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Introduction:The COVID-19 pandemic response limited access to many traditional forms of physical activity (PA). Purpose:To assess changes in objectively measured PAofUniversity staff during the initial stageofthe COVID-19 pandemic.Methods:We implemented a repeated measures natural experiment design. PA data (walking distance, steps∙d#x2D;1, and Moderate#x2D;to#x2D;Vigorous PA (MVPA) time) from commercial grade triaxial accelerometers were collected from employees (N#x3D;625) of a large, public university in the southeast United States during the months of Jan#x2D;May in calendar years 2019 and 2020.Results#x3A;Walking distance (6#x2D;9#x25;, p#x3C;0.001) and steps∙d#x2D;1(7#x2D;11#x25;, p#x3C;0.001) were lower during April and May 2020 compared to 2019. However, MVPA time was not significantly different among calendar years for the months of March#x2D;May. Steps∙d#x2D;1significantly decreased after WHO's worldwide pandemic declaration (10,348#xB1;171 v. 9551#xB1;156 steps∙d#x2D;1, p#x3C;0.001) and campus closure (10,100#xB1;160 v. 9,186#xB1;167 steps∙d#x2D;1, p#x3C;0.001). Conversely, steps∙d#x2D;1significantly increased after implementation of the state's "Healthy at Home" order (9,693#xB1;177 vs. 10,156#xB1;185 steps∙d#x2D;1, p#x3C;0.001).Conclusion: A decrease in daily steps, but not MVPA, suggests increased sedentary behavior, not reduced participation in exercise, during the early stages of the COVID#x2D;19 pandemic. Specific pandemic response policies may positively or negatively affect PA and sedentary behavior.

There is concern that regional anesthesia is associated with increased risk of complications, including return to the hospital for uncontrolled pain once the regional anesthetic wears off.Retrospective database review of patients who underwent open reduction and internal fixation of a closed ankle fracture from 2014-16 who received general anesthesia alone (GA) or general anesthesia plus regional anesthesia (RA).9459 patients met inclusion criteria. Patients in the RA group had significantly longer operative duration in both inpatient (GAI=71min vs RAI=79min, p=0.002) and outpatient setting (GAO=66min vs RAI=72min, p0.001), lower overall LOS (GA=1.7 days vs RA=1.1 days, p0.001), and higher readmission rate for pain (RAO=4 [0.3%] vs GAO=1 [0.0%], p=0.007).Patients who received supplemental regional anesthesia had shorter hospital LOS, increased operative time, and increased readmission rates for rebound pain. However, the small number of patients needing readmission are not clinically significant demonstrating that regional anesthesia is safe, effective and readmission for rebound pain should not be a concern.III.

Background Treatment of blunt splenic trauma (BST) continues to evolve with improved imaging for detection of splenic vascular injuries. Purpose To report on treatments for BST from 11 trauma centers, the frequency and clinical impact of splenic vascular injuries, and factors influencing treatment. Materials and Methods Patients were retrospectively identified as having BST between January 2011 and December 2018, and clinical, imaging, and outcome data were recorded. Patient data were summarized descriptively, both overall and stratified by initial treatment received (nonoperative management [NOM], angiography, or surgery). Regression analyses were used to examine the primary outcomes of interest, which were initial treatment received and length of stay (LOS). Results This study evaluated 1373 patients (mean age, 42 years ± 18; 845 men). Initial treatments included NOM in 849 patients, interventional radiology (IR) in 240 patients, and surgery in 284 patients. Rates from CT reporting were 22% (304 of 1373) for active splenic hemorrhage (ASH) and 20% (276 of 1373) for contained vascular injury (CVI). IR management of high-grade injuries increased 15.6%, from 28.6% (eight of 28) to 44.2% (57 of 129) (2011-2012 vs 2017-2018). Patients who were treated invasively had a higher injury severity score (odds ratio [OR], 1.04; 95% CI: 1.02, 1.05

Infiltrative-appearance hepatocellular carcinoma presents a challenge to clinicians as diagnostic criteria continue to evolve and evidence-based treatment guidelines have yet to be established. While transarterial radioembolization has shown efficacy in hepatocellular carcinoma, many studies exclude infiltrative-appearance HCC in their analysis. The purpose of this study was to describe imaging features of infiltrative-appearance hepatocellular carcinoma and evaluate effects of radioembolization on survival. In a retrospective review, infiltrative HCC patients treated from 2008 to 2017 were identified. Patients were divided into two groups: TARE versus systemic therapy/palliative care. Demographics, dates of diagnosis/expiry, albumin, international normalized ratio (INR), sodium, alpha-fetoprotein (AFP), creatinine, Child-Pugh class, model for end-stage liver disease (MELD) score, bilirubin, radiation dose and volume were collected. Patients with bilirubin > 3 were excluded. Mann–Whitney U test and Fisher’s exact test assessed differences between groups. Kaplan–Meier survival and Cox proportional hazard analyses were performed. Fifty-three patients were identified, 15 underwent TARE while 38 served as control. Mean age was 60, 43 patients were male. The mean overall survival was 16.2 months for the TARE group and 5.3 months for the control group (Log-rank p

Background The obesity epidemic has spread rapidly across the United States. Although overweight and obese patients have a paradoxically lower risk for postoperative morbidity and mortality, the risks associated with extreme classes of obesity (morbid obesity, super obesity, and super-super obesity) have not been described. Methods We queried the National Surgical Quality Improvement Program database from 2012 to 2016. Of 1,815,251 surgical cases, there were 3,946 vascular cases, 237,777 emergency procedures, and 75,177 cases with missing data that were removed. The remaining 1,378,711 cases were included in this analysis. Multivariable linear and logistic regression was performed to assess the impact of body mass index on postoperative outcomes. Results Patients within the super obesity and super-super obesity groups had the highest procedure-adjusted mortality risk among all body mass index classes (odds ratio = 2.31 and 2.63, respectively). Morbid obesity and underweight groups had moderate risk (odds ratio = 1.37 and 1.88, respectively), while those in the overweight and obesity class I and II cohorts had improved or equivocal mortality risk compared to normal body mass index class patients. Risk-adjusted and unadjusted multivariable models demonstrated that extreme obesity classes (morbid obesity, super obesity, and super-super obesity) have a graduated escalation of perioperative morbidity, infectious, and critical care complications. Conclusion Further detailing extreme obesity-related risk beyond the obesity class III umbrella is necessary for accurate risk prediction, especially with the rising prevalence of elective nonbariatric surgery in this population. Preoperative risk assessment tools should consider subgroup risk adjustment to delineate true postoperative complication risk, facilitate patient education, and address modifiable risk factors before surgery.

BACKGROUND Over the past 20 years, innovations in microsurgical technique have coincided with advances in orthoplastic approaches. However, no single algorithm exists to guide management of limb salvage versus amputation. As such, one would expect these procedures to be performed at equal rates given studies showing similar outcomes. Anecdotally, the observation at the authors' institution is that amputations are being performed more frequently. The purpose of this study was to determine trends in lower extremity trauma management. METHODS A retrospective cohort study was conducted at a Level I trauma center on patients with Gustilo type IIIB/IIIC lower extremity trauma from 2005 to 2014. Overall, 148 patients were included. Patients were subdivided into amputation (n = 69) and reconstruction (n = 79) cohorts. The Spearman rank correlation coefficient was used to compare trends in amputation and reconstruction groups. Plastic surgery consultation data were analyzed using the Mann-Whitney U and chi-square tests and the Pearson correlation coefficient. RESULTS Amputation was performed more frequently over the study period (r = 0.292; p < 0.001). Plastic surgeons were consulted in 67.5 percent of cases. A plastic surgery consultation was obtained in only 30 percent of amputation cases (p < 0.001). CONCLUSIONS Although the data show a trend toward amputation and a shift in management of lower extremity trauma, the observed trend may be attributable in part to deviation from an orthoplastic approach to lower extremity trauma. However, lower extremity reconstruction remains a viable option in select patients, and advances in microsurgery can provide excellent outcomes in the face of severe lower extremity trauma.

