Browsing by Subject "Retrospective Studies"
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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 Characterization and Differences Between Possible and Probable Mild Cognitive Impairment in an Alzheimer’s Disease Center(2015-08-31) Weaver, Victoria Allison; Rossetti, Heidi; Lacritz, Laura H.; Silver, Cheryl H.BACKGROUND: Mild cognitive impairment (MCI) is considered an intermediate state between normal aging and dementia. A subjective cognitive complaint (SCC) is a key component in the diagnosis of MCI. However, some individuals with SCCs do not show objective impairment on neuropsychological measures and there has been debate about the role of SCCs for the characterization of MCI. This study aimed to examine the differences in neurocognitive function and other risk factors between MCI subtypes and better understand the role of the SCC when objective cognitive impairment is not present. SUBJECTS: This retrospective study includes 395 participants [age (M, SD) =67.5(7.2), education (M, SD)=15.10(2.7)], from the Alzheimer’s Disease Center (ADC) at the University of Texas Southwestern Medical Center who were English speaking and between the ages of 50-90. Participants received a comprehensive clinical assessment including neuropsychological testing and diagnosis, which was made via multidisciplinary group consensus. This study consisted of participants classified at their baseline ADC visit as individuals with SCC but normal cognitive performance (possible MCI, n=83), individuals with SCC and abnormal cognitive performance (probable MCI, n=121), and normal controls (n=191). METHOD: Differences in performance on neuropsychological measures among possible MCI, probable MCI, and normal control groups were examined using MANOVA. Differences in the frequency of selected cognitive and vascular risk factors, including APOE4, hypertension, high cholesterol, and diabetes mellitus, were examined using chi square test of independence. Demographic differences (age, education, gender, depression, and premorbid intelligence) across groups were compared using either ANOVA or chi square. RESULTS: Normal controls performed significantly better than the probable MCI group on the MMSE, TMT-A, TMT-B, Block Design, WCST, FAS, Animal Fluency, and BNT (p<.05). On the CVLT, normal controls demonstrated fewer intrusion errors, higher total learning scores, and better long delay free recall than both the possible and probable MCI groups, and similarly, the possible MCI group performed significantly better than the probable MCI group. The frequency of APOE4 did not differ significantly among groups (p>.05). The probable MCI and possible MCI group had significantly higher rates of hypertension (58%, 59%) compared to the normal control group (46%). The probable MCI group had significantly higher rates of high cholesterol (66%) than the possible MCI group (18%). The probable MCI group had significantly more males, lower education, and higher GDS scores compared to NC groups (p<.05). DISCUSSION: This study demonstrated that the probable MCI group differed from normal controls on measures of memory, executive function, and language, and had higher rates of hypertension and high cholesterol. Although statistically significant differences among all three groups on measures other than complex verbal memory were not seen; closer examination of the neurocognitive test scores showed that the possible MCI group performances were qualitatively more similar to that of the probable MCI group rather than the NC group. This may support the notion that individuals with a SCC but without overt impairment on testing do share commonalities with those with clear MCI, indicating that SCC do carry clinical significance and warrant evaluation and monitoring over time in older individuals.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 Comparison of Video-Assisted Thoracoscopic (VATS) Lung Biopsy vs. Bronchopulmonary Alveolar Lavage (BAL) for Diagnosis of Fungal Disease in Pediatric Oncology Patients(2015-01-26) Compton, Jeffrey; Burkhalter, Lorrie; Cohn, Shannon; Murphy, Joseph T.BACKGROUND: Pulmonary fungal infection is a known complication of the treatment of pediatric malignancy. Accurate diagnosis has relied on culture of fungi from either pulmonary lavage fluid or open biopsy of lung parenchyma. Minimally invasive lung biopsy techniques have decreased the morbidity and mortality of diagnostic lung biopsy procedures, however little data exists comparing diagnostic yields (DY) of bronchopulmonary lavage (BAL) lung washings versus video-assisted thoracoscopic surgery (VATS) tissue biopsy. METHODS: With IRB approval, the Oncology Registry and Electronic Medical Records at our institution were queried for pediatric oncology patients (age<18yrs) who have had either BAL and/or VATS for assessment of possible pulmonary fungal infection as suggested by CT imaging during treatment for various malignancies from March 2005 to May 2014 for a retrospective analysis. RESULTS: 106 pediatric oncology patients were identified to have undergone 146 procedures (116 BAL; 30 VATS) resulting in overall yield of 39 pulmonary fungal infections (30 BAL; 9 VATS). Overall DY was 27%, (BAL 26%; VATS 30%). While 25 patients had multiple procedures; 14 patients had sequential evaluations within 4 weeks to assess for persistent infection: 7 had multiple BAL; 1 had multiple VATS; 8 had BAL and VATS. Of the 8 who had sequential BAL and VATS procedures; in 50% the results were consistent (3 cases BAL/VATS both negative; 1 case BAL/VATS both positive); and 50% were discordant (2 had positive BAL / negative VATS; 2 had negative BAL / positive VATS). The combined use of both procedures within 4 weeks resulted in a 63% DY when all positive findings are considered. CONCLUSION: BAL and VATS procedures individually resulted in comparably low diagnostic yields for detection of pulmonary fungal infection in pediatric oncology patients; however when these procedures are employed sequentially within 4 weeks of each other, the diagnostic yield increased substantially.Item Does a Positive Family History of Glaucoma Foretell Severity?