West Virginia University Hospital Research Articles

Association of autoimmune and autoinflammatory disorders with chronic rhinosinusitis in children

BackgroundIncreasing evidence suggests that autoimmune disorders and their immunomodulating medications may increase the risk of rhinosinusitis. The goal of this study is to determine if autoimmune and autoinflammatory diseases are associated with increased risk of chronic rhinosinusitis (CRS) in children. MethodsA retrospective case-control study of pediatric patients (age 2–18 years) seen in the West Virginia University Hospitals System in the past 10 years was performed. Cases were children with autoimmune or autoinflammatory diseases. Controls were children without any autoimmune or autoinflammatory disorders. Query of our electronic medical record (Epic) was performed using ICD-10 codes. Univariate (unadjusted) and multivariate (adjusted) logistic regression were used to calculate the strength of association of autoimmune or autoinflammatory disorders with CRS and the other airway disorders while adjusting for age, sex, and race. Results420582 pediatric patients were queried with mean age of 10.8 years (SD of 4.8, range of 2–18 years), and 47.9% being female. 1956 (0.5%) had autoimmune disorders and 293 (0.07%) had autoinflammatory disorders. Both autoimmune and autoinflammatory disorders increase the odds of having CRS in the unadjusted [OR = 3.36, p < 0.001 and 5.69, p < 0.001 for the respectively] and the adjusted [OR = 2.90, p < 0.001 and OR = 5.07, p < 0.001 respectively after adjusting for age, sex, and race] models. ConclusionAutoimmune and autoinflammatory disorders increase the risk of CRS and chronic rhinitis in children.

Impact of a pharmacy technician on an interprofessional antithrombotic stewardship program at an academic medical center.

The need for monitoring and standardization of anticoagulation management has garnered the attention of national organizations, driving the implementation of antithrombotic stewardship programs (ASPs). Established ASPs have highlighted interdisciplinary collaboration between physicians, nurses, and pharmacists and demonstrated financial benefits and positive patient care outcomes. While pharmacy technicians are key members of the pharmacy profession, they are rarely utilized to expand clinical programs. The aim of this report is to describe the impact of adding a pharmacy technician to an ASP at an academic medical center. The departments of pharmacy and quality at West Virginia University Hospitals (WVUH) developed a business plan and financially justified an ASP. The ASP was implemented in January 2022 and consisted of 2 full-time clinical pharmacist specialists, 1 full-time clinical pharmacy technician, 2 full-time clinical nurse specialists, and 1 part-time physician medical director. The clinical pharmacy technician's primary role was to review patients' sequential compression device (SCD) compliance and newly started oral anticoagulants prior to discharge. The clinical nurse specialists educated patients newly started on oral anticoagulants within 24 hours of discharge and triaged any postdischarge medication access issues. The medical director provided high-level program oversight and acted as a clinical consultant on complex patient cases. In the first 6 months after the program's implementation, the clinical pharmacy technician made 174 recommendations to the clinical pharmacist specialists regarding discharge transitions of care and assessed SCD compliance in 246 patients. Of the 246 patients assessed, 217 patients (88%) were deemed to be noncompliant. The pharmacy department at WVUH successfully justified and implemented an interprofessional ASP at an academic medical center, which is the first ASP to date to incorporate a clinical pharmacy technician.

Analysis of Inferior Vena Cava Filter Indications and Retrieval Rates at an Academic Medical Center in Appalachia

