WellStar Health System

Tandem lesions (TLs) are a subtype of acute ischemic stroke, which involve an extracranial carotid lesion (ie, severe carotid stenosis ≥70%) with large vessel occlusion. While large vessel occlusion has a standard approach with mechanical thrombectomy (MT), the best practice for intervention of the carotid lesion is not well-established. Utilizing data from the ASSIST registry, we investigated the differences in clinical and procedural outcomes between acute versus nonacute stenting. The ASSIST registry (an international acute ischemic stroke MT prospective study) was utilized to identify the subgroup of patients with acute ischemic stroke secondary to TL who received MT. The TLs were grouped by MT+acute carotid stenting (CAS) versus MT+acute carotid nonstenting. The demographics and clinical outcomes (90-day modified Rankin Scale score) were compared between TL and non-TL groups, and between MT+CAS and MT+acute carotid nonstenting. Multivariable analyses were performed to determine independent predictors of clinical outcomes. A total of 183 of 1270 (14.4%) TLs were identified in the ASSIST registry. MT+CAS was performed in 83 of 183 (45.4%) subjects, and 100 of 183 (54.6%) received MT+acute carotid nonstenting. There are no significant differences at baseline between the 2 groups in the National Institutes of Health Stroke Scale score, Alberta Stroke Program Early Computed Tomography Score, or target vessel. Achieving a modified Rankin Scale score of 0 to 2 at 90 days was 70.9% in the MT+CAS group versus 48.9% in the MT+acute carotid nonstenting group (P=0.001), with a modified Rankin Scale score of 0 to 2 being significantly associated with the MT+CAS group in multivariable analysis (odds ratio, 2.14 [95% CI, 1.01-4.51]). There was no significant difference in mortality or symptomatic intracerebral hemorrhage between the groups. In acute ischemic stroke, secondary to TLs treatment with thrombectomy and acute carotid stenting is associated with improved 90-day functional outcome without an increase in symptomatic intracerebral hemorrhage compared with no acute stenting approach. URL: https://www.clinicaltrials.gov; Unique identifier: NCT03845491.

Abstract Background Due to a 120% increase in patients living with HIV (PLWH) admitted to our institution over the prior 3-year period, a pharmacy resident-driven ARVSP was implemented to augment the existing antimicrobial stewardship program. This study evaluated the feasibility and impact of an ARVSP conducted by non-infectious diseases trained, post-graduate year 1 (PGY1) pharmacy residents at a large, academic medical center.Figure 1:Chart review documentation via an Epic i-Vent.Table 1:Summary Data.OI = Opportunistic Infections, PPx = Prophylaxis, TOC = Transitions of Care, DDI = Drug-Drug Interaction, EMR = Electronic Medical Record Methods This was a single-center, retrospective pilot study. From 7/1/2022 to 2/1/2023 the PGY1 ARVSP followed a standard operating procedure (SOP) for evaluating medication regimens of admitted PLWH on antiretroviral (ARV) therapy. The SOP included a checklist to minimize prescribing errors, drug-drug interactions (DDI), and optimize ARV regimens for admitted patients, particularly with changing clinical status. Daily chart reviews included external prescription history, outpatient notes, inpatient medications, and clinical status (Figure 1). Patient interviews were conducted to confirm ARV regimens, drug allergies, home medications, outpatient HIV follow-up plan, and barriers to medication access.Table 2:Drug Interaction Summary.CYP = cytochrome P450, High-risk = anticoagulants, antiplatelets, antiepileptics, antiarrhythmics, HMG-CoA reductase inhibitors, antipsychotics, and antibioticsTable 3:PGY1 individual survey responses.PGY1 = post graduate year 1; HIV = human immunodeficiency virus; ARVs = antiretrovirals Results A total of 220 patients were reviewed during the 7-month ARVSP pilot period. Over 100 unique interventions were identified by the ARVSP team, including DDI, dosage adjustments, need for opportunistic infection prophylaxis, incorrect route of administration, or incorrect dose/regimen resumed inpatient (Table 1). The majority of the DDI identified involved potential issues with drug absorption but a significant number of high-risk and CYP-mediated DDI were also found (Table 2). PGY1 residents were surveyed throughout the pilot and self-identified improvement to the level of independence in patient interviewing, reconciling medications, and documenting clinical activities in the medical record (Table 3). Conclusion PGY1 residents implemented ARVSP activities into their daily workflow without limiting their direct patient care responsibilities. They successfully identified ARV medication errors and reported improvements in their ability to manage ARV pharmacotherapy. PGY1 pharmacy residency programs can adapt similar ARVSPs to augment their training programs and support medication optimization in this high-risk patient population. Disclosures All Authors: No reported disclosures

