USC Medical Research Articles

Immunonutrition with Omega-3 Fatty Acid Supplementation in Severe TBI: Retrospective Analysis of Patient Characteristics and Outcomes.

Early evidence-based medical interventions to improve patient outcomes after traumatic brain injury (TBI) are lacking. In patients admitted to the ICU after TBI, optimization of nutrition is an emerging field of interest. Specialized enteral nutrition (EN) formulas that include immunonutrition containing omega-3 polyunsaturated fatty acids (n-3 PUFAs) have been developed and are used for their proposed anti-inflammatory and proimmune properties; however, their use has not been rigorously studied in human TBI populations. A single-center, retrospective, descriptive observational study was conducted at the LAC + USC Medical Center. Patients with severe TBI (sTBI, Glasgow Coma Scale score ≤ 8) who remained in the ICU for ≥2 weeks and received EN were identified between 2017 and 2022 using the institutional trauma registry. Those who received immunonutrition formulas containing n-3 PUFAs were compared with those who received standard, polymeric EN with regard to baseline characteristics, clinical markers of inflammation and immune function, and short-term clinical outcomes. A total of 151 patients with sTBI were analyzed. Those who received immunonutrition with n-3 PUFA supplementation were more likely to be male, younger, Hispanic/Latinx, and have polytrauma needing non-central nervous system surgery. No differences in clinical markers of inflammation or infection rate were found. In multivariate regression analysis, immunonutrition was associated with reduced hospital length of stay (LOS). ICU LOS was also reduced in the subgroup of patients with polytrauma and TBI. This study identifies important differences in patient characteristics and outcomes associated with the EN formula prescribed. Study results can directly inform a prospective pragmatic study of immunonutrition with n-3 PUFA supplementation aimed to confirm the biomechanistic and clinical benefits of the intervention.

Clinicopathologic comparison of basal cell carcinoma among a diverse patient population in Los Angeles County.

Basal cell carcinoma (BCC) is the most common malignancy in the United States. The majority of cases are identified in Non-Hispanic Whites (NHW) and are far less demonstrated in patients of colour (POC). However, the Hispanic population represents a large and growing proportion of the US population, and skin cancer diagnoses in Hispanics are rising. Thus, the goal of this study is to examine clinicopathologic differences between BCC in Hispanics versus NHW. A retrospective chart review of Hispanic and NHW patients with BCC at Los Angeles County+USC Medical Center from January 2018 to March 2020 was performed. In total, 101 BCC samples from the first 100 patients identified of Hispanic ancestry, as well as 50 BCC samples identified from the first 50 patients identifying as NHW, were included for analysis. Patient characteristics (age, sex, medical history, and ethnicity), as well as tumour characteristics (location, subtype, tumour depth, and perineural invasion), were collected. We used between subjects t-tests for continuous variables, and chi-square tests for categorical variables. In total, 151 specimens were collected amongst 122 subjects (79 Hispanics and 43 NHW patients). Among NHW, the majority of patients (74.4%) were men, but among the Hispanic population, the majority (68.4%) were female (p<0.001). Prior history of other skin cancer was more common among NHW (67.4%) than Hispanics (31.6%) (p=<0.001). The Hispanic population had a significantly higher proportion of head and neck tumours (p=0.0004) but a lower proportion of extremity tumours (p=0.001) compared to NHW. Pigmented BCC was significantly more common among Hispanic patients (p<0.01). Finally, within the Hispanic group, there was a significant association between sex and histology (p=0.004), with Hispanic men demonstrating more aggressive mix histology compared to Hispanic women. Our study supports the notion that BCC disparities occur among POC compared to NHW. This includes variations in epidemiologic factors such as sex and past medical history, primary tumour location, and pathologic characteristics. Further research should be conducted to identify additional differences in skin cancer presentation in POC to reduce the gaps in skin cancer knowledge and care.

Outcomes of Local Versus Free Flaps for Reconstruction of the Proximal One-Third of the Leg.