(2014-02-04) Vu, Khiem; Markel, Nathan; Parikh, Kisan; Adams-Huet, Beverley; Li, Xilong; Kooner, KaranjitPURPOSE/RELEVANCE: There is a threefold increase in the risk of primary open-angle glaucoma (POAG) in individuals with positive family history. We wished to see if the family history also led to a more severe form of the disease. METHODS: In an IRB-approved retrospective chart study at a university-affiliated medical center, data was collected from 224 patients diagnosed with glaucoma. Positive family history was defined by first, second, or third degree relatives affected (FHx-pos). Patients with negative family history were referred to as controls. Patients with unknown family history were excluded. Age, gender, race, BMI, cup/disk ratio (C/D), visual field defects, intraocular pressure (IOP), central corneal thickness (CCT), and current glaucoma medications were recorded. FHx-pos and control groups were compared using Fisher's Exact and Wilcoxon Rank sum tests for categorical and continuous variables, respectively. RESULTS: Among patients with glaucoma, there were 82, 120, and 22 patients with positive, negative, and unknown family history, respectively. The FHx-pos group was 47.6% white, 39% black, and 13.4% Hispanic, while the control group was 40.8% white, 40.8% black, and 18.4% Hispanic; no clinically significant differences were noted. Both groups were similar in age (63.3±14.8 vs. 64.9±11.8 years, p=0.5) and CCT (539 vs. 540 μm, p=0.8). The FHx-pos group was predominantly female (70.7% vs. 45%, p<0.001), had elevated IOPs (16.9±4.0 vs. 15.7±4.2 mm Hg, p=0.040), and were prescribed more glaucoma medications (98.9 vs. 92.5%, p=0.05). The mean C/D for both groups was approximately 0.73 (p=0.86) with the FHx-pos group having slightly more optic cupping (29.6 vs. 26.1% of patients, defined as C/D > 0.9; p=0.6). DISCUSSION: The results suggest that glaucoma patients with affected relatives tend to be female. Sex-specific genetic factors or expression may contribute to disease progression, but a full mechanism has yet to be completely delineated. The FHx-pos group also had higher IOP, required more medications, and experienced slightly more optic nerve cupping, all of which indicate a more severe form of the disease. CONCLUSION: The results of this study corroborate the importance of taking a family history of glaucoma. This is especially important for females, for whom aggressive treatment may be necessary. The gender finding merits further study into the possible heritability of predisposing factors in the pathogenesis of POAG in female populations. REFERENCES: Fingert JH. Primary open-angle glaucoma genes. Eye. 2011; 25, 587-595Item Engraftment of Tumorgrafts Predicts for Development of Metastasis in Patients with Localized Renal Cell Carcinoma(2014-02-04) Thomas, Felix; Li, Xiaoyue; Pavia-Jimenez, Andrea; Toffessi, Vanina; Cohn, Shannon; Christie, Alana; Brugarolas, JamesPURPOSE: This retrospective study compares tumorgraft engraftment with development of metastatic renal cell carcinoma (RCC) in patients after the resection of localized tumor in order to determine the potential clinical applications of tumorgraft models. MATERIALS AND METHODS: We analyzed tumorgraft lines derived from primary tumor samples of 180 patients. Odds ratios and Kaplan-Meier analyses were used to determine the correlation between tumor engraftment and patient outcome. RESULTS: There were primary tumor samples from a total of 22 patients who had metastatic disease at the time of surgery. These tumors engrafted at a higher frequency than those of patients who did not have metastatic disease at the time of surgery (OR=3.39, p=0.0099). Of the 158 patients who had localized RCC at the time of surgery, patients whose tumors engrafted developed metastasis at a higher frequency (OR=3.53, p=0.01174) than those whose tumors did not engraft. Patients with engrafted tumors also had a marked decrease in progression-free survival and RCC-specific progression-free survival, but not overall survival. CONCLUSIONS: Engraftment of tumors in mice may be an independent predictor of patient outcome and thus has the potential to become a powerful clinical tool. It also may provide an experimental system to dissect determinants of metastases. Finally, selecting tissue from patients with metastatic RCC at the time of surgery can be used to increase the efficiency of engraftment in RCC tumorgraft models.Item Frequency of Vascular Assessment in Patients with Non-Healing Foot Wounds(2017-01-17) Bhattatiry, Mitu; Koshy, Thomas; Kumbhani, Dharam J.BACKGROUND: Lower extremity wounds can be a significant source of morbidity and mortality. Assessment of lower extremity perfusion is recommended for non-healing ulcers. Our study aims to evaluate management strategies for foot wounds at a large tertiary hospital. METHODS: The retrospective cohort included all patients seen in the Parkland ASC Foot Wound clinic from 2/1/2014 to 6/31/2014. Charts were reviewed to collect demographic characteristics, wound characteristics, type of vascular assessment and wound outcomes. PAD was defined as an ABI <0.9 and non-compressible disease (NCD) as ABI >1.4. Wounds were characterized as non-healing if there was no evidence of improvement after 3 months of follow up. Statistical analysis was then performed on patients with non-healing wounds and no previous history of peripheral vascular disease. RESULTS: The population of 438 patients was 70% male with a median age of 56 and median BMI of 30. The majority of patients were Hispanic (45%) with Caucasian and African-American each representing 25%. Patients had diabetes (87%), hypertension (82%), hyperlipidemia (59%), known CAD (19%), known PVD (36%), previous CVA (6%), CKD (25%), and tobacco use (51%). An ABI was performed in 42% of the cohort (either within 2 years or up to 3 months after the visit). After excluding patients with a known history of PVD, an ABI was performed in 27 patients (27%) with non-healing wounds. Those patients undergoing ABIs were older (56 vs 50, p=0.006), had lower BMI (30 vs 34, p=0.04) and higher prevalence of CKD (40% vs 15%, p=0.007). After adjusting for common risk factors