Introduction: Inferior vena cava (IVC) filters are placed for prevention of pulmonary embolism in patients with venous thromboembolism (VTE) and a contraindication to anticoagulation. Additional clinical indications for IVC filters, such as pre-operative prophylaxis for VTE and extensive VTE, are controversial and vary across clinical guidelines. Current guidelines recommend that IVC filters be retrieved after resolution of their clinical indication. A common problem is failure to retrieve IVC filters when indicated, resulting in prolonged or indefinite placement of these devices. Failure to remove IVC filters contributes to an increased risk of filter-associated complications such as device migration, embolization to the cardiopulmonary circulation, perforation and increased risk of deep vein thrombosis (DVT). The goal of this study is to identify IVC filter indications and retrieval statistics at our academic medical center in Appalachia. We seek to compare our performance to national averages, identify the reasons for failure of retrieval in our patient population and develop quality improvement initiatives to improve our performance. Methods: An IRB-approved, single-institution, retrospective chart review was conducted for all patients who had an IVC filter placed between January 2020 and December 2022 at West Virginia University Hospital. Patient demographics, comorbidities, placement indications, retrieval statistics and filter-associated complications were obtained from the electronic medical record (EMR). Patients who had a permanent IVC filter placed were excluded from the final analysis. Statistical analysis was performed using Mann-Whitney U and Chi squared tests where appropriate to compare the retrieval and failure of retrieval groups. Results: The study sample (n=450) had a mean age of 65.3±15.4 years and was comprised of 54.2% males and 45.8% females. West Virginia residents comprised 82.4% of the study sample. The most common reported clinical indications for placement included VTE with a contraindication to anticoagulation (62.4%), preoperative prophylaxis for VTE (15.8%), extensive VTE (15.3%), pharmacomechanical thrombectomy (15.0%) or other (3.1%). The rate of IVC filter retrieval was 25.4% (n=114). The most common reasons for failure of retrieval were loss to follow-up (31.8%), other reasons including provider or patient preference (31.5%), patient death (28.3%), clinical indication remains present (5.7%) and unsuccessful retrieval (2.7%). Patients in the failure of retrieval group (n=114) were significantly older (69 vs 61 years, p&amp;lt;0.001) and had a higher frequency of clinical indications for history of VTE with a contraindication to anticoagulation (231 vs 50 patients, p&amp;lt;0.0001) and extensive VTE (49 vs 20 patients, p&amp;lt;0.0001) compared to retrieval group (n=336). There was a nonsignificant trend toward greater frequency of chronic conditions in the failure of retrieval group including cancer history (101 vs 26 patients, p=0.15), heart failure (44 vs 11, p=0.41) and hypercoagulable disease (16 vs 2 patients, p=0.26). Conclusions: Our institution had a lower IVC filter retrieval rate than the estimated average of 34% reported in a systematic review by Angel et al. Patients with comorbid conditions tended to not undergo retrieval, predisposing them to a higher risk of filter-associated complications. A history of VTE with a contraindication to anticoagulation was the most common clinical indication for placement, but the other most common indications are not universally guideline recommended which identified an area of opportunity for multidisciplinary provider education. Patient loss to follow-up is the predominant reason for failure of retrieval at our institution, which is consistent with the healthcare disparity faced by our predominantly rural, Appalachian patient population of travelling long distances to our tertiary center to obtain specialty care. Quality improvement strategies to mitigate this limitation in the context of IVC filter placement through close local follow-up for timely reassessment, retrieval evaluation and removal will be developed.

Abstract P180: Disparities in Occurrence of Stroke Among Heart Failure Patients- A Case Control Study Evaluating Impact of Community Socioeconomic Distress Index

Introduction: Ischemic stroke is common complication among heart failure patients. Community-level socio-economic distress has been linked to adverse clinical outcomes in prior research. However, few to no studies have examined the relationship between neighborhood level socio-economic distress and stroke within a population of heart failure patients exclusively. Hypothesis: Odds of stroke among patients with heart failure are higher in neighborhoods with increased socio-economic distress, controlling for patient demographic and clinical comorbidities. Methods: Two separate cohorts of heart failure patients were assembled using ICD9/10 codes to identify all patients with a heart failure diagnosis seen at West Virginia University Hospital Systems (WVU Medicine) between 2008 and 2020 and Charleston Area Medical Center (CAMC) between 2017 and 2020. Cases were defined as heart failure patients with a diagnosis of ischemic stroke. Controls were defined as heart failure patients without a diagnosis of stroke and were matched to cases 4:1 on five-year age grouping and sex at birth. Distressed communities index (DCI) was linked to clinical data by patient zip code of residence. Neighborhoods with a DCI above 75 were classified as distressed, while those below were noted as non-distressed. Multivariable conditional logistic regression was used to identify significant associations at the 95% confidence level within each cohort separately. Results: In total there were 26,532 unique heart failure patients in the WVU Medicine cohort and 20,070 in the CAMC cohort. Of these, 10.3% (n=2,741) of the WVU Medicine cohort and 4.5% (n=900) of the CAMC cohort met the case definition of having had a diagnosis of stroke. Among patients in the WVU Medicine cohort with heart failure who experienced a stroke, 47.1% (n=1,291) were male and had an average age of 72.4 (± 12.9). In the CAMC cohort, among heart failure patients who experienced a stroke, 51.1% (n=460) were male and the average age was 70.9 (± 11.8). After controlling for demographics and clinical comorbidities, conditional logistic regression analyses identified a statistically significant association between neighborhood-level socio-economic distress in both the WVU Medicine cohort (OR = 1.31; 95% CI = 1.20 - 1.44) and the CAMC cohort (OR = 1.29; 95% CI = 1.027 - 1.454). Conclusion: Neighborhood-level socio-economic distress was associated with prevalence of stroke among heart failure patients. This is a critical finding for rural states, such as West Virginia, as it has the ability to inform placement of new satellite clinics among large hospital systems, or government funded clinics, such as federally qualified health centers, to address inequities in care for patients living in medically underserved communities.

Detection of high-grade glioma clusters: Spatial case-control study using EMR data from 2010-2021.

