65.09 Outcomes After Discharge From The Surgical Intensive Care Unit to Long Term Acute Care Hospitals

Posted on January 18, 2016

T. S. Jones1, A. Bhakta1, E. L. Jones1, M. Nguyen1, M. Lyaker1, C. Byrd1, D. S. Eiferman1 1The Ohio State University,Columbus, OH, USA

Introduction:

Patients with prolonged hospitalizations in the Surgical Intensive Care Unity (SICU) often have ongoing medical needs that require further care at Long-Term Acute Care Hospitals (LTACHs) upon discharge. Setting expectations for patients and families after protracted SICU hospitalizations is challenging, and there is limited data to guide these conversations. The purpose of this study was to determine patient survival and readmission rates after discharge from the SICU to a LTACH.

Methods:

All patients admitted to the SICU at an academic tertiary care medical center from 2009 to 2014 were retrospectively reviewed. Patients represented all surgical subspecialties except cardiac and vascular surgery patients. Primary outcomes measured included complication rates defined by NSQIP, thirty day readmission rates to the SICU and mortality within one year of discharge.

Results:
296 patients were discharged directly from the SICU to a LTACH. The majority were male (64%) with a mean age of 61 ±16 years. Mean length of stay in the SICU prior to LTACH discharge was 27 ±15 days. The overall complication rate was 99% (293 of 296 patients); the most frequent complication was ventilator dependence greater than 48 hours (277 patients, 94%) followed by pneumonia (139 patients, 47%), sepsis (78 patients, 26%) and acute renal failure (32 patients, 11%). Two hundred and seventy-five patients (93%) required tracheostomy and enteral feeding access prior to discharge and 19 patients (6%) were newly dependent on hemodialysis. Mean GCS at time of discharge was 11. Overall thirty day readmission rate was 20%. There were 86 deaths within 1 year from discharge (29%) with an overall 3 year mortality of 35%

Conclusion:
Patients who are discharged to LTACHs have prolonged intesive care unit hospitalizations with high complication rates. After discharge, these patients have high readmission and one year mortality rates. Patients and families should be counseled about these outomces to allow for realistic expectations of survival following prolonged intensive care hospitalizations.

65.05 Overcoming the Weekend Effect: Impact of Electronic Medical Record System and Vendor Functionality

Posted on January 18, 2016

A. N. Kothari1,3, R. H. Blackwell3, R. M. Yau3, V. Chang2,3, M. A. Zapf2,3, T. Markossian2, G. N. Gupta3, P. C. Kuo1,3 1Loyola University Medical Center,Department Of Surgery,Maywood, IL, USA 2Loyola University Chicago Stritch School Of Medicine,Maywood, IL, USA 3Loyola Department Of Surgery,1:MAP Analytics Group,Maywood, IL, USA 4DePaul University,College Of Computing And Digital Media,Chicago, IL, USA

Introduction:
We previously demonstrated implementation of electronic medical record (EMR) systems as a mechanism to overcome the weekend effect (WE) in emergent/urgent surgery. We hypothesized this was related to EMR systems improving OR throughput and care transitions on the weekend. Our objective was to study how individual components of EMR systems contributed to overcoming the WE to test this hypothesis.

Methods:
This was a population-based cohort review using the 2011 Florida HCUP SID database and HIMSS Analytic database. We used prolonged weekend length of stay compared to the weekday at the hospital-level as a surrogate for the WE. Patients who underwent urgent/emergent surgical intervention at hospitals with the WE were propensity matched to patients at hospitals without the WE using patient (demographic, clinical) and hospital (case-mix, structural) characteristics.

Results:
2,841 patients comprised each matched group. EMR in the OR (O.R. 2.52, 95% C.I. [1.77, 3.60]) and electronic medication reconciliation (O.R. 2.43, 95% C.I. [2.10, 2.80]) were associated with overcoming the WE. Computerized physician order entry (O.R. 0.66, 95% C.I. [0.59, 0.75]), electronic bed management systems (O.R. 0.48, 95% C.I. [0.41, 0.55]), and electronic OR scheduling (O.R. 0.51, 95% C.I. [0.35, 0.75]) appeared to be risk factors for the WE. However, specific EMR vendor products within each of those cateogries could protect against the WE (see Table).

Conclusion:
EMR components that influence OR throughput and care transitions impact the ability for hospitals to overcome the WE. Additionally, these results are the first to demonstrate vendor-specific EMR functionality can significantly impact patient care.

65.06 As Safe as We Claim? A Population Based Analysis of Pyloromyotomy Outcomes in California

Posted on January 18, 2016

C. M. Kelleher1,2, P. T. Masiakos1,2, D. C. Chang2,3 1Massachusetts General Hospital,Pediatric Surgery,Boston, MA, USA 2Harvard School Of Medicine,Brookline, MA, USA 3Massachusetts General Hospital,Surgery,Boston, MA, USA

Introduction: Pyloromyotomy for hypertrophic pyloric stenosis is considered a safe pediatric surgical procedure with few complications or readmissions. Although the incidence of complications has been reported, the rate of readmissions on a population level is unknown.

Methods: Data was abstracted from the longitudinally linked Office of Statewide Health Planning and Development data from the State of California from 1995 to 2009, which allows patient tracking across all hospitals and across all years within California. Inclusion criteria were primary procedure code of pyloromyotomy, a diagnosis code of hypertrophic pyloric stenosis, and no prior record of any in-hospital admission.

Results: A total of 1900 patients were identified (16.8% girls, 31.7% whites, 5.1% blacks, and 58.2% Hispanics). 3.53% of the patients were found to have a significant congenital or comorbid condition; another 0.84% of patients were born prematurely. The median length of stay was 2 days (IQR 2-3 days). The in-hospital complication rate was 5.16%; There were no deaths. The rate of 30-day all-cause readmission was 4.01%, with a median of 0% across hospitals (IQR 0%-1.1%); and 13.2% of readmissions occurred at a different hospital. Surgically-related readmission rate was 2.16%. All-cause readmissions at 60 days, 90 days, 180 days, and 1 year were 5.8%, 7.3%, 10.4%, and 13.7%, respectively. The top three primary diagnoses on readmission were hypovolemia, upper respiratory infections, and post-operative infections.

Conclusion: Thirty day readmission for a surgical complication occurs in 1 of 50 patients undergoing a pyloromyotomy for hypertrophic pyloric stenosis and for all causes is 1 in 25 patients. This data can help inform physicians, families and policy makers about rates of hospital readmission in this common pediatric surgical procedure.