both age and CKD were remained statistically significant (p=0.004 and p=0.001, respectively). Among the ABIs performed, 4 (15%) were found to have PAD, 13 (48%) were normal and 10 (37%) had non-compressible disease. Patients with CAD were also more likely to undergo peripheral angiography with intervention compared to patients with (50% vs 7%, p=0.02) and remained statistically significant after adjusting for traditional risk factors (p=0.001) DISCUSSION: Although strongly recommended in all patients, an ABI measurement was performed in <50% of patients with a lower extremity wound or ulcer. Although the foot wound population has a high rate of vascular risk factors, a vascular assessment was performed in the minority of patients. Patients who underwent vascular assessment and were found to have evidence of ischemia were more likely to undergo subsequent revascularization.Item Hippocampal Volume Changes in Patients with Asthma(2015-01-26) Carlson, Scott; Jeon-Slaughter, Haekyung; Kim, Julie; Khan, David A.; King, Kevin; Lucarelli, Richard T.; McColl, Roderick; Peshock, Ronald M.; Brown, E. SherwoodBACKGROUND: Prior research suggests a possible association between asthma and decreased hippocampal volumes. OBJECTIVE: This study examines the association between asthma and hippocampal volume. METHODS: We conducted an analysis of participants in the Dallas Heart Study (DHS). The DHS collected an epidemiological sample of Dallas County residents to explore risk factors for heart disease. Included were 1,287 adults with complete data on study variables and without history of stroke, emphysema, or more than 5 drinks per day. Study variables included gender, age, race, and education as demographic characteristics, cognitive ability measured by the Montreal Cognitive Assessment (MoCA), and brain segment volumes measured by FreeSurfer. Study outcome variables were total, right, and left hippocampal volumes measured using FreeSurfer. General Linear Models (GLM) were conducted to examine the association of asthma diagnosis with hippocampal volumes after controlling for demographic characteristics, total MoCA score, and brain segment volume. Analysis of Variance (ANOVA) was used to examine the effect of gender on hippocampal volumes. RESULTS: The prevalence of lifetime asthma diagnosis among our study samples was 10.8% with 9.6% in males and 11.7% in females. Our study participants with a self-reported asthma diagnosis had significantly smaller estimated total, right, and left hippocampal volumes (95% CI 0.13%-2.9%; p = 0.03) than those without an asthma diagnosis. Asthma was significantly associated with total, right, and left hippocampal volumes in males, while not significantly associated in females after controlling for demographic characteristics, total MoCA score, and brain segment volume. Total, right, and left hippocampal volumes of males with asthma diagnoses, respectively, were 3.0% smaller (95% CI 0.77%-5.2%; p = 0.008), 2.9% smaller (95% CI 0.58%-5.2%; p = 0.014), and 3.1% smaller (95% CI 0.70%-5.6%; p =0.012) than males without asthma. CONCLUSION: Hippocampal volume in a large and diverse sample of adults was significantly smaller in people with asthma as compared to those without asthma. This difference in volume was limited to males. These findings suggest that asthma may be associated with structural brain differences as well as respiratory effects. Because the hippocampus is a brain region involved in memory formation these findings may have implications for treatment adherence.Item Housing Quality as a Potential Risk Factor for Locally Acquired Malaria Infection in Swaziland(2016-01-19) Allen, Regan; Mkhonta, Nomcebo; Pindolia, Deepa; Ntshalintshali, Nyasatu; Novotny, Joseph; Dufour, Mi-suk Kang; Gosling, Roly; LeMenach, Amaud; Cohen, Justin; Midekisa, Alemayehu; Greenhouse, Bryan; Kunene, Simon; Hsiang, Michelle S.Poor housing quality may confer greater risk of malaria infection by means of increased mosquito exposure; however, evidence in low transmission settings is lacking. In this study, surveillance data was used to examine the relationship between housing quality and locally-acquired infection in the low transmission setting of Swaziland. A retrospective analysis was conducted utilizing data collected from passive and active surveillance. Subjects included malaria index cases diagnosed at health facilities as well as their household and community members screened in reactive case detection from August 2012 to March 2015. Subjects reporting travel in the past 8 weeks and/or residing beyond 500m from the index case were excluded. Using bivariate and multivariable logistic regression, adjusted for household-level clustering, the relationships between infection (testing positive by Rapid Diagnostic Test (RDT), microscopy, or loop-mediated isothermal amplification (LAMP)) and housing quality, as well as other epidemiological factors were analyzed. Housing quality was assessed by individual components (wall, roof and window type) as well as a composite housing quality index. Cases included 280 index cases and 131 RDT or LAMP positive individuals identified in active surveillance. These cases were compared to 8668 non-infected household members and neighbors of index cases. In the multivariable model, poor quality external wall was associated with higher infection odds (OR 4.59 95%CI 1.93-10.95). There was a trend in the association with both poor quality roof and windows. Using the composite housing index, compared to good quality housing, moderate quality housing was significantly associated with higher infection odds (OR 1.67 95%CI 1.09-2.57). There was a notable, yet non-significant trend in the association with poor quality housing (OR 2.05 95%CI 0.99-4.26). In the composite housing model, coverage of vector control interventions was independently associated with protection. Compared to no vector control (neither sleeping under an insecticide treated bed net (ITN) nor a sprayed structure), coverage with either an ITN or spraying conferred protection (OR 0.61 95%CI 0.40-0.94), as did coverage with both interventions (OR 0.10 95%CI 0.01-0.73). The findings of this study suggest that housing quality, especially wall material, is an important determinant of locally-acquired infection in Swaziland, suggesting improved housing as a potential control and elimination strategy in low transmission settings.Item How Do Open Distal Tibia Fractures Differ from Open Tibial Shaft Fractures?