Background: About half of Minneapolis VA patients reside in rural areas, receiving their primary care at a Community Based Outpatient Clinic (CBOC). Although some CBOC’s are over 200 miles away, patients must travel to the Twin Cities for surgical services. 

Methods: The 167 consecutive patients who opted for telehealth postoperative visits were surveyed. Data collected included travel time and distance to the Minneapolis VA and their local CBOC, need for transportation assistance to the clinic/VA, complications as a result of telehealth and a 1-10 overall satisfaction score. 

Results: Respondents reported a mean + SD satisfaction score of 9.60 ± 1.20, with a mean cost savings of $51.94 ± $40.92, decrease in travel time of 99.4 ± 76.58 minutes and no post-surgical complications missed. 

Conclusions: The telehealth program appears to be safe, saves time and money for veterans and results in extremely high patient satisfaction.


Efficacy of Telehealth for Postoperative Visits at the Minneapolis VA

Background:
Unintended perioperative hypothermia, defined as having a core-body temperature less than 36 degrees Celsius, occurs in 78.6 % of patients undergoing general anesthesia. Additionally, it is also seen post-operatively in the SICU as well. Concurrently, peri and postoperative hypothermia is also associated with higher rates of infection, increased recovery time, cardiovascular diseases, perioperative hemorrhage, and impairment of drug metabolism. Therefore, it is crucial to limit the incidence of peri and postoperative hypothermia because it is both adjustable and advantageous for the patient. Doing so limits postoperative complications and future surgical interventions. The research goal was to determine the efficacy of using either a water-circulating device or a forced air warming system maintaining both peri/postoperative normothermia during thoracic and abdominal surgeries.

Methods:
A systematic review of randomized controlled trials and non-randomized studies addressing the efficacy of surgical warming systems was conducted. The impact of a water circulating device and a forced air warming system on maintaining peri and postoperative normothermia during abdominal and thoracic surgical procedures were analyzed.

Results:
The initial search of databases returned a total of 28 publications. Five total randomized controlled studies and non-randomized studies were included and analyzed in this review. There was a statistically significant difference in mean core body temperature in patient’s using the water-circulating device when compared to the forced air warming system during thoracic and abdominal procedures perioperatively in both the randomized controlled studies and non-randomized studies, mean difference of 0.45, p=0.0002, 95% CI [0.21,0.69] and mean difference of 0.47, p=0.001, 95% CI [0.18,0.75], respectively. There was not a statistically significant difference in mean core body temperature in patient’s using the water-circulating device when compared to the forced air warming system during thoracic and abdominal procedures postoperatively in the randomized controlled studies, mean difference of 0.41, p=0.34, 95% CI [-1.08,1.33]. There was a slight difference in the maintenance of normothermia postoperatively in the nonrandomized studies, mean difference of 0.89, p=0.02, 95% CI [0.12,1.65].

Conclusion
The investigated water warming system results in better maintenance of intraoperative normothermia than routine air forced warming applied to the upper and lower body.


Water Circulating Device versus Forced Air Warming System in Prevention of Hypothermia during Thoracic and Abdominal Surgeries: a Meta Analysis

Background: Pulmonary hypertension (PH) is a fatal disease associated with pulmonary vascular remodeling that leads to right ventricular (RV) failure and death. While miR-10b-5p exerts pro-proliferative effects in various cancers via inhibition of its targets cell adhesion molecule 1 (CADM1) and apoptotic peptidase activating factor 1 (APAF1), its role in PH is elusive. We hypothesize that PH is associated with upregulation of lung miR10b-5p and downregulation of its targets CADM1 and APAF1. Further, miR10b-5p inhibition may rescue pre-existing PH.

Methods: PH was induced in male rats by monocrotaline (MCT; 60mg/kg sc; n=4; followed for 30-days) or Sugen/Hypoxia (SuHx; SU5416; 20mg/kg sc and 10% O2 hypoxia for 3-wks followed by normoxia for 2-wks; n=3). In vivo inhibition of miR10b-5p was performed from day14-30 after MCT (5 intratracheal injections of antagomir every 3-4 days; 5nM/ injection; n=3). PBS treated MCT rats served as controls (n=5). Rats were followed by echo. RV catheterization was performed terminally, and RV hypertrophy index was calculated. MiRNA microarray was performed to assess miR10b in rat lungs. Lungs were stained to quantify vascular remodeling. RT-PCR was performed to assess gene expression. Human pulmonary artery smooth muscle cells (HPASMCs) were incubated with miR10b mimic for 24h to assess proliferation. Data are mean±SEM. 

