Valley Medical Center Research Articles

P-1698. Prevalence of Anaerobes, Enterococcus, and Pseudomonas Among Patients with Complicated Biliary Infections

Abstract Background Current 2010 Infectious Diseases Society of America (IDSA) guidelines indicate that community acquired biliary infections do not require antimicrobial therapy directed against Enterococcus spp., Pseudomonas (PSA), or anaerobes in the absence of select risk factors. We evaluated empiric prescribing practices for complicated biliary infections at Valley Medical Center (VMC). Methods This was a single center retrospective study including patients 18 years or older with complicated biliary infections admitted at VMC from 1/1/2018 - 2/28/2022. Patients who did not require surgical intervention, had no cultures collected, or noted cephalosporin allergy were excluded. The primary outcome was to evaluate the prevalence of anaerobic, Enterococcus spp., and PSA bacteria isolated from culture. Secondary outcomes evaluated rate of Intensive Care Unit (ICU) admissions, all cause 30-day readmission, and C. difficile infections (CDI). Results 191 patients with complicated biliary infections with culture data were included. Anaerobes and Enterococcus spp. were the most commonly isolated organisms, accounting for 19.4% and 11.5%, respectively. Of anaerobic cultures obtained, 6 (3.1%) were identified as gram-negative anaerobes and 26 (13.6%) were identified as gram-positive anaerobes. Pseudomonas spp. was uncommon (0.5%). 78 (40.8%) had negative cultures. 85 (44.5%) received empiric ceftriaxone. Of those on ceftriaxone, 75 also received metronidazole. 88 (46.1%) received empiric piperacillin tazobactam and the remaining 18 patients received alternative therapies. 59 (30.9%) were either admitted or transferred to ICU during their index admission. Of these, 48 (81.4%) were on piperacillin tazobactam. Similar all-cause 30-day readmission was observed among patients on ceftriaxone and piperacillin tazobactam (43.4%). Diagnosis with CDI within 90 days of discharge was uncommon (1.6%). Conclusion PSA and Gram-negative anaerobe prevalence was low; Enterococcus and Gram-positive anaerobes was higher. Lower rates of ICU admission and CDI were observed in patients on ceftriaxone, though may be in part due to less severe illness. Additional studies are needed to evaluate risk factors that may be predictive of Enterococcus and anaerobic infection. Disclosures All Authors: No reported disclosures

642. The Role of Electronic Medical Record Automation in Latent Tuberculosis Screening and Treatment in a Large Health System

Abstract Background Valley Medical Center is a tertiary county hospital in San Jose, California that also staffs 12 clinics. Our institution’s Mycobacterial and Refugee Health Clinic is the main referral center for latent tuberculosis (LTBI) and active TB cases in the county. The USPFTF recommends screening for LTBI in asymptomatic adults who are at higher risk. This is challenging in primary care settings where physicians often see a high number of patients within limited time frames. There are many points on the LTBI care cascade (Figure 1) where patients can fall off. In the age of automation, technological tools can be designed to help reduce clinician burden.Figure 1:Latent Tuberculosis Care CascadeSource: California Department of Public Health Tuberculosis Control Branch Methods An EMR tool was engineered to prompt physicians to order a QuantiFERON (QFN) if a patient meets certain criteria: 18 years or older, no prior QFN or TB skin test, and any of the following risk factors: HIV positive, in custody, drug use, homelessness, or non-English primary language (proxy for foreign birth). This EMR tool went live on 8/9/22. Using EMR data-collection tools, a retrospective analysis was done among patients who had a clinical encounter (office visit or telemedicine) between 8/9/21-8/9/22 and 8/9/22-8/9/23 (one year before and after implementation of the tool). We determined the number of patients who were eligible for screening, obtained a QFN, had a positive QFN, initiated, and completed treatment. A 2-sample Z-test was used to assess temporal trends.Table 1:LTBI Care Cascade for Patients Seen by a Primary Care Physician in 8/9/21-8/9/22 and 8/9/22-8/9/23 Results From 8/9/22-8/9/23, 34251 patients were marked eligible for LTBI screening based on the EMR tool (Table 1, Figure 2). The proportion of patients tested for LTBI increased from 45.3% to 81.2% (p-value < 2.2e-16). The proportion of positive LTBI results increased from 8.6% to 12.4% (p-value < 2.2e-16). The number of patients who initiated treatment increased from 545 (40.8%) to 1038 (30%). The number of patients who completed treatment increased from 417 (76.5%) to 770 (74.2%).Figure 2:LTBI Care Cascade for Patients Seen by a Primary Care Physician in 8/9/21-8/9/22 and 8/9/22-8/9/23 Conclusion This study highlights that a low-cost EMR intervention can lead to substantial increases in LTBI screening, and as a result higher treatment completion. EMR automation can also improve accuracy in screening, reflected by the increased proportion of positive QFN results. Future tools involving digital technology can be designed to reduce drop-offs at other points along the LTBI cascade as well. Disclosures All Authors: No reported disclosures