Reconstruction of the proximal one-third of the leg often requires soft tissue transfer to facilitate limb salvage. Tissue transfers are usually local or free flaps depending on wound dimensions, location, and surgeon preference. Historically, the proximal third of the leg was covered with pedicle flaps, but recently, we have used more free flaps in this position. Using data from a level 1 trauma center, we sought to evaluate outcomes of surgical management of proximal-third leg reconstruction across local and free flaps. This is an institutional review board-approved, retrospective chart review undertaken at LAC + USC Medical Center from 2007 to 2021. Patient history, demographics, flap characteristics, Gustilo-Anderson fracture classification, and outcomes were collected and analyzed in an internal database. Outcomes of interest included flap failure rates, postoperative complications, and long-term ambulatory status. Among 394 lower extremity flaps placed, 122 flaps involved the proximal-third leg across 102 patients. Average age of patients was 42.8 ± 15.2 years; of note, the free flap cohort was significantly younger than the local flap cohort (P = 0.019). Ten local flaps suffered from infectious complications: osteomyelitis (n = 6) and hardware infection (n = 4), versus only 1 free flap that suffered from hardware infection; notably, these differences were not significant across cohorts. Free flaps had significantly more flap revisions (13.3%; P = 0.039) and overall flap complications (20.0%; P = 0.031) compared with local flaps; however, partial flap necrosis (4.9%) and flap loss (3.3%) were not significantly different across cohorts. Overall flap survival was 96.7%, and full ambulation was achieved in 42.2% of patients without significant differences across cohorts. Our evaluation of proximal-third leg wounds demonstrates fewer infectious outcomes with free flaps compared with local flaps. There are multiple confounding variables; however, this finding may speak to the reliability of a robust free flap. Overall, there was no significant difference in patient comorbidities across flap cohorts with great overall flap survival. Ultimately, flap selection did not affect rates of flap necrosis, flap loss, or final ambulatory status.

Infectious Disease

Infectious Disease

Psychiatric Emergencies in Los Angeles County During, and After, Initial COVID-19 Societal Restrictions: An Interrupted Time-Series Analysis

Emergency department (ED) visits for psychiatric care in the US reportedly declined during the COVID-19 pandemic. This work, however, does not control for strong temporal patterning in visits before the pandemic and does not examine a potential “rebound” in demand for psychiatric care following the relaxation of initial societal restrictions. Here, we examine COVID-19-related perturbations in psychiatric care during and after the 1st stage of societal restrictions in the largest safety-net hospital in Los Angeles. We retrieved psychiatric ED visit data (98,888 total over 156 weeks, Jan 2018 to Dec 2020) from Los Angeles County + USC Medical Center. We applied interrupted time series methods to identify and control for autocorrelation in psychiatric ED visits before examining their relation with the 1st stage of societal restrictions (i.e., March 13 to May 8, 2020), as well as the subsequent “rebound” period of relaxed restrictions (i.e., after May 8, 2020). Psychiatric ED visits fell by 78.13 per week (i.e., 12%) during the 1st stage of societal restrictions (SD = 23.99, p < 0.01). Reductions in ED visits for alcohol use, substance use, and (to a lesser extent) anxiety disorders accounted for the overall decline. After the 1st stage of societal restrictions, however, we observe no “rebound” above expected values in psychiatric ED visits overall (coef = − 16.89, SD = 20.58, p = 0.41) or by diagnostic subtype. This pattern of results does not support speculation that, at the population level, foregoing ED care during initial societal restrictions subsequently induced a psychiatric “pandemic” of urgent visits.

Time to Diagnosis and Treatment in an Underserved, Predominantly Hispanic Population of Adults in East Los Angeles- a Retrospective Study of Acute T- Lymphoblastic Leukemia/Lymphoma (T-ALL/LBL) Patients