INTRODUCTION Autologous fat grafting (AFG) is a popular and effective method of breast reconstruction after mastectomy; however, the oncological safety of AFG remains in question. The aim of this study was to determine whether AFG increases the risk of cancer recurrence in the reconstructed breast. METHODS A matched, case-control study was conducted from 2000 to 2017 at the senior author's institution. Inclusion was limited to female patients who underwent mastectomy and breast reconstruction with or without AFG. Data were further subdivided at the breast level. χ analyses were used to test the association between AFG status and oncologic recurrence. A Cox proportional-hazards model was constructed to assess for possible differences in time to oncologic recurrence. The probability of recurrence was determined by Kaplan-Meier analyses and confirmed with log-rank testing. RESULTS Overall, 428 breasts met study criteria. Of those, 116 breasts (27.1%) received AFG, whereas 312 (72.9%) did not. No differences in the rates of oncologic recurrence were found between the groups (8.2% vs 9.0%, P < 1.000). Unadjusted (hazard ratio = 1.03, confidence interval = 0.41-2.60, P < 0.957) and adjusted hazard models showed no statistically significant increase in time to oncologic recurrence when comparing AFG to non-AFG. In addition, no statistical differences in disease-free survival were found (P = 0.96 by log rank test). CONCLUSION Autologous fat grafting for breast reconstruction is oncologically safe and does not increase the likelihood of oncologic recurrence. Larger studies (eg, meta analyses) with longer follow-up are needed to further elucidate the long-term safety of AFG as a reconstructive adjunct.

Introduction:We examined the effect of operative duration on morbidity in minimally invasive radical prostatectomy. Operative duration has been shown to be a risk factor for negative outcom...

The optimal dose and duration of tissue plasminogen activator (tPA) administered with ultrasound-facilitated catheter-directed thrombolysis (USCDT) to patients with acute PE remains to be determined. Our institution recently adopted a shorter duration (4 h) of USCDT and lower dosing strategy (tPA 1 mg/h) based on data from the OPTALYSE PE Trial. The purpose was to evaluate the implementation at our institution of shorter duration (4 h) of USCDT and lower dosing strategy (tPA 1 mg/h) as outlined by OPTALYSE PE Trial. This was a retrospective, single-center, observational study included patients from 01/01/2017 to 12/31/2018 in a large, academic medical center. Group 1 represented patients who underwent USCDT prior to 01/18/18. Group 2 represented patients who underwent USCDT after 01/18/18 and received 4 h of USCDT and tPA 1 mg/h/catheter. The primary outcome was intensive care unit (ICU) length of stay (LOS). Secondary outcomes were the proportion of patients experiencing a composite of major adverse events (death, recurrent PE, major bleeding, or stroke), change in right ventricle size/function and pulmonary artery pressures, need for mechanical respiratory or hemodynamic support, hospital LOS and drug cost. A total of 31 patients were included in the study: twenty patients in Group 1 and eleven patients in Group 2. Median ICU LOS was 3.5 days in Group 1 and 1 day in Group 2. Group 2 had reduced MACE, requirement for mechanical respiratory or hemodynamic support, hospital LOS, drug costs and adverse events. Implementation of a shorter duration of USCDT and lower dosing strategy for tPA in patients with acute PE may be one strategy to reduce the total ICU LOS and costs associated with care.

OBJECTIVES Analyze risk factors affecting length of stay (LOS) for patients presenting with deep neck space infections including care by medical versus surgical team. METHODS This is a retrospective chart review from January 2005 through May 2018 at the University of Kentucky analyzing factors related to deep neck space abscesses. Patients included adults >18 years old admitted for deep neck space infections undergoing surgical intervention. This study compared effects of treatment on a medical versus surgical service on LOS while accounting for patient confounders. Independent variables included age, gender, tobacco use, medical comorbidities, Charlson comorbidity index, American Society of Anesthesiology (ASA) classification, presence of drain, readmissions, and repeat surgical interventions. Univariate and multivariate analysis were performed. RESULTS One hundred sixty-three patients were included in the analysis. LOS was significantly longer for those on medicine services (P

The cost of phytonadione tablets has increased markedly and is significantly higher than the intravenous formulation. The intravenous formulation given orally is a potential alternative but has not been directly evaluated in comparison to the commercially available tablet. The objective of this study was to evaluate the efficacy of phytonadione intravenous solution given orally compared to commercially available phytonadione tablets for reversal of coagulopathy related to warfarin.We conducted a retrospective, observational study of adult patients who received phytonadione tablets and the IV formulation orally for warfarin-related coagulopathy. The international normalized ratio (INR) was measured before and after phytonadione administration. The primary outcome was INR1.5 at 24 h after phytonadione administration.From January 1, 2015 to August 1, 2018 a total of 200 patients were identified. In total, 58% (The IV phytonadione solution given by mouth and the tablet formulation performed similarly.

BackgroundDespite some evidence for gender differences in associations between military veterans’ mental health and suicidal ideation (SI), gender-specific prospective studies are lacking. The aims of this prospective study were to: (1) examine gender differences in veterans’ initial status and trajectories of mental health severity and SI status and (2) identify temporal sequencing of mental health predictors of SI.MethodsSurveys of 1035 US veterans were administered at 3 time-points (T1, T2, T3) over a 7-year period following military separation, with an initial assessment within 2 years of military separation.ResultsMen reported higher baseline PTSD and alcohol misuse severity than women. No baseline gender difference in SI prevalence was detected. Baseline gender differences in mental health severity were maintained over time. For both men and women, remittance of SI was more likely from T1 to T2 than from T2 to T3 while chronic SI was more likely from T2 to T3. The strongest predictors of T3 SI were prior SI followed by alcohol misuse, depression, and PTSD severity with stronger effects for T2 predictors than T1.ConclusionThe maintenance of baseline gender differences throughout trajectories of mental health predictors of SI supports the need for ongoing gender-specific mental health services. Current governmental interorganizational efforts are focused on suicide prevention during the first year after military service completion. Our findings indicate a need to extend mental health screening and treatment beyond the early post-military period to reduce risk and recurrence of SI for both men and women.

