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Item Stepwise Diagnosis of a Chiari Malformation Post-Concussion and Return-to-Play Management in a High School Soccer Athlete(2023) Martinez, Richard; Bejarano, Michael; Rauf, Ali; Clearfield, DanielBackground: Limited data exist concerning recommendations on return-to-play for patients with a Chiari I malformation (CIM). A Chiari malformation is a condition involving the brain and spinal cord that results from a structural defect of the occiput. This leads to brain tissue extending through the foramen magnum which can places pressure on the cerebellum and spinal cord leading to neurological manifestations. Much of the symptoms associated with Chiari malformations are present due to the build-up of pressure around surrounding structures. (1) Case Information: This case study details the management of a 15-year-old female soccer player who was diagnosed with a CIM following a traumatic brain injury (TBI). The patient initially presented to a sports medicine clinic with concussion signs and symptoms that magnified over the course of the first week following the TBI. The patient’s increase in symptom severity combined with behavioral changes prompted further investigation, which led to the detection of a CIM. Her case emphasizes the potential for neurological deficits caused by a head trauma to be complicated by CIM. It likewise illustrates the need to evaluate prolonged concussion symptoms for potential anatomical abnormalities. In this case report, we follow the patient’s initial diagnosis of concussion and discuss the progression of her symptoms that warranted additional evaluation. We address the neurological workup involved in recognizing how this patient’s presentation suggested a secondary cause for her symptoms. Furthermore, we review relevant literature in reference to current rehabilitative management for CIM. Conclusions: This case presents a model for how an underlying CIM can exacerbate the development of symptoms acquired through a concussion. It also demonstrates the methods a physician can use in the progression of treatment and tools used to pursue when an initial TBI is not alleviated from conservative therapy or medication. Through this discussion, we provide clinicians with a valuable reference when assessing risk in athletes with CIMs who seek to return to their sport.Item Multi-hazard assessment in Kyrgyzstan’s Osh Region using Maximum Entropy(2023) Mendoza, Edna Patricia; Pourghasemi, Hamid Reza; Haque, UbyduPurpose: Climate change impacts natural processes that lead to increased warming and extreme precipitation. As global temperatures continue to rise, an increase in the frequency of climate- and weather-related disasters is expected. Over the past decade, approximately 200 million people were affected by disaster events, with 81,000 deaths per year on average. Majority of the impacts occurred in the 40 most mountainous countries, including Kyrgyzstan in Central Asia. More than 80% of the land area in Kyrgyzstan is mountainous and highly hazardous. The Osh Region in Kyrgyzstan, in particular, is a site that suffers multiple types of natural hazards, such as floods, landslides, earthquake, and drought. These hazards pose a great risk to the mountain communities. Currently, the susceptibility distribution of the multiple hazards in the Osh Region, and the populations exposed to it remain to be assessed. The goal of this study was to harmonize three natural hazards – flood, landslides, and wildfire – of the Osh Region in a generalized multi-hazard susceptibility map (MHSM) that incorporates bioclimatic and geo-environmental factors for disaster risk management and response planning. Methods: Inventory maps for single hazard susceptibility were prepared by processing thematic layers from remotely-sensed data, hazard catalogs, and bioclimatic data. A total of 37 covariates (19 bioclimatic variables and 18 geo-environmental factors) were selected as predictors using Maximum Entropy (MaxEnt) machine learning algorithm. Accuracy metric of the predictive model was evaluated using the "receiver operating characteristic” (ROC) curve and computing for the "area under the ROC curve” (AUC-ROC). Moreover, MaxEnt was able to estimate percent variable contributions and permutation importance for each of the predictors. The generated single-hazard susceptibility maps were harmonized into a multi-hazard susceptibility map in ArcGIS 10.8. Results: The results show significant predictive performance and degree of fitting of MaxEnt for flood, landslides, and wildfire, obtaining high AUC-ROC (> 0.9). The land cover covariate contributed to wildfire and landslide. Elevation covariate occurred most to wildfire