Browsing by Subject "Clinical Research"
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Item Altered Atrial Remodeling in the Muscular Dystrophies(2019-01-22) Kappalayil, Anishka; Patel, Vishal; Cheeran, Daniel; Tassin, Tara C.; Zaha, Vlad; Peshock, Ronald M.; Mammen, Pradeep P. A.INTRODUCTION: Muscular dystrophies (MD) are genetic disorders that cause progressive peripheral skeletal myopathies. The specific mutations lead to a cycle of muscle degeneration and regeneration in MD patients, ultimately producing progressive skeletal muscle wasting. Many of the MD patients also develop associated cardiomyopathies and in 2018 is the leading cause of death. Our group has demonstrated that MD patients have very small left ventricular (LV) masses as well as depressed LVEF. This data suggest that the mode of maladaptive cardiac remodeling may be different in MD vs NICM patients. However, it remains unknown the degree of atrial remodeling that occurs in MD patients. Therefore, the central hypothesis of this study is that atrial remodeling in MD patients is altered in comparison to non-ischemic cardiomyopathy patients. METHODS: Utilizing the UTSouthwestern Cardiomyopathy Clinic, MD and NICM patients were identified. Data was extracted from cardiac MRIs to measure left atrial (LA) volumes and function. The variables used were the LA end systolic volume (LA-ESV), LA end diastolic volume (LA-EDV), and LA ejection fraction (LAEF). These measures were normalized to the body surface area (BSA). We collected data on 78 MD patients (33 MD females, 45 MD males) and 80 NICM patients (28 NICM females, 52 NICM males). Utilizing unpaired two-sided T-test, LA data was analyzed between the matched MD and NICM patients. RESULTS: The MD and NICM patient cohorts showed significant differences in the LA structure and function. CONCLUSION: Collectively, the data suggests alternative mode of maladaptive cardiac remodeling in MD vs NICM patients. Thus, further investigation into the mechanism that leads to MD-associated cardiomyopathy may ultimately identify novel therapeutic targets for the amelioration of this disease entity.Item Analysis of Resident Conducted Social Determinants of Health Informed Home Visits(2020-01-21) Cline, Matthew; Day, Philip; Gimpel, Nora; Pagels, PattiCONTEXT: Home visits can improve quality of care, save money, improve health outcomes, and provide a unique opportunity for residents to learn more about patients' social context and assess the various social determinants of health (SDH) that impact patients' health and wellbeing. In order to facilitate a SDH-focused visit, the Department of Family and Community Medicine at UT Southwestern implemented a brief SDH questionnaire in all home visits. OBJECTIVE: The objective of this study is to assess patient self-reported SDH and resident reflections on patient social status, the utility of a SDH survey during home visits, and resident comfort levels with addressing patient SDH HUMAN SUBJECTS REVIEW: This study was approved as an "exempt" study by the UTSW IRB DESIGN: Mixed methods pilot study utilizing patient self-reported data and open- ended reflection questions SETTINGS: Home health visits for patients from an urban safety-net clinic in Dallas, TX. Participants: Adult patients >18 years of age, selected by the resident INTERVENTION/INSTRUMENT (AS PERTINENT): Quantitative survey domains include: demographics, financial status, social support, safety, employment, and living conditions. Open response questions queried resident impressions of the survey, comfort during the interview, new insights about the patient, impact on future practice, and ability to address SDH concerns. ANTICIPATED RESULTS: 42 surveys collected from 42 home visits. Most patients were female (61.9%) and African-American (45.2%), aging from 25 to 88 years (mean=60.24). Prevalence of adverse SDH were relatively low. Common themes of resident responses: positive utility of the survey as a guide for understanding and assessing patient SDH; wide variation in comfort level when inquiring about patient SDH with positive influence from prior experience, assistance from colleagues, or prior good relations with patients; and expressed intention to include SDH assessment in their continuing career. CONCLUSIONS: Residents recognized the value of assessing SDH during home visits and expressed implement a standardized process for selecting patients for home visits as this was largely left to the discretion of the resident. More thorough assessment of patient SDH may help to craft a more robust and standardized system to prioritize patients that would most benefit from receiving home visits.Item Assessing Disease Severity in Cutaneous Lupus Patients Using Natural Language Processing(2024-01-30) Wang, Laura; Nezafati, Kuroush; Rong, Ruichen; Park, Andrew; Zhu, Jane; Xiao, Guanghua; Xie, Yang; Yang, Donghan M.; Chong, Benjamin F.BACKGROUND: Cutaneous lupus erythematous (CLE) is an autoimmune skin disorder that manifests as inflammatory cutaneous lesions commonly in photosensitive areas. It is often chronic in nature, with exacerbations that can lead to hyperpigmentation and scarring. One tool used to measure disease activity and damage in CLE patients is the Cutaneous Lupus Erythematosus Disease Area and Severity Index (CLASI) score. There has been little work done previously using natural language processing (NLP) in dermatology to assess disease severity, though there is promising potential for its use given the role of narrative data in dermatology. OBJECTIVE: We aim to develop a NLP model that interprets physical examination (PE) documentation in CLE patients and computes disease severity scores in the form of CLASI activity and damage scores. METHODS: Dataset was derived from 50 patients enrolled in the UTSW CLE registry. 89 clinical exams of 24 patients were used in a training set, used to train the NLP model. 