Yale University School of Medicine Archives - Page 2 of 3 - Academic Surgical Congress Abstracts Archive

50.11 Laparoscopic Versus Open Common Bile Duct Exploration: Trends And Outcomes in Choledocholithiasis

Posted on January 31, 2019

M. L. Warren¹, T. Wyatt¹, R. Dev¹, B. K. Patel¹, J. Luo², Y. Zhang^2,3, K. Y. Pei¹ ¹Texas Tech University Health Sciences Center,Surgery,Lubbock, TX, USA ²Yale School of Public Health,Environmental Health Sciences,New Haven, CT, USA ³Yale School of Medicine,Section Of Surgical Outcomes And Epidemiology,New Haven, CT, USA

Introduction:

There is renewed interest in performing primary laparoscopic common bile duct exploration for choledocholithiasis, but endoscopic retrograde cholangiopancreatography has largely replaced common bile duct exploration while surgical volume and experience are likely low. Despite increasing experience and familiarity with advanced laparoscopic skills, it is unknown whether US surgeons are increasingly adopting laparoscopic common bile duct exploration for common bile duct stones.

Methods:

The ACS NSQIP database was queried for patients undergoing laparoscopic (CPT code 47564) or open common bile duct exploration (CPT code 47610) for diagnosis of choledocholithiasis (identified by ICD 9 and ICD 10 codes) from 2005 to 2016. Trends information was evaluated as percentages of total procedures performed from NSQIP participating hospitals. Standard descriptive statistics was analyzed and multivariable logistic regression were utilized to compare outcomes of interest including complications, mortality, reoperation, and length of stay.

Results:

A total of 1073 procedures were included for analysis. Among NSQIP participating hospitals, the majority of explorations were performed laparoscopically but the percentage of laparoscopic common bile duct exploration remains largely unchanged (Figure 1). After adjusting for patient characteristics, laparoscopic common bile duct exploration was associated with decreased overall complications [OR 0.25 95% CI (0.15-0.40)] and length of stay [OR 0.10 95% CI (0.06-0.16)]. There were no differences in 30-day mortality [OR 0.87 95% CI (0.15-5.00)]or reoperation [OR 0.19 95% CI (0.02-2.23).

Conclusion:

Most NSQIP participating hospitals perform laparoscopic common bile duct exploration but overall experience with common bile duct explorations were low in general. Laparoscopic exploration was associated with decreased overall complication and length stay.

49.20 Advanced age does not preclude good outcomes during surgical treatment of colovesical fistula

Posted on January 31, 2019

B. J. Resio¹, J. Reguero Hernandez¹ ¹Yale University School Of Medicine,Surgery,New Haven, CT, USA

Introduction:

It is commonly believed that surgical treatment of colovesical fistula in the elderly carries an increased mortality and morbidity. Thus, patients are often not referred to surgeons for definitive repair and risk undergoing urgent fecal diversion when presenting with urosepsis. The objective of this study was to evaluate current outcomes of colovesical fistula repair in the elderly population with specialized care by colorectal surgeons at an academic tertiary referral hospital and across the country.

Methods:

Consecutive patients age 65 and older who underwent surgery for colovesical fistula were identified from chart review of an academic, tertiary referral hospital (2012-2018) and from the National Surgical Quality Improvement Project (NSQIP) Database (2016). Main outcome measures included surgical approach, complications and mortality. More granular outcomes of permanent ostomy, recurrence, anastomotic leaks, complication type, conversion to open and temporary diverting ostomy were analyzed among patients available for chart review at the tertiary referral hospital.

Results:

A total of 209 elderly patients underwent elective, partial colectomy for vesico-intestinal fistula at NSQIP hospitals in 2016. Fifty-six percent of cases were laparoscopic, complications occurred in 26% of patients and mortality was 2.4%. Eleven elderly patients presented with sepsis, 82% had complications and mortality was 9%.