and flood susceptibility. Distance to faults contributed to landslides, while precipitation of the coldest quarter contributed to flood. A MHSM was then generated after overlaying and fitting the single-hazard maps. The MHSM showed that 37% of Osh Region’s area is susceptible to the three hazards. Within this area, 33% is susceptible to landslides, 17% to flood, and 5% to wildfire. The population exposed to these hazards will be investigated in a future study. Conclusion: The multi-hazard susceptibility map can be a useful planning tool for government administrators in the Osh Region to identify areas susceptible to hazards at a regional scale. This information can promote risk-informed policy and investment decisions to minimize disaster-induced losses and damages, such as fatalities and infrastructure damage, in the long term.Item Attractiveness of Anthropometrically Average Facial Anatomy: Is the Whole a Sum of Its Parts?(2023) Georgy, JohnGoals/Purpose: Literature suggests that faces that possess average anatomy for the population are considered more attractive. When patients seek facial cosmetic surgery, they often have a certain feature or features that they desire improvement on. With the subjective and evolving nature of beauty, it can be difficult for plastic surgeons to differentiate between relative change and definite improvement. Thus, identifying ideal dimensions of facial features would provide evidence-based guidance for aesthetic surgery. This study aims to investigate the independent relationship between measurements of anthropometrically average facial features and perceived beauty, as well as their relative importance to each other and the overall perception. Methods/Technique: Ratings: To assess perceived attractiveness, crowdsourcing, a well-founded online method of studying aesthetic and reconstructive outcomes, was utilized. The photographs were uploaded to Google Forms with multiple-choice responses ranging from 1-7, with 1 and 7 being the least and most attractive, respectively. The images were presented in a random order to each respondent. Monochrome photos were used to negate the biases of hair, skin, and eye color. Measurements: Our female and male cohorts each consisted of standardized frontal-view photos of 41 individuals, with 1 composite derived from the other 40. Composite images were generated using Webmorph.org, which is a web-based software that specializes in averaging and transforming faces. Each face had the same number of standardized points placed manually to delineate the position of facial landmarks. The corresponding points allowed for averaging each facial landmark across all the faces to develop the composite. All photos were calibrated by interpupillary distance. Next, linear facial features (including measurements of the upper face, middle face, lower face, and facial height and width) were measured by pixels with WebMorph.org. Lastly, angular facial features were measured in degrees using Mirror software. Statistical Analysis: A t-test was used to verify that the composite with average facial features was the most attractive in each cohort. After verifying that the average faces were most attractive, a Spearman correlation test calculated correlation coefficients between facial measurements and perceived attractiveness. A larger correlation coefficient indicates a stronger association between average facial measurements and perceived attractiveness. p<0.05 was considered significant. Results: For the male and female cohorts, the respondents (n=870 and 876, respectively) found the composites (derived from average facial anatomy) significantly more attractive than the rest of the cohort (both p<0.0001). For the male cohort, only anthropometrically average upper lip height had a statistically significant correlation with attractiveness (Table 1) (R=0.376; p=0.017). For the female cohort, only anthropometrically average bigonial width had a statistically significant correlation with attractiveness (R= 0.352; p=0.026). Conclusion: Our study identifies average male lip height and average female bigonial features significantly correlated with perceived beauty. Though overall average faces were found to be significantly more attractive, the majority of facial features when independently analyzed for their correlation with beauty were not found to be significantly associated. Our findings suggest that the attractiveness of the average face is not largely due to the summative attractiveness of its individual facial components.Item Examining Familiarity with Location and People in Association with Protective Behavioral Strategy Use Among Adolescents and Young Adults at the Daily-Level(2023) Cross, Allison; Zhou, Zhengyang; Fairlie, Anne; Litt, Dana