35 clinical exams of 26 patients were selected for a validation set, used to test the model's accuracy in prediction. An entity dictionary was defined that provided rules for labeling vocabulary pertinent to CLASI scores within the PE note. This was used to label the relationships between entities in the training and validation sets. The BERT (Bidirectional Encoder Representations from Transformers) model was trained to predict all entities and relationships in the notes, based on which the CLASI scores were calculated. After training, the model was applied to the validation set. In evaluation, scores generated from the model were compared to the ground-truth CLASI scores based on human annotation. RESULTS: The model-predicted scores had a correlation of 0.79 and 0.86 with the ground truth on the activity and damage scores, respectively, in the training set, and a 0.61 and 0.79 correlation in the validation set. The model had 0.84 and above for accuracy, recall, precision and F1 within the sub-goal of determining the category of score severity (high or low), for both training and validation sets. CONCLUSIONS: Using PE notes as the input, a BERT-based NLP model can be trained to predict CLASI scores in CLE patients. If successfully implemented, this algorithm can significantly increase the volume of real-world data available for CLE research by efficiently processing PE notes in the EHR. Future steps are to increase the size and representation of the training set to improve accuracy and external validity of BERT's predictions.Item Assessing Laboratory Values in Transgender Women Treated with Cross-Sex Hormone Therapy(2018-01-23) Jiao, Rhoda; SoRelle, Jeffrey A.; Gao, Emily; Veazey, Jonas; Frame, Ithiel J.; Gimpel, Nora; Patel, Khushbu; Pagels, PattiOBJECTIVE: Laboratory results are used to guide clinical decision making, and reference ranges are developed to describe the variation seen in healthy individuals so that pathologic values can be distinguished from normal physiologic values. For transgender individuals taking cross-sex hormone therapy, changes in physiology can be expected to accompany the masculinization or feminization induced by the treatment, but the effect of these changes on laboratory tests is not well defined and cannot be easily predicted. This study seeks to evaluate the response of common laboratory tests to hormone replacement therapy (HRT) in transgender women (male-to-female, MTF), comparing to natal male and female populations. METHODS: We conducted a retrospective chart review for MTF and FTM (female-to-male) patients before initiating HRT and MTF patients after receiving HRT for 6-24 months at transgender-specific clinics in an urban county hospital (Parkland Hospital, Dallas, TX) and a community clinic (Resource Center, Dallas, TX). We collected demographic information, medical history, and laboratory values for CBCs, complete metabolic panels, liver function tests, lipids, and hormone levels taken throughout their course of treatment. RESULTS: In one of the largest studies of laboratory values in transgender patients, patient charts of 120 transgender women were reviewed, with a median age of 27 years. After initiating HRT, MTF patients showed a significantly increased estrogen and decreased testosterone (p<0.0001). Changes in hematologic parameters included decreases in red blood cell count, hemoglobin, and hematocrit (p<0.0001) and an increase in platelets (p=0.0001). Changes in metabolic parameters include decreases in sodium, creatinine, and alkaline phosphatase (p<0.0001). CONCLUSION: Better understanding the extent of expected changes in laboratory values can enable clinicians to more accurately evaluate the effects of HRT and choose appropriate treatments for individuals in the transgender population.Item Assessing the Relationship Between Telomere Length and Adipose Tissue Distribution(2018-01-23) Bleiberg, Benjamin; Ayers, Colby; Neeland, Ian J.BACKGROUND: A telomere is a region of repetitive nucleotide sequences at each end of a chromosome, which protects the end of the chromosome from deterioration. Telomere shortening, a surrogate marker of cellular aging, may accelerate from the inflammatory stressors of obesity. The association between adipose tissue depots and telomere length is unknown. METHODS: Data were analyzed from 2,551 participants in the Dallas Heart Study, a prospective multiethnic cohort. The sample composition was 41% male, 59% female, 48% African American, 35% Caucasian, 15% Hispanic and participants had a mean age of 51 years with 23.4% >60 years of age. Leukocyte telomere length (LTL) was determined using qPCR on DNA isolated from circulating leukocytes. Visceral (VAT) and subcutaneous (SAT) abdominal fat masses were measured by MRI, lower body fat (LBF) by dual x-ray absorptiometry, and liver fat by MR spectroscopy. Linear regression was used to evaluate the association between LTL and body fat depots. RESULTS: In univariate analysis, shorter LTL was associated with higher VAT (p=.0002) and less LBF (p=.02). Shorter telomeres were also associated with older age, male sex, hypertension, diabetes, smoking, decreased kidney function and decreased physical activity (p<0.05 for all). Adjustment for age and sex attenuated the relationships between LTL and VAT, SAT, LBF, and liver fat. No significant interactions were seen by stratification within age groups or by severity of obesity. Variable Beta unadjusted p unadjusted Beta adjusted p adjusted VAT -0.072 0.0002* 0.009 0.6 SAT 0.021 0.29 0.016 0.38 Lower Fat 0.048 0.02* 0.024 0.19 Liver Fat 0.03 0.41 0.032 0.4 Adjustments for age and sex and * p<0.05 Standardized β coefficients = estimated unit change in 1-SD of the log-transformed variable for a 1-SD increase in the telomere parameter CONCLUSIONS: While LTL is associated with pathogenic patterns of adipose tissue, this association is confounded by the close relationship between LTL and temporal aging. These findings suggest that cellular aging is not independently linked to variation in adipose tissue distribution patterns.Item The Association Between Tobacco Use and Intradialytic Hemodynamics in Hemodialysis Patients(2018-01-23) Sonderman, Mark; Van Buren, Peter NoelBACKGROUND: Intradialytic hypotension is known to be associated with increased mortality in maintenance hemodialysis patients. Smoking is a modifiable risk factor