A total of 21 elderly patients underwent surgery at a single, academic, tertiary referral hospital. Eighteen patients underwent elective surgery, 94% underwent laparoscopic approach, 6% converted to open and 11% underwent a temporary diverting ostomy with primary anastomosis. There was 1 permanent ostomy among the elective group.There were no mortalities, anastomotic leaks or recurrences with a median follow up of 12 months (IQR:4-34). One elderly patient had major complications (arrhythmia, COPD exacerbation, pneumonia) and 22% had minor complications (ileus most common). Three patients presented with urosepsis, underwent urgent diverting colostomy and 2 of 3 were not subsequently reversed (ages 92,96).

Conclusions:

Elderly patients who present with urosepsis from colovesical fistula and require urgent surgery may have a higher risk of permanent ostomy, mortality and complications. Elective repair is safe in the elderly across the country, with a low rate of mortality and morbidity. Chances of permanent ostomy or open approach are low at a tertiary center. Surgical treatment of colovesical fistula should be offered to elderly patients.

44.14 Penicillin Prevents Rat Colonic Ischemia, Validating its Use in Ischemic Gastrointestinal Disease

Posted on January 31, 2019

T. M. Gisinger^1,2, V. M. Baratta², M. Barahona², J. Ollodart², D. Mulligan², J. P. Geibel^2,3 ¹Paracelsus Medical University,Department Of Medicine,Salzburg, SALZBURG, Austria ²Yale University School of Medicine,Department Of Surgery,New Haven, CT, USA ³Yale University School of Medicine,Department Of Cellular And Molecular Physiology,New Haven, CT, USA

Introduction: Ischemic colitis (IC) is the most common type of intestinal ischemia and arises when the colonic blood supply does not meet cellular metabolic demands. Though clinical evidence is lacking, many patients with IC are nonoperatively managed with empiric antibiotics. It has been proposed that antibiotics mitigate ischemia by reducing bacterial translocation and preventing breakdown of the epithelial barrier. In this study, we demonstrate that colonic tissue perfused with Penicillin G is more resilient to ischemic injury than tissues not exposed to the drug. These findings suggest a new clinical management paradigm of preventing ischemic conditions of the gastrointestinal tract.

Methods: Colon segments from rats were obtained and perfused with an ex-vivo intestinal perfusion device. The perfusion device consists of concentric chambers that contain the bowel segments perfused at 37°C. FITC-Inulin, fluorescein isothiocyanate, was used to assess the ischemic conditions of the intestinal grafts in real-time; a drop in fluorescence (FITC-Inulin concentration) is indicative of cellular ischemic injury. Intestinal segments were perfused with 4-(2-hydroxyethyl)-1-piperazineethanesulfonic acid, HEPES-Ringer. To create an ischemic environment, the HEPES-Ringer was pre-saturated with 100% N2 and perfused on extraluminal surface of all rat colonic segments. The intraluminal components of experimental colons were perfused with 5 mM Penicillin G, whereas control segments were not.

Results: Control (without Penicillin G) distal colon samples showed a significant decrease in FITC-inulin fluorescence compared with experimental (with Penicillin G) distal colons, (26.98 ± 5.035 μM FITC vs 43.62 ± 1.569 μM FITC, respectively p 0.0083, Figure 1). This indicates that Penicillin G minimizes colonic fluid secretion, which is a marker for cell death. A similar trend was seen with proximal colon rat segments (42.7 ± 1.984 μM vs. 33.28 ± 3.455 μM FITC, p 0.0356).

Conclusion: Patients with ischemic colitis are often clinically treated with antibiotics, though the pathophysiological basis of their use is not well-proven. Our study shows that Penicillin G exposure prolongs colonic viability under ischemic conditions. This result will help further guide clinical management of ischemia in the gastrointestinal tract. Further investigation of the precise mechanism by which Penicillin G mitigates ischemia needs to be conducted.

