BACKGROUND:Stroke requires timely intervention, with carotid endarterectomy (CEA) and carotid artery stenting (CAS) increasingly used in select acute carotid-related stroke patients. We aimed to build a model to predict neurologic functional independence (modified Rankin scale [mRS] <= 2) in this high-risk group.STUDY DESIGN:We analyzed data from 302 stroke patients undergoing urgent CEA or CAS between 2015 and 2023 at a tertiary comprehensive stroke center. Predictors included (1) stroke severity (NIH Stroke Scale), (2) time to intervention (<= 48 hours), (3) thrombolysis use, and (4) frailty risk score. Two-way interactions were included to enhance generalizability without overfitting. Multiple models were constructed and selected based on the area under the receiver operating characteristic curve. The primary endpoint was discharge neurological functional independence (mRS <= 2).RESULTS:Presenting clinical factors and neurological outcomes data from 302 patients undergoing urgent CEA and CAS during the index hospitalization from 2015 to 2023 at a tertiary comprehensive stroke center formed the model's foundation. Most patients (72.8%, 220 of 302) were discharged functionally independent (mRS <= 2). The combined 30-day rate of stroke, death, and MI was 8.3% (25 of 302), 6.5% (14 of 214) for CEA alone, and 12.5% (11 of 88) for CAS. The model, incorporating thrombolysis, time to intervention, stroke severity (NIH Stroke Scale), and frailty risk, correctly predicted 93% of functional independence outcomes (area under the receiver operating characteristic curve 0.808).CONCLUSIONS:We present a novel model using 4 clinical factors-stroke severity, time to intervention, thrombolysis use, and frailty risk-to predict functional neurologic independence with 93% accuracy in patients undergoing urgent carotid interventions for acute stroke. This high predictive capability can enhance clinical decision-making and improve patient outcomes by identifying those most likely to benefit from timely carotid revascularization.

Background: While the connection between alcohol and risky behavior is well known, a clear correlation between alcohol misuse and contracting sexually transmitted infections (STIs) has not been determined. The 4-question CAGE questionnaire-the acronym stands for attitudes and activities related to alcohol use-is often administered at primary care annual visits to screen patients for alcohol abuse. This study assessed the relationship between CAGE scores and STI results to determine if the CAGE questionnaire could help determine the need for STI screening at annual visits. Methods: All patients who received a CAGE screening from 2015 to 2022 at a Gulf South health system were included in the analysis. The primary outcome of the study was the relationship between a positive CAGE score (a score ≥2) and a positive STI result. STIs included in the primary analysis were human immunodeficiency virus (HIV), hepatitis B, syphilis, chlamydia, gonorrhea, and trichomoniasis. The correlation between a positive CAGE score and hepatitis C was examined as a secondary outcome. Results: A total of 40,022 patients received a CAGE screening during the study period, and 757 (1.9%) scored ≥2 on the CAGE questionnaire. Significant associations were found between a positive CAGE score and hepatitis B (odds ratio [OR]=2.69, 95% CI 1.91, 3.80; P<0.001), gonorrhea (OR=5.43, 95% CI 1.80, 16.39; P=0.003), and hepatitis C (OR=2.10, 95% CI 1.57, 2.80; P<0.001). No associations were found between a positive CAGE score and HIV, chlamydia, or trichomoniasis. No patients with a CAGE score ≥2 had a syphilis diagnosis; therefore, no syphilis analysis was possible. Conclusion: Based on the results of this study, patients with a CAGE score ≥2 may benefit from screening for hepatitis B, hepatitis C, and gonorrhea at their primary care annual visit. Early STI detection could lead to prompt treatment and prevent further transmission and complications.

High prevalence of depression or anxiety with opioid use for chronic pain complicates co-management and may influence prescribing behaviors. Compare clinical effectiveness of electronic medical record clinical decision support (EMR-CDS) versus additional behavioral health (BH) care management for reducing rates of high-dose opioid prescriptions. Type 2 effectiveness-implementation hybrid stepped-wedge cluster randomized trial in 35 primary care clinics within a health system in LA, USA. Patients aged 18+ receiving chronic opioid therapy for non-cancer pain with depression or anxiety and matched controls. EMR-CDS included opioid risk mitigation procedures. BH care included cognitive behavioral therapy; depression or anxiety medication adjustments; and case management. Outcomes of interest included difference-in-difference (DID) estimate of changes in probability for prescribing high-dose morphine equivalent daily dose (MEDD ≥50 mg/day and MEDD ≥90), average MEDD, and rates of hospitalization, emergency department use, and opioid risk mitigation. Most participants were female with 3+ pain syndromes. Data analysis included 632 patients. Absolute risk differences for MEDD≥50 and ≥90 decreased post-index compared to pre-index (DID of absolute risk difference [95