M.; Graupensperger, Scott; Lewis, MelissaPurpose: Despite protective behavioral strategies (PBS) often being a central component to alcohol prevention programs, many adolescents and young adults who drink alcohol use few to no PBS. Therefore, it is important to determine factors associated with PBS use. Situational factors such as social and physical environments have shown to influence drinking behavior. In addition, many PBS are often related to peers and location and thus may influence PBS use or nonuse. The study aimed to investigate the associations between situational familiarity (i.e., familiarity with locations and people) and PBS use at the daily level among adolescents and young adults. Method: Participants were recruited in Texas for a longitudinal ecological momentary assessment (EMA) study that involved a 3-week EMA burst design (8 surveys per week; up to 2x/day) with bursts occurring quarterly over 12-months. Participants who reported drinking days and answered PBS items were included in the current analyses. Data: The analytical sample consisted of 3,921 drinking days from 579 participants (55.44% females; 45.12% White, Non-Hispanic; ages 15 to 25 (mean = 21.04)). Data were analyzed with mixed effects zero-inflated Poisson models for each PBS outcome (i.e., serious harm reduction, limiting/stopping, manner of drinking). Results: Within-person results indicated when participants had elevated (i.e., higher than their own average) familiarity with location (e.g., How familiar are you with the locations you were at yesterday?), they were less likely to use harm reduction PBS (RR) = 0.94, p < 0.001) and limiting/stopping PBS (RR = 0.96, p = 0.001). Results showed that on drinking days with elevated familiarity with people (e.g., How familiar are you with the people you were with yesterday?), individuals were more likely to use limiting/stopping PBS (RR = 1.04, p = 0.01). There were no significant daily-level associations between familiarity with people or location and manner of drinking PBS. Conclusion: Results suggest that adolescent and young adult PBS use, particularly serious harm reduction and limiting/stopping PBS, can vary based on familiarity with people and location on a daily level. Alcohol prevention approaches, such as just-in-time intervention strategies, should consider how to increase PBS use even when drinking in more familiar situations or with less familiar people.Item Opportunities to Enhance Primary Care Management of Osteoporosis: A Mixed Methods Study(2023) Hernandez, Christian; Camp, Kathlene E.; Gandy, LauraPurpose: The incidence of osteoporotic fractures is greater than that of heart attack, stroke, and breast cancer combined. However, healthcare providers often focus on other comorbidities at the expense of bone health management. Primary healthcare is poised to play a significant role in protecting bone health, yet osteoporosis (OP) care is often delayed until after the initial fracture. This research aimed to determine potential gaps in primary care management of osteoporosis and to attain insight from multiple stakeholders’ experiences to understand care expectations and opportunities to enhance services. Methods: This research was performed within a geriatric practice setting using a convergent, mixed methods study design. This study included geriatric practice specialists from multiple disciplines (n=9) and patients selected to represent both male and female genders, diverse age groups, and varying bone health diagnoses (n=9). Quantitative data was attained through a 3-year (October 2018-2020) retrospective chart review to collect patient demographics, health-related measures, and outcomes. A physician survey provided further quantitative data on practice patterns and preferences. Qualitative data was attained through physician interviews and focus groups by engaging clinicians and patients on five key topics related to care decisions, screening, intervention, care expectations, and improvement opportunities. Quantitative descriptive data was used to attain varying distribution points on demographics and alignment with performance measures and clinical practice guidelines. Additional quantitative data was evaluated for consensus through responses from a Qualtrics physician survey regarding practice patterns and preferences. Qualitative data from focus groups and physician interviews were processed in distinct stages using Ritchie and Spencer’s framework analysis. Integration of quantitative and qualitative results was achieved during analysis and interpretation. Results: The chart review consisted predominantly of female patients, 95.9% (375/391). A diagnosis of osteopenia with and without fracture was 7.4% (29/391) and 22.3% (87/391); osteoporosis was 23.5% (92/391) and 46.8% (183/391), respectively. In the presence of osteoporosis or fracture, 44.7% (123/275) and 38.8% (47/121) were prescribed OP medication, respectively. 