UT Southwestern Medical School

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Welcome to the UT Southwestern Medical School’s electronic theses and dissertations (ETD) collection.

Most UT Southwestern ETDs are subject to a default embargo period of two (2) years from the date of degree conferral. These embargoed ETDs are unavailable until the embargo expires.

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Print theses and dissertations from 1943 to 2004 are located in the Library's Special Collections and Archives (Room E3.314) and are available by appointment. (Note: Former students may request a digitized copy of their work by email, but other users may submit an Interlibrary Loan request.) For more information, contact archives@utsouthwestern.edu.

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The 18-Month Curriculum: The Impact of Mixed Learning Clerkships
(2022-05) Kwon, Adelaide Jiwon; Sendelbach, Dorothy; Faulkner, Christopher; Tessnow, Alex
BACKGROUND: UT Southwestern implemented a new, 18-month, shortened pre-clerkship curriculum in the Fall of 2015 in order to increase the clerkship phase from 1 year to 18 months, beginning mid-second year. In keeping with this new curriculum schedule, it was necessary to combine MS2 and MS3 students on clerkships from January to June; during that time, both MS2 and MS3 students are on the same clerkship simultaneously, creating opportunities for informal near-peer learning. Each clerkship handles this mixing differently: some create mixed-year teams, others group students together with their peers, while still others do not create teams at all. OBJECTIVE: We are interested in determining the impact of mixing students on team dynamics, narrative assessments, and grades. HYPOTHESIS: Upperclassmen and underclassmen participating on the same clerkships in a mixed learning environment will report predominantly positive experiences but will have significant differences in their grades and narrative assessments compared to each other. METHODS: A tri-pronged approach was taken, looking at qualitative student perspectives, qualitative attending perspectives, and quantitative scores on de-identified student evaluations. In the first arm of the study, students in the classes of 2020 and 2021 were sent a voluntary survey seeking comments regarding their experiences on mixed clerkships and to indicate their interest in participating in a follow-up 30-minute focus group interview. Four purposeful focus groups of 4-5 students, two groups from each class, were interviewed to learn more about perceived advantages and disadvantages of mixed clerkships. Interviews were audio-recorded, transcribed, and coded for themes. Transcripts were validated by the interviewees and de-identified prior to analysis. In the second and third arms of the study, student evaluations from 2019 in the Internal Medicine, Pediatrics, and Psychiatry clerkships were gathered and de-identified. From these, 120 narrative assessments were randomly selected for qualitative analysis. Final grades and four scored skills were selected for quantitative analysis. Finally, de-identified quantitative data from 2015-2016, prior to the implementation of the 18-month curriculum, were analyzed for additional insights. RESULTS: In the first arm of the study, interviewees reported overall positive experiences with mixed clerkships. Common perceived advantages as an MS2 paired with MS3s included being able to ask "dumb" questions without being judged; being taught "practical" skills such as how to use the electronic medical record (EMR) and how to write a note; having fears allayed through candid discussions; and having a sense of camaraderie. Common advantages as an MS3 paired with MS2s included satisfaction in teaching MS2s and being motivated by MS2 enthusiasm. Perceived disadvantages were less commonly mentioned but still present, and mostly centered around fears of being compared by evaluators. In the second and third arms of the study, the mixed clerkships of Pediatrics and Psychiatry tended to show more significant differences in MS2 and MS3 evaluations than the non-mixed clerkship of Internal Medicine. However, this was highly nuanced, and there was some, but not consistent, division between differences observed in "learned" skills such as history-taking or note-writing and "inherent" skills such as professionalism or confidence. Comparison with students on the old curriculum also revealed significant differences with different MS2 and MS3 cohorts suggesting both positive and negative effects of the mixed learning environment on student evaluations. CONCLUSION: Overall, students reported more positive experiences and perceived advantages on mixed clerkships than negative experiences and disadvantages. However, attendings reported a higher proportion of significant differences between less and more experienced students on mixed clerkships. Despite this, the impact of cross-class comparison versus other factors, such as natural student improvement, contributing to these differences is unclear, and therefore mixed clerkships resulting from the 18-month curriculum have had a generally positive impact despite some negative effects. Further research, including research into other assessments of educational outcomes such as shelf exam scores as well as research into cross-clerkship comparisons, is needed to provide a fuller picture of the impact of these mixed clerkships.
3 Tesla Magnetic Resonance Imaging of Hippocampal Asymmetry: Results from the Dallas Heart Study
(2013-06-01) Lucarelli, Richard T.; Peshock, Ronald M.
BACKGROUND: Asymmetry of the hippocampus is regarded as an important clinical finding but limited data on hippocampal asymmetry is available for the general population. Here we present hippocampal asymmetry data from the Dallas Heart Study determined by automated methods and its relationship to age, sex, and ethnicity. METHODS: 3D-MPRAGE MRI were obtained in 2082 DHS-2 participants. The MR images were analyzed using two standard automated brain segmentation programs, FSL-FIRST and Freesurfer. Individuals with imaging error, self-reported stroke, or major structural abnormalities were excluded. Statistical analyses were performed to determine significance of the findings across age, sex, and ethnicity. RESULTS: At the 90th percentile FSL-FIRST demonstrated hippocampal asymmetry of 9.8% (95% CI 9.3 to 10.5%). The 90th percentile of hippocampal asymmetry measured by the difference between hippocampii over the larger hippocampus was 17.9% (95% CI 17.0 to 19.1%). Hippocampal asymmetry increases with age (P=0.0216) and men have greater asymmetry than women as shown by FSL-FIRST (P=0.0036), but ethnicity is not significantly correlated with asymmetry. To confirm these findings Freesurfer was used. Freesurfer showed asymmetry of 4.4% (95% CI 4.3 to 4.7%) normalized to total volume, and 8.5% (95% CI 8.3 to 9.0%) when normalized by difference/larger hippocampus. Freesurfer also showed that hippocampal asymmetry increases with age (P=0.0024), and that men had greater asymmetry than women (P=0.03). CONCLUSION: There is a significant degree of hippocampal asymmetry in the population. The data provided will aid in the research, diagnosis, and treatment of temporal lobe epilepsy and other neurological disease.
