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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Now showing 1 - 20 of 223

The Effect of Antibiotic Prophylaxis on Infection Rates in Mohs Micrographic Surgery: A Single-institution Retrospective Study
(2021-05-01T05:00:00.000Z) Li, Jeffrey Niu; Srivastava, Divya; Nijhawan, Rajiv I.; Nguyen, Khang
BACKGROUND: Data and recommendations regarding antibiotic prophylaxis in dermatologic surgery vary in terms of effectiveness in preventing surgical site infection, prosthetic joint infection, infective endocarditis, and specifics regarding administration. OBJECTIVE: The objective of this study is to describe the effect of antibiotic prophylaxis (AP) in Mohs micrographic surgery (MMS) on infective endocarditis, prosthetic joint infection, and surgical site infection. METHODS: A single-institution retrospective cohort study of antibiotic use (pre-/intra-operative, post-operative or none) among 2,364 patient encounters treated with MMS was performed. Information regarding patient demographics, surgical site infection, prophylactic antibiotic administration (e.g. none, pre-/intraoperative loading dose, postoperative), type of repair, tumor type, surgery site, duration of patient stay, and other relevant covariates were collected. Inclusion criteria also included those who had at last one follow-up appointment or phone call with any provider after surgery. Bivariate logistic regression evaluated for associations between patient and operative characteristics, antibiotic use, and infectious complications. RESULTS: 85.8% of patients received no AP, 10.0% received post-operative AP, and 4.1% received pre-/intra-operative AP. The overall surgical site infection (SSI) rate was 1.3%. SSI did not differ between patients who received pre-/intra-operative prophylaxis, post-operative prophylaxis or no antibiotics. One patient receiving pre-/intra-operative prophylaxis developed SSI. Repairs involving porcine xenografts and interpolation/pedicle flaps were associated with increased SSI. In addition, there were no patients who post-operatively experienced an infected joint or infective endocarditis. CONCLUSION: There was no difference in rates of SSI when comparing MMS patients who received pre-/intra-operative, post-operative or no AP. There were no cases of infective endocarditis or infected prosthetic joints.
Cervical Cancer Treatment Pathway in Botswana
(2021-05-01T05:00:00.000Z) Mehta, Priyanka Chetan; Grover, Surbhi; Nwachukwu, Chika; Kumar, Kiran
BACKGROUND: The incidence and mortality of cervical cancer in Botswana are among the highest in the world. Despite availability of chemoradiation and government funding for cancer treatment, many patients referred for chemoradiation in Botswana do not receive treatment. OBJECTIVES: This study sought to determine the proportion of cervical cancer patients referred for chemoradiation who do not receive cancer treatment and identify factors associated with receipt or non-receipt of treatment. Time between key steps in the care cascade was quantified to identify points that contribute to delays in care. This study also examined the impact of Princess Marina Hospital's multidisciplinary gynecologic oncology (PMH MDT) clinic on treatment receipt. METHODS: 230 patients with biopsy-proven cervical cancer were enrolled from January 2015 to July 2018 at Princess Marina Hospital in Gaborone, Botswana and followed until November 2019. Patient demographics, clinical characteristics, treatment characteristics, and time between steps in the care cascade were compared between treated and untreated patients using Wilcoxon rank sum tests, chi-squared tests, student's t tests, and univariate binomial logistic regression. RESULTS: 43 (18.7%) patients did not receive cancer treatment. Higher FIGO stage at initial presentation (OR: 0.50, 95% CI: 0.31-0.83, p < 0.01) and presentation during MDT clinic's first year (OR: 0.30, 95% CI: 0.15-0.59, p < 0.001) were associated with significantly lower odds of receiving treatment. Age, residential distance from treatment site, and HIV status were not predictive of treatment receipt. The largest discrepancy in time between treated and untreated patients was median time between pathology report and first MDT clinic visit: 22 days for treated patients (IQR: 9-63; n = 162) vs. 44 days for untreated patients (IQR: 9-146; n = 33) (p > 0.05). CONCLUSION: The MDT model is an evidence-based strategy to improve care coordination and reduce treatment disparities, thus improving outcomes for cancer patients. While there are still gaps in Botswana's cervical cancer care cascade, the PMH MDT clinic has led to significant improvements in cancer care among this population. The PMH MDT clinic provides strong evidence that MDT clinics can and should be established in under-resourced settings.
Development of a Holistic Specialty Interest Assessment Tool: A Pilot Project for a Resource Allocation Paradigm
(2021-05-01T05:00:00.000Z) Raphel, Tiana Janae; Sulistio, Melanie; Sendelbach, Dorothy; Trello-Rishel, Kathlene
BACKGROUND: Current specialty matching tools quantify students' enjoyment completing highly specific tasks. However, the importance of accounting for multifaceted influences on specialty choice grows. OBJECTIVE: Our purpose was to better understand how personality and personal values affect ultimate specialty choice. METHODS: We performed a literature search to identify important drivers of specialty choice. Next, we created and administered an original specialty interest assessment tool in response to literature search. We used the Ten-Item Personality Inventory (TIPI) to measure personality and we performed multivariate logistic regressions to assess for the significance of personality and personal values in determining specialty choice among current physicians and graduating medical students. RESULTS: Two-hundred and eight non-graduating medical students, 66 graduating medical students and 819 physicians completed administered surveys. Agreeableness and conscientious were significant in choosing Primary Care (PC) and Life Style Friendly (LF) specialties. Importance of salary was a significant predictor of choice of both PC and LF specialties. CONCLUSIONS: Personality and personal values were found to be significant predictors of ultimate specialty choice.