P-2220. Real-World Utilization of a Multiplex Pneumonia PCR Panel on Antimicrobial Stewardship and Antibiotic Use

Abstract Background In October 2022 the Queen of the Valley Medical Center (QVMC) microbiology department implemented the Biofire® Pneumonia Pathogen Panel polymerase chain reaction (PCR) for identification of viral and bacterial pathogens along with resistance genes. This may aid in improved identification of pneumonia pathogens with a quicker turnaround time. In contrast, respiratory cultures take multiple days to return with both the organism and antibiotic susceptibility, which delays the time to achieving targeted therapy. Methods This was a retrospective cohort study from October 2022 to April 2023. Patients were included if they were admitted to QVMC and had a positive pneumonia PCR. Patients were excluded if they were receiving antibiotics for an indication other than pneumonia, if they did not receive antibiotics, or if they were discharged, transferred or died prior to the PCR result. The primary outcome was if the patient achieved targeted therapy. Secondary outcomes included time to targeted therapy, actions performed based on the results, and correlation between respiratory culture results and PCR. Results Fifty-nine patients were included for analysis. Most patients had a diagnosis of CAP (n = 43, 72%), vs. HAP (n = 8, 14%), and VAP (n = 8, 14%). Targeted therapy was achieved in 41 patients (70%). Seven (12%) of these patients had empiric therapy which was also targeted therapy. The mean time from PCR collection to the start of targeted therapy was 23.11 hours. For patients who had respiratory cultures collected, the mean time to final identification with susceptibilities was 40.6 hours. Therefore, targeted therapy was achieved at least 17 hours sooner than if de-escalation or escalation was solely dependent upon respiratory culture results. There were 47 antimicrobial stewardship recommendations documented, and 31 (66%) were accepted by providers. Forty-four patients (75%) also had respiratory cultures collected, and only 19 (43%) had organism growth. Conclusion Utilizing multiplex PCR technology for patients with pneumonia can be useful for antimicrobial stewardship programs by providing higher rates of pathogen identification and resistance data compared to respiratory culture alone. This allows for improved time to targeted therapy. Disclosures All Authors: No reported disclosures

Statin use is associated with protection against acute cholangitis in patients with primary sclerosing cholangitis: a multi-center retrospective cohort study.

Patients with primary sclerosing cholangitis (PSC) are at increased risk for acute cholangitis. The epidemiological risks for cholangitis are poorly studied despite the high morbidity associated with this infection. This study's aim was to understand the impact of statins on acute cholangitis in PSC. This multicenter, retrospective cohort study assessed data from 294 patients with PSC at Stanford Medical Center, Baylor Medical Center, and Valley Medical Center. Clinical factors associated with development of cholangitis were identified using multivariable Cox regression. The patients were predominantly male (68.7%) with a median age at enrollment of 48 years [IQR: 31.0-60.8]. Fifty patients (17.0%) were prescribed statins. Median follow-up time was 6 years [IQR: 2.0-12.0], in which 29.6% (n=87) developed cholangitis.In multivariable analysis, statins were associated with an 81% reduction in cholangitis (HR 0.19, 95% CI 0.03-0.64). Statins were associated with a lower incidence of cholangitis at 36 months compared with patients not on statin therapy (incidence of 11.9% vs 34.7%, p<0.001). Statins were also associated with increased time-to-stricture (p=0.004), an outcome known to be associated with PSC complications1,2. Statin therapy is associated with reduced risk of cholangitis in PSC, possibly by delaying time to development of a dominant or high-grade strictures. In patients with PSC, use of statin therapy may be a beneficial modality to prevent the development of cholangitis and warrants further investigation.