e14016 Background: High-grade gliomas (HGGs), like Glioblastomas (GBMs), are the most common malignant intracranial tumors with dismal prognosis. Rural areas have higher HGG related mortality and lesser research advancements. The objective of this study was to identify zip codes with disproportionate risk of HGGs compared to other brain malignancies. Methods: Patients’ electronic health data for this case-control study was extracted from West Virginia University Hospital Systems, 2010-2021. HGG cases were defined using diagnoses codes ICD10-C71 and ICD9-191 (excluding low grade gliomas). The control group was defined by using diagnoses codes ICD10-D32, C79.3, C71 (excluding HGG cases) and ICD9-225.2, 225.4, 198.3, 191 (excluding HGG cases). Controls were exact matched four controls to every case based upon patient five-year age categories and gender. Clustering was assessed globally through difference in Ripley’s-K between cases and controls; and locally using scan statistics. Results: The locations of HGGs and other brain tumors were clustered in the northern and northeastern regions of WV. Global cluster analyses detected statistically significant dispersion of HGG cases compared to our control group. Local cluster analysis identified multi-zip code cluster of HGG patients in northeastern WV between 2010-2021. The average relative risk of HGG compared to other brain malignancies was 1.25, indicating a 25% increase in risk of HGGs compared to other brain cancers within this region. While the local cluster was not statistically significant, the zip code level estimates of relative risk within the cluster ranged from 0.00 to 5.01. This indicated that certain zip codes within the cluster had five times the risk of HGGs compared to non-HGG brain malignancies relative to zip codes outside of the cluster. Conclusions: Findings indicate community level disparities in risk of HGGs relative to other brain malignancies. Additionally, results suggest that HGG cases are seen across the state at a more dispersed pattern than for non-HGG related brain tumors. These overall spatial trends could potentially be attributable to differences in clinical practice, access to care, or social determinants of health throughout WV. Spatial multivariable modeling techniques are needed to identify the specific neighborhood level factors associated with disproportionate patterns of risk identified for WV HGG patients.

Addressing rural health disparity with a novel hospital sleep apnea screening: Precision of a high-resolution pulse oximeter in screening for sleep-disordered breathing.

High-resolution pulse oximetry (HRPO) may offer a low-cost and simple screening option for sleep-disordered breathing (SDB) that could be vitally important in rural areas with limited healthcare resources and specialty care. Our team hypothesized that application of this technology to a broad cohort of rural dwelling hospitalized individuals would demonstrate congruence similar to previous urban studies comparing HRPO to portable sleep monitors. This retrospective study was conducted at West Virginia University Hospital and compared indices obtained from HRPO with those obtained from a type III portable sleep monitor (PM) on the same night. A total of 365 individuals underwent evaluation. The mean oxygen desaturation index (18.8 ± 19.3 events/h) from the HRPO was slightly higher than the mean respiratory event index (16.0 ± 18.1 events/h, p ≤ 0.001) from the PM. ROC curves were developed for thresholds of apnea severity predicted by the screening program. The AUC values for all three thresholds exceeded 0.92 and for a respiratory event index (REI) of ≥ 30 was 0.965. Indices from the PM and HRPO demonstrated agreement in those individuals with screening suggestive of moderatetosevere disease. This study demonstrates that use of HRPO in screening for SDB in hospitalized patients from rural communities is as accurate as PM and may serve as a simple cost-effective tool to address sleep health disparities in these regions with significant health inequity. Our data extend previous findings by applying HRPO to a larger hospitalized cohort with highly prevalent cardiopulmonary disease.

A Comparative Study of Braided versus Barbed Suture for Cystotomy Repair.

BackgroundIn this study, we aim to compare outcomes after cystotomy repair between standard sutures (910 polyglactin, poliglecaprone) versus barbed (V-LocTM 90) suture. As a secondary outcome, we analyzed factors for suture preference between the two groups.MethodsA retrospective chart review was undertaken for surgeries complicated by cystotomy, identified by ICD-9/10 codes from 2016 to 2019 at West Virginia University (WVU) Hospital. Comparisons were made between cystotomy repair using barbed suture versus standard braided suture. Injuries were categorized by procedure, surgical route, type of suture used in repair, and subsequent complications related to repair. Primary endpoints were examined by Pearson’s Chi-square test and interval data by t-test. A p < 0.05 was significant.ResultsSixty-eight patients were identified with iatrogenic cystotomy at WVU. Barbed suture was used for cystotomy repair in 11/68 (16.2%) patients. No significant difference was seen in postoperative outcomes between patients repaired with barbed suture versus standard braided suture. Barbed suture was significantly more likely to be used for cystotomy repair in minimally invasive surgery (p = 0.001). It was most often utilized in a robotic approach 7/11 (63.6%) followed by laparoscopic 3/11 (27.3%). Body mass index (BMI) was significantly higher in patients receiving a barbed suture repair (p = 0.005).ConclusionBarbed suture may be comparable to standard braided suture for cystotomy repair. Barbed suture may offer a practical alternative to facilitate cystotomy repair in minimally invasive surgery, especially in patients with a high BMI.