OBJECTIVES:This study evaluated whether a novel standardized heparin dosing protocol used during atrial fibrillation catheter ablation resulted in a higher percentage of therapeutic activated clotting time (ACT) values compared to historic nonstandardized procedures. DESIGN:A retrospective cohort study SETTING: This study was conducted at Ochsner Medical Center, the largest tertiary-care teaching hospital in New Orleans, LA PARTICIPANTS: Patients undergoing catheter-based atrial fibrillation ablation INTERVENTIONS: The authors implemented a standardized heparin protocol, and enrolled 202 patients between November 2020 and March 2021. The historic controls consisted of 173 patients who underwent atrial fibrillation ablation between April 2020 and September 2020. Heparin administration in the control group was based on physician preference and was nonstandardized. MEASUREMENTS AND MAIN RESULTS:The primary endpoint was the percentage of intraprocedural ACTs in therapeutic range (≥300 to <450 s). Secondary endpoints included first measured ACT at ≥300 s and percent of measured ACTs in the supratherapeutic range (>450 s). Comparisons were performed using chi-squared tests or Fisher exact tests. Patients in the intervention group had a higher mean percentage of ACTs in the therapeutic range compared to the control group (84.9% vs. 75.8%, p<0.001). More patients in the intervention group reached therapeutic ACT on the first measurement compared to the control group (70.3% vs. 31.2%, p<0.001). CONCLUSION:During catheter-based cardiac ablation procedures, a novel standardized unfractionated heparin dosing protocol resulted in a higher percentage of ACTs in the target range, and a higher proportion of initial ACTs in the therapeutic range compared with baseline nonstandardized heparin dosing.

Introduction Carotid artery disease is an important cause of ischemic strokes. Patient selection for urgent carotid interventions (ie. carotid endarterectomy [uCEA] and carotid artery stenting [uCAS]) performed within 2 weeks of event during index hospitalization is primarily based on overall health and risk profile. Identifying high-risk patients remains a challenge. Frailty, a decline in function related to aging, has emerged as an important factor in the treatment of the elderly population. This study aimed to design a quantitative risk score based on frailty for patients undergoing uCEA and uCAS following an acute stroke. Methods A total of 307 acute stroke patients treated with uCEA or uCAS were identified from a prospectively maintained database. Frailty scores were calculated using the Hospital Frailty Risk Index based on ICD-10 codes. Stroke-specific risk categories were created based on the incidence of stroke, death, and myocardial infarction (MI) associated with frailty scores. Primary endpoints included 30-day stroke, death, and MI, while the secondary endpoint was discharge modified Rankin scale (mRS). Statistical analyses were performed using SAS software. Results The average age was 65.9 years; hypertension, history of tobacco use, and hyperlipidemia were the most common comorbidities. The median Hospital Frailty Risk Score was 27, the majority of patients in this study were in the intermediate and high risk frailty groups (50.5% and 41.7%, respectively). uCAS patients had a higher median presenting NIHSS (8 vs. 2, p<0.001) and shorter median time to intervention compared to uCEA patients (1 vs. 3 days, p=<0.001). The 30-day composite stroke, death, and MI rate was 8.1%, with higher rates observed in patients with frailty scores >30 (11.7%) and uCAS (12.2%). Hemorrhagic conversion and death were more common in uCAS patients. Functional independence (mRS 0-2) was observed in uCEA patients after minor stroke and in uCAS patients after minor or moderate stroke. Patients with high-risk frailty score (>30) presenting with a moderate stroke were more likely to be functionally dependent (mRS>2) on discharge (67% vs 41.3%, p<0.001). Conclusion Frailty is a valuable prognosticative tool for clinical outcomes in patients undergoing urgent carotid interventions following an acute stroke. Higher frailty scores were associated with increased stroke, death, and MI rates. Frailty also influenced functional dependence at discharge, particularly in patients with moderate stroke. These findings highlight the importance of considering frailty in the decision-making process for carotid interventions. Further research is needed to validate these findings and explore interventions to mitigate the impact of frailty on outcomes.