(2018-01-23) Nguyen, Ivy; Ho, Christine AnnPURPOSE: The purpose of this study was to compare a cohort of open distal tibia fractures to open tibial shaft fractures in regards to injury severity, method of fixation, and outcomes. METHODS: This is a retrospective review of 49 open distal tibia fractures (group D) with a mean age of 8.7years and 56 open tibia shaft fractures (group S) with a mean age of 8.6years, treated from 2007-May2017 at a single level 1 pediatric trauma center. Mann Whitney test was used to compare means between groups. RESULTS: Extremely high energy trauma (ATV, GSW, vehicular collision, lawnmower, crush, fall >8 feet) was the mechanism of injury in 90% (44/49) in group D and 77% (43/56) in group S (p=0.119). Mean AIS lower extremity scores were significantly higher in group S compared to group D (2.74 vs 2.55, p=0.043), as were mean Injury Severity Scores (13.10 vs 9.36, p=0.053). There were more Gustilo type II fractures in group S (42% vs. 35%), and more Gustilo type III fractures in group D (51% vs 39%) which trended towards significance (p=0.0622). 88% (43/49) of open distal tibia fractures had ipsilateral fibular involvement, compared to 71% (40/56) of open tibial shaft fractures (p=0.054). Tibial fixation methods were statistically different between the 2 groups (Table 1, p=0.0377), but incidence of fibular fixation was not statistically different (group D-12% vs group S-5%, p=0.4348). While surgical time and fluoroscopy times were not significantly different between the two groups, group D had longer mean length of hospitalization (8.44vs6.36 days, p=0.006), mean duration of immobilization (135vs100 days, p=0.033), and longer mean time to full weight bearing (77vs40 days, p=0.006). Rate of hardware removal (group D-49%, group S-52%) and radiographic angulation at final follow-up were not statistically significantly different between the two groups (p>0.05). Mean time to union was prolonged for both groups (178 days group D-178 days, group S-139 days, p=0.231). CONCLUSIONS: Open distal tibia fractures are significant for extremely high energy of injury. Alternate methods of fixation for open distal tibia fractures such as external fixation, K wires, and ORIF are more likely to be utilized than flexible intramedullary nailing. Open distal tibia fractures have longer hospital stays, immobilization, and time to full weightbearing but radiographic outcomes and time to union are comparable. SIGNIFICANCE: This study increases awareness of the difference in injury severity, fixation methods, and clinical course between open distal tibia and open tibial shaft fractures.Item How Learning Strategies and Academic Parameters Predict Medical Student Success(2024-01-30) O'Connell, Michael; Badia, Rohit; Tellez, Juan; Cook, Grayden; Sachs, ArleneBACKGROUND: Student scores on the Learning and Study Strategies Inventory (LASSI), an assessment of academic skills, have been shown in previous studies to be significantly different between U.S. medical students based on their scores in various examinations during the preclerkship curriculum. This study aimed to evaluate LASSI and other early academic performance markers for predicting the likelihood of shelf exam underperformance in third-year medical students. METHODS: A retrospective analysis of student-specific demographic information and medical school exam performance from 220 medical students from the University of Texas Southwestern was performed. Students were then categorized based on underperformance (score in <25th percentile) on each NBME shelf exam and statistical analysis was performed to identify predictors of shelf underperformance. RESULTS: For predicting Surgery shelf underperformance, pre-clerkship final exam average (PCA), STEP 1, and LASSI Time Management (TMT) were statistically significant in univariate analysis. Internal Medicine: PCA, STEP 1, LASSI Attitude (ATT), Test Strategies (TST), and TMT. Pediatrics: PCA and STEP 1 quartile. Obstetrics-Gynecology: PCA, STEP 1, and LASSI Anxiety (ANX), with ANX an independent predictor on multivariate analysis. Neurology: PCA, STEP 1, LASSI ANX, Information Processing (INP), TST, and average LASSI, with PCA, LASSI Concentration (CON), TMT, and ANX independent predictors on multivariate analysis. Family Medicine: PCA, STEP 1, LASSI ANX, TST, and Using Academic Resources (UAR), with PCA an independent predictor on multivariate analysis. Psychiatry: only STEP 1 was significant. CONCLUSION: In contrast to previous studies, no single LASSI scale was significantly associated with underperformance on all 7 NBME shelf exams. Univariate analysis identified several LASSI scales that correlated with NBME underperformance, but the drastic inter-clerkship heterogeneity makes use of these scales in early academic intervention impractical. Conversely, PCA was found to be strongly associated with shelf exam underperformance.Item Investigating Resource Utilization in Elective Spine Patients with Affective Disorders: A Retrospective Analysis of a Cohort of 1199 Elective Spine Patients(2021-05-01T05:00:00.000Z) Christian, Zachary Kemon; Bagley, Carlos; Aoun, Salah; Dodds, JeffreyBACKGROUND: In elective spine surgery patients, affective disorders (ADs) are associated with increased preoperative opioid use to control pain, longer length of hospital stays, and increased postoperative readmission rates. When assessing healthcare resource utilization, how ADs influence perioperative electronic patient portal (EPP) communication with care providers has not been explored. It is also unclear how ADs influence in-patient and postoperative opioid consumption. OBJECTIVE: To investigate the resource utilization of patients with ADs in our population by analyzing the relationship between AD and both perioperative EPP communication, opioid use, and surgical outcomes. METHODS: The records of 1199 consecutive