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Item Accuracy of MRI in Assessment of High-Grade Partial Distal Biceps Tears(Sage, 2025) Schmidt, Gregory J.; Fischer, James P.; Hoyer, Reed W.; Greenberg, Jeffrey A.; Crosby, Nicholas E.; Graduate Medical Education, School of MedicineBackground: Magnetic resonance imaging (MRI) is commonly used to diagnose and assess the extent of partial distal biceps injuries. The aim of this study was to report on the accuracy of MRI and the effect of injury history and study timing on its performance. Methods: A retrospective review of all patients who underwent surgical treatment of partial thickness distal biceps tears at a single center by multiple surgeons was performed. Inclusion criteria consisted of the performance of a preoperative MRI and documentation of the intraoperatively visualized extent of the tear, and 68 patients met the criteria for inclusion. A chart review was completed to evaluate the symptom duration, injury history, and tear extent. Results: All patients had distal biceps tears of greater than 50% intraoperatively. However, MRI did not indicate any tearing in 20 (29%) patients, and its sensitivity for high-grade tear was 44%. Magnetic resonance imaging was significantly less likely to be read as high-grade tears in patients with insidious onset of their symptoms in comparison with patients who reported a traumatic onset (27% vs 55%, P = .024). However, the time from symptom onset to MRI did not significantly correlate with diagnosis of a high-grade tear on MRI (r = -0.15, P = .21). Conclusions: These results indicate that MRI can underreport partial distal biceps tear extent, and this more commonly occurs in patients with insidious onset of pain.Item P-1749. Implementation of an Automatic 36-hour Stop Order on Empiric Meropenem Usage(Oxford University Press, 2025-01-29) Parker, Connor; Schneider, Jack G.; Boyd, LaKeisha; Kussin, Michelle L.; Graduate Medical Education, School of MedicineBackground: Implementation of automatic stop orders (ASOs) for empiric antimicrobials have reduced antimicrobial use without negatively impacting patient outcomes. Given a recent increase in empiric meropenem use at our tertiary referral pediatric hospital, a 36-hour meropenem ASO option was implemented in the EMR for patients with sepsis requiring empiric antibiotics active against ESBL-producing organisms. We sought to evaluate the impact this initiative had on meropenem use and safety outcomes. Methods: A 36-hour ASO for meropenem was implemented on October 12th, 2022. We conducted a single-center, retrospective pre/post evaluation of order set implementation of all patients admitted to Riley Hospital for Children and treated with meropenem between 9/01/2019–9/01/2021 (pre-intervention) and 10/13/2022–10/13/2023 (post-intervention). The primary outcome was meropenem utilization, as measured by the number of meropenem days and doses per admission. Secondary outcomes included total hospital and ICU mean length of stay (LOS), mortality within 30 days of meropenem exposure, and 30-day readmission rate. Results: 309 admissions during which meropenem was administered were included. Demographics between pre-ASO (147 patients; n = 193 admissions) and post-ASO (88 patients; n = 116 admissions) groups were similar. There was no difference in the number of meropenem days (pre and post-ASO: median = 4; p = 0.88) or the number of meropenem doses (pre-ASO: 11 vs. post-ASO: 10; p = 0.63). Secondary safety outcomes including death within 30 days of meropenem administration (8.7% vs. 8.7%; p = 0.99), hospital LOS (18 vs 15.5 days; p = 0.42), ICU admission, and 30-day readmission rate were not significantly different. The new ASO was utilized in 23.3% of admissions in the post-implementation period. Conclusion: Use of the new ASO was not widely adopted, making evaluation of impact difficult. No significant difference in meropenem use nor clinical outcomes were identified after implementation, which has informed the next Plan-Do-Study-Act (PDSA) cycle for quality improvement at our center, likely with a focus on EMR modifications and education.Item P-1502. Clindamycin and Group A Streptococcus: Is It Time To Say Goodbye?