Efficacy of Botswana's National Cancer Treatment Strategy: A Preliminary Analysis of Radiation Therapy in Breast Cancer Patients
(2021-05-01T05:00:00.000Z) Shah, Sidrah Mariam; Grover, Surbhi; Chang, Mary; Nwachukwu, Chika
BACKGROUND: Breast cancer is a significant threat to public health in low- and middle-income countries (LMIC) globally, with the observation of an alarming increase in incidence in sub-Saharan Africa. Radiation Therapy (RT) is an essential component of breast cancer treatment and many LMIC currently lack access to RT. In Botswana, cancer care for citizens is paid for by the government, which has resulted in a unique investment in RT compared to other countries in the region. However, breast cancer mortality remains high, warranting further investigation into patient access to and receipt of RT. OBJECTIVE: This project seeks to investigate and present preliminary data on the percentage of breast cancer patients in Botswana qualifying for RT who actually went on to initiate RT. Demographic and clinical characteristics of breast cancer patients in Botswana are also presented. METHODS: Demographic, clinical, and treatment information was collected prospectively on all breast cancer patients presenting to the Breast Multidisciplinary Team (MDT) clinic at Princess Marina Hospital (PMH) in Gaborone, Botswana from January 2015 to October 2020. Patients with incomplete treatment information were excluded from the analysis. Patients who should have received RT were identified based on National Comprehensive Cancer Network (NCCN) guidelines. RESULTS: A total of 131 patients were included in the analysis. Of these, 29.8% were HIV-positive and 77.5% presented with advanced-stage disease. The vast majority of patients underwent mastectomy, and only 35% received chemotherapy. Based on NCCN guidelines, 121 patients qualified for receipt of radiation. In this population of breast cancer patients in Botswana, 92.6% of patients who needed RT received it. CONCLUSION: Based on this preliminary analysis, the investment of Botswana's Ministry of Health in RT for its citizens is seeing encouraging success among breast cancer patients. This analysis was limited by incomplete treatment information on the majority of breast cancer patients in this cohort, limiting the sample size in the final analysis. Further study is needed to characterize completion of RT in this population and factors that affect this.
Flexibility of Functional Neuronal Assemblies Supports Human Memory
(2021-05-01T05:00:00.000Z) Umbach, Gray Steven; Lega, Bradley C.; Pfeiffer, Brad E.; Rugg, Michael D.
BACKGROUND: Assemblies, groups of neurons that fire together on short timescales, could provide the fundamental building block of cognition but have eluded observation in human recordings. OBJECTIVE: Leveraging a large single unit dataset obtained from human epilepsy patients, we observe neuronal assemblies and relate their composition and dynamics to human memory for the first time. METHODS: We enrolled human epilepsy patients implanted with electrodes capable of recording both large-scale brain oscillations as well as the spiking activity of single neurons. Using established methods, we identified groups of neurons that consistently fire within 25 ms of each other across recording. We extracted several features of these assemblies, such as the order of neuron firing within the identified groups, the relationship of assembly activity to underlying gamma oscillations (40 Hz), and the dynamics of neuron membership in assemblies across recording. RESULTS: We find that assemblies are comprised of sequences of neurons phase-locked to underlying gamma oscillations, and that both the consistency of these sequences and their reactivation rate correlates with successful memory. Further, we find that the relative contribution of each neuron to the assembly drifts across recording. The magnitude of drift predicts memory performance and varies along the hippocampal longitudinal axis. CONCLUSION: Our data provide human validation to the hypothesized relevance of transiently co-active neurons to memory. This work has important implications for the continuing efforts to develop brain computer interface devices that rescue cognitive deficits and for elucidating the fundamental mechanisms by which the brain constructs thought.
Ice-POP: Ice Application for Post-Operative Pain: A Randomized Controlled Trial
(2021-05-01T05:00:00.000Z) Kenyon, Laura Elizabeth; Kho, Kimberly A.; Shields, Jessica; Weix, Patrick
BACKGROUND: The Opioid Crisis is directly linked to over-prescription of opioids by physicians. Non-opioid and non-pharmacologic forms of post-operative pain management need to be explored. Cryotherapy, accomplished with the use of ice, is a non-pharmacologic form of pain relief. There is limited data regarding cryotherapy and its application in abdominal surgery. OBJECTIVE: To investigate the effectiveness of cryotherapy as an additional form of pain control in women undergoing total laparoscopic hysterectomy (TLH) for benign gynecologic conditions through a randomized trial. METHODS: 52 patients were randomized evenly to receive standardized post-operative pain management with or without cryotherapy (abdominal ice packs applied directly following surgery). VAS pain scores and narcotic usage were collected at the patient's pre-op appointment, before surgery, at discharge, during a 1-day post-op phone interview, and at a 2-week post-op appointment. Questions about the patient's perception of pain were asked during the postoperative day 1 phone call. Quality of recovery scales were collected at enrollment and the 2-week post-op appointment. Demographic data, VAS pain scores, and narcotic usage were analyzed for significance via the student's t-test. RESULTS: There was no statistically significant difference (p < 0.05) between the patient group receiving ice and no ice based on demographics, VAS pain score, narcotic usage, quality of recovery, and perception of pain control. However, for patients using ice, VAS pain scores were lower on postoperative day 1 and narcotic usage was lower in the post-anesthesia care unit (PACU). Patient perception of ice was largely positive with 87% of patients reporting they would use ice again while 83% would recommend ice to family/friends. Of note, less than half (38%) of opioids prescribed were used within 2 weeks post-op. CONCLUSION: Based on the minimal risks of ice, low cost, and perceived benefit by patients including the opportunity for patient autonomy, we would recommend using ice immediately following surgery. Ice is a reasonable alternative to decrease the number of opiates prescribed.
