrated with a gain of 1.96 QALYs and 3.69 life years over a lifetime. Sensitivity analysis demonstrated that SOC treatment never met equivalent cost-effectiveness. Our model demonstrates that IVF + PGT-M for selection against SCD, compared with lifetime SOC treatment for those affected, is the most cost-effective strategy within the United States healthcare sector.

To Study the Frontal Lobe Alterations in Patients of Schizophrenia

ABSTRACT Background: Schizophrenia is one of the most perplexing of all brain conditions due to its persistent and severe psychotic manifestations with variable cognitive dysfunction. The pathophysiology of schizophrenia being unknown, the fact that brain circuits are involved and the areas frequently affected being the limbic system, forebrain, and the hindbrain becomes a fertile area for exploration. Aim: The aim was to study the frontal lobe alterations in patients of schizophrenia. Materials and Methods: A cross-sectional, analytical, and comparative study was done in a tertiary care medical college and research center. Forty patients of schizophrenia with 40 age- and sex-matched healthy individuals were included in the study after informed consent and an institutional ethical clearance. Self-made demographic and clinical questionnaire, the Positive and Negative Syndrome Scale, Frontal Assessment Battery (FAB), Stroop test, and Wisconsin Card Sorting Test (WCST) were applied to all the subjects. Results: A significant difference in cognitive impairment was found in patients as compared to controls, seen by a poor performance of patients in FAB and WCST along with a higher Stroop effect. Duration of illness, family history of psychiatric illness, number of episodes, and comorbid substance use were found to be positive predictors of higher cognitive impairment. Conclusion: There is a significant level of frontal lobe dysfunction seen in patients of schizophrenia on Stroop test, FAB, and WCST. Family history of psychiatric illness and substance use, especially tobacco, are the factors worsening cognitive dysfunction, while education plays a protective role.

Association between serum progesterone levels on the day of frozen-thawed embryo transfer and pregnancy outcomes after artificial endometrial preparation

BackgroundPrevious studies have examined that a range of optimal serum P level during the implantation period was associated with optimal live birth rates. However, those results obtained with vaginal or intramuscular route of progesterone administration for luteal phase support (LPS) alone. Is there a relationship between the serum progesterone (P) on the day of frozen-thawed embryo transfer (FET) with the likelihood of a live birth (LB) in artificial cycles (AC) when using a combination of oral dydrogesterone and vaginal progesterone for LPS?MethodsThis was a retrospective study of 3659 FET cycles with artificial endometrial preparation in a Chinese tertiary-care academic medical centre from January 2015 to February 2017. Endometrial preparation was performed using estradiol (E2) valerate (Fematon-red tablets) 8 mg/d beginning on day 3 of the cycle, followed by administration of P both orally (8 mg/d Fematon-yellow tablets) and vaginally (400 mg/d; Utrogestan). The primary endpoint was live birth rate (LBR). The association between the serum P level on the embryo transfer day and pregnancy outcomes was evaluated by univariable and multivariable logistic regression analysis.ResultsThe LBRs according to the serum P quartiles were as follows: Q1: 35.7%; Q2: 37.4%; Q3: 39.1% and Q4: 38.9%. Logistic regression analysis showed that the odds of a LB were not significantly different between the low (P < 7.9 ng/mL) and high (P ≥ 7.9 ng/mL) progesterone groups before or after adjustment (crude OR = 0.89, 95% CI: 0.76–1.04; adjusted OR = 0.89, 95% CI: 0.75–1.04).ConclusionThe present study suggests that the serum P levels on the day of embryo transfer (ET) do not correlate with the likelihood of a LB in artificial cycles when using a combination of oral dydrogesterone and vaginal progesterone for luteal phase support.

Relationship Between Physician Burnout and Workplace Specific Stressors: The Loss of Positive Perception

To evaluate relationships between physician-reported workplace burnout and ratings of potential workplace stressors. A voluntary survey on workplace burnout was conducted by physicians at a university-affiliated tertiary care medical center including the work-related domain of the Copenhagen Burnout Inventory, no/little burnout (considered non-burnout): <50 points and moderate-to-severe burnout: >50 points, General Self-Efficacy Scale: (0-40 points), Insomnia Severity Index (0-28), Perceived Stress Scale (0-40), and questionnaire of 19 potential workplace stressors by 5-point Likert scale from strongly negative to very positive. Analysis was performed with the χ2 and Student t-test. Ninety (78%) respondents completed all components. Workplace burnout occurred in 54 (60%) respondents. General Self-Efficacy Scale was lower in those with burnout (31.3 vs 33.5; P = .008), whereas Insomnia Severity Index and Perceived Stress Scale were higher (9.8 vs 5.7; P < .001, 21.9 vs 20.3; P = .024, respectively). Electronic medical records (EMRs), billing, and delays were viewed as negative stressors for all-comers (burnout vs non-burnout): EMR (81% vs 64%; P = .19), billing (61% vs 47%; P = .25), and delays (86% vs 76%; P = .32), respectively. The ability to complete work was also a negative stressor but significantly more prevalent with concomitant burnout (55% vs 22%; P = .005). Positive factors identified by both groups included clinical decision-making (80% vs 83%; P = .053) and patient interaction (57% vs 69%; P = .06). Staff/peer relationships (P = .029) and team communication (P = .014) were viewed as positive factors by both, but significantly more in those without burnout (Table). Both groups rated clinical work volume (P = .40), adequate staff (P = .66), hospital mandates (P = .75), and insurers (P = .82) in top 5 workplace stressors. Physicians possess high self-efficacy. Still, workplace burnout is common and associated with higher stress levels, sleep dissatisfaction, and lower self-efficacy. Billing, delays, EMR, support staff, and hospital mandates are negative stressors regardless of burnout status. Physician perception regarding inability to complete work may indicate progression toward burnout. Otherwise, burnout is characterized by subtle loss of positivity particularly relationships and communication rather than overt pessimism and may go unrecognized. This underscores the need for early detection and intervention to prevent burnout and promote physician well-being.TableDifferences in perception of workplace factors by burnout statusVery negativeNegativeNeutralPositiveVery positiveP valueNon-burnoutBurnoutNon-burnoutBurnoutNon-burnoutBurnoutNon-burnoutBurnoutNon-burnoutBurnoutStaff/Peer relations3661519295341199.029Team communication0261119285355224.014Scheduling procedures03108376423153010.029Hospital discharge381825495924662.026Completing work3231932392731989.005Patient unit proximity069643653715118.042Data are presented as percentage.Boldface P values represent significance P < .05. Open table in a new tab

