University Of Pennsylvania Health System Research Articles

A qualitative study identifying the potential risk mechanisms leading to hospitalization for patients with chronic lung disease

BackgroundCare management programs for chronic lung disease attempt to reduce hospitalizations, yet have not reliably attained this goal. A key limitation of many programs is that they target patients with characteristics associated with hospitalization risk but do not specifically modify the mechanisms that lead to hospitalization. Research QuestionWhat are the common mechanisms underlying known patient-level risk characteristics leading to hospitalizations for acute exacerbations of chronic lung disease? Study Design and MethodsWe conducted a qualitative study of patients admitted to the University of Pennsylvania Health system with acute exacerbations of chronic lung disease between January and September 2019. We interviewed patients, their family caregivers, and their inpatient and outpatient clinicians about experiences leading up to the hospitalization. We analyzed the interview transcripts using triangulation and abductive analytic methods. ResultsWe conducted 69 interviews focused on the admission of 22 patients with a median age of 66 years (interquartile range 60 to 70), of whom 16 (73%) were women and 14 (64%) were Black. We interviewed 22 patients, 14 caregivers, 19 inpatient clinicians, and 14 outpatient clinicians. We triangulated the available interview data for each patient admission and identified the underlying mechanisms of how several known patient characteristics associated with risk actually led to hospitalization. These mechanisms included limited capacity for home management of acute symptom changes, barriers to accessing care, chronic functional limitations, and comorbid behavioral health disorders. Importantly, many of the clinical, social, and behavioral mechanisms underlying hospitalizations were present for months or years prior to the symptoms that prompted inpatient care. InterpretationCare management programs should be built to target specific clinical, social, and behavioral mechanisms that directly lead to hospitalization. Upstream interventions that reduce hospitalization risk are possible given that many contributory mechanisms are present for months or years before the onset of acute exacerbations.

Text Message-Based Assessment of 90-Day Modified Rankin Scale After Stroke.

The modified Rankin Scale (mRS) is commonly used to measure disability after stroke, traditionally assessed through telephone or in-person evaluation. Here, we investigated the validity of mRS assessment through an automated text messaging system based on the simplified mRS questionnaire as an alternative method to traditional methods of assessment. A total of 250 patients admitted to 3 hospitals within the University of Pennsylvania Health System with ischemic or hemorrhagic stroke were enrolled. Participants received automated text messages sent 48 hours before their outpatient appointment at about 90 days after stroke. The mRS scores were assigned on the basis of participant responses to 2 to 4 text questions eliciting yes/no responses. The mRS was then evaluated in person or by telephone interview for comparison. Responses were compared with κ. A total of 142 patients (57%) completed the study. The spontaneous response rate to text messages was 46.5% and up to 72% with an additional direct in-person or phone call reminder. Agreement was substantial (quadratic-weighted κ=0.87 [95% CI, 0.83-0.89]) between responses derived from the automated text messaging and traditional interviews. Agreement for distinguishing functional independence (mRS 0-1) from dependence (mRS 2-5) was substantial (unweighted κ=0.79 [95% CI, 0.69-0.90]). An automated text messaging system is a feasible method for remotely obtaining the mRS after stroke and a potential alternative to traditional in-person or telephone assessment. Further studies are needed to evaluate the generalizability of text message-based approaches to stroke outcome measurement.

Radio-anatomical evaluation of clinical and radiomic profile of multi-parametric magnetic resonance imaging of de novo glioblastoma multiforme

BackgroundGlioblastoma (GBM) is a fatal, fast-growing, and aggressive brain tumor arising from glial cells or their progenitors. It is a primary malignancy with a poor prognosis. The current study aims at evaluating the neuroradiological parameters of de novo GBM by analyzing the brain multi-parametric magnetic resonance imaging (mpMRI) scans acquired from a publicly available database analysis of the scans.MethodsThe dataset used was the mpMRI scans for de novo glioblastoma (GBM) patients from the University of Pennsylvania Health System, called the UPENN-GBM dataset. This was a collection from The Cancer Imaging Archive (TCIA), a part of the National Cancer Institute. The MRIs were reviewed by a single diagnostic radiologist, and the tumor parameters were recorded, wherein all recorded data was corroborated with the clinical findings.ResultsThe study included a total of 58 subjects who were predominantly male (male:female ratio of 1.07:1). The mean age with SD was 58.49 (11.39) years. Mean survival days with SD were 347 (416.21) days. The left parietal lobe was the most commonly found tumor location with 11 (18.96%) patients. The mean intensity for T1, T2, and FLAIR with SD was 1.45E + 02 (20.42), 1.11E + 02 (17.61), and 141.64 (30.67), respectively (p = < 0.001). The tumor dimensions of anteroposterior, transverse, and craniocaudal gave a z-score (significance level = 0.05) of − 2.53 (p = 0.01), − 3.89 (p < 0.001), and 1.53 (p = 0.12), respectively.ConclusionThe current study takes a third-party database and reduces physician bias from interfering with study findings. Further prospective and retrospective studies are needed to provide conclusive data.

