Faculty Bibliography

OBJECTIVE:To compare cost and reimbursement of robotic and abdominal sacrocolpopexy procedures to evaluate which approach may minimize costs while improving the hospital profit margin. METHODS:We performed an IRB-exempt retrospective cohort study investigating all patients who underwent robotic or abdominal sacrocolpopexy at our hospital between July 1, 2018 and May 31, 2022. Patient demographic, procedural, and postoperative course data were extracted via chart review including duration of procedure, time in operating room, complications, and length of hospital stay. The billing department provided information on estimated cost of stay and reimbursement rates. RESULTS:A total of 203 robotic and 291 abdominal cases were included in analysis. The groups had significant differences in demographics, including race and insurance status. Abdominal procedures were associated with lower costs ($7675.99 vs 8747.48, P <.0001) and higher reimbursement rates ($ 16,210.48 vs $ 10,102.28, P <.0001), with the total collected (reimbursement minus cost), or profit margin, differing significantly ($8534.50 vs $1354.80, P <.0001). Discrepancies in reimbursement and profit remained after controlling for secondary procedures. Abdominal cases also had shorter average duration (129.9 vs 168.4 minutes, P <.0001). Abdominal sacrocolpopexy was associated with higher estimated blood loss (109.2 vs 97.9, P <.0001) and longer hospital stay (26.3 vs 15.9 hours, P <.0001). CONCLUSION:Despite longer hospital stays and slightly higher estimated blood loss, abdominal sacrocolpopexy appears to have lower costs and higher reimbursement rates than robotic sacrocolpopexy, with a higher profit margin for the hospital.

AIM/UNASSIGNED:Little is known about the incidence of clinical deterioration and cardiopulmonary arrest (CPA) on general hospital units in low-and middle-income countries (LMICs) or how rapid response systems (RRSs) might impact these events. Implementation of RRSs in high-income countries has been shown to reduce the incidence of CPA and mortality. The aim of this study was to determine whether implementation of an RRS is feasible in an LMIC medical center. METHODS/UNASSIGNED:We developed and implemented an RRS in a large academic medical center in Lagos, Nigeria, in three phases: (1) Needs assessment and stakeholder engagement, (2) Infrastructure setup and education, and (3) Implementation and data collection. We collected data on incidence of rapid response events, attendance ratio and time of arrival of the designated clinical staff, triggers for the rapid response calls and common interventions at the events. RESULTS/UNASSIGNED:Over the 7 months study period, 997 patients were admitted to the intervention-eligible units, and 95 RRS events occurred in 55 patients. In 11 RRS activations (11.6%), no rapid response team member responded. Anesthesia residents attended 73.7% of the events, and anesthesia techs and nurses attended roughly 38% each. Internal medicine residents responded to 13.7% of RRS activations. The average time to arrival was 13 min. The most common trigger was altered mental status, followed by hypoxia and hypotension. Seventy-six percent of patients survived their initial RRS activation, and 83% died while in hospital. Common interventions were vasopressor use, oxygen supplementation, and intravenous fluid administration. No patient was transferred to the designated intensive care unit after an RRS activation owing to lack of beds. Six patients were transferred to the makeshift ICU, all of which required vasopressor support. CONCLUSION/UNASSIGNED:While barriers remain, the development and implementation of an RRS program in an LMIC medical center is feasible.