(Oxford University Press, 2025-01-29) Mann, Keeret; Zijoo, Ritika; Lugar, Richard G.; Graduate Medical Education, School of MedicineBackground: Group A streptococci (GAS) can cause invasive disease leading to Toxic Shock Syndrome (TSS), a condition linked with high mortality. Initial antibiotic therapy for GAS-TSS includes beta-lactams and clindamycin. When clindamycin resistance is noted, linezolid may be used instead until clinical stability is achieved. We reviewed GAS susceptibility at IUH Ball Memorial Hospital to assess appropriateness of initial clindamycin use as adjunctive therapy for GAS-TSS. Methods: GAS positive cultures recovered from 1/1/23 – 12/31/23 at IU Health Ball Memorial Hospital, Muncie, IN were reviewed. Results: Out of 162 cultures positive for GAS, 29 (17.9%) had susceptibility results. All 29 GAS specimens were sensitive to penicillin and linezolid, but only 16/29 (55.2%) specimens were sensitive to clindamycin. Table 1. and Chart 1. show susceptibility results for penicillin, clindamycin, erythromycin, and linezolid. Table 2. shows number of specimens with inducible clindamycin resistance. Chart 2. shows various sources of culture specimens. Conclusion: GAS susceptibility testing was performed with invasive infections or when requested. Significant resistance was noted to clindamycin. Although our data is limited by a small sample size, it is in line with trends noted by US CDC’s Active Bacterial Core surveillance reports. This raises concern over initial use of clindamycin for TSS before susceptibilities are available. There are both advantages and disadvantages associated with use of clindamycin or linezolid. There is more data to support clindamycin use, however it is linked with increased risk of C. difficile infections. There is limited data for the use of linezolid for this indication, but it does maintain better susceptibility and negates the use of vancomycin at time of empiric therapy. Even though more data may be needed to definitively recommend linezolid over clindamycin or vice versa, clinical decisions will need to be made prior to susceptibility results. We recommend clinicians utilize their local antibiograms to guide decision making, while also accounting for patient factors. This also provides an opportunity for the development of clinical practice guidelines to better assist clinicians in the community.Item P-1606. Utilizing Diagnostic Stewardship to Help Increase the Yield and Clinical Value of Broad Range PCR Testing at a Tertiary Children’s Hospital(Oxford University Press, 2025-01-29) Fortna, Sarah; Alali, Muayad; Prabhudas-Strycker, Kirsten; Mellencamp, Kagan A.; Boyd, LaKeisha; Goings, Michael; Khan, Haseeba; Fahey, Mackenzie; Samaro, Matthew; Schneider, Jack G.; Graduate Medical Education, School of MedicineBackground: Broad range PCR testing (BR-PCR) in various clinical samples has the ability to provide timely diagnoses that cannot always be made through conventional testing (CT), yet its diagnostic yield and clinical impact have been variable, especially by specimen type. As such, we developed an ID-physician led diagnostic stewardship approval protocol to help optimize test usage. Methods: We conducted a single-center, retrospective pre/post study to assess the impact of an ID-led diagnostic stewardship approval protocol for BR-PCR testing. All clinical specimen types obtained for BR-PCR at Riley Hospital for Children were evaluated between 10/1/2019 to 4/30/2022 (pre-intervention) and 5/1/2022-12/31/2023 (post-intervention). Clinical relevancy of BR-PCR results was determined after review from two ID physician experts and compared between the two time periods, along with clinical impact and overall cost savings. Results: A total of 931 BR-PCR tests were sent from 238 specimens collected from 175 patients in the pre-intervention period, while 208 BR-PCR tests were sent from 65 specimens collected from 65 patients in the post-intervention period. Clinical relevancy of results was determined to be 30.7% and 56.9% for pre-and post-intervention periods, respectively (p< 0.001). 