Abstract Introduction Penile and scrotal ring entrapment (PSRE) is a rare but potentially serious condition requiring prompt Urologic intervention. It occurs when a constricting object is placed around both the penis and scrotum, leading to impaired circulation, edema, bladder perforation, tissue necrosis, sepsis, and even death. Several techniques have been previously described for the removal of constricting devices both in the setting of the emergency room and the operating room. Due to the variable access to instruments and urologists across care centers, novel approaches to successfully removing constricting devices, especially those made of durable metals, must be made aware to health care personnel. Objective This study aims to review three clinical presentations, management techniques, and outcomes of PSRE in a tertiary care setting with particular emphasis on a novel technique using a Stryker drill commonly utilized by neurosurgeons. Methods Two cases of penoscrotal ring entrapment and one case involving a metal threaded nozzle piece were retrospectively reviewed. The cases were assessed based on duration of entrapment, clinical symptoms, and management techniques utilized. The various removal methods, including manual lubrication, use of ring cutter, bolt cutter, and Stryker neurosurgical drill with a burr drill bit, were evaluated for their efficacy and outcomes. Additionally, existing literature was reviewed to identify highly successful strategies employed by urologists to treat patients with penile, scrotal, and penoscrotal entrapment with rings of various materials. Results All three methods used to alleviate penile or penoscrotal entrapments were safe and effective, including the novel approach using a neurosurgical instrument to remove rings of a tough composition. Poor follow-up was noted for all three cases. Based on literature review a common methodology to treat penoscrotal ring entrapment includes the use of bolt cutters. Additionally, one example of an algorithmic approach to the treatment of penoscrotal entrapment has been proposed. Conclusions Timely diagnosis and appropriate management of PSRE are crucial to prevent complications. The novel use of a neurosurgery drill with burr drill has now been demonstrated as a safe and effective means to remove metal rings around the penoscrotal junction. PSRE should be approached in a fashion that is least invasive to most invasive. Although creativity can be necessary when approaching rare cases, there is a need for a more algorithmic approach. Overall, there is a lack of follow-up in this patient population and educating the patient on common sequelae is paramount. Disclosure Any of the authors act as a consultant, employee or shareholder of an industry for: Coloplast, Medtronic

BackgroundLarge language models (LLMs) have shown the ability to diagnose complex medical cases, but only limited studies have evaluated the performance of LLMs in the development of evidence-based treatment plans. The purpose of this evaluation was to test four LLMs on their ability to develop safe and efficacious treatment plans on complex patients managed in the intensive care unit (ICU).MethodsEight high-fidelity patient cases focusing on medication management were developed by critical care clinicians including history of present illness, laboratory values, vital signs, home medications, and current medications. Four LLMs [ChatGPT (GPT-3.5), ChatGPT (GPT-4), Claude-2, and Llama-2–70b] were prompted to develop an optimized medication regimen for each case. LLM generated medication regimens were then reviewed by a panel of seven critical care clinicians to assess safety and efficacy, as defined by medication errors identified and appropriate treatment for the clinical conditions. Appropriate treatment was measured by the average rate of clinician agreement to continue each medication in the regimen and compared using analysis of variance (ANOVA).ResultsClinicians identified a median of 4.1–6.9 medication errors per recommended regimen, and life-threatening medication recommendations were present in 16.3%–57.1% of the regimens, depending on LLM. Clinicians continued LLM-recommended medications at a rate of 54.6%–67.3%, with GPT-4 having the highest rate of medication continuation among all LLMs tested (p < 0.001) and the lowest rate of life-threatening medication errors (p < 0.001).ConclusionCaution is warranted using present LLMs for medication regimens given the number of medication errors that were identified in this pilot study. However, LLMs did demonstrate potential to serve as clinical decision support for the management of complex medication regimens given the need for domain specific prompting and testing.