Development of Video and Simulation-Based Communication Skills Learning: Responding to Emotions
(2021-05-01T05:00:00.000Z) Nguyen, Trung Tan; Siropaides, Caitlin; Sendelbach, Dorothy; Abraham, Reeni
PROBLEM: Responding appropriately to patients’ emotions and concerns is vital for excellent patient care and outcomes. There is a lack of training in this area, with the need to educate healthcare providers about how to appropriately respond to emotions. While communication skills training programs exist for undergraduate medical education, medical students often feel unprepared in responding to patients’ emotions INTERVENTION: A 90-minute small group exercise was developed for second-year pre-clinical students at a large United States medical school in Texas. The exercise consisted of faculty-facilitated small group discussion of two video examples of a patient encounter, comparing clinician responses to patient emotions. The exercise utilized a framework for identifying skills and patient impact of verbal expressions of empathy to different patient emotions. CONTEXT: This curriculum sought to demonstrate examples of strong patient emotions for preclerkship students, and introduce a framework of concrete communication skills that can positively impact a clinical encounter. Data was collected by questionnaires delivered immediately pre-session and post-session, as well as 3 months post-session. Survey questions assessed student perception of effectiveness of the exercise, student-reported preparedness and feeling equipped to perform various communication skills during clinical visits. Paired t-tests were performed and data analyzed for qualitative responses. OUTCOMES: The process evaluation yielded a positive subjective learner response to the exercise which was sustained at 3-month follow-up. The students (N=161 paired for the immediate pre- and post-survey) reported significant increases in knowledge and preparedness to recognize and appropriately respond to different patients’ emotions (P= 0.001). Qualitative data were also captured in the surveys. LESSONS LEARNED: This video-based small group discussion of skills to express verbal empathy is perceived by pre-clinical medical students to be beneficial, and to improve their knowledge and preparedness for using empathic skills in the future. There is a need for further investigation whether this type of communication skills training results in behavior change and is sustained long-term.
The Role of Hypertension and Type II Diabetes in Glaucoma Severity
(2021-05-01T05:00:00.000Z) Tong, Betty Le; Kooner, Karanjit; Petroll, W. Matthew; Chiu, Michael
BACKGROUND: Hypertension (HTN) and Type II Diabetes (DM) are risk factors associated with the development of primary open angle glaucoma (POAG), but the effects of these diseases on POAG severity are not well known. OBJECTIVE: To evaluate for differences in glaucoma severity for patients with (1) HTN alone, (2) DM alone, (3) both HTN and DM, and (4) neither HTN nor DM. METHODS: In this IRB approved retrospective chart review study, we selected a total of 767 patients with POAG or ocular hypertension (OHT) seen at UT Southwestern Aston eye clinic in Dallas, Texas. The inclusion criteria were patients who were > 18 years old, had open angles, and no evidence of secondary glaucoma or retinal/optic nerve pathologies. Variables collected included: visual acuity, intraocular pressure, central corneal thickness, visual fields, blood pressure, HgbA1c, demographic factors (age, race, gender), and optic coherence tomography angiography (OCTA) data such as mean macular vessel density (VD), peripapillary VD, peripapillary retinal nerve fiber layer (RNFL), and total ganglion cell complex (GCC). RESULTS/CONCLUSION: Out of a total of 1104 participants reviewed, we selected 767. Among the included patients, there were 149 (19.5%) subjects without POAG, 122 (15.9%) with OHT, 95 (12.4%) with mild POAG, 137 (17.9%) with moderate POAG, and 262 (34.2%) with severe POAG. Regarding the four comorbid disease groups of interest, there were 212 (27.6%) control patients with neither HTN nor DM, 318 (41.5%) with HTN alone, 47 (6.1%) with DM alone, and 190 (24.8%) with both HTN and DM. All comorbidity groups had more female than male, and the average age of the groups ranged from 66-72 years old. We did not find a significant difference in the distribution of glaucoma severity between those with HTN/DM and those without. OCTA analysis corroborated our findings.
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.