Abstract 142: Automated Text-Messaging System for Assessment of 90-day Modified Rankin Scale After Stroke

Background: The modified Rankin scale (mRS) is commonly used to measure disability after stroke, traditionally assessed through telephone or in-person evaluation. Here, we investigated the validity of mRS assessment through automated text-messaging as an alternative method to traditional assessments. Methods: Two hundred and fifty patients admitted to 3 hospitals within the University of Pennsylvania Health System with ischemic or hemorrhagic stroke were enrolled. Participants received automated text-messages 48 hours prior to their outpatient appointment at about 90-days post-stroke. The mRS scores were assigned based on participant responses to 2-4 yes/no questions, based on the simplified modified Rankin scale questionnaire (SmRSq). The mRS was then evaluated in-person or by telephone interview for comparison. Responses were compared with kappa(κ). Results: Among the one hundred and forty-two patients (57%) who completed the study: mean age 62 years; 45% female; 48% white, 45% black; 84% ischemic stroke; median baseline NIHSS 4. The patient was the responder in 63%, surrogate in 37%. Spontaneous response rate to text messages was 46% and up to 72% with an additional direct in-person or phone call reminder. Agreement (Figure) was substantial (quadratic-weighted κ=0.87) between responses derived from the automated text messaging and traditional interviews. Agreement for distinguishing functional independence (mRS 0-2) from dependence (mRS 3-5) was substantial (unweighted κ=0.79). Conclusion: An automated text messaging system is a feasible and highly reliable tool for determining mRS and can serve as an alternative to traditional in-person or telephone assessment.

Race, Ethnicity, and Other Patient and Clinical Encounter Characteristics Associated with Patient Experiences of Access to Care.

The Press Ganey (PG) Outpatient Medical Practice Survey measures patients' experiences of healthcare access in the U.S. We aimed to identify differences in experiences of access to care by patient race, ethnicity, and other sociodemographic characteristics, an important first step in informing health policy and ensuring equitable healthcare delivery. We performed a cross-sectional analysis of PG surveys for adult outpatient visits within the University of Pennsylvania Health System from 2014-2017, including 119,373 unique patients. Compared with White patients, Black (odds ratio [OR] 0.84; 95% confidence interval [CI] 0.80-0.87), Asian (OR 0.62; 95% CI 0.58-0.66), and other/unknown race patients (OR 0.83; 95% CI 0.72-0.94) were each less likely to report the maximum score for timely access to care. Patients of all minoritized groups, as well as those whose primary language was not English, reported lower scores in secondary access measures related to communication and respect, compared to White and primarily English-speaking patients, respectively. Efforts to improve the experience of access to care among racial and ethnic minoritized patients are imperative to achieve equity in healthcare delivery.

1799. Patients Who Inject Drugs (PWID) and Unstable Housing are Associated with Invasive Group A Strep Infection: A retrospective collaboration between two large, quaternary care hospital systems in Philadelphia

Abstract Background Invasive infections involving Group A Streptococcus (iGAS), defined as infections beyond simple skin and soft tissue infection or pharyngitis, are rising nationally. We report an increase in incidence of iGAS at two urban, quaternary care health systems that contain 6 hospitals in the city of Philadelphia. Methods All blood, sterile fluid, and tissue cultures that yielded Streptococcus pyogenes were identified using the laboratory information systems at the Temple University Health System and the University of Pennsylvania Health System. Two cohorts were compared: cases diagnosed between January 1, 2019 and December 31, 2019, and between January 1, 2021 to December 31, 2021. We excluded 2020 data to avoid analysis of disease incidence when hospital admission patterns may have been highly biased due to COVID-19 pandemic. Electronic health records were reviewed and data pertaining to demographics, month of infection, culture site, HIV status, HCV status, housing status, and injection drug use were abstracted. Descriptive statistics were used to summarize findings. Results In 2021, there were 301 unique cases of iGAS (148 involving bacteremia) compared to 169 in 2019 (with 70 cases of bacteremia). This represented an overall increase in iGAS of 178% and a 211% increase in cases involving bacteremia. Of the cases in 2021, 210 (69.8%) were PWID compared to only 54 (32%) in 2019, a 388% increase. In 2021, 7.5% of patients had a diagnosis of HIV compared to 8.9% in 2019, but a large percentage did not have an HIV test (37% in 2019 and 19% in 2021). HCV Antibody positivity was 52.3% in 2021 versus 26.6% in 2019. Housing instability was recorded in 151 cases (50.2%) in 2021 and 31 (18.3%) in 2019, a 487% increase. Table 1 Demographic and clinical characteristics of iGAS cases in 2019 and 2021 Table 2 Age and Sex data in PWID Conclusion From 2019 to 2021, there was an increase in iGAS infections among an adult population in a large metropolitan city. We noted a 178% total increase in iGAS during our study period, with a 388% increase among PWID and 487% increase among those unstably housed. As the overdose crisis continues, public health practitioners and medical providers should be aware of the increase in iGAS when providing empiric treatment for PWID with infections and utilize local and national resources to report and manage cases. Disclosures Sara K. Schultz, MD FACP FIDSA, AbbVie: Advisor/Consultant