that is more commonly seen in patients with large decreases in intradialytic blood pressure as compared to any other intradialytic blood pressure pattern. However, the mechanisms of this association are unknown. We sought to explore the effect of lifetime tobacco use on vascular hemodynamics during dialysis. METHODS: We used impedance cardiography to measure total peripheral resistance index (TPRI) in 65 hypertensive hemodialysis patients. Additionally, we obtained blood pressure measurements before, during, and after midweek hemodialysis treatments. We then compared intradialytic hemodynamic changes between never smokers (n=35) and current or former smokers (n=30) using simple and multivariable linear regression. RESULTS: The mean change in TPRI during a single dialysis session was -438 dynes/sec/cm2/m2 in smokers and -105 dynes/sec/cm2/m2 in non-smokers (p=0.1). The intradialytic systolic blood pressure nadir was 115 mmHg in smokers and 123 mmHg in non-smokers (p=0.1). In multivariable linear regression controlling for diabetes, ultrafiltration rate, and other factors associated with intradialytic blood pressure changes, smoking was independently associated with lower nadir SBP (p=0.01) with a trend to also have a greater decrease in TPRI (p=0.08). CONCLUSIONS: Hemodialysis patients with a smoking history demonstrate a tendency towards a greater reduction in intradialytic TPRI as compared to non-smokers, with a significant independent association for lower nadir SBP. Smoking status should be aggressively ascertained in dialysis patients with significant intradialytic hypotension, but further studies are required to determine the effect of smoking cessation on intradialytic hemodynamics.Item Association of African Ancestry with Left Ventricular Hypertrophy Assessed by Electrocardiographic Voltage and Cardiac Magnetic Resonance: The Dallas Heart Study(2018-01-23) Alame, Aya J.; Garg, Sonia; Kozlitina, Julia; Ayers, Colby; Drazner, Mark H.INTRODUCTION: Left ventricular hypertrophy (LVH) is more common in blacks than whites, despite adjusting for differences in blood pressure. Whether environmental or genetic factors lead to this increased prevalence of LVH in blacks is unknown. If genetic factors are involved, we hypothesized that the proportion of African ancestry among self-reported blacks would be associated with an increased risk of LVH in this ethnic group. METHODS: Participants from the Dallas Heart Study underwent genotyping, an electrocardiogram (ECG), and Cardiac Magnetic Resonance (CMR) imaging. Ancestral admixture proportions were estimated using genetic markers (Illumina Exome Chip) and ADMIXTURE software assuming 3 ancestral populations. In this analysis, we included participants that self-identified as black or white (n=2077). First, we tested the association of genetically inferred African ancestry (AFR) and self-reported black race, separately, using multivariable linear regression models, with three LVH phenotypes: 12-lead ECG voltage, LV concentricity0.67 (LV mass/volume0.67, a marker of concentric LVH), and LV Wall Thickness (LVWT). Next, we entered both AFR and black race into the same models to determine if the association of black race with LVH would be accounted for by AFR. Finally, we tested the association of AFR with LVH phenotypes among self-reported blacks. RESULTS: The study cohort consisted of 1,251 black and 826 white participants. Black race and AFR were individually associated with ECG voltage, LV concentricity0.67, and LVWT (Table 1). When AFR and black race were entered together into multivariable models, AFR, but not black race, was significantly associated with the LVH phenotypes (Table 1). Among self-reported blacks, AFR remained significantly associated with these LVH phenotypes (Table 1). CONCLUSIONS: The association of black race with LVH phenotypes can be captured more robustly with a genetic estimate of African ancestry. Further, within blacks, the proportion of AFR was associated with LVH phenotypes. These data support a genetic basis, related to African ancestry, for the increased prevalence of LVH in blacks.Item Cataract Surgery and Intraocular Pressure (IOP)(2018-01-23) Noorani, Sahar; Deng, Ted; Yang, Alex; AlSalem, Munsif; Bowman, Wayne; Whitson, Jess; Blomquist, Preston; Mootha, Vinod; Adams-Huet, Beverley; Li, Xilong; Kooner, KaranjitPURPOSE: The effect of cataract surgery on IOP in patients with glaucoma is not well understood. We sought to analyze fluctuations in IOP in controls, glaucoma suspects, and patients with mild, moderate, and severe primary open angle glaucoma (POAG) undergoing cataract surgery in a well-diversified population. METHODS: In an IRB-approved retrospective study, 236 controls (Group A), 37 glaucoma suspects (Group B), and 96 patients with POAG (mild, moderate, severe; Groups C-E) were recruited. One eye was randomly selected per patient. Exclusion criteria included: <18 years, secondary glaucoma, one functional eye, or follow-up <3 months. Data collected included age, race, gender, glaucoma family history, CCT, axial length (AXL), anterior chamber depth (ACD), lens thickness (LT), IOP, and visual acuity (VA). Post-operative IOP and VA were determined at several intervals. Linear trends over groups A-E were made with a Jonckheere-Terpstra test. χ2 analyses were used to evaluate differences between groups A-E. Wilcoxon Rank-Sum test was used to evaluate postoperative changes. Multiple linear regression was used to evaluate predictors of IOP change at 1 year. RESULTS: IOP reduction at 1 year in groups A-E were 8.6%, 8.1%, 10.8%, 18.3%, and 9.1%, respectively. Medications at 1 year did not change significantly. In POAG eyes, higher pre-op IOP and more medications were predictive of a higher reduction in IOP at 1 year (β= -0.62, -1.60; p<0.05). In control eyes, higher pre-op IOP and higher CCT were predictive of more IOP reduction at 1 year (β= -0.53, -0.02; p<0.05). DISCUSSION: In this population, all groups showed reduction of IOP after cataract surgery. Among the glaucoma groups, severe glaucoma patients had the lowest reduction of IOP (9.1%), most probably due to reduced outflow