Total Vaginal Hysterectomy Using a Vessel Sealer Device Vs. Conventional Suture Ligation Technique: A Retrospective Cohort Analysis

<h3>Study Objective</h3> The aim of this study is to evaluate the duration of surgery, blood loss, and complications when performing a total vaginal hysterectomy (TVH) using a blood vessel sealer (BVS) device compared to standard technique. <h3>Design</h3> retrospective cohort analysis. <h3>Setting</h3> Tertiary care center serving a rural population. <h3>Patients or Participants</h3> 146 women undergoing TVH at the West Virginia University Hospitals system. The indications for the vaginal hysterectomy were recorded as either abnormal uterine bleeding (AUB), pelvic organ prolapse (POP), or other. Patient characteristics were recorded. The primary endpoint was the comparison of surgical times between the BVS and standard technique groups. Secondary endpoints were the amount of blood loss and complications after surgery between both groups. Complications were defined by blood loss >500 ml, conversion to laparotomy/laparoscopy, blood transfusion, urinary or bowel injury, readmission within 30 days, postoperative fever, and vaginal wall or labial burning. <h3>Interventions</h3> Use of a vessel sealer vs conventional technique. <h3>Measurements and Main Results</h3> Out of 142 surgeries, 102 patients had hysterectomies using standard technique and 40 used the BVS device. The two most common hysterectomy indications were AUB (32 with the vessel sealer and 45 with conventional technique) and POP repair (8 with the vessel sealer and 57 with conventional technique). Although the BVS group had faster surgical times than the standard technique group, the difference was not statistically significant (99.4 vs 112.1 minutes; p=0.0777). There was a significant difference in surgical blood loss in the vessel sealer group compared to the group of traditional surgery (240.5 vs 169.1 mL; p = 0.0343). There were no significant differences in complications following a TVH with a vessel sealer compared to the standard technique (OR=0.61; 95% CI 0.24 - 1.52). <h3>Conclusion</h3> The use of the vessel sealer device was not associated with decreased surgical times or complications and instead showed an increase in surgical blood loss.

ICU Mortality in Patients With Coronavirus Disease 2019 Infection: Highlighting Healthcare Disparities in Rural Appalachia.

OBJECTIVES:To assess 30-day mortality in coronavirus disease 2019 acute respiratory distress syndrome patients transferred from rural Appalachian hospitals.DESIGN:Retrospective case controlled, based on consecutive patients transferred and admitted from rural hospitals to a tertiary-care ICU. The primary outcome was all-cause 30-day mortality. Kaplan-Meier method and log-rank test were used in the survival data analysis.SETTING:Medical ICU, West Virginia University Hospital, Morgantown, WV.PATIENTS:All adult patients admitted to the ICU for coronavirus disease 2019 disease between September 30, 2020, and December 2, 2020.INTERVENTION:Not applicable.MEASUREMENTS AND MAIN RESULTS:Seventy-nine consecutive coronavirus disease 2019 patients were admitted to the ICU during the defined period. Overall mortality of the cohort was 54%. Of the 79 patients, 50 were transferred from critical access hospitals/rural facilities with coronavirus disease 2019–induced acute respiratory distress syndrome. A control group consisted of 39 patients admitted to the ICU with noncoronavirus disease 2019 acute respiratory distress syndrome who were intubated and mechanically ventilated. Thirty-day mortality in patients with coronavirus disease 2019 admitted to the ICU was significantly higher than the control group (68% vs 42%) (p = 0.034). Mean Sequential Organ Failure Assessment scores were similar in both coronavirus disease 2019 acute respiratory distress syndrome group and controls. Intubation in patients 70 years or older and mechanical ventilation for over 5 days was associated with significantly higher mortality.CONCLUSIONS:Our data on critically ill and mechanically ventilated coronavirus disease 2019 acute respiratory distress syndrome patients transferred from critical access hospitals/rural facilities have increased mortality compared with noncoronavirus disease 2019 acute respiratory distress syndrome controls. These data suggest that lack or delay in access to tertiary care may impact coronavirus disease 2019 outcome in rural areas. Intubated patients 70 years old or more and mechanical ventilation for over 5 days may be a risk factor for increased mortality. These data may help physicians and hospital administrators in rural areas for optimal utilization of limited resources.

Clinical and demographic factors associated with stimulant use disorder in a rural heart failure population

BackgroundHeart failure is becoming increasingly common among patients under 50 years of age, particularly in African Americans and patients with stimulant use disorder. Yet the sources of these disparities remain poorly understood. This study identified key demographic and clinical factors associated with stimulant use disorder in a largely rural heart failure patient registry. MethodsPatient records reporting a diagnosis of heart failure between January 2008 and March 2020 were requested from West Virginia University Hospital Systems (n=37,872). Odds of stimulant use disorder were estimated by demographic group (age, race, sex), insurance carrier, and clinical comorbidities using logistic regression. ResultsMultivariable regression analysis identified higher odds of stimulant use disorder among Black/African Americans (1.95 [1.32, 2.77]) and patients who report drinking one or more alcoholic drinks per week (2.23 [1.72, 2.88]). Lower odds of stimulant use disorder were identified among patients with hypertension (0.59 [0.47, 0.73]), or diabetes (0.65 [0.52, 0.81]).. Likewise, lower odds of stimulant use disorder were noted among females, patients older than 30 years of age and those not enrolled in Medicaid. ConclusionThese results highlight the alarming extent to which Medicaid enrollees, Black/African Americans, people aged 18–24 and 25–44, or persons with a past alcohol use disorder diagnosis are associated with stimulant use disorder among heart failure populations living in largely rural areas. Additionally, they emphasize the need to develop policies and refine clinical care that affects this vulnerable population's prognoses.