Age and Gender Disparities in Burden of Hypertensive Heart Disease Attributable to Lead Exposure from 1990 to 2021: A Global Benchmarking Analysis Background: Hypertensive heart disease (HHD) remains a major global contributor to cardiovascular mortality and morbidity. Lead exposure is a recognized environmental risk factor that exacerbates hypertension and its complications. This study aims to evaluate the age-specific burden of HHD attributable to lead exposure across the years 1990, 2000, and 2021, focusing on trends in mortality, disability-adjusted life years (DALYs), and years lived with disability (YLDs). Methods: We estimated deaths, DALYs, and YLDs due to HHD attributable to lead exposure, stratified by 5-year age group, sex, year and location across the 204 countries and territories from 1990-2021 using standardized global burden of disease study 2021 methodology. Annualized percentage changes (APC) were calculated for multiple time intervals to assess temporal and sex-specific trends. Result: From 1990 to 2021, deaths due to hypertensive heart disease attributable to lead exposure increased by 83% (95% UI: 6%–137%), DALYs rose by 50% (4%–92%), and YLDs surged by 150% (27%–176%). Regionally, the greatest increase in total percentage change (TPC) in deaths occurred in South Asia (146%), followed closely by Central Europe, Eastern Europe, and Central Asia (139%), Latin America and the Caribbean (81%), and North Africa and the Middle East (79%). Stratified by socio-demographic index (SDI), the most pronounced rise in deaths was observed in high SDI regions (146%), with notable increases also recorded in low-middle SDI (97%), high-middle SDI (96%), low SDI (76%), and middle SDI (63%). Age-specific trends revealed minimal change in individuals aged 20–54 years (1% increase), while those aged 55 years and above exhibited a substantial 94% rise in DALYs. In the same older age group, YLDs increased by 65% during the study period. Gender-disaggregated analysis showed a disproportionately greater increase among females compared to males: deaths rose by 92% vs. 74%, DALYs by 57% vs. 43%, and YLDs by 170% vs. 134%, respectively. Conclusion: The burden of hypertensive heart disease attributable to lead exposure has significantly increased over the past three decades, with disproportionately higher impacts among older adults, high-SDI regions, and females, underscoring the need for targeted environmental and cardiovascular interventions.

Introduction Preclinical animal experiments and initial feasibility studies in humans have shown encouraging outcomes using the novel Saccular Endovascular Aneurysm Lattice (SEAL™) system for the treatment of both ruptured and unruptured wide‐neck intracranial aneurysms (IAs). The SEAL™ Interventional Pivotal IDE PMA Trial (SEAL™ IT) is designed to assess the safety and efficacy of the SEAL™ in patients with saccular IAs. This ongoing, prospective, multicenter trial includes three study arms and will enroll a total of 279 participants with wide‐neck bifurcation (WNBA), sidewall (SW), or acutely ruptured IAs across 50 U.S. sites. Methods Eligibility requirements include patients aged 20‐80 years with a wide‐neck saccular intracranial aneurysm (2‐19 mm) deemed suitable for treatment with the SEAL™ Intrasaccular Device (SID). Participants receive treatment using the SEAL™ device (Galaxy Therapeutics Inc.) and are monitored at discharge, and again at 3, 6, and 12 months, followed by yearly assessments for up to 5 years. The primary efficacy outcome is defined as complete aneurysm occlusion at 12 months without evidence of parent vessel stenosis or the need for retreatment, as determined by an independent core laboratory. Key safety outcomes include neurological death within 12 months, stroke occurring within the first 30 days, and ipsilateral stroke between 30 days and 1 year. Results As of submission, 163 WNBA, 58 WNSW, and 33 ruptured for a total of 254 patients (76.3% female; mean age 61.7 ± 11.3) have been enrolled at 50 sites. Mean aneurysm width was 5.2 ± 2.1, neck size of 3.7 ± 1.4, and neck‐to‐dome ratio of 1.4 ± 0.32. SEAL Arc was used in 63.6% and SEAL Base in 36.4%. Technical device success rate is 100% for WNBA, 94.8% WNSW, and 97.0% ruptured. The interim complete occlusion rate for the primary group is 84.5% at most recent date based on available imaging. Conclusion Preliminary data for the SEAL™ intrasaccular device is promising; Safety and effectiveness updates will be presented at the SVIN Conference.