Background: In Louisiana, colorectal cancer (CRC) incidence and mortality exceed national rates. Census tract, sex, and racial disparities across the state are well documented. This study examined whether there were subpopulation differences in associations between CRC screening, area deprivation index (ADI), and patient characteristics. Methods: This retrospective observational study included patients aged 50 to 75 years who received care within Ochsner Health in Louisiana between July 1, 2012, and December 31, 2020. Logistic regression models were used to generate adjusted odds ratios (95% CI). Results: A total of 75,344 patients met eligibility criteria for inclusion in the data analysis (60% female, 36% Black, 56% with spouse/partner, 42% Medicare/Medicaid,17% living in high deprivation areas, 41% with 2+ chronic conditions, 56% never smoked, 51% obese). Living in areas with less deprivation (state decile 1-3 vs 8-10: 1.19 [1.14-1.24]), number of comorbidities (3+ conditions: 1.15 [1.12-1.17]), and prior outpatient visits (1.63 [1.58-1.67]) increased odds of CRC screening. Male sex (0.82 [0.79-0.84]), age group 55 to 59 years (0.97 [0.95-0.99]), and Medicaid insurance (0.89 [0.86-0.92]) decreased odds of screening. ADI was collinear with sex, race, marital status, body mass index, and smoking status. In subgroup analyses, between-group differences in strength of associations of CRC screening with ADI and patient characteristics varied most prominently by race. Conclusion: There may be an unmeasured social context explaining persistent racial differences among factors associated with CRC screening. A combination of census tract and individual-level social determinants may guide population health management for at-risk subpopulations.

A diverting loop ileostomy (DLI) is used to protect a distal gastrointestinal anastomosis at risk of leakage. While patients typically prefer early DLI closure, surgeons vary in opinion regarding optimal timing. This study evaluated whether the timing of DLI closure impacts outcomes. A retrospective review was performed on patients who underwent DLI creation within one health care system between 2012 and 2020. Patient characteristics and postoperative outcomes were compared across ileostomies closed in ≤2 months, 2-4 months, and >4 months. Outcomes examined included anastomotic leak, other complications, reintervention, and death within 30 days. A total of 500 DLIs were analyzed for the study, 455 of which were closed. The three closure groups were similar in patient characteristics and comorbidities. None of the outcome variables analyzed in this study demonstrated a statistically significant difference between groups, suggesting that in patients otherwise fit for surgery, DLI closure can be safely performed within 2 months of creation.

Background: Carotid interventions are increasingly performed in select patients following acute stroke. We aimed to determine the effects of presenting stroke severity (National Institutes of Health Stroke Scale [NIHSS]) and use of systemic thrombolysis (tissue plasminogen activator [tPA]) on discharge neurological outcomes (modified Rankin scale [mRS]) after urgent carotid endarterectomy (uCEA) and urgent carotid artery stenting (uCAS). Methods: Patients undergoing uCEA/uCAS at a tertiary Comprehensive Stroke Center (January 2015 to May 2022) were divided into two cohorts: (1) no thrombolysis (uCEA/uCAS only) and (2) use of thrombolysis before the carotid intervention (tPA thorn uCEA/uCAS). Outcomes were discharge mRS and 30-day complications. Regression models were used to determine an association between tPA use and presenting stroke severity (NIHSS) and discharge neurological outcomes (mRS). Results: Two hundred thirty-eight patients underwent uCEA/uCAS (uCEA/uCAS only, n = 186; tPA thorn uCEA/uCAS, n = 52) over 7 years. In the thrombolysis cohort compared with the uCEA/uCAS only cohort, the mean presenting stroke severity was higher (NIHSS = 7.6 vs 3.8; P =.001), and more patients presented with moderate to severe strokes (57.7% vs 30.2% with NIHSS >4). The 30-day stroke, death, and myocardial infarction rates in the uCEA/uCAS only vs tPA thorn uCEA/uCAS were 8.1% vs 11.5% (P =.416), 0% vs 9.6% (P <.001), and 0.5% vs 1.9% (P =.39), respectively. The 30-day stroke/hemorrhagic conversion and myocardial infarction rates did not differ with tPA use; however, the difference in deaths was significantly higher in the tPA thorn uCEA/uCAS cohort (P <.001). There was no difference in neurological functional outcome with or without thrombolysis use (mean mRS, 2.1 vs 1.7; P =.061). For both minor strokes (NIHSS <= 4 vs NIHSS >4: relative risk, 1.58 vs 1.58, tPA vs no tPA, respectively, P =.997) and moderate strokes (NIHSS <= 10 vs NIHSS >10: relative risk, 1.94 vs 2.08, tPA vs no tPA, respectively; P =.891), the likelihood of discharge functional independence (mRS score of <= 2) was not influenced by tPA. Conclusions: Patients with a higher presenting stroke severity (NIHSS) had worse neurological functional outcomes (mRS). Patients presenting with minor and moderate strokes were more likely to have discharge neurological functional independence (mRS of <= 2), regardless of whether they received tPA or not. Overall, presenting NIHSS is predictive of discharge neurological functional autonomy and is not influenced by the use of thrombolysis.