44.12 Penicillin’s Protective Effect on Colonic Ischemia is Mediated by H,KATPase

Posted on January 31, 2019

T. M. Gisinger^1,2, V. M. Baratta¹, M. J. Barahona¹, J. Ollodart¹, D. Mulligan¹, J. P. Geibel^1,3 ¹Yale University School Of Medicine,Department of Surgery,New Haven, CT, USA ²Paracelsus Medical University,Department of Medicine,Salzburg, SALZBURG, Austria ³Yale University School Of Medicine,Department of Cellular and Molecular Physiology,New Haven, CT, USA

Introduction: Ischemic colitis is one of the most common types of intestinal ischemia. Currently, many patients with ischemic colitis are treated with empiric antibiotics, even though the mechanism of action is not fully understood. Previously, we established that Penicillin G has a protective effect from ischemia in the rat colon. In this study, we demonstrate that the protective effect is mediated through stimulation of the colonic H,KATPase, independent of the Nitric Oxide (NO) pathway.

Methods: The colonic segments were harvested from Sprague Dawley male rats and perfused with an ex-vivo intestinal perfusion device. Each colon was maintained at 37°C and perfused both from the luminal and basolateral side. FITC-Inulin, fluorescein isothiocyanate, was used to assess the ischemic conditions of the colonic grafts in real-time. Colonic segments were perfused with 4-(2-hydroxyethyl)-1-piperazineethanesulfonic acid, HEPES-Ringer solution. To create an ischemic environment, HEPES-Ringer was pre-saturated with 100% N2 and exposed to the extraluminal components of all colonic segments. For the experimental colonic tissues, the intraluminal compartments were perfused with 5 mM Penicillin G and 10 μM SCH-28080, a known colonic H,KATPase inhibitor. The intraluminal components of the control group were exposed to 5 mM Penicillin G. To test the NO-dependent mechanism, we used L-NAME, N(ω)-nitro-L-arginine methyl ester, a NO synthesis inhibitor. The intraluminal compartments of the experimental tissue were exposed to 30 μM L-NAME with 5 mM Penicillin G, while control tissues were exposed to 5 mM Penicillin G.

Results: The colon samples exposed to Penicillin G and SCH-28080 exhibited a significant decrease in FITC-Inulin fluorescence, compared with the control colonic tissue exposed to Penicillin G, (36.39 ± 2.721 μM FITC-Inulin vs 43.62 ± 1.569 μM FITC-Inulin, respectively, p 0.0401, Figure 1). We observed no statistically significant difference in the FITC-Inulin concentration between tissues exposed to L-NAME with Penicillin G versus tissues exposed to only Penicillin G.

Conclusion: Our study unveils the mechanism of Penicillin G’s protective effect from ischemia. Our results indicate that Penicillin G’s protective effect against ischemia acts by stimulating the colonic H,KATPase and is not NO-dependent. Therefore, Penicillin G not only has its well-known antimicrobial properties, but also appears to modulate a transport protein on the colonic cell membrane. A better understanding of Penicillin G’s effects on colonic tissue may help further guide the clinical management of ischemia in the gastrointestinal tract.

44.11 Nanoparticle activation of the Calcium Sensing Receptor prevents Ischemic Injury in the Rat Intestine

Posted on January 31, 2019

M. J. Barahona¹, M. Finotti^1,4, J. Ollodart¹, V. M. Baratta¹, T. M. Gisinger^1,2, G. Caturegli^1,4, R. M. Maina^1,4, F. D’Amico^1,4, D. Mulligan¹, J. P. Geibel^1,3 ¹Yale University School Of Medicine,Department Of Surgery,New Haven, CT, USA ²Paracelsus Medical University,Department of Medicine,Salzburg, SALZBURG, Austria ³Yale University School Of Medicine,Department of Cellular and Molecular Physiology,New Haven, CT, USA ⁴University of Padua,Department Of Transplantation And Hepatobiliary Surgery,Padua, PADUA, Italy

Introduction: The intestine is one of the most susceptible organs to ischemia making it extremely difficult to transplant. There is a need for the development of innovative methods to preserve intestinal viability. New efforts are focused on creating particle based delivery systems in the range from 10-1000 nm, or collectively known as nanoparticles. Formulation of nutraceuticals into nanoparticles and nanocomplexes can better facilitate delivery and cellular uptake in colonic systems. Here, we examined how calcium nanoparticle perfusion targeting the Calcium Sensing Receptor (CaSR) could reduce intestinal ischemic damage in the mammalian colon.