39.9% (156/391) presented with health conditions that could attribute the bone loss to secondary osteoporosis. 69.2% (259/372) of women ≥ 65 y.o. age and 33.3% (5/15) of men ≥ 70 y.o age had a documented dual-energy X-ray absorptiometry (DXA). Per quality metrics, 73.8% (48/65) of women aged 67-85 received a DXA and/or 43.1% (28/65) received OP medications within 6 months of fracture. Physician surveys revealed consistent practice patterns between physicians except for drug monitoring practices and comfort with using anabolic therapies. The US Preventive Services Task Force guideline was the predominant resource for OP management guidance. The focus group and interviews yielded four main themes: 1) condition awareness and fracture risk; 2) pharmacotherapy hesitancy and intervention preferences; 3) expectations of care; and 4) opportunities to enhance care. Conclusions: The findings identified gaps and opportunities to enhance primary care osteoporosis management, reflecting all stakeholder input. The data provides insight into pragmatic approaches for future quality improvement implementation to enhance primary care management of osteoporosis.Item Outcomes of a Team-Based Chronic Care Management Service in a Dual-Eligible Medicare and Medicaid Population with Diabetes Mellitus(2023) Nguyenly, Angel; Aguiniga, Ashlyn; Rodriguez, Emmanuel; Ebert-Blackburn, Didi; Wesling, MeganTitle: Outcomes of a Team-Based Chronic Care Management Service in a Dual-Eligible Medicare and Medicaid Population with Diabetes Mellitus Purpose: Patients receiving Medicare and Medicaid benefits (dual-eligible) have a higher prevalence of multiple comorbidities, including diabetes mellitus. This same population is less likely to have routine preventative measures completed and a higher incidence of disease-related complications. The purpose of this study is to evaluate the effectiveness of a team-based Chronic Care Management (CCM) program in achieving health outcomes in dual-eligible patients with type 2 diabetes (T2D) and the financial sustainability of a CCM program. Methods: Dual-eligible patients with T2D meeting CCM enrollment criteria were evaluated in a retrospective, pre-/post- intervention, observational chart review study from March 2019 to August 2021. Statistical analyses using non-parametric tests evaluated clinical outcomes (e.g., hemoglobin A1c), preventative measures and clinical staff encounters. Preliminary financials are reported descriptively. Results: Twenty-six patients were included in the analysis. There was a significant reduction in mean A1c levels (8.15% to 7.34%, p = 0.035). Changes in preventative metrics included a statically significant increase in statin prescriptions (p=0.039) while a non-significant increase in pneumococcal and influenza vaccine rates and depression screenings is noted. $14,721.00 was billed to insurers for the service with a reimbursement rate of 39.6%. Conclusion: This study shows that team-based patient care in a CCM program improves A1c levels and supports achievement of preventative measures. Full realization of intervention impact limited by the lack of in-person access to healthcare services due to shutdowns in response to the global pandemic.Item Design of mini Cas9 proteins using computational tools(2023) Artiles, Maria; Jayasinghe Arachchige, Vindi; Liu, JinPurpose: Adeno-associated viral (AAV) vectors are routinely used for the delivery of CRISPR-Cas systems. These vectors can only package molecules up to ~4.7 kilobase pair (kbp) in size. The most widely used Cas protein is Streptococcus pyogenes Cas9 (SpCas9), which is comprised of 1368 amino acid (aa) residues and is 4.3 kbp in size. Therefore, delivery of the CRISPR-Cas9 and the guide RNA (gRNA) requires the use of two separate vectors, which decreases the overall effectiveness of the system. In this study we used computational tools to facilitate the design of mini Neisseria Meningitidis Cas9 (Nme1Cas9) nucleases, of 900 aa in length or less, that can be packed with its associated guide gRNA in a single vector. Nme1Cas9 is a promising system, given that in its wild-type conformation, it already is 286 aa residues smaller than the widely used SpCas9[LJ1] ; and it has shown promising effectiveness in mammalian cells. Additionally, Nme1Cas9 also has a longer spacer derived guide sequence than other orthologs, and a longer protospacer adjacent motif (PAM[LJ2] )consensus, which reduces the propensity to off-target effects. For