Infectious diseases like infective endocarditis (IE) may manifest or progress differently between sexes. This study sought to identify the differences in demographic and clinical characteristics among male and female patients with IE. Data were obtained from a newly developed registry comprising all adult patients with first IE admission at the four major tertiary cardiovascular centers in West Virginia, USA during 2014–2018. Patient characteristics were compared between males and females using Chi-square test, Fisher’s exact test, and Wilcoxon rank-sum test. A secondary analysis was restricted to IE patients with drug use only. Among 780 unique patients (390 males, 390 females), significantly more women (a) were younger than males (median age 34.9 vs. 41.4, p < 0.001); (b) reported drug use (77.7% vs. 64.1%, p < 0.001); (c) had tricuspid valve endocarditis (46.4% vs. 30.8%, p < 0.001); and (d) were discharged against medical advice (20% vs. 9.5%, p < 0.001). These differences persisted even within the subgroup of patients with drug use-associated IE. In a state with one of the highest incidences of drug use and overdose deaths, the significantly higher incident IE cases in younger women and higher proportion of women leaving treatment against medical advice are striking. Differential characteristics between male and female patients are important to inform strategies for specialized treatment and care.

Introduction Life-threatening infections such as infective endocarditis (IE) are increasing simultaneously with the injection drug use epidemic in West Virginia (WV). We utilized a newly developed, statewide database to describe epidemiologic characteristics and healthcare utilization among patients with (DU-IE) and without (non-DU-IE) drug use-associated IE in WV over five years. Materials and methods This retrospective, observational study, incorporating manual review of electronic medical records, included all patients aged 18–90 years who had their first admission for IE in any of the four university-affiliated referral hospitals in WV during 2014–2018. IE was identified using ICD-10-CM codes and confirmed by chart review. Demographics, clinical characteristics, and healthcare utilization were compared between patients with DU-IE and non-DU-IE using Chi-square/Fisher’s exact test or Wilcoxon rank sum test. Multivariable logistic regression analysis was conducted with discharge against medical advice/in-hospital mortality vs. discharge alive as the outcome variable and drug use as the predictor variable. Results Overall 780 unique patients had confirmed first IE admission, with a six-fold increase during study period (p = .004). Most patients (70.9%) had used drugs before hospital admission, primarily by injection. Compared to patients with non-DU-IE, patients with DU-IE were significantly younger (median age: 33.9 vs. 64.1 years; p < .001); were hospitalized longer (median: 25.5 vs. 15 days; p < .001); had a higher proportion of methicillin-resistant Staphylococcus aureus (MRSA) isolates (42.7% vs. 29.9%; p < .001), psychiatric disorders (51.2% vs. 17.3%; p < .001), cardiac surgeries (42.9% vs. 26.6%; p < .001), and discharges against medical advice (19.9% vs. 1.4%; p < .001). Multivariable regression analysis showed drug use was an independent predictor of the combined outcome of discharge against medical advice/in-hospital mortality (OR: 2.99; 95% CI: 1.67–5.64). Discussion and conclusion This multisite study reveals a 681% increase in IE admissions in WV over five years primarily attributable to injection drug use, underscoring the urgent need for both prevention efforts and specialized strategies to improve outcomes.