adult patients who underwent elective spinal surgery between January 2010 and August 2017 at a single institution were retrospectively reviewed for analysis. Primary outcomes included the number of perioperative EPP messages sent, perioperative narcotic use, rates of peri-operative complications, hospital length of stays, Emergency Department visits within 6 weeks, and readmissions within 30 after surgery. In the subanalysis, patients with patient-reported outcome measures for pain, anxiety, and depression within 30 days prior to surgery were used to assess whether preoperative narcotic use correlated with reported preoperative pain levels. RESULTS: Patients with an AD were more likely to take narcotics before surgery and to have active EPP accounts compared to controls. They were also more likely to send postoperative messages, and tended to send more messages. The AD group had higher rates of postoperative complications, ED visits, and readmissions postoperatively. The AD group also requirement more opioid in the inpatient setting and were more likely to refill prescriptions for opioid medications 3- and 12-months after surgery. In the subanalysis, the average rating of pain intensity was notably higher in the AD group; however, there was no statistically significant difference in rates of narcotic use between low- and high-pain cohorts. This was not the case for the control group. CONCLUSION: AD patients have increased EPP communication, perioperative opioid use, and postoperative complications. Addressing these concerns early and advocating for resources for this population may prevent more serious morbidity, reduce costs, address the opioid crisis, and improve patient care.Item Magnetic Resonance Prediction of Placenta Accreta Spectrum in Pregnancy: Validation of Radiomic Features(2024-01-30) Martinez, Danielle; Do, Quyen N.; Xi, Yin; Twickler, Diane M.INTRODUCTION: Placenta accreta spectrum (PAS) or placental invasion into the uterine myometrium in women with previous cesarean delivery has become increasingly prevalent, affecting 1 in 500 pregnancies. Depending on the severity of placental invasion, patient management may involve a total hysterectomy at the time of cesarean delivery. We previously identified radiomic features from PAS-suspected MR images that were highly predictive of patient surgical outcome. After developing the algorithm, we needed to establish a validation cohort to test the radiomic model, a necessary step for reproducibility and generalization. PURPOSE: To validate the radiomic features previously found to correlate with the need for cesarean hysterectomy in patients with a high-risk for placenta accreta spectrum (PAS). METHOD: We performed an IRB approved retrospective review of 53 pregnancies from 2019 to 2023 of patients with clinically suspected PAS who had MR studies. Volumetric placental, uterus, and internal os regions of interest (ROIs) were manually segmented under the supervision of a board- certified radiologist with 30 years of OBGYN MR experience. Radiomic features were extracted following the image biomarker standardization initiative guideline using the pyRadiomics package. Placental Location within the Uterus (PLU) was described by a customized radiomic feature, determined as the angle between 2 vectors, with the tail being the epicenter of the uterus to the internal os and the epicenter of the placenta. RESULT: From our study, 25 patients (32.8±5.5 y/o) required cesarean hysterectomy with pathologic confirmation of PAS while 28 (33.0±5.6 y/o) underwent regular cesarean delivery. Estimated blood loss and gestational age at delivery were significantly different between groups (p<0.05). PLU and several other radiomic features were significantly different between those who required hysterectomy after cesarean delivery compared to those who did not in this new validation cohort of patients (p<0.05). DISCUSSION: We demonstrated that Placental Location within the Uterus (PLU) and other radiomic variables were predictive in detecting patients that needed hysterectomy in a validation cohort. This is an important step toward the development of a reliable, reproducible, and generalizable radiomic model for the prediction of PAS severe enough to result in cesarean hysterectomy.Item Malignant Childhood Ovarian Cancer: A Ten-Year Retrospective Review(2024-01-30) Laboret, Bretton; Bonnyman, Claire; Murphy, Joseph T.BACKGROUND: Although pediatric ovarian cancer is rare (2.1-2.6/ 100,000 females per year), 10-30% of masses are malignant. Our primary aim was to confirm the incidence and type of ovarian malignant and borderline neoplasms over a ten-year period, and to describe their presentation and clinical characteristics. Furthermore, through analysis of pre-operative workups, we sought to elucidate better predictive indicators of malignancy to help guide future treatment. METHODS: Retrospective analysis of patients (<19 years old) who underwent surgery for borderline or malignant ovarian tumors from 01/01/2009 to 12/31/2018 was performed. Patient records were analyzed for age, presentation, serum marker levels, imaging findings, treatment (surgical plan and therapy), and patient outcomes. RESULTS: A total of 42 malignant and 7 borderline ovarian tumors were included in this study. Germ cell tumors were the most common malignancy (64%) followed by stromal tumors (31%), while one epithelial mucinous tumor and one small cell tumor were found (2% each). Of the borderline tumors, serous (71 %) were more common than mucinous tumors (29%). Average patient age was 13 ± 3.9 years, and the primary presenting symptoms were pain (45%) or abdominal distension (43%). Significant elevations in alpha fetoprotein, beta human chorionic gonadotropin, lactate dehydrogenase and cancer antigen-125 serum tumor markers were noted in malignancies. Eighty-eight percent of surgeries were performed as laparotomies, and the most common operation was salpingo-oopherectomy (67%). The average tumor size was 14.6 cm. ±6.6 cm. and the majority were characterized as heterogeneous (80%). All tumors were resected, and 21 (50%) malignant tumors received postoperative chemotherapy, while no