Results: MCT and SuHx rats developed severe PH. MiRNA microarray revealed a 3-fold increase in miR10b in MCT rat lungs. PCR validated increased miR10b in MCT and SuHx rat lungs. Further, there was a significant downregulation of miR10b targets CADM1 (MCT 1.64-fold; SuHx 1.48-fold) and APAF1 (MCT 1.23-fold; SuHx 1.21-fold) in lungs. In vivo knockdown of miR10b resulted in rescue of PH in MCT rats (RVSP: 50.7±4.42 in antagomir vs. 95.81±3.70 mmHg in placebo; p<0.005; RV hypertrophy index: 0.52±0.02 in antagomir vs. 0.80±0.07; p<0.05; RVID: diastolic 2.44±0.68 in antagomir vs. 4.55±0.42 mm; p<0.05). PCR demonstrated 30% decrease in lung miR10b and histology revealed reduced pulmonary arteriolar medial wall thickness (32.72±1.12 in antagomir vs. 42.24±3.26% in placebo, p<0.005) in rats treated with antagomir. Finally, miR10b overexpression resulted in HPASMC proliferation in a dose-dependent manner.

Conclusion: Pre-clinical PH is associated with an increase in miR10b-5p expression and decrease in its targets CADM1 and APAF1. miR10b-5p inhibition rescues experimental PH and may serve as a novel therapeutic target.


MicroRNA10b-5p Inhibition as a Novel Therapeutic Strategy for Severe Pulmonary Hypertension

Robotic assisted surgery (RAS) is a form of minimally invasive surgery. During RAS, surgical instruments are connected to a robotic system that is controlled by a surgeon located at an isolated console. Although RAS has advantages such as faster recovery times and less post-operative pain for patients, there are challenges that the technology brings to the operating room such as changes in workflow and space constraints. Therefore, we sought to understand expert perspectives on current and future challenges of surgical team members during the use of RAS. This study aims to identify expert perceptions of RAS for potential future opportunities and improvements for RAS workflow. In-person observations were conducted to learn more about the overall process and workflow of RAS. Focus groups were conducted with eleven surgical techs, eight circulating nurses, and two medical administrations. The focus group questions were used for insights on staff demographics, RAS experience between different hospitals, built environments, training, and interactions. These results were then used to perform a thematic analysis, and the following themes emerged: training, usability, communication, environment, management, and scheduling. These themes were further broken down into subthemes. Definitions and quotes were used to help define each subtheme. Further thematic analysis needs to be conducted to gain additional perspectives from other RAS operating room team members.

Integrating Expert Perspectives On Current and Future Challenges for Robotic Assisted Surgery (RAS) Workflow

Background: Many medical schools have begun including health systems science (HSS) in their curricula to address emerging healthcare needs. With this principle in mind, a clinical reasoning exercise was developed by the Johns Hopkins neurology clerkship team in 2017. Students are given a standardized case of a patient presenting with falls and asked to develop an assessment & plan. During the COVID-19 pandemic, Johns Hopkins replaced tiered grading (honors/high pass/pass/fail) with pass/fail grading for core clerkships. This study seeks to determine if clerkship grading (tiered versus pass/fail) influences the quality of the differential diagnoses, localization of the disease process, clinical reasoning, and diagnostic/management options.

Methods: Data was extracted from the case reports submitted by students in the Neurology clerkship between 2017 and 2022. Report elements in tiered versus pass/fail curricula were compared using chi-squared tests.

Results: Of the 592 students, 306 (51.7%) were in the tiered curriculum, and 286 (48.3%) were in the pass/fail curriculum. With respect to differential diagnoses, students were more likely to include drug-induced parkinsonism (p<0.05) in the tiered system, and Lewy body dementia (p<0.05) in the pass/fail system. The inclusion of other diagnoses was not significantly different between the two systems. For localization, students were more likely to localize to the substantia nigra specifically (p<0.05) in the pass/fail compared to tiered system. Clinical reasoning elements like dysautonomia and timing (p<0.05) were cited more in the tiered system, while discussion of REM sleep behavior was not significantly different between the two systems. Students were more likely to order labs but less likely to order imaging (p<0.05) in the tiered versus pass/fail system. Lastly, for management, students were more likely to request outside consultations/referrals, initiate physical therapy, stop metoclopramide, and treat urinary symptoms and hypotension (p<0.05) in the tiered versus pass/fail system. Treatment with carbidopa-levodopa did not significantly differ between the two systems.