Accuracy in Diagnosing Pediatric Appendicitis: Discordance in Diagnosis and Masqueraders
(2016-04-04) Farzal, Zehra; Fischer, Anne C.; Piper, Hannah; Schindel, David
BACKGROUND: The classification of perforated versus nonperforated appendicitis remains poorly defined despite being clinically significant and requiring dramatically different therapeutic approaches. We hypothesized that there is substantial variability in the determination of perforated and nonperforated appendicitis across specialties due to the lack of standardized criteria. To identify and quantify the degree of variability in the diagnosis of acute versus perforated appendicitis, a comparative analysis of radiologic results, operative findings, and pathologic review was undertaken to identify the degree of discordance across specialties as the primary objective. Given the new suggested paradigm of non-operative management of acute appendicitis, a secondary objective was to identify the incidence of atypical diagnoses detected among appendectomy specimens to better elucidate those potentially missed in non-operative management. METHODS: An IRB-approved retrospective review of 1311 appendectomies over a 16-month period at an independent children's hospital allowed a comparison of the diagnostic classification of appendicitis as perforated (PA) or nonperforated (NPA) based on radiology (R), operative (O), and pathology (P) reports. Three groups, P+O (N=1241), P+R (N=516), O+R (N=512), were compared to identify inter-specialty discordance in classification. The length of stay (LOS) was analyzed as a proxy for clinical behavior to confirm that the diagnostic classification was consistent with the clinical behavior of being perforated or nonperforated (PA with LOS >48hours and NPA with LOS ≤48 hours). Given the numerous pathologic descriptives of appendicitis, a more extensive pathologic review of all appendectomies was done to identify an intra-specialty variance in diagnostic classification and to identify any other diagnosis in the setting of presumed appendicitis. This arm of the study involved an expanded IRB-approved retrospective review of pediatric patients (n=6816) who underwent appendectomies at an independent children's hospital over an 11-year period from January 2000 to December 2010. Inclusion criteria were age <17 and surgery for presumed appendicitis, thus excluding incidental appendectomies (n=269) with a final review of 6547 specimens. RESULTS: In the assessment of the degree of discordance, the subsets P+O, P+R, O+R revealed a discordance of 11%, 15.7% and 16.6% within the classification of appendicitis respectively. In the O+R group, 35% of the cases that were operatively designated as 'perforated' contradicted the radiologic diagnosis of being 'nonperforated' appendicitis. Cases designated as PA in all subsets (P+O, P+R, O+R) clinically behaved as perforated with a mean LOS>48 hours (97, 95, 95, respectively), whereas the cases designated as nonperforated appendicitis (NPA) exhibited greater variation from the expected LOS≤48 hours, with means 35, 83, and 62, respectively. The more exhaustive pathologic review identified 7 classifications for appendicitis in 91.6% patients, 5% false positives, and ~3% coincident other diagnoses. 5998 (91.6%) subjects showed true appendicitis including acute non-perforated, perforated, chronic, suppurative, gangrenous, necrotizing, and catarrhal appendicitis. In 224 subjects (3.4%), diagnoses other than appendicitis were identified: non-inflammatory obstruction (n=71), other infectious etiologies (n=58), non-specific inflammatory changes (n=58), extra-appendiceal pathology (n=31), tumors (n=10), and foreign body (n=2). Of the tumors, 6 patients with true appendicitis had co-existing carcinoid tumors. 325 specimens (5.0%) were documented as negative appendicitis. CONCLUSION: Variability in the classification of appendicitis between specialties suggests an error rate inherent in diagnosis. This error rate may explain why identifying best clinical guidelines for length of antibiotic therapy and treatment has been elusive. Standardizing classification criteria across specialties may help identify best practices for optimal use of hospital resources and improve diagnostic accuracy for meaningful clinical trials. This study represents the largest analysis of the incidence of pathologies that mimic appendicitis in the pediatric population, conveying a broad overlap of diagnoses that present in a similar fashion. Given how commonly appendicitis is diagnosed, follow-up for routine appendectomies has been streamlined and expedited in such a way that the review of pathology by the practitioner may be overlooked. The number of infectious etiologies and tumors detected reinforces the increasing importance of pathology review in post-operative follow-up to appropriately diagnose uncommon conditions that may necessitate further work-up and treatment. Additionally, the possibility of missing an alternative or co-incidental diagnosis such as a carcinoid tumor in the non-operative management of appendicitis merits some reflection in planning operative versus non-operative management. Given the recent popularity of non-operative therapy for appendicitis, this research gives the clinician a reliable incidence of other potential diagnoses if symptoms recur. Having percentages for conditions that present similarly also allows for proper counseling of patients who opt for non-operative management.
Acetaminophen Dose Does Not Predict Outcome in Acetaminophen-Induced Acute Liver Failure
(2010-04-09) Gregory, Blake Elizabeth; Lee, William M.
Acetaminophen is a dose-dependent toxin. Prognosis in severe acute liver injury is related presumably in part to the dose ingested. We sought to assess the value of acetaminophen dosing information in patients with acute liver failure due to acetaminophen toxicity to determine the role of dose as a prognostic indicator. Methods: Prospective data from 113 acute liver failure patients having single time point ingestions of acetaminophen were analyzed. Multivariate and chi-square tests were used to determine the relationship of dose to clinical outcome. We also used the Mann-Whitney U test to compare prognosis and survival in ALF with acetaminophen dose ingested. Results: Multivariate and chi-square analysis failed to show any relationship between acetaminophen dose and spontaneous survival. A separate analysis showed no correlation between acetaminophen dose and clinical prognostic indicators. Conclusions: Dose of acetaminophen ingested did not seem to play a role in prognosis. The most important prognostic factor was coma grade on admission to study. Acetaminophen dosing information is not always obtainable. When it is, it adds little to the clinical assessment. Severity of encephalopathy is a more reliable indicator of prognosis in these critically ill patients.
Acres of Diamonds: Rediscovering Community Assets in Dallas Backyards
(2016-04-01) Chavda, Avinash Suresh; Rhee, Chanhaeng; Reed, W. Gary
BACKGROUND: Diabetes directly affects 8% of the US population and poses a growing burden to healthcare providers, to the health system, and to society. Cultivating self-efficacy enhances personal agency and enables patients to take an active role in the management of their disease. Effectively cultivating self-efficacy among patients from diverse backgrounds requires a patient-tailored assessment of existing gaps in patients' diabetes self-management skills. Tying patients to existing community health resources through ZIP code-based mapping is an effective patient-tailored intervention that creates long lasting change in diabetes self-management. To this end, a two-armed approach to community resource mapping was taken: In the first arm, existing resources in the categories of exercise, nutrition, and diabetes management were catalogued and mapped across Dallas County ZIP codes; in the second arm, patient awareness of existing resources across the same three categories was mapped across Dallas County ZIP codes. A comparison of each study arm across overlapping ZIP codes showed that resources abound in Dallas, but awareness of these resources is the limiting factor in fostering increased patient self-efficacy. To increase self-efficacy and empower patients to improve self-management of their diabetes, patients should be connected with community resources to tackle the issue of underutilization of community resources and thereby gain "mastery experiences." OBJECTIVE: This project hypothesizes that community resources are plentiful in Dallas and that there is a relative lack of awareness of community resources, limiting patient self-management of diabetes. METHODS: This study mapped community assets in the categories of exercise, nutrition, and diabetes management across the Dallas ZIP codes with the heaviest burden of diabetes. This study then mapped awareness of these same resources and compared both maps to identify a disconnect between community resources and the communities they serve. RESULTS: Sample maps of community assets in several of 14 target ZIP codes were produced with the aid of Google maps, showcasing the abundance of community resources throughout the ZIP codes of Dallas County, including those with poor clinical and socioeconomic measures. Though results may not be representative of individual ZIP codes, awareness of resources appears to vary more directly with these clinical and socioeconomic measures than does true resource distribution. CONCLUSION: This study applies quality improvement and process analysis tools to empirically advance theoretical population health frameworks. Asset cataloguing and geospatial mapping demonstrate an abundance of community resources evenly distributed throughout Dallas but a dearth of resource awareness that loosely correlates with negative community measures. Such measures include median household income, BMI, HbA1C, and crime index. Continued indexing of Dallas County resources with more sophisticated mapping software will yield asset catalogues more consistent in their value to society; and continued awareness surveying is necessary to develop representative ZIP code awareness maps for deep comparison of these objective resource and subjective awareness measures.
