Charleston Area Medical Center

778 Background: Enfortumab vedotin (EV) plus pembrolizumab (Pem) has demonstrated superior efficacy in clinical trials for metastatic urothelial carcinoma (mUC). To assess the performance of this regimen in routine practice, we conducted real-world comparative outcomes analysis versus gemcitabine plus platinum (GEM + Plat) using the TriNetX Research Network. Methods: Adults (≥18 years) with stage IV mUC between 2019 and 2025 were included. Cohorts were defined by index therapy with EV + Pem or GEM + Plat. Propensity-score matching (1:1) was used to match on age, sex, race, ethnicity, metastatic location, and comorbidities. Outcomes were analyzed within 720 days post-index using Kaplan–Meier and risk estimates. Results: Matching yielded 325 patients per arm, and the cohorts were well-balanced (mean age 70 years, 75% male). Overall survival favored EV + Pem, with 12-month survival of 72.5% versus 62.8% (p = 0.017) and 24-month survival of 57.1% versus 48.2% (p = 0.010) (Table 1). Time to next treatment was markedly longer with EV + Pem (HR 0.08, 95% CI 0.06–0.10, p < 0.001), with only 64 of 325 EV + Pem patients initiating subsequent therapy within 24 months. The risk of treatment-related adverse-event proxies (neuropathy, dermatitis, or pruritus) was higher with EV + Pem (p < 0.001), while inpatient/ED visits were less frequent at both six months (p = 0.001) and twelve months (p = 0.008). Laboratory comparisons at 0–12 weeks showed no difference in mean eGFR, creatinine, or albumin, while hemoglobin was higher with EV + Pem (p< 0.0001). Conclusions: In this large propensity-matched real-world cohort, first-line EV + Pem was associated with improved overall survival, prolonged treatment durability, and lower health-care utilization compared with GEM + Plat, albeit with higher adverse effects. Real-world outcomes: EV + Pem vs GEM + Plat. Endpoint EV + Pem GEM + Plat HR * /OR @ (95% CI) P 12-month OS (%) 72.5 62.8 0.70 (0.52–0.94) 0.017 24-month OS (%) 57.1 48.2 0.70 (0.53–0.92) 0.010 Adverse Effect proxies (%) 45.1 27.8 2.71 (2.01–3.64) <0.001 Inpatient/ED visits 6 mo (%) 58.2 71.1 0.76 (0.63–0.92) 0.001 Inpatient/ED visits 12 mo (%) 65.8 78.2 0.67 (0.65–0.94) 0.008 Hb < 10 g/dL (%) 46.5 80.0 0.47 (0.38–0.57) <0.001 eGFR (mean) 63.8 65.1 – 0.59 Albumin (g/dL, mean) 3.57 3.53 – 0.41 AST (U/L, mean) 31.2 26.1 – 0.002 ALT (U/L, mean) 27.4 22.7 – 0.03 *Hazard Ratio. @ Odds Ratio.

39 Background: Prostate cancer is a leading cause of cancer-related death among men in the United States (U.S). Despite therapeutic advances, racial disparities persist, with African American men experiencing higher incidence and poorer survival. Data on racial differences in inpatient outcomes, particularly in-hospital mortality, remain limited. This study evaluated racial and ethnic variations in in-hospital mortality among patients hospitalized with malignant prostate cancer (MPC) in the U.S. Methods: The U.S National Inpatient Sample (NIS) from 2016 to 2020 was queried for patients diagnosed with MPC. We used International Classification of Diseases, 10th Revision, Procedure Coding System (ICD-10-PCS) code “C61” to identify patients who were hospitalized for MPC. The study was exempt from institutional review board approval as the NIS database contains deidentified patient information. Multivariable regression analysis was performed to determine the odds of in-hospital mortality among patients with MPC. Multivariable logistic regression followed by marginal effects was used to plot yearly trends in in-hospital mortality. All the outcomes were adjusted for age, gender, Charlson comorbidity index (CCI) and hospital characteristics. All Statistical analyses were conducted using STATA 19 software. Results: The current retrospective study analyzed 98,000 patients hospitalized for MPC between 2016 to 2020. The racial distribution among study patients included: Whites (68,000; 69.4%), African Americans (17,738; 18.1%), Hispanics (7,154; 7.3%), and other minorities (5,098; 5.2%). African Americans were more likely to be hospitalized at a relatively younger age, and with a higher co-morbidity burden (mean age: 69.4 years; mean CCI: 5.5; p<0.01) when compared to Whites (mean age: 73 years; mean CCI: 4.8), Hispanics (mean age: 71.1 years; mean CCI: 5.1) and other minorities (mean age: 71.5 years; mean CCI: 5.0). A total of 3,626 (3.7%) patients died during the study period. On multivariable analysis, a higher absolute in-hospital mortality was observed in African Americans (OR: 1.14, 95% CI: 1.07 – 1.22, p <0.01) and other minorities (OR: 1.19, 95% CI: 1.06 – 1.34, p <0.01), when compared to Whites (OR: reference). Similarly, an increasing trend of in-hospital mortality was observed in African Americans (from 1.6% mortality per annum in 2016 to 2.0% in 2020; trend p <0.01) and Hispanics (from 1.1% mortality per annum in 2016 to 1.6% in 2020; trend p = 0.02). No change in mortality was observed among Whites (trend p = 0.171) and other minorities (trend p = 0.479) during the study period. Conclusions: Racial disparities persist in in-hospital outcomes among patients with MPC in the U.S. African American and Hispanic patients experienced increasing in-hospital mortality over time, highlighting the need for targeted interventions to address inequities in access, comorbidity management, and inpatient care.