e16236 Background: Surgical resection is the only potentially curative option for pancreatic cancer (PC). Unfortunately, just 15-20% of patients (pts) have resectable disease at the time of diagnosis. Recently, for a variety of reasons, neoadjuvant chemotherapy (NAC) has been widely adopted in both borderline resectable and resectable tumors. Most guidelines recommend either modified FOLFIRINOX (mFOLFIRINOX) or gemcitabine and NAB-paclitaxel (GnP) in this setting. This is largely based on phase II trials and extrapolations from trials in the metastatic setting. Here we investigate the difference in tumor regression score (TRS) and clinical outcomes between these regimens. Methods: We retrospectively collected data from pts who underwent resection of PC after NAC at Ochsner Health between July 2012 and July 2021. Primary objective was TRS on operative pathology as assessed by the reading pathologist. Secondary objectives were progression free survival (PFS) from the date of surgery and overall survival (OS) from the date of diagnosis. TRSs were dichotomized as complete (0)/moderate (1) responses versus (vs) minimal (2)/poor (3) responses. The dichotomized score was assessed using log-binomial regression. Kaplan-Meier survival analysis was utilized to estimate PFS and OS. Survival curves were compared by the log-rank test. Results: We identified 96 pts with PC who had NAC followed by surgical resection. Mean age at diagnosis was 65.7. 55% had borderline resectable and 45% had clearly resectable disease at diagnosis. 74 pts received mFOLFIRINOX and 22 pts received GnP. Pts receiving GnP were more likely to be older (71 vs 64, P = 0.001) and have a worse Eastern Cooperative Oncology Group performance status (PS) (P = 0.019). TRSs were similar between the 2 groups with 58.1% and 59.1% in each group achieving a TRS of 2. 7 pts in the mFOLFIRINOX group had TRS of 0 (CR) while 0 pts in the GnP group had a TRS of 0. When controlling for age and PS, risk ratio for a lower TRS (0/1 vs 2/3) with mFOLFIRINOX vs GnP was 1.22 (0.27 - 5.47). 40% and 36.4% had disease recurrence after mFOLFIRINOX and GnP, respectively. Median PFS and OS were 15.6 and 23.4 months (m) in the mFOLFIRINOX group and 18.9 and 27.6 m in the GnP group (P = 0.996, P = 0.933, respectively). On multivariate analysis, controlling for age and PS, hazard ratios for OS and PFS with mFOLFIRINOX vs GnP were 0.86 (95% CI 0.38–2.18) and 1.17 (95% CI 0.53–2.84), respectively. Conclusions: Our study showed no difference in TRS between mFOLFIRINOX or GnP as NAC, although the small number of pts who received GnP precluded statistical inference. Differences in survival outcomes between the two NAC regimens were not significantly different, and outcomes were comparable to those reported in the phase II SWOG S1505 trial. Large prospective trials comparing these two regimens in terms of efficacy and toxicity will be required to better answer these questions.

e20023 Background: The IMWG recommends using 18F-FDG PET/CT (PET) to monitor response to therapy in multiple myeloma (MM). Prior studies in patients who received chemotherapy before autologous stem cell transplant (ASCT) found that severe FDG uptake on PET was associated with inferior event free survival. However, novel agents and monoclonal antibodies have changed the landscape of MM and chemotherapy is no longer used as initial treatment making the role of PET before ASCT unclear. This study explores findings on pre-ASCT PET that may predict shorter remissions after ASCT. Methods: This was a retrospective cohort study. Patients were included if they had a PET at least 60 days before ASCT between 2014 and 2021. All patients achieved at least a partial response (PR) prior to ASCT. The primary endpoint, PFS was defined as time to progression on labs, imaging or bone marrow biopsy necessitating change in therapy or resulting in death after ASCT. The cytogenetic risk category (CG), number of bone lesions at diagnosis, presence of severe FGD uptake on PET (defined as SUV max ≥ 4.2) and persistence of lesions on PET was recorded. Patients who did not experience the event of interest were censored at their last date of clinic follow up. Hazard ratios (HR) for disease progression were estimated using Cox proportional hazards models. Results: 151 patients were included in our study. All patients underwent induction with a 3-drug regimen containing a proteasome inhibitor (PI) and/or an immunomodulatory agent (IMiD). 32% had high risk CG, 44% had > 3 bone lesions at diagnosis, 24% had severe FDG uptake and 29% had > 3 lesions on pre-ASCT PET. The presence of high-risk CG [HR 2.08 (1.03 – 4.17)] and severe FDG uptake on diagnostic PET [HR 6.43 (2.58 – 16.07)] was associated with more aggressive disease and shorter PFS. Patients with > 3 lesions in their pre-transplant PET had a statistically significant decreased PFS [HR 2.01 (1.02 – 3.96)] compared to those with ≤ 3 lesions. Conclusions: This study found that that persistence of > 3 lesions on pre-ASCT PET were an adverse finding associated with an increased risk of progression. To our knowledge these findings have not previously been shown in patients treated with PIs and IMiDs before ASCT. Significantly shorter PFS was observed in patients with high-risk CG and severe FDG uptake on initial PET, consistent with our knowledge of MM. In addition to established risk factors for aggressive disease, persistence of > 3 bone lesions on PET/CT could be used to identify a high-risk group of patients who may benefit from more intensive surveillance or therapy after ASCT. [Table: see text]