65.02 Trends of Inpatient Surgeries in Pediatric Inflammatory Bowel Disease Patients in the United States

Posted on January 18, 2016

A. L. Stokes1, C. Hollenbeak1, T. Falaiye1 1Penn State Hershey Medical Center,Hershey, PA, USA

Introduction: Pediatric inflammatory bowel disease is globally increasing in incidence. Advances in medical and surgical therapy have improved outcomes over the past two decades. While inpatient hospitalizations and rates of surgery are reportedly decreasing in other countries, trends in the rates of various types of inpatient surgeries in the United States have not been widely reported.

Methods: Pediatric patients ≤20 years of age with either Crohn’s disease (CD) or ulcerative colitis (UC) were identified in the HCUP KID database (2003, 2006, 2009, 2012). Surgeries including bowel resection, stoma creation, and perianal or percutaneous drainage procedures were identified using ICD-9 procedure codes. Logistic regression was used to identify factors associated with surgical intervention, while linear regression was used to identify factors associated with LOS and costs. Regression was also used to test the significance of trends in procedure rates over time. Survey weights were used to obtain estimates of national trends.

Results: Increasing numbers of hospitalizations for both CD and UC patients from ages 0 to 20 were found from 2003-2012 (up from 126 per 100,000 hospitalizations to 197 for CD; up from 68 per 100,000 to 115 for UC, both p<0.001). UC patients had higher LOS (6.4 vs. 5.4 days, p<0.001) and hospitalization costs ($15,011.20 vs. $12,356.80, p<0.001). CD had higher rates of intestinal resection (10.0% vs. 8.1%, p<0.001), but rates of stoma creation were higher in UC (8.6% vs. 2.2%, p<0.001). Factors associated with both intestinal resection and stoma creation (ileostomy or colostomy) include age between 10-20 years, male gender, Caucasian or Asian race, elective admission, and admission to an urban teaching hospital (all p<0.05). Whereas resection was associated with CD and fewer comorbidities, stoma creation was associated with UC and greater number of comorbidities (all p<0.01). Perianal drainage and percutaneous drainage procedures were both significantly associated with CD diagnosis. Rates of these procedures did not change significantly over time, except for increased stoma creation in CD (OR 1.06, 95% confidence interval [CI] 1.03-1.09) and increased percutaneous drainage in UC (OR 1.07, CI 1.00-1.14).

Conclusion: Despite increasing hospitalizations, the rates of common procedures in pediatric IBD patients have remained stable in the US over the last decade, with the exception of increasing stoma creation in Crohn’s patients. This plateau may indicate improved medical control of IBD obviating the need for surgery, or changing indications for surgical treatment. Further studies examining changes in the timing of surgery and the effects of biologic agents on surgical rates are warranted.

65.03 Extremes of Age Predict Readmission Following Elective Colorectal Surgery

Posted on January 18, 2016

L. Theiss1, L. Goss1, D. I. Chu1, M. Morris1 1University Of Alabama At Birmingham,Department Of Surgery,Birmingham, Alabama, USA

Introduction: Surgeons are operating on a growing population of elderly adults. Elderly patients are defined in most studies as anyone greater than 65 years. Few studies have characterized the elderly population by age groups. We hypothesize that increasing age is associated with worse post-operative outcomes including readmission.

Methods: We queried the 2011-2013 National Surgical Quality improvement Program (NSQIP) cohort for patients who underwent an elective colectomy and stratified them into age categories: 18-50, 51 to 60, 61 to 70, 71 to 80, and over 80. Univariate and bivariate comparisons analyses were performed. Using backwards logistic regression, we adjusted for difference in demographics, surgical characteristics, co-morbidities, and complications to identify independent predictors for readmission.

Results: Of the 70,843 patients who underwent elective colorectal surgery: 19.4% were under 50, 22.9% were 51 to 60, 25.5% were 61 to 70, 19.9% were 71 to 80, and 12.3% were over 80,.52.7% were women. Patients over 80 were primarily independent (90.2%) and had the longest length of stay (7 days, p<0.01) compared to all other age groups. The most frequent operation in this cohort was partial colectomy (40.4%), followed by LAR/DLI (34.6%), ileocecectomy (18.3%), and total colectomy (4.2%). Almost half of all colectomies were performed laparoscopically (46.5%). Post-operative outcomes differed significantly based on age (Table 1). Overall SSI rate was 8.4% and was the lowest in patients >80 years old (6.6%). Mortality rates increased with increasing age. Individuals under 50 had the highest readmission rate (12.3%) while individuals age 50-60 had the lowest (9.9%). In the fully adjusted model, patients under 50 years of age (OR 1.2 CI 1.1-1.3) and over 80 years of age (OR 1.14 CI 1.03-1.26) had a significantly higher chance of readmission.

Conclusion: Patients over 80 years and those under age 50 have the highest risk of readmission following elective colorectal surgery. Increasing age is also associated with increased mortality and increased hospital length of stay. As post-operative outcomes including readmission are being used as a quality metric, age of the patient undergoing the procedure should be considered.

65.04 Leucocyte Filtered Blood Transfusions are Associated with Decreased Postoperative Infections

Posted on January 18, 2016

S. Kwon3, R. S. Chamberlain1,2,3 1Saint Barnabas Medical Center,Surgery,Livingston, NJ, USA 2New Jersey Medical School,Surgery,Newark, NJ, USA 3St. George’s University School Of Medicine,St. George’s, St. George’s, Grenada

Introduction: Leucocyte filtered blood (LFB) has been shown to prevent cytomegalovirus reactivation, HLA immunization and recurrent febrile non-hemolytic reactions. LFB has been reported to decrease postoperative infections, however, prior reports are conflicting and contradictory. This meta-analysis examines the impact of LFB on the overall incidence of postoperative infections.

Methods: A comprehensive literature search of PubMed, Google Scholar, and the Cochrane Central Registry of Controlled Trials from January 1966 to July 2015 was conducted. Keywords included in the search were ‘leuk(c)oreduced’, ‘leuk(c)odepleted’, ‘filtered’, ‘white cell reduced’, ‘leuk(c)ocyte reduced’, ‘leuk(c)ocyte depleted’, and transfusions. Studies that compared LFB to non-leucocyte filtered blood and reporting postoperative infections were included. Outcomes analyzed included postoperative infections under ‘as per protocol’ (APP) and ‘intention-to-treat’ (ITT), as well as length of stay (LOS).