Conclusion: Although clerkship grading does not appear to influence differential formation or clinical reasoning strongly, it does influence diagnostic testing and management choices. Tiered grading correlates with aspects of HSS, including value-based care (deferring imaging, stopping metoclopramide) and interprofessional collaboration (consults, physical therapy).

Looking Backwards to Look Forward: An Analysis of Clinical Reasoning Reports in the Neurology Core Clerkship before and after the transition to Pass/Fail Grading

Background
Drug-induced hypersensitivity syndrome (DIHS) is a severe, potentially life-threatening drug reaction with cutaneous and internal organ involvement. DIHS can lead to various autoimmune conditions, occurring in about 10% of patients, including thyroiditis. This case highlights the need for post-DIHS thyroiditis screening.

Case Presentation
A 32-year-old woman presented to the emergency department with fever, morbilliform eruption, facial swelling, lymphadenopathy, and laboratory studies notable for atypical lymphocytes (4%), eosinophilia (1400), and aminotransferase abnormalities (AST 61, ALT 265). Two weeks prior, she initiated a course of oral trimethoprim-sulfamethoxazole. History, clinical exam, and laboratory findings were consistent with DIHS. She was treated with high-dose corticosteroids with a resolution of the eruption and stabilization of hepatic enzymes. At follow-up in an outpatient dermatology clinic four weeks after discharge, she was noted to have clinically painful thyromegaly, fever, tachycardia, and palpitations. She was referred to the ED to expedite workup for suspected symptomatic hyperthyroidism. Workup revealed TSH of 0.01 (L), FT4 >7.7 (H), TSI <0.10, TRAb negative, and TPO Ab 202 (H). Thyroid ultrasound showed enlarged thyroid with heterogenous echotexture. Endocrinology diagnosed her with thyroiditis and prescribed atenolol for symptom management. She continued to have heat intolerance, palpitations, and faint pink macules on her lower legs. She initiated low-dose methimazole with a resolution of symptoms.

Discussion

One of the most common drug classes to cause post-DIHS autoimmune thyroiditis are sulfa drugs and antiepileptics. The most commonly seen issues that arise in the thyroid post-DIHS are Hashimoto’s thyroiditis and Graves’ disease, which have been observed to occur between 2 months and 3 years after the diagnosis of DIHS. As seen in this case, the patient experienced debilitating symptoms of thyroiditis within 1 month, which could have been minimized with early screening and recognition. This case emphasizes the importance of dermatologic follow-up for patients diagnosed with DIHS and the role of post-DIHS screening for autoimmune thyroid disease, as missed diagnosis of delayed sequelae can lead to significant morbidity.

Importance of Post-Drug Induced Hypersensitivity Syndrome Thyroiditis Screening

**Scoring is only possible in the semifinals hall**

**Abstract:**



Acute osteomyelitis in the setting of chronic steroid therapy for the treatment of 17-alpha-hydroxylase deficient congenital adrenal hyperplasia

Evaluating Demographic Reporting in Publicly Available Prostate MRI Data Sets

Background: Breast cancer is the second most common cancer amongst women in the United States. From 2013 to 2018, the breast cancer death rate fell by 1%; this decline was attributed to earlier screening and awareness. Early diagnosis of breast cancer can reduce morbidity and the intensity of treatment plans (ex: chemotherapies). There are many different screening tests to predict 5 year and lifetime risk of breast cancer. These screening tests and software programs have large variabilities in their risk prediction. Recent publications show a 5% to 19% overdiagnosis of breast cancer in women. In this study we predicted the 5-year risk, 10-year risk, and lifetime risk of breast cancer for mammogram patients using four different breast cancer screening tools: Mammorisk, Tyer Cuzick 2013 (TC 2013), Tyer Cuzick 2017 (TC 2017), and Gail. We compared their variability using t test statistical analysis. The purpose of our study is to determine the precision of these screening tests and begin streamlining the screening process for breast cancer. 

Methods: We collected Mammorisk data from 242 participants at Southwood Imaging (Youngstown, OH) who came in for their annual mammogram. Most women were between 40 to 70 years old. While participants waited to be screened, we asked them to fill out a questionnaire. The questionnaire contained 19 questions about the patient’s personal health, prior breast biopsies, and family history of breast cancer. We put this additional patient information into the additional screening tests Tyer Cuzick 2013, Tyer Cuzick 2017, and Gail. We calculated the 5-year risk and lifetime risk for each patient. We then measured the 5-year risk, 10-year risk, and lifetime risk assessment using t-test statistical analysis (two tailed). 