BACKGROUND An increasing number of clinical practice guidelines recommend screening children with obesity for non-alcoholic fatty liver disease (NAFLD). However, there is limited evidence regarding what parameters should be used to initiate the screening. OBJECTIVE The objective of this study was to determine whether obesity class rather than age group can identify a higher percent of children at risk of NAFLD as assessed by abnormal alanine aminotransferase (ALT). METHODS This is a cross-sectional study in a regional referral clinic for evaluation of obesity. Children were stratified by age group or by obesity class, and data obtained at first visit were analysed. RESULTS Of the 784 children, 482 were ≥10, 209 were 6 to 9 and 93 were 2 to 5 years of age. Abnormal ALT was observed in 32.1%, 46.9% and 61.0% of children with class I, II or III obesity, respectively (p

Alzheimer disease (AD) is a neurodegenerative disease characterized by a cognitive decline leading to dementia. The most impactful genetic risk factor is apolipoprotein E (APOE). APOE-ε4 significantly increases AD risk, APOE-ε3 is the most common gene variant, and APOE-ε2 protects against AD. However, the underlying mechanisms of APOE-ε4 on AD risk remains unclear, with APOE-ε4 impacting many pathways. We investigated how the APOE isoforms associated with the neuroinflammatory state of the brain with and without AD pathology. Frozen brain tissue from the superior and middle temporal gyrus was analyzed from APOE-ε3/3 (n = 9) or APOE-ε4/4 (n = 10) participants with AD pathology and APOE-ε3/3 (n = 9) participants without AD pathology. We determined transcript levels of 757 inflammatory related genes using the NanoString Human Neuroinflammation Panel. We found significant pathways impaired in APOE-ε4/4-AD individuals compared to APOE-ε3/3-AD. Of interest, expression of genes related to microglial activation (SALL1), motility (FSCN1), epigenetics (DNMT1), and others showed altered expression. Additionally, we performed immunohistochemistry of P2RY12 to confirm reduced microglial activation. Our results suggest APOE-ε3 responds to AD pathology while potentially having a harmful long-term inflammatory response, while APOE-ε4 shows a weakened response to pathology. Overall, APOE isoforms appear to modulate the brain immune response to AD-type pathology.

BACKGROUND Health care disparities in Appalachia are well documented. However, no previous studies have examined possible differences in the utilization of breast reconstruction (BR) in Appalachia. This study aims to determine if a disparity in BR utilization exists in women from Appalachia Kentucky. METHODS A retrospective, population-based cohort study was conducted from January 1, 2006, to December 31, 2015. The Kentucky Cancer Registry was queried to identify population-level data for female patients diagnosed with breast cancer and treated with mastectomy. A multivariate logistic regression model controlling for patient, disease, and treatment characteristics was constructed to predict the likelihood of BR. RESULTS Bivariate testing showed differences (P < 0.0001) in BR utilization between Appalachian and non-Appalachian women in Kentucky (15.0% and 26.3%, respectively). Multivariate analysis showed that women from Appalachia (odds ratio, 0.54; confidence interval (95), 0.48-0.61; P < 0.0001) were less likely to undergo BR than non-Appalachian women. Interestingly, the rate of BR increased over time in both Appalachian (r = 0.115; P < 0.0001) and non-Appalachian women (r = 0.148; P < 0.0001). CONCLUSIONS Despite the benefits of BR, women from Appalachia undergo BR at lower rates and are less likely to receive BR than non-Appalachian Kentuckians. Although the rates of BR increased over time in both populations, access to comprehensive breast cancer care remains a challenge for women from Kentucky's Appalachian region.

Aims The management of cranial chordomas is controversial. We provide a comprehensive review of the evolving patterns of care of cranial chordomas in the USA. Materials and methods We analysed the National Cancer Database (NCDB) and the Surveillance, Epidemiology, and End Results (SEER) database between 2004 and 2014 for clinical characteristics and long-term survival, and the National Surgical Quality Improvement Program (NSQIP) dataset between 2005 and 2016 for perioperative characteristics and surgical morbidity. Results In total, 936 patients were identified from the NCDB, 405 patients from SEER and 64 patients from the NSQIP. Most patients were men (56.2, 54.8 and 57.8% in NCDB, SEER and NSQIP, respectively) and White (80.9 and 83.2% in NCDB and SEER, respectively). Surgery was the preferred treatment modality (87.3% in NCDB and 86.2% in SEER). Surgery was carried out alone (41.8% in NCDB and 40.7% in SEER) or in combination with radiation (42.1% in NCDB and 45.4% in SEER). Proton therapy was the most common type of radiation (32.2% in NCDB), particularly after 2011. The median operative time, median hospital length and postoperative morbidity were significantly higher in chordoma patients compared with patients who underwent other skull-base procedures. The 5-year survival rate was 79.8% in NCDB and 76.9% in SEER. There was a trend towards longer survival in patients receiving surgery and radiation, which has been increasingly used since 2004. Patients younger than 60 years had a decreased risk of mortality. Conclusions Our analysis reflects patterns of care in the USA. The use of surgery and radiation is increasing, with a trend towards longer survival. Surgery is complicated with long operative time, hospital stay and a higher rate of complications.

OBJECTIVES Ketamine is a safe and widely used sedative and analgesic in the pediatric emergency department (ED). The use of intranasal (IN) ketamine in exchange for the administration of intravenous sedatives or analgesics for procedural sedation in pediatric patients is not commonplace. The goal of this study was to evaluate provider perceptions and patient outcomes at varying doses of IN ketamine for anxiolysis, agitation, or analgesia. METHODS From January 2018 to May 2018, we performed a prospective survey and chart review of pediatric patients receiving IN ketamine. The primary outcome was to determine provider satisfaction with using IN ketamine. Secondary objectives included comparing outcomes stratified by dose, adverse events, assessing for treatment failure, and ED length of stay (LOS). As a secondary comparison, patients receiving IN ketamine whom otherwise would have required procedural sedation with intravenous sedatives or analgesics were placed into a subgroup. This subgroup of patients was compared with a cohort who received intravenous sedatives or analgesics for procedural sedation during a similar period the preceding year (January 2017 to June 2017). RESULTS Of the 196 cases, 100% of the providers were comfortable using IN ketamine. The median overall provider satisfaction was 90 out of 100, the perception of patient comfort was 75 out of 100, and perceived patient comfort was maximized when using doses between 3 and 5 mg/kg. There were 15 (7.7%) patients who experienced ketamine treatment failure. Overall, the rate of adverse events was 6%, but were considered minor [nausea (n = 3; 1.5%), dizziness (n = 2; 1%), and drowsiness (n = 2; 1%)]. No patients required respiratory support or intubation. The mean LOS was 237.9 minutes, compared with those who underwent procedural sedation with an LOS of 332.4 minutes (P < 0.001). CONCLUSIONS This study demonstrates that IN ketamine was able to provide safe and successful analgesia and anxiolysis in pediatric patients in an ED setting. In addition, providers expressed a high degree of satisfaction with using IN ketamine (90 out of 100) in addition to a high degree of patient comfort during the procedure (75 out of 100). Intranasal ketamine provides an alternative to intravenous medication normally requiring more resource-intensive monitoring. Procedural sedations are resource and time intensive activities that increase ED LOS. Intranasal ketamine used for anxiolysis and analgesia offers the benefits of freeing up resources of staff and monitoring while enhancing overall throughput through a pediatric ED.

Introduction: Operative duration (OD) is associated with complications but has been poorly studied in minimally invasive partial nephrectomy (MIPN). We seek to examine the relationship bet...

Introduction:As value based health care gains favor and reimbursement models move toward quality rather than quantity of care, a better understanding of cost and its predictors becomes incr...