Advanced MR Imaging of Bone Marrow: Quantification of Signal Alterations on T1-Weighted Dixon and T2-Weighted Dixon Sequences in Red Marrow, Yellow Marrow and Pathologic Marrow Lesions
(2019-03-27) Sasiponganan, Chayanit; Chhabra, Avneesh; Pezeshk, Parham; Ashikyan, Oganes
BACKGROUND: Characterization of bone marrow through qualitative changes in signal intensity (SI) have not been evaluated on T2-weighted (W) Dixon imaging. OBJECTIVE: We hypothesized that T2W Dixon imaging SI changes are similar to those on T1W Dixon imaging and can be used to effectively characterize bone marrow. METHODS: 144 patients (77 controls with yellow and red marrow regions, 64 lesions--33 benign and 31 malignant) between January 2016 - December 2017 were retrospectively identified. For the control group, fixed 2 cm2 region of interests (ROI) were drawn at L5, bilateral ilium and femurs on in-phase and opposed-phase T1W and T2W Dixon images. For the lesion group, ROI of best fit were drawn around each lesion on in-phase and opposed-phase T2W Dixon images. SI changes for each group were compared. Inter-reader analysis was performed. RESULTS: Yellow marrow exhibited smaller SI changes as compared to red marrow on both T1W and T2W Dixon at all locations (p < 0.0001) except at L5 on T2W Dixon (p = 0.206). Both benign and malignant lesions showed significantly smaller SI changes as compared to both yellow (p = 0.0087, p <0.0001) and red marrow (p = 0.0004, p < 0.0001) on T2W Dixon. Malignant lesions exhibited smaller SI change as compared to benign lesions on T2W Dixon (p = 0.0005). Signal intensity loss on both red and yellow marrow were smaller on T1W Dixon as compared to T2W Dixon (0.49-0.64, 0.27-0.31 vs 0.70-0.74, 0.48-0.71). Inter-reader agreements were excellent (0.91-0.97). CONCLUSION: SI change calculated from T2W Dixon imaging can adequately differentiate between yellow marrow, red marrow and osseous lesions--both benign and malignant.
The Aftermath of Conservative Management of Placenta Accreta: Can These Women and Their Uteri Handle Another Pregnancy?
(2015-12-11) Knypinski, Julia; Wells, C. Edward; Pearson, Mary Jane; Mihalic, Angela
BACKGROUND: Placenta accreta, an invasion of the placenta into the myometrium of the uterus, is one of the leading causes of postpartum hysterectomies. The American Congress of Obstetrics and Gynecology (ACOG) recommends that when placenta accreta is suspected, a hysterectomy should be performed without attempting to remove the placenta. Several methods exist for the conservative management of placenta accreta, which leaves women capable of subsequent pregnancies. OBJECTIVE: The purpose of this literature review is to evaluate the fertility and pregnancy outcomes of women who undergo conservative management of placenta accreta. METHODS: An online literature search was performed looking for key works. Retrieved articles, their references, and past literature reviews on the subject were screened for relevance. RESULTS: Several studies assessing the fertility outcomes of women after conservative management of placenta accreta were found. 345 subsequent live births were documented with a recurrence rate of placenta accreta of 21%. It was found that previous C-sections and placenta previa pose the greatest statistical risk for placenta accreta. Relatively few women desired another pregnancy and postpartum hemorrhage can have a significant negative psychological impact on women. CONCLUSION: Women who undergo conservative management of placenta accreta can successfully carry pregnancies to term. Children born of these pregnancies have no neonatal morbidity. The rate of recurrence of placenta accreta and postpartum hemorrhage remains high.
Albumin Is Predictive of 1-Year Mortality After Transcatheter Aortic Valve Replacement
(2020-05-01T05:00:00.000Z) Hebeler, Katherine Rachel; DiMaio, J. Michael; Edgerton, James; Hamandi, Mohanad
BACKGROUND: A validated model for predicting 1-year outcomes after transcatheter aortic valve replacement (TAVR) does not exist. Frailty markers have been proposed as potential variables to assess individual patient risk. TAVR-specific risk models may benefit from frailty markers, and sarcopenia may represent an objective frailty marker. OBJECTIVE: This study assessed the predictive ability of sarcopenia and frailty markers on 1-year mortality after TAVR. METHODS: We evaluated 470 patients undergoing TAVR at a single center. Frailty was assessed using 4 markers (gait speed, handgrip strength, serum albumin, and Katz activities of daily living). Sarcopenia was measured as the cross-sectional psoas muscle area on pre-TAVR computed tomography. Performance of four models incorporating Society of Thoracic Surgeons Predicted Risk of Mortality (STS-PROM), frailty, and/or sarcopenia metrics for predicting 1-year mortality was assessed with area under the curve, Hosmer-Lemeshow statistics, and calibration plots. RESULTS: A total of 63 (13.4%) deaths occurred by 1-year. STS-PROM alone was poorly predictive of 1-year mortality (AUC 0.52, 95%CI: 0.42, 0.68). Only the model including both sarcopenia and all frailty markers (AUC 0.61, 95%CI: 0.53, 0.68) significantly improved predictive ability compared to STS-PROM alone (p = 0.05). Albumin was the only frailty marker significantly associated with increased risk for 1-year mortality (p=0.03). Psoas muscle area, as a surrogate for sarcopenia, was not significantly associated with increased risk for 1-year mortality. CONCLUSIONS: Most commonly used pre-TAVR risk assessments are poorly predictive of 1-year mortality. Albumin was the only frailty marker that was associated with higher mortality. Future studies should investigate whether optimization of nutritional status can improve outcomes following TAVR.