facility. However, the medication load stayed unchanged in all groups. In the control group, pre-op IOP and thicker CCT determined post-op IOP reduction. CONCLUSION: IOP reduction one year after cataract surgery in glaucomatous eyes is dependent on higher pre-op IOP and increased glaucoma medications. In non-glaucomatous eyes, higher pre-op IOP and thick CCT determine the degree of post-operative IOP reduction.Item Central Hemodynamic Monitoring of Train Drivers in Western Russia(2020-01-21) Duncan, Steven G.; Chang, Mary P.; Orlov, Sergei A.; Gorenkov, Roman V.BACKGROUND: Train drivers are exposed to work-related stressors which contribute to higher rates of cardiovascular disease. No studies have characterized precursors of this effect in Western Russia. AIM: This project aims to identify early disturbances and trends in central hemodynamic parameters among young locomotive driver assistants in order to elucidate patterns of decompensation. METHODS: This study is a retrospective review of hemodynamic parameters among train conductors in the Moscow region of the Russian Federation from December 2003 to September 2004. Subjects underwent regular hemodynamic monitoring within this period before every train departure. Automated oscillometric methods were used to obtain resting measurements of blood pressure, cardiac output, pulse wave velocity, and systemic vascular resistance with the device "KAP CG osm – 'Globus'". Men with pre-existing hypertension were excluded. RESULTS: The sample was comprised of 168 individuals and 8674 unique measurements; the mean age was 26.2 ± 4.6 years with an average of 52 ± 17 measurements per person over 33.8 ± 8.9 weeks. The average values for each hemodynamic parameter were within normal limits. Across all measurements, heart rate showed the greatest time-independent variation while systolic blood pressure showed the least; coefficients of variation (σ/x̄) were 10.6% and 6.8% respectively. Hypertensive episodes were observed in 36.3% of participants. Strong, positive correlations were observed between diastolic blood pressure and systemic vascular resistance (r = 0.72, p < 0.001), systolic blood pressure and cardiac output (r = 0.71, p < 0.001) respectively. Older subjects tended to have higher diastolic blood pressure (r = 0.51, p < 0.001). Over time, systemic vascular resistance showed the greatest variance with an average upward trend when data were fit to a linear regression model. Increasing systemic vascular resistance over time was positively correlated with decreasing systolic blood pressure and increasing diastolic blood pressure. DISCUSSION: Persistent changes in central hemodynamics can precede the development of clinical arterial hypertension. The results of this study suggest that implementation of early monitoring and prophylactic measures may be beneficial for high-risk individuals.Item Cesarean Section and Risk of Adenomyosis: A Retrospective Study(2022-02-01) Ford, Lauren; Allen, Regan; Wilson, Ava; Xiao, Heather; Sendukas, Emily; Chao, LisaBACKGROUND: History of uterine surgery, most notably a history of dilation and curettage (D&C), has been shown to be a risk factor for the development of adenomyosis. The association between prior cesarean sections (CS) and adenomyosis remains unclear. OBJECTIVE: The primary aim of this study is to determine if there is an association between adenomyosis and history of uterine surgery, including CS, D&C, and myomectomy. We also examine if repeat uterine surgery increases the risk of adenomyosis development. STUDY DESIGN: In this retrospective case control study we collected data from the electronic medical records of all women who underwent hysterectomy for benign indications at Parkland Hospital between January 2014 and December 2018. We then compared patients with and without adenomyosis on surgical pathology regarding history of uterine surgery, including CS, myomectomy and D&C. RESULTS: 2,911 patients were included in final analysis. History of any uterine surgery was associated with an increased risk of adenomyosis. Patients with a history of D&C were significantly more likely to have adenomyosis on surgical pathology (OR 1.57, 95% CI 1.30-1.90). There was also risk associated with repeat D&C (OR 1.31, 95% CI 1.01-1.72). The association between history of prior CS was not statistically significant (OR 1.12, 95% CI 1.00-1.37). A history of prior myomectomy was also not significantly associated with adenomyosis (OR 0.95, 95% CI 0.59-1.54). CONCLUSION: Of the risk factors explored, history of any uterine surgery, D&C and repeat D&C were associated with an increased risk of adenomyosis, which is consistent with prior studies. There was not an association between history of CS or increasing numbers of repeat cesareans with adenomyosis development. This contradicts the theory that disruption of uterine endometrium and the trauma of cesarean section predisposes individuals to developing adenomyosis. This is the largest retrospective case control study to date investigating this association, and with the results found, it can be concluded that CS individually do not increase the risk of adenomyosis.Item Changes in Rate of Methicillin-Resistant Staphylococcus Infection in a Community Neonatal Intensive Care Unit Before and During the COVID-19 Pandemic(2024-01-30) Blumenfeld, Abby; Hagans, Michelle; Chan, ChristinaBACKGROUND: Methicillin-Resistant Staphylococcus aureus (MRSA) infections represent a significant healthcare challenge, particularly in neonatal intensive care units (NICUs) where patients experience increased morbidity and mortality. MRSA transmission has not been well studied in the setting of enhanced infection precautions (EIP) taken during the COVID-19 pandemic - such as universal masking and enhanced hand hygiene. OBJECTIVE: This retrospective cohort study compared rates of MRSA infection in a community NICU during two distinct time periods: January 2016 to March 2020 (Pre-EIP: before EIP was instituted) and April 2020 to December 2022 (With-EIP: after EIP was instituted). METHODS: During the study period, 74 neonates admitted to the NICU tested positive