Introduction: West Virginia has the highest incidence of obesity, smoking, and diabetes within the United States, placing its population at higher risk of stroke. In addition to these endemic risk factors, Appalachia faces various socioeconomic and health care access challenges that could negatively impact stroke incidence and outcomes. At present, there are limited data regarding geographic variables on stroke outcomes in rural Appalachia. We set out to quantify Appalachian geographic patterns of stroke incidence and outcomes. Methods: This is a retrospective analysis of all patients hospitalized with a diagnosis of stroke in West Virginia's largest tertiary hospital. During the study (2000–2018), 14,488 patients were analyzed, with an emphasis on those who died from stroke (n = 1022). We first used institutional ICD-9/10 data alongside demographics information and chart reviews to evaluate disease patterns while also exploring emerging hot spot pattern changes over time; we then exploited an emerging time series analysis using temporal trends to assess differing instances of stroke occurrence regionally with hot spots defined as higher than expected incidences of stroke and stroke death. Results: Data analysis revealed several hot spots of increasing stroke and mortality rates, many of which achieved statistically significant variance compared to expected norms (P = 0.001). Moreover, this study revealed high-risk zones in rural West Virginia wherein the incidence and mortality rates of stroke are suggestively higher and less resistance to economic change than urban centers. Conclusions: Stroke incidence and mortality were found to be higher than expected in many areas of rural West Virginia. The higher stroke risk populations correlate with area that may be impacted by socioeconomic factors and limited access to primary care. These high-risk areas may therefore benefit from investments in infrastructure, patient education, and unrestricted primary care.

Introduction Early promising results of renal nerve denervation awakened interest in developing medical device alternatives for patients with resistant hypertension. The subsequent sham-controlled renal nerve denervation randomized trials were disappointing leading researchers and innovators to explore alternative device and trial designs to address this significant unmet need. We describe the innovation process leading to the first endovascular carotid baroreflex amplification device currently undergoing clinical trials in the United States and Europe. Areas covered We provide a brief overview of carotid baroreceptor physiology and then couple this knowledge with the fundamental principles of strain pattern changes that led to the proposed innovation. The mechanism of blood pressure reduction via enhancing innate physiologic carotid sinus baroreceptor signaling through changes in pulsatile focal carotid bulb strain is described alongside preclinical testing and early clinical results. Expert opinion The collective data to date suggest endovascular carotid baroreflex amplification may be an innovative alternative for resistant hypertension patients. However, well-controlled studies will be needed to assess efficacy, safety, durability, and risk: benefit of this permanent intravascular carotid implant. Subject codes high blood pressure, hypertension, treatment, physiology

THE DISTRIBUTION OF CHF WITHIN SOUTHERN WEST VIRGINIAFrank H Annie, PhD1; Muhammad Yasin, MD2, Aravinda Nanjundappa, MD2;1. CAMC Health Education and Research Institute3200 MacCorkle Ave. SE, Charleston, WV 25304.2. CAMC Vascular Center of Excellence, Charleston Area Medical Center.3200 MacCorkle Ave SE, Charleston, WV 25304Study Locations:Charleston Area Medical Center, 3100 McCorkle Ave SE, Charleston, WV, 25302 and Charleston Area Medical Center Research Institute and Center for Clinical Sciences Research, 3200 McCorkle Ave SE, Charleston, WV, 25302Correspondence:Frank Annie M.A; MPA, PhDResearch ScientistCAMC Health Education and Research Institute3200 MacCorkle Ave. SE,Charleston, WV 25304Phone 304-388-9921Fax: 304-388-9921Email: Frank.H.Annie@camc.orgTotal word count: 593Author Disclosure Block: NoneKey words: Access, CHFRunning Title: The Distribution of CHFTotal Number of Tables and Figures: Figures 1Per the United States (U.S) Census Bureau, rural areas are geographic designations excluding all population, housing, and territory included within an urbanized area or cluster (1). Approximately 20% of the U.S. population lives in these rural designations. The literature reports that rural populations face more barriers associated with access and quality of care compared with urban groups. Cultural attitudes, access difficulty, and absence of services are a few of several contributing factors (2).However, there is little evidence that specifically addresses the needs of rural patients suffering from congestive heart failure (CHF). A number of factors can cause CHF, including coronary artery disease, valvular disease, and systemic hypertension. Poor health literacy, roughly defined as the degree of difficulty an individual has while attempting to obtain, process, and understand basic health information and services, is associated with earlier heart failure hospitalization and all-cause mortality in rural patients with CHF in the U.S. (3). Elderly U.S. veterans who reside in rural designations are more vulnerable to delayed CHF treatment due to lack of transportation (4).Whether patients with CHF who reside in rural designations struggle to comprehend information due to culturally-based reservations or lack resources available to their urban counterparts, it is important to identify those who require improved access so that their perspective and needs can be better assessed. Appalachia is a distinct, non-homogenous region within the U.S. that is comprised of 13 states, in which 42% reside in rural areas or clusters (5). We conducted a retrospective analysis of CHF cases from 2005-2016 obtained from our Charleston Area Medical Center (CAMC) data warehouse in Charleston, West Virginia. Using a Hot Spot Analysis, we aimed to identify patients with CHF from rural territories and housing who have limited access. After the data were analyzed (n=22,404), patients were identified and examined using Arch 10.8 and geocoded. To investigate any potential spatial relationships, and a Hot Spot Analysis was performed. We controlled for population in order to understand the areas in which CHF had statistical significant hot and cold zones.The results suggest within (Figure 1) that areas in which CHF cases are further from major hospitals in Southern West Virginia appear to have increased cold spots within these zones. These zones are illustrated in bright blue and have a (P = 0.001). These results suggest access and health care resources are still a significant issue within Southern West Virginia, as illustrated in (Figure 1). These at-risk zones are outside the baseline 5 miles radius of the majority of substantial statistical zones. These results also suggest that further access in the form of CHF clinics and other households of access is essential.Figure LegendFigure 1 – Hot Spot Analysis of Congestive heart failure (CHF) (n=22,404)