OBJECTIVES/OBJECTIVE:Metal artifact reduction MRI can exceed specific absorption rate (SAR) limits due to high-bandwidth radiofrequency pulses, causing scan interruptions and prolonged acquisition times. The aim of the current study is to reduce SAR and potentially scan time in metal artifact reduction MRI using an optimized variable refocusing flip angle (VRFA) scheme compared with the standard constant refocusing flip angle (CRFA). MATERIALS AND METHODS/METHODS:Three VRFA variants (VRFA1 to VRFA3) were developed to maximize tissue signal and contrast while minimizing SAR and image blur. The optimal variant was selected through quantification of metal artifacts and image blur in phantoms and tissue signal in a volunteer. Patients with hip arthroplasty underwent CRFA and optimal VRFA imaging using high-bandwidth turbo-spin-echo (HBW-TSE) and compressed-sensing slice-encoding-for-metal-artifact-correction (CS-SEMAC) sequences. Three readers ranked paired CRFA and VRFA scans for quality. Analyses included repeated measures ANOVA, noninferiority testing, and paired t/Wilcoxon signed-rank tests. RESULTS:CRFA and VRFA1 to VRFA3 showed no significant differences in image blur (full-width-at-half-maximum, mean ± SD, 1.9 ± 0.2 vs 1.9 ± 0.2 vs 1.9 ± 0.3 vs 1.9 ± 0.3 pixels, P = 0.06) or metal artifacts (8.2 ± 2.8 vs 8.4 ± 2.7 vs 8.4 ± 2.6 vs 8.4 ± 2.7 pixels, P = 0.57). The optimal VRFA variant (VRFA3) preserved 81% of CRFA fat-muscle contrast at 77% SAR and 70% scan time on proton-density (PD), and 94% of fluid-muscle contrast at 80% SAR and 67% scan time on short-tau-inversion-recovery (STIR). In 23 patients [mean age, 67.3 y ± 12.2 (SD); 14 females], the optimal VRFA was noninferior to CRFA in all quality metrics (all 95% CI < noninferiority margin = 0.1) and significantly reduced SAR (mean, PD-HBW-TSE/STIR-HBW-TSE/PD-CS-SEMAC/STIR-CS-SEMAC: 1.11/1.35/1.17/1.18 vs 1.85/1.83/1.49/1.46 W/kg, all P ≤ 0.001). In HBW-TSE, reduced SAR allowed longer echo trains and 15% to 32% shorter scan times. CONCLUSION/CONCLUSIONS:Metal artifact reduction MRI with VRFA reduces SAR without compromising image quality. It allows shorter acquisitions in HBW-TSE.

BACKGROUND:Orofacial pain, affecting 10-15% of adults, is a prevalent form of chronic pain that remains a major clinical challenge. The Schwann cell involvement in this pathophysiology is not fully understood. Low-density lipoprotein receptor-related protein 1 (LRP1) in Schwann cells has an unclear role in orofacial pain mechanisms. FINDINGS/RESULTS:mice displayed defective oxLDL uptake and excessive H₂O₂ release. Conditioned medium from LRP1 ablated Schwann cells induced orofacial hypersensitivity in vivo and robustly activated TG neurons in vitro in a TRPV1/TRPA1 dependent manner. CONCLUSIONS:Our results demonstrate that Schwann cell LRP1 safeguards mitochondrial function and supports neuron-glia metabolic coupling in the trigeminal system. The finding that LRP1 deficiency in Schwann cells drives orofacial pain in the absence of external insults highlights Schwann cells as active drivers, rather than passive amplifiers of chronic pain and identifies LRP1 as a promising target for orofacial pain management.

BACKGROUND:Electrophysiologic care is increasingly a critical element of cardiovascular care, especially among older adults. OBJECTIVE:We investigated access to common electrophysiologic procedures among Medicare beneficiaries in the United States (US). METHODS:We used US Medicare Physician and Other Practitioners data (2013-2020) to identify centers providing pacemaker implantation and atrial fibrillation (AF) ablation, and linked it to county and zip code-level demographic data from the Agency for Healthcare Research and Quality to evaluate the density and trends in the number of centers across states and counties. For each US zip code, we determined the closest center where electrophysiologic procedures were performed and the travel duration using the Google Maps application programming interface. We also examined the association between sociodemographic factors and travel time to the nearest clinician using multivariable logistic regression models. RESULTS:In 2020, 3022 Medicare providers performed pacemaker implantations across 1392 centers, and 1661 providers performed AF ablations across 852 centers. However, only 20% of US counties had facilities performing pacemaker implantation, and just 16% had sites offering AF ablation. In 45% of counties, individuals needed to drive ≥1 hour to reach a site for pacemaker implantation. For AF ablation, this number increased to 50%. Longer travel times were associated with non-urban zip codes, higher percentage of Hispanic residents, less than high school education, and median annual income <$59,000. CONCLUSION/CONCLUSIONS:There are demographic and geographic disparities in access to interventional electrophysiologic care among Medicare beneficiaries in the US, with lower access among residents of rural areas and socio-economically disadvantaged groups.