Background Sarcopenia is one of the most common complications of cirrhosis. Liver transplantation (LT) is the treatment of choice for patients with early-stage hepatocellular carcinoma (HCC) that are unsuitable for resection. Methods We performed a retrospective analysis of 163 patients transplanted at our institution with HCC from 1998 to 2016. Sarcopenia was diagnosed based on the skeletal muscle mass on computed tomography imaging using SliceOmatic 5.0 software at L3 level (≤52.4 cm2/m2 in males and ≤38.5 cm2/m2 in females). Results From the 163 patients who underwent LT for HCC, 119 had available computed tomography scan. From those, 61 were identified as sarcopenic by lumbar skeletal muscle index (LSMI), of which 53 patients were male (86.9%) with a median age of 59 y (56-64). The most common etiologies of cirrhosis were hepatitis C virus infection (55.7%) and alcohol liver disease (46.7%). A multivariable analysis was performed to find predictors of sarcopenia. Alpha-fetoprotein level >100 mg/dL (OR, 6.577; 95% CI: 1.370-51.464; P = 0.034) and gender (male) (OR, 5.878; 95% CI: 1.987-20.054; P = 0.002) were independently associated with the presence of sarcopenia in this cohort. Patients in the lowest quartile for LSMI had prolonged length of stay compared to the rest of the patients (P = 0.029). Conclusions Alpha-fetoprotein level >100 mg/dL is associated with almost 6-fold increased risk of sarcopenia in patients with HCC undergoing LT. Patients in the lowest quartile of the LSMI are associated with 70% increased risk of prolonged length of stay in this cohort.

Neuroendocrine tumors (NETs) are a relatively rare category of cancers that arise in the gastrointestinal (GI) tract and other organs. Extended hepatectomies including resection of multiple organs are often necessary to achieve negative margins.We performed a review of patients undergoing liver resection for NET liver metastases from 2005 to 2015 using National Surgical Quality Improvement Program. We compared patients undergoing hepatectomy alone (HA) versus hepatectomy and a concomitant GI surgery procedure (colorectal, small bowel, and pancreatic) to evaluate postoperative infectious complications.During the study period, 354 patients underwent liver resection for metastatic NET. Hepatectomy alone was performed in 98 patients, and concomitant GI surgery was performed in 256 patients, including 83 colorectal resections (HCCR), 68 small bowel resections, 75 distal pancreatectomies, and 35 pancreaticoduodenectomies (HCPD). Infectious complications were more likely to occur in those undergoing HCPD (60%, P 0.001), and HCCR (32.5%, P 0.05) than in those undergoing HA (16.3%). Patients undergoing HCPD and HCCR had a 7.69-fold and 2.52-fold increased risk of infectious complication, respectively, compared with HA after adjustment for other infection risk factors.Neuroendocrine liver metastases requiring liver resection with concomitant colorectal resection or pancreaticoduodenectomy are at significantly increased risk of developing infectious complications.

OBJECTIVE Ceftriaxone and cefotaxime are appealing options for the treatment of neonatal infections. Guidelines recommend cefotaxime as the cephalosporin of choice in neonates because of ceftriaxone's potential to cause hyperbilirubinemia. Unfortunately, due to cefotaxime discontinuation, providers must choose between alternative antibiotics. Clinicians at our institution adopted a protocol allowing for the utilization of cefepime and ceftriaxone for the management of neonatal sepsis. The objective of this study was to compare the incidence of hyperbilirubinemia between ceftriaxone and cefotaxime in the treatment of neonatal infections beyond the first 14 days of life. METHODS This was a retrospective chart review of patients receiving ceftriaxone or cefotaxime for the treatment of neonatal infections. Patients were 15 to 30 days old at the time of antimicrobial administration and received at least 1 dose of ceftriaxone or cefotaxime during hospital admission. Patient characteristics and bilirubin levels were compared between ceftriaxone and cefotaxime. RESULTS The analysis included 88 patients. There was no statistically significant difference between groups in age, gestational age, weight, and baseline total calcium and bilirubin levels. Normal baseline bilirubin levels increased to an abnormal level after antibiotic administration in 2 patients in the cefotaxime group and 1 patient in the ceftriaxone group. The median number of doses of cefotaxime and ceftriaxone were 3 and 2, respectively. CONCLUSION Patients who received a short-term course of ceftriaxone did not have a higher likelihood of developing hyperbilirubinemia compared with those who received a short-term course of cefotaxime during their hospital stay.

Aim of the study Most survivors of an in-hospital cardiac arrest do not leave the hospital alive, and there is a need for a more patient-centered, holistic approach to the assessment of prognosis after an arrest. We sought to identify pre-, peri-, and post-arrest variables associated with in-hospital mortality amongst survivors of an in-hospital cardiac arrest. Methods This was a retrospective cohort study of patients ≥18 years of age who were resuscitated from an in-hospital arrest at our University Medical Center from January 1, 2013 to September 31, 2016. In-hospital mortality was chosen as a primary outcome and unfavorable discharge disposition (discharge disposition other than home or skilled nursing facility) as a secondary outcome. Results 925 patients comprised the in-hospital arrest cohort with 305 patients failing to survive the arrest and a further 349 patients surviving the initial arrest but dying prior to hospital discharge, resulting in an overall survival of 29%. 620 patients with a ROSC of greater than 20 min following the in-hospital arrest were included in the final analysis. In a stepwise multivariable regression analysis, recurrent cardiac arrest, increasing age, time to ROSC, higher serum creatinine levels, and a history of cancer were predictors of in-hospital mortality. A history of hypertension was found to exert a protective effect on outcomes. In the regression model including serum lactate, increasing lactate levels were associated with lower odds of survival. Conclusion Amongst survivors of in-hospital cardiac arrest, recurrent cardiac arrest was the strongest predictor of poor outcomes with age, time to ROSC, pre-existing malignancy, and serum creatinine levels linked with increased odds of in-hospital mortality.

Objectives We investigated whether platelet count associated with biomarkers of endothelial function, and additionally sought to identify novel predictors of outcomes in a cohort of patients with severe sepsis at a quaternary care academic medical center. Design Prospective, observational cohort. Patients Eighty-six sepsis patients admitted into intensive care units were prospectively enrolled into an on-site sepsis registry and biobank. Interventions None. Measurements and main results Platelet count, mean platelet volume, platelet mass, plasma angiopoietin-1 and angiopoietin-2, syndecan-1, platelet factor 4, sCD40L concentrations, and plasma autotaxin activity were determined for each patient at enrollment. Patient mortality was recorded up to 30 days following hospital discharge. Platelet count and plasma sCD40L was significantly lower in patients who did not survive up to 30 days following hospital discharge. Angiopoietin-2 and the angiopoietin-2/1 ratio were significantly higher in patients who did not survive up to 30 days following discharge. Furthermore, plasma autotaxin activity was significantly higher in patients who did not survive up to 30 days. Interestingly, autotaxin activity correlated with platelet count and the ratio of angiopoietin-2/1 across our population. Conclusions Platelet count, the ratio of angiopoietin-2/1, and autotaxin activity all predicted 30-day mortality. Autotaxin activity within the plasma correlates with both platelet counts and vascular dysfunction biomarkers across both survivors and non-survivors indicating a possible involvement of autotaxin within sepsis.