Percutaneous coronary artery intervention (PCI) for unprotected left main coronary artery (LMCA) has emerged as a viable option with outcomes comparable to coronary artery bypass grafting in certain patient populations. Intravascular ultrasound has played an important role in optimizing PCI results

Objectives: To confirm whether a relationship exists between male sex and coronavirus disease 2019 (COVID-19) mortality and whether this relationship is age dependent. Patients and Methods: We queried the COVID-19 Research Network, a multinational database using the TriNetX network, to identify patients with confirmed COVID-19 infection. The main end point of the study was all-cause mortality. Results: A total of 14,712 patients were included, of whom 6387 (43%) were men. Men were older (mean age, 55.0 +/- 17.7 years vs 51.1 +/- 17.9 years; P<.001) and had a higher prevalence of hypertension, diabetes, coronary disease, obstructive pulmonary disease, nicotine dependence, and heart failure but a lower prevalence of obesity. Before propensity score matching (PSM), all-cause mortality rate was 8.8% in men and 4.3% in women (odds ratio, 2.15; 95% CI, 1.87 to 2.46; P<.001) at a median follow-up duration of 34 and 32 days, respectively. In the Kaplan-Meier survival analysis, the cumulative probability of survival was significantly lower in men than in women (73% vs 86%; log-rank, P<.001). After PSM, all-cause mortality remained significantly higher in men than in women (8.13% vs 4.60%; odds ratio, 1.81; 95% CI, 1.55 to 2.11; P<.001). In the Kaplan-Meier survival analysis, the cumulative probability of survival remained significantly lower in men than in women (74% vs 86%; log-rank, P<.001). The cumulative probability of survival remained significantly lower in propensity score matched men than in women after excluding patients younger than 50 years and those who were taking angiotensin-converting enzyme inhibitor or angiotensin receptor blocker medications on admission. Conclusion: Among patients with COVID-19 infection, men had a significantly higher mortality than did women, and this difference was not completely explained by the higher prevalence of comorbidities in men. (C) 2020 Mayo Foundation for Medical Education and Research

Author BlockFrank H Annie, PhD1, Mark C Bates, MD2, Aravinda Nanjundappa,MD2, Ali Farooq, MD2, Elise Anderson, MD2, Megan Wood, DNP21CAMC Health Education and Research Institute3200 MacCorkle Ave. SE, Charleston, WV 25304.2CAMC Vascular Center of Excellence, Charleston Area Medical Center.3200 MacCorkle Ave SE, Charleston, WV 25304