Introduction Acute T-lymphoblastic leukemia/lymphoma (T-ALL/LBL) comprises approximately 25% of adult ALL cases, while early T cell precursor ALL/LBL (ETP-ALL/LBL) is a small subset of T-ALL/LBL comprised of only early T cell precursors with a specific immunophenotype. Due in part to its rarity, limited data exists on underserved T-ALL patients specifically. Underserved patients face unique barriers in accessing healthcare and studies have found that these patients are at risk of delayed presentation for both acute and chronic conditions. Our study investigates duration from symptom onset to diagnosis and treatment in a predominantly underserved population of adults treated in East Los Angeles. Methods A retrospective chart review was performed of all patients with a confirmed pathologic diagnosis of T-ALL/LBL at two hospitals serving the population of East Los Angeles: Los Angeles County +USC Medical Center and Norris Comprehensive Cancer Center. We identified thirty-one patients diagnosed with T-ALL/LBL between January 1st, 2011 and January 1st, 2020. Demographic, clinical, and pathologic data were abstracted from medical records. Two patients were excluded from the analysis of extramedullary and mediastinal disease as this information was missing in their medical records. The primary aim of the study was to determine time from symptom onset to diagnosis and treatment. SAS software was used to conduct Kaplan-Meier analysis, in which six patients with unknown follow-up status are censored. Results In this study, 26 out of 31 patients (84%) had a non-ETP-ALL phenotype (T-ALL/LBL), while the remaining 5 (16%) were classified as ETP-ALL. The majority of the patients in this cohort were male (19/31; 61%) and Hispanic (17/31; 55%). The median age at diagnosis was 32 years (13-66). The median duration from symptom onset to diagnosis was 19 (2-192) days. The median duration from symptom onset to treatment was 29 days (3-240). The median duration from time of diagnosis to initiation of treatment was 6 days (1-48). The median white blood cell count at presentation was 8.1 per microliters (1.8 to 526.0 × 10^9/L). The median peripheral blood blasts at presentation was 35% (0%-91%). The median bone marrow blast percentage at diagnosis was 68%(0%-97%). Extramedullary disease at diagnosis was present in 76% (22/29), with the majority (59%; 17/29) presenting with bulky mediastinal disease. CNS disease was present in one patient (3%) at the time of diagnosis. USC-ALL was the most common induction regimen, received by 68% (21/31); followed by Hyper-CVAD, received by 23% (7/31). Two patients (6%) received alternative regimens and one patient (3%) did not undergo chemotherapy. Hematopoietic stem cell transplantation was performed in 48% (15/31). Currently, 55% (17/31) of patients are known to be alive, 26% (8/31) are deceased, and 19% (6/31) had unknown outcome, as they were lost to follow-up. One-year overall survival (OS) was 76% in T-ALL/LBL and 75% in ETP ALL/LBL patients, while both 3-year and 6-year OS were 65% and 75%, respectively. Conclusions Our study reveals that a predominantly underserved cohort of patients was diagnosed and treated within comparable timeframes to the general population reported in the existing literature. One study of mixed hematologic malignancies found a median interval from onset of symptoms to presentation of 30 days, whereas our patients presented within a median of 19 days after symptom onset. The same study showed a median of five days from time of diagnosis to initiation of treatment, as compared to a median of six days in our cohort. Studies have reported worse outcomes and complications in patients who presented later in their disease process, so our data is reassuring in that this underserved population is establishing care and being treated promptly. This underserved patient population in East Los Angeles is unique, however; many underserved patients do not have access to a major comprehensive cancer center, such as the patients in this study, who received care at Norris Comprehensive Cancer Center. Underserved T-ALL/LBL patients are an understudied population, and more research needs to be undertaken to evaluate the impact of the timing of diagnosis and treatment on the outcomes in this vulnerable patient population.

Emergency Department Utilization Among Undocumented Latino Patients During the COVID-19 Pandemic

ObjectiveTo determine whether Latino undocumented immigrants had a steeper decline in Emergency Department (ED) utilization compared to Latino Medi-Cal patients in a Los Angeles safety-net hospital, March 13, 2020, to May 8, 2020.Study DesignThe data were extracted from patient medical records for ED visits at LAC + USC Medical Center from January 2018 to September 2020. We analyzed weekly ED encounters among undocumented Latino patients in the nine-week period after COVID was declared a national emergency. We applied time-series routines to identify and remove autocorrelation in ED encounters before examining its relation with the COVID-19 pandemic. We included Latino patients 18 years of age and older who were either on restricted or full-scope Medi-Cal (n = 230,195).ResultsAll low-income Latino patients, regardless of immigration status, experienced a significant decline in ED utilization during the first nine weeks of the pandemic. Undocumented patients, however, experienced an even steeper decline. ED visits for this group fall below expected levels between March 13, 2020, and May 8, 2020 (coef. = − 38.67; 95% CI = − 71.71, − 5.63). When applied to the weekly mean of ED visits, this translates to a 10% reduction below expected levels in ED visits during this time period.ConclusionUndocumented immigrants’ health care utilization was influenced by external events that occurred early in the pandemic, such as strict stay-at-home orders and the public charge rule change. Health care institutions and local policy efforts could work to ensure that hospitals are safer spaces for undocumented immigrants to receive care without immigration concerns.

