Renown Regional Medical Center

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.

e23074 Background: Renown Regional Medical Center (RRMC) in Reno, Nevada, serves as a primary treatment center for non-small cell lung cancer (NSCLC) patients from Washoe County and rural Nevada. Timeliness of treatment is critical in improving NSCLC outcomes. Sociodemographic factors, including sex, rural versus urban residency, race, and actionable mutation status, may significantly influence treatment access and timeliness of care. Considering the unique population dynamics of northern Nevada, we aimed to evaluate how these factors impact treatment patterns and overall outcomes in our specific cohort. Methods: Retrospective data analysis was performed on NSCLC patients stage 1-IV treated at RRMC in Northern Nevada from January 2023 to January 2024. Timelines between the first symptom, diagnosis, and treatment initiation were compared by sex, distance from treatment centers ( > 30 miles vs. ≤30 miles), race (White vs. Non-White), and actionable mutation status (EGFR, ALK, ROS1, KRAS G12C, MET, BRAF, NTRK, RET and HER2). Median time intervals, interquartile ranges, and distributions of rural/urban residence and sex were analyzed, and statistical significance was assessed using P values. Continuous variables (time) were described by median along with the interquartile range (25 th -75 th percentiles) due to the non-normal distribution of the data. Categorical variables (Sex, region, cancer stage) were described in the form of frequency and percentage. Results: The median first symptom to treatment interval was 33.5 days shorter for females (104 days) than males (137.5 days) (P = 0.010). The median time between diagnosis to treatment interval was 45 days for females vs. 65 days for males (P = 0.018). No significant differences were found between first symptom to treatment or initial diagnosis to treatment intervals based on proximity to care ( > 30 miles vs. ≤30 miles) (P = 0.845 and P = 0.478, respectively).There were no significant differences in first symptom to treatment or initial diagnosis to treatment intervals between White and Non-White patients (P = 0.656 and P = 0.305 respectively).There were no significant differences in first symptom to treatment intervals between patients with and without actionable mutations (P = 0.830). Conclusions: Previous research has identified that male gender is an independent unfavorable prognostic indicator for NSCLC survival. Our findings align with this, demonstrating that men have longer delays in care. Preliminary findings suggest significant sex-based disparities in treatment timeliness for NSCLC in Northern Nevada, with males experiencing prolonged delays in care. Interestingly, no significant differences were observed based on distance from primary residence to RRMC, race, or actionable mutation status. These results underscore the critical need to address barriers to equitable care, particularly those exacerbating sex-based disparities in treatment delays.

Patients with a mechanical mitral valve have an increased risk of thrombosis, and guidelines recommend a higher international normalized ratio goal for vitamin K antagonists-based anticoagulation. Guidelines provide recommendations for bridging with unfractionated heparin; however, there is no clear guidance on the heparin infusion intensity that should be used. This study was a retrospective, single-center, cohort study of patients aged ≥18 years or older with a mechanical mitral valve admitted from June 2019 to September 2022 who were maintained on a singular heparin infusion intensity nomogram for at least 48 hours. The patients were stratified into either a low- or a high-intensity heparin infusion nomogram. The exclusion criteria included non-nomogram heparin infusions and patients within 30 days of valve implantation. The primary outcome of this study was a composite of all bleeding events (major, clinically significant nonmajor, and minor bleeding). The secondary outcomes included bleeding events, analyzed individually, and thrombotic events. Seven total bleeding events were observed between the 2 groups, with 1 minor bleeding event in the low-intensity group and 6 bleeding events in the high-intensity group. One thrombotic event occurred in the high-intensity group. No statistically significant differences were found between the primary and secondary outcomes. Future studies are necessary to guide heparin infusion intensity selection in patients with mechanical mitral valves.