Methods: Small intestinal segments from Sprague-Dawley male rats were obtained and perfused with an ex-vivo intestinal perfusion device. Segments were perfused with and without calcium nanoparticles in an induced ischemic environment, 100% N₂and 4-(2-hydroxyethyl)-1-piperazineethanesulfonic acid (HEPES),compared to small intestine segments perfused without an ischemic environment (HEPES). Fluid secretion or absorption of the intestine was measured by fluorescein isothiocyanate-inulin (FITC-Inulin). Using FITC-Inulin concentration we assessed the ischemic conditions (decreased fluorescence) of the perfusate through the intestinal grafts in real-time.

Results: Small intestinal segments exposed to 100% N₂developed a significantly greater degree of ischemic damage when compared to intestine perfused with normal HEPES buffer, p <0.0001. In this nitrogen-induced ischemic environment, the presence of 1.0 mM, 2.5 mM and 5.0 mM of calcium carbonate nanoparticles prevented the damage (increased fluid secretion, p <0.0001, Figure 1). Intestinal segments exposed to nitrogen and nanoparticles resisted ischemia to a greater extent than segments exposed to normal HEPES p <0.0001.

Conclusion: Calcium carbonate nanoparticles targeting the CaSR can mitigate ischemic damage in the small intestine. These results suggest that nanoparticles may be a novel therapeutic vector for reducing ischemic and inflammatory injury. This suggests that nanoparticle activation of CaSR would be an important prophylactic therapy to improve organ viability.

44.06 Activation of the Vacuolar H⁺-ATPase via CaSR Activation in the Rat

Posted on January 31, 2019

M. J. Barahona¹, J. Ollodart¹, T. M. Gisinger^1,3, V. M. Baratta¹, Y. W. Stroehl^1,2, D. Mulligan¹, J. P. Geibel^1,4 ¹Yale University, School of Medicine,Department Surgery,New Haven, CT, USA ²Charité University Medicine Berlin,Faculty Of Medicine,Berlin, BERLIN, Germany ³Paracelsus Medical University,Department Of Medicine,Salzburg, SALZBURG, Austria ⁴Yale University School Of Medicine,Department Of Cellular And Molecular Physiology,New Haven, CT, USA

Introduction: Gastroesophageal reflux disease is a prevalent chronic disorder, yet symptom management is often difficult to achieve or maintain. Traditional treatments involve proton pump inhibitors and H₂-receptor antagonists, though many patients have persistent symptomatology. Recently, an unaccounted apical vacuolar H⁺-ATPase was identified and found to be activated in the absence of H,KATPase activity. This H⁺-ATPase is activated by the calcium-sensing receptor (CaSR), which is in turn modulated by the calcium-activated chloride channel (CaCC). Production of gastric acid via this mechanism can be inhibited by blocking gastric CaCC. Tannic acid has been shown to block the CaCC in other organ systems. Here, we demonstrate that modulation of CaSR via the calcimimetic R568 and CaCC, via tannic acid can indirectly influence acid secretion through the vacuolar H⁺-ATPase.

Methods: Gastric glands from rats were isolated via a hand dissection technique. The individual glands were then perfused in vitro with a K⁺-free HEPES (4-(2-hydroxyethyl)-1-piperazineethanesulfonic acid) to suppress H,KATPase activity. The control group was perfused with 400 nM R568 hydrochloride, a positive allosteric modulator and agonist of CaSR, while the experimental group was perfused with 400 nM R568 hydrochloride and 200 µM tannic acid. Next, the extracellular calcium concentration was elevated to 5.0 mM in the presence and absence of R568 and tannic acid. The H⁺-ATPase activity was selectively monitored with the rate of proton extrusion (ΔpH/min) on individual parietal cells by observing a change and recovery rate of intracellular pH after acid loading the cells with various solutions, leaving only the H⁺-ATPase as an active proton secretory pathway.