Ischemic index and distribution of retinal capillary non-perfusion in neovascular glaucoma.

Neovascular Glaucoma (NVG) is a condition normally caused by hypoxic posterior ocular disease, which produces angiogenic factors such as vascular endothelial growth factor (VEGF) that stimulate new vessel proliferation of the anterior segment and angle, eventually leading to angle closure, reduced outflow of aqueous humor and increased intraocular pressure. Without treatment elevated intraocular pressure can rapidly progress to loss of vision. Treatment includes addressing the intraocular pressure and reducing the ischemic drive with panretinal photocoagulation (PRP) of the ischemic retina. Recent imaging advancements allow for ultra-widefield fluorescein angiography (UWFA) which expand the amount of peripheral retina that can be evaluated for non-perfusion. Here we aim to study patterns of non-perfusion in NVG using a group of PRP naïve patients with recent onset NVG. This study is a retrospective single-center cross-sectional study of patients seen at LAC + USC Medical Center from January 2015 to April 2020 with new onset NVG, without PRP and with UWFA completed. The percentage of ischemic index of the retina was calculated from the UWFA and evaluated in three distinct zones centered on the fovea: the posterior pole, the mid periphery, and far periphery. To increase sample size, a confirmatory group was included, with PRP allowed prior to UWFA but not before diagnosis. In addition, the time between diagnosis and UWFA was increased to 6 months. A total of 11 eyes met inclusion criteria for the primary group. Ischemic index was found to be 91% in the far periphery, 77% in the mid periphery, and 42% at the posterior pole. The total average ischemic index was 76%. There was a statistically significant difference between the far periphery and posterior pole and mid periphery and posterior pole. A total of 24 eyes met criteria for the confirmatory group. Ischemic index for the confirmatory group was found to be 93% in the far periphery, 75% in the mid periphery, and 35% at the posterior pole. There was a statistically significant difference between the far periphery, posterior pole and mid-periphery. This knowledge can be used to further guide treatment and understand risk for NVG.

A Value-Added Health Systems Science Intervention Based on My Life, My Story for Patients Living with HIV and Medical Students: Translating Narrative Medicine from Classroom to Clinic.

In 2018-2019, at the Keck School of Medicine of the University of Southern California (KSOM), we developed and piloted a narrative-based health systems science intervention for patients living with HIV and medical students in which medical students co-wrote patients' life narratives for inclusion in the electronic health record. The pilot study aimed to assess the acceptability of the "life narrative protocol" (LNP) from multiple stakeholder positions and characterize participants' experiences of the clinical and pedagogical implications of the LNP. Students were recruited from KSOM. Patients and staff were recruited from the Maternal, Child, and Adolescent/Adult Center for Infectious Disease and Virology (MCA) at Los Angeles County+USC Medical Center. Ten patients, seventeen students, and ten MCA staff participated in the pilot study. Qualitative methods were used to gather data from students', patients', and staff's perspectives. Three themes emerged from the thematic analysis: (1) patients' life narratives conveyed their unique life experiences and voices; (2) the protocol could result in wide-ranging effects on HIV care; (3) the LNP enabled students to contribute value to patients' healthcare. Across groups, participants considered the LNP an acceptable intervention. The LNP, its limitations, and implications for HIV care, narrative medicine, and health information technology are presented.

