Billings Clinic

Introduction: Post-acute care (PAC) facilities across Montana, Nebraska, and North Dakota participated in the American Heart Association’s (AHA) Tri-State Mission: Lifeline Stroke PAC Initiative, a quality improvement initiative focused on improving stroke rehabilitation across Midwest states from 2022 to 2024. Participating facilities agreed to implement evidence-based practice outlined by AHA’s PAC Stroke Program Standards. Purpose: The Tri-State Mission: Lifeline Stroke PAC Initiative aimed to assist facilities to implement evidenced-based care and track key performance measures and outcome metrics to facilitate ongoing quality improvement. 15 skilled nursing facilities, 7 inpatient rehabilitation facilities, and 15 critical access hospitals participated across three states with emphasis on developing programs in rural communities. Methods: Participating facilities collected quarterly data for six clinical measures and three outcome metrics detailed in the PAC stroke program standards. Data was entered on the Quality and Certification Tool (QCT) platform to track progress and compare to other sites in the initiative. Group data was reviewed with facilities each quarter on virtual learning collaboratives. Results: Positive improvements were reported in four measures: percentage of patients with aphasia receiving speech therapy, patients receiving comprehensive stroke education, patients with impaired mobility who are on a VTE prophylaxis plan, and patients receiving a phone call within 3 business days of discharge. Performance remained consistent in two measures: percentage of patients receiving a depression screening and patients that had an admission assessment completed by an MD or APP in the first 24 hours. Outcome metrics of average length of stay, number of patients, and discharge disposition remained consistent. Conclusion: Focused quality improvement efforts can positively impact key measures and metrics in post-acute stroke programs. While positive trends were observed in four measures, further evaluations need to be done with larger patient volumes and extended periods of time.

BackgroundDigital Cognitive Assessments (DCA) are a promising solution for early dementia detection. BrainCheck has developed an evidence‐based DCA tool, BrainCheck Assess (BC‐Assess), designed to help healthcare providers quickly and reliably evaluate patients with cognitive impairments. Previous studies demonstrated that BC‐Assess effectively distinguishes individuals with normal cognition, mild cognitive impairment, and dementia. This study aims to assess the test‐retest reliability and concurrent validity of BC‐Assess vs traditional paper‐and‐pencil neuropsychological tests.MethodIn collaboration with Brainbox Solutions Inc., 529 participants, who self‐reported as cognitively healthy, were recruited from four US clinical sites after informed consent (NCT04423198). A subset completed BrainCheck assessments twice, with >7 days between tests (test‐retest subset), and another subset completed both BrainCheck assessments and corresponding paper‐and‐pencil tests during the same visit (concurrent validity subset). The BC‐Assess includes assessments evaluating cognitive domains of memory (Immediate/Delayed Recognition), executive function (Stroop), attention and mental flexibility (Trails A/B), and processing speed (Digit Symbol Substitution). These assessments were paired with traditional tests, including the Hopkins Verbal Learning Test (HVLT), Stroop Color Word Test, Trail Making Test, and Wechsler Adult Intelligence Scale (WAIS), respectively. Test‐retest reliability was assessed using intraclass correlation coefficients (ICCs), and Pearson's correlations evaluated concurrent validity between BrainCheck assessments and paper‐and‐pencil tests.ResultThe test‐retest subset included 60 participants (28 females; age range 18‐84 years: M = 48, SD = 18; 30 with ≤12 years education). ICC values for BrainCheck assessments ranged from 0.69‐0.89 (p < .001), indicating moderate to good reliability. For concurrent validity, data from 68 participants (34 females; age range 18‐82 years: M = 48, SD = 18; 33 with ≤ 12 years education) revealed moderate correlations (r = 0.31–0.57, p < = .01) between BrainCheck assessments and their paper‐based counterparts.ConclusionThe results demonstrate that BrainCheck offers reliable and valid assessments of cognitive function, comparable to traditional paper‐and‐pencil tests. These findings further validate BC‐Assess as an effective cognitive screening tool.