Results: 16 RCTs involving 6,776 randomized (ITT) patients (4,514 transfused (APP) patients) in various clinical settings (7 cardiac, 5 colorectal, and 4 other) were evaluated. The LFB group had an overall 25.6% reduction in postoperative infection risk when analyzed by APP (RR=0.744; 95% CI [0.593-0.934]; p=0.011) and 21.7% risk reduction when analyzed by ITT (RR=0.783; 95% CI [0.646-0.949]; p=0.013). When analyzed by APP, cardiac and colorectal surgeries derived the greatest infection reduction benefit (RR=0.748; 95% CI [0.623-0.897]; p=0.002 and RR=0.447; 95% CI [0.199-1.006]; p=0.052). LFB was also associated with a significant reduction in LOS (Standardized Difference of Mean (SDM) =-0.539; 95% CI [-1.038- -0.0040]; p=0.034).

Conclusion: LFB transfusions are associated with a significant decrease in postoperative infections for both APP and ITT populations, particularly in cardiac surgery patients. Additional adequately powered studies are needed to fully understand the benefits of LFB.

64.20 Safety of Prone Jackknife Position in Ambulatory Anorectal Surgery

Posted on January 18, 2016

F. Cheema1, S. Lee1, M. Zebrower2, J. L. Poggio1 1Drexel University College Of Medicine,Department Of Surgery,Philadelphia, PA, USA 2Drexel University College Of Medicine,Department Of Anesthesiology & Perioperative Medicine,Philadelphia, PA, USA

Introduction: Prone jackknife position allows for improved anatomical exposure during anorectal procedures. Debate exists regarding morbidity and anesthetic complications in this position. The primary objective of this study was to determine morbidity and mortality rates of ambulatory anorectal surgeries in prone jackknife position. The secondary objective was to determine which patient characteristics led to higher risk of morbidity and mortality.

Methods: Retrospective chart analysis was performed on 210 patients undergoing ambulatory anorectal surgery in the prone jackknife position in an academic hospital from 2012 to 2014. Factors analyzed were age, sex, clinical diagnosis, procedure, past medical history, ASA physical status classification, current smoking status, minimum intra-operative mean arterial pressure (MAP), minimum O2 saturation, estimated blood loss, fluids, anesthesia duration, antibiotic administration, days to discharge and 30-day readmissions. All patients underwent general anesthesia. Data was provided from history & physical forms, operative notes, anesthesia flowsheets and progress notes. Frequencies and means of the factors were calculated. Mortality was included only if it occurred within 30 days of surgery.

Results: Of 210 patients undergoing ambulatory anorectal surgery, there were no mortalities within 30 days of surgery. Mean age was 44.6 and 72.4% of patients were male. Complication rate was 3.3% with urinary retention taking up 42% of that. 30-day readmission rate from surgery was 1%. This encompassed two cases of rectal bleeding status-post excision & fulguration of anal condylomas and bright red blood per rectum status-post hemorrhoid surgery. 98.1% of patients were discharged same day of surgery. Mean minimum intra-operative MAP and O2 saturation was 70.6 and 98.7%, respectively. The most common clinical diagnoses were anal condylomas (37.6%), hemorrhoids (14.8%) and pilonidal cysts (11%). The most common procedures therefore were excision & fulguration, hemorrhoidal surgery and pilonidal cyst excision. Anal condyloma was the most common past medical history (40.4%), followed by HIV/AIDS (39%) and hypertension (32.3%). Current smoking rate was 45.7%. Mean ASA classification was 2.29, with mean blood loss of 6.22 cc, mean fluids given of 1015 cc, and mean anesthesia duration of 92 minutes. Antibiotics were not administered in 68.1% of cases.

Conclusion: Prone jackknife position in ambulatory anorectal surgeries under general anesthesia provides enhanced exposure and is a safe procedure with no mortality and minimal morbidity. Total complication rate was 3.3%, urinary retention being most common. Given the results, this study provides evidence that ambulatory anorectal surgery in prone jackknife position is relatively safe in terms of morbidity and mortality as well as anesthetic complications when considering the factors analyzed in this study.

64.21 Simulating the Operating Room as a Transition to Surgical Internship

Posted on January 18, 2016

Z. J. Ahola1, C. W. Lee1, S. Agarwal1, H. Jung1, A. O’Rourke1, A. Liepert1 1University Of Wisconsin,Department Of Surgery,Madison, WI, USA

Introduction: Nontechnical skills demonstrated by surgeons in the operating room are known to play an important role in ensuring patient safety and good surgical outcomes. Recognition of communication, leadership, and interpersonal skills as vital components of formal surgical training has resulted in ACGME-accredited skills training initiatives among residencies nationwide. However, early evaluation among medical students considering surgical careers has yet to be studied, and no specific training interventions have been initiated among graduating medical students to date. The purpose of this study was to examine and identify the influences of an early training intervention on teamwork and team performance among medical school graduates continuing onto surgical internship through the use of video recordings of an animal model operative simulation.

Methods: Video recordings of nine graduating medical student interactions were obtained during a full-day surgical case simulation utilizing porcine models. The animal model simulation was the final day of a two-week surgery intern preparatory curriculum for graduating medical students accepted into ACGME-accredited surgical internships. Two randomly assigned groups of students utilized two separate porcine models to perform common operative procedures, termed learning modules. Students received real-time instruction and feedback from residents and attending surgeons. The tasks were primarily performed by the students. All video recordings were reviewed for outcomes pertaining to teamwork knowledge, skills, and attitudes of the participants. The number of actions initiated and task, skill, and team activities were recorded for each individual. This study was qualitative and observational in nature.

Results: Nine medical students were de-identified and randomly divided into two groups, A and B. Team A consisted of 5 subjects, and Team B consisted of 4. The primary observations among participants included various dimensions of teamwork as follows: willingness to participate, encouragement of others, and self-appointed versus instructor-appointed leadership. Dominant individuals were identified as having the greatest hands-on participation and the greatest number of self-initiated actions within each learning module. The cumulative count of self-initiated actions was 55 in Team A and 41 in Team B. The cumulative count of instructor-initiated behaviors was 44 in Team A and 42 in Team B.