these reasons, Nme1Cas9 provides an ideal starting point for the development of engineered mini Cas9 protein, allowing us to exploit its natural features and optimize them with the use of computational tools including artificial intelligence (AI) and machine learning. Methods: We used The Protein Data Bank (PDB) database, UniProt database, and ChEMBL database to obtain the sequences and crystal structures of Cas orthologs and their associated gRNA and DNA sequences. Next, we identified the known DNA and RNA interacting residues of Nme1Cas9 from the available literature. Sequence alignments were performed with CLUSTAL OMEGA. Structural visualizations and reductions were performed with ChimeraX and Yasara software. AlphaFold2 was used for 3D structure prediction and molecular dynamics (MD) simulations were used to determine the stability of designed proteins. Results/Conclusions: We generated a library of mini Nme1Cas9 sequences that are less than 900 aa in length. The AI based modeling studies using the Alphafold2 have shown similar folding of these mini Cas proteins compared to their original counterparts. MD simulations confirm their stability in the presence of DNA and gRNA. Further validation of the designed proteins and their experimental testing is under investigation at this point of the study. Keywords: CRISPR-Cas9, Cas9, mini Cas9, Cas9 orthologs, AI.Item Hyperkalemia in Adolescent Idiopathic Scoliosis Patients with Tranexamic Acid Administration(2023) Craddock, Germain; LaMont, Lauren; Hamby, Tyler; Reyes, KristyIntroduction: Tranexamic acid (TXA) is used intraoperatively to reduce blood loss in various fields such as obstetrics, spine, and major joint replacement surgeries. Between May and June 2022, we identified more than three cases of intraoperative hyperkalemia that we believed to be influenced by TXA administration in our adolescent idiopathic scoliosis posterior spinal fusion (AISPSF) patient population. Methods: A systematic review of our intraoperative hyperkalemia patients was conducted and narrowed to three patients with minimal pharmacodynamic, metabolic, or pathological influences. Each patient’s timeline of intraoperative hyperkalemia was charted along with medical interventions to reduce patient’s potassium levels. Results: Patients 1-3 received a bolus of 5000 mg TXA an hour prior to the initial incision. Their maintenance doses were set to 10 mg/kg/hr, with infusion rates ranging from 4.95 mL/kg – 8.93 mL/kg. TXA administration was halted when potassium levels exceeded 5.5 mmol/L, and anesthetic intervention ensued to ensure patients rapidly reduced intraoperative potassium and avoided any unnecessary untoward effects of hyperkalemia. Of note, most interventions involved the administration of 10% CaCl, four puffs of (45 mcg/act) Levalbuterol, and an increase in ventilation in addition to cessation of TXA administration. Cessation of TXA administration alone was able to reduce hyperkalemia as well. Conclusion: Upon initial review, we could not identify preoperative factors or intraoperative changes that could have led to hyperkalemia. To prevent potential complications associated with acute intraoperative hyperkalemia, we are currently working on a retrospective review of institutional TXA administration for AISPSF cases and matching patients that did and did not suffer from episodes of intraoperative hyperkalemia by age, gender, diagnosis, levels of surgery, length of procedure, and preoperative potassium to better identify the influence TXA administration plays on AISPSF intraoperative hyperkalemia.Item Design of Man-made Miniature CRISPR-Cas Proteins Using Computational and Artificial Intelligence Technologies(2023) Jayasinghe-Arachchige, Vindi; Madugula, Sita Sirisha; Nammi, Bharani; Nukala, Nihitha; Wang, Shouyi; Liu, JinPurpose: The CRISPR/Cas system is a popular genome editing technique that uses a guide RNA and specific proteins known as Cas proteins for its function. A major challenge in harnessing CRISPR-Cas technology for applications in living organisms is the lack of an efficient delivery system. Due to the larger size of available Cas proteins used in this tool, it is challenging to encapsulate the CRISPR components into a single vehicle for delivery. To address this issue, we have used computational and Artificial Intelligence (AI) tools on designing compact-size Cas proteins that have a similar function and are more efficient than available Cas proteins. Methods: The available crystal structures of the smallest CRISPR-Cas systems were utilized and further reduced. A novel method termed the "Blocks and Gaps approach” was employed to design new mini-Cas proteins with a size range of 450-500 amino acids in length. The