Introduction/Purpose Balloon guide catheters (BGCs) may improve recanalization outcomes in mechanical thrombectomy by providing proximal flow control and reducing distal embolization. We evaluated the safety and efficacy of EMBOGUARD ™ compared to conventional guide catheters in acute ischemic stroke thrombectomy. Materials/Methods Consecutive patients undergoing mechanical thrombectomy for stroke at four thrombectomy‐capable centers from January 2022 to December 2024 were retrospectively analyzed and stratified by use of EMBOGUARD ™ versus conventional guide catheters. Patients were eligible for inclusion if they were aged 18‐85 years with an initial NIHSS score &gt;5, had a last known well time to procedure start &lt;24 hours, demonstrated baseline functional independence (mRS 0‐1), and presented with involvement of intracranial vessels including the internal carotid artery beyond the petrous segment and/or middle cerebral artery. Patients were excluded if they had tandem ipsilateral proximal extracranial stenosis, previous stent placement in the target lesion, steno‐occlusive disease related to intracranial atherosclerotic disease with ≥50% stenosis/occlusion, pre‐treatment CT ASPECTS &lt;5, any intracranial hemorrhage within the prior 30 days, or untreated chronic subdural hematoma &gt;5 mm thickness. The primary outcome was first‐pass effect (modified TICI [mTICI] ≥2c in a single pass without adjunctive treatment). Secondary outcomes included successful recanalization (mTICI ≥2b), favorable functional outcome (mRS 0‐2 at 90 days), procedural metrics, and safety endpoints. Univariate comparisons, propensity score matching (PSM), sensitivity analyses (by site and vessel), and missing data analysis were performed. Results Among 178 patients (EMBOGUARD ™ n=135; conventional n=43), baseline characteristics were balanced except for higher atrial fibrillation (33.3% vs 20.9%, p=0.044) and intracranial ICA occlusions (17.8% vs 9.3%, p=0.012) with EMBOGUARD ™ . First‐pass effect occurred in 33.3% (45/135) with EMBOGUARD ™ vs 37.2% (16/43) with conventional catheters (p=0.678). Successful recanalization rates were similar (86.7% vs 86.0%, p=0.924). A higher proportion of EMBOGUARD ™ patients achieved favorable 90‐day outcomes (45.7% vs 22.5%, p=0.012). Procedural time was numerically shorter with EMBOGUARD ™ (43.3±35.3 vs 54.2±30.3 min, p=0.089). Symptomatic intracerebral hemorrhage (2.0% vs 0.0%, p=0.373) and 90‐day mortality (13.7% vs 16.7%, p=0.656) were comparable. PSM validated these findings, confirming no difference in first‐pass effect and a persistent benefit in functional outcome (43.2% vs 22.5%, p=0.047). Sensitivity analyses by vessel occlusion revealed first‐pass effect rates for ICA: 50.0% vs 25.0%; M1: 44.8% vs 45.0%; beyond M1: 6.8% vs 31.6% (EMBOGUARD ™ vs conventional, respectively). Two centers adopted only EMBOGUARD ™ . Conclusion In this multicenter retrospective study, EMBOGUARD ™ balloon guide catheter was not superior to conventional guide catheters for first‐pass effect but was associated with significantly better 90‐day functional outcomes. Operator experience, case selection, and site‐level adoption may influence effectiveness; prospective trials are needed.