CE-452778-1 LEFT ATRIAL MECHANICAL DYSFUNCTION AND THE INCIDENCE OF ATRIAL FIBRILLATION WITHIN 1 YEAR OF EMBOLIC STROKE OF UNKNOWN SOURCE

Atrial fibrillation (AF) is detected in a significant proportion of patients with embolic stroke of unkown source (ESUS) on subsequent cardiac monitoring and represents an indication for anticoagulation to prevent future stroke in these patients. Left atrial mechanical dysfunction often precedes development of atrial fibrillation and may represent an upstream marker which can readily be assessed at the point of care to inform decisions about future stroke prevention in people with ESUS. To evaluate the association between left atrial mechanical dysfunction, measured by left atrial emptying fraction (LAEF) and reservoir strain (LARS), and incident atrial fibrillation in patients with ESUS. Patients with interpretable echocardiograms who received an implantable loop recorder for ESUS at a tertiary care medical center between 2015 and 2022 were included and followed for 1 year. LAEF and LARS were calculated from two-dimensional transthoracic echocardiograms. Covariates including congestive heart failure, hypertension, age, diabetes, sex, stroke/transient ischemic attack, and vascular disease were ascertained by review of hospital medical records. Incident AF post ESUS was obtained from review of loop recorder data. Odds ratios were calculated using logistic regression models. Two-sided student's T-test was used to compare means of continuous variables. 167 patients (mean age 74.4 years, 52.1% female) were followed for 1 year after ESUS. AF was detected in 49 (20.3%) patients. Patients who developed AF had lower LAEF (46.78% vs 57.50%, P<0.01) and LARS (24.33% vs 31.60%, P<0.01) compared to those who did not develop AF. LAEF and LARS were independently associated with AF within 1 year of ESUS (Table). Left atrial mechanical dysfunction, detected by meeasurement of left atrial reseervoir strain and emptying fraction, is independently associated with the incidence of atrial fibrillation within 1 year of ESUS.

PO-04-216 PATIENT ENABLED INR OPTIMIZATION : A MULTICENTER PROSPECTIVE STUDY

For patients using Vitamin K antagonists (VKA), maximizing time within the therapeutic range (TTR) reduces stroke, major hemorrhage, and death. Despite improvements in counselling and patient education, patients using Vitamin K antagonists have a poor TTR. The objective of this study was to evaluate the effectiveness and safety of a smartphone application for improvement in TTR with minimal physician interference. Content was customized on a smartphone based platform (INR Assist) for patients using VKA which included automated INR dosage adjustment, tracking, reminders, and education. A multicenter prospective open-label study was conducted at two tertiary care medical centers with patients using VKA for at least the previous 6 months. In order to tailor INR dose adjustment, patients were enrolled into either normal bleeding/thrombotic risk (Group A), high bleeding risk (Group B) or high thrombotic risk (Group C) at the discretion of the treating physician. The primary endpoint of the study was the change in TTR before and after 6 months of using INR Assist. Secondary endpoints included stroke, major bleeding, and red-alerts (INR not in TTR for 3 consecutive entries, INR>6.0, INR<1.5) by the application that required direct physician assistance. There were 184 patients (mean age 50.5 + 8.2, males 68.5%) using VKA for either AF stroke prevention (54.9%), metallic valve replacement (38.6%), or venous thromboembolism (6.5%) were included in the study between January 2019 and June 2022. The number of patients enrolled in Groups A, B, and C were 145 (90.2%), 10 (6.0%), and 7 (3.8%), respectively. After a minimum of 6 months of using INR Assist, TTR improved from 59.2 + 6.7% to 80.5 + 9.4% (p<0.001). The improvement in TTR was similar in all three groups (p<0.001). There were fewer bleeding(3.1% vs. 1.2%, p=0.105) and thrombotic events (2.5% vs. 0.6%, p=0.115) following utilization of INR Assist. Overall there were 27 red-alerts during the study period. These alerts included INRs not within therapeutic range for 3 consecutive entries (n=9, 33.3%), INR > 6.0 (n=11, 40.7%), and INR < 1.5 (n=7, 25.9%). Smart phone based mobile application (INR Assist) by patients using VKAs was safe and led to an improvement in TTR.