Faculty Bibliography

OBJECTIVE:Social determinants of health (SDOH) may impact the incidence of Respiratory Syncytial Virus (RSV) infection and the uptake of vaccinations in pregnancy. The objective of this study is to identify contributors to disparities in RSV vaccination in pregnancy. DESIGN/METHODS:This is a retrospective cohort study of patients delivering at term within three hospitals during February and March 2024, comparing pregnant patients identified as receiving vs not receiving RSV vaccinations. This period and gestational age were chosen to include patients who would have qualified for RSV vaccination administration. Vaccination status was extracted from standardized admission templates where these variables were recorded as discrete fields. Patients without RSV vaccination information were excluded. Sociodemographic factors, COVID vaccination status, and delivery campus were evaluated. Outcomes were analyzed using chi-squared, t-test, and McNemar test. RESULT/RESULTS:2181 patients met inclusion criteria and RSV vaccination information was available for 1548 patients (71%) with a 14% vaccination rate. Compared to those not vaccinated (n=1332), RSV vaccinated patients (n=216) were more likely to be older (30.7 vs 34.8, p<0.001), have private insurance (42% vs 85%, p<0.001), speak English (82% vs 95%, p<0.001), and deliver at our regional perinatal center (26% vs 77%, p<0.001). 50% of RSV vaccinated patients had a history of COVID vaccination compared to 33% of those not vaccinated against RSV (p<0.001). CONCLUSIONS:SDOH were associated with differences in RSV vaccination status. In addition, patients without RSV vaccination were less likely to have had COVID vaccination. These findings highlight the need to address SDOH to increase vaccination rates for vulnerable populations.

BACKGROUND/UNASSIGNED:Patients with bicuspid aortic stenosis who receive transcatheter aortic valve replacement (TAVR) may require subsequent valve interventions in their lifetime; however, the feasibility of redo-TAVR in this population is uncertain. We aimed to assess redo-TAVR feasibility in bicuspid patients and develop a predictive virtual valve planning algorithm. METHODS/UNASSIGNED:We studied computed tomography scans of bicuspid patients who received a balloon-expandable transcatheter heart valve (THV) in the LRT trial (Low Risk TAVR). Redo-TAVR feasibility, determined by valve-to-coronary and valve-to-aorta measurements on 30-day computed tomography, was assessed according to raphe location and calcification. A virtual valve planning algorithm was developed using baseline and 30-day computed tomography scans. RESULTS/UNASSIGNED:<0.001) due to favorable shifting of the THV away from the coronary ostia. A bicuspid virtual planning algorithm accounting for 83.4% THV underexpansion, resulting in an 11.9% taller frame and translation of the THV away from the calcified raphe (mean valve shift 6.6 mm) achieved 86.7% sensitivity and 88.9% specificity for predicting redo-TAVR feasibility. CONCLUSIONS/UNASSIGNED:Calcified raphe in left/right cusp fusion shifts the THV away from the coronary ostia, reducing coronary obstruction risk during redo-TAVR. Underexpansion causing increased THV frame height and valve shifting is common in bicuspid patients; a virtual planning algorithm accounting for these aspects can accurately assess redo-TAVR risk. REGISTRATION/UNASSIGNED:URL: https://www.clinicaltrials.gov; Unique identifier: NCT02628899.

Background and ObjectivesWhile hearing loss is a known risk factor for dementia, the impact of incident hearing loss on subsequent dementia risk remains underexplored. This study examined the association between newly reported hearing loss and dementia risk in U.S. adults, focusing on critical intervention periods for dementia prevention.Research Design and MethodsParticipants from the Health and Retirement Study who reported no hearing loss or hearing aid use in 2010 or 2012 were included. Incident hearing loss and dementia were assessed via self-report and proxy report. Pooled logistic regression models with inverse probability weighting estimated the cumulative incidence of dementia at 2, 4, 6, and 8 years after baseline. Risk ratios (RR) with 95% confidence intervals were calculated from 200 bootstrap samples. Subgroup analyses were conducted by age, sex, and cardiovascular disease (CVD) status.ResultsAmong 13,599 participants, 1125 (8.3%) reported incident hearing loss. Dementia incidence was higher among those with hearing loss (6.6%) compared to those without (4.9%). Starting at 4 years, incident hearing loss was associated with a higher dementia risk, persisting at 8 years (RR = 1.34; 95% CI: 1.05, 1.59). This association was significant among individuals aged 50-64 years and those with CVD.Discussion and ImplicationsIncident hearing loss is associated with a heightened dementia risk, particularly in midlife and among individuals with CVD. Future research should investigate the effectiveness of timely interventions aimed at preventing dementia in individuals with hearing loss.

