Mission Hospital

BACKGROUND: About one-fourth of ischemic strokes are recurrent. Finding a specific etiology facilitates targeted secondary prevention. The American Heart Association (AHA) Get-With-The-Guidelines-Stroke® Registry (GWTG-S) suggests more than 50% of patients are discharged with a cryptogenic or undocumented etiology. We sought to determine baseline characteristics associated with cryptogenic stroke and whether more thorough hospital investigation reduces cryptogenic classification. METHODS: In 2022, the AHA, along with HCA Healthcare and HCA Healthcare Foundation, designed and launched Getting to the Heart of Stroke TM (GTTHOS) in 10 HCA Healthcare advanced stroke centers to improve evidence-based stroke evaluation, promote neurology/cardiology collaboration, and better identify barriers to care. GTTHOS data from 2022-2024 were harvested from GWTG-S, noting baseline characteristics (demographics, insurance status, medical history, NIHSS) and utilization of three diagnostic tests: cervical carotid imaging, intracranial vascular imaging, and short-term cardiac rhythm monitoring. Multivariate analysis sought to associate baseline features and test utilization with cryptogenic vs. non-cryptogenic etiology. RESULTS: We identified 15,216 patients with cryptogenic (5,468, 35.94%) or non-cryptogenic (9,748, 64.06%) ischemic stroke. Cryptogenic patients had lower median age (69 vs. 72 years, p < 0.0001), more frequent vascular risk factors (hypertension, diabetes, dyslipidemia), and lower prevalence of heart failure or coronary disease (Table 1). Baseline differences were small and mostly nonsignificant when adjusted for covariates. Performing diagnostic tests was associated with higher likelihood of identifying a non-cryptogenic etiology (Table 2): intracranial vascular imaging (aOR = 1.24, p = 0.0146), carotid imaging (aOR = 1.67, p < 0.0001), and short-term cardiac rhythm monitoring (aOR = 1.23, p = 0.0004). Test utilization was highest in cryptogenic stroke. CONCLUSIONS: Performance of diagnostic tests (intracranial vascular imaging, carotid imaging, and short-term cardiac monitoring) was strongly associated with greater likelihood of identifying a non-cryptogenic stroke etiology. Cryptogenic patients were thoroughly, though not exhaustively, assessed with these tests, making it unlikely that cryptogenic strokes were simply under-tested. Opportunities exist for improved adherence to AHA acute and post-acute testing guidelines.

Abstract Background: The prevalence of type 2 diabetes mellitus is rising globally, leading to an increase in diabetic kidney disease. About 20-40% of diabetic patients develop chronic kidney disease, which poses a burden on patient management. Kidney dysfunction can be prevented if the predisposing factors are identified and controlled. Also, effective management interventions can be instituted if detected early. Objective: This cross-sectional study assessed kidney dysfunction and its determinants among type 2 diabetics. Methods: Two hundred and four (204) participants were recruited. Blood samples were collected, serum creatinine measured and the estimated glomerular filtration rate (eGFR) calculated. Data on demographics, medical history, and lifestyle factors, were collected through structured questionnaires. Results: The prevalence of kidney dysfunction was 32.35%, with 23.5% presenting hyperfiltration and 8.82% showing decreased GFR (<90 mL/min/1.73m²). Sex, history of alcohol consumption, and treatment with glimepiride or tamsulosin were associated with abnormal GFR (p<0.05). Male patients had significantly higher odds of developing low GFR, while patients on glimepiride had significantly higher odds of developing high GFR. However, past alcohol consumers showed lower odds of developing kidney dysfunction. Conclusion: These findings underline the need for targeted interventions to manage and prevent the progression of kidney dysfunction to chronic kidney disease in this population.