BACKGROUND: PERTs are a new, multidisciplinary approach to PE care. They were conceived to efficiently identify and risk stratify PE patients and standardize care delivery. More research needs to be conducted to assess the effects that PERTs have had on PE care. This study sought to determine the effects of a PERT on quality and overall value of care. METHODS: This was a retrospective study of all patients 18 years of age or older who presented with a principal diagnosis of an acute PE based on available ICD codes from January 1, 2010 to December 31, 2018. Patients who did not have an imaging study, i.e., CTPA or ECHO, available were excluded. Patients were divided into Pre- (before October 2015) and Post-PERT eras (after October 2015) and stratified based on the presence of right heart strain/dysfunction on imaging. All quality outcomes were extracted from the EMR, and cost outcomes were provided by the financial department. RESULTS: 530 individuals (226 Pre-PERT and 304 Post-PERT) were identified for analysis. Quality outcomes improved between the eras; most notably in-hospital mortality decreased (16.5 vs. 9.6) and hospital LOS decreased (7.7 vs. 4.4) (p

Introduction: Moyamoya is a chronic cerebrovascular condition of unclear etiology characterized by progressive occlusion of 1 or both internal carotid arteries with neovascular collateral formation. With both an idiopathic form (moya­moya disease) and congenital condition-associated form (moyamoya syndrome), it can cause ischemic and hemorrhagic stroke. Recent findings in Kentucky have challenged traditional estimates of its incidence in US populations. Using the Kentucky Appalachian Stroke Registry (KApSR), our aim was to further characterize its incidence as a cause of stroke and to understand the patient population in Appalachia. Methods: A retrospective review of moyamoya patients was performed using the KApSR database. Data collected included demographics, county location, risk factors, comorbidities, and health-care encounters from January 1, 2012, to December 31, 2016. Results: Sixty-seven patients were identified; 36 (53.7%) resided in Appalachian counties. The cohort accounted for 125 of 6,305 stroke admissions, representing an incidence of 1,983 per 100,000 stroke admissions. Patients presented with ischemic strokes rather than hemorrhagic strokes (odds ratio 5.50, 95% CI: 2.74–11.04, p < 0.01). Eleven patients (16.4%) exhibited autoimmune disorders. Compared to the general population with autoimmune disorder prevalence of 4.5%, the presence of autoimmunity within the cohort was significantly higher (p < 0.01). Compared to non-Appalachian patients, Appalachian patients tended to present with lower frequencies of tobacco use (p = 0.08), diabetes mellitus (p = 0.13), and hypertension (p = 0.16). Conclusions: Moyamoya accounts for a substantial number of stroke admissions in Kentucky; these patients were more likely to develop an ischemic stroke rather than a hemorrhagic stroke. Autoimmune disorders were more prevalent in moyamoya patients than in the general population. The reduced frequency of traditional stroke risk factors within the Appalachian group suggests an etiology distinct to the population.

The value of proximal fecal diversion for patients undergoing colectomies is an ongoing debate. Previous studies have shown a benefit in decreased anastomotic leak rates and mitigation of the morbidity of a leak, especially in high-risk populations. However, more recent data suggests increased morbidity with fecal diversion, creating a complication with an unknown degree of anastomotic leak reduction. Therefore, we aimed to determine the impact on morbidity of a diverting loop ileostomy (DLI) in patients with a high risk of anastomotic leak.The ACS-NSQIP database was queried (via CPT code) for adult patients (age ≥18 years) who underwent a colectomy only or colectomy with ileostomy (CWI) between Jan 2013 and Dec 2016. We compared thirty-day outcomes between a 3:1 propensity-matched colectomy only group to patients who had a CWI. We used risk factors for anastomotic leak as a basis of our propensity match which included preoperative smoking, steroid use, preoperative weight loss, preoperative transfusion, hypoalbuminemia, and leukocytosis; intraoperative match variables included indication for surgery, wound class, duration of operation, primary CPT code, elective vs. emergent, and inpatient vs. outpatient surgery.We identified 39,588 patients from the NSQIP database who had a colectomy only or a CWI. The colectomy only group was older (age 63 vs 52 years p 0.001), overweight (BMI 34 vs 26.7, p 0.001), more likely to be diabetic (16% vs 9.5%, p 0.001) and hypertensive (49.3% vs 31.4%). However, the CWI group had higher steroid use (36.8% vs 10%, p 0.001), preoperative sepsis (13.2% vs 2.5%, p 0.001), smoking rate (25.7% vs 15.4%, p 0.001), and preoperative weight loss (12.5% vs 4.9%, p 0.001). Our propensity analysis matched 2274 colectomy only patients and 758 CWI patients. Baseline demographics were similar between groups. While the mortality rate was similar between groups (1.5% vs 1.8%, p = 0.8), CWI patients had longer length of stay (median 8 vs 7 days, p 0.001), higher renal injury rates (3.2% vs 0.9%, p 0.001), higher readmission rates (18.8% vs 11%, p 0.001) and higher overall NSQIP morbidity (44.5% vs 37.6%, p = 0.001). The anastomotic leak rate was 3.8% in the CWI group and 5.1% in the colectomy only group (p = 0.09).Significant thirty-day morbidity exists with a diverting ileostomy among high-risk colectomy patients with minimal benefit in anastomotic leak rates.

Objective To assess the timing and variables associated with damage to flexible ureteroscopes (fURS) at our institution. Flexible ureteroscopy is an important modality in the treatment of benign and malignant conditions of the upper urinary tract. While the durability and versatility of fURS have improved considerably, repair costs remain high and time out of commission diminishes workflow. After purchasing new digital fURS, we studied how and when these instruments were being damaged. Materials and Methods Between September 1, 2017 and June 30, 2018, we performed leak testing on fURS both before and after use. We gathered intraoperative data related to the user, the surgical indication, and the associated tools used in all cases that employed a digital or fiber optic fURS. Categorical and continuous variables were analyzed to identify risk factors for intraoperative fURS damage. Results During the study period, complete data was gathered for 281 cases. Twenty-two fURS failed leak testing indicating an overall leak failure rate of 7.8%. Of these, 15 failed leak testing preoperatively indicating nonoperative damage occurring sometime during transport, handling, or sterile processing. The other 7 failures occurred during the procedures. No intraoperative variables were significantly associated with failures. Conclusion Our institutional leak failure rate is 8% (22/281). The majority of these failures did not occur during surgery. Of the 7 that occurred during surgery, larger stone burden and higher wattage showed mild association. Ongoing evaluation will target minimizing fURS damage outside of the operating room.

Introduction To our knowledge there are no studies evaluating urethroplasty practice patterns among genitourinary reconstructive surgeons. Methods An electronic survey was sent to members of the Society of Genitourinary Reconstructive Surgeons. Respondents were queried regarding approach to bulbar urethral reconstruction in 6 index cases. Results A total of 91 society members who regularly treated men with urethral strictures responded to the survey. For a 1.5 cm stricture excision and primary anastomosis was the preferred treatment, although less unanimously than expected (only 83% in older men and 67% in younger men). For 2.5 cm strictures urethroplasty with buccal mucosal graft was the preferred treatment for a 35-year-old man, and excision and primary anastomosis for a 65-year-old man. Excision and primary anastomosis was preferred less frequently in younger patients and in patients with longer strictures (Cochran Q test, p Conclusions Urethroplasty consisting of excision and primary anastomosis is performed less commonly than expected among genitourinary reconstructive surgeons. Considerable variation exists regarding operative technique, management of buccal mucosal graft harvest site and substitution onlay site.