An Internal Medicine Learning Collaborative Facilitating a Virtual Continuing Medical Education Program in Guyana and the Wider Caribbean During the COVID-19 Pandemic.

To collaborate and share medical knowledge between US and Caribbean physicians during the COVID-19 pandemic via a free online continuing medical education (CME) series. Method: This was a multi-institution collaborative effort between the Southern Regional Area Health Education Center and Cape Fear Valley Medical Center, both located in North Carolina, USA, and its Caribbean partners, the Guyana Medical Council and Ministry of Health, and the University of the West Indies Medical Alumni Association, Jamaica. The lecture series ran from July 2021 to October 2022. The Zoom (Zoom Video Communications Inc., San Jose, CA, USA) meeting platform was used for the monthly lectures on the fourth Thursday between 7 and 8 p.m. Eastern Standard Time (EST). Results: Analysis of program data from July 2021 through October 2022 (excluding December 2021) found 1,105 unique individuals engaged in the 15 continuing education sessions. The series had a cumulative total of 2,411 participants, with a mean session participation of 161 and a range of 94 to 299 participants per lecture. An outcome survey assessing the reasons for attendance identified that the most significant factors in their participation in the series were: a) the quality of educational content (83.21%), b) the ease of access and Zoom platform (81.76%), and c) the lectures being offered at no cost (61.31%), and 80.84% gained new medical knowledge leading to practice changes. Conclusion: The Internal Medicine Learning Collaborative (IMLC) model can be easily replicated by following the steps outlined. It overcomes barriers such as travel and quarantine restrictions and is cost-effective to initiate and maintain. It allows physicians with access to resources and specialty training in the United States to share medical knowledge with colleagues in the developing world where such access may be limited, thus promoting health care and continuing education activity in their respective regions using freely available technologies.

Gierigheid is die wortel van alle kwaad

Gierigheid is die wortel van alle kwaad

Every Deep-Drawn Breath: A Critical Care Doctor on Healing, Recovery, and Transforming Medicine in the ICU, by Wes Ely. Published by Scribner, New York, NY. 332 pages, $28.00. 2021. ISBN: 9781982171148.

1 Cardiac Surgical ICU, Cape Fear Valley Medical Center, Fayetteville, NC 2 Department of Anesthesiology, Perioperative, and Pain Medicine, Stanford University School of Medicine, VA Palo Alto Health Care System, Palo Alto, CA

Pagetoid Dyskeratosis of the Hand With Parallel Ridge Pattern on Dermoscopy and Expression of Bcl-10 by Immunohistochemistry.

*Department of Dermatology, Oregon Health and Science Center, Portland Oregon †Department of Dermatology, Valley Medical Center, Renton Washington; and ‡Department of Pathology, Virginia Mason Medical Center, Seattle WA. Correspondence: Steven M. Ruhoy, MD, Department of Pathology, Virginia Mason Medical Center, Seattle WA (e-mail: [email protected]). The authors declare no conflicts of interest.

Prevalence and attributable risk factors of respiratory distress syndrome among neonates confined at Cagayan Valley Medical Center: A retrospective study

Prevalence and attributable risk factors of respiratory distress syndrome among neonates confined at Cagayan Valley Medical Center: A retrospective study

Effects of Labor Support Education on Nursing Knowledge, Confidence, and Cesarean Rates

Despite physical, psychological, and financial consequences, nulliparous, term, singleton, vertex (NTSV) cesareans have continued to rise. A goal of Healthy People 2020 was to reduce NTSV cesarean rates to 24.7%. In 2020, Carilion New River Valley Medical Center (CNRVMC) reported a monthly NTSV cesarean rate of 50%, with a yearly mean of 30.4%. Research suggests that registered nurses can significantly contribute to the reduction of cesareans through evidence-based labor support (EBLS). To reach the Healthy People 2020 goal at CNRVMC, an EBLS education program was implemented to reinforce nurse-led interventions that support normal physiological birth.

Residents Are Coming: A Faculty Development Curriculum to Prepare a Community Site For New Learners.