1118 Background: Patients with breast cancer (BC) are frequently prescribed opioids for pain management, placing them at risk of opioid use disorder (OUD). This study analyzes the prevalence of OUD and identifies factors contributing to its risk among BC patients in the United States. Methods: We conducted a retrospective analysis using the National Inpatient Sample (NIS) database, a Healthcare Cost and Utilization Project (HCUP) component. Females with BC were identified through ICD-10 codes. The Cochran-Armitage trend test assessed OUD prevalence trends from 2016 to 2022. Multivariable regression models estimated the impact of multiple patient demographics and comorbidities on the presence of OUD. Results: Among 1,189,884 females aged≥18 with BC, 2.3% (27,500) had OUD. The mean age of OUD patients was 58.38 years, compared to 64.46 years in the non-OUD cohort. OUD prevalence was highest in those aged 18–50 years (3.8%), followed by 51–60 years (3.0%), and lowest in those > 60 years (1.7%). Between 2016 and 2020, OUD prevalence increased from 1.9% to 2.8%, followed by a decline to 2.4% in 2022 (p-trend < 0.01). Factors that were linked with higher OUD involved patients with neoplasm-related pain(NRP)(aOR 5.718, 95% CI 5.549-5.893, p < 0.01), on palliative care (aOR 1.397, 95% CI 1.353-1.443, p < 0.001), with metastasis (aOR 1.573, 95% CI 1.526-1.621, p < 0.01), depression (aOR 1.447, 95% CI 1.400-1.495, p < 0.01), bipolar disorder (aOR 2.173, 95% CI 2.038-2.317, p < 0.01), suicidality (aOR 3.228, 95% CI 2.938-3.546, p < 0.01), and anxiety (aOR 1.617, 95% CI 1.572-1.664, p < 0.01). Moreover, substance use such as cocaine (aOR 5.252, 95% CI 4.708-5.859, p < 0.01) and amphetamine (aOR 3.948, 95% CI 3.443-4.527, p < 0.01) was also associated with higher odds, while cannabis users (aOR 0.876, 95% CI 0.793-0.968, p < 0.01) had lower odds of OUD. Our study further found racial disparities, with reduced odds among Blacks ( vs Whites, aOR 0.933, 95% CI 0.901-0.967, p < 0.01) and Hispanics (vs.Whites, aOR 0.866, 95% CI 0.827-0.906, p < 0.01). Socio-economic differences were also noted, with lower odds among those of the 26th-50th (vs. 0-25th, aOR 0.932, 95% CI 0.9-0.966, p < 0.01), 51st-75th (vs. 0-25th, aOR 0.951, 95% CI 0.918-0.986, p < 0.01), and 76th-100th (vs. 0-25th, aOR 0.916, 95% CI 0.882-0.951, p < 0.01) household income quartiles. Conclusions: This study showcases the significant prevalence and impact of OUD among BC patients, identifying socioeconomic and racial disparities, and key risk factors such as NRP, psychiatric comorbidities, and concurrent substance use, like cocaine and amphetamines. Interestingly, cannabis use was associated with a lower risk of OUD, which may reflect its role as an alternative pain management strategy. Overall, this study suggests the need to adopt crucial preventative measures against OUD in patients exhibiting these characteristics.

e16398 Background: The healthcare burden of pancreatic cancer in the United States is exponentially growing, with an added impact on the elderly population. Although recent studies have suggested that frailty may impact the therapeutic outcomes of several cancers, large-scale data on its role among PC patients undergoing chemotherapy is lacking. We propose to bridge this gap through the National Inpatient Sample (NIS) analysis, which aims to aid in risk stratification and improved surveillance during hospitalizations for developing these complications. Methods: We analyzed NIS data between 2016 and 2022 for PC patients aged > 60 who were admitted for chemotherapy. Frailty was assessed using the Johns Hopkins Adjusted Clinical Groups (ACG) frailty indicator list. Frail patients were compared to non-frail patients to evaluate differences in demographics and in-hospital complications. Results: Of the 6625 PC adults older than 60 years who were admitted for chemotherapy, 44.5%(2945 patients) were classified as frail. The number of patients in the non-frail group included more females(50.3%), while in the frail group, 51.6% were males. However, this was not significant (p = 0.127). The frail group reported a higher mean age of 70.11 years (vs. 69.17 years, p < 0.01). An estimated 22.9% of the frail group was on palliative care, while it involved only 9.2% among the non-frail patients(p < 0.01). Several complications were more common among our frail cohort, including gastrointestinal bleeding(aOR 1.495, 95% CI 1.192-1.875, p < 0.01), sepsis(aOR 1.406, 95% CI 1.169-1.691, p < 0.01), hypotension(aOR 1.555, 95% CI 1.237-1.956, p < 0.01), acute kidney injury(AKI)(aOR 1.683, 95% CI 1.469-1.928, p < 0.01), and all-cause death(aOR 1.338, 95% CI 1.038-1.725, p = 0.025). Events of chemotherapy induced agranulocytosis(aOR 1.196, 95% CI 0.910-1.571, p = 0.199), acute liver failure(aOR 1.177, 95% CI 0.744-1.860, p = 0.486), and intensive care unit(ICU) admission(aOR 1.201, 95% CI 0.939-1.537, p = 0.145) were similar. Conclusions: Frailty in PC patients undergoing chemotherapy is associated with poorer outcomes, including increased mortality. These findings emphasize the need to consider risk stratification for complications in this patient population, aiding in developing frailty-driven management protocols to improve chemotherapy outcomes. These measures can help improve the quality of care for frail PC patients undergoing chemotherapy and reduce the healthcare burden of managing these complications.