Healthcare Leadership in the COVID-19 Pandemic: From Innovative Preparation to Evolutionary Transformation.

PurposeIn pandemics, centralized healthcare leadership is a critical requirement. The objective of this study was to analyze the early development, operation, and effectiveness of a COVID-19 organizational leadership team and transformation of healthcare services at West Virginia University Hospitals and Health System (WVUHS). The analysis focused on how Kotter’s Leading Change eight-stage paradigm could contribute to an understanding of the determinants of successful organizational change in response to the COVID-19 pandemic.MethodsThe fifteen core leaders of WVUHS COVID-19 strategic system were interviewed. A qualitative thematic analysis of the interviews was used to evaluate key aspects of leadership dynamics and system-wide changes in healthcare policies and protocols to contain the pandemic. Outcome measures included the degree to which WVUHS could handle and contain COVID-19 cases as well as COVID-19 death and vaccination rates in West Virginia compared with other states.ResultsThe leadership team radically and rapidly revamped nearly all healthcare policies, procedures, and protocols for WVUHS hospitals and clinics, and launched a Hospital Incident Command System. As a result of this effective leadership team and strategic plan, WVUHS surge capacity was adequate for COVID-19 cases. In addition, West Virginia was an early frontrunner in COVID-19 vaccination rates as well as lower death rates.ConclusionWVUHS’s leadership response to the COVID-19 pandemic followed Kotter’s eight-stage paradigm for Leading Change in organizations, including the establishment of a sense of urgency, formation of a powerful guiding coalition, creation of a vision, communication of the vision, empowerment of others to act on the vision, plan for and creation of short-term wins, consolidation of improvements and production of more changes, and institutionalization of new approaches. This approach was effective in limiting the spread and impact of COVID-19 within the hospital network and across the state, with many lessons learned along the way.

Transition to an In-House Night Float System for Critical Care Fellows: Resident Experience, Morbidity, and Mortality in a Rural Academic Hospital.

BackgroundIn-house night call systems for ICUs are frequently implemented to enable hands-on patient care and provide direct supervision of resident physicians at night. Previous studies have highlighted the benefits of an in-house night float (NF) such as minimized time to intervention but failed to consistently demonstrate an improvement in patient outcomes. This study aimed to evaluate the impact of an in-house critical care fellow at night on the resident experience and assess for impact on patient morbidity and mortality.MethodsAn in-house overnight critical care fellow shift was implemented at West Virginia University Hospital in 2018. Resident physicians rotating overnight in the medical ICU (MICU) for six-month periods before and after the intervention were anonymously surveyed. A retrospective chart review of 300 patients admitted overnight to the MICU was performed. Multiple patient outcomes from the pre (2017) and post (2018) intervention periods were collected and compared using a two-sample t-test.ResultsIn the post-intervention survey, nearly every element of resident experience improved (availability of support, comfort in performing invasive procedures, and input in treatment plans), and far fewer residents felt overwhelmed relative to the pre-intervention survey. The resident experience markedly improved with the addition of an in-house critical care fellow.For the retrospective chart review, both groups had similar severity of illness and there was no change in ICU or hospital length of stay. No difference in mortality was found, though the study was underpowered for this outcome. For secondary measures, there was no difference in mechanical ventilation or use days, though more procedures performed were overnight compared to the former staffing model.ConclusionsImplementation of an in-house overnight critical care fellow shift in the MICU positively impacted resident experience without worsening patient outcomes. The intervention did not worsen measures of morbidity or mortality but did lead to an increased number of procedures performed overnight. The model of in-house NF coverage continues to be preferred by clinicians.

The positive environmental impact of virtual isotretinoin management.

Other medical specialties have studied how their practices influence the environment, but environmental impact studies in the field of dermatology remain limited. With respect to dermatology, vehicle emissions by patients traveling to and from appointments are an important factor influencing climate change. This study was undertaken to determine the greenhouse gas emissions avoided by managing isotretinoin virtually at West Virginia University Hospital. A retrospective cross-sectional study was conducted during the COVID-19 outbreak from March 25 to December 1, 2020, where travel data were acquired and converted to emission data. 5,137kg of GHG emissions in CO2 equivalents were prevented by managing isotretinoin virtually during the study period. 49400kg of GHG emissions in CO2 equivalents would be prevented annually. This is the emission load released when 24690kg of coal are burned. Environmental impact studies in the field of dermatology remain limited. GHG emissions were significantly reduced by virtually managing isotretinoin at a single institution. The practice of dermatology could reduce its carbon footprint by managing isotretinoin virtually, even in non-pandemic periods. Given that isotretinoin management represents a small percentage of the overall carbon footprint associated with dermatology, dermatologists should identify other conditions amenable to virtual medicine to produce greater environmental impact.