Conclusion: Dominant leadership was evident within each learning module. However, cumulative results of self and instructor-initiated behaviors were similar between groups. Common learning characteristics among early surgical trainees include shared learning, willingness for participation, and self and instructor-initiated leadership roles. This study demonstrates that video recordings of high-fidelity surgical scenarios in porcine operative models may be used to identify leadership and teamwork behaviors.

65.01 One-Sided Conversations: Prevalence of Communication Disabilities in the Adult Surgical Population

Posted on January 18, 2016

W. A. Davis1, B. Smalls1, A. Haider1, M. Morris1 1Brigham And Women’s Hospital,Center For Surgery And Public Health, Department Of Surgery,Boston, MA, USA

Introduction:
Communication disabilities, including hearing, speech, language, and voice problems, are a barrier to effective communication in the healthcare setting. The extent of communication disabilities in the surgical population has never been described. We aimed to describe the prevalence of communication disabilities in adult surgical patients from a nationally representative sample.

Methods:
We conducted a cross-sectional analysis using the 2012 National Health Interview Survey (NHIS). NHIS is a nationally representative, stratified, multistage survey that uses face-to-face interviews with non-institutionalized respondents to estimate health care utilization, access, and health-related behaviors for the U.S. population. In 2012, NHIS included a one-time supplemental section focused on communication disabilities. We utilized the 2012 NHIS Sample Adult Core questionnaire to examine the frequency of hearing, speech, language, and voice disabilities in a subpopulation of adult NHIS respondents who reported an inpatient or outpatient surgical procedure within the last twelve months. Additional surgical details were not available. We then conducted subgroup analyses by age, gender, race, ethnicity, and geographic region. To generalize observed results to the U.S. population, survey weights and variance estimations were applied to all statistics.

Results:
In 2012, 12.2% (95% CI: 11.7-12.7%) of the US adult population reported a surgical procedure within the last year, and 22.9% (95% CI: 22.3-23.5) experienced a communication disability. Subpopulation analysis limited to surgical patients (Table 1) revealed that approximately one third (33.8%, 95% CI: 32.1-35.5) reported a communication disability. The most commonly reported disability was hearing (23.5, 95% CI: 21.8-25.2) followed by voice (12.8, 95% CI: 11.6-14.0), speech (4.6, 95% CI: 3.7-5.5), and language (2.2, 95% CI: 1.7-2.8).

Conclusion:
Patients with communication disabilities comprise a major segment of the U.S. adult surgical population. This high prevalence, when combined with a lack of medical professional training and awareness, not only calls into question surgeons’ ability to provide patient-centered care to a significant percentage of their patient population, but also suggests an opportunity to address a source of preventable adverse events, inadequate informed consent, and poor patient satisfaction.

64.17 Post-operative Non-ICU Admission Following Robotic Pancreaticoduodenectomy is Safe and Reduces Cost

Posted on January 18, 2016

K. E. Cunningham2, M. S. Zenati2, J. Petrie3, J. Steve2, M. E. Hogg2, H. J. Zeh2, A. H. Zureikat2 2University Of Pittsburgh Medical Center,Surgical Oncology,Pittsburgh, PA, USA 3University Of Pittsburgh Medical Center,Finance,Pittsburgh, PA, USA

Introduction: Immediate post-operative admission to the ICU following pancreaticoduodenectomy (PD) has been standard of care for many institutions. Over the last decade, minimally invasive pancreaticoduodenectomy has emerged as safe and feasible. The aim of this project was to examine if omission of an immediate post-operative ICU admission would be safe and result in decreased length of stay (LOS) and reduced cost for patients undergoing robotic pancreaticoduodenectomy (RPD).

Methods: From December 2014 to June 2015, a non-ICU admission policy on post-operative day zero (POD0) was implemented for all patients undergoing RPD. Prior to this date, all RPDs were routinely admitted to the ICU on POD0. Using a prospectively maintained database, we compared the outcomes of the non-ICU RPD cohort to patients routinely admitted to the ICU post-operatively prior to implementation of this policy (January 2014-November 2014). All cases were analyzed on an intent-to-treat basis, thereby minimizing selection bias.

Results: The ICU cohort (n=49, average age 65.6 ±12, 51% females) and non-ICU cohort (n=34, average age 66.4 ± 9, 38% females) were comparable with no statistically significant differences with respect to age, sex, BMI, CCI and ASA score, pre-operative tumor size, diagnosis, receipt of neoadjuvant therapy, operative time, and estimated blood loss. Seven patients (21%) from the non-ICU group were directly admitted to the ICU post-operatively based on unpredicted changes in intra-operative clinical status necessitating ICU care. They were included in the non-ICU group and their outcomes were analyzed on an intent-to-treat basis. The rates of Clavien complications, pancreatic leak, reoperation, readmission and mortality demonstrated no statistically significant difference between both groups (Table 1). A statistically significant trend toward reduced total hospital LOS in the non-ICU group was noted (median 6.95 days versus 7.7 days, P=0.083). This reduced LOS and avoidance of routine post-operative ICU admission translated into a cost reduction from $25,812 (IQR $19,875 -$29,853) in the ICU group to $19,739 (IQR $17,964 -$25,521) in the non-ICU group, P=0.01. The reduction in cost remained statistically significant even after adjusting for all related demographics and perioperative characteristics.

Conclusion: A standard policy of omitting a post-operative ICU admission on POD0 following RPD is safe and can result in reduced length of stay and overall savings in total hospital cost.

64.18 Postoperative Functional Decline in Older Adults

Posted on January 18, 2016

J. R. Berian1,2, K. Y. Bilimoria1,3, C. Y. Ko1,5, T. N. Robinson4, R. A. Rosenthal6 1American College Of Surgeons,Division Of Research And Optimal Patient Care,Chicago, IL, USA 2University Of Chicago,Department Of Surgery,Chicago, IL, USA 3Northwestern University,Department Of Surgery,Chicago, IL, USA 4University Of Colorado Denver,Department Of Surgery,Denver, CO, USA 5University Of California – Los Angeles,Department Of Surgery,Los Angeles, CA, USA 6Yale University School Of Medicine,Department Of Surgery,New Haven, CT, USA

Introduction: Geriatric-specific outcomes such as functional decline are critically relevant for older adults as they consider whether to undergo an operation.