Alcohol Self-Help Groups in Saint Vincent and the Grenadines: A Cultural Approach
(2016-04-29) Chhabra, Divya Kiran; Brenner, Adam; Gimpel, Nora; Niwagaba, Lillian
INTRODUCTION: In 2004, there were 4.1 deaths from alcohol use disorders per 100,000 people in Saint Vincent and the Grenadines (SVG)- one of the highest rates in the world. There are no medical resources currently for patients with alcoholism in this country. Thus, work was done to pilot self-help groups modeled on Alcoholic Anonymous (AA), in SVG in summer 2012. A follow-up team returned to SVG in summer 2013 to assess the success of those groups and to pilot more groups in various regions. The team worked to tailor a unique self-help program specific to the cultural foundation of the local community. This study looks at what specific factors were associated with the groups that attained success, explores local perceptions regarding alcoholism, and delved into what techniques may aid in preventing alcoholism in this country from the ground up. METHODS: The goal of the second phase of the project was multi-faceted and was accomplished via three medical students traveling to the country for approximately 9 weeks. The first goal involved ascertaining the reason as to what qualities made the Barrouallie group, the only remaining self-help group from the first phase, sustainable and what qualities caused the other groups to cease meeting. Secondly, due to the needs for programming in other communities, a large goal was to expand the program using the knowledge obtained in qualitative analysis to start other groups. Lastly, the group aimed to analyze the local adult populations general attitude and understanding of alcoholism as a disease process. Due to the limitations of the project in 2012, this second phase foremost sought to deeply understand the community needs and cultural factors that influence alcoholism and the use of AA in this country. By working towards an understanding rather than immediate progress in terms of number of self-help groups, the team aimed to create sustainable self-help groups. Ultimately, five new self-help groups were piloted by the end of the 2013 summer. These groups were located in Bequia (two meetings over summer 2013), Kingstown (two meetings), SVG Mental Health Center in Glen (four meetings), and Troumaca (one meeting) and consisted of 2-10 members. The team, after surveying the area to assess alcohol-related education in local schools, also piloted education sessions for local children and adolescents in Troumaca, Kingstown, and Arnos Vale. RESULTS: The only remaining self-help group after the 2012 pilot program was Barrouallie. This group had 9 participants attending since August 2013. Eight of them have stopped drinking completely, and the 9th member has been sober since July 2013. Eight members agreed that the group was "very helpful," and five of them joined the group through word of mouth. One participant noticed the "seriousness" of the group he saw at the park, so he decided to join. This openness was not apparent in the failed groups from 2012. When asked what could make their group more successful, approximately 66% of the subjects stated "encouraging more people to join the group." Of the former participants, 100% of them answered "yes" to whether the group helped them overcome their drinking problem. The former subjects stopped coming due to pregnancy or schedule conflicts. The current participants felt that forgoing anonymity would help to disseminate the group elsewhere in SVG. The group was then aired on local television to spread their message, and they also expressed interest in being aired on the radio and recruiting locals they knew in other villages to start groups in their own communities. The Barrouallie group chose to display shirts conveying their dedication to abstaining from alcohol and place their meetings in open areas where anyone could be welcome. Other pertinent suggestions from former participants to recruit new participants included finding the alcoholics at the rum shops themselves. Lastly, in the convenience sample from Kingstown, 75% of subjects claimed alcoholism is "not a disease," and the majority weren't aware of its specific organ effects and were not educated in school regarding alcohol and drug abuse and their repercussions. RECOMMENDATIONS: Unlike the AA model, which is based on the premise of privacy and unrevealed identities outside of those at the meetings, the only group that was sustained in SVG from the summer 2012 phase of the project explicitly and voluntarily shed its anonymity. This philosophy of community engagement and self- identification was used for establishing five new self-help groups whose viability is currently being assessed. The open culture of SVG allowed a unique group design to attain success. In a country so close-knit and small, obtaining the western ideal of privacy and confidentiality is not only extremely difficult, but simply may not lead SVG towards a decrease in alcoholism. For this culture, openness may be the form of therapy that can make this feat possible. The lack of alcohol education was apparent when the majority of locals surveyed didn't realize that it is a disease or how it affects the organs. The team initiated an educational campaign at camps and churches to promote prevention of alcoholism at an early age. The team recommends that in the future, a two-tiered approach must be utilized to decrease the incidence of alcoholism in SVG: one aimed at prevention in schools via education, and the second aimed at non-anonymous self-help groups led by local community leaders such as nurses or community-known peace corps members rather than necessarily an alcoholic as the AA would advocate. Cultural competency must be taken into consideration when implementing programs to address alcohol use disorders, as alcoholism is an overlooked global issue.
Anal Cancer Screening in a High-Risk Population: A Quality Improvement Initiative
(2019-03-29) Bieterman, Andrew; Reed, W. Gary; Anandam, Joselin; Lau, Abby; Quinn, Andrew
BACKGROUND: The main risk factor for the development of anal cancer is acquisition of the human papilloma virus (HPV). Individuals infected with the human immunodeficiency virus (HIV) have a higher prevalence of HPV and subsequently developing HPV induced dysplasia. The incidence of anal cancer among HIV positive men who have sex with men (MSM) has been estimated to be approximately twice that of HIV negative MSM with rates as high as 112-144 per 100,000. By relying on similarities between the anus and the cervix, and the established success of cervical cytology screening in reducing the incidence of cervical cancer, anal cancer screening programs have been established to identify pre-cancerous lesions. LOCAL PROBLEM: A retrospective chart review of anal cancer incidence at Parkland Hospital revealed a significant burden of anal cancer amongst HIV positive patients. As such, Parkland has decided to implement a policy of annual anal cancer screening among all HIV patients via anal cytology screening and referrals to proctology for any abnormal anal cytology samples. METHODS: In order to assess the monthly anal cancer screening rate, we looked at the absolute number of anal cytology samples performed in a 28 day period. The list of anal cytology samples performed was pulled from the Cerner laboratory information system (LIS) and correlated with a quarterly chart review using the electronic medical record (EMR). Utilizing, QI MACROS in EXCEL, we were able to create a run chart to identify trends in anal cancer screening rates over the duration of the project. We used chi-squared test of independence and unpaired t-test to determine statistical significance. INTERVENTIONS: We implemented a multi-step process involving over 10 Plan-Do-Study Act (PDSA) cycles for increasing the number of anal cytology samples performed in the clinic. The three most impactful PDSA cycles are discussed in the article. RESULTS: The primary outcome of monthly anal cancer screening rate increased over the duration of the project from an average of 19.5 in 2015 to 58.6 samples collected per month in 2018, a 199.3% increase relative to baseline (p < 0.001). While the interventions implemented were successful in increasing anal cancer screening rates, we were unable to determine which of the PDSA intervention cycles had the biggest impact on altering the clinic practice. Over the duration of the project, we screened 1908 patients. Of the patients screened, we identified 249 patients with abnormal anoscopy findings. Amongst the patients that had anal lesions on anoscopy, 10 developed anal cancer, 4.0%. When taking a closer look at these individuals and the electronic medical record, 3 patients were found to be completely asymptomatic at the most recent clinic prior to collection of the anal pap and would not have been referred to proctology if it weren't for the screening test, which ultimately resulted in an earlier diagnosis CONCLUSION: We were successful in taking previously proven interventions for increasing cervical cancer and adapting them for anal cancer. By increasing awareness to both patients and providers on the risks of anal cancer, instructing providers on the methods to screen for the disease, and providing timely feedback, we were able to increase the anal cancer screening rate in this large urban clinic with limited resources.