LBA5515 Background: Batiraxcept is an Fc-fusion protein engineered to have a 200-fold higher affinity than wild-type AXL for its activating ligand GAS6. Batiraxcept sequesters GAS6 and inhibits its interaction with AXL. The Phase 1b study demonstrated safety with batiraxcept in combination with paclitaxel. Methods: This was a global, placebo-controlled, double-blind, phase III trial (ClinicalTrials.gov identifier: NCT04729608). Patients with PROC were randomly assigned 1:1 to receive intravenous batiraxcept every 2 weeks (D1, 15 every 28 days) with once-a-week IV paclitaxel (D1, 8, 15 every 28 days) or placebo with paclitaxel until disease progression. The primary endpoint was progression-free survival as assessed by investigator-assessed progression-free survival and secondary endpoint was overall survival. The randomization was stratified by platinum-free interval (< 3 months, 3 to 6 months), prior lines (1 to 2, 3 to 4), and prior bevacizumab status (yes, no). Exploratory endpoints include objective response rate, duration of response, quality of life, clinical benefit rate, and pharmacokinetic and pharmacodynamic profile. Results: A total of 366 participants were randomly assigned, and analysis was performed based on intent-to-treat. There were 183 participants who had prior bevacizumab and 177 with no prior bevacizumab. Median PFS (mPFS) was 5.13 months in the batiraxcept + paclitaxel arm and 5.49 months in the control paclitaxel arm, hazard ratio (HR) 1.29 (CI, 1.01 to 1.64; p=0.98). Median OS with batiraxcept + paclitaxel was 14.29 months versus 14.39 months, HR 1.06 (CI 0.77 to 1.46; p=0.64). Objective response rates (ORRs) per RECIST 1.1 were similar in both arms: 25.1% with batiraxcept + paclitaxel versus 26.2% with control paclitaxel arm. An exploratory analysis of the 304 evaluable tumors found that 61 (20%) of tumors had high AXL expression by immunohistochemistry (IHC). In participants with high tumor AXL expression, median PFS was 5.78 months in the batiraxcept + paclitaxel arm and 3.71 months in the control paclitaxel arm, HR 0.55 (CI, 0.31 to 0.98; p=0.042). For high AXL expressing tumors, median OS was 17.8 months in the batiraxcept + paclitaxel cohort and 8.11 months in the paclitaxel cohort, HR 0.32 (CI, 0.14 to 0.73; p=0.006). Conclusions: The addition of batiraxcept to paclitaxel did not improve PFS or OS. However, in AXL high tumors, the PFS and OS were higher in participants who received batiraxcept with paclitaxel compared to paclitaxel alone. Clinical trial information: NCT04729608 .

Critical Care Medicine: January 2022 - Volume 50 - Issue 1 - p 593 doi: 10.1097/01.ccm.0000811076.64515.54

Patient: Female, 26-year-oldFinal Diagnosis: Internal carotid artery dissectionSymptoms: Dysarthria • gaze palsy • hemiplegia • sensory lossMedication: —Clinical Procedure: Endovascular stenting and mechanical thrombectomySpecialty: Neurology • RadiologyObjective:Unusual clinical courseBackground:National guidelines and consensus statements suggest a 24-hour window for endovascular recanalization in patients presenting with acute ischemic stroke due to large-vessel occlusion. However, the safety and efficacy of extending the window for intervention remains to be definitively established.Case Report:A healthy 26-year-old woman presented with headache, left-sided hemiplegia, and rightward gaze palsy 2 days after a minor trauma. Time last known well was approximately 50 hours prior to presentation. Computed tomography angiography revealed dissection of the distal right internal carotid artery and occlusion of the M1 segment of the right middle cerebral artery. Magnetic resonance imaging showed a small area of acute infarct in the right basal ganglia and right insular cortex, but suggested a large ischemic penumbra; this was confirmed with cerebral perfusion analysis. In light of the patient’s young age and potential for penumbral salvage, mechanical thrombectomy of an M1 thrombus and stenting of an internal carotid artery dissection were performed nearly 60 hours after the onset of symptoms. The patient demonstrated marked clinical improvement over the following days and was discharged home in excellent condition one week after presentation. Based on our clinical experience and other emerging data, we propose that extension of the 24-hour window for endovascular intervention may improve functional outcomes among select individuals.Conclusions:A 24-hour window for endovascular thrombectomy is appropriate for many patients presenting with acute ischemic stroke. However, in select individuals, extension of the window to 48 hours or beyond may improve functional outcomes.