BACKGROUND:Despite recent improvements in radiation safety, interventionalists are increasingly exposed to radiation during cardiac catheterization laboratory (CCL) procedures. The RADPAD was designed as a protective scatter-radiation absorbing shield with the goal of reducing scatter radiation. Early studies demonstrated between a 20 and 62 % relative reduction in scatter radiation. The purpose of this study was to examine the impact of the RADPAD through a randomized controlled trial in a large contemporary CCL. DESIGN/METHODS:The ATTENUATE (v) Trial is an investigator-initiated, prospective, randomized controlled trial which will randomize 1000 CCL procedures 1:1 to use of the RADPAD vs. no use of the RADPAD. The primary outcome of interest is the most proximal operator's dose-area product (DAP)-normalized operator dose (E) defined as E divided by DAP. Additional subgroup analysis comparing types of procedure will also be performed. Every case will utilize contemporary radiation safety equipment. SUMMARY/CONCLUSIONS:The ATTENUATE Trial is the largest randomized controlled trial to evaluate the utility of the RADPAD in reducing relative operator exposure in a contemporary CCL including coronary and structural interventions.

This study aimed to assess factors impacting obstetric triage time to disposition. The primary and secondary hypotheses were that high-risk patients and patients evaluated during periods with less staffing would experience prolonged length of stay (LOS), respectively.This single-site, retrospective cohort study analyzed 9,704 obstetric triage visits of 6,182 patients between January 1, 2022, to February 28, 2023. Inclusion criteria included patients 18 years or older with one or more evaluations. Exclusion criteria included scheduled admissions, unknown chief complaints, triage time under 10 minutes, and patients under 18 years old. A total of 6,612 visits representing 4,390 patients were included. The visits were stratified by disposition: admission versus nonadmission (transfer or discharge). Descriptive statistics analyze continuous variables. Frequencies and percentages were calculated for categorical variables. SAS was used for chi-square or Fisher's exact test for categorical variables and the two-sample t-test or Mann-Whitney test for continuous data. Statistical significance was p-value < 0.05.Of 6,612 visits, 3,475 admissions, and 3,137 nonadmissions occurred. The most common chief complaints were contractions (42%), amniotic fluid index evaluation (18%), and preeclampsia evaluation (8%). Admitted compared with nonadmitted patients had shorter LOS (64 minutes vs. 185 minutes, p < 0.001). Admitted compared with nonadmitted patients had shorter LOS by chief complaint, gestational age, high-risk maternal-fetal medicine status, time of day, and day of the week (all p < 0.001).Nonadmitted, maternal-fetal medicine and preterm patients evaluated during daytime and weekdays had significantly longer LOS. Vulnerable populations and target times for triage workflow improvement were identified. · Patient and unit factors influenced LOS.. · Nonadmitted patients had triple the LOS.. · High-risk patients had longer LOS.. · Daytime and weekday visits had longer LOS..

BACKGROUND:Disruption of ambulatory healthcare in New York City (NYC) during the COVID-19 pandemic was common, but the impact on the cardiometabolic health of vulnerable patient groups is unknown. Therefore, we estimated the effect of total care disruption (TCD) on blood pressure (BP) control among older NYC residents with hypertension and at least one other chronic condition, and examined whether neighborhood poverty moderated this impact. METHODS:From the INSIGHT Clinical Research Network, we identified NYC residents ≥50 years of age with hypertension and at least one other chronic condition. TCD was defined as no ambulatory or telehealth visit during the pandemic. We contrasted the change in prevalence of controlled BP (BP <140/90) before and after the pandemic among those with and without TCD via an inverse probability weighted (IPW) difference-in-difference regression model. RESULTS:Among 212,673 eligible individuals, mean age was 69.5 years (SD: 10.2 years) and 15.1% experienced TCD. BP control declined from 52.4% to 45.9% among those with TCD and from 53.6% to 48.9% among those without TCD. After IPW adjustment, a larger decline in BP control was noted among those with TCD (adjusted difference-in-difference = 1.13 percentage points (95% CI 0.32-1.94, p-value=0.0058)). There was no consistent difference in the relationship between TCD and post-pandemic BP control across neighborhood poverty levels. CONCLUSION/CONCLUSIONS:COVID-19-related TCD was associated with a modest decline in BP control among older adults with hypertension in NYC; this was not moderated by neighborhood poverty level.

BACKGROUND:The prognostic impact of cohesin mutations in patients with acute myeloid leukemia (AML) and myelodysplastic syndromes (MDS) is controversial. METHODS:In patients with AML and MDS who underwent next-generation sequencing at the authors' center during 2017-2023, the authors assessed the landscape of cohesin mutations and the impact of co-occurring mutations on overall survival (OS) and compared outcomes between patients with cohesin mutations and those with wild-type (WT) cohesin genes. RESULTS:The study included 83 patients, 36 with cohesin mutations (STAG2, n = 28; SMC1A, n = 7; SMC3, n = 3; co-expression of cohesin mutations, n = 2) and 47 with WT cohesin genes. Of the 36 patients with cohesin mutations, 17 (47%) had AML (six de novo and 11 secondary), and 19 (53%) had MDS. Patients who had STAG2 mutations had better median OS than patients who had only SMC1A and SMC3 mutations (26 vs. 10 months; p = .043). SRSF2 mutation was the most frequent co-occurring mutation (n = 12; 33%) and was associated with worse median OS than WT SRSF2 (13 vs. 43 months; p = .016). Seven patients (19%) with cohesin mutations underwent hematopoietic transplantation; their median OS was 70 months. Compared with the WT cohesin group, patients who had cohesin mutations were more likely to have adverse-risk AML (82% vs. 53%). The median OS was similar among patients with adverse-risk AML in the cohesin-mutation and WT cohesin groups (10 vs. 14 months, respectively; p = .9). CONCLUSIONS:The current study provides insight into the prognostic impact of cohesin mutations and co-occurring mutations in patients with myeloid malignancies.