Palliative Care for Refugees and Asylees: A Systematic Review and Single-Institution Analysis of Healthcare Utilization
(2021-05-01T05:00:00.000Z) Tao, Zoe Renee; Gimpel, Nora; McGregor, Tamara; Dussel, Veronica; Wang, Winnie
BACKGROUND: Palliative care addresses physical, psychosocial, and spiritual dimensions of suffering. Palliative care may have significant impact for populations such as refugees and asylees, who flee conflict and persecution and may have a high burden of chronic and life-limiting illness. OBJECTIVES: The goal of this systematic review was to synthesize existing observational studies on palliative care for refugees and asylees. Additionally, the goal of the accompanying single-institution review was to analyze healthcare access and utilization in a safety net refugee outreach clinic. METHODS: A systematic review was undertaken using PRISMA guidelines. Six full-length articles were selected for review. National Consensus Project palliative care domains were utilized for thematic analysis. A retrospective chart review was undertaken for refugee patients establishing care between 2014-2016. Data was extracted on demographics, insurance status, and outpatient clinic and emergency department (ED) visits. RESULTS: Articles selected for systematic review covered heterogeneous research methodology and refugee populations, with all investigators originating from high-income nations. Identified Challenges and Practices to palliative care encompassed all NCP domains, and Recommendations for palliative care for refugees and asylees encompassed all but the Ethical and Legal aspects of care. In our single-institution review, we found that most refugee patients were able to maintain healthcare insurance and attended follow-up primary care visits, with few relying on the ED for primary care. CONCLUSIONS: Greater attention and funding should be allocated to lower-income nations for addressing refugee palliative care needs. Increased focus should be given to studying ethical, legal, and systemic barriers to care. Outpatient care in safety net hospitals may be an important means of addressing refugee and asylee palliative care in well-resourced settings.
Incidence and Predictors of a Difficult Airway in Lean vs. Obese Surgical Patients: A Large Prospective Cohort Study
(2021-05-01T05:00:00.000Z) Smith, Katelynn Marie; Moon, Tiffany; Fox, Pamela; Ogunnaike, Babatunde
BACKGROUND: With the high incidence of obesity rates, the determination of whether obese individuals are more difficult to intubate is of the utmost importance. This study aimed to determine the incidence of difficult intubation in obese vs lean patients in the general surgery population at a large tertiary, teaching hospital and assess obesity as a risk factor for difficult intubation. In addition, this study examined additional patient characteristics and anthropometric factors as independent predictors of difficult intubation. I hypothesize that obesity will not be a significant risk factor for difficult intubation. Instead factors such as age, higher Mallampati score, and male sex will be better predictors of difficult intubation. METHODS: This prospective cohort observational study enrolled 4,003 patients undergoing general endotracheal anesthesia. Emergent cases, patients with a known or suspected difficult airway, and patients not expected to initially undergo direct laryngoscopy were excluded. Patients were stratified into two cohorts based on body mass index (BMI): a non-obese group (BMI <30 kg m-2) and an obese group (BMI ≥30 kg m-2). Intubation difficulty was determined using the Intubation Difficulty Scale (IDS). RESULTS: The incidence of severely difficult intubation (IDS ≥ 5) was 5.9% in the obese cohort compared to 4.6% in the non-obese cohort which was not significant (p= 0.061). Controlling for other factors, obese patients were more likely to be difficult to intubate (odds ratio (OR), 1.438; 95% confidence interval (95% CI), [1.064, 1.943], p=0.001). In the analysis of additional patient characteristics and anthropometric values, age > 45 years (OR, 1.586; 95% CI, [1.064, 1.943], p<0.001), male sex (OR, 2.034; 95% CI, [1.532, 2.702], p<0.001), Mallampati score of 3-4 (OR, 2.441; 95% CI, [1.820, 3.273], p<0.001), neck circumference (OR, 1.096 per cm increase; 95% CI, [1.066, 1.128], p<0.001), thyromental distance (OR, 0.757 per cm increase; 95% CI, [0.691,0.830], p<0.001) and sternomental distance (OR, 0.923 per cm increase; 95% CI, [0.770, 0.874], p<0.001) were also significant. However, inter-incisor distance and waist circumference were not. CONCLUSIONS: Obese patients are more likely to be difficult to intubate. However, male sex, age > 45 years, and a high Mallampati score are stronger predictors of difficult intubation compared to BMI. Therefore, while BMI still provides relevant information, BMI alone should not be used as a sole predictor of difficult intubation.