borderline cases received therapy. Average postoperative follow-up time was 38.6 months, and forty-five (92%) patients were alive at the time of data collection. CONCLUSIONS: Germ cell tumors were confirmed as the most common pediatric ovarian malignancy, followed by stromal tumors. Very few epithelial tumors were noted, as compared to prior studies. Borderline neoplasms were uncommon and had favorable outcomes. In treating pediatric ovarian malignancy, we aim to maximize patient survival while preserving fertility. We recommend a standardized preoperative workup consisting of multi-modal imaging studies and a complete tumor marker panel for all patients presenting with suspicion for an ovarian tumor.Item Parent-Reported Anxiety in Children with Secondary Generalized Seizures(2010-11-02) Benitez, Oscar J.; Stavinoha, Peter L.This study examined the role of seizure type in determining different levels of parent-reported anxiety, when taking demographic, medically-related, and medication-related variables into account. One-hundred nineteen children with epilepsy aged 4 to 17 years old underwent a retrospective chart review. Demographic, medically-related, and medication-related variables, such as age, gender, ethnicity, handedness, median household income, age of onset, seizure etiology, lateralization, EEG findings, MRI findings, number of antiepileptic drugs prescribed, side-effect profile of medication, and therapy regimen, were reviewed as well as parent-reported anxiety and depression on the Behavior Assessment System for Children, Second Edition (BASC-2). Findings of the current study replicated previous research suggesting that children with epilepsy have higher average levels of depression and anxiety than the normative population. Children with epilepsy had similar levels of depression, regardless of seizure type. Children with partial seizures with secondary generalization had higher levels of anxiety symptoms compared to children with generalized seizures, but similar levels to those with partial seizures. The current study’s findings could have occurred due to the possible cueing components associated with having partial seizures with secondary generalization. The findings suggest a negative impact that behavioral symptoms of depression and anxiety may have on seizure-related care. The current study expanded upon previous research by using a parent-report measure in which both depression and anxiety scales were normed with the same sample of children. Furthermore, the current study focused on children with secondary generalized seizures as a unique subtype and addressed anxiety specifically, which has been less researched than depression.Item Radiographic Challenges and Considerations with Cancer Immunotherapy(2020-05-01T05:00:00.000Z) Popat, Vinita; Gerber, David E.; Ariizumi, Kiyoshi; Minna, John D.; Khan, Saad A.BACKGROUND: With immune checkpoint inhibitor therapy, we observe new and challenging radiographic patterns such as hyperprogression and pseudoprogression. This begs the question - are there radiographic parameters that can predict response to immune checkpoint inhibitors? Historically, tumor burden has been considered an impediment to efficacy of immunotherapeutic agents, such as vaccines and allogeneic stem cell transplant. However, the association between tumor burden and efficacy of immune checkpoint inhibitors is unknown. We sought to determine the association between radiographic tumor burden parameters and efficacy of immune checkpoint inhibitors in advanced lung cancer. MATERIALS AND METHODS: We performed a retrospective analysis of patients with advanced lung cancer treated with immune checkpoint inhibitor monotherapy. Demographic, disease, and treatment data were collected. Serial tumor dimensions were recorded according to Response Evaluation Criteria in Solid Tumors 1.1. Associations between radiographic tumor burden (baseline sum of longest diameters [BSLD], longest single diameter) and clinical outcomes (radiographic response, progression-free survival, and overall survival) were determined using log-rank tests, cox proportional-hazard regression, and logistic regression. RESULTS: Among 105 patients, median baseline sum of longest diameters was 6.4 cm; median longest single diameter was 3.6 cm. BSLD was not associated with radiographic response, progression-free survival, or overall survival. In univariate and multivariate analyses, no significant associations were observed for the other radiographic parameters and outcomes when considered as categorical or continuous variables. CONCLUSIONS: Although tumor burden has been considered a mediator of efficacy of earlier immunotherapies, in advanced lung cancer it does not appear to impact outcomes from immune checkpoint inhibitors.Item A Ready Reference for Estimating Dose to Pelvic Node Metastases from High Dose Rate Brachytherapy (HDR-BT) in Cervical Cancer(2014-02-04) McKeever, Matthew R.; Hwang, Lindsay; Barclay, Jennifer; Dubas, Jeffrey; Xi, Yin; Bailey, April; Albuquerque, KevinINTRODUCTION: Metastasis to lymph nodes is one of the best predictive indicators of recurrence and death for cervical cancer patients. A dose of greater than 55 Gy is recommended for nodes 2 cm or less for durable control. It is expected that nodes closer to the radiation source will receive a higher dose. In this study we explored the relationship between lymph node location and the Point A dose as a means of assisting the radiation oncologist to determine the required boost dose. METHODS: This retrospective study from 2009 through 2013 included 29 cervical cancer patients receiving high dose rate brachytherapy and had a total of 60 metastases to pelvic lymph nodes. The lymph nodes were mapped and contoured in the treatment planning system.. The external beam and brachytherapy doses and percentage of brachytherapy point A dose received by each lymph node were calculated. RESULTS: The median doses from brachytherapy and external beam radiation to the lymph nodes were 5.5 Gy (range, 1.4-12.4 Gy) and 49.6 Gy (range, 42.5-62.9 Gy), respectively. The median total dose for all lymph nodes was 56.5 Gy (range, 46.5-66.3 Gy). The dose from