Results: The 5-year risk did not significantly differ between breast cancer risk models. The 10-year risk did not significantly differ between breast cancer risk models. The results showed statistically significant differences between lifetime risk for breast cancer risk models. Mammorisk and TC2017 lifetime risks differed by 0.544. The difference in percent lifetime risk between the Mammorisk and TC2013 models was -2.666. Mammorisk and Gail lifetime risks varied by 0.104. Even though our lifetime risk data was significant, the effect size was low . So some of our data may be inconclusive.

Conclusion: Our study indicated a lack of significant difference in 5-year and 10-year risk between models, but lifetime risk did significantly differ between breast cancer risk models. This creates variability that is difficult for physicians to interpret. This can affect physicians’ decision making and future patients’ health outcomes. Additional studies with a larger and more diverse population are needed for definitive evidence in variability between breast cancer risk models. Our study is a first step in finding a streamlined way to approach breast cancer risk in patients. In creating a streamlined approach radiologists will be able to care for cancer patients in a more organized manner.

Variability Between Different Breast Cancer risk Models and Effects on Various Parameters

Background: While most births in the U.S occur in a hospital, out-of-hospital births have been increasing in popularity with one in every 61 births occuring at home or in a community birthing center. The fear of disrespect and loss of autonomy have been cited as primary drivers for planned home births with data showing higher rates of mistreatment occurring in hospital settings than at home. This was especially apparent for individuals who transferred from a community setting to the hospital after the onset of labor. Approximately 10% of home births will experience transfer to a hospital due to urgent and non-urgent reasons. Despite this, there are still no standardized guidelines for managing home birth transfers to hospital care which can lead to delays in receiving care. Additionally, there have been reports of significant opposition to home births among hospital-based clinicians (HBCs) which negatively impacts the birthing person’s experience with hospital births. 

Washington’s Smooth Transitions™ Quality Improvement Program aims to better understand the perceptions of birthing persons on transfers from planned community births to hospitals in order to identify barriers and areas of improvement. 

Methods: Smooth Transitions distributed an online mixed-methods survey to birthing persons upon discharge to capture lived experiences of home to hospital birth transfers in 17 Washington-based hospitals. Free response questions inquired about quality of care, overall birthing experience, and collaboration between the birthing care team. The data was coded for thematic content to identify best practices and potential areas of improvement.

Results: A total of 190 birthing persons completed the survey. 18% of these respondents felt that their personal preferences were not respected by the HBCs and 21% felt pushed into agreeing with care options. Birthing persons valued the HBCs respecting their autonomy, birth plan, and support team. Areas of improvement included shorter check-in times, allowing the community midwife to be present and more involved in care plans, and better patient education provided by the HBCs.

Conclusion: Birthing persons’ perceptions of transfers help us better understand opportunities for improving their experience with hospital births. Respondents self-reported various levels of disrespect, lack of autonomy, and inadequate informed consent by HBCs which were exacerbated by patient-provider disagreements around care plans. Further efforts need to be made to understand and reconcile the goals of care for HBCs, patients, and their support team. This will help to create a best practices guideline for these transfers and improve maternal and fetal health outcomes.

Patient Perceptions on Transfers from Planned Community Births to Hospital care in Washington State

Background
Scleroderma is a rare, chronic autoimmune disease that is characterized by thickening of the skin and other connective tissues in the body. Nodular scleroderma (NS) is a rare cutaneous form of scleroderma that can occur primarily with systemic sclerosis. Due to the rarity of NS, it is important to recognize these lesions, if presenting early in disease progression, as a sign of underlying scleroderma before internal organ damage becomes apparent. 

Case Presentation
A 42-year-old female with a history of systemic sclerosis presented with an enlarging left supraclavicular nodule. Upon physical exam, a 1.1cm erythematous nodule was found. The patient had clinical findings consistent with systemic sclerosis, including Raynaud’s phenomenon, gastroesophageal reflux disease, sclerodactyly, dyspnea on exertion, and skin tightening. The patient had been treated with CellCept 1500mg twice daily and responded very well to therapy. Pertinent laboratory data included speckled antinuclear antibodies (1:320 titer) and positive anti-RNA polymerase III antibodies (>80 units). 

The lesion was initially excised to rule out diagnosis of a cyst. However, histopathological analysis demonstrated a nodular proliferation of dense fibrotic collagen with scattered bland fibroblasts. A sparse perivascular and periadnexal lymphocytic infiltrate in the dermis was present with notable eccrine coil trapping. A CD34 stain showed markedly diminished dermal dendritic cells within the fibrotic nodule. Considering the patient’s known history of anti-RNA polymerase III-positive systemic sclerosis and histopathological findings, the focal lesion was consistent with nodular scleroderma. No subsequent treatments were performed.