Antimicrobial resistance patterns and empiric antibiotic selections for patients admitted from post-acute care facilities.

To characterize the susceptibilities of positive bacterial cultures and the appropriateness of empiric antimicrobial regimens for patients admitted from post-acute care facilities (PACFs). This was a retrospective quality improvement study. The study included patients admitted from a PACF to one of 2 tertiary care teaching hospitals within the University of Pennsylvania Health System, located in Philadelphia, PA, from August 2020 to December 2021. Patients were included if they had at least one positive culture within 72 hours of admission. A total of 167 patients and 230 isolates from the study period were evaluated. The majority of positive cultures were from a urinary source (114 of 230, 49.6%). Nineteen patients (11.4%) had a history of multidrug-resistant organisms. The most common empiric antibiotics used were vancomycin (61.7%) and cefepime (59.3%). Sixty-one patients (36.5%) received inappropriate empiric therapy based on the culture results. When comparing our hospitals' general antibiogram to that of only PACF patients, Escherichia coli and Klebsiella pneumoniae had at least a 20% difference in susceptibility to levofloxacin, ceftriaxone, and cefepime. Extended-spectrum β-lactamase resistance was also higher in the PACF cohort (odds ratio, 2.09; 95% confidence interval, 1.4-3.1). Clinically significant differences in antimicrobial susceptibility were found among patients admitted from PACFs compared to our health system's general antibiogram. The increased resistance rates identified in this study support the need for hospitals to evaluate this at-risk patient population, which may drive changes to empiric antibiotic prescribing practices.

PATH-39. INTERPRETABLE IDH CLASSIFICATION FROM H&amp;E-STAINED HISTOLOGY SLIDES

Abstract BACKGROUND Infiltrating gliomas are the most common primary adult brain tumors. Isocitrate dehydrogenase (IDH) mutation is a key driver of gliomagenesis in 25–30% of infiltrating gliomas and correlates with favorable prognosis when compared with the histologically-similar but biologically-distinct IDH-wildtype glioblastoma. We sought an interpretable computational pipeline to predict IDH status from digitized histopathology glioma sections (Whole Slide Images - WSI) and identify associated cell-level morphology. Materials and METHODS We identify 799/1122 TCGA-GBM and TCGA-LGG tumors (1534 WSIs) with available IDH status. 379 of these tumors (756 WSI) are IDH-wildtype and 420 tumors (778 WSI) are IDH-mutant. Each H&amp;E-stained WSI undergoes comprehensive curation to remove artifactual content before classification. Our interpretability mechanism is based on weakly-supervised attention-based multiple-instance-learning. IDH-associated morphology in each WSI is evaluated by a HoverNet model from the 50 highest-attention tiles. Classification performance was assessed using 10-fold cross-validation, with training (80%), validation (10%), and test (10%) sets stratified on the patient/tumor level, without controlling for grade. An additional out-of-sample hold-out test set of 82 IDH-wildtype and 32 IDH-mutant tumors from the University of Pennsylvania Health System was further used for independent evaluation. RESULTS Quantitative performance evaluation revealed AUC=0.92 and Balanced Accuracy=0.84 on the TCGA test set, and AUC=0.88 and Balanced Accuracy=0.80 on the independent hold-out UPenn set. When comparing identified IDH-wildtype with IDH-mutant tumors (and while excluding glioblastoma with lower-grade histology), the former shows significantly (p&amp;lt; 0.00005) higher distribution of neoplastic and necrotic cells and significantly (p&amp;lt; 0.00003) lower distribution of inflammatory and connective cell type tissue. CONCLUSION Histological prediction of IDH status represented an ideal prototype to interrogate WSI towards identifying clinically-relevant tumor biomarkers. Detailed interpretation of results reveals computational predictions being driven by human-identifiable features at the patch level. This study robustly identifies morpho-IDH correlates and could enable further prognostic refinement of patients.

The impact of hypertonic saline on damage control laparotomy after penetrating abdominal trauma.