The Use of Barbed Suture for Cystotomy Repair — a Novel Approach

Study Objective In this study, we aim to compare outcomes after cystotomy repair between standard sutures (910 poliglactin, poliglecaprone) versus barbed (V-Loc TM 90) suture. As a secondary outcome, we analyzed risk factors for suture preference between the two groups. Design Retrospective cohort study. Setting N/A Patients or Participants Surgeries complicated by cystotomy, identified by ICD-9/10 codes from 2016 to 2019 at West Virginia University (WVU) Hospital. Interventions Comparisons were made between cystotomy repair using barbed suture versus standard braided suture. Injuries were categorized by procedure, surgeon specialty, surgical route, type of suture used in repair, and subsequent complications related to repair. Primary endpoints were examined by Pearson's Chi-square test and interval data by t-test. A p value < 0.05 was significant. Measurements and Main Results Sixty-eight patients were identified with iatrogenic cystotomy at WVU. Barbed suture was used for cystotomy repair in 11/68 (16.2%) patients. No significant difference was seen in postoperative outcomes between patients repaired with barbed suture versus standard braided suture. Barbed suture was significantly more likely to be used for cystotomy repair in minimally invasive surgery (p= 0.001). It was most often utilized in a robotic approach 7/11 (63.6%) followed by laparoscopic 3/11 (27.3%). Body mass index was significantly higher in patients receiving a barbed suture repair (p=0.005). Conclusion Barbed suture is not inferior to standard braided suture for cystotomy repair and does not cause an increase in complication rate. Barbed suture offers a practical alternative to facilitate cystotomy repair in minimally invasive surgery, especially in patients with a high BMI. In this study, we aim to compare outcomes after cystotomy repair between standard sutures (910 poliglactin, poliglecaprone) versus barbed (V-Loc TM 90) suture. As a secondary outcome, we analyzed risk factors for suture preference between the two groups. Retrospective cohort study. N/A Surgeries complicated by cystotomy, identified by ICD-9/10 codes from 2016 to 2019 at West Virginia University (WVU) Hospital. Comparisons were made between cystotomy repair using barbed suture versus standard braided suture. Injuries were categorized by procedure, surgeon specialty, surgical route, type of suture used in repair, and subsequent complications related to repair. Primary endpoints were examined by Pearson's Chi-square test and interval data by t-test. A p value < 0.05 was significant. Sixty-eight patients were identified with iatrogenic cystotomy at WVU. Barbed suture was used for cystotomy repair in 11/68 (16.2%) patients. No significant difference was seen in postoperative outcomes between patients repaired with barbed suture versus standard braided suture. Barbed suture was significantly more likely to be used for cystotomy repair in minimally invasive surgery (p= 0.001). It was most often utilized in a robotic approach 7/11 (63.6%) followed by laparoscopic 3/11 (27.3%). Body mass index was significantly higher in patients receiving a barbed suture repair (p=0.005). Barbed suture is not inferior to standard braided suture for cystotomy repair and does not cause an increase in complication rate. Barbed suture offers a practical alternative to facilitate cystotomy repair in minimally invasive surgery, especially in patients with a high BMI.

Understanding Risk Factors for Amputation in Patients With Diabetes and/or Peripheral Arterial Disease in a Highly Rural State