60 Background: Bone-modifying agents (BMAs) are standard in metastatic prostate cancer, preventing skeletal complications but risking medication-related osteonecrosis of the jaw (MRONJ). Evidence guiding prostate-specific management remains sparse. We investigated real-world MRONJ risk, systemic outcomes, and bone metabolism with RANKL inhibitors (RANKLi) versus bisphosphonates (BP). Methods: Men with metastatic prostate cancer (TriNetX Global, 2000–2024) receiving RANKLi or BP were propensity-matched 1:1 (n = 10,964) for key clinical and treatment factors, including baseline corticosteroid use, osteoporosis, osteopenia, and vitamin D levels. Primary endpoints included MRONJ incidence and hazard; secondary outcomes included antibiotic use (≤2 years), survival, and metabolic bone indices. Results: RANKL inhibition was associated with a significantly higher MRONJ incidence (1.30% vs 0.64%; OR 2.05, 95% CI 1.35–3.13; HR 1.82, 95% CI 1.18–2.79; both p < 0.01). Antibiotic use within 2 years was greater with RANKLi (38.5% vs 34.1%; p < 0.001). Despite these toxicities, RANKLi conferred superior overall survival (37.4 vs 32.5 months; HR 0.89, 95% CI 0.83–0.95; p < 0.0001) and reduced hypercalcemia (0.21% vs 0.46%; p = 0.0278). Conclusions: RANKL inhibition nearly doubled MRONJ risk compared with bisphosphonates but provided clear survival and metabolic advantages. The absolute MRONJ risk remained low yet clinically meaningful, reinforcing the importance of proactive dental surveillance and multidisciplinary care. These findings highlight a critical therapeutic balance of greater skeletal and survival benefit at the cost of increased MRONJ risk while managing metastatic prostate cancer. Outcomes with RANKL inhibitors versus bisphosphonates. Outcome RANKL Inhibitors Bisphosphonates p-value Effect Estimate (95% CI) Medication-related osteonecrosis of the jaw (MRONJ) 1.30% (71/5,460) 0.64% (35/5,460) 0.0008 OR 2.05 (1.35–3.13); HR 1.82 (1.18–2.79) Antibiotic use (≤2 years) 38.5% 34.1% <0.001 — Median overall survival (months) 37.4 32.5 <0.0001 HR 0.89 (0.83–0.95) Hypercalcemia incidence 0.21% 0.46% 0.0278 —

Amyloidosis is increasingly recognized as a contributor to heart failure, particularly among older adults and patients with heart failure with preserved ejection fraction (HFpEF). Despite advances in diagnostic imaging and disease-modifying therapies, amyloidosis remains underdiagnosed in many settings, and population-level data examining its co-occurrence with cardiovascular disease on death certificates are limited. This study examined two decades of national mortality data to evaluate deaths co-coded with amyloidosis and cardiovascular disease (CVD) in the United States and to assess temporal trends and demographic disparities in age-adjusted mortality rates. A retrospective analysis was conducted using mortality data from the CDC WONDER database spanning 1999-2020. Age-adjusted mortality rates (AAMRs) per 1,000,000 persons were calculated, and trends were assessed using Average Annual Percentage Change (AAPC) and Annual Percent Change (APC) using Joinpoint 5.0.2. Between 1999 and 2020, 26,391 amyloidosis and CVD-related deaths occurred among adults aged 25 years and older in the United States. The overall AAMR for deaths co-coded with amyloidosis and CVD increased from 4.40 in 1999 to 9.31 in 2020, with an AAPC of 3.49 (p < 0.001). The most pronounced increase occurred between 2018 and 2020 (APC: 13.60). Rates were higher among men than women, with both sexes showing a marked increase in the last decade. African American or Black individuals had the highest rates (11.40), followed by White (5.11) and Hispanic (3.86) individuals. Rates were highest in the Northeast region (6.71). Metropolitan areas had higher rates than non-metropolitan areas (5.73 vs. 4.76), with a more pronounced increase in metropolitan regions. Age-adjusted mortality rates for deaths co-coded with amyloidosis and cardiovascular disease have increased over time, likely reflecting improved recognition and documentation. Higher rates of co-coded deaths were noted among men, African Americans, and individuals in the Northeast region, highlighting potential disparities in diagnostic access and recognition.