Determination of the Optimal Targeted Prostate Biopsy Strategy
(2021-05-01T05:00:00.000Z) Subramanian, Naveen Gopal; Costa, Daniel N.; Pedrosa, Ivan; Yokoo, Takeshi
BACKGROUND: Prostate cancer is one of the leading causes of cancer-related mortality in men and is treated in different ways based on the aggressiveness of the disease. The traditional method of diagnosis has been the systematic biopsy, which frequently underestimates or completely misses the disease. Recently, targeted prostate biopsies using pre-biopsy multiparametric MRI (mpMRI) have increased the detection of clinically significant disease. Of these methods, the two most sophisticated types are the MRI-TRUS fusion biopsy and the direct in-bore biopsy. Data comparing the diagnostic accuracy of these approaches and optimization of the biopsy procedure are lacking. OBJECTIVE: To compare the diagnostic accuracy of in-bore biopsy and MRI-TRUS fusion biopsy at accurately determining the index lesion grade group compared to radical prostatectomy (Aim 1), and to establish the optimal number of cores taken during in-bore biopsies to maximize detection of clinically significant disease while minimizing duration of the biopsy (Aim 2). METHODS: In Aim 1, patients that had at least one prostate lesion with abnormal mpMRI (at least one PI-RADS score 3 lesion) followed by targeted biopsy between April 2017 and January 2019 were included. The decision of what biopsy method to use for each patient was made by the ordering provider. The index lesion was defined as the largest lesion that exhibited the highest grade group (GG) and/or stage. The reference standard was the highest GG obtained from the radical prostatectomy specimen. In Aim 2, patients with abnormal mpMRI followed by in-bore biopsy between May 2017 and December 2019 were included. The endpoints of the study were the detection rate of clinically significant disease (defined as a GG of at least 2) and the GG upgrade (defined as the increase in the cumulative maximum GG with each additional core). RESULTS: In Aim 1, there was a statistically significant difference in the number of GG upgrades between the two biopsy types, with the in-bore biopsy having fewer (14%) upgrades than the fusion biopsy (30%; p=0.012). The mean net GG change was also significantly lower in the in-bore cohort (-0.11) compared to the fusion cohort (+0.16; p=0.0085). The GG concordance of the in-bore cohort (61%) was higher than the fusion cohort (53%) when compared to radical prostatectomy. In Aim 2, clinically significant cancers were detected by the first biopsy core in 78% of cases, the second core in 13% of cases, and the third core in 8.1% of cases. Only two lesions had the fourth core find csPCa. GG upgrade from insignificant to significant disease was also higher in the second and third cores (3%) compared to the fourth and fifth cores. The fourth and fifth cores only detected 0.3% of clinically significant tumors and resulted in only 1.2% of GG upgrades. CONCLUSION: Direct in-bore MRI-guided biopsy has greater diagnostic accuracy and a lower incidence of GG upgrades compared to MRI-TRUS fusion biopsy. Three cores per lesion was determined to offer the optimal balance between increasing the detection of clinically significant cancers and minimizing biopsy duration. Future work will center around cost-effective analyses and the impact on long-term patient outcomes.
Cholecystitis Fast Track Pathway Provides Safe, Value Based Care on Busy Acute Care Surgery Service
(2021-05-01T05:00:00.000Z) Houshmand, Natasha Nazerani; Reed, W. Gary; Cripps, Michael W.; Phelps, Eleanor
BACKGROUND: Fast track (FT) pathways have been adopted across a multitude of elective surgeries, with the culmination of their progress resulting in higher value-based care of the patient. However, these programs have been slow to be adopted into the acute care surgery (ACS) realm. We hypothesized that a FT pathway implemented in an ACS service would safely hasten patient progress to the operating room while decreasing patient length of stay. To minimize variation, we have selected a singular, common operation, the cholecystectomy, which can be compared across two hospitals with well-established ACS services, one with a FT pathway and one with a traditional pathway. METHODS: All patients at both hospitals that underwent an urgent or emergent laparoscopic cholecystectomy for acute cholecystitis between May 1, 2019 and October 31, 2019 were queried using CPT codes. Patients that required a conversion to open or partial cholecystectomy were excluded because they no longer qualified for the fast track pathway. Retrospective chart review was used to gather information relating to the patients' demographics, presentation, operative and hospital course, and outcomes. Time to OR and hospital length of stay were the primary outcomes. RESULTS: There was a total of 479 urgent or emergent laparoscopic cholecystectomies performed during the 6 months for acute cholecystitis. Four hundred and thirty (89.8%) were performed under the FT pathway and 49 (10.2%) were performed under the traditional pathway. The median [IQR] time to the OR following surgical consultation was not different between the two pathways: 14.1 hours [8.3-29.0 hours] for FT and 18.5 hours [11.9-25.9 hours] for traditional (p=0.316). However, the median length of stay was shorter by 15.9 hours in the FT cohort (22.6 hours, [14.2-40.4] vs 38.5 hours, [28.3-56.3]; p<0.0001). Under the FT pathway, 33% of patients were admitted to the hospital and 75.6% were discharged from the PACU, as compared to 91.8% and 12.2% on the traditional pathway, respectively (both p<0.0001). 59.6% of FT patients received a phone call follow up, as opposed to the traditional pathway where all patients had clinic follow up (p<0.001). ED bounce back rate, readmission rates, and complication rates were similar between the FT and traditional pathways (p>0.2 for all). On multivariate analysis, having a fast track pathway was an independent predictor of discharge within 24 hours of surgical consultation (OR 7.6, 95% CI 2.9-20.2, p<0.0001). CONCLUSION: Use of a fast track program for patients with acute cholecystitis has a significant positive impact on hospital resource utilization without compromise of clinical outcomes. Shorter times in the hospital and fewer clinic appointments benefit the hospital, surgeon, and patient. Incorporation of a FT pathway into all areas of ACS should be investigated.