An Analysis of Maternal Health in Burkina Faso
(2014-04-11) Merrill, Elisabeth Mercedes; Mihalic, Angela
Since the year 2000, countries around the world have focused on achievement of the Millennium Development Goals, the fifth of which is to “improve maternal health”. Burkina Faso has made good strides towards improving maternal health and has achieved a 57% reduction in the maternal mortality ratio between 1990 and 2010. While the lifetime risk of maternal death remains elevated at 1 in 55, in recent years the government has instituted several programs aimed at improving women’s health with varied results. This paper aims to survey the state of maternal health in Burkina Faso and evaluate the impact that government policies such as subsidies have had on the overall picture of maternal morbidity and mortality.
Anesthesia in Open Inguinal Hernia Repair: The History, Progression, and Current Status
(2019-03-27) Argo, Madison Bailey; Huerta MD, Sergio; Phung MD, Tri; Sharma MD, Rohit
BACKGROUND: The benefits of local anesthesia in open inguinal hernia repairs was first noticed in the second half of the 20th century, however, for unknown reasons, this practice has nearly been entirely replaced with other anesthetic techniques. In fact, in the United States and globally, the predominant anesthetic techniques employed include general and regional anesthesia leaving local anesthesia immensely underutilized. It was only after implementing local anesthesia at the North Texas Veterans Affairs Health Care System (VANTHCS) in 2015, driven by the increasing amount of patient comorbidities, that this underutilization was recognized. This infrequency and variation in the choice of anesthetic technique for open inguinal hernia repair (OIHR) worldwide, seems to be guided primarily by surgeon preference. The factors determining the use of local anesthesia compared to spinal and general anesthesia (all other forms of anesthesia) remains equivocal as previous data has compared individually spinal anesthesia or general anesthesia to local anesthesia. In the present study: (1) the experience implementing an LA program for OIHR at the VA North Texas Health Care System is described, (2) we present data regarding the underutilization of LA in the USA and underdeveloped countries, (3) and we present an analysis of all randomized controlled trials (RCTs) in patients undergoing open inguinal hernia repair comparing local anesthesia to all other forms of anesthesia to objectively assess the respective outcomes. OBJECTIVE: We hypothesize the use of LA in OIHR is: a) underutilized, b) readily implementable in an academic center with minimal training, and c) advantageous and provides benefit to the patient over other anesthetic techniques in terms of outcomes and operative room times. METHODS: I. We retrospectively analyzed a prospectively collected database at the VANTHCS to determine the implementation of a LA program for OIHR. II. We interrogated a database from a third world country in Guatemala, Hospital Nacional de San Benito (HNSB) to determine current practices at that hospital with regards to the choice of anesthesia for OIHR. We also collected data on other developing countries to determine current practices as well. III. PubMed, MEDLINE, Ovid Syntax from 1976 to May 2018, the Cochrane Library, Google, and Google Scholar were reviewed by two independent reviewers following PRISMA guidelines. We identified 83 potential manuscripts, following exclusion of papers that were not OIHR, did not include anesthesia type, and non-randomized trials, 18 RCT's were available for inclusion. The parameters evaluated were short-term complications (urinary retention, wound infections, and hematomas), patient satisfaction, length of hospital stay (LOS), total surgical time, total operating room time, and postoperative pain. Review Manager 5.3 was used to test for overall effect between the included studies. RESULTS: Data obtained from the VANTHCS showed there was a rapid implementation of LA for OIHR. Data from HNSB showed that 95% of OIHR are performed under regional anesthesia and the rest via GA. A study in Ghana showed a substantial underutilization of local anesthesia. A meta-analysis showed that LA was favored in many analyses and weighed statistical significance was notable for several important outcomes. Overall complication rate was similar in LA vs. AO (p=0.06). Wound infection and hematoma were similar between LA vs. OA (p=0.17 and p=0.62; respectively). Urinary retention was significantly decreased in LA (p=0.0002). Collectively, patient satisfaction was not inferior and tended to favor the use of LA vs. OA (p=0.11). Total surgical time was similar in LA vs. AO (p=0.86), but operating room time was significantly decreased when LA was used (p<0.0001; 95% CI [-16.6 to -5.9]). Seven of the ten studies that recorded LOS reported a significant decrease when LA was used. Four separate studies reported cost. LA was less expensive than AO in all aspects (costs of anesthetic materials, intraoperative and early postoperative costs, and in total healthcare costs). CONCLUSION: The use of LA can be easily implemented at a VA hospital. LA is substantially underutilized in the US and around the world. Our meta-analysis demonstrated that LA is a well-tolerated anesthetic approach for OIHR and ought to be utilized more in the United States and globally. Specifically, OR times and urinary retention were significantly improved with LA vs. AO. Additionally, LA improves the economic burden by decreasing operating room time and decreasing overall intraoperative and early postoperative costs, which is significant for a procedure performed so frequently. LA underutilization is quite apparent and significant future research should be focused on education and implementation of this technique globally.
Appropriateness of Preoperative Antimicrobial Therapy Does not Impact Outcomes Following Surgery for Infective Endocarditis
(2017-03-29) Squiers, John Jay; DiMaio, J. Michael; Le, Binh-Minh (Jade); McGuire, Darren K.