Chemotherapy completion rate for locally advanced rectal cancer at a safety-net hospital.

e15597 Background: Patients with locally advanced rectal cancer (LARC) typically receive chemoradiation prior to surgery, followed by adjuvant chemotherapy (standard). Recently there has been a growing trend toward total neoadjuvant therapy (TNT), in which all chemotherapy is given in the neoadjuvant setting, having the advantage of higher chemotherapy completion rates. Data exploring adherence to both standard therapy and TNT within a vulnerable, underserved population is lacking. Within our safety-net hospital, we determined the chemotherapy completion rates for LARC patients who received TNT vs standard treatment. We also compared two populations within the standard treatment group- those who received all doses of prescribed adjuvant chemotherapy (AC) and those who did not. Methods: A retrospective chart review was performed for all patients with LARC (stage II or III) presenting to Los Angeles County + USC Medical Center from 2015 to 2020. Patients who progressed prior to receiving their first dose of chemotherapy and patients lost to follow-up were excluded. Patient demographics, stage, neoadjuvant/adjuvant treatment, operative characteristics, and postoperative course were abstracted. T-tests and Wilcoxon rank-sum tests were used to compare means and medians, respectively; chi-squared tests were used to compare categorical variables. Results: 67 patients were included- 59 in the standard group and 8 in the TNT group. Mean follow-up was 30 months. All patients in the TNT group completed neoadjuvant chemotherapy. In the standard treatment group, the overall AC completion rate was 81% (n = 48) (Complete Group). 19% (n = 11) did not receive all prescribed doses of AC (Incomplete Group). Compared to patients in the Incomplete Group, patients in the Complete Group were significantly older (mean age 55 vs 48, p = 0.017), had a shorter mean time interval from surgery to initiation of AC (9 weeks vs 13 weeks, p = 0.016), and were less likely to experience a delay in receiving AC &gt; 90 days (15% vs 46%, p = 0.022). In total, 12 patients (20%) in the standard group experienced a delay in AC, of which six (50%) were due to anastomotic leak and/or pelvic abscess. Three of those patients who experienced a delay (25%) required either drain placement or re-operation to address their complication. More patients in the Complete Group went on to have their temporary stomas reversed compared to those in the Incomplete Group (94% vs 70%, p = 0.031). Conclusions: While this population had a high AC completion rate, a meaningful proportion of all patients (though more in the Incomplete Group) experienced a delay in AC &gt; 90 days, with surgical complications responsible for the delay in half of these patients. In contrast, all patients who received TNT completed neoadjuvant chemotherapy. TNT may be a reasonable alternative to reduce therapy delays and further improve chemotherapy completion rates in an underserved population.

739. A Two-Center Assessment of Histopathologic Diagnostic Performance for Fungal Organism Identification

BackgroundAccurate detection and identification of invasive fungal pathogens relies on concordance of several complementary laboratory techniques, including fungal culture, serology, and histopathologic identification. Histopathologic stains such as the Gomori methenamine silver stain (GMS) are used to highlight fungal cell wall in tissue specimens. We sought to determine the diagnostic performance of histopathology fungal stains as compared to fungal culture for diagnosis of invasive fungal tissue infection at tertiary medical centers with dissimilar patient populations.MethodsWe performed a retrospective review of all surgical pathology specimens with reported GMS results and concurrent fungal culture at Keck Medical Center (Keck) and Los Angeles County + USC Medical Center (LAC). Ratios of GMS diagnostic performance were compared using chi-squared analyses, with fungal culture as the gold standard for detection.ResultsOf 1347 LAC surgical pathology specimens stained with GMS to evaluate for fungal infection, 229 (17.0%) had concurrent tissue specimens submitted for fungal culture. Of 1546 Keck GMS-stained surgical pathology specimens, 358 (23.2%) had concurrent tissue for fungal culture. GMS stain performance at LAC showed a sensitivity of 53.7% (95% CI: 37.4-69.3%) and specificity of 90.4% (95% CI: 85.2-94.2%). At Keck, GMS showed a sensitivity of 64.1% (95% CI: 52.4-74.7%), specificity of 88.9% (95% CI: 84.7-92.4%), without significant difference in performance between sites, (p=0.27) and (p=0.62), respectively. Among filamentous fungi, GMS false negative frequency at LAC was 5.3% (10/190) and 4.0% (11/277) at Keck, without significant difference (p=0.51). A subset of pathology reports suggested the fungus genus based on histologic morphology. Of 10 LAC pathology specimens with fungal genus specified, 2 (20.0%) reports gave the incorrect genus and 8/18 (44.4%) reports at Keck gave incorrect genus as per concurrent culture isolate result.Table 1. Diagnostic performance of GMS histopathology stain on surgical pathology specimens compared to tissue fungal culture at LAC and Keck Medical Centers from July 2015 through December 2018. ConclusionGMS stain had low-to-moderate sensitivity when compared to fungal tissue culture. Increased submission of concurrent tissue for fungal culture is likely to improve detection. When genus level identification was attempted, fungal forms were incorrectly identified in about one-third of histopathology specimens.Disclosures All Authors: No reported disclosures

Occult Pneumothorax Identification on Extended Focused Assessment with Sonography for Trauma Examination in Children.