Barriers to Cochlear Implantation
(2021-05-01T05:00:00.000Z) Balachandra, Sanjana; Hunter, Jacob B.; Kutz, J. Walter; Isaacson, Brandon
INTRODUCTION: Cochlear implantation (CI) is the most effective treatment for profound sensorineural hearing loss, despite the low utilization of CI in the United States. Only about 5-7% of CI-eligible adults pursue CI, for reasons which remain unclear. OBJECTIVE: Our research has two primary aims: 1) to identify sociodemographic disparities in CI in Texas and explore trends using an all-payer database from 2010-2017; and 2) to investigate patient-reported barriers to, and motivators for, pursuing CI. METHODS: Aim 1) The publicly available Texas Outpatient Surgical and Radiological Procedure Data was accessed to analyze outpatient CI cases in the entire state of Texas. Variables analyzed include patient age, sex, race/ethnicity, and insurance status. Population data from the American Community Survey were utilized to generate CI utilization rates by patient demographic characteristics. Insurance data was obtained from the Kaiser Family Foundation. Aim 2) A single-institutional review of CI candidates between December 2010 and December 2018 was performed to identify patients who did not pursue surgery, as well as those who pursued surgery after a delayed time period or at a different institution. A 21-question survey was developed internally, aimed at identifying and ranking patients' concerns regarding surgical risks, adaptation to the CI, time commitment to adapt, costs, loss of residual hearing, and lack of benefit. Current hearing aid usage and familiarity with other CI users were also analyzed. The survey was administered via email or telephone. RESULTS: Aim 1) 6,158 CI cases were identified during the study period. The number of CI per year nearly doubled from 497 in 2010 to 961 in 2017. The majority of CI recipients were white (59.5%), male (51.9%), and privately insured (47.9%). Patients over 75 demonstrated the greatest increase in the CI rate per 100,000 population, increasing from 4.60 in 2010 to 14.30 in 2017. All racial/ethnic groups noted an increase in the CI per 100,000 population, with white patients demonstrating the highest rate in 2017, at 4.36 CI per 100,000 population. Asian patients had a 502% increase in the CI rate (from 0.42 to 2.53), compared with 87.9%, 84.4%, and 69.2% increases for White, Black, and Hispanic populations, respectively. Medicaid recipients were the only insurance group that did not experience a statistically significant growth from 2010-2017 (3.27 to 3.49, p=0.26). Aim 2) Fifty-two survey responses were received, comprised of 27 patients who did not pursue CI and 25 patients who did. The most commonly reported barrier was a belief that CI would not significantly improve the ability to communicate, followed by concerns over the post-operative recovery process, risks of surgery, and risks of losing music appreciation. Anesthetic risk and cost were the least important reasons not to pursue CI. The most commonly reported facilitator was a belief that hearing loss was affecting job performance. CONCLUSIONS: CI became more widespread between 2010-2017; however, vast disparities exist in who benefitted most from this growth in CI. Black and Hispanic populations had lower CI per 100,000 population than their white peers, while patients >65 years of age accounted for the greatest increase in CI. Moreover, the decision not to pursue CI despite eligibility is multifactorial and includes concern for minimal hearing benefit and perioperative risks. These factors should be taken into consideration when counseling patients on CI surgery. Resources should be devoted to promote CI to disadvantaged groups as identified in our research.
Bone Health Outcomes in Post-Lung Transplant Patients with Cystic Fibrosis
(2023-05-01T05:00:00.000Z) Tran, Triet Vincent Minh; Maalouf, Naim M.; Jain, Raksha; Lederer, Eleanor D.
BACKGROUND: Osteoporosis is a common comorbidity in patients with cystic fibrosis (CF). Although lung transplantation (LTx) improves quality of life of CF patients, there is little research examining long-term bone health outcomes following LTx in these patients. OBJECTIVE: We sought to compare long-term bone health outcomes in LTx patients with and without CF, as well as determine factors associated with adverse bone health in CF patients. METHODS: Data were collected on 59 patients who underwent LTx between 2006-2019, including 30 with CF and 29 without CF. We compared baseline characteristics, long-term bone mineral density (BMD) trends, and fracture incidence between the two patient populations, and examined factors associated with post-LTx fractures in CF patients. RESULTS: Compared with non-CF patients, patients with CF were younger, had lower body mass index, and lower baseline BMD Z-scores at the lumbar spine, femoral neck, and total hip (all p<0.001). BMD at all sites declined in both groups in the first year post-LTx. In subsequent years, CF patients exhibited better BMD recovery relative to pre-transplantation, but continued to have lower BMD post-LTx. Post-transplant fractures occurred in 30% and 34% of CF and non-CF patients, respectively. CF patients who developed fractures after LTx had significantly lower BMD and lower pre-transplantation percent predicted forced expiratory volume in one second (FEV1%). CONCLUSION: Although CF patients exhibit better BMD recovery following LTx compared to their non-CF counterparts, CF patients start with significantly lower pre-LTx BMD and experience a similarly high rate of post-LTx fractures. These findings highlight the unique contribution of the CF disease process to bone health, as well as a clear need for better prevention and treatment of osteoporosis in CF patients before and after LTx.
Improving Adherence to an Integrated Spontaneous Awakening and Spontaneous Breathing Trial Protocol
(2023-05-01T05:00:00.000Z) Seal, Brayden Christopher; Reed, W. Gary; Bartolome, Sonja; Kershaw, Corey D.