BACKGROUND: A long-standing paradigm of the surgical management of infective endocarditis was to delay surgery until the infection was adequately treated out of concern for increased technical difficulties due to acutely inflamed valvular tissue present during active infection. Up to half of patients with infective endocarditis may initially receive bacteriologically inadequate antimicrobial therapy, delaying time to surgery in these patients. However, several benefits of earlier surgery in certain patients with infective endocarditis and guideline-directed indication(s) for surgery have emerged over the last decade. Thus, surgeons are increasingly faced with a decision whether to operate on patients with infective endocarditis whose infection may not be adequately treated prior to surgery. OBJECTIVE: We sought to examine the characteristics of patients with infective endocarditis requiring surgical treatment and to determine whether the appropriateness of preoperative antimicrobial therapy impacted their short-term and long-term outcomes. METHODS: Records of 335 consecutive patients undergoing valve surgery to treat infective endocarditis between 1990-2013 at a single center were retrospectively reviewed. All patients with definite or possible infective endocarditis, defined by modified Duke criteria, and with positive blood cultures prior to surgery were included in the study. Two infectious disease clinicians, blinded to patient outcomes, graded appropriateness of preoperative antimicrobial regimens. RESULTS: A total of 270 patients (190 men; mean age 46.2 years) met inclusion criteria. Appropriate preoperative antimicrobial therapy was administered to 217 (80%) patients. Enterococci and fungal infections were more common in the inappropriately treated group, as was recurrent infective endocarditis. A history of viral hepatitis was less common in the inappropriately treated group. Otherwise, there were no significant differences in the rates of baseline comorbidities, valve involvement, or etiologic microorganisms among the groups. Operative mortality was 12.9% overall, with no significant difference between the appropriately (14%) and inappropriately (8%) treated groups (p=0.28). There was no difference in unadjusted, all-cause, five-year survival between the appropriately (48%) and inappropriately (52%) treated groups (log-rank p=0.30). CONCLUSION: There were no significant differences in short- and long-term mortality between patients receiving appropriate versus inappropriate preoperative antimicrobial therapy prior to valve surgery for infective endocarditis. Surgeons should not hesitate to operate on patients with infective endocarditis and a guideline-directed indication for valve surgery, even if their preoperative antimicrobial regimen has been inadequate.
Aspirin Use Is Associated with Improved Outcomes in Inflammatory Breast Cancer Patients
(2023-05-01T05:00:00.000Z) Johns, Christopher Lee; Kim, D. W. Nathan; Alluri, Prasanna; Liu, Yu-Lun
PURPOSE: Inflammatory breast cancer (IBC) is the most aggressive form of breast cancer and has a high propensity for distant metastases. Our previous data suggested that aspirin (ASA) use may be associated with reduced risk of distant metastases in aggressive BC; however, there are no reported studies on the potential benefit of ASA use in patients with IBC. METHODS: Data from patients with non-metastatic IBC treated between 2000-2017 at two institutions, were reviewed. Overall survival (OS), disease-free survival (DFS), and distant metastasis-free survival (DMFS) were performed using Kaplan-Meier analysis. Univariate and multivariable logistic regression models were used to identify significant associated factors. RESULTS: Of 59 patients meeting the criteria for analysis and available for review, 14 ASA users were identified. ASA users demonstrated increased OS (p=.03) and DMFS (p=.02), with 5-year OS and DMFS of 92% (p=.01) and 85% (p=.01) compared to 51% and 43%, respectively, for non-aspirin users. In univariate analysis, pT stage, pN stage, and aspirin use were significantly correlated (p < .05) with OS and DFS. On multivariable analysis, ASA use (HR=.11, CI 0.01- 0.8) and lymph node stage (HR=5.9, CI 1.4-25.9) remained significant for OS and DFS (aspirin use (HR =0.13, CI 0.03-0.56) and lymph node stage (HR=5.6, CI 1.9-16.4). CONCLUSION: ASA use during remission was associated with significantly improved OS and DMFS in patients with IBC. These results suggest that ASA may provide survival benefits to patients with IBC. Prospective clinical trials of ASA use in patients with high-risk IBC in remission should be considered.
Assess Effectiveness of Opioid Prescription Policies for Acute Pain Management
(2022-05-01T05:00:00.000Z) Machchhar, Arti; Reed, W. Gary; Phelps, Eleanor; Kandil, Enas
BACKGROUND: In 2017, the Department of Health and Human Services (HHS) declared the Opioid Crisis a public health emergency. Regulatory agencies and institutions have adopted several guidelines to ensure opioids are prescribed appropriately. In October 2014, the DEA changed the schedule of hydrocodone combination products (HCPs) from schedule III to schedule II narcotics. This led to a substantial rise in Tylenol 3 prescriptions at the University of Texas at Southwestern Medical Center (UTSW) due to the institutional guideline that prevents residents from prescribing schedule II narcotics without documented approval from an attending physician. OBJECTIVE: We sought to evaluate whether the UTSW guideline preventing residents from prescribing schedule II narcotics serves to improve patient safety and pain management. METHODS: Prescription data and associated patient demographic data was pulled directly from the UTSW electronic medical record (EMR) for one year prior to and following the rescheduling of HCPs. Additional data was pulled for the 2019 and 2020 calendar years. The proportion of T3 and schedule II narcotic prescriptions was calculated for all time periods and stratified for age, race, provider type, and department. RESULTS: One year before the rescheduling of hydrocodone, the vast majority of prescriptions were schedule II narcotics at 98.92% and T3 was very rarely prescribed at 1.08%. In 2014 - 2015 following the rescheduling of HCPs, there was an overall decrease in opioid prescriptions and the proportion of T3 prescriptions rose to 49.94%. In 2019 and 2020, the overall number of opioid prescriptions increased to 17,297 in 2019 and 15,395 in 2020 and the proportion of T3 prescriptions decreased to 37.12% and 33.89% respectively. CONCLUSION: The rescheduling of HCPs led to the dramatic shift in Tylenol 3 prescriptions, indicating that regulatory agencies and institutional guidelines are driving prescribing habits. Tylenol 3 is being prescribed at a significant rate however, information regarding its addictive potential, metabolic effects, and potential adverse effects remains relatively unknown. The drug policies and institutional guidelines discussed disproportionately affect people of color and lower socioeconomic class.