Discussion
Nodular scleroderma is an atypical cutaneous presentation of systemic sclerosis and patients who are well-controlled on immunosuppressive therapy with few to no signs of internal organ disease are still susceptible to developing these lesions. Thus, diagnosis and treatment of NS remains a challenge. NS usually presents as 2 mm - 3 cm firm nodules or plaques resembling keloid or morphea, usually distributed on the trunk, neck, proximal extremities, and face. The pathogenesis of NS is also not well understood. Previous reports have shown that there may be a role for increased expression of connective tissue growth factor, tenascin, epidermal growth factor, or transforming growth factor beta in the formation of NS. 

Furthermore, treatment of NS is difficult as these lesions are resistant to many non-surgical interventions and remain stable over time. As in our case, surgical excision of NS has been the only treatment reported so far that results in full removal of NS, but not necessarily prevention of NS recurrence.


Systemic Sclerosis with a Rare Presentation of Nodular Scleroderma

Background:
Annually, over 300 million patients undergo surgery requiring the administration of a combination of anesthetic pharmacologic compounds (APCs). Surgery is associated with significant tissue trauma, triggering a complex inflammatory response that engages the innate and adaptive branches of the immune system. Complications, including end-organ damage, infections, and protracted recovery, arise as pro-inflammatory and immune-suppressive responses tilt out of balance. Accumulating evidence suggests that, in addition to desired anesthetic properties, many APCs have immune-modulatory properties that can positively or negatively impact surgical recovery. However, the effect of APCs on specific innate and
adaptive immune cell functions warrants further exploration to personalize anesthetic choice based on individual patient and surgery needs. We hypothesize that APCs alter critical immune cell responses and effector functions implicated in the human immune response to trauma and injury.

Methods:
We developed a high-throughput multiplex mass-tag barcoding (MCB) assay to screen 16 commonly administered APCs for their capacity to modulate trauma-related immune and adaptive immune responses. These include general and local anesthetics, narcotic and benzodiazepine analgesics, neuromuscular blocking agents, and NSAIDs. We also selected ten additional compounds frequently used in anesthesia settings: antiemetics, diuretics, antidotes, catecholamines, and beta blockers. Using single-cell mass cytometry, we quantify the effect of each APC on 1500 intracellular signaling responses in 25 innate and adaptive immune cell subsets in whole blood samples (500µL) across a range of drug concentrations and stimulation conditions, including lipopolysaccharide (LPS), interferon alpha (IFNa), and a cocktail of interleukins 2, 4, and 6.

Results:
A first MCB screen was completed using flunisolide, a glucocorticoid compound with a known immunosuppressive effect, allowing for assay optimization. This identified marked changes in protein phosphorylation of inflammatory pathways between immune cells exposed and not exposed to flunisolide. These results show that flunisolide inhibited adaptive immune cell subsets to a greater extent than innate immune cell subsets in a cell-type and signaling response-specific manner.

Conclusion:
Having established the MCB experimental framework, the next experiments will systematically evaluate the immune-modulatory properties of the proposed library of APCs. Eventually, the MCB assay could be utilized clinically to determine the immune-modulatory effect of a complex anesthesia regimen – a first step toward personalized anesthesia.

Underline digital video library

Efficacy of Telehealth for Postoperative Visits at the Minneapolis VA

Water Circulating Device versus Forced Air Warming System in Prevention of Hypothermia during Thoracic and Abdominal Surgeries: a Meta Analysis

MicroRNA10b-5p Inhibition as a Novel Therapeutic Strategy for Severe Pulmonary Hypertension

Integrating Expert Perspectives On Current and Future Challenges for Robotic Assisted Surgery (RAS) Workflow

Looking Backwards to Look Forward: An Analysis of Clinical Reasoning Reports in the Neurology Core Clerkship before and after the transition to Pass/Fail Grading

Importance of Post-Drug Induced Hypersensitivity Syndrome Thyroiditis Screening

Acute osteomyelitis in the setting of chronic steroid therapy for the treatment of 17-alpha-hydroxylase deficient congenital adrenal hyperplasia

Evaluating Demographic Reporting in Publicly Available Prostate MRI Data Sets

Variability Between Different Breast Cancer risk Models and Effects on Various Parameters

Patient Perceptions on Transfers from Planned Community Births to Hospital care in Washington State

Systemic Sclerosis with a Rare Presentation of Nodular Scleroderma

A High-Throughput Mass Cytometry Assay to Investigate Immune Cell Modulation of Anesthetic Drugs

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