Introduction: In the current climate of cost containment and fiscal responsibility, high-value implant alternatives offer a substantial opportunity for savings in the treatment of orthopedic trauma patients. As patents have expired on many commonly used trauma implants, high-value alternatives have become available. The purpose of this study was to examine the clinical and economic impact of a cost containment program utilizing high-value, single lag screw cephalomedullary hip nail implants for treating intertrochanteric femur fractures. Design: Retrospective comparative cohort study. Setting: Level II trauma center Patients/Participants: 885 patients (347 Males and 538 Females) with intertrochanteric femur fractures. Intervention: Patients treated with high-value single lag screw cephalomedullary implants were compared to those treated with conventional implants during the same period. Main Outcome Measurements: Operative records were reviewed to identify intraoperative complications, operative time, and estimated blood loss. Cases involving infection, malunion, nonunion, or the need for repeat surgery were documented. Hospital financial records were evaluated to determine implant costs. Results: 443 patients were treated with the high-value implant, while 442 patients received conventional single lag screw cephalomedullary implants over the same period. No difference was observed in intraoperative complications or estimated blood loss. Operative time was significantly shorter in the high-value implant group (p=2.3E-10). There was no increase in postoperative infection rates, implant complications, malunion, or nonunion. Overall, the hospital saved a total of $512,994 on implant costs. Conclusions: Implant costs decreased significantly without an increase in complication rates or changes in radiographic outcomes. These savings were essential to our success in the Bundled Payment for Care Improvement (BPCI) initiative. Additionally, the savings can be reinvested into the trauma program in alignment with OTA/AAOS position statements and guidelines, as well as to support gainsharing and co-management initiatives. Level of Evidence: Level III - Retrospective comparative cohort study Keywords: Cephalomedullary nail, Hip fracture, High-value implants, Cost containment, Orthopaedic trauma.

BackgroundANCA-associated vasculitis is a systemic autoimmune disease involving small- and medium-sized blood vessels. Eosinophilic granulomatosis with polyangiitis (EGPA, previously Churg Strauss Syndrome) is the least common form in childhood with few cases reported. We present two unique pediatric cases, both of which were treated with anti-interleukin-5 therapy.Case presentationCase one is a 13-year-old male with asthma and allergies who presented with one month of cough and periorbital edema and subsequently developed submandibular swelling. Evaluation identified chronic sinusitis, weight loss, positive c-ANCA and anti-MPO IgG antibodies, peripheral blood eosinophilia, pulmonary eosinophilia, tracheal and pulmonary nodules, and eosinophilic infiltration of the submandibular salivary gland with granulomas and fibrosis fitting a diagnosis of EGPA. He improved with glucocorticoids and mepolizumab with a significant partial response, and eventually switched to benralizumab and mycophenolate mofetil with complete response. Case two presented at 19-months-old in acute respiratory distress with a history of reactive airway disease. EGPA diagnosis was confirmed on lung biopsy (eosinophilic capillaritis and interstitial expansion of eosinophils) in the setting of anti-MPO and p-ANCA positivity. He has done very well on mepolizumab for three years.ConclusionsTo our knowledge, this is the first reported case of submandibular salivary gland infiltrate in a child with EGPA and the youngest successfully treated patient with EGPA reported in the literature. These cases demonstrate the variation in age and disease manifestations seen in children with EGPA as well as positive responses to anti-interleukin-5 therapy. Children with EGPA may present with common or unusual complaints and require astute recognition to avoid delays in diagnosis and long-term damage.

TPS3634 Background: For patients with oligometastatic colorectal cancer (CRC), aggressive local therapy of isolated metastases, particularly in the liver, has been associated with long-term progression-free and overall survival (OS) primarily based on retrospective evidence. However, in patients with limited metastatic CRC that is deemed inoperable or those with additional disease outside of the liver or lungs, the role of local ablative therapies, including microwave ablation (MWA) and stereotactic body radiation therapy (SBRT), to render patients disease free is less clear. Despite the long history of treating oligometastatic CRC with local therapy, which is largely provider biased, questions remain regarding the benefit of extending the paradigm of metastatic directed therapy to patients with more extensive disease. This trial seeks to use a pragmatic multimodality approach that mirrors the current clinical dilemma. This study is designed to evaluate the safety and efficacy of adding total ablative therapy (TAT) of all sites of disease to standard of care systemic treatment in those with limited metastatic CRC. Methods: A022101/NRG-GI009 is a National Clinical Trials Network randomized phase III study planned to enroll 364 patients with newly diagnosed metastatic CRC (BRAF wild-type, microsatellite stable) without peritoneal metastasis or liver-only disease on baseline imaging. Patients receive first-line systemic therapy for 12-39 weeks. Patients with ≤4 sites of metastatic disease following initial systemic therapy that are amenable to any combination of surgical resection, MWA, and/or SBRT are then randomized 1:1, stratified by number of metastatic organ sites (1-2 vs. 3-4), timing of metastatic disease diagnosis (de novo vs. secondary), and presence of metastatic disease outside the liver/lungs in at least 1 site. Patients in Arm 1 will receive TAT consisting of treatment of all metastatic sites with SBRT, MWA, and/or surgical resection followed by standard of care systemic therapy. Patients in Arm 2 will continue with standard of care systemic therapy alone. The primary endpoint is OS. Secondary endpoints include event-free survival, treatment-related toxicities, and local recurrence with exploratory biomarker analyses. The study needs 346 evaluable patients combined in the 2 arms to demonstrate an improvement in OS with a hazard ratio of 0.7 to provide 80% power with a one-sided alpha of 5%. The trial utilizes a group sequential design with two interim analyses (25% and 50% of events) for futility. The trial activated in January 2023 and recruitment is ongoing. Support: U10CA180821, U10CA180882; https://acknowledgments.alliancefound.org. U10CA180820 (ECOG-ACRIN); U10CA180868 (NRG); U10CA180888 (SWOG); Clinical trial information: NCT05673148 .