for MRSA (56 Pre-EIP and 18 With-EIP). MRSA cases were collected using laboratory and electronic medical record review. Cases were reported as infections per 1,000 patient days (IP-1000). Statistical analysis with two-sample t-tests assuming unequal variance and chi squared tests for independence were performed. RESULTS: There was a significant decrease in MRSA IP-1000 from 1.90 Pre-EIP to 0.93 With-EIP (p=0.0006). The prevalence of MRSA clusters, defined as three infections within a 30-day period, decreased from 0.27 Pre-EIP compared to 0.03 With-EIP (p=0.0004). However, The Pre-EIP cohort had a younger average gestational age (30.2 vs 33.8 weeks, p=0.001), higher rates of very low birth weight (59% vs 28%, p=0.021), and fewer inborn neonates (88% vs 100%, p=0.115) - factors known to increase risk of MRSA infection. CONCLUSION: These findings suggest that EIP may have contributed to the reduction in MRSA clusters observed in this community NICU. Findings are limited by differences in cohort risk factors, small study population, variabilities in infection precautions throughout the pandemic, and the inherent bias of retrospective cohort analysis. This underscores the importance of prevention strategies and highlights the potential benefits of continued enhanced infection precautions in reducing the transmission of MRSA in vulnerable inpatient populations.Item ChatGPT Responses to Glaucoma Questions Based on Patient Health Literacy Levels(2024-01-30) Mekala, Priya; Patel, Monica; Suresh, Sruthi; Saleh, Ibrahim; Kooner, KaranjitBACKGROUND: Glaucoma is a complex, progressive neurodegenerative disease of the optic nerve, commonly found in the elderly. Patients usually do not understand the complexities of the disease and struggle to find answers from different glaucoma sources and sites which may be difficult to understand. AI chatbots such as ChatGPT(r) have recently emerged as a useful tool to gather information on any medical question. However, the role of ChatGPT in generating answers to glaucoma treatment questions is not well documented. Health literacy is defined as the basic reading and mathematical skills required to find, understand, and use health-related information. The average reading level among US adults is 7th-8th grade; however, most medical information is often written at a higher reading level. The purpose of this study was to determine whether ChatGPT can tailor responses to glaucoma treatment questions based on patient health literacy levels. HYPOTHESIS: We hypothesize that ChatGPT may satisfactorily tailor answers to glaucoma questions based on patient health literacy level. METHODS: We selected 27 common questions relating to glaucoma medications, lasers, and surgical treatments. The questions were inputted into ChatGPT, first without instructions. Then, ChatGPT was instructed to tailor responses to 4 health literacy levels based on the US National Assessment of Health Literacy: below basic (BB), basic (B), intermediate (I), and proficient (P). Responses were analyzed using Flesch-Kincaid (FKC) grade level [0-18+] corresponding to years of education, word count, and syllables. Kruskal-Wallis rank sum tests were used to analyze the data. RESULTS: The mean FKC grade level of ChatGPT responses without any instructions about health literacy levels was 12.83, corresponding to a 12th-grade or "fairly difficult to read" level. When instructed to tailor responses, the mean FKC grade level of BB, B, I, and P responses were 11.50, 12.49, 12.95, and 13.12 (p<0.001), respectively. The mean word count of BB, B, I, and P answers (82, 117, 163, 177, respectively) correspondingly increased (p<0.001). CONCLUSION: ChatGPT in its current form is unable to provide easy to comprehend responses to glaucoma questions for the public. Future AI chatbots may need to be trained on not only the specific databases, such as medical, conversational, computer science, and finance, but to be able to provide easily understandable answers at all levels of health literacy to cater to a wider sector of society.Item Choice of Anesthetic Induction Drugs for Tracheal Intubation in Critically Ill Patients and Impact on Outcomes: A Systematic Review(2024-01-30) Khawaja, Asad; Karamchandani, Kunal; Tyagi, Abhay; Singh, Preet MohinderBACKGROUND: Airway management in critically ill patients can significantly impact patient outcomes, and the choice of induction drugs used for endotracheal intubation (TI) is key for a successful and safe airway management. However, critically ill patients often have physiologic derangements leading to complications such as hypoxemia, hypotension, arrythmias, and cardiac arrest. HYPOTHESIS: This review aims to analyze the usage and outcomes of induction drugs used for airway management in critically ill adult patients to determine if there are select induction drugs that have better success rates and patient outcomes. METHODS: We searched the Cochrane Central Register of Controlled Trials, MEDLINE, and EMBASE for randomized controlled trials published since January 1, 2003, on critically ill adult patients who underwent TI in an emergency, ICU, or trauma setting. Our search yielded 1526 results, of which 18 were chosen. FINDINGS: These 18 studies include 15 randomized control trials, 2 ongoing phase 4 clinical trials, and 1 single blinded randomized study, for a total of 3142 patients. Etomidate and ketamine were the two most common drugs used, with 13 studies involving the use of etomidate, for a total of 1470 patients, and 7 studies involving the use of ketamine, for a total of 1082 patients. Etomidate and ketamine were compared the most frequently (n = 7), followed by etomidate and midazolam (n = 4). Most studies were performed in either the ICU (n = 6) or the ED/ER (n = 5). Hospital mortality (n = 10) and peri-intubation hypotension (n = 11) were also the most common outcomes studied. CONCLUSIONS: In general, there was no major trend that could be identified regarding patient outcomes when two induction drugs were compared with each other. This was due to the variability in the use of induction drugs for TI in critically ill patients and their