PURPOSE:Our objective was to determine significant predictors of spinal cord ischemia (SCI) following Thoracic Endovascular Aortic Repair (TEVAR) and to further develop a simple and clinically orientated risk score model.METHODS:A retrospective review of data from the Society of Vascular Surgery/Vascular Quality Initiative national data set was performed for all patients undergoing TEVAR from January, 2014 to June 2018. Preoperative demographics, procedure-related variables, and clinical details related to SCI were examined. A SCI risk score was developed utilizing a multivariable logistic regression model.RESULTS:For the 7889 patients in the final analysis who underwent TEVAR during the study period, the mean age was 67.6 ± 13.9, range 18 to 90 years, and the majority was male (65%). Postoperative outcomes included stroke (3.0%), myocardial infarction (2.9%), inhospital mortality (5.4%), transient SCI (1.5%), and permanent SCI (2.1%). Nearly half of the overall cases were performed in high volume centers. Predictors of increased risk for SCI included age by decade (odds ratio [OR]: 1.2), celiac coverage (OR: 1.5), current smoker (OR: 1.6), dialysis (OR: 1.9), 3 or more aortic implanted devices (OR: 1.7), emergent or urgent surgery (OR: 1.5), adjunct aorta-related procedure (OR: 2.5), adjunct not related (OR: 2.6), total estimated length of aortic device (19-31 cm, OR: 1.9 and ≥32 cm, OR: 3.0), ASA class 4 or 5 (OR: 1.6), and procedure time ≥154 minutes (OR: 1.8). Two predictors decreased the risk of SCI, cases from high-volume centers (OR: 0.6) and eGFR ≥ 60 (OR: 0.6). To evaluate the risk score model, probabilities of SCI from the original regression, raw score, and raw score categories resulted in area under the curve statistics of 0.792, 0.786, and 0.738, respectively.CONCLUSIONS:Spinal cord ischemia remains one of the most feared complications of TEVAR. Incidence of SCI in this large series of patients with TEVAR was 3.6% with nearly 60% being permanent. The proposed model provides an assessment tool to guide clinical decisions, patient consent process, risk-assessment, and procedural strategy.