The inability to achieve primary fascial closure (PFC) after emergency laparotomy increases the rates of adverse outcomes including fistula formation, incisional hernia, and intraabdominal infection. Hypertonic saline (HTS) infusion improves early PFC rates and decreases time to PFC in patients undergoing damage control laparotomy (DCL) after injury. We hypothesized that in patients undergoing DCL after penetrating abdominal injury, HTS infusion would decrease the time to fascial closure as well as the volume of crystalloid required for resuscitation without inducing clinically relevant acute kidney injury (AKI) or electrolyte derangements. We retrospectively analyzed all penetrating abdominal injury patients undergoing DCL within the University of Pennsylvania Health System (January 2015-December 2018). We compared patients who received 3% HTS at 30mL/h (HTS) to those receiving isotonic fluid (ISO) for resuscitation while the abdominal fascia remained open. Primary outcomes were the rate of early PFC (PFC within 72h) and time to PFC; secondary outcomes included acute kidney injury, sodium derangement, ventilator-free days, hospital length of stay (LOS), and ICU LOS. Intergroup comparisons occurred by ANOVA and Tukey's comparison, and student's t, and Fischer's exact tests, as appropriate. A Shapiro-Wilk test was performed to determine normality of distribution. Fifty-seven patients underwent DCL after penetrating abdominal injury (ISO n = 41, HTS n = 16). There were no significant intergroup differences in baseline characteristics or injury severity score. Mean time to fascial closure was significantly shorter in HTS (36.37h ± 14.21 vs 59.05h ± 50.75, p = 0.02), and the PFC rate was significantly higher in HTS (100% vs 73%, p = 0.01). Mean 24-h fluid and 48-h fluid totals were significantly less in HTS versus ISO (24h: 5.2L ± 1.7 vs 8.6L ± 2.2, p = 0.01; 48h: 1.3L ± 1.1 vs 2.6L ± 2.2, p = 0.008). During the first 72h, peak sodium (Na) concentration (146.2mEq/L ± 2.94 vs 142.8mEq/L ± 3.67, p = 0.0017) as well as change in Na from ICU admission (5.1mEq/L vs 2.3, p = 0.016) were significantly higher in HTS compared to ISO. Patients in the HTS group received significantly more blood in the trauma bay compared to ISO. There were no intergroup differences in intraoperative blood transfusion volume, AKI incidence, change in chloride concentration (△Cl) from ICU admit, Na to Cl gradient (Na:Cl), initial serum creatinine (Cr), peak post-operative Cr, change in creatinine concentration (△Cr) from ICU admission, creatinine clearance (CrCl), initial serum potassium (K), peak ICU K, change in K from ICU admission, initial pH, highest or lowest post-operative pH, mean hospital LOS, ICU LOS, and ventilator-free days. HTS infusion in patients undergoing DCL after penetrating abdominal injury decreases the time to fascial closure and led to 100% early PFC. HTS infusion also decreased resuscitative fluid volume without causing significant AKI or electrolyte derangement. HTS appears to offer a safe and effective fluid management approach in patients who sustain penetrating abdominal injury and DCL to support early PFC without inducing measurable harm. Level III.

Establishing a patient‐centered, multidisciplinary pharmacogenomics clinic in an academic health system: Successes, challenges, and future direction

AbstractIntroductionPharmacogenomics (PGx) testing uses a patient's deoxyribonucleic acid (DNA) profile to tailor medications with the goal of preventing adverse drug reactions and improving pharmacotherapy outcomes. Despite the availability of evidence‐based guidelines that assist with interpretation of PGx results, PGx testing has not been widely adopted.ObjectiveTo describe how a multidisciplinary PGx clinic was implemented within the University of Pennsylvania Health System (Penn Medicine) including the clinical workflow, challenges to implementation, and future directions.MethodsThis project qualified as Quality Improvement by the University of Pennsylvania's Institutional Review Board and adheres to the Standards for Quality Improvement Reporting Excellence (SQUIRE) 2.0 guidelines. Clinic metrics were collected from February 2019 until December 2022. Data collected included patient demographics; the timing of PGx test ordering and appointments; number and frequency of actionable PGx phenotypes; number of current or historical medications impacted by PGx test results; and patient's out‐of‐pocket cost for PGx test.ResultsOf the 69 patients included, the majority were female (58%), white (84%), with a mean age of 48 years. The overall time between the dates of the PGx test order and clinic visit was 37 days. The time between the dates of the PGx test order and the PGx test results were generated was 18 days. All patients had at least one actionable PGx phenotype and 74% had three or more. The most frequent actionable phenotypes were found in the cytochrome P450 PC19 (CYPC19) (60%) and CYP2D6 (58%) genes. The percentage of patients that had drug‐gene interactions that affected their current medications and explained historical medication intolerances were 25% and 17%, respectively. Out‐of‐pocket costs were less than $300 for most patients who had a PGx test ordered by the clinic physician.ConclusionThis paper has established a sustainable PGx clinic workflow with dedicated personnel. In the future we intend to increase the availability of our services.