Suboptimal care for ST-elevation myocardial infarction (STEMI) in low- and middle-income countries is a significant problem. Registries from Latin America, Africa, and Asia show that <65% of patients receive reperfusion therapy, and widespread treatment delays and a lack of access to optimal therapies lead to preventable deaths and complications. While current guidelines provide a blueprint for care, their implementation in low-resource settings requires specific guidance that considers geographical, logistical, and economic realities. This clinical consensus offers a new framework for developing STEMI care systems in these countries. We propose a flexible, three-model pathway, based on the initiatives such as STEMI India and Stent - Save a Life. The models include a fibrinolysis model, a pharmaco-invasive strategy model, and a primary percutaneous coronary intervention (PCI) model. This approach emphasizes adaptability, allowing local STEMI systems to be tailored to specific circumstances. The framework also addresses specific, common challenges, such as delayed access to primary PCI, reperfusion in patients with cardiogenic shock and expected delayed PCI, fibrinolysis in patients with a high risk of bleeding, and the absence of fibrin-specific fibrinolytics, catheterization labs, or reperfusion therapies at all. The consensus also highlights the importance of continuous improvement, patient education, and adopting secondary prevention strategies. Ultimately, this framework is designed to help healthcare providers and leaders in developing countries improve their regional STEMI care systems.

BACKGROUND:Wearable accelerometers, which continuously record physical activity metrics, are commonly used in mobile health-enabled cardiac rehabilitation (mHealth-CR). The association between adherence to accelerometer use during mHealth-CR and improvement in clinical outcomes, such as functional capacity, is understudied. The emergence of artificial intelligence (AI) technology provides novel opportunities to investigate accelerometry use patterns in relation to mHealth-CR outcomes. OBJECTIVE:In this study, we sought to use an AI clustering framework to identify distinct behavioral phenotypes of adherence to accelerometer use. We then aimed to quantify the association of these adherence phenotypes with functional capacity improvements in older adults undergoing mHealth-CR. METHODS:We analyzed data from the RESILIENT (Rehabilitation at Home Using Mobile Health in Older Adults After Hospitalization for Ischemic Heart Disease) trial, the largest randomized clinical study to date comparing mHealth-CR versus usual care in older adults (aged ≥65 years). Intervention arm participants were instructed to wear a Fitbit accelerometer for the 3-month study duration. Adherence to accelerometer use was quantified as overall adherence (percentage of days worn) via k-means clustering AI-derived measures and compared with changes in 6-minute walk distance (6-MWD), adjusted for demographic and clinical covariates. RESULTS:Among 271 participants with a mean age of 71 years (SD 8), of whom 198 (73%) were male, accelerometers were worn for an average of 76 days (95% confidence limits 73,78) over 3 months. Adjusted analyses showed a weak association between days of wear and improvement in 6-MWD, with every 30 additional days associated with an 11-meter improvement (P=.08). Our k-means clustering framework identified adherence phenotypes at two resolutions: low resolution (k=2 clusters) and high resolution (k=8 clusters). The consistently high adherence cluster trended toward a 24.6-meter improvement in 6-MWD compared to the low and declining adherence clusters (n=39; 95% CI 0.7-49.9; P=.06). The 8-cluster phenotyping revealed a richer set of adherence patterns, with the consistently high adherence cluster in this analysis having a 38.5-meter (95% CI 2.2-74.7; P=.04) improvement in 6-MWD than the low adherence cluster, as well as greater average daily steps over the 3-month intervention (mean 7518, SD 3415 vs mean 4800, SD 2920 steps; P=.008). CONCLUSIONS:A time-series AI clustering framework identified a range of behavioral phenotypes representing different degrees of adherence to accelerometer use. Regression analysis identified a weak association between the higher adherence phenotype and functional capacity improvement in older adults undergoing mHealth-CR. Our AI-derived accelerometry adherence phenotypes may offer a new approach to tailor mHealth-CR regimens to individual patients, potentially leading to better outcomes in this high-risk population. TRIAL REGISTRATION/BACKGROUND:ClinicalTrials.gov NCT03978130; https://clinicaltrials.gov/study/NCT03978130. INTERNATIONAL REGISTERED REPORT IDENTIFIER (IRRID)/UNASSIGNED:RR2-10.2196/32163.