Methods: The American College of Surgeons (ACS) National Surgical Quality Improvement Program (NSQIP) collects novel geriatric-specific data as part of the Geriatric Surgery Pilot Project. A retrospective analysis was conducted on a cohort of patients from 25 participating hospitals collected between January and September 2014. Functional status represents an individual’s ability to perform the activities of daily living. The main outcome of interest was decline in functional status from preoperative baseline compared to at the time of hospital discharge (independent preoperatively to partially or totally dependent postoperatively, or partially dependent preoperatively to totally dependent postoperatively). Excluded cases were orthopedic and spinal procedures, death within 30 days, and patients whose preoperative functional status was total dependence. Multivariable logistic regression was performed to identify significant predictors for functional decline.

Results: The study included 6,295 patients with the average age of 74±8 years. The rate of functional decline was 15% among patients <=65 years of age, 14% for ages 66-75 years, 23% for ages 76-85, and 39% for those over age 85 years. On multivariable regression, significant predictors for functional decline included age 76-85 or >85 (OR 1.6 and 2.6, respectively, 95% CI 1.1-2.3 and 1.7-4.0, respectively), female sex (OR 1.3, 95% CI 1.1-1.5), ASA class 3 or 4 (OR 2.7 and 3.3, respectively with 95% CI 1.1-7.2 and 1.3-9.0, respectively), history of COPD (OR 1.3, 95% CI 1.0-1.7), diabetes requiring insulin (OR 1.3, 95% CI 1.0-1.6), disseminated cancer (OR 1.6, 95% CI 1.2-2.1), having experienced a fall within 1 year prior to the operation (OR 1.6, 95% CI 1.3-2.0), or the use of a mobility aid preoperatively (OR 2.0, 95% CI 1.7-2.4). Additional factors associated with functional decline were an emergency operation (OR 2.3, 95% CI 1.8-2.9) or experiencing postoperative complication (OR 1.7, 95% CI 1.4-2.1). Factors found to be protective were overweight status (OR 0.8, 95% CI 0.7-0.9) and other race (non-white, non-Hispanic, non-black)(OR 0.4, 95% CI 0.3-0.5).

Conclusion: Functional decline occurs in older adults following surgery. This occurs in the ‘younger old’ as well as ‘oldest old’. Adjusted analysis finds that advancing age, female sex, high ASA class, certain comorbidities, prior falls and use of mobility aids are associated with functional decline. Counselling high-risk patients about the risk of losing independent functional status is an important component of preoperative decision-making for older adults.

64.14 Monitoring Surgery and Anesthesia: A Global Drive for Better Data

Posted on January 18, 2016

J. S. Ng-Kamstra1,2,3, N. P. Raykar1,2,4, S. Mukhopadhyay1,2,5, R. R. Yorlets2, G. Anderson1,2,6, S. Saluja1,2,7, G. Toma1,2, A. Silverstein1,2,8, B. B. Massenburg1,2,9, E. Bruno1,2,10, H. E. Jenny1,2,9, I. H. Marks1,2,11, L. Ilcisin1,2,12, R. Sood1,2,8, S. Sharma1,2, J. G. Meara1,2, M. G. Shrime1,2,13 1Harvard Medical School,Department Of Global Health And Social Medicine,Boston, MA, USA 2Boston Children’s Hospital,Department Of Plastic And Oral Surgery,Boston, MA, USA 3University Of Toronto,Division Of General Surgery,Toronto, ON, Canada 4Beth Israel Deaconess Medical Center,Department Of Surgery,Boston, MA, USA 5University Of Connecticut Integrated Residency Programs,Department Of Surgery,Storrs, CT, USA 6Massachusetts General Hospital,Department Of Surgery,Boston, MA, USA 7Weill Cornell Medical College,Department Of Surgery,New York, NY, USA 8University Of Miami Miller School Of Medicine,Miami, FL, USA 9Icahn School Of Medicine At Mount Sinai,Department Of Medical Education,New York, NY, USA 10University Of Tennessee Health Science Center College Of Medicine,Memphis, TN, USA 11Barts And The London School Of Medicine And Dentistry,London, ENGLAND, United Kingdom 12Harvard Medical School,Department Of Medical Education,Boston, MA, USA 13Massachusetts Eye And Ear Infirmary,Department Of Otology And Laryngology And Office Of Global Surgery,Boston, MA, USA

Introduction:
Most of the world cannot access safe, affordable surgical and anesthesia care when needed. The global need for expanded access has been quantified, but surgical systems at a country level remain poorly described. The Lancet Commission on Global Surgery developed a set of six indicators that can point to opportunities to strengthen surgical systems, however, these are not yet uniformly collected. We aimed to collect country-level data on the proportion of the population within two hours of a surgical hospital (two-hour access), the number of surgical, anesthesia, and obstetric specialists per 100,000 population (SAO density), the number of surgical procedures per 100,000 population per year (surgical volume), the perioperative mortality rate (POMR), and the number of individuals who face impoverishing and catastrophic expenditures paying for surgery each year. Our goal is to collect robust data on at least 50% of countries for each indicator so that the World Bank can include these among the World Development Indicators.

Methods:
Collaborators contributed modelled estimates of surgical volume and SAO density, and a co-author provided modelled estimates of impoverishing and catastrophic expenditures. To collect primary data from Ministries of Health for the remaining indicators, we trained a team of eight research associates, developed an online data management system, assembled country contacts at Ministries of Health, and developed a strategy for outreach. With the support of our team, health leaders around the world reported data for their respective countries.

Results:
This work is ongoing, with anticipated completion in autumn 2015. To date, we have assembled modelled data on surgical volume, SAO density, and catastrophic and impoverishing expenditures for 194, 167, and 186 out of 215 countries, respectively. Two weeks after starting data collection, we have contacted 212 of 215 Ministries of Health. We have obtained at least partial data for 41 countries and have active communication with 44 more. Of these, 45 responses were from high-income countries (of 80 HIC total), 14 from upper-middle-income countries (of 53 UMIC), 14 from lower-middle-income countries (of 51 LMIC), and 12 from low-income countries (of 31 LIC).

Conclusion:
We have met WDI inclusion thresholds for four indicators using modelled data. New primary data will help to improve these estimates and to advance our understanding of the two remaining indicators: two-hour access and POMR. This effort will send a signal to the global health community that surgery is an "indivisible, indispensable part of health care" that requires investment and continual monitoring during the era of the Sustainable Development Goals.