OBJECTIVES It is unknown whether the addition of M-mode to B-mode ultrasound (US) has any effect on the overall accuracy of interpretation of lung sliding in the evaluation of a pneumothorax by emergency physicians. This study aimed to determine what effect, if any, this addition has on US interpretation by emergency physicians of varying training levels. METHODS One hundred forty emergency physicians were randomized via online software to receive a quiz with B-mode clips alone or B-mode with corresponding M-mode images and asked to identify the presence or absence of lung sliding. RESULTS The sensitivity, specificity, and accuracy of the diagnosis of lung sliding with and without M-mode US were compared. Overall, the sensitivities, specificities, and accuracies of B-mode + M-mode US versus B-mode US alone were 93.1% and 93.2% (P = .8), 96.0% and 89.8% (P

Author(s): Song, Kristine; Chakraborty, Amit; Dawson, Matthew; Dugan, Adam; Adkins, Brian; Doty, Christopher | Abstract: Introduction: Medical education is a rapidly evolving field that has been using new technology to improve how medical students learn. One of the recent implementations in medical education is the recording of lectures for the purpose of playback at various speeds. Though previous studies done via surveys have shown a subjective increase in the rate of knowledge acquisition when learning from sped-up lectures, no quantitative studies have measured information retention. The purpose of this study was to compare mean test scores on written assessments to objectively determine if watching a video of a recorded lecture at 1.5x speed was significantly different than 1.0x speed for the immediate retention of novel material.Methods: Fifty-four University of Kentucky medical students volunteered to participate in this study. The subjects were divided into two separate groups: Group A and Group B. Each group watched two separate videos, the first at 1.5x speed and the second at 1.0x speed, then completed assessments following each. The topics of the two videos were ultrasonography artifacts and transducers. Group A watched the artifacts video first at 1.5x speed followed by the transducers video at 1.0x speed. Group B watched the transducers video first at 1.5x speed followed by the artifacts video at 1.0x speed. The percentage correct on the written assessment were calculated for each subject at each video speed. The mean and standard deviation were also calculated using a t-test to determine if there was a significant difference in assessment scores between 1.5x and 1.0x speeds.Results: There was a significant (p=0.0188) detriment in performance on the artifacts quiz at 1.5x speed (mean 61.4; 95% confidence interval [CI]-53.9, 68.9) compared to the control group at normal speed (mean 72.7; 95% CI- 66.8, 78.6). On the transducers assessment, there was not a significant (p=0.1365) difference in performance in the 1.5x speed group (mean 66.9; CI- 59.8, 74.0) compared to the control group (mean 73.8; CI- 67.7, 79.8).Conclusion: These findings suggest that, unlike previously published studies that showed subjective improvement in performance with sped-up video-recorded lectures compared to normal speed, objective performance may be worse. [West J Emerg Med. 2017;1(4)–0.]

Intravenous N-acetylcysteine (IV NAC) is currently the approved treatment for acetaminophen (APAP) overdose with a three-step regimen totaling 300 mg/kg over 21 hours. Due to the complexity of this...

Background We evaluated perioperative outcomes in super obese patients (body mass index >50 kg/m2) undergoing liver resection using the American College of Surgeons National Surgical Quality Improvement Program. Methods Patients undergoing hepatectomy recorded in the American College of Surgeons National Surgical Quality Improvement Program dataset from 2005 to 2015 were analyzed. Out of 21,228 hepatectomies in the National Surgical Quality Improvement Program dataset, 146 were performed on super obese patients. Results Seventy-two percent of the super obese patients were female with a median age of 50.6 years, and 10% were classified as American College of Surgeons Class ≥III. In this group, 69.2% were hypertensive, 38.4% were diabetics, and 17.8% had dyspnea. The median operation time was 248 minutes in the super obese group, greater than any other body mass index class. Twenty-two percent of these patients required perioperative transfusion, although 74% underwent partial hepatectomies. Body mass index >50 kg/m2 significantly increased morbidity in patients undergoing hepatectomies, almost 2-fold. Infectious complications increased by 86%, and the risk of developing critical care complications increased by 63%. Conclusion Our data show that super obesity (body mass index >50 kg/m2) is the strongest independent predictor of perioperative morbidity. These patients also are at much greater risk of infectious complications and critical care complications. Future studies should be conducted using weight loss strategies in extreme obese patients to reduce their risk of life-threatening complications after hepatectomy.

Iliac arterial stenting is performed both in the operating room (OR) and the catheterization lab (CL). To date, no analysis has compared resource utilization between these locations.Consecutive patients (n = 105) treated at a single center were retrospectively analyzed. Patients included adults with chronic, symptomatic iliac artery stenosis with a minimum Rutherford classification (RC) of 3, treated with stents. Exclusion criteria were prior stenting, acute ischemia, or major concomitant procedures. Immediate and two-year outcomes were observed. Patient demographics, perioperative details, physician billings, and hospital costs were recorded. Multivariable regression was used to adjust costs by patient and perioperative cost drivers.Fifty-one procedures (49%) were performed in the OR and 54 (51%) in the CL. Mean age was 57, and 44% were female. Severe cases were more often performed in the OR (RC ≥ 4; 42% vs. 11%, P 0.001) and were associated with increased total costs (P 0.01). OR procedures more often utilized additional stents (stents ≥ 2; 61% vs. 46%, P = 0.214), thrombolysis (12% vs. 0%, P = 0.011), cut-down approach (8% vs. 0%, P = 0.052), and general anesthesia (80% vs. 0%, P 0.001): these were all associated with increased costs (P 0.05). After multivariable regression, location was not a predictor of procedure room or total costs but was associated with increased professional fees. Same-stay (5%) and post-discharge reintervention (33%) did not vary by location.The OR was associated with increased length of stay, more ICU admissions, and increased total costs. However, OR patients had more severe disease and therefore often required more aggressive intervention. After controlling for these differences, procedure venue per se was not associated with increased costs, but OR cases incurred increased professional fees due to dual-provider charges. Given the similar clinical results between venues, it seems reasonable to perform most stenting in the CL or utilize conscious sedation in the OR.

Introduction Civilian gunshot open-fracture injuries portray a significant health burden to patients. Use of antibiotics is endorsed by guideline recommendations for the prevention of post-traumatic infections, however, antimicrobial selection and their associated outcomes remains unclear. Therefore, we sought to compare infectious and other clinical outcomes between three antimicrobial cohorts in patients with gunshot-related fractures requiring operative intervention. Materials and methods Patients were identified by retrospectively querying the University of Kentucky Trauma Registry for gunshot wound victims. A narrow regimen, an expanded gram-negative regimen, and a regimen containing a fluoroquinolone antimicrobial were identified for comparison. The primary outcome was a composite of infections at or before 14 days of hospitalization. Secondary endpoints included hospital length of stay, incidence of multidrug resistant bacteria and methicillin-resistant Staphylococcus aureus colonization, number of drug-related adverse events, number of Clostridium difficile infections, and 30-day mortality. Results 252 patients were selected for inclusion: 126 in the narrow regimen, 49 in the expanded gram-negative regimen, and 77 in the fluoroquinolone-based regimen. There were no statistical differences in the primary endpoint of early infectious outcomes between groups (p = 0.1797). The expanded gram-negative regimen was associated with increased hospital length of stay, and increased incidence of multi-drug resistant bacteria and methicillin-resistant Staphylococcus aureus colonization. There were no statistically significant differences in any of the remaining secondary endpoints. Conclusion In this study evaluating civilian gunshot trauma, broad spectrum antibiotic coverage was not associated with improvements in post-traumatic infections. A randomized trial is needed to confirm these results.

Introduction and Objective: Quality-based reimbursement continues to gain popularity as value-based care becomes more prominent. Our goal is to describe the impact of preoperative characte...

INTRODUCTION AND OBJECTIVES:Extended PACU length of stay (PLOS) can frustrate patients and physicians, delay postoperative care pathways, and potentially increase cost. Predictors of increased PLOS...