Amputation is a devastating but prevenTable complication of diabetes and peripheral arterial disease (PAD). It is a marker of severe disease and of disparities in quality of care. Rural populations have multiple risk factors for amputation; however, there is a significant gap in amputation research in rural communities. This study sought to identify risk factors for amputation in the highly rural state of West Virginia using a large, longitudinal institutional database. The West Virginia Clinical and Translational Science Institute Integrated Data Repository, a longitudinal database of more than 2 million patients, containing electronic health record data for all inpatient and outpatient encounters at West Virginia University and West Virginia University-affiliated hospitals and clinics comprised the sample for analyses. Adults (≥18 years) with recorded diagnoses of diabetes and/or PAD between 2011 and 2016 were included based on International Classification of Diseases, 9th clinical modification, and 10th edition clinical modification codes. Major and minor amputations were identified using Current Procedural Terminology codes. Trauma patients were excluded. Descriptive analyses and multivariable logistic regression models examining factors associated with major, minor and any amputation were performed. During the study period, 50,276 patients were treated for diabetes and/or PAD, 369 (7.3/1000) had any amputation over the study period; 210 had major (4.2/1000) amputations, 128 had minor (2.5/1000) amputations and 31 patients had both (0.6/1000). On multivariable analyses (Table I), male sex, self-pay, Medicaid, and Medicare insurance status all had significantly higher risk for major amputation. Minor amputation, which is often considered protective for major amputation, was found to increase the odds of major amputation 11.7 times. PAD patients had 12.3 times higher odds of any amputation compared to patients with diabetes, while patients with both diabetes and PAD had a 51.8 times higher odds of any amputation compared to patients with diabetes alone. C-statistics for all models were over 0.8, indicating a strong model. This unique longitudinal dataset has allowed us to identify several important features of diabetes and PAD-related amputation in our patient population: the first is that West Virginians undergo amputation for diabetes and/or PAD at rates more than double (7.3/1000 compared to the national prevalence of 2.4/1000) the rest of the country. In addition, patients with PAD alone or PAD plus diabetes had strikingly higher odds for amputation compared to diabetes alone. This suggests that population-based interventions for amputation prevention may be more successful if focused on PAD risk factor modification, such as tobacco cessation and medical optimization, rather than just simple diabetic foot care measures.TableMultivariable analysis of odds of major, minor and any amputation in patients with diabetes and/or peripheral artery disease (PAD) in West VirginiaVariableMajor (adjusting for minor)Minor (excluding majors)Any amputationMinora11.79 (7.19-19.33)––Rural (defined using Rural-urban community area code)1.09 (0.8-1.48)0.82 (0.52-1.29)0.98 (0.77-1.27)Tobacco user0.91 (0.57-1.44)0.9 (0.48-1.71)0.9 (0.62-1.31)Male vs female2.15 (1.61-2.85)2.63 (1.77-3.9)2.43 (1.93-3.07)Medicaid vs private1.79 (1.18-2.71)0.88 (0.51-1.51)1.35 (0.98-1.87)Medicare vs private1.54 (1.04-2.26)0.7 (0.43-1.15)1.12 (0.83-1.52)Self-pay vs private1.83 (1.09-3.07)1.42 (0.76-2.66)1.69 (1.13-2.52)Age0.99 (0.98-1)0.99 (0.97-1.01)0.99 (0.98-1)CAD0.36 (0.27-0.49)0.18 (0.12-0.28)0.26 (0.2-0.33)PAD vs diabetes13.78 (7.75-24.49)8.4 (4.18-16.85)12.29 (7.93-19.07)PAD and diabetes vs diabetes41.07 (23.27-72.46)52.52 (27.43-100.53)51.81 (33.85-79.3)CHF1.11 (0.79-1.54)1.5 (0.94-2.38)1.24 (0.95-1.62)CKD1.83 (1.32-2.54)1.5 (0.95-2.36)1.75 (1.34-2.27)COPD0.99 (0.73-1.34)1.07 (0.7-1.64)1 (0.78-1.29)Hypercholesterolemia0.97 (0.73-1.3)0.76 (0.52-1.13)0.89 (0.71-1.13)Obesity0.92 (0.68-1.25)0.92 (0.61-1.4)0.93 (0.73-1.19)Renal failure1.47 (0.97-2.24)0.85 (0.43-1.7)1.24 (0.87-1.77)C-statistic0.8500.8160.841Text in bold indicates statistically significant findings.aFor those with both major and minor amputations, we only counted minors occurring before major to see if that led to higher odds of major amputations. Open table in a new tab

461 Obstructive Sleep Apnea Is Associated With an Increased Risk of Barrett's Esophagus

INTRODUCTION: Current guidelines suggest screening at-risk groups of patients for Barrett's esophagus (BE), a precursor to esophageal cancer. Although BE and obstructive sleep apnea (OSA) have common risk factors, including elevated body mass index (BMI) and gastroesophageal reflux disease (GERD), the relationship between these two conditions has not been well established. METHODS: Retrospectively, all patients who had undergone a polysomnography and esophagogastroduodenoscopy (EGD) at West Virginia University Hospital from 2013 to 2018 were identified and divided into groups based on the presence or absence of OSA. Clinical course and procedure reports were reviewed to identify relevant variables. RESULTS: 1091 patients met inclusion criteria. 60.9% were female, and mean age of participants was 53.5 years. Univariate analysis revealed that male gender, age, diagnosis of OSA, severity of OSA, and a clinical diagnosis of GERD were associated with Barrett's esophagus (P values &lt; 0.05). Multiple logistic regression incorporating age, sex, clinical diagnosis of GERD, smoking history, BMI, Helicobacter pylori status, and presence of hiatal hernia was utilized. Patients with OSA had an increased risk of Barrett's esophagus when compared with those without OSA [P &lt; 0.001, Odds Ratio 3.26 (1.72-6.85)]. The risk increased with increasing severity of OSA, categorized in apnea-hyponea index increments of 10. In a separate multivariable regression model where OSA was graded in AHI increments of 10, an increased risk for Barrett's esophagus with every 10 point increase in AHI was found (OR 1.10, 95% CI: 1.02 – 1.19). BMI, evaluated in increments of 5, was not associated with BE. The association of OSA with BE remained unchanged in a separate model incorporating a binary variable with BMI of greater than 30 used as a surrogate for central adiposity. CONCLUSION: OSA is associated with Barrett's esophagus, a relationship that is independent of other known risk factors. Additionally, this risk increases with increasing severity of OSA. Future efforts should determine if patients with severe OSA need to be screened for Barrett's esophagus due to its potential for causing esophageal cancer.

Independent association of obstructive sleep apnea with Barrett's esophagus.