This manuscript is a transcript of the presidential panel that took place took place during the Annual Scientific Meeting of the Southern California Chapter of the American College of Surgeons. The surgeon's status as a leader is often assumed, and surgeons are often found in leadership positions outside the operating room. Yet, throughout medical and surgical education, formal leadership and management curricula are lacking. In this presidential panel, the path to leadership for surgeons was discussed by experts from their distinct lenses-academic medicine, surgical education, health care administration, and private practice. Surgeon leaders discussed good leadership traits and conflict management, and answered audience questions.

ABSTRACT Introduction Metastasis-directed treatment (MDT) is progressively expanding its scope in the treatment of metastatic renal cell carcinoma (mRCC), finding application both in cases of oligometastatic disease, whether synchronous or metachronous, and in oligo-progression during systemic therapy (ST). This updated narrative review incorporates recent advancements in managing oligometastatic and oligo-progressive RCC. A PubMed literature search using keywords related to mRCC and its treatments was made. Observational studies, clinical trials, and reviews were analyzed, selecting the most relevant articles based on evidence strength. Areas covered We analyzed the current role of surgery, both on the primary than on metastatic sites, and the recent advantages in both radiotherapy, ST and focal therapies. Lastly, we focused on single metastatic sites of interest. Expert opinion Nowadays personalized tailored treatments are the key, integrating multimodal approaches like metastasectomy, radiotherapy, and ST. While the role of cytoreductive nephrectomy remains debated, metastasectomy and radiotherapy demonstrates potential in managing both oligometastatic and oligo-progressive disease, either alone or in synergy with ST, though more robust evidence is needed. Future research should focus on identifying biomarkers for treatment selection, optimizing therapy timing, and refining patient stratification to enhance outcomes.

Background: Nearly one million individuals in the U.S. experience ischemic stroke annually and one-year recurrent stroke risk may exceed 10%. The American Heart Association (AHA) Get-With-The-Guidelines-Stroke® Registry (GWTG-S) suggests that more than 40% of patients with stroke are discharged with a cryptogenic or undocumented etiology which may lead to suboptimal secondary prevention. Consequently, improved neurology and cardiology collaboration and evidence-based post-stroke evaluation may help identify stroke etiology, reduce recurrences and improve outcomes. Methods: In 2022, the AHA, in collaboration with HCA Healthcare and HCA Healthcare Foundation, designed and launched Getting to the Heart Of Stroke TM in 10 HCA Healthcare advanced stroke centers (GTTHOS) to improve neurology and cardiology collaboration, evidence-based post-stroke diagnostic evaluation and assessment of social determinants of health and barriers to care. Components included a learning collaborative model, virtual performance improvement consultations, Plan-Do-Study-Acts, multidisciplinary teams and performance improvement feedback. This analysis compared GTTHOS centers to the rest of HCA Healthcare’s GWTG-S centers (Non-GTTHOS; n=112) at baseline (2022) and follow-up (2023), using custom and existing GWTG-S metrics. Results: At follow-up, GTTHOS documented higher stroke etiology rates (58.06% vs. 48.63%), lower cryptogenic stroke (31.01% vs. 34.89%) and lower undocumented stroke etiology (10.93% vs. 16.48%)(all vs. baseline; p<0.0001). GTTHOS also demonstrated significantly increased use of evidence-based post-stroke diagnostic evaluation, including intracranial vascular and carotid imaging, echocardiography, short-term and extended (surface, implantable) cardiac monitoring. Lastly, GTTHOS documented significantly higher stroke etiology rates, lower cryptogenic stroke, lower undocumented stroke etiology and higher rates of several components of evidence-based post-stroke diagnostic evaluation at follow-up vs. Non-GTTHOS (Table; Figure 1, 2). Conclusion: In this novel AHA initiative, assessed in over 100 U.S. centers, Getting to the Heart Of Stroke TM is associated with improved determination of stroke etiology and use of evidence-based post-stroke diagnostic evaluation. These findings suggest that the initiative, which includes improved neurology and cardiology collaboration, may contribute to improved diagnosis of stroke etiology, improve secondary prevention and clinical outcomes.