BACKGROUND:We aimed to understand the association of gastrointestinal (GI) symptoms at initial presentation with clinical outcomes during COVID-19 hospitalization. METHODS:This retrospective, multicenter cohort study included consecutive hospitalized COVID-19 patients from a single, large health system. The presence of GI symptoms was assessed at initial presentation and included one or more of the following: nausea, vomiting, diarrhea and abdominal pain. Patients were divided into three cohorts: Only GI symptoms, GI and non-GI symptoms and only non-GI symptoms. The primary outcome was association of GI symptoms with mortality. Secondary outcomes included prevalence of GI symptoms and survival analysis. RESULTS:A total of 1672 COVID-19 patients were hospitalized (mean age: 63 ± 15.8 years, females: 50.4%) in our system during the study period. 40.7% patients had at least one GI symptom (diarrhea in 28.3%, nausea/vomiting in 23%, and abdominal pain in 8.8% patients), and 2.6% patients had only GI symptoms at initial presentation. Patients presenting with GI symptoms (with or without non-GI symptoms) had a lower mortality rate compared to patients presenting with only non-GI symptoms (20% vs. 26%; p < 0.05). The time from hospitalization to being discharged was less for patients presenting with only GI symptoms (7.4 days vs. > 9 days, p < 0.0014). After adjusting for other factors, the presence of GI symptoms was not associated with mortality (p > 0.05). CONCLUSION:Among a hospitalized COVID-19 positive Southern US population, 41% patients presented with either diarrhea, nausea, vomiting or abdominal pain initially. The presence of GI symptoms has no association with in-hospital all-cause mortality.

COVID-19 provokes a profound inflammatory response that can lead to significant maternal morbidity. The impact on a developing fetus is not well-described, especially in regards to the timing of maternal infection. We sought to determine whether gestational age at diagnosis of maternal COVID-19 is associated with adverse neonatal outcomes. We conducted a retrospective cohort study of all pregnant patients tested for COVID-19 from March to November 2020 in a single academic center. The groups were categorized into early (prior to 20 weeks), late (20 weeks or greater) or no COVID infection. The primary outcome was a neonatal composite including small for gestational age, stillbirth, preterm delivery, NICU admission, and neonatal COVID infection at the time of birth. Secondary outcomes included the individual components of the neonatal composite. 9,062 neonates were born to 8,889 pregnant patients. 351 pregnant patients tested positive for COVID-19 including 55 with early and 296 with late COVID-19. Neonatal composite was more common in the COVID-positive group than the COVID-negative group (OR 1.37, p=0.01). Although the frequency of the neonatal composite was similar in the early and late infection groups (OR 1.37, p=0.30), when comparing the early COVID group to the COVID-negative group, the odds of the primary outcome were increased in the early COVID group (OR 1.79, p=0.04). Gestational age at delivery, preterm birth rate, and SGA were similar across all groups. NICU admission was more common in the COVID positive groups (OR= 1.42, p=0.009), but was similar when comparing early and late infections (OR 1.05, p=0.88). There was no increase in spontaneous abortion or stillbirth in COVID-positive patients. Maternal COVID-19 is associated with an increased rate of an adverse neonatal composite outcome and NICU admission. While the rate of the neonatal composite is similar in patients who are diagnosed prior to and after 20 weeks of gestation, those diagnosed prior to 20 weeks are at significantly higher risk compared to COVID-negative patients.View Large Image Figure ViewerDownload Hi-res image Download (PPT)