This curriculum is designed for emergency medicine attendings in varying years of community practice to prepare them for Emergency Medicine (EM) residents. 15 months. Emergency medicine is a growing field with new residencies approved every year. A strong, competent cadre of clinical educators is essential to the success of any residency, and new programs have the challenge of developing their clinical faculty into outstanding teachers. There is minimal literature guidance for navigating this transition. Our site is a community tertiary care center in the process of applying for an EM residency. We focus on our experience designing a faculty development curriculum to accommodate the needs of a diverse group of physicians in all stages of their careers. We will demonstrate that a curriculum satisfying all stakeholders can easily be implemented in a way that allows for robust participation without excessive additional administrative burden. Our goal is to prepare community-based EM attendings to be outstanding educators to future residents by augmenting their knowledge of current educational practice and adult learning theory, literature review, and biostatistics. The educational strategies used in this curriculum included lectures, guided discussion, small group discussion, and asynchronous learning. This curriculum was implemented in the Geisinger Wyoming Valley Medical center targeted at staff physicians. This educational study was deemed exempt by the institutional review board (IRB). We electronically collected retrospective survey data using a 5-point Likert scale as well as free text responses. The primary measure was agreement with the statement, "Faculty development time makes me feel more prepared to be a clinical educator." We also surveyed whether this was felt to be an appropriate use of time, self-reported growth in key educational and biostatistical domains, and likeliness to change practice based on the material. Responses collected from core faculty after the sessions indicated a uniformly positive review of the series itself with the primary outcome receiving a 4.6 rating on a 5-point Likert scale (strong agreement). Faculty reported that these brief sessions improved the quality of the departmental staff meetings (average rating 4.7/5). Journal club sessions were rated as positive (4.7/5) and attendees self-reported growth in statistical literacy and security in clinical practice. We demonstrated successful implementation of a faculty development curriculum that was favorably assessed by all key stakeholders. Faculty self-reported growth in all educational and clinical domains evaluated. It was successfully implemented without substantially increasing the time burden for physicians with robust clinical and administrative schedules. We feel this is generalizable to other sites seeking to start an EM residency and is useful for sites with existing residencies to efficiently deliver content to junior faculty. Emergency medicine, faculty development, journal club, virtual learning.

Identifying barriers to utilization of a medication access program among referred patients surveyed after discharge from an acute care hospital

BackgroundFor uninsured residents of select counties in North Carolina, the Cumberland County Medication Access Program (CCMAP) provides prescriptions at no cost. Uninsured patients hospitalized at Cape Fear Valley Medical Center are referred to CCMAP at discharge by Cape Fear Valley Health System employees, primarily coordination of care personnel and outpatient pharmacy personnel. The purpose of this study was to describe the most frequently reported utilization barriers among surveyed patients referred to CCMAP after discharge from Cape Fear Valley Medical Center. MethodsThis was a single-center, survey-based, descriptive research study. Referring Cape Fear Valley Health System employees collected the medical record number of patients referred to CCMAP at discharge between October 22, 2020 and December 31, 2020. These patients were contacted via a research team member by telephone at least 30 days after discharge to voluntarily participate in a survey regarding their ability to receive prescriptions from CCMAP after discharge. Patient-reported utilization barriers and demographics were recorded. A similar survey was voluntarily completed by referring health system employees. Employee-reported utilization barriers were collected to identify discrepancies in perceived utilization barriers among discharged patients and referring health system employees. ResultsThere were 69 patients referred to CCMAP at discharge by outpatient pharmacy personnel. A total of 17 patients met inclusion criteria and completed the survey. Of these, 35.29% of the patients reported their greatest utilization barrier to be uncertainty about how to apply for CCMAP. In addition, 25 surveys were completed by referring outpatient pharmacy personnel. Of these, 56% of the participants reported they believe the greatest utilization barrier to be patient uncertainty about how to apply for CCMAP. ConclusionsUninsured patients discharged from Cape Fear Valley Medical Center could benefit from increased assistance with completing CCMAP applications and enrollment with the program before discharge to improve continuity of care.

What are the outcomes of screening for intimate partner violence in primary care?

University of Washington Family Medicine Residency at Valley Medical Center, Renton, WA QueerDoc: Queer and Gender Affirming Care (Private practice), Seattle, WA University of Washington Medical Library, Seattle, WA The authors declare no conflicts of interest.