BACKGROUND: Integration of nursing-driven spontaneous awakening trial (SAT) and respiratory therapy-driven spontaneous breathing trial (SBT) protocols for patients on mechanical ventilation in the intensive care unit (ICU) is associated with fewer ventilator days, shorter ICU stays, and reduced hospital length-of-stay. However, institutional adherence is often suboptimal due to the complexity and multidisciplinary nature of these integrated protocols. This project aims to describe baseline compliance with our institution's SAT/SBT protocol, identify factors influencing compliance, and increase adherence to the existing SAT/SBT protocol in the ICU to a goal of greater than 95% compliance by August 2023. LOCAL PROBLEM: Data from a retrospective chart review indicated a SAT screen rate of 63.8% and a SBT screen rate of 85%. Therefore, the SAT/SBT protocol adherence at our institution is sub-optimal. METHODS: Initially, we determined baseline adherence rates through a retrospective chart review of SAT and SBT documentation. Specifically, we identified the rates of correctly performed SAT and SBT screenings for all eligible patients and the subsequent rates of correct SAT and SBT performance for patients who passed the appropriate screening. We then sought to identify factors influencing adherence to the SBT/SAT protocol by employing an ethnographic approach, including: (a) process mapping of the integrated SAT/SBT protocol, (b) literature-driven surveys using the Likert scale to assess potential barriers to protocol adherence, (d) informal interviews with nurses and respiratory therapists, and (e) direct observation in the medical ICU. Individual factors identified were organized using the Systems Engineering Initiative for Patient Safety (SEIPS) sociotechnical framework. The SEIPS model allowed for further design of targeted interventions to improve protocol adherence. RESULTS: Factors influencing adherence were identified from survey responses by 63 nurses and 26 respiratory therapists, 30 hours of direct observation, and tabulated comments from surveys and informal interviews. Prominent factors influencing compliance included knowledge of the protocol, protocol variation across intensive care units, accessibility of the protocol, ease of documentation in the electronic medical record (EMR), and the exclusion of nurses and respiratory therapists in physician-led ICU rounds. CONCLUSION: Data from a retrospective chart review and ethnographic investigation of SAT/SBT protocols indicated sub-optimal adherence. Further investigation into the specific factors influencing adherence allowed us to propose specific interventions to improve performance. Such future interventions will include: (a) EMR redesign using feedback obtained in our investigation to improve accessibility and allow reliable surveillance of protocol adherence, (b) enhanced, standardized multidisciplinary ICU rounds, (c) protocol education sessions, (d) continuous monitoring of protocol metrics with intermittent feedback provided to staff, and (e) a Quality Assurance and Performance Improvement Workgroup dedicated to regular engagement of key stakeholders for process improvement.
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.
Improving Adherence to Opioid Prescribing CDC Guidelines for Chronic Pain
(2021-05-01T05:00:00.000Z) Zamir, Aemen; Reed, W. Gary; Kandil, Enas; Phelps, Eleanor
BACKGROUND: The Centers for Disease Control and Prevention have released treatment guidelines for chronic pain care as concerns about opioid overuse and abuse increase. Additionally, The Texas Medical Board has outlined their policy for the use of medication for non-malignant chronic pain purposes in Rule 170.3 of the Texas Administrative Code. Some of the requirements include a signed pain management agreement, regular review of the Prescription Monitoring Program, a urine drug screen, and documentation of completion of requirements in patient's medical records. OBJECTIVE: Establish baseline adherence to TMB policy for opioid prescribing and implement electronic medical record tools to facilitate completion of requirements METHODS: A preliminary chart review of patients on the opioid registry, an intervention in early phase of implementation meant to easily identify patients receiving opioids for chronic pain, was conducted to determine baseline adherence to Rule 170.3 amongst physicians. Several CDC guidelines which corresponded with TMB requirements were chosen. Post-intervention data was collected from the chronic opioid registry regarding the percentage of patients who had annual review of Prescription Monitoring Database, a urine drug screen, a pain management agreement, and documentation of completion of requirements in patient's medical records. RESULTS: Of the 206 patients studied through chart review pre-intervention, only 6% had all three TMB mandated elements in their charts. After implementing the EMR tools meant to facilitate completion of TMB laws and CDC guidelines, the percentage of patients with a urine drug screen and review of PDMP increased while the percentage of patients with a pain management agreement in their chart decreased. CONCLUSION: Poor compliance in the UTSW system necessitates tools that will streamline the process for completing and documenting the requirements. The implementation of the EHR tools and the opioid registry best practice alerts, as they were rolled out by the Opioid Task Force, helped facilitate completion of requirements.