patient outcomes. Comparing findings of different studies was limited by the heterogeneity of the studies. Further research is needed to identify the impact of the choice of induction drugs for TI in critically ill patients.Item Cholesterol Efflux Capacity: Biological and Clinical Determinants in a Large Multi-Ethnic Population Study (Dallas Heart Study)(2018-01-23) Akinmolayemi, Oludamilola; Rohatgi, AnandBACKGROUND: Cholesterol efflux capacity characterizes the ability of HDL to accept cholesterol from extrahepatic cells in the periphery to the liver, which is a crucial step in reverse cholesterol transport. Cholesterol efflux capacity has been shown in clinical studies to be inversely correlated with prevalent coronary disease and incidence of cardiovascular events, but it is still unclear what biological and clinical determinants drive cholesterol efflux capacity. OBJECTIVES : To determine the biological and clinical variables that associate with cholesterol efflux capacity measured with two different methods in a large multi-ethnic population study (Dallas Heart Study 2) and how these associations differ by sex, race, history of diabetes, and history of cardiovascular disease. METHODS: Cholesterol efflux capacity was measured in the cohort (DHS-2) using both fluorescence (BODIPY) and radiolabeled methods. Statistical analysis was performed using Jonckheere-Terpstra trend test, Mann-Whitney test, and multivariate linear regression. Two-sided p values <0.05 were considered to indicate statistical significance. RESULTS: A total of 2373 participants were included. The median age was 51 years, 57% were women, 51% were black, 5% had history of CVD, and 17% had history of diabetes. Cholesterol efflux capacity measured by radiolabeled method was significantly higher in women than in men (P<0.001). Blacks had the lowest cholesterol efflux capacity measured by both BODIDY (p=0.010) and radiolabeled (p<0.001) methods. Participants without history of CVD had higher cholesterol efflux capacity measured by radiolabeled method compared to those with history of CVD (p=0.048). In multivariate regression, risk factors and circulating markers explained more of the variance in efflux using radiolabel than the variance in efflux using BODIPY (R2 0.195 vs. 0.099) with some overlapping and some distinct markers. Stratification by history of CVD, history of diabetes, race, and sex categories did not alter the findings. CONCLUSION: Our analysis revealed that biological and clinical variables that associate with cholesterol efflux capacity vary with measurement methods, but further studies with different study population validating these differences are needed. An understanding of these differences will be useful in identifying targets to improve cholesterol efflux capacity.Item Clinical Features and Outcomes of Black Patients with Melanoma: A Case Series Between 2006-2022(2024-01-30) Brown, Ariel B.; Wix, Sophia N.; Heberton, Meghan; Adamson, Adewole S.; Gill, Jennifer G.BACKGROUND: The incidence of melanoma in Black patients is rare, therefore most studies describing outcomes have been performed using population databases with limited patient-level information. OBJECTIVE: To describe specific anatomic sites, clinical features, histologic subtypes, risk factors, and outcomes of Black patients with melanoma. METHODS: Case series of Black patients with melanoma identified between January 2006 and October 2022 at University of Texas Southwestern Medical Center and Parkland Health in Dallas, TX. Participants included self-identified Black patients with a histopathologic diagnosis of melanoma. Data collection included demographics, clinical characteristics, personal and family medical history, immunosuppression history, comorbidities, histopathology reports, imaging reports, melanoma treatments and responses, time to progression, metastatic sites, and survival. Kaplan-Meier analysis captured melanoma-related survival by primary site. RESULTS: Of the 48 patients identified, the median age at diagnosis of melanoma was 61.5 (range: 23-86) with the majority being female (30/48). Seventy-five percent (30/40) of primary cutaneous melanomas were located on acral skin despite only one-third (10/30) being histologically classified as acral lentiginous melanomas. Compared to those with acral disease, patients with non-acral cutaneous melanomas were more likely to be immunocompromised (40% vs. 7%) or have a personal history of cancer (60% vs. 17%) with all (3/3) superficial spreading melanoma patients having a history of both. No patients had more than 1 confirmed primary melanoma. In total, 13 (27%) Black patients with melanoma developed stage IV disease, of which 12 ultimately died due to disease progression. Those diagnosed with advanced acral melanoma, mucosal/ocular melanoma, or unknown primary had the poorest melanoma outcomes. No patients with non- acral cutaneous melanomas developed distant metastases or died of their disease. CONCLUSION: Most cutaneous melanomas in Black patients occur on acral sites. Non-acral cutaneous melanomas had limited contribution to melanoma mortality in Black patients and were diagnosed primarily in immunocompromised patients or those with a history of other cancers. Improving melanoma mortality in Black patients will require focused therapeutic and early detection strategies for acral, mucosal/ocular, and melanoma of unknown primary.Item Cocaine Use and General Anesthesia: A Prospective Study of Cardiovascular Effects(2018-01-23) Vu, Kevin; Kim, Agnes; Lu, Rachael; Sharifi, Eve; Moon, Tiffany SunBACKGROUND: Cocaine usage in surgical patients is a concern for many hospitals. In large urban hospitals, up to 1.0% of elective surgical patients and 38% of major trauma victims may test positive for cocaine preoperatively. Previous retrospective studies have shown that cocaine positive surgical patients do NOT have an increase in adverse hemodynamic events, length of stay, or mortality compared to cocaine negative controls. However, prospective studies evaluating the impact of recent cocaine use on intraoperative hemodynamics plus inflammatory and cardiac