136. Don’t Sweat the Small Stuff: Solutions for Large-Scale Stewardship Obstacles

BackgroundIn an effort to support stewardship endeavors, the MITIGATE (a Multifaceted Intervention to Improve Prescribing for Acute Respiratory Infection for Adult and Children in Emergency Department and Urgent Care Settings) Toolkit was published in 2018, aiming to reduce unnecessary antibiotics for viral respiratory tract infections (RTIs). At the University of Washington, we have incorporated strategies from this toolkit at our urgent care clinics. This study aims to address solutions to some of the challenges we experienced.Challenges and Solutions MethodsThis was a retrospective observational study conducted at Valley Medical Center (Sept 2019-Mar 2020) and the University of Washington (Jan 2019-Feb 2020) urgent care clinics. Patients were identified through ICD-10 diagnosis codes included in the MITIGATE toolkit. The primary outcome was identifying challenges and solutions developed during this process.ResultsWe encountered five challenges during our roll-out of MITIGATE. First, using both ICD-9 and ICD-10 codes can lead to inaccurate data collection. Second, technical support for coding a complex data set is essential and should be accounted for prior to beginning stewardship interventions of this scale. Third, unintentional incorrect diagnosis selection was common and may require reeducation of prescribers on proper selection. Fourth, focusing on singular issues rather than multiple outcomes is more feasible and can offer several opportunities for stewardship interventions. Lastly, changing prescribing behavior can cause unintended tension during implementation. Modifying benchmarks measured, allowing for bi-directional feedback, and identifying provider champions can help maintain open communication.ConclusionResources such as the MITIGATE toolkit are helpful to implement standardized data driven stewardship interventions. We have experienced some challenges including a complex data build, errors with diagnostic coding, providing constructive feedback while maintaining positive stewardship relationships, and choosing feasible outcomes to measure. We present solutions to these challenges with the aim to provide guidance to those who are considering using this toolkit for outpatient stewardship interventions.Disclosures All Authors: No reported disclosures

PATIENT SAFETY Incident reports reflect ongoing blame games

Barbara Wyand Walker is an infection control coordinator at Greenbrier Valley Medical Center in Ronceverte, W.V. The author has disclosed no financial relationships related to this article.

Pharmacy student involvement in a transition of care program

Background and purposeCape Fear Valley Medical Center (CFVMC) implemented a Community Paramedic Program (CPP) to improve the transition of hospitalized patients to the home setting. In this program, paramedics conduct home visits for 30 days after qualifying patients are discharged. This article describes pharmacy services provided to CPP patients by fourth-year pharmacy students on Advanced Pharmacy Practice Experiences (APPE) that assisted with home visits. Educational activity and settingStudents were oriented to the CPP and patient interview technique was assessed through a role-play scenario. A standardized form was created to record drug-related problems (DRP) identified and patient education provided to patients. The primary outcome describes types of DRP identified and education provided. Secondary outcomes compare the types and average number of DRP per patient identified by students as compared to the standard of care (pharmacist review of medications electronically) and trends in patients readmitted within 30 days following discharge. FindingsEleven students visited 124 patients and recorded 145 DRP. Extra/continuation of medications stopped at discharge and issues related to medication safety were the most common DRP. The most frequent type of education provided was medication use related. On average, students provided one counseling session per patient. Discussion and summaryStudent involvement is an added benefit to the CPP by providing face to face education and re-assessment of medications at follow-up visits. This article summarizes a unique teaching platform utilizing students to extend care. Real world experiences in programs like the CPP provide students the opportunity to sharpen critical thinking and problem-solving skills necessary for maturing professionally.

P224 Comparison of clinical outcomes and radiographic characteristics between smear negative (clinically diagnosed) and smear positive (bacteriologically diagnosed) pulmonary tuberculosis with category I (2HRZE/4HR) treatment at Cagayan valley medical center: a pilot study

P224 Comparison of clinical outcomes and radiographic characteristics between smear negative (clinically diagnosed) and smear positive (bacteriologically diagnosed) pulmonary tuberculosis with category I (2HRZE/4HR) treatment at Cagayan valley medical center: a pilot study