Results: After exposure to R568 in glands from fasted animals there was increased vacuolar H⁺-ATPase activity with normal extracellular (1.0 mM) Ca²⁺with a rate of proton extrusion increase of 0.01255 ± 0.00120 ΔpH/min. Elevations in Ca²⁺concentration (1.0 mM to 5.0 mM) caused a further increase in K⁺-independent H⁺ secretion 0.01621 ± 0.00087 ΔpH/min. When tannic acid, an inhibitor of CaCC was added to the perfusates with 1.0 mM Ca²⁺and 5.0 mM Ca²⁺^,there was a significant inhibition of proton secretion under all conditions with a lower proton extrusion relative to the control 0.00296 ± 0.00027 ΔpH/min (p<0.0001) and 0.00409 ± 0.00053 ΔpH/min (p<0.0001), respectively.

Conclusion: An increase in extracellular calcium concentration leads to CaSR stimulation and elevated H⁺-ATPase activity. In this study, we demonstrate tannic acid-induced inhibition of the H⁺-ATPase through inactivation of the CaCC. The inhibition of H⁺-ATPase activity along with H,KATPase activity theoretically may lead to complete blockade of gastric acid production under resting and stimulated conditions. The CaSR along with CaCC can be important new pharmacologic targets to suppress acid secretion.

42.01 Surgical Trainees’ Sense of Responsibility for Patient Outcomes: A Multi-Institutional Appraisal

Posted on January 31, 2019

R. W. Randle¹, S. L. Ahle², D. M. Elfenbein⁵, A. N. Hildreth⁴, J. A. Greenberg³, P. J. Schenarts⁷, J. W. Kempenich⁶ ¹University Of Kentucky,Department Of Surgery,Lexington, KY, USA ²Yale University School Of Medicine,Department Of Surgery,New Haven, CT, USA ³University Of Wisconsin,Department Of Surgery,Madison, WI, USA ⁴Wake Forest University School Of Medicine,Department Of Surgery,Winston-Salem, NC, USA ⁵University Of California – Irvine,Department Of Surgery,Orange, CA, USA ⁶University Of Texas Health Science Center At San Antonio,Department Of Surgery,San Antonio, TX, USA ⁷University Of Nebraska College Of Medicine,Department Of Surgery,Omaha, NE, USA

Introduction:
Surgeon educators express concern about their current ability to impart a strong sense of patient ownership to trainees. We hypothesized that surgical residents’ sense of patient ownership would be associated with their perceived autonomy and other modifiable factors in the modern training environment. We aimed to compare resident and faculty perceptions on residents’ sense of personal responsibility for patient outcomes and to correlate patient ownership with resident and residency characteristics.

Methods:
An anonymous electronic questionnaire surveyed 373 residents and 390 faculty at 7 academic surgery residencies across the U.S. We used a modified version of a validated psychologic ownership scale to measure patient ownership among surgical trainees.

Results:
Respondents included 123 residents and 136 faculty (response rate 33% and 35%, respectively). Overall, 91.1% of resident respondents agreed that faculty modeled strong patient ownership, and 78.0% of faculty agreed that residents took personal responsibility for patient outcomes. 75.6% of residents perceived they felt a similar or higher degree of patient ownership than their faculty, but only 26.4% of faculty agreed. Faculty underestimated the proportion of residents that routinely checked on their patients when “off-duty” or “off-service” (36.8% vs 92.6% per resident report (p<0.001). Faculty and residents perceived that greater operative autonomy provided residents with a higher level of ownership (Figure). Almost all faculty (97.8%) reported providing more autonomy to residents who display strong patient ownership, but only 53.7% provide more autonomy in order to increase ownership.
Higher means on the patient ownership scale correlated with female sex (5.9 vs. 5.5 for males, p=0.009) and advanced PGY level (5.3, 5.5, 5.7, 5.8, 6.1, for PGY1-5, respectively, p=0.02). Additionally, residents who reported that patient outcomes affected their mood when off-duty achieved higher ownership means than those who claimed outcomes did not affect their mood (5.8 vs 4.8, p<0.001). Trainees who perceived better resident camaraderie (p=0.004), faculty mentorship (p<0.001), and that their program provided an appropriate degree of autonomy (p=0.03) felt greater responsibility for patient outcomes.