BACKGROUND:The current mainstays of ischemic stroke treatment include the use of thrombolysis (tissue plasminogen activator [tPA]), urgent carotid endarterectomy (uCEA) or urgent carotid artery stenting (uCAS), and mechanical endovascular reperfusion/thrombectomy (MER). Scarce data describe the presenting stroke severity and neurologic outcomes for these acute ischemic stroke interventions, alone or in combination. The authors hypothesize that patients undergoing carotid interventions experience better functional neurologic outcomes than other stroke interventions. METHODS:A comprehensive stroke center dataset was combined with data for stroke-related procedures, comorbidities, complications, and physician documentation collected from electronic medical record data. A total of 10,975 patient encounter records from January 1, 2015, through July 31, 2021, were retrieved. The presenting stroke severity was determined by vascular/stroke neurologists using the National Institutes of Health Stroke Scale (NIHSS). Functional neurologic outcomes were reported using the modified Rankin scale (mRS) score, which quantifies the degree of neurologic disability. Because mRS values were only available for 3627 encounters in the original dataset, the authors developed a machine learning algorithm to analyze physician documentation and assign an mRS value. After the exclusion and machine learning analysis, a total of 5170 patient encounters were included for statistical analysis. Statistical analyses included the χ2 test, one-way analysis of variance and logistic regression on 30-day complications, stroke severity, and neurologic outcomes. RESULTS:Patients were divided into five cohorts: (1) uCEA or uCAS (n = 189), (2) tPA alone (n = 1053), (3) MER alone (n = 418), (4) tPA + MER (n = 199), and (5) no intervention (n = 3311). Patients undergoing uCEA/uCAS were significantly more likely to be male, smokers, and have a history of peripheral arterial disease compared with other stroke cohorts. The length of stay was shortest for patients who only received tPA or no intervention (6 days), followed by uCEA/uCAS (7.2 days), MER (10.2 days), and tPA + MER (8.8 days) cohorts (P < .001). The 30-day mortality was highest in the MER cohort (12.2%) and lowest in the uCEA/uCAS cohort (2.6%). The uCEA/uCAS cohort compared with other cohorts had the lowest presenting stroke severity (NIHSS 4.9 vs NIHSS 6.9-16.0), and best neurologic outcomes (mRS 1.7 vs mRS 1.8-2.6). CONCLUSIONS:After an ischemic stroke, patients undergoing urgent carotid interventions had the lowest presenting stroke severity (NIHSS) and highest rate of independent neurologic outcomes (mRS) compared with other stroke interventions. Incoming stroke severity correlates with functional neurologic outcomes, and patients who present with an NIHSS of 10 or less who undergo uCEA/uCAS have a high likelihood of independent neurologic functional outcome (mRS of ≤2).

Background Percutaneous cholecystostomy tube (PCT) drainage is an effective management strategy for acute cholecystitis in patients medically unfit for surgery. However, little is known about the fate of patients managed by PCT. We conducted this study to determine tube management outcomes for patients with acute cholecystitis managed by PCT. Methods The electronic record was queried to identify patients with acute cholecystitis managed by PCT from 2012-2020. Patients were divided into three groups for analysis: 1) ultimately managed by cholecystectomy, 2) eventual confirmation of distal flow of bile from the gallbladder and tube removal, and 3) tubes left in place without further management. Results A total of 179 patients with acute cholecystitis treated by PCT were included. Sixty-six patients never fully recovered from the medical insult associated with their diagnosis of acute cholecystitis and had their tubes left in situ. Sixty-four of these 66 patients (97%) died during follow-up. The remaining 113 patients recovered from their illness and presented to clinic for evaluation for tube removal and/or cholecystectomy. When distal biliary flow was confirmed, tube removal was favored (n = 70). When cystic duct outflow occlusion persisted, cholecystectomy was planned for patients who became acceptable surgical candidates (n = 43). For patients managed by cholecystectomy, 8 were approached open and 35 laparoscopically, with 12 of 35 (34.3%) converted to open and 23 (65.7%) completed laparoscopically. Conclusion Our study favors PCT removal for patients who recover from their acute illness when distal bile flow from the gallbladder is confirmed. We reserve cholecystectomy for patients who recover from their illness and demonstrate persistent cystic duct outflow obstruction.

OBJECTIVE:To investigate whether specific social determinants of health could be a "health barrier" toward achieving blood pressure (BP) control and to further evaluate any differences between Black patients and White patients. PATIENTS AND METHODS:We conducted a retrospective cohort study of 3305 patients with elevated BP who were enrolled in a hypertension digital medicine program for at least 60 days and followed up for up to 1 year. Patients were managed virtually by a dedicated hypertension team who provided guideline-based medication management and lifestyle support to achieve goal BP. RESULTS:Compared with individuals without any health barriers, the addition of 1 barrier was associated with lower probability of control at 1 year from 0.73 to 0.60 and to 0.55 in those with 2 or more barriers. Health barriers were more prevalent in Black patients than in those who were White (44.6% [482 of 1081] vs 31.3% [674 of 2150]; P<.001). There was no difference at all in BP control between Black individuals and those who were White if 2 or more barriers were present. CONCLUSION:Patient-related health barriers are associated with BP control. Black patients with poorly controlled hypertension have a higher prevalence of health barriers than their White counterparts. When 2 or more health barriers were present, there was no differences in BP control between White and Black individuals.