brachytherapy accounted for 9.97% of the total dose to the lymph node. The location of the lymph node affected the dose received. The common iliac nodes, which were furthest from the uterus, received 3.18 Gy (11.09 % of point A); the internal iliac nodes received 4.29 Gy (16.43% of point A); and the external iliac nodes, which were closest to the uterus, received 6.05 Gy (21.75% of point A). As expected, nodes closer to the uterus received higher doses of brachytherapy radiation. DISCUSSION AND CONCLUSION: The common iliac nodes received the smallest fraction of the brachytherapy dose and thus need the greatest external boost dose. Also the internal iliac lymph nodes above the sacroiliac joint, the external iliac lymph nodes anterior to the acetabular line, and the external iliac nodes lateral to the external iliac artery received a smaller amount of the brachytherapy dose than the rest of the nodes in their group. This will require them to have a higher boost dose from external beam compared to other nodes in their group. The results of this study provide radiation oncologists a reference for determining which nodes require an external beam boost dose and the optimal boost dose for those nodes. Improved optimization of the boost dose should lead to better local control and outcomes for patients.Item Reflections on a Single Institution Cochlear Implant Experience(2020-05-01T05:00:00.000Z) Schauwecker, Natalie Marie-Rose; Hunter, Jacob B.; Kutz, J. Walter; Isaacson, BrandonOBJECTIVE: To utilize cochlear implant (CI) outcomes to further explore health disparities, hearing preservation (HP) surgery, and standardization of pre- and post-operative CI assessment, with the goal of predicting and improving CI outcomes, including quality of life. STUDY DESIGN: Retrospective chart review of adult patients who underwent CI evaluation and surgery at a single institution between 2009 and 2018. MAIN OUTCOME MEASURES: Improvement in open sentence testing postoperatively, according to patient marital status, race, and gender, as well as HP status. RESULTS: Post-operative performance: Of the 402 total patients who underwent CI during the study period, 372 were followed and programmed at the institution. A total of 87% of these patients achieved "good performance" with their CI, based upon an improvement in post-operative open sentence testing ≥10%. Patient demographics, including gender, age, marital status, and race did not significantly affect whether a patient achieved higher post-operative performance levels. Unmarried patients saw poorer outcomes, but this did not reach significance (37.5% vs 24.3%, p = 0.2123). HEARING PRESERVATION: HP surgery evolved during the study period, with modern "soft surgery" technique defined by perioperative steroids, round window cochleostomy, and atraumatic CI insertion. A slight majority of HP surgical patients maintained low frequency hearing postoperatively (54.2%). However, documentation of preserved hearing was limited, with only 53.7% of patients with recorded unaided audiograms. Analyzing speech perception outcomes, HP candidates, and patients who underwent "soft surgery," did not demonstrate significantly larger improvements with their post-operative open sentence testing when compared to patients who underwent standard CI, and were concurrently not HP candidates, during the study period (overall improvement: 41% vs 53% respectively, p = 0.10). Additionally, non-white hearing preservation candidates were less likely to retain low frequency hearing post-operatively, but this did not reach significance in the study population (22.2% vs 8.5%, p=0.0992). However, HP surgery, and overall CI surgery outcomes assessment was limited by lack of standardized documentation. CONCLUSIONS: Unmarried patients and non-white patients continue to warrant special attention post-operatively to ensure equability in CI. HP surgery has evolved over the past decade. All, patients, should also have their quality of life evaluated, with standard assessment through open sentence testing failing to demonstrate the added benefit of HP, and likely the overall benefit of any CI. There continues to be a need for standardization in CI evaluation, documentation, and follow-up to allow for larger outcomes based research. IRB: STU 032018-085 PROFESSIONAL PRACTICE GAP AND EDUCATIONAL NEED: The field of CI is in need of large outcome based studies to better predict which patient factors, including demographics and HP status, may predict CI success. DESIRED RESULT: Systematic review of a decade of cochlear implantation outcomes in order to identify areas in which improvement will result in increased ability to assess outcomes, and augmented cochlear implant success leading to improved CI patient quality of life.Item Retrospective Evaluation of Patient Outcomes with Ketorolac Shoulder Injections(2016-01-19) Kurth, Alexander; Kukowski, Nathan; Khazzam, Michael; Romero, JoseBACKGROUND: Corticosteroid injections are a commonly used treatment modality in patients with various shoulder pathologies who have failed to respond to other conservative management options such as systemic NSAID medications and physical therapy. However, clinical trials have demonstrated that corticosteroids demonstrate limitations such as spontaneous tendon rupture following local injection, tendon and ligament atrophy, fragmentation of collagen bundles, decreased mechanical properties, and delayed healing. One could extrapolate that injection of an NSAID medication, such as Ketorolac, may provide similar pain reduction with fewer injurious secondary effects. The objective of this study is to retrospectively examine outcomes in patients after glenohumeral or subacromial injections of Ketorolac. METHODS: This longitudinal, case-series based, retrospective study examines the outcomes in patients who received glenohumeral or subacromial injections of Ketorolac from 1/1/2014 through 3/30/2015 at an outpatient orthopaedic surgery clinic. Shoulder pathologies considered include adhesive capsulitis, atraumatic rotator cuff tears, arthritis, and tendinitis. Dependent variables that were monitored and analyzed include pre and post-injection