Tracheostomy is associated with decreased in‐hospital mortality during severe COVID‐19 infection

Tracheostomy is associated with decreased in‐hospital mortality during severe COVID‐19 infection

Contemporary Obstetric and Neonatal Outcomes in Sickle Cell Disease: A Retrospective Cohort Study.

Sickle cell disease is associated with adverse perinatal outcomes. Aspects of sickle cell disease in pregnancy, such as health care utilization and neonatal abstinence syndrome, are understudied. We aimed to describe contemporary sickle cell disease outcomes in a U.S. hospital system to improve perinatal counseling. We conducted a retrospective cohort study of patients with sickle cell disease who delivered at >20 weeks' gestation at two sites within the University of Pennsylvania Health System from May 1, 2017 to August 30, 2020. Descriptive statistics were utilized. Over the study period, 48 patients with sickle cell disease had 52 deliveries of 53 neonates. Sickle cell disease-related morbidity was prevalent prior to pregnancy; 27% had a history of avascular necrosis, and 58% had experienced acute chest syndrome. In the year prior to pregnancy, 52% used daily opioids. During pregnancy, more than half of patients were admitted at least once for sickle cell disease-related complications, spending a median 3 days admitted interquartile range (0-23); >10% spent >70 days of pregnancy admitted. New daily opioids were prescribed during pregnancy for 10% to manage pain crises. Acute chest syndrome was experienced by 23% of patients during pregnancy, and 8% required placement of long-term intravenous access. Preterm delivery <37 weeks occurred in 48%. The primary cesarean rate in nulliparas was 43%. Additionally, 50% experienced a hypertensive disorder of pregnancy, 35% underwent transfusion during delivery admission, and 10% had a perinatal venous thromboembolism. Finally, 53% of neonates were admitted to the intensive care unit. Low birth weight was noted in 34%, severe respiratory distress in 15% of infants, and neonatal abstinence syndrome in 21%. Sickle cell disease remains associated with significant perinatal morbidity and need for hospitalization. These data provide contemporary outcomes to target improvements in the care of patients with sickle cell disease. · SCD was associated with significant perinatal morbidity and healthcare utilization.. · Most patients with SCD required hospitalization during pregnancy.. · Neonates of patients with SCD experienced preterm birth, NICU admission, and neonatal abstinence syndrome..

Effects of the COVID-19 Pandemic on H&N SCCa Incidence: A Population-based Analysis.