Occult pneumothoraces (OPTXs) are defined by air within the pleural space that is not visible on conventional chest radiographs (CXR). The aim of this study was to understand how frequently the Extended Focused Assessment with Sonography for Trauma (eFAST) examination identifies occult PTX in a pediatric blunt trauma population as compared with a criterion standard of chest computed tomography (CCT). This study is a secondary analysis of blunt trauma patients younger than 18 years who underwent CCT at Los Angeles County +USC Medical Center Emergency Department from October 2015 to April 2017. The eFAST examination was performed and documented by an emergency medicine resident with attending oversight or by an emergency medicine attending for each trauma. The eFAST results were reviewed for patients diagnosed with small or trace pneumothoraces identified on CCT. Of 168 pediatric trauma patients undergoing CCT, 16 had OPTXs not seen on CXR and 4 patients had a small/trace PTX without a corresponding CXR performed. None were identified on eFAST. Although the sample size in this data set was small, our eFAST examinations identified none of 16 proven and 4 presumed OPTXs. The standard eFAST examination performed poorly in the detection of OPTXs in this single-center study of pediatric blunt trauma victims.

S1270 Inappropriate PPI Use in an Urban Resident Primary Care Clinic

INTRODUCTION: Proton pump inhibitors (PPIs) are an efficacious treatment for gastroesophageal reflux disease (GERD) and dyspepsia. The American College of Gastroenterology (ACG) guidelines recommend a time-limited 8 weeks of therapy with PPIs for GERD and dyspepsia. PPIs are frequently prescribed in the primary care setting but can be over-prescribed or prescribed for too long. This can result in polypharmacy and other adverse medication-associated side effects. We evaluated the appropriateness of PPI use in patients with GERD and dyspepsia at LAC + USC Medical Center's resident primary care clinic. METHODS: We retrospectively analyzed all the patients seen in one week at LAC + USC's resident primary care clinic. Provider documentation was used to determine reasons for PPI use, indications to continue, and plans to trial off. RESULTS: Patients prescribed a PPI tended to be older (mean age 57.3 [55.8–58.9] vs 53.3 [52.0–54.5], P < 0.01), had more medical issues (7.3 [6.8–7.8] vs 5.6 [5.4–5.8], P < 0.01), specifically rheumatologic conditions (14.2% vs 5.9%, P < 0.01), and were more frequently followed in Gastroenterology specialty clinic (9.7% vs 2.6%, P < 0.01). Among patients on PPIs, 47% were prescribed it for GERD or dyspepsia, while 32% had no reason documented (Figure 1). 49 of 73 (67%) patients on a PPI for GERD or dyspepsia had been on a PPI for greater than two months without an indication to continue PPI therapy, and only 2 of 49 (4%) had a trial off PPI. CONCLUSION: The majority of patients prescribed a PPI for GERD or dyspepsia at the LAC + USC Resident Primary Care Clinic were on the medication for longer than the 8 weeks recommended by the ACG. During the root cause analyses for the inappropriate use of PPIs, gaps in house staff knowledge around guideline directed therapy and PPI side effects, time constraints associated with caring for a patient population with multiple comorbidities, and poor provider documentation in the electronic medical records were identified as significant contributing factors. To address gaps in knowledge, we plan to implement succinct and high yield didactic sessions for residents on appropriate PPI use and monitor for improvements in both documentation and adherence to ACG recommendations.Table 1.: Patient demographics and PPI use in primary care clinic. PPI = proton pump inhibitor, IDDM = insulin-dependent diabetes mellitus, NIDDM = noninsulin dependent diabetes mellitus, CKD = chronic kidney disease, CHF = congestive heart failure, CAD = coronary artery disease, ESRD = end stage renal disease, GERD = gastrointestinal esophageal reflux disease, PUD = peptic ulcer diseaseFigure 1.: Analysis of PPI prescriptions in primary care clinic. PPI = proton pump inhibitor, GERD = gastroesophageal reflux disease.