biomarkers have not been undertaken. HYPOTHESIS: This study will test the hypothesis that patients who have 1) a preoperative toxicity screen that demonstrates recent cocaine use, are 2) undergoing non-emergent surgery with general anesthesia, and 3) have normal vital signs will NOT experience an increased incidence of adverse perioperative cardiovascular events compared to similar control patients with a negative toxicity screen. METHODS: This prospective study stratifies patients into cocaine positive and cocaine negative cohorts. Cocaine positive patients were non-toxic with positive urine toxicology, while cocaine negative patients were defined as having used cocaine in the past year with negative urine toxicology. Anesthesia protocol was standardized. The primary outcomes measured were intraoperative hemodynamics and vasoactive medications, with a secondary outcome of pre- vs. post-operative troponin levels. DATA: Preliminary outcome analysis of cocaine positive (N = 59) and cocaine negative patients (N = 40) are shown in the table below: Primary Hemodynamic Outcomes as Percentage of Anesthesia Duration Hemodynamic Events Cocaine Negative Cocaine Positive MAP <55 or >110 mmHG 1.8 1.4 HR <50 or >100 BPM 3.2 2.7 Perioperative Change in Troponin T No Change 95.0% 100.0% Decrease 2.5% 0.0% Increase 2.5% 0.0% CONCLUSION: The data supports the idea that positive cocaine urine toxicology tests in non-toxic individuals are not associated with increased cardiovascular instability or troponin elevation. Thus, automatic cancellation of these patients may not be warranted. Further analysis of the full study cohort (N = 300) will be completed at the end of 2017.Item Comparisons of Anterior Vaginal Wall Indentation Parameters in Age-Matched Control and Prolapse Patients Using an Operator Independent Artificial Finger(2018-01-23) Wang, Connie; Abraham, Michael R.; Abrego, Christopher E.; Shiakolas, Panos S.; Zimmern, Philippe E.GOAL: To compare reaction forces of the human anterior vaginal wall in control (C) and prolapsed (P) women in response to pressure applied at different angles of indentation through an automated artificial finger equipped with a distal sensor. METHODS: Following IRB approval, a tripod-mounted, artificial finger equipped with a calibrated, piezoresistive sensor at its tip and automated by NI LabView 2015 software for motion control via an actuator was used to create anterior vaginal wall deformations at 10, 15 and 20 degree angles. Age-matched women in the C and P groups were compared. All measurements were performed in the supine position in the operating room, with patients under general anesthesia prior to the start of the operation and after the bladder was drained. Each deformation included a 1 second upwards indentation, a 1 second maintenance "hold", and a 1 second return of the fingertip to the baseline. Measurements were done in triplicate with a 3 second interval between each deformation sequence. Real-time voltages, equivalent to reaction forces sensed by the sensor during each indentation, were modeled as function of motion profiles and analyzed in Excel. The motion profile of each indentation was used to calculate baseline voltage, amplitude change over the 1 second interval of upwards indentation, and slope of the upwards indentation curve in its median 0.5 second range. RESULTS: Five women of similar age group (mean 64, 51-73) were studied in each group. A significant difference was observed between all degrees of indentation in baseline voltage in P and C groups (p<0.05). At 10 and 20 degrees of indentation, there was a significant difference in amplitude change between P and C groups, while there was a significant difference in slope of indentation at 15 degrees between P and C groups. CONCLUSION: The biomechanical properties of the human anterior vaginal wall can be objectively determined by a new device resembling the human finger. This mounted, free-standing artificial finger can apply a predictable and reproducible deformation to the anterior vaginal wall to compare the indentation properties of vaginal tissue in prolapsed and non-prolapsed conditions.Item Deep Venous Thrombosis and Pulmonary Embolism after Lower Extremity Amputation in Patients with Diabetes(2018-01-23) Gallaway, Kathryn E.; Ahn, Junho; Raspovic, Katherine M.; Wukich, Dane K.This study aims to identify risk factors for deep venous thrombosis (DVT) and pulmonary embolism (PE) in patients with diabetes mellitus (DM) undergoing a lower extremity amputation (LEA). A retrospective analysis of 36,445 LEA cases from the American College of Surgeons-National Surgical Quality Improvement Program (ACSNSQIP) database was performed. 23,380 patients with DM and 13,065 patients without DM were evaluated to determine whether DM is correlated with an increased risk of DVT and PE. Specific risk factors for DVT and PE in this population were also evaluated. The incidence of DVT in post-LEA patients with DM was 0.94% compared to 1.36% in patients without DM (p=0.0002). The incidence of PE in patients with DM was 0.37% compared to 0.54% in patients without DM (p<0.0001). Although statistically significant, this small increase in DVT/PE risk appears to be driven by a higher proportion of "completely dependent" patients without DM (p<0.0001). Patients with "completely dependent" pre-op functional status were 2.59 times more likely to develop a DVT (95% CI: 1.81-3.70) and 3.36 times more likely to experience a PE (95% CI: 1.97-5.72), while "independent" patients were significantly less likely to experience either complication. Level of amputation (LOA) was also associated with an increased risk of DVT and PE. Patients who underwent a below knee amputation (BKA) were 2.12 times more likely to experience a DVT/PE (95% CI: 1.40-3.12) and patients with an above knee amputation (AKA) were 1.82 times more likely to experience a DVT/PE (95% CI: 1.40-3.21). Patients who underwent a transmetatarsal amputation (TMA) were significantly less likely to experience either complication. Other statistically significant risk factors identified in this study include prior myocardial