The COVID-19 epidemic has led to an unpreceded disruption in health care systems worldwide. Concerns have been recently raised about young patients with COVID-19 presenting with large ischemic strokes.1Oxley TJ Mocco J Majidi S Kellner C.P. Shoirah H. Paul Singh I. De Leacy R.A. Shigematsu T Ladner T.R. Yaeger K.A. Skliut M. Weinberger J. Dangayach N.S. Bederson J.B. Tuhrim S. Fifi J.T. Large-vessel stroke as a presenting feature of Covid-19 in the young.N Engl J Med. 2020; Crossref PubMed Scopus (1545) Google Scholar Data on stroke in COVID-19 patients remain limited to a few case reports.1Oxley TJ Mocco J Majidi S Kellner C.P. Shoirah H. Paul Singh I. De Leacy R.A. Shigematsu T Ladner T.R. Yaeger K.A. Skliut M. Weinberger J. Dangayach N.S. Bederson J.B. Tuhrim S. Fifi J.T. Large-vessel stroke as a presenting feature of Covid-19 in the young.N Engl J Med. 2020; Crossref PubMed Scopus (1545) Google Scholar In this focused analysis, we investigated the incidence and outcomes of acute ischemic stroke in young adults using a multinational database. We queried the TriNetx Research Network to select patients <50 years of age with laboratory confirmed COVID-19 infection between January 20, 2020 to April 24, 2020. Patients were identified as COVID-19 positive if they had a billable code for COVID-19 and had an associated positive laboratory confirmation of the infection (eTable-1). TriNetX is a global federated health research network providing access to statistics on electronic medical records (diagnoses, procedures, medications, laboratory values, genomic information) from patients in predominately large healthcare organizations. The TriNetx database (COVID-19 Research Network) is a network of 37 global healthcare organizations (36% based in the United States [US] and 64% outside of the US). The diagnosis of acute ischemic stroke was established via validated international classification of diseases 10th revision diagnosis codes.2Alhajji M Kawsara A Alkhouli M Validation of acute ischemic stroke codes using the international classification of diseases tenth revision.Am J Cardiol. 2020; 125: 1135Abstract Full Text Full Text PDF PubMed Scopus (25) Google Scholar Descriptive statistics were presented as frequencies with percentages for categorical variables and as mean ± standard deviation for continuous measures. Baseline characteristics were compared using a Pearson chi-squared test for categorical variables and an independent-samples t test for continuous variables. All-cause mortality was displayed in the 2 cohorts using the Kaplan Meier method, and statistical significance of the differences between the 2 groups were assessed with the Log-Rank Test. A total of 9,358 COVID-19 positive patients age ≤50 years of age were identified in the database, of whom 33.2% were hospitalized for severe symptoms. The incidence of acute ischemic stroke was 64/9,358 (0.7%). Compared with patients who did not experience a stroke, those with acute ischemic strokes were older (39.3 ± 9.0 vs 36.7 ± 8.5 years, p < 0.001), but had similar proportions of females (60.9% vs 60.4%, p = 0.93). They, however, had higher prevalence of key co-morbidities: hypertension (61.0% vs 11.7%); diabetes (32.8% vs 6.5%); heart failure (15.6% vs 1.5%), nicotine dependence (34.4% vs 5.9%); obesity (46.9% vs 17.4%); chronic obstructive lung disease (15.6% vs 1.0%); prior history of stroke (28.1% vs 0.5); and renal insufficiency (15.6% vs 2.0%), p < 0.001 for all. Median follow up was 16.5 days in the stroke cohort and 36.5 days in the no stroke cohort. All-cause mortality occurred in 10/64 patients (15.6%) in the stroke cohort vs. 58/9,294 patients (0.6%) in the no stroke cohort. In the Kaplan Meier survival analysis, patients with stroke had significantly lower odds of survival compared with those without stroke (p-log rank <0.001) (Figure 1). To our knowledge, this is the first study to report the incidence and outcomes of acute ischemic stroke in young adults with COVID-19 infection. We found a low overall incidence but a grim prognosis of acute ischemic stroke among unselected young adults with COVID-19. The findings of this analysis need to be interpreted in the context of its limitations. Due to the nature of this observational database, it is not possible to distinguish whether patients presented with strokes then tested positive for COVID-19 or vice versa. Also, given the lack of a control arm without COVID-19, these findings cannot confirm an association between COVID-19 and increased risk of ischemic stroke especially with the higher prevalence of comorbidities in the stroke cohort. No relevant disclosures.

Background The opioid crisis has disproportionally affected Appalachia. One of the potentially lethal and costly complications associated with IV drug use is infective endocarditis (IE). The goal of this study was to assess the trend and costs of substance abuse associated IE admissions in Southern West Virginia. Methods This is a retrospective analysis of cost, incidence, and geographic patterns of all patients admitted over the last decade with concomitant drug abuse (cocaine, amphetamine, sedative, and other/mixed drug abuse) and IE in the largest tertiary care center for Southern West Virginia. A time series model was used to investigate the effect of drug use on the incidence of IE. Results A total of 462 patients were hospitalized with IE and concomitant illicit drug use. IE cases increased from 26 admissions in 2008 to 66 in 2015. Patterns of increases in mixed drug use (DRG most often associated with IV drug use in our center) mirrored increases in IE ( P = 0.001). From 2008 to 2015, the total hospital charges were $17 306 464 on 462 cases of illicit drug associated IE. Only a fraction of the billed fees (22%) was collected ($3 829 701). Conclusions The number of patients hospitalized with IE has dramatically increased over the last decade in a pattern that mirrors the increase in mixed drug use. The majority of payers were from underfunded state programs or private pay and thus, only 22% of the hospital charges were paid, leaving a hospital deficit of over $13 476 763 during the study period.