64.15 Does Gender of Admitting Trauma Surgeon Impact Patient Outcomes?

Posted on January 18, 2016

P. P. Patel1, J. C. Kubasiak1, F. Bokari1, A. J. Dennis1, K. T. Joseph1, F. L. Starr1, D. E. Wiley1, K. K. Nagy1 1John H. Stroger, Jr. Hospital Of Cook County,Trauma,CHICAGO, IL, USA

Introduction:

Research has shown that gender differences in both leadership behavior and effectiveness exist in the boardroom. Many studies have demonstrated that female senior executives operate with a greater degree of energy and intensity, are more assertive and competitive in their approach to achieving goals, and obtain a better financial bottom line. The aim of this study is to evaluate if these female leadership advantages exist in a resuscitation room by examining if a team led by a female trauma surgeon has better patient outcomes.

Methods:

We preformed a retrospective cohort study involving all adult trauma patients who were admitted to our level 1 trauma center from July 1, 2012 to September 30, 2012. Our center is led by 6 full-time surgical attendings (male = 3, female = 3) with call distributed equally amongst all attendings. The goal was to evaluate the effect of the gender of the admitting trauma surgeon on patient disposition (home, observation, ICU or operating room) while controlling for patient sex, age, mechanism of injury and trauma severity as defined by the Injury Severity Score (ISS). Secondary outcomes included length of stay (LOS), readmissions, and mortality. Statistical analysis was performed using a χ 2 test to obtain likelihood ratios and Student’s t-test when appropriate.

Results:
654 patients were enrolled in the study of which 647 patients were analyzed. The study population was 80% male with a mean age of 35.1 years and mean ISS of 8. No difference was noted between patients seen by male and female attendings. When stratified by ISS, no statistically significant relationship was found between the gender of the admitting trauma surgeon and patient disposition after initial resuscitation. Mean LOS, readmissions, and mortality were also equal.

Conclusion:

Patients with equal ISS were given the same disposition after resuscitation, averaged the same LOS, and had no difference in readmission or mortality regardless of the gender of the admitting surgeon. Our results suggest that although males and females may have different leadership styles, in the setting of leading the resuscitation of an acutely injured patient, the gender of the trauma surgeon does not impact outcomes.

64.16 Management and prognosis of elderly breast cancer in Japan, retrospective cohort study

Posted on January 18, 2016

A. Yamada1, K. Narui1, S. Adachi1, H. Shima2, K. Kida2, S. Sugae2, M. Tanabe3, Y. Ichikawa4, K. Takabe5, T. Ishikawa6, I. Endo2 1Yokohama City University Medical Center,Breast And Thyroid Surgery,Yokohama, KANAGAWA, Japan 2Yokohama City University Graduate School Of Medicine,Gastroenterological Surgery,Yokohama, KANAGAWA, Japan 3Yokohama City University Medical Center,Pathology,Yokohama, KANAGAWA, Japan 4Yokohama City University Graduate School Of Medicine,Oncology,Yokohama, KANAGAWA, Japan 5Virginia Commonwealth University,Surgical Oncology,Richmond, VA, USA 6Tokyo Medical University Hospital,Breast Surgery,Shinjuku, TOKYO, Japan

Introduction: Japanese population is increasingly aging. Standard of care for elderly patients is controversial. The aims of this study are to clarify tumor characteristics, management, and prognosis of elderly breast cancer patients.

Methods: This is a retrospective single-center cohort included 647 of elderly (older than 65 years) among 2288 patients who underwent surgery between May 1993 to June 2014. The patients were divided into three groups according to age, younger than 64 (young), from 65 to 74 (young-old), and older than 75 (old-old).

Results:Elderly patients had advanced stage at diagnosis (stage III and IV =11.6: 11.4: 15.2%), no difference in estrogen/progesterone-receptor (hormone receptor: HR) positive (83.1: 80.7: 82.4%), and less HER2 positive tumors (14.1: 10.1: 7.8%). They were more likely to undergo mastectomy (44.4: 42.1: 51.5%) and to omit axillary surgery (0.2: 0.7: 2.1%). Among entire patients, elderly patients were less likely to receive adjuvant systemic therapy (92.5: 91.3: 76.6%) and radiotherapy after breast conserving surgery (91.6: 85.0: 22.9%) compared with their younger counterparts. Among HR positive patients, more than 90% of patients received adjuvant hormone therapy (97.0: 96.0: 91.9%), and less likely to receive chemotherapy (46.4: 28.4: 10.1%), however 5 years disease free survival are not different among age (90.5: 89.8: 92.5%). On the other hand, among HR negative patients, elderly patients, especially old-old, were less likely to receive to chemotherapy (89.3: 82.0: 38.2%) and had shorter 5 years DFS (74.2: 77.5: 65.0%).

Conclusion:Prognosis did not differ despite the variation of treatments among age in HR positive patients. On the other hand, patients between 65 and 74 were likely to receive almost same treatment as younger than 64 and had similar prognosis, whereas patients older than 75 were less likely to receive aggressive systemic treatment and resulted in worse prognosis in HR negative patients.

64.11 Efficiency Interventions Improve Staff Satisfaction with Operating Room Turnover Times

Posted on January 18, 2016

A. J. Douglas2, B. Pankratz2, J. Fenne2, R. I. Shoff2, C. P. Heise2 2University Of Wisconsin,School Of Medicine And Public Health,Madison, WI, USA

Introduction: There is debate in the literature about the usefulness of improving operating room (OR) turnover time since translation into cost savings or increased revenue is inconsistent. However, turnover time is rated by staff as a significant source of inefficiency and dissatisfaction in the OR. Increasing OR staff satisfaction by decreasing turnover times may itself be valuable by improving employee retention and workplace atmosphere. Our objective is to examine the impact of quality improvement (QI) efforts aimed at decreasing time between surgeries on OR efficiency and staff satisfaction.

Methods: OR turnover efficiency improvements were implemented in inpatient surgery at an academic hospital. From 2012-2014, turnover times were tracked both before and after efficiency implementation and a staff satisfaction survey was distributed yearly to OR nurses, surgeons, and anesthesiologists. Statistical analysis of survey results included t-tests and one-way analysis of variance (ANOVA).

Results: Average turnover time decreased 5 minutes total, from 43 to 38 minutes (a 12% reduction in turnover time). Staff satisfaction with turnover times increased across all disciplines (p < 0.05), and overall mean increased from 1.94 ± 0.88 to 3.15 ± 1.35 (p < 0.001), with 1 = ‘poor’ and 5 = ‘outstanding.’ Satisfaction increased among nurses by 1.21 ± 0.22 (p < 0.001), surgeons by 1.22 ± 0.27 (p < 0.001), and anesthesiologists by 1.25 ± 0.41 (p = 0.005).