The United States opioid epidemic combined with the COVID-19 pandemic has demonstrated a 32% rise in non-prescribed fentanyl use and 12.5% rise in heroin use per urine drug test analyses (1). A subset of COVID-19 survivors given inpatient opioids are also being prescribed opioids at discharge. The goal of this investigation is to determine the incidence of chronic opioid use, which is defined as opioid use for 3 months or more, following discharge of in-patient admits for management of COVID-19 with in-patient opioid use in order to evaluate at-risk patient populations and to assess follow-up outcomes following discharge.

BACKGROUND:Obesity-associated chronic conditions (OCC) are prevalent in medically underserved areas of the Southern US. Continuity of care with a primary care provider is associated with reduced preventable healthcare utilization, yet little is known regarding the impact of continuity of care among populations with OCC. This study aimed to examine whether continuity of care protects patients living with OCC and the subgroup with type 2 diabetes (OCC+T2D) from emergency department (ED) and hospitalizations, and whether these effects are modified by race and patient residence in health professional shortage areas (HPSA) METHODS: We conducted a retrospective federated cohort meta-analysis of 2015-2018 data from four large practice-based research networks in the Southern U.S. among adult patients with obesity and one more more additional diagnosed OCC. The outcomes included overall and preventable ED visits and hospitalizations. Continuity of care was assessed at the clinic-level using the Bice-Boxerman Continuity of Care Index RESULTS: A total of 111,437 patients with OCC and 47,071 patients with OCC+T2D from the four large practice-based research networks in the South were included in the meta-analysis. Continuity of Care index varied among sites from a mean (SD) of 0.6 (0.4) to 0.9 (0.2). Meta-analysis demonstrated that, regardless of race or residence in HPSA, continuity of care significantly protected OCC patients from preventable ED visits (IRR:0.95; CI:0.92-0.98) and protected OCC+T2D patients from overall ED visits (IRR:0.92; CI:0.85-0.99), preventable ED visits (IRR:0.95; CI:0.91-0.99), and overall hospitalizations (IRR:0.96; CI:0.93-0.98) CONCLUSION: Improving continuity of care may reduce ED and hospital use for patients with OCC and particularly those with OCC+T2D.

e16242 Background: Pancreatic cancer (PC) is a highly fatal disease, and multiple studies have shown that African Americans (AA) have a higher incidence of PC compared with Whites and have a higher risk of PC-related mortality. Differences in known risk factors for PC including cigarette smoking, obesity, diabetes and family history have been demonstrated to not fully account for the racial disparity in incidence. Furthermore, differing mortality rates by race are not entirely attributable to variables such as access to care and disparate management. Whether there are molecular and biologic differences in PC that could explain these disparities is a question that has important scientific and clinical consequences. Unfortunately, most large studies of genomic alterations in PC include very few AA patients (pts). This study tries to characterize molecular alterations seen in AA pts with PC. Methods: The electronic medical record was queried for all self-identified Black or AA pts who were diagnosed with PC and had molecular profiling from November 2015 to November 2021. Patient demographics, clinical characteristics and molecular genomics were analyzed. The primary outcome was percent of patients with specific KRAS mutations. The secondary outcome was differences in KRAS mutations by gender. Results: We identified 50 AA pts with PC who underwent molecular profiling, 19 of whom (38%) were female. As expected, most (66%) were advanced stage at diagnosis. 32 pts (64%) had tissue-based molecular profiling with 18 (36%) having blood-based testing. A KRAS mutation was identified in 38 pts (76%). 15 (30%), 12 (24%), and 11 (22%) had G12V, G12D, and G12R mutations in KRAS, respectively. Men were more likely to have a G12D mutation (35.5% vs 5.3%, P = 0.018), and women were more likely to have a G12V mutation (47.4% vs 19.4%, P = 0.036). There was no significant difference in overall survival between men and women. 30 pts (60%) had additional mutations other than KRAS. 6 pts (12%) did not have a KRAS mutation detected despite the presence of other alterations. 4 pts had no mutations detected on molecular next generation sequencing, 3 of which had blood-based testing. Conclusions: In our review of genomic mutations of AA pts with PC, KRAS G12V mutations were most common. Only 24% of our studied population had KRAS G12D mutations. The frequency of specific KRAS mutations differs from what has been described in the literature among predominantly White pts with PC, where almost half of pts have a G12D mutation and 28% and 17% harbor G12V and G12R mutations, respectively. Two major limitations of this study are the small sample size which limits definitive comparisons between races, and the imperfect sensitivity of molecular profiling. KRAS is thought to be present in > 90% of PC, but the mutation was only identified in 76% of our pts. Further studies should be conducted to determine whether different molecular characteristics could account for racial disparities in PC mortality.