This manuscript is a review of the preclinical and early clinical findings related to a unique fluorinated polyphosphazene nanolayer device surface modification. Polyzene-F (PzF) is a novel, high-molecular weight, highly pure polyphosphazene that was designed to enhance the biologic interface between a medical device surface and human tissue or blood. The polymer also has unique mechanical properties that for the first time allow implants to be paved with a coating that has a nanoscale thickness of < 50 nm. The coating has inherent thrombus resistant properties and takes on biomimetic properties soon after implant due to favorable protein adhesion. Over the last 1.5 decades, PzF has undergone extensive preclinical testing including benchtop endothelial cell migration and platelet adhesion studies followed by increasingly sophisticated evaluation in 16 different animal models. The coating consistently has shown reduced platelet adhesion, decreased clotting, reduced inflammation, and accelerated healing compared with different surfaces as well as uncoated controls. These preclinical findings have translated into early compelling clinical evidence that suggest enhanced healing and reduced thrombosis can be achieved with a PzF-coated implant. There are now two PzF nanocoated products approved by the US Food and Drug Association (FDA), embolic spheres, and a coronary stent. This is the first detailed overview of the history, preclinical findings, and current clinical results attributed to the PzF coating with emphasis on the coronary stent Cobra-PzF. Lay Summary Over the last few decades, we have seen remarkable advances in medical technology including the development of less invasive surgical alternatives for the treatment of heart and vascular disease. One of the key advances in treating or preventing heart attack, stroke, and limb loss has been the development of stents. Stents are small, metallic, mesh-like devices that can be expanded within blocked vessels via small catheters placed through the groin or wrist. These stents provide structural support while the vessel heals. One of the challenges with stents and other permanent device implants is related to how our bodies react to foreign materials. One of the most feared complications of stents is clotting, which can result in abrupt closure of the treated artery. In the case of heart stents, abrupt closure can cause a heart attack or even sudden death whereas clotting within stents in the neck arteries (carotids) can cause stroke. Additional normal body defense mechanisms include complicated immune responses that trigger inflammation and can cause scarring resulting in early recurrence of the blockage or so-called "restenosis." In an effort to eliminate restenosis, many stents are now coated with drugs that slow or prevent healing. The downside of this approach has been the need for long-term blood-thinning medications like Plavix and aspirin. In this article, we review the history and current clinical findings of a new way to potentially make medical implants invisible to the normal foreign body defense responses that cause subsequent complications. The innovation involves the development of a new compound called Polyzene-F (CeloNova BioSciences, San Antonio, TX) that can be placed on the surface of a device in a layer that is extremely thin. This new coating is so thin it cannot be seen with even the strongest available microscopes and falls into a new category of material science called nanotechnology. Nanotechnology involves materials that are measured on a molecular level rather than the traditional measurements used in the field of medical devices. We describe many experiments done on the benchtop alongside animal studies and early clinical results that support the hypothesis that an enhanced biologic response can be expected for implants coated with Polyzene-F. The initial types of heart disease patients being studied with this new coated stent (Cobra-PzF) are those at high risk for bleeding since we know these patients are less tolerant of blood-thinning medicine. This initial narrow focus was selected based on the experience from our team and others suggesting animal studies do not always predict how humans respond to new treatments coupled with the knowledge that drug-eluting stents are getting better each day. We do see signals in the completed Cobra-PzF clinical trials that clotting and recurrence (restenosis) are low, but these studies do not directly compare this device to alternative stents in a type of study we call a "randomized trial." There is an ongoing large randomized trial comparing the Polyzene-F nanocoated stent (Cobra PzF) with contemporary drug-eluting stents in patients at high risk for bleeding, which should complete enrollment in 2019. At the same time, the US FDA-approved Polyzene-F-coated microbeads (Embozene, Boston Scientific, Marlborough, MA) are being studied for the treatment of tumors and cancer. If an enhanced biologic response is proven in the ongoing randomized trials being conducted on the currently approved Polyzene-F-coated devices, then this new surface enhancement may have broader application for a variety of medical device implants.