Abstract WP410: From the Ground to Target Stroke Elite Plus

Background: Geisinger Wyoming Valley Medical Center (GWV), in Wilkes-Barre, Pennsylvania, serves a population of approximately 320,000 people throughout Luzerne. In 2013, the stroke program was launched in GWV secondary to community need. In less than three years we achieved the highest quality metric from the American Heart and American Stroke Association. Here we describe highlights of our intuitive strategies and achievements. Methods: The following strategies were employed to achieve this goal. The Stroke Program Coordinator was an emergency medical service provider and emergency department nurse manager. A stroke bay was added directly outside of the ED Computer Tomography(CT) suite, patients were immediately triaged and taken directly to CT. A nurse navigator was implemented for daily rounding to provide stroke education to patients and families and collect real-time data. The real-time data abstraction and feedback system allowed opportunity for immediate action and timely targeted education. Weekly in-services were held with the inpatient nursing staff where issues were further reviewed and education provided on an ongoing basis. Staff education has been the main priority and nursing management was closely involved. A systematic approach has been implemented for patients requiring weekend stroke education. A stroke topic was included in our monthly nursing newsletter. Results: In less than three years we were able to achieve Target Stroke Elite Plus, the highest recognition from the American Heart and American Stroke Association. Sixty-seven percent (95% CI: 63.5-80.5%) of our acute stroke patients had a door-to-needle time below 45 minutes. Compliance with all our core measures more than 95% (95% CI: 93.4- 96.6%), and rehabilitation, in hospital antithrombotic treatment, discharge antithrombotic more than 99% of the time. Conclusion: A collaborative model and multidisciplinary approach is associated with improved guideline adherence. In conclusion, this model and our strategies can be successfully applied in other community hospitals.

Reflection on the Differences and Similarities of Mental Health Care in Virginia and Taiwan: Geography, History, Culture, and Nurse Practitioners

Sponsored by the pilot overseas internships project of the Ministry of Education, Taiwan, the authors and ten undergraduate students from Taiwan visited several mental health facilities in Virginia for one month. These facilities included the Catawba State Hospital, Salem Veteran Affairs Medical Center, Carilion Saint Albans Behavioral Health (New River Valley Medical Center), Warm Hearth Village, Adult & Child Family Counseling private outpatient clinic, the Free Clinic of the New River Valley, New Life Clubhouse, and Self-Government Program for Assertive Community Treatment. In-depth dialogue and participation in nursing care under the supervision of registered nurses facilitated the authors' reflection on mental health care and the roles and functions of Taiwanese nurse practitioners. The present article adopts a macro view in order to compare the related issues between Taiwan and Virginia, including: geographic features, history, culture of health-seeking behavior, healthcare insurance, and the relationships among various professionals. How these issues relate to social-cultural background and how the overall healthcare environment impacts upon the roles of nurse practitioners in Taiwan are rarely discussed in literature. We expect that this cross-cultural contrast and reflection will elicit a better understanding of how these factors have shaped and affected the roles of Taiwanese nurse practitioners. Further, suggestions about how to improve the nursing profession in Taiwan are presented.

Electrophysiological observations of acute His bundle injury during permanent His bundle pacing

BackgroundPermanent His bundle pacing (HBP) is a physiological alternative to right ventricular pacing (RVP). Catheter manipulation during HBP can cause trauma to the His bundle during implantation. We sought to determine acute and long-term incidence of His bundle (HB) injury with HBP. MethodsPatients undergoing permanent HBP at Geisinger Wyoming Valley Medical Center from 2006 to 2014 formed the study group. Patients with pre-existing His-Purkinje disease (HPD) were excluded from the study. Any development of new bundle branch block (BBB) or AV block (B) during acute HBP lead-induced block was recorded. Resolution of AVB and/or BBB was documented. ResultsHBP was attempted in 450 patients. In 358 patients without HPD, 28 (7.8%) developed acute HB injury in the form of complete AVB (4, 1.1%), RBBB (21, 5.9%) or LBBB (3, 0.8%) during HBP lead placement. In all 7 patients with AVB or LBBB, conduction completely recovered. The HB electrogram from the lead displayed injury current in all 7 patients. Lead-induced RBBB resolved in 12 of 21 patients and persisted in 9 (2.5%) patients. Pacing from the HBP lead resulted in correction of acute conduction block in 27 of 28 patients and 8 of 9 patients with chronic RBBB. None of the patients with transient conduction block developed new conduction disease during follow-up of 21±19months. ConclusionsDespite acute trauma to HB in 7.8% of patients undergoing permanent HBP, complete resolution of conduction block occurred in 19 of 28 patients (68%). RBBB persisted in 9 patients (32%) but mostly normalized with HBP.