23.1% of post intervention results led to a change in clinical management, compared to 12.6% in the pre-intervention period (p=0.035). Bronchial lavage (BAL) was the most common specimen type with 52.9% of results being clinically relevant post-intervention, compared to 29.6% in the pre-intervention period; p=0.068). Results that led to a clinical change in management were also slightly higher but non-significant for BALs post-intervention (11.8% vs 9.9% pre intervention; p=0.816). Overall cost savings post-intervention was estimated to be $200,000. Conclusion: Use of an ID-physician led diagnostic stewardship approval protocol led to an overall improvement in clinical utility for BR-PCR testing at our institution and was influenced by specimen type. Prospective, multi-center studies are needed to determine which specimen types, diagnoses, and potential diagnostic stewardship measures will help increase the yield and clinical value of BR-PCR testing.Item Primary Repair of Chronic Distal Biceps Tendon Tears(Sage, 2024) Schmidt, Gregory J.; Dmochowski, Jakub M.; Gudeman, Andrew S.; Cage, Emily S.; Greenberg, Jeffrey A.; Hoyer, Reed W.; Graduate Medical Education, School of MedicineBackground: This study reports the clinical results following primary repair of distal biceps tendon ruptures more 6 weeks after injury. Methods: A retrospective review of distal biceps tendon repairs performed by 8 different hand surgeons from January 1, 2015 to October 15, 2020 was performed. Patients with complete tears surgically treated ≥6 weeks after injury without tendon graft were included. Thirty patients qualified and underwent chart review for complication and range of motion (ROM) data. They were contacted for final patient-reported outcome measures (PROMs) using Quick Disabilities of the Arm, Shoulder, and Hand (QuickDASH) and Patient Reported Elbow Evaluation (PREE) scores. Final PROMs were obtained from 21 patients with an average follow-up of 31.3 months (range: 4-71 months). Results: Average time from injury to repair was 71 days (range: 42-204). The average QuickDASH score was 6.6 (±6.2) and PREE score was 7.8 (±8.0). The amount of elbow flexion necessary to complete the repair was documented in 21 patients and averaged 64º (±10º). Postoperatively, patients achieved an average extension/flexion of 1º (±1º) to 138º (±2º) and pronation/supination of 76º (±4º) to 77º (±3º). Complications were reported in 14 patients (47%) and included 2 re-ruptures, 1 adhesive scar formation, 1 superficial infection, 1 intraoperative lateral antebrachial cutaneous nerve laceration, 12 neuropraxias, and 1 case of heterotopic ossification (HO). Conclusions: Primary repair of chronic distal biceps tendon tears greater than 6 weeks from injury demonstrated excellent PROMs and elbow ROM. However, the complication rate may be higher than early repair.Item EXTH-43. Targeting the DNA Damage Response Through Combination MDM2 and AKT Inhibitor Therapy Improves Temozolomide Effectiveness in Chemo-Resistant Glioblastoma(Oxford University Press, 2023-11-10) Koenig, Jenna; Bailey, Barbara; Alfonso, Anthony; Saadatzadeh, M. Reza; Bijangi-Vishehsaraei, Khadijeh; Pandya, Pankita; Damayanti, Nur; Dobrota, Erika; Young, Courtney; Shannon, Harlan; Pollok, Karen; Graduate Medical Education, School of MedicineTemozolomide remains the lone pharmacotherapeutic option for glioblastoma (GBM), yet the development of resistance to temozolomide has been a major challenge contributing to the persistent median < 2-year survival for patients after diagnosis. Tumor heterogeneity and induction of treatment response networks, such as the DNA damage response (DDR), are major contributors to temozolomide resistance in GBM. Targeting DDR treatment response networks, such as the MDM2/p53/p73 and PI3K/AKT/mTOR networks, with small-molecule inhibitors (SMIs) presents an opportunity to disrupt resistance mechanisms and enhance temozolomide efficacy. We utilized a triple drug combination of clinically relevant concentrations of the blood-brain-barrier penetrant SMIs of AKT (ipatasertib; GDC-0068) and MDM2 (idasanutlin; RG7388) with temozolomide to evaluate this targeted strategy using the recurrent, temozolomide-resistant, p53wt GBM10 xenoline. Proliferation studies demonstrated dose-related additive to synergistic inhibition of proliferation at clinically relevant concentrations of ipatasertib and idasanutlin. Further, IncuCyte live-cell imaging demonstrated dose-and time-related growth inhibition of these GBM cells and apoptosis marked by increased cleaved caspase 3 expression following the temozolomide+idasanutlin+ipatasertib triple combination treatment. Cells treated with temozolomide+idasanutlin+ipatasertib also displayed senescence phenotypes, with increased cell cycle arrest and elevated expression of SPiDER β-Gal expression and cell-cycle inhibitors such as p53 and p21. Experiments are in progress to determine the extent to which the effects of temozolomide+idasanutlin+ipatasertib combination therapy are dependent on p53 using siRNA knockdown of p53. In the present study, targeting the temzolomide-induced DNA damage response with idasanutlin+ipatasertib increased the effectiveness of temozolomide. These results indicate that this triple combination may be a promising approach to improving patient outcomes in temozolomide-resistant GBM.Item Parent Perspectives for Type B Ulnar Polydactyly Management(Sage, 2023) Goebel, Gunnar J.; Loewenstein, Scott N.; Adkinson, Joshua M.; Graduate Medical Education, School of MedicineBackground: Type B ulnar polydactyly is one of the most commonly encountered congenital hand differences and can be treated with ligation or excision. The purpose of this study was to determine what factors families consider in selecting treatment for their child with type B ulnar polydactyly. Methods: We reviewed treatment outcomes and administered a survey by telephone to parents of children with type B ulnar polydactyly treated at a pediatric hospital between 2015 and 2020. We assessed satisfaction, reasons for choosing treatment, and post-management complications. Results: The families of 70 of the 156 consecutive treated patients were successfully contacted and agreed to participate (45% response rate). The mean follow-up was 27 months. Twenty-eight chose in-office suture ligation and 42 chose excision. Rapid treatment was prioritized by those who opted for in-office ligation (P = .044). The complication rate for suture ligation was significantly higher than excision (P < .0001), with the most common complication being a residual remnant (nubbin or neuroma stump) (64%). Respondents with residual remnant reported significantly less satisfaction with the appearance of their child's hand (P < .001) and with treatment outcomes (P = .028) compared to those without residual remnants. Conclusions: Factors considered by parents in choosing type of treatment for type B ulnar polydactyly vary and may be significantly influenced by the surgeon. Although the majority of parents remain extremely satisfied with their child's outcome regardless of management type, time to treatment plays a determinative role in parents opting for ligation rather than excision in the operating room.Item Left ventricular circumferential strain and coronary microvascular dysfunction: A report from the Women’s Ischemia Syndrome Evaluation Coronary Vascular Dysfunction (WISE-CVD) Project(Elsevier, 2021) Tamarappoo, Balaji; Samuel, T. Jake; Elboudwarej, Omeed; Thomson, Louise E. J.; Aldiwani, Haider; Wei, Janet; Mehta, Puja; Cheng, Susan; Sharif, Behzad; AlBadri, Ahmed; Handberg, Eileen M.; Petersen, John; Pepine, Carl J.; Nelson, Michael D.; Bairey Merz, C. Noel; Graduate Medical Education, School of MedicineAims: Women with ischemia but no obstructive coronary artery disease (INOCA) often have coronary microvascular dysfunction (CMD). Left ventricular (LV) circumferential strain (CS) is often lower in INOCA compared to healthy controls; however, it remains unclear whether CS differs between INOCA women with and without CMD. We hypothesized that CS would be lower in women with CMD, consistent with CMD-induced LV mechanical dysfunction. Methods and results: Cardiac magnetic resonance (cMR) images were examined from women enrolled in the Women's Ischemia Syndrome Evaluation-Coronary Vascular Dysfunction Project. CS by feature tracking in INOCA women with CMD, defined as myocardial perfusion reserve index (MPRI) <1.84 during adenosine-stress perfusion cMR, was compared with CS in women without CMD. In a subset who had invasive coronary function testing (CFT), the relationship between CS and CFT metrics, LV ejection fraction (LVEF) and cardiovascular risk factors was investigated. Among 317 women with INOCA, 174 (55%) had CMD measured by MPRI. CS was greater in women with CMD compared to those without CMD (23.2 ± 2.5% vs. 22.1 ± 3.0%, respectively, P = 0.001). In the subset with CFT (n = 153), greater CS was associated with increased likelihood of reduced vasodilator capacity (OR = 1.33, 95%CI = 1.02-1.72, p = 0.03) and discriminated abnormal vs. normal coronary vascular function compared to CAD risk factors, LVEF and LV concentricity (AUC: 0.82 [0.73-0.96 95%CI] vs. 0.65 [0.60-0.71 95%CI], respectively, P = 0.007). Conclusion: The data indicate that LV circumferential strain is related to and predicts CMD, although in a direction contrary with our hypothesis, which may represent an early sign of LV mechanical dysfunction in CMD.Item Editorial: New developments in pathways toward diversity and inclusion in STEM: A United States perspective(Frontiers Media, 2022) Gates, Alexander E.; Gilbert, Juan; Botanga, Chris; London, Bonita; Nguyen, Kim; Graduate Medical Education, School of MedicineItem The impact of COVID‐19 on clinical outcomes among acute myocardial infarction patients undergoing early invasive treatment strategy(Wiley, 2022) Sharma, Prerna; Shah, Kajal; Loomba, Johanna; Patel, Arti; Mallawaarachchi, Indika; Blazek, Olivia; Ratcliffe, Sarah; Breathett, Khadijah; Johnson, Amber E.; Taylor, Angela M.; Salerno, Michael; Ragosta, Michael; Sodhi, Nishtha; Addison, Daniel; Mohammed, Selma; Bilchick, Kenneth C.; Mazimba, Sula; Graduate Medical Education, School of MedicineBackground: The implications of coronavirus disease 2019 (COVID-19) infection on outcomes after invasive therapeutic strategies among patients presenting with acute myocardial infarction (AMI) are not well studied. Hypothesis: To assess the outcomes of COVID-19 patients presenting with AMI undergoing an early invasive treatment strategy. Methods: This study was a cross-sectional, retrospective analysis of the National COVID Cohort Collaborative database including all patients presenting with a recorded diagnosis of AMI (ST-elevation myocardial infarction (MI) and non-ST elevation MI). COVID-19 positive patients with AMI were stratified into one of four groups: (1a) patients who had a coronary angiogram with percutaneous coronary intervention (PCI) within 3 days of their AMI; (1b) PCI within 3 days of AMI with coronary artery bypass graft (CABG) within 30 days; (2a) coronary angiogram without PCI and without CABG within 30 days; and (2b) coronary angiogram with CABG within 30 days. The main outcomes were respiratory failure, cardiogenic shock, prolonged length of stay, rehospitalization, and death. Results: There were 10 506 COVID-19 positive patients with a diagnosis of AMI. COVID-19 positive patients with PCI had 8.2 times higher odds of respiratory failure than COVID-19 negative patients (p = .001). The odds of prolonged length of stay were 1.7 times higher in COVID-19 patients who underwent PCI (p = .024) and 1.9 times higher in patients who underwent coronary angiogram followed by CABG (p = .001). Conclusion: These data demonstrate that COVID-19 positive patients with AMI undergoing early invasive coronary angiography had worse outcomes than COVID-19 negative patients.