Assessing Self-Care Perception in Patients Living with Type 2 Diabetes and Their Physicians
(2021-05-01T05:00:00.000Z) Balakrishnan, Naveen Kishore; Day, Philip; Kale, Neelima; Schneider, David
BACKGROUND: Type 2 diabetes mellitus (T2D) is chronic illness affecting millions in the United States. Patients living with T2D require highly individualized care and significant patient effort. This effort is comprised of the patient's self-care with regards to medication, diet, lifestyle, and mental health. Self-efficacy is a patient's ability to feel agency over their illness and therefore feel able to maintain self-care. Previous literature suggests that improving a patient's self-efficacy through various behavioral health interventions may improve a patient's ability to manage their T2D. Additionally, interventions on self-efficacy are thought to work regardless of health literacy level and might be a generalizable intervention. However, while validated surveys assessing patient diabetes distress, quality-of-life, social determinants of health, adverse childhood events, and more exist, no literature was found attempting to understand a patient's perspective on their self-care, and by extension, their self-efficacy. Under the premise that consistent beliefs between patient and physician regarding self-care are necessary to make meaningful plans promoting self-care and self-efficacy, the authors developed the term self-care perception consistency to assess relationship between patient and physician perceptions of a patient's self-care. OBJECTIVE: The objective is to assess the consistency between patient and physician perceptions of patient self-care through a biopsychosocial and structural/social determinants of health lens. METHODS: This study uses a cross-sectional, quantitative data set obtained by the Research Residency Network of Texas (RRNeT) through a 71-item survey study. This survey was completed across 12 Family Medicine residencies in Texas and included individuals between 18-75 who were living with T2D. Responses ranged from short free response to Likert-scale based questions and covered topics such as demographics, social determinants of health, patient self-care, diabetes distress, quality-of-life, adverse childhood events, and more. The physicians of each patient were asked to complete a shorter 10-item survey with broader analogous questions to the patient survey. This data was collected through RedCap and analyzed through RStudio. RESULTS: The term self-care perception consistency was coined to describe the relationship between the patient's and physician's perception of the patient's self-care. Self-care perception consistency was found to be lacking 31.2% of the time. Only HgA1c (p<0.01) was inversely correlated with self-care perception consistency in both the univariate and multivariate analyses of demographic factors and social determinants of health. Additional analysis was completed to assess the relationship of HgA1c control, patient diabetes distress, patient quality-of-life, and the physician survey with self-care perception consistency. Self-care perception consistent and inconsistent groups were found to have significantly different HgA1c control distributions (p < 0.01) in the subset of patients that rated their self-care positively, but no significant difference was found in the group that rated their self-care negatively. Patient self-care ratings were best correlated with their diabetes distress (p<0.01) and HgA1c (p<0.01) while physician ratings of patient self-care were best correlated with their perception of HgA1c, perception of patient diabetes distress, perception of patient quality-of-life, and perception of patient social connectedness (p<0.01 for all). Notably, trending diabetes distress, quality-of-life, the physician survey, and social determinants of health across patient self-care ratings in self-care perception consistent versus inconsistent groups revealed that only the physician survey showed opposite trends across the consistent and inconsistent groups. CONCLUSION: Self-care perception consistency was found to be lacking 31.2% of the time. Notably, HgA1c is correlated with patient and physician perceptions of patient self-care (p<0.01 for both); however, in instances of patient-physician self-care perception inconsistency, HgA1c is not correlated with patient self-care perception. Instead, diabetes distress remains predictive of patient self-care rating in all instances (p<0.01). Patient-physician self-care perception inconsistency is also associated with inconsistency in patient and physician perceptions of the patient's diabetes distress. As diabetes distress remains consistently correlated with patient self-care rating, using the validated diabetes distress survey-17 with an additional question regarding self-care may help physicians better understand patients and therefore target appropriate education and psychosocial interventions.
Assessing the Need for and Developing a Standardized Patient Handover Curriculum for Undergraduate Medical Education
(2017-04-03) Gajera, Prakash; Reed, W. Gary; Greilich, Philip; Ambardekar, Aditee
BACKGROUND: Improving patient handoff communication is a national patient safety goal; however, few medical schools have standardized handoff training curricula for their medical students. Studies show that a large number of medical students perform handoffs and observe handoff errors during their clerkships [1,2]. This lack of formalized training has a negative impact on medical student perceptions of handoffs [3]. This project assessed the need for handoff education at our institution and developed a curriculum aimed at medical students. IMPLEMENTATION: Clerkship directors were interviewed & preclinical medical students were surveyed for a stakeholder analysis. Prior to starting core clerkships, 200 total students participated in four 1-hour workshops consisting of a 20-minute lecture and three 10-minute handoff scenarios. Trained residents performed the scenarios and led group discussions. Pre- and post-course engagement surveys were used to evaluate the workshop. EVALUATION & OUTCOMES: Clerkship directors desired handoff training before clerkships; however, there was concern that the curriculum would be too advanced. Survey of pre-clinical students showed 71% had heard of standardized patient handoffs, but 94% had no training. 75% believed training should be done prior to core clerkships, and 64% believed handoff simulations were the best method for learning. Students scored 10.7% higher on the post-engagement quiz and 98% of students believed they better understood the elements of a good handoff after the workshop. IMPACT & LESSONS LEARNED: Standardized patient handoff curriculum designed for preclinical medical students improved confidence and knowledge about the handoff process. Concerns about creating handoff curriculum for medical students were addressed by focusing on general concepts rather than specific handoff tools and by creating simple handoff evaluation scenarios. Further work will focus on evaluating the impact of this workshop on the handoff experience during clerkships.
Assessing the Relationship Between Electronic Medical Record (EMR) Generated QTc Alerts and Cancer Patient Mortality
(2020-05-01T05:00:00.000Z) Bleiberg, Benjamin Aaron; Khan, Saad A.; Gerber, David E.; Terauchi, Stephanie