Importance:The 2 primary efforts of Medicare to advance value-based care are Medicare Advantage (MA) and the fee-for-service-based Medicare Shared Savings Program (MSSP). It is unknown how spending differs between the 2 programs after accounting for differences in patient clinical risk. Objective:To examine how spending and utilization differ between MA and MSSP beneficiaries after accounting for differences in clinical risk using data from administrative claims and electronic health records. Design, Setting, and Participants:This retrospective economic evaluation used data from 15 763 propensity score-matched beneficiaries who were continuously enrolled in MA or MSSP from January 1, 2014, to December 31, 2018, with diabetes, congestive heart failure (CHF), chronic kidney disease (CKD), or hypertension. Participants received care at a large nonprofit academic health system in the southern United States that bears risk for Medicare beneficiaries through both the MA and MSSP programs. Differences in beneficiary risk were mitigated by propensity score matching using validated clinical criteria based on data from administrative claims and electronic health records. Data were analyzed from January 2019 to May 2022. Exposures:Enrollment in MA or attribution to an accountable care organization in the MSSP program. Main Outcomes and Measures:Per-beneficiary annual total spending and subcomponents, including inpatient hospital, outpatient hospital, skilled nursing facility, emergency department, primary care, and specialist spending. Results:The sample of 15 763 participants included 12 720 (81%) MA and 3043 (19%) MSSP beneficiaries. MA beneficiaries, compared with MSSP beneficiaries, were more likely to be older (median [IQR] age, 75.0 [69.9-81.8] years vs 73.1 [68.3-79.8] years), male (5515 [43%] vs 1119 [37%]), and White (9644 [76%] vs 2046 [69%]) and less likely to live in low-income zip codes (2338 [19%] vs 750 [25%]). The mean unadjusted per-member per-year spending difference between MSSP and MA disease-specific subcohorts was $2159 in diabetes, $4074 in CHF, $2560 in CKD, and $2330 in hypertension. After matching on clinical risk and demographic factors, MSSP spending was higher for patients with diabetes (mean per-member per-year spending difference in 2015: $2454; 95% CI, $1431-$3574), CHF ($3699; 95% CI, $1235-$6523), CKD ($2478; 95% CI, $1172-$3920), and hypertension ($2258; 95% CI, $1616-2,939). Higher MSSP spending among matched beneficiaries was consistent over time. In the matched cohort in 2018, MSSP total spending ranged from 23% (CHF) to 30% (CKD) higher than MA. Adjusting for differential trends in coding intensity did not affect these results. Higher outpatient hospital spending among MSSP beneficiaries contributed most to spending differences between MSSP and MA, representing 49% to 62% of spending differences across disease cohorts. Conclusions and Relevance:In this study, utilization and spending were consistently higher for MSSP than MA beneficiaries within the same health system even after adjusting for granular metrics of clinical risk. Nonclinical factors likely contribute to the large differences in MA vs MSSP spending, which may create challenges for health systems participating in MSSP relative to their participation in MA.

ObjectiveDetermine whether an individual is at greater risk of severe acute respiratory distress syndrome coronavirus 2 (SARS-CoV-2) infection because of their community or their individual risk factors.Study design and setting4,752 records from two large prevalence studies in New Orleans and Baton Rouge, Louisiana were used to assess whether zip code tabulation areas (ZCTA)-level area deprivation index (ADI) or individual factors accounted for risk of infection. Logistic regression models assessed associations of individual-level demographic and socioeconomic factors and the zip code-level ADI with SARS-CoV-2 infection.ResultsIn the unadjusted model, there were increased odds of infection among participants residing in high versus low ADI (both cities) and high versus mid-level ADI (Baton Rouge only) zip codes. When individual-level covariates were included, the odds of infection remained higher only among Baton Rouge participants who resided in high versus mid-level ADI ZCTAs. Several individual factors contributed to infection risk. After adjustment for ADI, race and age (Baton Rouge) and race, marital status, household size, and comorbidities (New Orleans) were significant.ConclusionsWhile higher ADI was associated with higher risk of SARS-CoV-2 infection, individual-level participant characteristics accounted for a significant proportion of this association. Additionally, stage of the pandemic may affect individual risk factors for infection.