The incidence and mortality of anal squamous cell carcinoma (ASCC) are rising, with greater than 80% of cases linked to human papillomavirus (HPV), primarily HPV16. Post-treatment surveillance can be challenging due to the limitations of anoscopy, digital anal rectal exam (DARE), and imaging. Plasma tumor tissue modified viral (TTMV)-HPV DNA has shown strong sensitivity, specificity, and predictive value in detecting the recurrence of HPV-driven oropharyngeal cancer. Here, we investigate the ability of TTMV-HPV DNA for the early recurrence detection of ASCC. This retrospective clinical case series included 117 patients with HPV-driven ASCC across 7 U.S. centers, monitored with TTMV-HPV DNA during routine clinical care between March 2020 and June 2024. Physician-reported clinical data and biomarker testing data were combined to create a comprehensive, longitudinal dataset for evaluating test performance metrics. Patients had a median age of 63 years and median post-diagnosis follow-up of 19 months. HPV status was primarily confirmed by TTMV-HPV DNA (52%) or p16 immunohistochemistry (39%). Of those tested for TTMV-HPV DNA pretreatment, 85% had a positive result. TTMV-HPV DNA clearance during or within three months post-treatment was associated with significantly better recurrence-free survival. The per-patient surveillance sensitivity, specificity, positive predictive value (PPV), and negative predictive value (NPV) were 82.8%, 98.4%, 96.0%, and 92.5%. Of 24 patients with a documented recurrence and a positive TTMV-HPV DNA test, the test was the first evidence of recurrence in 14 patients (58.3%), with a median lead time of 59 days (range: 10-536). TTMV-HPV DNA accurately resolved 94.3% of cases with indeterminate clinical findings. TTMV-HPV DNA testing provides a sensitive and specific approach for detecting patients with recurrent ASCC and resolving the status of patients with indeterminate clinical findings.

Lung adenocarcinoma may resemble the clinical presentation of an infectious or inflammatory lung disease. The coexistence of lung cancer, and polyserous effusions is uncommon, which may cause a diagnostic challenge. However, any polyserous effusions at a young age must always be suspicious for malignancy. We report a case of 38-year-old male patient with polyserous effusions and pneumonia who was treated accordingly and showed clinical improvement with a significant reduction of pericardial and pleural effusions. Subsequent testing and a biopsy resulted in the histopathological diagnosis of an adenocarcinoma of the lung. Nonrecurrent polyserous effusions in lung adenocarcinoma are uncommon, and negative cytology results may not exclude malignancy due to the moderate sensitivity of pleural and pericardial fluid cytology. Clinicians should remain vigilant for false-negative results, especially in younger patients. Malignancy should not be ruled out because pleural and pericardial fluid cytology have a sensitivity of 60% and 92%, respectively. Our case highlights the diagnostic challenges posed by atypical presentations of lung adenocarcinoma and emphasizes the importance of considering malignancy in the differential diagnosis of polyserous effusions, even when initial cytology results are negative. Clarifying the rationale for this study enhances its relevance and impact.