generated protein sequences (1 million) were subsequently used in machine learning-based two classification models to filter out the non-Cas proteins from it. The resultant Cas protein sequences were used in homology-modeling-based (Swiss-Model) and AI-based (Alphafold2) protein structure prediction methods to obtain their 3D structures. Further, the global and local structural features as well as the solubility of these proteins were analyzed, and top candidates were subjected to molecular dynamics (MD) simulations including substrate DNA and gRNA. Results/Conclusions: A library of man-made miniature Cas proteins was generated, and these proteins are less than half the size of the widely used CRISPR-Cas such as Cas9 or Cas12a. 50% of these were predicted as Cas proteins by both the machine learning-based classification models used. And 90% of them show similar 3D structures as their original counterparts. 10% of these passed through the final validations. Experimental testing of the activity of these designed proteins is to be investigated at this point of the study.Item Leading Predictors of Economic Burden Among Postmenopausal Women with Heart Failure: An Application of Machine Learning with XGBoost and SHapley Additive exPlanations(2023) Dehghan, Arshama; Park, Chanhyun; Sambamoorthi, Nethra; Shen, Chan; Shara, Nawar; Sambamoorthi, UshaObjective: Heart Failure is associated with high direct healthcare costs, including out-of-pocket spending by the patients. However, there are knowledge gaps in HF research among postmenopausal women. Therefore, this study uses machine learning methods to identify leading predictors and their associations with economic burden among postmenopausal women (age > 50 years) with heart failure. Methods: This cross-sectional study used data from postmenopausal women with heart failure from the 2020 Medical Expenditure Panel Survey (MEPS: weighted N= 600,742). The economic burden was measured with total healthcare expenditures by the payors (third-party expenditures) and out-of-pocket expenditures by the patients and their families. We employed eXtreme Gradient Boosting (XGBoost) regression to determine key predictors. Global and local interpretations of associations were performed using SHapley Additive exPlanations (SHAP). Our predictive model used 21 features such as age, health status including comorbidities (anxiety, arthritis, asthma, cancer, COPD, depression, diabetes, high cholesterol, hypertension, and thyroid disease), perceived physical and mental health status, and polypharmacy. Social determinants of health (SDoH) consisted of marital status, health insurance coverage, prescription drug coverage, education, poverty status, and region. The model building included 70% training and 30% testing split of the data, 10-fold cross-validations, and up to six rounds of optimization using Python 3.9.12. Model performance metrics included absolute mean squared errors, root mean squared error and coefficient of determination; these were evaluated using the test dataset. Results: The model offered excellent accuracy as evidenced by its low mean absolute errors (0.442,0.310), root mean square errors (0.452,0.342), and high coefficients of determination (0.935,0.987) for third-party and out-of-pocket expenditures, respectively. The top 10 leading predictors of third-party expenditures included polypharmacy, age, resident of the Midwest region, asthma, perceived physical and mental health, anxiety, hypertension, white race, and low income. The SHAP plots from the third-party expenditures revealed complex relationships of age, physical, and mental health with the target variable. Polypharmacy, low income, anxiety, and asthma were associated with higher third-party expenditures. Non-Hispanic white Women and those with hypertension had lower third-party expenditures. The top 10 leading predictors of out-of-pocket expenditures included age, Latinx ethnicity, asthma, cancer, being poor, having middle income and high income, prescription drug coverage, private insurance, and polypharmacy. Out-of-pocket expenditure plots only highlighted age as the key complex factor. Being poor, having middle income, and reporting Latinx ethnicity were associated with lower out-of-pocket expenditures. High income, prescription drug coverage, private insurance, polypharmacy, and the presence of asthma and cancer were associated with higher out-of-pocket expenditures. Conclusion: The leading predictors differed by payor source. SDoH were associated with economic burden, suggesting that addressing SDoH may reduce healthcare costs. Cost-containment policies, programs, and interventions at the payor and patient levels need to include effective comorbidity management