OBJECTIVE:Preterm birth (PTB) remains one of the biggest public health challenges with both obstetric and perinatal implications. While a prior PTB is a known risk factor for recurrence, the understanding of the influence of factors such as race/ethnicity, gestational age, PTB subtypes, and interpregnancy intervals (IPI) remains limited. This study aimed to assess whether these factors modify PTB recurrence risk. METHODS:We conducted a retrospective cohort study of singleton pregnancies in Kaiser Permanente Southern California (2009-2022) using electronic health record data from 82,610 women with two pregnancies and 14,925 women with three. PTB subtypes, spontaneous (sPTB) and indicated (iPTB), were identified through natural language processing. Logistic regression was used to estimate adjusted odds ratios (aOR) and 95% confidence intervals (CI). RESULTS:A first PTB was associated with a 6-fold increased risk of PTB in the second pregnancy compared to an uncomplicated pregnancy (23.29% vs. 4.98%, respectively; aOR, 5.60, 95% CI: 5.23-5.99). Those with a history of sPTB (aOR: 5.32, 95% CI: 4.87, 5.81) and iPTB (aOR: 8.26, 95% CI: 7.18, 9.50) had increased risk for the same respective subtype at their second pregnancy. PTB recurrence risk persisted across race/ethnicity categories. In women with PTB in both prior pregnancies, the risk for PTB in a third pregnancy was significantly higher (aOR 14.59, 95% CI 11.28-18.88). The recurrence of PTB between 1st and 2nd pregnancy was substantially higher for those who delivered at 20-33 weeks of gestation, regardless of PTB subtype. Non-Hispanic Black and Asian/Pacific Islander women had higher recurrence risk compared to non-Hispanic Whites. CONCLUSION/CONCLUSIONS:These findings highlight disparities in PTB recurrence by race/ethnicity and PTB subtype among a large integrated healthcare system in Southern California, underscoring the need for targeted interventions, particularly for sPTB.

Idursulfase is the first-line and only available enzyme replacement therapy (ERT) for Mucopolysaccharidosis type II (MPS II), or Hunter Syndrome. Deficiency in the lysosomal enzyme iduronate-2-sulfatase leads to progressive skeletal deformities, neurologic deterioration, airway obstruction, and cardiomyopathy. In severe cases, these deformities can lead to death during teenage years (Stapleton et al. 2017). Continuous treatment with ERT is essential to prevent irreversible changes. However, 16 out of 108 (15%) patients had hypersensitivity reactions to idursulfase during clinical trials. Hypersensitivity reactions have also been reported several years into treatment (Elaprase 2018). Therefore, it is critical to evaluate for hypersensitivity reactions and desensitize patients to idursulfase. We report a fourteen-year-old male who was evaluated using a nonirritating skin test concentration and underwent a novel desensitization protocol for Lysosomal Storage Disease ERT.

Hyperattenuating contents detected in the gastrointestinal (GI) tract on CT scans are commonly seen and are almost always due to the purposeful ingestion of an oral contrast agent, usually barium- or iodine-based, used for evaluating the GI tract. Occasionally, other ingested material such as antacids or other medications, foreign objects, and medical devices can also be hyperattenuating. While these are usually correctly identified, these materials can potentially be misdiagnosed as a pathologic condition. Lokelma (sodium zirconium cyclosilicate (SZC)) is an increasingly used agent to treat hyperkalemia and has a hyperattenuating appearance on CT due to the presence of zirconium. However, this is not well known to the radiologic community. Here, we describe a case where SZC was seen in the GI tract on CT and misinterpreted as an acute GI bleed. A 72-year-old woman underwent single (portal venous) phase intravenous contrast-enhanced abdominal and pelvic CT after presenting to the ED with a lower GI bleed. The CT showed intraluminal hyperattenuation within the cecum, which was diagnosed prospectively as an active GI bleed. A CT angiogram of the abdomen and pelvis performed the following day for follow-up showed the hyperattenuating contents to be present on the non-IV contrast-enhanced series of the study, thereby proving that it was not due to active bleeding. Further investigation of the patient's medical record showed that the patient was being treated with SZC for hyperkalemia, accounting for the hyperattenuating cecal contents. Awareness of the hyperattenuating appearance of SZC on CT by radiologists and clinical staff can help avoid confusion and misdiagnosis.