2541. Impact of a Combined Infectious Disease-Critical Care Medicine (ID-CCM) Track on Fellowship Recruitment

Background There has been a declining national trend in recent years of resident applications to Infectious Disease (ID) fellowship programs. This dearth of interested and available applicants has resulted in many programs failing to fill some or all of their fellowship slots. Our ID fellowship program, founded in 2013 at Allegheny General Hospital, had met with similar difficulty. Methods To increase the recruitment pool of candidates and combat the challenge to fill our positions, we incorporated a combined 3 year ID-Critical Care Medicine (CCM) track in 2016, initially with one of our two annual fellowship slots allotted to this track. This entailed a collaborative effort between the ID and CCM divisions, an internal application completion outlining the need and rationale for this combined program, and finally, approval from the institutional as well as the Accreditation Council for Graduate Medical Education (ACGME). Results The number of applicants interviewed from 2013 to 2016 for ID (pre-inception of the ID-CCM track), as well as those for ID, ID-CCM, or those interviewing for both tracks following 2016, were counted. We noted a consistent increasing trend in the numbers interviewed for both the ID (4, 8, and 12 total applicants) and ID-CCM (4, 10, and 12 total applicants) tracks over the three since the inception of our combined fellowship program; 3 additional applicants in years 2017 and 2018, and 5 in 2019, expressed interest in either ID or ID-CCM (Graph 1). This favorably amounted to filling our training positions. Conclusion Implementation of a combined ID-CCM fellowship program proved to be a viable strategy to increase the number of applicants at our institution. Given the success of having one dually-accredited slot, we have expanded the combined-track to both positions. As the first fully-integrated ID-CCM fellowship program in the country, we may be pioneering this novel training pathway for future physicians. Disclosures All authors: No reported disclosures.

Postoperative Imaging Findings Associated with Transpalpebral Craniotomy Approach to Anterior Cranial Fossa

Background and Purpose The transpalpebral “eyelid” approach is a novel alternative to the traditional ciliary or supraciliary incision for supraorbital frontal craniotomy and access to the anterior cranial fossa. Though a prior publication from our institution has described the surgical approach in detail along with cosmetic and clinical outcomes, postoperative imaging findings have not yet been described. As this surgical technique becomes more widely practiced, it is essential for neuroradiologists, oculoplastic surgeons, and skull base neurosurgeons to be familiar with the expected postoperative imaging findings, especially those that prompt subsequent intervention. Materials and Methods A retrospective, institutional review board approved review was performed of 102 patients who underwent transpalpebral surgical approach at Allegheny General Hospital from June 2007 through May 2015. Operative reports, pathology reports, preoperative imaging, postoperative imaging, and postoperative clinical documentation were reviewed. Results Forty-nine percent of patients had solely benign expected postoperative imaging findings, 37% had various atypical findings not requiring further intervention (most commonly asymmetric globe protrusion and bone cement in a paranasal sinus), 6% had findings prompting minimally invasive bedside procedures (most commonly pseudomeningocele), and 8% had findings requiring surgical intervention. Conclusion The majority of imaging following the transpalpebral approach showed typical, benign findings, such as minimal pneumocephalus and asymmetric globe protrusion. Nonetheless, members of the clinical team should be aware of the small number of findings requiring intervention, especially pseudomeningocele.

Allegheny General Hospital experience with LDR prostate brachytherapy comparing Pd-103 with I-125.

274 Background: To report a retrospective review of a single institution’s experience treating patients with localized adenocarcinoma of the prostate with low-dose rate brachytherapy (LDR-BT) comparing clinical outcomes at 5 years of patients treated with Pd-103 vs. I-125. Methods: 332 hormone-naïve patients with localized adenocarcinoma of the prostate were treated with LDR-BT without androgen deprivation therapy (ADT) between 1998-2008 at Allegheny General Hospital. 300 patients had more than 12 months of follow-up and were included in the statistical analysis. 40 patients (13%) were treated with Pd-103 and 260 (87%) were treated with I-125. The decision to treat with Pd-103 was based on physician preference and pretreatment urinary AUA score. Both treatment groups (Pd-103 vs. I-125) were otherwise stratified similarly with regards to median patient age (65 vs. 65), NCCN low-risk category (87.5% vs. 89.9%), Gleason score 6 (92.5% vs. 88.1%), Clinical T1c (85% vs. 79.9%), pretreatment median PSA (5.9 vs. 5.6), and pretreatment mean AUA score (8 vs. 6.5). All pathology was reviewed by a single genitourinary pathologist. All prostate seed implants were performed by a single radiation oncologist. Results: Median follow-up was 67 months for Pd-103 patients and 80 months for I-125 patients. Mean D90 for the Pd-103 group was 140.7 Gy versus 170.9 Gy in the I-125 group. There was one biochemical failure in the Pd-103 group and 21 biochemical failures in the I-125 group. 5-year biochemical failure free-survival rates were 95.7% for the Pd-103 group and 90.1% for the I-125 group (p=0.13). Conclusions: Prior studies have shown no difference in outcomes between patients treated with Pd-103 and I-125 for early stage prostate cancer. Therefore the choice of isotope in LDR-BT is based on urologist and/or radiation oncologist preference and patient clinical presentation (AUA score). Our institution’s experience indicates a trend towards increased rates of biochemical failure in a homogenous group of patients treated with I-125 compared to Pd-103. Due to the retrospective nature of our study as well as the limited number of patients, this requires validation in a prospective trial.

Roundtable: Reflections on the Scientific Sessions

Following PHA's International PH Conference and Scientific Sessions in Indianapolis on June 20–22, 2014, a group of clinicians gathered by phone to discuss the highlights of the meeting they would take to their practice. Guest editor Anna R. Hemnes, MD, Assistant Professor of Medicine and Assistant Director, Pulmonary Vascular Center at Vanderbilt University and Chair of the Scientific Sessions, facilitated the call. Discussants were Raymond Benza, MD, Cardiovascular Institute, Allegheny General Hospital, Pittsburgh; Karen Fagan, MD, University of South Alabama, Mobile; Steven M. Kawut, MD, MS, Penn Cardiovascular Institute, University of Pennsylvania School of Medicine, Philadelphia; Jeffrey S. Sager, MD, MSc, Santa Barbara, CA; and Glenna Traiger, RN, MS, CNS-BC, Pulmonary Hypertension Program, UCLA.

Validation of a Feedback-Controlled Elbow Simulator Design: Elbow Muscle Moment Arm Measurement

The Allegheny General Hospital (AGH) elbow simulator was designed to be a closed-loop physiologic simulator actuating movement in cadaveric elbow specimens via servoelectric motors that attach to the tendons of the biceps, brachialis, triceps, and pronator teres muscles. A physiologic elbow simulator should recreate the appropriate moment arms throughout the elbow’s range of motion. To validate this design goal, muscle moment arms were measured in three cadaver elbow specimens using the simulator. Flexion-extension moment arms of four muscles were measured at three different pronation/supination angles: fully pronated, fully supinated, and neutral; pronation-supination moment arms were measured at three different flexion-extension angles: 30 deg, 60 deg, and 90 deg. The tendon-displacement method was used in these measurements, in which the ratio of the change in musculotendon length to the change in joint angle was computed. The numeric results compared well with those previously reported; the biceps and pronator teres flexion-extension moment arms varied with pronation-supination position, and vice versa. This is one of the few reports of both flexion-extension and pronation-supination moment arms in the same specimens, and represents the first use of closed-loop feedback control in the AGH elbow simulator. The simulator is now ready for use in clinical studies such as in analyses of radial head replacement and medial ulnar collateral ligament repair.