The LaryngoscopeEarly View Rapid Communication Effects of the COVID-19 Pandemic on H&N SCCa Incidence: A Population-based Analysis Neel R. Sangal MD, Corresponding Author Neel R. Sangal MD [email protected] orcid.org/0000-0002-8221-8438 Department of Otolaryngology – Head and Neck Surgery, University of Pennsylvania Health System, Philadelphia, Pennsylvania, USA Send correspondence to Neel R. Sangal, MD, Department of Otolaryngology – Head and Neck Surgery, University of Pennsylvania Health System, 3400 Spruce Street, Philadelphia, PA 19107, USA. Email: [email protected]Search for more papers by this authorPraneet Kaki BS, Praneet Kaki BS Department of Otolaryngology – Head and Neck Surgery, University of Pennsylvania Health System, Philadelphia, Pennsylvania, USASearch for more papers by this authorJason Brant MD, Jason Brant MD orcid.org/0000-0002-3492-0679 Department of Otolaryngology – Head and Neck Surgery, University of Pennsylvania Health System, Philadelphia, Pennsylvania, USA Veterans Affairs Medical Center, Philadelphia, Pennsylvania, USASearch for more papers by this authorRobert M. Brody MD, Robert M. Brody MD orcid.org/0000-0001-6639-8830 Department of Otolaryngology – Head and Neck Surgery, University of Pennsylvania Health System, Philadelphia, Pennsylvania, USA Veterans Affairs Medical Center, Philadelphia, Pennsylvania, USASearch for more papers by this author Neel R. Sangal MD, Corresponding Author Neel R. Sangal MD [email protected] orcid.org/0000-0002-8221-8438 Department of Otolaryngology – Head and Neck Surgery, University of Pennsylvania Health System, Philadelphia, Pennsylvania, USA Send correspondence to Neel R. Sangal, MD, Department of Otolaryngology – Head and Neck Surgery, University of Pennsylvania Health System, 3400 Spruce Street, Philadelphia, PA 19107, USA. Email: [email protected]Search for more papers by this authorPraneet Kaki BS, Praneet Kaki BS Department of Otolaryngology – Head and Neck Surgery, University of Pennsylvania Health System, Philadelphia, Pennsylvania, USASearch for more papers by this authorJason Brant MD, Jason Brant MD orcid.org/0000-0002-3492-0679 Department of Otolaryngology – Head and Neck Surgery, University of Pennsylvania Health System, Philadelphia, Pennsylvania, USA Veterans Affairs Medical Center, Philadelphia, Pennsylvania, USASearch for more papers by this authorRobert M. Brody MD, Robert M. Brody MD orcid.org/0000-0001-6639-8830 Department of Otolaryngology – Head and Neck Surgery, University of Pennsylvania Health System, Philadelphia, Pennsylvania, USA Veterans Affairs Medical Center, Philadelphia, Pennsylvania, USASearch for more papers by this author First published: 05 June 2023 https://doi.org/10.1002/lary.30804 Editor's Note: This Manuscript was accepted for publication on May 21, 2023 The authors have no other funding, financial relationships, or conflicts of interest to disclose. Read the full textAboutPDF ToolsRequest permissionExport citationAdd to favoritesTrack citation ShareShare Give accessShare full text accessShare full-text accessPlease review our Terms and Conditions of Use and check box below to share full-text version of article.I have read and accept the Wiley Online Library Terms and Conditions of UseShareable LinkUse the link below to share a full-text version of this article with your friends and colleagues. Learn more.Copy URL No abstract is available for this article. BIBLIOGRAPHY 1Pujolar G, Oliver-Angles A, Vargas I, Vazquez ML. Changes in access to health services during the COVID-19 pandemic: a scoping review. Int J Environ Res Public Health. 2022; 19(3): 1749. 2Rygalski CJ, Zhao S, Eskander A, et al. Time to surgery and survival in head and neck cancer. Ann Surg Oncol. 2021; 28(2): 877- 885. 3Flynn W, Maqsood R, Maseland T, Montgomery J, Douglas C. Advancing head and neck cancer following the coronavirus disease 2019 pandemic. J Laryngol Otol. 2022; 136(11): 1118- 1124. 4Doll KM, Rademaker A, Sosa JA. Practical guide to surgical data sets: surveillance, epidemiology, and end results (SEER) database. JAMA Surg. 2018; 153(6): 588- 589. 5Schoonbeek RC, de Jel DVC, van Dijk BAC, et al. Fewer head and neck cancer diagnoses and faster treatment initiation during COVID-19 in 2020: a nationwide population-based analysis. Radiother Oncol. 2022; 167: 42- 48. 6Okuyama A, Watabe M, Makoshi R, Takahashi H, Tsukada Y, Higashi T. Impact of the COVID-19 pandemic on the diagnosis of cancer in Japan: analysis of hospital-based cancer registries. Jpn J Clin Oncol. 2022; 52(10): 1215- 1224. Early ViewOnline Version of Record before inclusion in an issue ReferencesRelatedInformation

Potentially avoidable emergency department use by patients discharged to skilled nursing facilities.

One-third of patients discharged from hospitals to skilled nursing facilities (SNF) are sent back to the Emergency Department (ED) within 30 days. Little is known about those patients who are discharged from the ED directly back to SNF. We considered these ED visits as potentially avoidable since they did not result in observation or hospitalization stay. Using a retrospective chart review of 1010 patients with ED visits within 14-days of discharge to SNF from University of Pennsylvania health system (UPHS) in 2020-2021, we identified 202 patients with potentially avoidable ED visits among medical and surgical patients. The most common reasons for these ED visits were mechanical falls (17.3%), postoperative problems (16.8%), and cardiac or pulmonary complaints (11.4%). Future interventions to decrease avoidable ED visits from SNFs should aim to provide access for SNF patients to receive timely outpatient lab and imaging services and postoperative follow-ups.

Conversion to Roux-En-Y Gastric Bypass: a successful means of mitigating reflux after laparoscopic sleeve gastrectomy.

Laparoscopic sleeve gastrectomy (LSG) has become the most common bariatric procedure due to the technical ease and weight loss success of the operation. However, there has been concern that LSG contributes to gastroesophageal reflux disease (GERD) postoperatively with a proportion of patients requiring conversion to a Roux-En-Y Gastric Bypass (RYGB). The objective of this study was to characterize the patients who underwent revision in our hospital system and to better understand pre-operative predictors of GERD and revision. After IRB approval, a retrospective review was conducted assessing for patients who had conversion of LSG to RYGB at three hospitals within the University of Pennsylvania Health System from January 2015 to December 2021. The patients' charts were then reviewed to evaluate for demographics, BMI, operative findings, imaging and endoscopic reports, and post-operative outcomes. 97 patients were identified who underwent conversion of LSG to RYGB between January 2015 and December 2021. The cohort was predominantly female (n = 89, 91.7%) with an average age of 42.7 ± 10.6years at the time of conversion. The most common indications for revision were GERD (72.2%) and obesity/insufficient weight loss (24.7%). Patients lost an average of 11.1 ± 12.9kg after revision to RYGB. Of the patients who underwent revision for GERD, 80.2% noted global symptomatic improvement after revision and 19.4% were able to stop their proton pump inhibitor (PPI) postoperatively, with most patients decreasing the frequency of the PPI use postoperatively. The majority of patients who underwent conversion from LSG to RYGB due to GERD and saw marked improvements in GERD symptoms and outcomes. These findings illuminate the real-world practices and outcomes of bariatric revisional procedures for reflux and the need for more research on standardized practice.