infarction, ASA classification of III-V, and female sex. Patients with a history of dialysis within 2 weeks of surgery had an increased risk of DVT (OR: 1.52, 95% CI: 1.15-2.02); however, no increased risk of DVT/PE in patients with Chronic Kidney Disease (CKD) stage III-V was found (OR: 1.19, 95% CI: 0.97, 1.45). Although DM is not associated with increased risk of DVT/PE, LOA is a significant predictor of DVT/PE risk. Diabetics with peripheral neuropathy may delay seeking treatment due to lack of pain, potentially resulting in higher LOA. Physicians should emphasize rapid evaluation and management of pressure sores to minimize LOA. Prophylactic antithrombotic protocols should also be considered for patients undergoing a high level amputation and for patients with comorbid risk factors such as cardiovascular disease or dependent functional status.Item Defining Screening Practices for Gestational Diabetes Mellitus at a Large, Urban Indian Community Hospital(2018-01-23) Iyengar, Meera; Balijepally, Ramya; Lingvay, IldikoBACKGROUND: The aim of this project was to outline screening practices for gestational diabetes mellitus (GDM) at Apollo General Hospital in Hyderabad, India to understand if GDM was being reliably diagnosed. Current screening guidelines for GDM advocate using an oral glucose challenge test in all high-risk women. Indian women have a 11-fold increased risk of developing GDM, demonstrating the need for a consistent and reliable screening practices. HYPOTHESIS: If Apollo General Hospital in Hyderabad, India is administering the gold standard screening method for GDM, then pregnant women coming to Apollo should receive an oral glucose tolerance test during their pregnancy. METHODS: A chart review of all deliveries at Apollo General Hospital from its opening in 2012 to 2016 was completed. Information from each chart regarding the hospitalメs screening practices for GDM including procedures, results, and follow-up practices was collected. RESULTS: GDM screening rates were high (92%), but not universal. Of the 208 patients reviewed, only 51% received a GTT or GCT sometime during pregnancy. An equal percentage of patients received either an RBS (36%) or GTT or GCT (36%) as their first screening test. The remaining patients received an FBS (21%) or PPBS (0.5%) as their first screening test. 8% were not screened for gestational diabetes mellitus during their pregnancy. 10 out of 208 reviewed patients were diagnosed with GDM, of whom 5 received either a GTT or GCT (45%). The prevalence of GDM at Apollo was 4.8% compared to global prevalence of 6%. CONCLUSIONS: Overall screening for GDM is high at Apollo General hospital. However, the screening practices vary considerably per patient, and only around 50% of women had received the gold standard test during their pregnancy. In addition, the prevalence of GDM at Apollo was lower than the global prevalence of 6%. This combined with the fact that Indian women have a 11-fold increased risk of developing GDM argue that RBS, FBS, PPBS or HbA1c may not be adequate tests to screen for GDM. Inconsistent screening practices prove the need for standardization and inquiry into patient and provider factors that influence the current variability in testing, as undiagnosed GDM can have serious consequences for both the mother and child.Item Delivery Continuity and Neonatal Disposition to Birthing Parent in Individuals with Substance Use Disorder at Parkland Health(2024-01-30) Afsari, Macy; White, Alesha; Morillos, Stephanie; Fisher, Amber; McNeil, Jessica; Faucher, Mary Ann; Cordova, Polly; Onisko, Nancy S.; Andino, Aldo; Kern, Joshua; Kleinschmidt, Kurt; McIntire, Donald D.; Adhikari, Emily H.OBJECTIVE: Infants born to individuals with substance use disorder (SUD) are at increased risk of removal from their parent. Individuals with SUD in pregnancy receive obstetric care by a multidisciplinary care team (MCT) at our safety-net hospital. We evaluated factors associated with delivery continuity and neonatal discharge to birthing parent among patients with SUD. STUDY DESIGN: This is a retrospective cohort study of pregnant patients with SUD who accessed Parkland Health (PHHS) between July 28, 2021 and June 25, 2022. We compared MCT interactions among patients who did and did not deliver at PHHS as well as neonatal disposition and outcomes for infants born to individuals with SUD and with specifically opioid use disorder (OUD). RESULTS: Among 256 pregnant individuals with SUD who accessed care in our system, 144 (56%) received care by our MCT during pregnancy or at the delivery hospitalization. 98 of these patients delivered at PHHS and 46 delivered elsewhere (68% vs 32%, p<0.001). Significantly more eligible individuals who delivered at PHHS accepted medication-assisted treatment (MAT) compared to those who did not (88% vs 70%, p=0.025). Of 139 patients with SUD who delivered at PHHS, 91 (65%) infants were discharged home with the birthing parent. Parents who went home with their infants were more likely to use cannabis (33% vs 4%, p<0.001) and less likely to use opioids (34% vs 63%, p=0.003). They attended more prenatal visits (median [IQR] 9 [5,11] vs 1 [0,4], p<0.001) and met less frequently with our multidisciplinary team providing integrated SUD treatment (1 [0,10] vs 4 [1, 14.5], p=0.026). Neonates discharged with the birthing parent were less likely to have a positive meconium (7% vs 75%, p<0.001) or urine toxicology (2% vs 67%, p<0.001) and were less likely to have a 5-minute Apgar <4 (0% vs 4%, p=0.04). Of 62 patients with OUD, 31 (50%) were discharged with their neonate. Those who used opioids alone were more likely than individuals with opioid-polysubstance misuse to retain charge of their infant (78% vs 43%, p=0.018). CONCLUSION: Increased interactions and MAT with a team specializing in care of pregnant patients with SUD is associated with delivery continuity. Neonatal disposition and outcomes are influenced more by maternal drug of choice and prenatal care attendance than by MCT interactions because of variance in SUD complexity. Opioid-polysubstance misuse is associated with separation of maternal infant dyad.