Migration of orthopedic screws into the bladder is a rare postoperative complication following surgical fixation of pelvic fractures. We present a case of a 61-year-old man who sustained a type 3 anteroposterior compression injury with pubic symphysis diastasis, left sacroiliac joint dislocation, and lumbar spine transverse process fracture. At the time of presentation open-reduction internal fixation of his pubic symphysis and closed-reduction percutaneous screw fixation of the left sacroiliac joint was performed. At his 6 month post operative visit, the patient was seen for follow up and reported mild pelvic pain and new urinary symptoms, including hematuria and recurrent urinary tract infections, which lead to further investigation. Imaging revealed findings concerning for migration of one of the pubic symphysis screws with bladder involvement. Cystoscopy confirmed the presence of a foreign body in the bladder. The patient subsequently underwent removal of the pelvic hardware, definitive bladder repair and left sacroiliac arthrodesis, followed by an uneventful postoperative course. This report describes the delayed presentation of spontaneous screw migration after repair of an open book pelvic fracture and describes the diagnostic and management considerations for patients with urinary symptoms after pubic symphysis open reduction internal fixation.

IMPORTANCE:This study provides nationally representative data on critical care advanced practice provider (APP) workforce structure and practice, addressing gaps in onboarding, productivity assessment, and administrative roles that influence workforce sustainability.OBJECTIVES:To analyze the composition of the clinical practice and workforce demographics of critical care medicine APPs.DESIGN, SETTING, AND PARTICIPANTS:We utilized a cross-sectional survey, which was distributed via email through the Society of Critical Care Medicine email list, targeting critical care APPs.MAIN OUTCOMES AND MEASURES:A total of 518 critical care APPs participated in the survey, comprising 63.2% advanced practice registered nurses, 28.8% physician assistants, and 8% clinical nurse specialists. The majority of the sample APPs worked 12-hour shifts covering days, nights, and weekends, with over 50% managing 6–10 patients per day shift. Common billing practices included critical care time (60.6%) and bedside invasive procedures (64.3%). Formal onboarding was reported by 68.6% of respondents, with academic hospitals more likely to offer such programs than community hospitals (72.3% vs. 27.7%; p < 0.001). Administrative APP roles were more prevalent in academic centers (p < 0.001) and were associated with greater access to professional development opportunities (p < 0.001). A significant proportion of respondents (41.5%) reported that their productivity was not formally measured. Notably, 22% of respondents reported an intent to leave the profession, particularly those lacking leadership or professional growth opportunities (p < 0.01).CONCLUSIONS AND RELEVANCE:This study captures practice trends and demographics of the critical care APP workforce. Day-to-day tasks among all respondents were globally clinically focused, but there were disparities in workload distribution, onboarding, productivity measurement, and administrative roles across types of centers. Additionally, there was significant association between limited professional growth opportunities and intent to leave critical care. These findings underscore the need for healthcare systems to invest in structured support, leadership development, and professional growth to enhance APP retention, engagement, and productivity. Further research is needed to identify efficient workload and staffing models.

These consensus guidelines by the American Clinical Neurophysiology Society (ACNS) describe best practices for performing intraoperative Electrocorticography (ioECoG) using subdural or depth electrodes for adult and pediatric population. A group of ACNS members was convened to develop technical standards for performing ioECoG. PubMed searches were performed to identify pertinent peer-reviewed literature. Sections were assigned to individual authors based on expertise. Consensus was achieved during subsequent group discussions to develop evidence-based recommendations to the extent possible. Communication between the neurosurgical and the neurophysiology teams is essential in verifying and documenting the location of the contacts. Most authors recommend ioECoG recordings of at least 5 and up to 30 minutes in duration to allow for sufficient observation of interictal activity. The anesthesia should be adjusted to allow continuous EEG activity and to minimize the effect on the ioECoG recording during general anesthesia or awake surgery. The surgical procedure and technical report should separate ioECoG recordings to define the irritative zone from ioECoG findings during functional mapping. The neurophysiology physician's physical presence in the operating room is required in the definition of the services. These consensus guidelines by the ACNS describe best practices for performing intraoperative ECoG based on published literature and expert consensus.