Changes in physical activity around the time of major adverse cardiac events in patients with implantable cardioverter-defibrillators.

With modern implantable cardioverter-defibrillators (ICDs), biometric measures including physical activity have become readily available to physicians. However, despite the increased availability, applications of these data to the clinical setting remain poorly studied. We sought to investigate whether changes in physical activity occur preceding and following cardiac events in patients with ICDs. We reviewed the electronic medical records of patients with ICDs implanted for any indication in 2018 and 2019 in the University of Pennsylvania health system. Patients with ICDs that reported physical activity were included in the study only if they experienced major adverse cardiac event(s) (MACE) that were preceded by at least 6months without MACE after device implantation. Seventy-four of the 827 charts reviewed met inclusion criteria. Baseline activity levels from 6 to 2months prior to MACE were 2.18-2.21h/day. In the month prior to MACE, average activity decreased significantly to 2.09h/day, and subsequently decreased again during the calendar month in which MACE occurred to 1.96h/day. The lowest average monthly activity levels occurred in the month after MACE, with incremental but non-significant recovery occurring over the subsequent 2months. In a cohort of ICD recipients, a significant decrease in physical activity was observed in the month preceding MACE. To our knowledge, this is the first study that observes time-dependent changes in activity in relation to MACE in a generalizable cohort of ICD recipients. ICD activity monitoring in patients at high risk for MACE may enhance patient care.

A randomized controlled trial of gamification, financial incentives, or both to increase physical activity among patients with elevated risk for cardiovascular disease: rationale and design of the be active study

Higher levels of physical activity are associated with improvements in cardiovascular health, and consensus guidelines recommend that individuals with or at risk for atherosclerotic cardiovascular disease (ASCVD) participate in regular physical activity. However, most adults do not achieve recommended levels of physical activity. Concepts from behavioral economics have been used to design scalable interventions that increase physical activity over short time periods, but the longer-term efficacy of these strategies is uncertain. BE ACTIVE (NCT03911141) is a pragmatic, virtual, randomized controlled trial designed to evaluate the effectiveness of 3 strategies informed by behavioral economic concepts to increase daily physical activity in patients with established ASCVD or 10-year ASCVD risk > 7.5% who are seen in primary care and cardiology clinics affiliated with the University of Pennsylvania Health System. Patients are contacted by email or text message, and complete enrollment and informed consent on the Penn Way to Health online platform. Patients are then provided with a wearable fitness tracker, establish a baseline daily step count, set a goal to increase daily step count by 33% to 50%, and are randomized 1:2:2:2 to control, gamification, financial incentives, or both gamification and financial incentives. Interventions continue for 12 months, with follow-up for an additional 6 months to evaluate the durability of behavior change. The trial has met its enrollment goal of 1050 participants, with a primary endpoint of change from baseline in daily steps over the 12-month intervention period. Key secondary endpoints include change from baseline in daily steps over the 6-month post-intervention follow-up period and change in moderate to vigorous physical activity over the intervention and follow-up periods. If the interventions prove effective, their effects on life expectancy will be compared with their costs in cost-effectiveness analysis. BE ACTIVE is a virtual, pragmatic randomized clinical trial powered to demonstrate whether gamification, financial incentives, or both are superior to attention control in increasing physical activity. Its results will have important implications for strategies to promote physical activity in patients with or at risk for ASCVD, as well as for the design and implementation of pragmatic virtual clinical trials within health systems.

Infrequent intrahousehold transmission of Clostridioides difficile between pet owners and their pets.