A Prospective Evaluation of Clinical Characteristics of Methamphetamine-associated Cardiomyopathy (MACM) in Comparison to a Matched-cohort with Non-methamphetamine Non-ischemic Cardiomyopathy

Background With globally increasing rates of methamphetamine (MA) abuse, there is a rising prevalence of methamphetamine-associated cardiomyopathy (MACM). The condition, however, is poorly characterized, leaving clinicians with little data to guide diagnosis and management. Purpose To compare clinical characteristics of prospectively encountered patients with MACM to those with non-MA non-ischemic cardiomyopathy (NMACM). Methods Consecutive patients with MACM confirmed by history presenting to Los Angeles County (LAC)+USC Medical Center between Jun 2018 and March 2020 were interviewed and studied. We retrospectively identified an age- and gender-matched cohort of NMACM and compared demographic, laboratory, and echocardiographic data between the two groups. Results 140 patients (70 MACM and 70 NMACM) were included. Mean age was similar (49.6±10 vs 48.2±10.5 years, p=0.45) and 94% of patients were male. Patients were predominantly Hispanic in both groups (51% vs 61%, p=0.232) with a greater proportion of Caucasians in the MACM group (21% vs 6%, p=0.007). Significantly more patients with MACM were homeless (47% vs 7%, p=0.001). 20% of MACM patients were college educated. The mean and median duration of MA use prior to a diagnosis of heart failure was 9.8 and 5.5 years, respectively. Two-thirds of MACM patients reported current MA use. MACM compared to NMACM was characterized by lower left ventricular ejection fraction (LVEF) [20% vs 26%, p Conclusion Compared to an age and gender matched cohort of NMACM, prospectively identified patients with MACM had a high incidence of homelessness and significantly more severe myocardial insult with greater degree of LV and RV dilatation and depression of LV function. Frequency or amount of MA use did not appear to be associated with severity of MACM.

Factors affecting recurrence rates in women with borderline ovarian tumors.

e18055 Background: Borderline or low malignant potential tumors of the ovary (BOTs) make up approximately 15-20% of all ovarian neoplasms. These tumors are considered indolent and usually confer an excellent overall survival in women who are treated utilizing a conservative surgical approach. However, recurrence rates can approach 30%. The aim of this study was to compare the type and mode of surgery and its impact on outcomes in patients with BOTs. Methods: An Institutional Review Board approved, retrospective cohort study identified all patients at Long Island Jewish Medical Center, North Shore University Hospital and USC Medical Center with BOTs who underwent surgery between January 2008 and May 2018. Demographics and outcome measures were obtained from the medical records. Prognostic factors for disease recurrence were studied including histological subtypes type of surgical procedure, including minimally invasive or open ovarian cystectomy and oophorectomy. Results: 260 patients were identified. 226 of these women (88%) had stage I disease at the time of diagnosis. There were 26 recurrences noted in the cohort, a recurrence rate of 10 percent. The median age was 50 years old (range 16-86). 145 patients (56%) underwent minimally invasive surgical procedures compared to 115 (44%) who had open laparotomy. 30 (12%) of the women underwent an ovarian cystectomy and 230 (88%) had an oophorectomy. The median time to disease recurrence was 25 months (range 4-94 months). There was significant difference in the recurrence free survival between the patients who had minimally invasive procedures and those who had open laparotomy (hazard ratio (HR) 2.69, 95% confidence interval (CI) 1.11-6.52). There was also significant difference in Recurrence Free Survival (RFS) and in those who underwent ovarian cystectomy and oophorectomy (HR 7.32, 95%CI 3.34-16.06). No difference in recurrence rates were noted between those with serous and mucinous histology. Conclusions: In this cohort of women with BOTs, the risk of recurrence was associated with minimally invasive surgery versus open laparotomy as well as ovarian cystectomy compared with oophorectomy. Conservative surgery for BOTs in young patients plays an important role for fertility preservation in these young women and can be curative. This study allows us to present additional information to address surgical approach and risk for disease recurrence in young women having fertility sparing and conservative surgery for BOTs.