Outcomes of Patients Diagnosed with Psychogenic Non-Epileptic Seizures
(2021-05-01T05:00:00.000Z) Ramamurthy, Swetha; Das, Rohit; Dave, Hina; Pershern, Lindsey
BACKGROUND: Psychogenic Non-Epileptic Seizures (PNES) is a complex neuropsychiatric illness that is very difficult to diagnose due to complex comorbidities and symptoms. There are also several risk factors associated with development of PNES that can contribute to the patient's presentation. However, there is very little literature on patient outcomes, management guidelines, and prognostic factors. Therefore, patients may not receive treatment according to a standard of care or in a streamlined manner which may worsen patient outcomes. OBJECTIVE: This study will examine 1) if patient outcomes improve with psychiatric or multidisciplinary management and 2) the influence of specific risk factors on patient outcomes. METHODS: This was a retrospective cohort study with data from chart review of the Parkland EMR. A total of 122 patients were examined who were diagnosed with PNES during an EMU admission in 2016. Demographic variables, risk factors for PNES, and treatment intervention information were extracted from each patient chart to be compared with the primary outcome variable. Patient outcomes were measured by recurrent symptoms leading to ED visits and/or EMU admissions after the initial 2016 admission. Descriptive analysis was done using Excel while statistical analysis comparing independent variables to patient outcome variables was done using SPSS 25. If the independent variable was a categorical variable, chi-square tests were used, but for continuous variables, Kruskal-Wallis rank sum tests were used. RESULTS: Preliminary findings showed no significant associations between receiving any singular intervention and patient outcomes. Unexpectedly multidisciplinary management such as therapy and psychiatric follow-up had no significant relationship with patient outcomes. Risk factors that may be associated with increased recurrent PNES symptoms include prior psychiatric disorders, prior ED visits or EMU admissions, and socioeconomic factors such as type of insurance and homelessness. CONCLUSION: Although multidisciplinary management did not show significant reduction in readmissions or ED visits for PNES symptoms, prior literature shows that psychiatric/psychological involvement can improve PNES outcomes. Treatment of PNES should be tailored for patients based on psychiatric/neurologic comorbidities and risk factors. Future research will need to explore the benefits of combinations of interventions and a multidisciplinary clinic such as a PNES clinic for these patients.
Weightbearing and Activity Restriction Treatments and Quality of Life in Patients with Perthes Disease
(2021-05-01T05:00:00.000Z) Do, Dang-Huy; Kim, Harry K. W.; Huo, Michael; Wells, Joel
BACKGROUND: Weightbearing and activity restrictions are commonly prescribed during the active stages of Perthes disease. These restrictions, ranging from cast or brace treatment with nonweightbearing to full weightbearing with activity restrictions, may have a substantial influence on the physical, mental, and social health of a child. However, their impact on the patient's quality of life is not well-described. OBJECTIVES: After controlling for confounding variables, are restrictions on weightbearing and activity associated with physical health measures (as expressed by the Patient-Reported Outcome Measurement Information System [PROMIS] mobility, PROMIS pain interference, and PROMIS fatigue), mental health measures (PROMIS depressive symptoms and PROMIS anxiety), and social health measures (PROMIS peer relationships)? METHODS: Between 2013 and 2020, 211 patients with Perthes disease at a single institution were assigned six PROMIS measures to assess physical, mental, and social health. Patients who met the following eligibility criteria were analyzed: age 8 to 14 years old, completion of six PROMIS measures, English-speaking, and active stage of Perthes disease (Waldenstrom Stage I, II, or III). Weightbearing and activity restrictions were clinically recommended to patients in the initial through early reossification stages of Perthes disease when patients had increasing pain, loss of hip motion, loss of hip containment, progression of femoral head deformity, increased hip synovitis, and femoral head involvement on magnetic resonance imaging (MRI), or as a postoperative regimen. Patients were categorized into four intervention groups based on weightbearing and activity regimen. We excluded 111 patients who did not meet the inclusion criteria. The following six pediatric self-report PROMIS measures were assessed: mobility, pain interference, fatigue, depressive symptoms, anxiety, and peer relationships. Analysis of variance (ANOVA) was used to compare differences between the mean PROMIS T-scores of these weightbearing/activity regimens. Results were assessed with a significance of p < 0.05 and adjusted for Waldenstrom stage, gender, age of diagnosis, and history of major surgery using multivariate regression analysis. RESULTS: After controlling for confounding variables, the mild- (β regression coefficient -15 [95% CI -19 to -10]; p < 0.001), moderate- (β -19 [95% CI -24 to -14]; p < 0.001), and severe- (β -25 [95% CI -30 to -19]; p < 0.001) restriction groups were associated with worse mobility T-scores compared with the no-restriction group, but no association was detected for the pain interference or fatigue measures. Weightbearing and activity restrictions were not associated with mental health measures (depressive symptoms and anxiety). Weightbearing and activity restrictions were not associated with social health measures (peer relationships). Earlier Waldenstrom stage was associated with worse pain interference (β 10 [95% CI 2 to 17]; p = 0.01) and peer relationships scores (β -8 [95% CI -15 to -1]; p = 0.03); female gender was linked with worse depressive symptoms (β 7 [95% CI 2 to 12]; p = 0.005) and peer relationships scores (β -6 [95% CI -12 to 0]; p = 0.04); and earlier age at diagnosis was associated with worse peer relationships scores (β 1 [95% CI 0 to 2]; p = 0.03). History of major surgery had no connection to any of the six PROMIS measures. CONCLUSION: We found that weightbearing and activity restriction treatments are associated with poorer patient-reported mobility in the active stages of Perthes disease after controlling for confounding variables, but not pain interference, fatigue, depressive symptoms, anxiety, or peer relationships. Understanding how these treatments are associated with Perthes disease patients' quality of life can aid in decision-making for providers, help set expectations for patients and their parents, and provide opportunities for better education and preparation. Because of the chronic nature of Perthes disease, future studies may focus on longitudinal trends in patient-reported outcomes to better understand the overall impact of this disease and its treatment.

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