BACKGROUND: EMR generated drug associated QTc alerts are generated frequently in cancer patient populations and in the last few years their annual frequency has outgrown the number of unique patient visits at our institution. Anecdotally, they are largely ignored by providers, contributing to provider cognitive burnout and alert fatigue. While they may be considered nuisance alerts, the EMR collects rich data on the circumstances underlying the alert, the patients impacted, and their outcomes. By querying the EMR, we aimed to risk stratify patients by cancer site and demographic factors and provide meaning to these alerts allowing providers to incorporate the information we have provided in clinical decision making regarding the care of cancer patients. Our project is the first large-scale analysis of EMR generated QTc prolongation alerts at a tertiary referral center in the United States. OBJECTIVE: Acute mortality of cancer patients varies significantly by cancer site and demographic factors following EMR generated drug associated QTc interval prolongation alerts. METHODS: UT-Southwestern's EMR was queried to identify all patients between 10/04/2005 (the date of the 1st recorded alert) and 08/13/2019 over 18-years of age with a diagnosis of cancer and EMR generated drug associated QTc interval prolongation alerts yielding a sample of 19,223 patients. We collected the alert triggering medications, patient demographics, cancer site, and mortality data to identify the time between a patient's 1st alert and recorded death date. Rates of death by age, ethnicity, gender, race, number of alerts, and primary cancer site were identified in the following intervals: within 10 days, 11-180 days, and 181-365 days. Kaplan-Meier Overall Survival Analysis with Cox regression and multinomial multivariable analysis controlling for age, race, ethnicity, and gender, and median survival data analytic methods were used to identify if there were statistically significant differences in mortality at the pre-specified time points based on the above listed variables. Head and neck cancer patients were used as our reference group for comparison when analyzing mortality by primary cancer site. This group was chosen as their rates of within 10-day mortality closely aligned with those predicted by the null hypothesis that there would be no difference in mortality rates within 10-days across primary cancer sites used in our preliminary chi-squared goodness of fit model. Additionally, for patients with EKG's recorded within 10 days of their 1st alert, QTc intervals utilizing Bazett's correction algorithm were collected and the recorded interval of patients with deaths within 10 days was compared to those who were alive after 10 days, with participants separated by gender. RESULTS: Analysis of mortality from a patient's 1st QTc alert demonstrated statistically significant (p<0.05) higher risk of ≤10-day mortality in: patients with increasing number of QTc alerts, particularly patients with 6-10, HR=1.67 or >11 HR=1.88 alerts. Additionally, increased ≤10-day mortality was demonstrated in cancer patients with male gender, (female patients demonstrated a HR=0.83, compared to a male reference group), African American, HR=1.26, or other/unknown race, HR=1.29, and age >70, hazard ratio (HR)=2.32. Chi-squared goodness of fit testing identified head and neck cancer patients had a ratio of expected (by chance) to observed mortality of 0.98 and given the close concordance with our null model, were used as our reference group in multivariable analysis. Compared to a head and neck cancer patient baseline, significantly increased ≤10-day mortality was seen in: GI, HR=2.16; lung, HR=1.94; blood, HR=1.46; soft tissue, HR=2.26; and female genital, HR=1.55 cancers. Male genital, HR=0.39; breast, HR=0.57; and endocrine, HR=0.48 cancers had significantly decreased ≤10-day mortality. Of patients with EKG's, male patients who died ≤10-days of their 1st alert had significantly longer QTc intervals than males who survived to day 11 (469 vs 450 milliseconds, p<0.0001). In patients with any cancer and a QTC alert, 0.01 (male genital)-2.50% (GI) died ≤10 days of their 1st alert. The majority of deaths recorded <1 year after a patient's 1st alert occurred between 11-180 days during which 2.93 (male genital)-23.8% (GI) of the total sample with that primary cancer site diagnosis died. 63.2 (GI)-95.9% (endocrine) of cancer patients were alive >1 year after their 1st alert. CONCLUSION: Our research supports the anecdotal suggestion that very few patients die within 10 days of their initial QTc alert, suggesting that in many cases they function as distractions, especially in male genital, breast, and endocrine cancer patients and females or individuals <50 years of age. However, they may also identify patients at imminent risk of death, particularly those with lung, soft tissue, GI, blood, and female genital cancers, or males, African Americans, and individuals >70 years of age. Further, our analysis shows that QTc alerts may be a negative prognostic factor as the patients with more alerts (>5) have greater ≤10-day mortality rates. Additionally, of the patients who die within 365 days of their first alert the vast majority across cancer sites die between 11-180 days.
Assessment of Circularized HPV16 E7 RNA, GLUT1, and PD-L1 in Anal Squamous Cell Carcinoma
(2020-05-01T05:00:00.000Z) Chamseddin, Bahir Hassan; Wang, Richard; Le, Lu Q.; Hammer, Suntrea
BACKGROUND: Anal squamous cell carcinoma (ASCC) is a rare, deadly malignancy caused by high-risk human papillomaviruses in up to 90% of cases and continues to be treated by cytotoxic therapy established 40 years ago. There is a dearth of reliable biomarkers for ASCC. The prognostic implication of programmed death-ligand 1 (PD-L1) expression remains controversial while other biomarkers, like glucose-1-transporter (GLUT1) expression levels, have not been examined in the setting of ASCC. More recently, covalently closed circular RNAs has been (circRNA) expression has been shown to be widespread in cancers, and circRNAs have been proposed to be potential biomarkers. In previous studies, we discovered a novel circular E7 RNA expressed by HPV16 (circE7), which has not been assessed as a potential biomarker in any diseases. OBJECTIVE: We hypothesize that human papillomavirus infection status, increased GLUT-1 expression, increased PD-L1 expression, and HPV E7 RNA expression will serve as biomarkers for higher mortality in patients with anal squamous cell carcinoma. METHODS: A retrospective, translational case series was conducted on twenty-two subjects to analyze PD-L1, GLUT1, HPV-ISH, and HPV circE7 in relation to the clinical features and overall survival of patients with anal squamous cell carcinoma. To supplement understanding of the HPV circE7 biomarker, bioinformatic analyses of RNA-Seq data from the Cancer Genome Atlas was performed on 875 subjects with HPV-driven head and neck cancer and cervical cancer. RESULTS: Improved overall survival could be predicted histologically by pure basaloid architecture (p=0.013), PD-L1 expression (p=0.08), HPV-ISH positivity (p<0.001), but not GLUT1 expression. Quantitative RT-PCR of archived tumors revealed that high levels of circE7 in ASCC were predictive of improved overall survival (p=0.023). Bioinformatic analyses suggested that the presence of high amounts of circE7 correlated to improved survival in 875 subjects (p=0.074). CONCLUSION: Glut-1 overexpression was ubiquitous among all anal squamous cell carcinoma cases but was not predictive of survival. This study adds to the growing evidence of PD-L1 expression correlation to improved survival in ASCC. CircE7 levels correlate with improved survival in anal squamous cell carcinoma but larger, prospective studies are necessary to confirm the potential role of circE7 as a biomarker.
Assessment of Dermatology Clinic Resources at Safety-Net Hospitals: Results from a National Survey
(2017-03-24) Malviya, Neeta; Chong, Benjamin F.; Pandya, Amit; Jacobe, Heidi
BACKGROUND: The extent of resources available to outpatient dermatology clinics at safety-net hospitals providing care to the underserved is not well characterized. Identification of resource gaps can direct strategies that improve dermatologic care to this population. OBJECTIVE: To determine the state of resources at safety-net dermatology clinics. We hypothesized that staffing and specialty services at safety-net hospital dermatology clinics were suboptimal, and that these clinics have long patient wait-times and high no-show rates. METHODS: A cross-sectional survey was conducted to assess resources at outpatient dermatology clinics in safety-net hospitals affiliated with US dermatology residency programs. Surveys consisting of 42 questions were sent via e-mail to the chiefs of outpatient dermatology clinics at 50 safety-net hospitals. The survey was administered between July and October 2016. RESULTS: 31 (62%) safety-net dermatology clinics participated in the survey. The median wait time for the third next available appointment for a new and follow-up patient was 45 (interquartile range: 30-90) days and 30 (16.5-55) days, respectively. The median no-show rate was 30% (24.5-35). Clinics reported median ratios of 3 providers to 1 nurse (1.75-4), and 2 providers to 1 medical assistant (2-4). 58.1% utilized non-paid dermatology attendings. 93.5% offered dermatopathology and pediatric dermatology services, while 41.9% had on-site Mohs surgery. CONCLUSION: Patients face long wait times and no-show rates are high, with suboptimal provider to support staff ratios. Most clinics had access to dermatology subspecialty care, such as pediatric dermatology, and dermatopathology. Expanding staffing, improving patient no-show rates, and use of teledermatology could improve access to dermatologic care in safety-net hospital systems.

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