strategies. The limitations of this study include cross-sectional study design, self-reported data that may be subject to recall bias, and severity of comorbidities that may affect the economic burden. However, the study also has several strengths, such as nationally representative data, the inclusion of SDoH, validated information on expenditures, and robust interpretable machine learning methods.Item General Anesthesia for Biopsy of Pediatric Mediastinal Mass with Tracheobronchial Compression(2023) Capps, Zachary; Worley, Joshua; Broadbent, DallenBackground: Mediastinal masses present anesthesiologists with significant challenges during the peri-operative period. These challenges include but are not limited to managing tracheobronchial compression, atelectasis, adequate ventilation, venous compression, and adequate systemic circulation. Bronchial compression can cause air trapping, meaning air can enter a section of the lung with enough pressure, but the compression prevents air from escaping the lung. This presents a problem for positive pressure ventilation (PPV). If using PPV, the positive pressure can surpass the compression when entering, but air cannot escape, causing an increased volume of entrapped air. This leads to two significant issues: 1) Decreased healthy lung volume leading to inadequate ventilation, and 2) Mediastinal deviation causing kinking of the IVC, leading to decreased preload and insufficient circulation. We recommend sustained spontaneous ventilation and lateral positioning to prevent these issues. Case Presentation: A 7-month-old_ _male,_ without significant past medical history, presents with a left-sided mediastinal mass. The mass caused left bronchial compression with subsequent air trapping in the lower lobe. An echo was performed to make sure the patient could tolerate general anesthesia to biopsy the mass. The echocardiogram resulted in no abnormal findings. The anesthesia team decided to use spontaneous breathing in order to prevent further air trapping. While the patient was under anesthesia the oxygen saturation began to decrease, and one of the anesthesia team members decided to give PPV. An x-ray was taken in the OR showing increased air trapping. The arterial line showed a physiologic tamponade causing a decreased systolic pressure of 50mmHg on each inspiration the patient took. Conclusion: Even when an echocardiogram results in no abnormal findings, it is still unsafe to use PPV ventilation because physiologic tamponade can be produced with increased air trapping. This is no longer postulated but is shown with the x-ray and arterial line findings.Item Single Agent Opioid vs Combination Agent Opioids in Postoperative Pain Control(2023) Aishat, Muhammad; Segovia, Alicia; Hamby, Tyler; Campbell, Throy; Brooks, Meredith; Gandhi, ArteeIntroduction: Treating post-surgery pain in pediatric populations often involves combination opiates, commonly hydrocodone and oxycodone. Unfortunately, this approach can lead to confusion for parents and concerns for overdose, as half of pediatric opioid prescriptions are considered high-risk. An opioid stewardship committee was established to oversee prescribing guidelines at Cook Children’s Medical Center (CCMC). This large-scale retrospective study examined whether educational interventions increased the likelihood of single-agent opioid prescriptions for post-surgery pain. This practice allows providers to more freely utilize NSAIDs and acetaminophen for postoperative pain. Methods: This was a retrospective single-center quality improvement (QI) project of all patients, who were prescribed opioids after surgery at CCMC in Fort Worth, TX between 3/1/2018 and 2/28/2022. Logistic regression was used to determine whether likelihood of single-agent (vs. combination) opioid prescriptions differed by intervention and department. Results: There were 5227 (38.30%) pre-intervention procedures and 8419 (61.70%) post-intervention procedures. Post-intervention procedures (vs. pre-intervention) were statistically significantly more likely to result in single-agent, rather than combination, opioid prescriptions (88.10% vs. 8.84%, OR=79.62, p<0.0001), and likelihood of single-agent opioid prescriptions significantly differed by department (p<0.0001). The proportion of single-agent opioids prescribed increased post-intervention in all 7 departments examined, and the proportion increased by 70% in the 3 departments with the most procedures: orthopedics, urology, and otolaryngology. Conclusion: Ongoing educational efforts by the Opioid Stewardship Committee have resulted in a sustained change in prescribing practices in multiple surgical departments from the use of combination to single-agent opioids.