Current guidelines suggest screening at-risk groups of patients for Barrett's esophagus (BE), a precursor to esophageal cancer. Although BE and obstructive sleep apnea (OSA) have common risk factors, including elevated body mass index and gastroesophageal reflux disease (GERD), the relationship between these two conditions has not been well established. Retrospectively, all patients who had undergone a polysomnography and esophagogastroduodenoscopy at West Virginia University Hospital from 2013 to 2018 were identified and divided into groups on the basis of the presence or absence of OSA. Clinical course and procedure reports were reviewed to identify relevant variables. One thousand ninety-one patients met inclusion criteria; 60.9% were female, and mean age of participants was 53.5years. Univariate analysis revealed that male gender, age, diagnosis of OSA, severity of OSA, and a clinical diagnosis of GERD were associated with BE (P values<0.05). Multiple logistic regression incorporating age, sex, clinical diagnosis of GERD, smoking history, body mass index, Helicobacter pylori status, and presence of hiatal hernia was utilized. Patients with OSA had an increased risk of BE than had those without OSA (P<0.001, odds ratio 3.26 [1.72-6.85]). The risk increased with increasing severity of OSA, categorized in apnea-hypopnea index increments of 10. Obstructive sleep apnea is associated with BE, a relationship that is independent of other known risk factors. Additionally, this risk increases with increasing severity of OSA. Future efforts should determine if patients with severe OSA need to be screened for BE due to its potential for causing esophageal cancer.

Knowledge and Attitudes of Health Care Providers Toward Transgender Patients Within a Rural Tertiary Care Center.

Purpose: Members of the transgender community face significant health disparities within our society, especially within the state of West Virginia, which is primarily rural. We sought to examine and compare existing attitudes and knowledge of resident and faculty physician medical professionals at our institution about treating transgender individuals within a rural tertiary care center.Methods: The Medical Practitioner Attitudes Towards Transgender Patients (MP-ATTS) survey and the Medical Practitioner Beliefs and Knowledge about Treating Transgender Patients (MP-BKTTP) survey were sent to all faculty and resident physicians at West Virginia University Hospitals. Demographics included information about gender, rurality of hometown, race, and description of medical practitioner status (i.e., years out of residency, residency status).Findings: In general, there were positive attitudes and reception of the survey among residents and faculty physicians. 76.45% of providers assumed that their patients were not transgender. More than 40% of respondents believed that they would need further education about transgender patients to provide appropriate health care. Male health care providers had significantly higher negative perceptions of the transgender community (N=85, M=4.46, standard deviation [SD]=0.55, p<0.0001) and perceived fewer barriers due to personnel (N=80, M=3.24, SD=0.96, p<0.0001).Conclusion: A clear need exists for increased training in transgender health care among physicians taking care of this patient population. A gender divide exists among health care providers within West Virginia over attitudes regarding the transgender community. Further studies are needed to fully understand the health care needs and barriers of the transgender population.

Image- guided balanced orbital decompression for the management of thyroid eye disease: An analysis of outcomes and complications

Background: Thyroid eye disease (TED) commonly presents with proptosis, lid retraction, and diplopia. Multiple surgical techniques have been described to rehabilitate the orbit and to restore vision. Balanced orbital decompression is advocated as a standard surgical technique, and image guidance is encouraged to minimize surgical risks. We evaluated the outcomes of patients who underwent image- guided balanced three walls orbital decompression for TED. Methods: An IRB approved retrospective chart review study was performed on all patients who underwent image-guided balanced orbital decompression between January 2010 and December 2016 at West Virginia University Hospital. Demographics, pre-operative and post-operative clinical data including indications, presence of pre- and post-operative diplopia, and exophthalmometry were abstracted. Results: 169 orbital decompressions in 103 patients were performed. The mean age was 56 years, and the prevalence of pre-operative diplopia was 73%. The incidence of new- onset post-operative diplopia was 5.8%. Among patients who had pre-operative diplopia, 48% had resolution of their diplopia post- operatively. The mean reduction in proptosis was 4.7 mm. No patient experienced intraoperative and/ or postoperative complications. Conclusion: Image-gulded balanced lateral, medial and inferior orbital decompression can result in improvement of visual aculty and resolution of pre- existing .diplopia while allowing for significant reduction in proptosis.

Glioblastoma Survival Outcomes at a Tertiary Hospital in Appalachia: Factors Impacting the Survival of Patients Following Implementation of the Stupp Protocol

Glioblastoma is a fatal brain cancer with low median and yearly survival rates. Standard of care for treating glioblastoma is gross total resection (GTR) coupled with the Stupp protocol, but various factors influence the interventions undertaken and survival achieved. As health disparities exist in rural areas, survival in these areas needs to be assessed to understand which factors detract from the successes of these standard medical interventions. We retrospectively determined impact of age at diagnosis, number of lesions, the molecular marker O6-methylguanine methyltransferase (MGMT), extent of surgery, and completion of the Stupp protocol on survival in patients treated at West Virginia University Hospitals. We also compared our findings with a pre-Stupp protocol study done in West Virginia in1996. Age <60 years at diagnosis, having the MGMT gene methylated, having a unifocal tumor, receiving GTR, adhering to the Stupp protocol, and undergoing a treatment course of GTR followed by the Stupp protocol significantly increased survival. Comparison with the 1996 study showed that although overall median survival has not increased, all interventions involving GTR have resulted in a significantly higher survival. We can serve our patient population by offering GTR to all adult patients with glioblastoma when no contraindications exist and ensuring that patients follow the Stupp protocol. After discharge, the Stupp protocol may not be followed or completed for a variety of reasons. In the future, we aim to assess these reasons and analyze other significant interventional and socioeconomic factors that influence survival.