The field of transcatheter aortic valve replacement (TAVR) has matured significantly with the outcome and durability data now supporting use in lower-risk patients. We present a preventable complication from early in our experience (5 years ago) that illustrates the importance of heart team communication and cautious multidiscipline cross-pollination during the formative years of a program. An 87-year old female developed confusion, slurred speech and left upper extremity weakness 1 day following TAVR with inconclusive findings on carotid artery duplex and transthoracic echocardiography. Subsequent CT-scan disclosed a linear, ring-like, structure in the ascending aorta. The foreign body (FB) was radiolucent and successfully snared via tactile sensation and anatomic landmarks informed by the CT. The extricated FB was the valvuloplasty balloon guard (BG) that was inadvertently introduced into the patient via ascending aortic large sheath access. The failure mode was traced back to the first time use of a new balloon system and unrecognized BG by the surgical physician and technician components of the Heart Team who took the lead role in device insertion due to the open chest access. Subsequently, the heart team made changes to mitigate similar future complications by sharing multidiscipline responsibility for all procedural steps and ensuring the use of all new adjuvant devices are preceded by a procedural pause and team consensus regarding device preparation and use. Additionally, the manufacturer addition of a radiopaque marker or flair on the valvuloplasty BG may be warranted.

Background: The D-dimer (DD) level combined with the pretest Wells criteria probability (WCP) score can safely exclude deep venous thrombosis (DVT). The objective of this study was to examine the correlation between DD results alongside WCP score with findings on venous duplex ultrasound (VDU). The hypothesis is that VDU remains overutilized in low-risk patients with negative DD and that higher DD levels may correlate with thrombus burden and location. Methods: Patients who presented to a high-volume tertiary care center with lower limb swelling with or without associated pain were retrospectively examined through June and July for 4 consecutive years (2012 to 2015). After calculating WCP, patients were divided into low-, moderate-, and high-risk categories. Electronic DD results utilizing enzyme linked immunosorbent assay, WCP data, and VDU analysis data were merged and analyzed based on receiver operator characteristic curve to determine the DD cutoff point for each WCP. Abnormal DD with an average value >= 0.6 mg/L fibrinogen equivalent units (FEUs) was correlated to positive DVT to differentiate proximal DVT (above popliteal vein) from distal DVT (below popliteal vein). Results: Data of 1,909 patients were analyzed, and 239 (12.5%) patients were excluded secondary to serial repeat visits or follow-ups, surveillance screens, and if they had a previous history of DVT. The average age was 62.1 +/- 16.3 years with more women (55.7%) and the majority presented with limb pain and edema (87%). DD studies were ordered and completed in 202 patients and correlated with all positive and negative DVT patients (100% sensitivity and negative predictive value, with specificity and positive predictive value of 14.9% and 15.9%, respectively). Twenty-six of 202 patients had DD that were in the normal range 0.1e 0.59 mg/L (FEU), all of which were negative for DVT (100% sensitive). Fifty one of 202 patients had DD values of 0.6-1.2 mg/L FEU, of which only 3 DVTs were recorded, and all of them were distal DVTs. In addition, 685 patients with WCP <1 and negative DD were sent for VDU. Thus, 762 patients had an unnecessary immediate VDU (Wells <= 1 and eDD) study during their initial presentation. Potential charge savings for VDU for all patients are 762 x $1,557 = $1,186,434 and DD for all patients are 762 x $182 = $138,684, with total potential savings of $1,047,750 (USD 2016). Conclusions: This study suggests that DD is still underutilized, and DD in conjunction with WCP could significantly reduce the number of unnecessary immediate VDUs. Higher value of DD (> 1.2 mg/L FEU) may raise concern for proximal DVT. Concern on cost-effectiveness exists and raises the demand for a proposed algorithm to be followed.