Conclusion: With LEAN improvement efforts we demonstrated moderate improvements in turnover times in the inpatient setting. Even modest reductions resulted in increased OR staff satisfaction with turnover. While time saved was unlikely to accommodate an extra surgical case, minimizing turnover time remains a sensible target for hospitals due to the positive effects on staff satisfaction.

64.12 Early Attending Surgeon Presence in the OR Suite Increases OR Efficiency

Posted on January 18, 2016

A. Clark1, J. L. Rabaglia1, A. P. Dackiw1, W. D. White1, F. Nwariaku1, S. A. Holt1, S. C. Oltmann1 1University Of Texas Southwestern Medical Center,Dallas, TX, USA

Introduction
Some surgical cases involve complex, pre-incision preparation in the operating room(OR). When a consistent team is not available, and/or when multiple trainees are involved, oversight by an experienced individual can facilitate a timely start. Thyroid, parathyroid and adrenal procedures represent cases in which patient positioning, ultrasonography, nerve monitoring, and/or vascular access for hormone measurements during the procedure may occur before the operation can start. The study hypothesized that early attending presence in the OR expedites surgery start time, improving OR efficiency and decreasing cost.
Methods
Patients undergoing thyroid, parathyroid or adrenal procedures at an urban teaching hospital were selected. Time points were recorded, and calculated as hours:minutes. Cost per minute (m) of OR time was $54. Patients were classified as in the OR ≤10m prior to attending arrival or >10m prior to attending arrival. Data are presented as mean ± SD.
Results
227 cases were performed over 14 months. Thyroidectomy was most common (n=166, 73%), with 54 parathyroid (25%) and 10 adrenal (4.4%) procedures. Combined thyroid and parathyroid procedures occured for 7. 89% were female patients, and a mean age 48±15.
128 patients (56%) were in the OR ≤10m prior to attending arrival and 99 patients (44%) were >10m (0:03±3 vs. 0:35±14, p<0.01). Gender distribution was equivalent (p=1.0). ≤10m patients were older (50±15 vs. 46±14, p=0.04). Adrenal cases were equivalent (5% vs. 4%, p=1), while ≤10m included more parathyroid (32% vs. 15%, p<0.01) and fewer thyroid cases (66% vs. 82%, p<0.01).
≤10m procedures started sooner after patient arrival in OR (0:40±11 vs. 1:03±19, p<0.01). Associated OR costs per minute were $2,206±614 vs. $3,430±1065 (p<0.01), or $1,202 savings before the operation even began in the ≤10m group.

Adrenal and parathyroid had equivalent attending time in the OR prior incision between ≤10m and >10m (p=0.98 and p=0.80). However, patient time in OR prior incision for adrenal cases (0:58±7 vs. 1:42±30, p<0.01) and parathyroid cases (0:39±9 vs. 1:06±13, p<0.01) were shorter in the ≤10m group. This equates to $2,416±477 in savings for adrenal and $1,458±244 for parathyroid cases. For thyroid, attending time in OR prior incision was longer in ≤10m than >10m (0:37±11 vs. 0:24±14, p<0.01), but cases still started sooner (0:40±11 vs. 1:00±17, p<0.01). This equates to $1076±120 in savings per thyroidectomy.

Conclusion
Early attending presence in the OR shortens time to incision, decreasing costs. For parathyroid and adrenal cases, this does not require additional time from the attending surgeon. In ORs without consistent teams or with multiple trainees, early attending presence in the OR improves OR efficiency and results in significant cost savings.

64.13 Analysis of Retracted Articles in the Surgical Literature

Posted on January 18, 2016

E. G. King1, I. Oransky2, T. E. Sachs1, D. B. Flynn3, A. Farber1, J. A. Kalish1, B. M. Krafcik1, J. J. Siracuse1 1Boston University School Of Medicine,Department Of Surgery,Boston, MA, USA 2The Center For Scientific Integrity And New York University Arthur L. Carter Institute,,New York, NY, USA 3Boston University,Alumni Medical Library,Boston, MA, USA

Introduction: Retractions of scientific articles represent attempts to correct the literature. Our goal was to examine characteristics of retracted surgery-related papers.

Methods: NCBI Pub-Med database was queried using ‘surgery,’ ‘surg,’ or ‘surgical’ and ‘retracted’ or ‘retraction.’ Unrelated and non-retracted articles were excluded. Article, journal, and retraction details were recorded.

Results: There were 186 retracted surgical papers identified from 1991-2015. Average time to retraction was 3.6 years. Retracted papers were most often seen in general (25.8%), cardiac (22%), and orthopedic (10.2%) surgery. Articles were related to anesthesia and basic science in 32% and 11% cases, respectively. Authors were most commonly from the United States (21.5%), Germany (19%) and Japan (16%). Median impact factor (IF) of retracted papers was 2.4 (0.27-12.48).

Retraction reasons were 1) content related: duplication (34%), falsified data (15%), data errors (9%), plagiarism (8%), and 2) administrative: IRB concerns (19%), author dispute (9%), copyright (2%). No reason was given in 8% and 24% were behind a paywall (requiring payment to view notice). Median IF was higher for administrative than content-related reasons (3.42 vs. 2.12, P<.01). Plastic surgery, transplant surgery, basic science, non-anesthesia content, and publisher were predictive of a paywall for the retraction (P<.01). IF, content, and publisher did not predict whether a reason for the retraction was given.

Conclusion: The majority of surgical retraction notices have a reason listed and do not require payment to read. These findings provide a baseline analysis for surgeons to identify reasons for retraction and to focus on areas for improvement in transparency.

64.09 Improved Surgeon First Case On Time Starts Enhance OR efficiency and Cost Savings

Posted on January 18, 2016

A. J. Douglas2, R. Shoff2, G. D. Kennedy2, C. P. Heise2 2University Of Wisconsin,School Of Medicine And Public Health,Madison, WI, USA

Introduction: Decreasing under-utilized time in the operating room (OR) has been suggested as a means of achieving meaningful cost reductions for hospitals. One proposed method is to improve on time first case starts in the OR, though related financial analysis is lacking. The purpose of this study is to determine the downstream effect and financial impact of improving on-time starts for the first case of the day in the outpatient operating room at an academic teaching institution.