Film Documents History of Deinstitutionalization and Its Impact on Today’s SMI Population

Film Documents History of Deinstitutionalization and Its Impact on Today’s SMI Population

Youth and Young Adult Victims of Interpersonal Violence at LA County + USC Medical Center: A Review of Epidemiology and Recidivism

Youth and young adult interpersonal violence (IPV) is a unique clinical challenge which merits study. This study defined the demographics and clinical outcomes of youth and young adult victims of IPV presenting to our hospital while examining violent injury recidivism. We reviewed patients aged 10 to 30 years admitted to our trauma bay as a victim of gunshot wound (GSW), stabbing wound, or blunt assault from 1998 to 2015 (n = 12,549). Logistic regression analysis was conducted to compare patient mortality across demographic characteristics, and Cox proportional hazards regression was used to determine risk factors for recidivism. Male (92%) and Hispanic patients (75%) constituted the majority of admissions. We observed differences in the mortality rate by gender (9% in males vs 5% in females, P < 0.001), race/ethnicity (5% non-Hispanic white vs 9% Hispanic, P = 0.001), insurance status (3% insured vs 10% uninsured, P < 0.001), and mechanism of injury (13% GSW, 2% stabbing wound, and 0.3% blunt assault, P < 0.001). Male gender, younger age, GSW, and amphetamine placed patients at higher risk for IPV recidivism (P < 0.05). This study demonstrates the need to better understand how demographics and economics are associated with youth and young adult IPV. In addition, future IPV prevention and intervention initiatives can be tailored to suit the unique needs of our population.

Adrián E. Ortega, MD, FASCRS, and Xavier Delgadillo, MD, EBSQ-C.

Dr. Adrián E. Ortega is a native Californian born in East Los Angeles in 1959. He graduated from Stanford University with distinction in 1981. He returned home to the LAC + USC Medical Center in 1985 after graduating from Harvard Medical School. He completed his general surgical residency at the University of Southern California (U.S.C.) in 1991, then he joined the faculty at U.S.C. Dr. Ortega was a pioneering surgeon clinically and academically in minimally invasive surgery early in his career. He was a founding member of the Colorectal Surgery Division at his institution in 1992. He completed his colorectal surgery fellowship in 1998 at U.S.C. under the tutelage of Dr. Robert W. Beart.

Readmission Rates for Heart Failure in a Safety-Net Hospital

Background Despite ongoing efforts, heart failure hospitalization (HFH) rates remain high. The underserved population may be at higher risk for readmission given limited access to health care professionals, advanced device-based therapies, and newer medications. The goal of the current study was to determine HFH rates in an urban Safety-Net hospital and to identify clinical and non-clinical factors that may influence these rates. Methods All patients g 18 years of age admitted to the Coronary Care Unit from March 2017 to February 2018 at Los Angeles County USC Medical Center were indexed in a database. Demographics, insurance status, history of drug use, ejection fraction (EF), etiology of heart failure, treatment received, and length of hospital stay were collected. All-cause and 30-day HFH rates were determined. Results During the study period, 188 patients were identified. Mean age was 58±14 years, 69% were male, 15% had preserved EF, and 35% had an ischemic cardiomyopathy. The prevalence of active tobacco/alcohol use was 42%. Active use of methamphetamines, heroin, cocaine, and/or cannabis was present in 18%. HFH at 30 days for the entire cohort was 17%. Length of hospital stay was 4.2±5.1days. Following the index hospitalization, only 45% of patients returned for a scheduled follow-up outpatient visit. On univariate analysis, current drug use, current alcohol/smoking, and homelessness were associated with an increased HFH rate within 30 days. On multivariate analysis, homelessness was the only independent risk factor associated with HFH (p=0.049). Conclusions Homeless individuals have a significantly increased risk for heart failure hospitalization. Additional interventions focused on improving post-discharge outpatient follow-up rates, targeting continued drug use, and facilitating adequate housing are required in the underserved population.

COMMENTARY

Los Angeles, California. Submitted: January 23, 2019, Accepted: January 26, 2019, Published online: February 1, 2019. Address for reprints: Demetrios Demetriades, MD, PhD, LAC + USC Medical Center, Los Angeles, CA; email: [email protected]. The authors declare no conflicts of interest.