Best practices for improving access to assessment of hereditary cancer risk in primary care are lacking. To compare 2 population-based engagement strategies for identifying primary care patients with a family or personal history of cancer and offering eligible individuals genetic testing for cancer susceptibility. The EDGE (Early Detection of Genetic Risk) clinical trial cluster-randomized 12 clinics from 2 health care systems in Montana, Wyoming, and Washington state to 1 of 2 engagement approaches for assessment of hereditary cancer risk in primary care. The study population included 95 623 English-speaking patients at least 25 years old with a primary care visit during the recruitment window between April 1, 2021, and March 31, 2022. The intervention comprised 2 risk assessment engagement approaches: (1) point of care (POC), conducted by staff immediately preceding clinical appointments, and (2) direct patient engagement (DPE), where letter and email outreach facilitated at-home completion. Patients who completed risk assessment and met prespecified criteria were offered genetic testing via a home-delivered saliva testing kit at no cost. Primary outcomes were the proportion of patients with a visit who (1) completed the risk assessment and (2) completed genetic testing. Logistic regression models were used to compare the POC and DPE approaches, allowing for overdispersion and including clinic as a design factor. An intention-to-treat analysis was used to evaluate primary outcomes. Over a 12-month window, 95 623 patients had a primary care visit across the 12 clinics. Those who completed the risk assessment (n = 13 705) were predominately female (64.7%) and aged between 65 and 84 years (39.6%). The POC approach resulted in a higher proportion of patients completing risk assessment than the DPE approach (19.1% vs 8.7%; adjusted odds ratio [AOR], 2.68; 95% CI, 1.72-4.17; P < .001) but a similar proportion completing testing (1.5% vs 1.6%; AOR, 0.96; 95% CI, 0.64-1.46; P = .86). Among those eligible for testing, POC test completion was approximately half of that for the DPE approach (24.7% vs 44.7%; AOR, 0.49; 95% CI, 0.37-0.64; P < .001). The proportion of tested patients identified with an actionable pathogenic variant was significantly lower for the POC approach than the DPE approach (3.8% vs 6.6%; AOR, 0.61; 95% CI, 0.44-0.85; P = .003). In this cluster randomized clinical trial of risk assessment delivery, POC engagement resulted in a higher rate of assessment of hereditary cancer risk than the DPE approach but a similar rate of genetic testing completion. Using a combination of engagement strategies may be the optimal approach for greater reach and impact. ClinicalTrials.gov Identifier: NCT04746794.

The novel Coronavirus Disease 2019 (COVID-19), caused by the SARS-CoV-2 virus, created a need for evidence-based guidelines for the evaluation, management, and follow-up after infection. Data have become rapidly available, creating a challenge for medical providers to stay abreast of the ever-evolving recommendations. This article, written collaboratively by pediatric cardiovascular experts, pediatricians, and sports medicine specialists, is focused on SARS-CoV- 2-related pediatric cardiac manifestations. It aims to provide a systematic review of high-yield literature related to all cardiovascular entities as a tool for primary pediatric clinicians to utilize as they consider the cardiac consequences of acute SARS-CoV-2 infection, MIS-C, vaccine-related myocarditis, return-to-play, and long COVID-19 syndrome.

Sodium-glucose transport protein 2 inhibitors (SGLT2i) are becoming commonplace in many chronic diseases: type 2 diabetes mellitus, heart failure, and chronic kidney disease. We present the case of a 65-year-old male with a history of type 2 diabetes who had been on an SGLT2i for over 12 months and was found to have euglycemic diabetic ketoacidosis (eDKA) occurring concurrently with a thyroid storm. This case report illustrates a unique scenario of two endocrine emergencies occurring simultaneously.