Companion animals have been shown to carry Clostridioides difficile strains that are similar or identical to strains found in people, and a small number of studies have shown that pets carry genetically identical C. difficile isolates as their owners, suggesting inter-species transmission. However, the directionality of transmission is ultimately unknown, and the frequency with which animals acquire C. difficile following their owners' infection is unclear. The goal of this study was to assess how often pets belonging to people with C. difficile infection carry genetically related C. difficile isolates. We enrolled pet owners from two medical institutions (University of Pennsylvania Health System (UPHS) and The Ohio State University Wexner Medical Center (OSUWMC)) who had diarrhoea with or without positive C. difficile assays and tested their faeces and their pets' faeces for C. difficile using both anaerobic culture and PCR assays. When microorganisms were obtained from both the owner and pet and had the same toxin profile or ribotype, isolates underwent genomic sequencing. Faecal samples were obtained from a total of 59 humans, 72 dogs and 9 cats, representing 47 complete households (i.e. where a sample was available from the owner and at least one pet). Of these, C. difficile was detected in 30 humans, 10 dogs and 0 cats. There were only two households where C. difficile was detected in both the owner and pet. In one of these households, the C. difficile isolates were of different toxin profiles/ribotypes (A+/B+ / RT 499 from the owner, A-/B- / RT PR22386 from the dog). In the other household, the isolates were genetically identical (one SNP difference). Interestingly, the dog from this household had recently received a course of antibiotics (cefpodoxime and metronidazole). Our findings suggest that inter-species transmission of C. difficile occurs infrequently in households with human C. difficile infections.

Addressing the National Crisis Facing Black and Latina Women, Birthing People, and Infants: The Maternal and Child Health Equity Summit.

To address the national crisis of maternal and infant health disparities, especially outcomes experienced by Black and Latina women and birthing people, The New York Academy of Medicine, the Icahn School of Medicine at Mount Sinai, the Blavatnik Family Women's Health Research Institute, and the University of Pennsylvania Health System and Perelman School of Medicine hosted the Maternal and Child Health Equity Summit. The primary purpose of the summit was to disseminate findings to a national audience of two National Institutes of Health-funded mixed-methods studies that investigated the contribution of hospital quality to disparities in maternal and infant Health in New York City (R01MD007651 and R01HD078565). In addition, the summit showcased factors in maternal and infant health inequity from leading diverse experts in both fields and identified outstanding challenges to reducing maternal and infant morbidity and mortality disparities and strategies to address them. Summit presenters and participants identified five primary areas of focus in proposed clinical actions and approaches for maternal and neonatal health care based on discussions during the summit: 1) quality and standardization of care; 2) adjustment of care strategy based on patient-reported experience; 3) health care professional and institutional accountability to patients; 4) commitment to building trust; and 5) anti-racism practices in education, training, and hiring. Recommendations from this conference should inform hospital care and public policy changes and frame a national agenda to address perinatal health disparities for Black, Indigenous, and other women and birthing people of color.

1146. Real-World Experience Highlighting Tocilizumab Use in the Treatment of COVID-19

Abstract Background Tocilizumab (TCZ) was approved by the Food and Drug Administration under emergency use authorization for treatment of COVID-19 in patients requiring supplemental oxygen, non-invasive or invasive mechanical ventilation, or extracorporeal membrane oxygenation. Despite multiple clinical trials, there remain unanswered questions surrounding TCZ use. Methods This multi-hospital retrospective cohort study included patients who received TCZ for COVID-19 between January 29th, 2021 and June 30th, 2021 at five University of Pennsylvania Health System (UPHS) hospitals. Patients were eligible for TCZ per UPHS criteria if they scored ≥ 5 on the World Health Organization (WHO) ordinal scale for ≤ 24 hours and experienced &amp;lt; 14 days of acute COVID-19 symptoms. Descriptive statistics were performed to characterize usage within the health system. Results This study evaluated 134 patients who received TCZ for the treatment of COVID-19. TCZ was ordered a median of 22 hours (interquartile range [IQR], 13.2 – 41.5) after hospital admission. A majority of patients (76.1%) were admitted to the intensive care unit and a small portion (12.7%) had a WHO ordinal scale that was &amp;gt;5 at time of TCZ order entry. All patients received concomitant dexamethasone therapy at a total prednisone equivalent of 400 mg (IQR, 335.6 – 480). Overall 33.6% of patients experienced an adverse event (ADE) within 30 days of TCZ administration (Table 1). Most common ADEs included bacterial infection (29.9%), hepatitis (6.7%), and fungal infection (3%); other etiologies of ADEs were not accounted for. All-cause mortality (Table 2) at day 30 occurred in 20.9% of patients and median time from TCZ administration to mortality was 12.5 days (IQR 5 – 18.3). Ninety-six patients in the cohort (71.6%) were discharged by day 30. Of the subgroup discharged by day 30, the majority (70.8%) were discharged to home. Conclusion Patients who received TCZ for severe COVID-19 experienced 20.9% mortality; mortality was higher among those with higher ordinal scale at the time of TCZ dosing. A large portion of patients (70.8%) were discharged to home within 30 days. One third of patients experienced an adverse event, primarily bacterial or fungal infection. Our experience may be useful in counseling patients about anticipated effects of TCZ. Disclosures George L Anesi, MD, MSCE, AHRQ, NHLBI, UpToDate: Advisor/Consultant|AHRQ, NHLBI, UpToDate: Grant/Research Support Kathleen Degnan, MD, Gilead: Grant/Research Support.