Purpose The purpose of this survey-based research project is to identify factors, including prior training, institution demographics, and pharmacist prioritization of services that may impact variability in practice among emergency medicine (EM) pharmacists. Methods An electronic survey was available for 6 weeks. Participants were contacted through professional membership directories. Survey questions addressed EM pharmacist training and institution demographics. Pharmacists were asked to define the frequency with which they performed ASHP-identified best practice services. Results Responses were received by 208 pharmacists (response rate = 9.4%) who were primarily from academic (48.1%) or community (47.6%) emergency departments (EDs). Pharmacists working in an academic ED were more likely to have EM postgraduate year 2 training (27.8%) compared to a community ED (11.2%) (p = 0.0182). Pharmacists practicing in an academic emergency department (ED) reported participating in traumas, care for boarded patients, and performing scholarly activities more frequently (p < 0.01) and medication reconciliations less frequently (p < 0.01) than those in a community ED. Most EM pharmacists reported postgraduate year 1 training (45.7%) as compared to postgraduate year 2 EM (18.3%) or critical care (13.7%) pharmacy residency training. Conclusion Institution and ED demographics as well as pharmacist level of training can affect the frequency of services provided in the ED setting.

BACKGROUND: Breast reconstruction (BR) is the reconstructive surgical technique that focuses on restoring normal form and function to the breast following oncologic resection. The goal of this study was to determine if BR disparities exist among rural female patients in Kentucky. METHODS: A retrospective (2006 – 2015), population-based cohort study was conducted on breast cancer patients (stages I-III) treated with mastectomy with or without BR. We used 2013 Beale codes to stratify patients according to geographic status. Chi-square tests were used to examine the association of BR along the rural-urban continuum. A multivariate logistic regression model controlling for patient, disease, and treatment factors was used to predict BR. The likelihood of BR was reported in odds ratios (OR) using a 95% confidence interval (CI). RESULTS: Overall, 10,032 patients met study criteria. Of those, 2,159 (21.5%) underwent BR. The rate of BR among urban, near-metro, and rural patients was 31.1%, 20.4%, and 13.4%, respectively (P < .001). Multivariate analysis revealed that women from near metro (OR 0.54, CI: 0.47–0.61; P < .001) and rural areas (OR 0.36, CI: 0.31–0.41; P < .001) were less likely to undergo BR than women from urban areas. CONCLUSION: Although BR benefits are well documented, women from rural Kentucky undergo BR at lower rates and are less likely to receive BR than their urban counterparts. Efforts should seek to promote equitable access to BR for all patients, including those from rural areas.

Author(s): Zhou, Zhengqiu; Mims, Theresa; Dugan, Adam; Trott, Terren; Sanderson, William; Bronner, Jonathan | Abstract: Introduction: Videoconferencing has been employed in numerous medical education settings ranging from remote supervision of medical trainees to conducting residency interviews. However, no studies have yet documented the utility of and student response to videoconference meetings for mid-clerkship feedback (MCF) sessions required by the Liaison Committee on Medical Education (LCME).Methods: From March 2017 to June 2018, third-year medical students rotating through the mandatory, four-week emergency medicine (EM) clerkship at a single medical school were randomly assigned either to a web-based videoconference meeting via Google Hangouts, or to a traditional in-person meeting for their MCF session. To compare students’ MCF experiences we sent out an electronic survey afterward to assess the following using a 0-100 sliding scale: overall satisfaction with the meeting; the effectiveness of communication; the helpfulness of the meeting; their stress levels, and the convenience of their meeting location. The survey also collected data on these demographic variables: the name of the faculty member with whom the student met; student gender, age, and interest in EM; location prior to meeting; meeting-method preference; and number of EM shifts completed.Results: During the study period, 133 third-year medical students responded to the survey. When comparing survey responses between individuals who met online and in person, we did not detect a difference in demographics with the exception of preferred meeting method (p=0.0225). We found no significant differences in the overall experience, helpfulness of the meeting, or stress levels of the meeting between those who met via videoconference vs. in-person (p=0.9909; p=0.8420; p=0.2352, respectively). However, individuals who met in-person with a faculty member rated effectiveness of communication higher than those who met via videoconference (p=0.0002), while those who met online rated convenience higher than those who met in-person (pl0.0001). Both effects remained significant after controlling for preferred meeting method (pl0.0001 and p=0.0003, respectively) and among EM-bound students (p=.0423 and pl0.0110, respectively).Conclusion: Our results suggest that LCME-required MCF sessions can be successfully conducted via web-based programs such as Google Hangouts without jeopardizing overall meeting experience. While the convenience of the meetings was improved, it is also important for clerkship directors to note the perceived deficit in the effectiveness of communication with videoconferencing.

Background To study mortality and infectious complications (IC) risk relative to operative duration in a large and contemporary cohort of patients undergoing hepatectomy. Methods A retrospective cohort study of 21,443 patients from the National Surgical Quality Improvement Program dataset of patients who underwent liver resection from 2012 to 2016. Results Patients undergoing hepatectomy during the study period (N = 21,443) had a mean operative duration of 243.5 min of which 16.6% (3533) developed at least one IC. The overall 30-day mortality was 1.6%. A significant increase in mortality and IC was demonstrated from 3 h of operating time (OR: 1.99 and OR: 1.94, respectively), peaking at 8 h (OR: 7.15 and OR: 6.37, respectively). Pneumonia, sepsis/septic shock, and SSI presented high prevalence and were linked to significant mortality. After case-matching, elective hepatectomy was associated with a 4-fold increased risk of infectious complications. Conclusions Operative duration was associated with a linear increased risk of mortality and IC after hepatectomy. The most critical determinants of IC were ASA class, COPD, CHF, and type of hepatectomy.

Background: Healthcare disparities in rural women are well-defined, however little is known about breast reconstruction (BR) utilization in this population, especially rural Kentucky. The goal of this study was to determine if disparities in BR exist among post-mastectomy rural female patients in Kentucky. Methods: The Kentucky Cancer Registry was used to identify patients diagnosed with breast cancer and treated with mastectomy from 2006-2015. Patients were subdivided into mastectomy-only and mastectomy plus BR groups. 2013 Beale codes were used to stratify patients according to urban, near-metro or rural status. Chi-square tests were used to examine the association of BR along the rural-urban continuum. A multivariate logistic regression model controlling for patient, disease and treatment factors was used to predict BR. The likelihood of undergoing BR was reported in odds ratios (OR) using a 95% confidence interval (CI). Results: Overall, 12,036 patients underwent mastectomy. Of these patients, 2,822 (23.4%) also underwent BR. The rate of BR among urban, near-metro and rural patients was 32.4%, 23.1% and 14.7%, respectively. Multivariate analysis revealed that women from near metro (OR 0.56, CI 0.50-0.63; p < 0.001) and rural areas (OR 0.38, CI 0.33-0.43; p Citation Format: Robert-Marlo F. Bautista, Ryan C. DeCoster, Jack C. Burns, Robert W. Edmunds, Adam J. Dugan, Brian J. Rinker, Matthew Webster, Henry C. Vasconez. Rural-urban differences in breast reconstruction utilization following mastectomy [abstract]. In: Proceedings of the Twelfth AACR Conference on the Science of Cancer Health Disparities in Racial/Ethnic Minorities and the Medically Underserved; 2019 Sep 20-23; San Francisco, CA. Philadelphia (PA): AACR; Cancer Epidemiol Biomarkers Prev 2020;29(6 Suppl_2):Abstract nr A126.