Methods: The Department of Surgery set a goal to decrease first case delays, specifically those attributable to surgeons. On time starts were defined as those beginning within 10 minutes of the scheduled start time. Beginning in fiscal year (FY) 2014, major efforts were made to improve surgeon related first start delays. On-time start percentage and over-utilized time were measured in the outpatient surgery setting and cost was estimated using a per-minute OR direct cost value. Fisher's exact chi square test was used to assess proportional differences in first case delay percentage between FY 2013 and 2014. An independent samples t-test was performed to analyze pre-post changes in mean monthly over-utilized time.

Results: At baseline, the rate of first-case delays in the Department of Surgery was 7.5%.Post improvement efforts, this rate improved to 4.8% (p < 0.05). The Department of Surgery saw a 51% drop in over-utilized time, corresponding to 998 fewer minutes that ORs ran past 5 pm.. The monthly average over-utilized time in the Department of Surgery decreased by 84 minutes per month (p < 0.05, 95% CI [22,146]). These improvements were estmated to translate into an average direct cost savings of $1,300.00 per month.

Conclusion: Improving on-time first case starts by promoting surgeon timeliness is associated with decreases in over-utilized time at the end of the OR day. While direct cost-savings in the outpatient surgery setting may be minimal, decreasing over-utilized time does have some financial benefit and likely improves the work environment by avoiding overtime staffing issues.

64.10 Telemedicine to Assess Ileostomy Output: A Feasibility Trial

Posted on January 18, 2016

B. Bednarski1, M. Katz1, J. Papadopoulos2, N. You1, M. Rodriguez-Bigas1, J. Skibber1, S. Matin2, G. Chang1 1University Of Texas MD Anderson Cancer Center,Surgical Oncology,Houston, TX, USA 2University Of Texas MD Anderson Cancer Center,Urology,Houston, TX, USA

Introduction:
Ileostomies are a routine part of the care of rectal cancer patients, but are associated with significant risk for dehydration, readmission, and acute kidney injury. Telemedicine has proven beneficial in decreasing readmission in chronic medical illnesses such as chronic heart failure, but its utility in the management of surgical patients is not well studied. The purpose of this study was to evaluate the feasibility of teleconferencing in the assessment of ileostomy output.

Methods:
An IRB-approved, prospective clinical trial was conducted at a single institution from November, 2014-June, 2015. Patients >18 years of age undergoing surgery with the potential for a new ileostomy were eligible. Teleconference rounds were conducted during their postoperative stay using Face Time on iPad2 tablets within a HIPPA compliant network. Teleconference rounds were followed immediately by in-person rounds. The attending surgeon evaluated the character of the ileostomy output via teleconference and subsequent in-person assessment utilizing 5-point likert scales: one rated thin to thick and one based on comparison to food products. The primary endpoint of feasibility was defined as 90% agreement between the teleconference and in-person assessments. Patient and physician satisfaction surveys were recorded. Secondary endpoints including output volume, need for antidiarrheal medications, and the incidence of dehydration related events (including need for outpatient intravenous fluids (IVFs) or readmission) were assessed.

Results:

Fifty patients were enrolled. Ileostomies were not required at surgery in ten patients who were excluded. Twelve patients did not have paired evaluations of the ostomy output and were unevaluable leaving 28 patient encounters with both teleconference and in-person evaluations. Agreement in the assessment of ileostomy output was 96.4% using the 5-point likert scale rated from thin to thick and 89.3% utilizing a comparison to food-based scale. Eleven patients (27.5%) were readmitted; including five patients for dehydration. An additional 3 patients required outpatient IVFs for an overall 20% rate of dehydration events (readmission or outpatient IVFs). Both patients and physicians viewed the teleconferencing favorably. For patients and physicians, 75% and 86.9%, respectively, felt videoconferencing should be a routine part of post-operative care. Similarly, 90.9% and 87%, respectively, felt comfortable with the use of videoconferencing in outpatient follow up.

Conclusion:
Teleconference evaluation is a feasible, reliable means of assessing ileostomy output with high patient and physician acceptance. While further study in the outpatient setting is warranted, the incorporation of early teleconference assessment after discharge may enable early intervention to improve patient outcomes by preventing dehydration and associated readmission.

64.05 A Public Health Perspective: How Often Does Optimal Care Begin Prior to the Surgical Admission?

Posted on January 18, 2016

R. L. Hoffman1, K. T. Collier1, J. Tong1, S. Dasani1, G. C. Karakousis1, R. R. Kelz1 1University Of Pennsylvania,Philadelphia, PA, USA

Introduction: The healthcare crisis in the United States is ongoing. Great debate exists over the best approach to control costs and improve the quality of care provided to patients. The goal of this study was to examine the association between patient characteristics and the ability to receive optimal patient care from a public health perspective using colorectal cancer as a model.

Methods: A retrospective cohort study was performed using inpatient claims from California and New York (2008-2011) for all patients admitted with a new diagnosis of colon (CC) or rectal cancer (RC). From a public health perspective, optimal care was defined as a patient who was not admitted through the emergency department and underwent surgery within the first 24 hours of admission for a known nonmetastatic CC or RC. Univariate and multivariate regression was used to compare patients who received optimal care to those who did not with planned subset analysis in the surgical cohort by malignancy.

Results: A total of 38,568 patients, 30,580 (79.3%) with CC and 7,988 (20.7%) with RC were identified. There were 5,626 patients with metastatic disease. There were 19,268 (50.0%) patients who had surgery within first 24hrs and 29,868 (77.4%) were not admitted via the emergency department. Optimal care was received by 14,109 (36.9%) patients; 8,807 (29.0%) of CC and 5,302 (67.6%) of RC patients (p<0.001). Patients with commercial insurance had the highest rates of optimal care (42.2%) compared to Medicare (34.6%), Medicaid (30.0%) and self-pay (21.3%; p<0.001). In multivariate analysis race, sex, number of comorbidities and insurance status were significantly associated with the likelihood of receiving optimal cancer care (see table).

Conclusion: Despite numerous public health campaigns to increase awareness of colorectal cancer and available screening modalities, less than 40% of patients receive optimal care leading up to definitive treatment. Future efforts to increase the proportion of patients receiving optimal care will depend on significant buy-in from patients, the physicians they encounter prior to surgery and policies that make compliance with screening recommendations more feasible.

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