shoulder specific pain (Visual Analogue Scale) and frequency and severity of adverse events. Other factors considered include co-morbidities, duration of physical therapy pre and post-injection, and other injections received. Established values regarding minimally clinical important differences and mean changes in these variables were compared to published standards. RESULTS: At first follow up, patients in both treatment arms reported decreased pain and increased tolerance of physical therapy following the injection of Ketorolac. In patients receiving glenohumeral injections, 71.4% described a reduction in pain compared to the visit at which they received the Ketorolac injection. On average, these patients reported their pain to be 4.29/10 (VAS) immediately prior to injection and 3.83 at their follow up appointment. For those receiving subacromial space injections, 83.3% noted reduced pain, with pain decreasing on average from 6.77 to 2.17. Importantly, no serious side effects were reported, despite many patients presenting with significant comorbidities. CONCLUSIONS: A Ketorolac injection into the glenohumeral joint yielded safe and efficacious results, similar to those seen with injection into the subacromial space. When compared to studies involving the use of corticosteroids for these same shoulder pathologies, Ketorolac appears to have at least equivalent efficacy, without exposing patients to the harmful side effects of corticosteroids.Item Retrospective Review of Postpartum Hemorrhage Incidence, Risk Factors, and Maternal Morbidity(2020-05-01T05:00:00.000Z) Chu, Tina Meikei; Morgan, Jamie; Horsager-Boehrer, Robyn; Reed, W. GaryBACKGROUND: Postpartum hemorrhage (PPH) remains one of the most common causes of maternal mortality worldwide. In the US, PPH accounts for 2-3% of yearly maternal deaths and is also associated with serious morbidity including the need for blood transfusion, ICU admission, and hysterectomy. In the recent years, PPH risk assessment tools have been widely implemented in an attempt to identify woman at risk for hemorrhage and preemptively mobilize resources. The most commonly used trinary assessment tool from the California Maternal Quality Care Collaborative (CMQCC) assigns women to a low, medium or high-risk category; however, its utility has only been validated in relation to need for blood transfusion, which can be subjective. LOCAL PROBLEM: The American College of Obstetricians and Gynecologists (ACOG) recently released maternal safety bundles to reduce obstetric complications and rates of maternal morbidity and mortality. At UT Southwestern's Clements University Hospital (CUH), obstetricians and gynecologists recognized that a three-category approach to PPH risk stratification may hinder efficient PPH diagnosis and management. The Maternal-Fetal Medicine team developed a quality improvement project to identify hemorrhage risk factors and implement a PPH risk score in the labor and delivery unit. METHODS: Retrospective cohort review of all deliveries at CUH between January 1, 2018 and December 31, 2018 was conducted. Data on all antepartum and intrapartum hemorrhage risk factors using the trinary risk score developed by the CMQCC was analyzed and used to assign a risk category low, medium or high. A validated formula, utilizing maternal height, weight, ante- and post-partum hematocrits, was used to calculate each patient's blood loss. Calculated blood loss, need for intervention (uterotonic administration) and maternal morbidities (need for blood transfusion, intensive care unit (ICU) admission, and/or hysterectomy) were correlated to PPH risk categorization as well as to a developed numeric risk score. PPH was defined as blood loss exceeding 1,000 mL. Data was analyzed using standard methods of rates and proportions, Chi-square, and Wilcoxon rank-sum tests with p<0.05 considered significant. Quality improvement tools, including PDSA cycles, process maps, a SIPOC diagram, and FMEA were developed. INTERVENTIONS: A modified PPH risk assessment score that assigned a point value of 1 or 2 to hemorrhage risk factors based on their perceived potential to lead to PPH was developed. RESULTS: Of the 1855 deliveries, the median calculated blood loss was 879 mL. The overall PPH rate was 25.9%. The rates according to PPH risk groups were 19.5%, 36.6%, and 27.9%, respectively. The rate of PPH was significantly lower in the low risk group (p<0.001) but did not differ between the medium and high-risk groups (p= 0.11). The median blood loss was lowest in the low risk group (p<0.001). The transfusion rate correlated with risk stratification, with rates of 0.9%, 2.7% and 7% in the low, medium and high-risk groups, respectively. Overall, 178 women (9.5%) were treated with uterotonics, 38 (2.0%) required transfusion, 7 (0.4%) needed ICU admission and 12 (0.6%) underwent hysterectomy. Relative to low and medium-risk stratifications, women in the high-risk group were 2.3 times more likely to require uterotonic administration. Women in the low-risk group were 83% less likely to experience transfusion, ICU admission or hysterectomy compared to medium and high-risk women. Conversely, women in the high-risk group had a 4.1 fold increase in these same morbidities. CONCLUSION: Relative to the low and medium-risk stratifications, women classified as high risk for hemorrhage are indeed more likely to require uterotonic administration and also suffer disproportionately higher maternal morbidity. The trinary risk stratification tool commonly used to predict PPH distinguishes women at lower risk for hemorrhage compared to the general population. However, determining which women are most likely to hemorrhage at delivery evades prediction using current risk assessment tools. Though hypothesized that a numeric scoring system would better predict PPH and morbidity than the currently used trinary risk assessment, this was not substantiated by our data. More work needs to be conducted to understand which of the identified risk factors is most highly associated with hemorrhage, particularly in the low and medium risk groups, since women in these groups make up the majority of the obstetric population.