To determine predictors of critical care complications (CCC) in patients undergoing hepatectomy.All hepatectomy patients in NSQIP from 2012 to 2016 were analyzed. CCC included prolonged ventilation (48 h), sepsis/septic shock, renal failure/insufficiency, cardiac arrest/AMI and pulmonary embolism.A total of 21,443 patients underwent hepatectomy during the study period. Overall rate of CCC was 11%, with the most common being sepsis/septic shock (6.1%) and respiratory failure (4.9%). On multivariate analysis the preoperative risk factors associated with CCC included ASA Class IV-V (OR:2.04, p 0.0001), diabetes (OR = 1.28, p = 0.0001), pre-operative ventilator use (OR: 17.75, p = 0.0003); COPD (OR: 1.65, p 0.0001); pre-operative weight loss10% (OR: 1.35, p = 0.0026); pre-operative sepsis (OR: 2.14, p 0.0001). Propensity score matched analysis demonstrated a significant increased risk of mortality in patients with CCC (OR: 26.75, p 0.0001) and a prolonged LOS of 10.5 days above the mean (β Estimate: 10.51, p 0.0001).ASA class, diabetes, COPD, pre-operative weight loss10% and pre-operative sepsis are the strongest predictors of CCC after hepatectomy. The presence of CCC significantly increased the risk of peri-operative mortality 26-fold.

Objective To demonstrate the safety and feasibility of outpatient surgical management for patients with acquired buried penis (ABP). Methods We conducted an Institutional Review Board approved review of patients who underwent surgical repair of ABP at a single institution from September 2014 to August 2017. Patient characteristics, operative details, and 30- and 90-day complications were assessed. Results Sixteen patients underwent surgical repair of ABP at the University of Kentucky during the study period. Mean age was 54 years (range 44-62). Median body mass index (BMI) was 47.7 (range 25.5-53.3). Patients largely underwent penile liberation, escutcheonectomy, and split thickness skin grafting. Concurrent scrotoplasty and urethroplasty were performed in select cases. The majority of patients 10/16 (62.5%) were discharged on the same day of surgery, while the remaining 6/16 (37.5%) were outpatient extended stay–and were discharged on postoperative day 1. The 30- and 90-day complications were 19% and 25% respectively, all were Clavien II. Split thickness skin graft take was 100%, and technical success was achieved in all patients. Patients with complications had higher BMIs, higher rates of diabetes, and higher rates of tobacco use, though only BMI reached statistical significance (P = .0150, P = .5846, and P = .0632) respectively. Conclusion Multi component repair of adult ABP can be safely done on an outpatient basis without need for routine inpatient admission and complex algorithms. The most common complication is surgical site infection, which arose in the first 30 days postoperatively. Higher BMI was a significant risk factor for complications.

Background/Aim We aim to study the impact of PH in patients undergoing gastrointestinal surgery (GI). Methods We queried the ACS-NSQIP database from 2005 through 2010 for patients undergoing GI surgery with PH. Esophageal varices (EV) diagnosis was used as a surrogate of PH. Results A total of 192,296 patients underwent GI surgery, of which 379 had PH. Regression analyses revealed that patients with PH had a 6-fold (95% CI 4.6–7.9) increase in 30-day mortality, a 3-fold (95% CI 2.5–3.7) increase in morbidity, a 3.2-fold (95% CI 2.6–3.9) increase in critical care complications (CCC), and a 6.5-day (95% CI 5.1–7.8) increase in hospital LOS. After PSM, the impact of PH on the outcomes remained. These differences were significant regardless of the emergent or elective status of the procedure. AUC analysis demonstrated that MELD and MELDNa + score greater than 10.5 was the most predictive of peri-operative mortality in elective PH cases. Conclusions PH is associated with an increased risk of poor surgical outcomes in patients undergoing elective and emergent gastrointestinal surgery.

Background: Infection following augmentation and prosthetic-based breast reconstruction can cause significant physical and psychological distress for patients. It may delay adjuvant therapies and compromise aesthetic outcomes. The aim of this study is to identify modifiable risk factors for infection and identify common bacterial isolates to achieve optimal outcomes for patients. Methods: A retrospective cohort study was performed for patients undergoing implant-based breast reconstruction over a 2-year period. In each case, we documented demographics, co-morbidities, complications and antibiotic use. We reviewed treatments, infectious species cultured where applicable and all outcomes. Results: A total of 292 patients met the inclusion criteria. Fifty-five patients (19%) developed an infection. Univariate analysis showed a significantly increased infection rate with longer operative times (P = 0.001) and use of tissue expanders (P = 0.001). Multiple logistic regression analysis confirmed drain use and elevated body mass index (BMI) as risk factors (odds ratio [OR] 2.427 and 1.061, respectively). After controlling for BMI, smoking status and radiation, we found an increased odd of infection with allograft use (OR 1.838) and a decreased odd with skin preparation using 2% chlorhexidine gluconate in 70% isopropyl (OR 0.554), though not statistically significant. Forty of 55 patients with infections had cultures, with 62.5% of isolates being Gram-positive species and 30% Gram-negative species. The median time to clinical infection was 25 days. Implant salvage with surgical interventions was achieved in 61.5% of patients. Conclusions: This study identified judicious use of drains and efficiency in the operating room as modifiable risk factors for infections following implant-based breast reconstruction. Prospective trials to analyse techniques for infection prevention are warranted. Implant salvage following infection is a possible end-point in the appropriate patient.

OBJECTIVE The aim of this study is to identify factors associated with increased resource use and total hospital cost (THC) after liver transplantation (LT). METHODS A study of LT patients undergoing surgery between January 2008 and December 2013 was performed. Main end points were LOS, intensive care unit length of stay (ICU LOS), days on the ventilator, THCs, service area costs. RESULTS A total of 191 patients undergoing LT were included in the analysis. Creatinine and blood transfusion were significantly associated with prolonged LOS, ICU LOS, and days on the ventilator. Multivariable analysis of predictors of THC demonstrated creatinine as a strong pre-operative factor. Creatinine was also a significant predictor of OR, ICU, pharmacy, in-patient (floor), diagnostics, and ancillary services cost. After controlling for intra-operative factors such as operative time and blood transfusions, we found that transfusions were the strongest independent predictors of total cost. Patients receiving

Objective To determine the characteristics and predictors of perioperative complications after male anterior urethroplasty. Materials and Methods The American College of Surgeons-National Surgical Quality Improvement Program is a validated outcomes-based program comprising academic and community hospitals in the United States and Canada. Data from 2007 to 2015 were queried for single-stage anterior urethroplasty using Current Procedure Terminology codes. The primary outcome was frequency of complications within the 30-day postoperative period. Preoperative and intraoperative parameters were correlated with morbidity measures, and univariate and multivariate regression analyses were used. Results A total of 555 patients underwent anterior urethroplasty, of whom 180 (32.4%) had graft or flap placement. Of the patients, 127 (22.9%) went home the same day after surgery, 255 (45.9%) stayed for 1 night, and 173 (31.2%) stayed for 2 or more nights. No deaths, cardiovascular complications, or sepsis were noted. Forty-seven patients (8.5%) had complications in the 30-day period. The most common complications were infection (57.4%), readmission (42.9%), and return to the operating room (17%). On univariate analysis, patients who had substitution urethroplasty (P = .04) and longer operative times (P = .002) were more likely to have complications, but only longer operative time showed significance on multivariate analysis (P = .006). Age, American Society of Anesthesiologists score, and length of stay were not predictive of complication frequency. Conclusion Anterior urethroplasty has low postoperative morbidity. Longer operative times were associated with increased rate of complications. Longer hospital stay after surgery is not protective against perioperative complications.