Conclusion:
Most faculty agree that residents assume personal responsibility for patient outcomes, but many still underestimate residents’ sense of patient ownership. Certain modifiable aspects of residency culture including camaraderie, mentorship, and autonomy are associated with patient ownership among trainees.

41.10 Predictors of Delayed Emergency Department Throughput among Blunt Trauma Patients.

Posted on January 31, 2019

B. Steren², M. Fleming¹, H. Zhuo³, Y. Zhang³, K. Pei^1,4 ¹Yale University School Of Medicine,Department Of Surgery,New Haven, CT, USA ²Yale University School Of Medicine,New Haven, CT, USA ³Yale University School Of Medicine,Section Of Surgical Outcomes And Epidemiology,New Haven, CT, USA ⁴Texas Tech University of Health Sciences Center, School of Medicine,Department Of Surgery,Lubbock, TX, USA

Introduction: Delayed emergency department (ED) throughput has been associated with increased mortality and increased length of stay (LOS) for various patient populations. Trauma patients often require significant effort in evaluation, work up, and disposition; however, patient and hospital characteristics associated with increased LOS in the ED remain unclear.

Methods: The Trauma Quality Improvement Project database (2014-2016) was queried for all adult blunt trauma patients. Patients discharged from the ED to the operating room were excluded. Univariate and multivariable linear regression analysis was conducted to identify independent predictors of prolonged ED length of stay, controlling for patient characteristics (age, gender, race, insurance status), hospital characteristics (teaching status, ACS level, geographic region) and injury severity score and abbreviated injury severity score (ISS and AIS).

Results: 412,000 patients met inclusion criteria for analysis. When controlling for covariates, an increase in age by 1 year resulted in 0.78 increased minutes in the ED (p<0.0001). On multivariable linear regression controlling for injury severity and comorbid conditions, non-white race groups, university status and northeast region were associated with increased ED dwell time. Black and Hispanic patients spent on average 41.76 and 40.06 more minutes respectively in the ED room when compared to white patients (p <.0001). Patients seen at University hospitals spent 52.50 more minutes in the ED when compared to community hospitals whereas patients at non-teaching hospitals spent 32.32 fewer minutes (p <.0001). Patients seen in the Midwest spent the least amount of time in the ED, with patients in the South, West, and Northeast spending 44.87, 36.02 and 89.41 more minutes respectively (p <.0001). Non-Medicaid patients at Level 1 trauma centers and those requiring intensive care admission had significantly decreased ED dwell time. Medicaid patients took the longest to move through the ED with Medicare, BlueCross and Private insurance outpacing them by 17.69, 26.67 and 27.11 minutes respectively (p <.0001). Level 1 trauma centers moved patients through the ED fastest, with level II centers experiencing 49.56-minute delays and level III centers experiencing 130.34-minute delays (p <.0001). Not surprisingly, patients admitted to the ICU spent the least amount of time in the ED when compared to those admitted to floor or other (p <.0001).

Conclusion: ED length of stay varied significantly by patient and hospital characteristics. Medicaid patients and university status were associated with significantly higher ED dwell time, while ACS level verification status had strong correlation with ED throughput. These results may allow targeted quality improvement programs to enhance ED throughput.

40.08 Vulnerability to Financial Hardship After Severe Traumatic Injury: The Impact of Socioeconomic Status

Posted on January 31, 2019

K. M. O’Neill³, R. A. Jean³, C. P. Gross², R. D. Becher³, R. Khera⁴, J. V. Elizondo⁵, K. Nasir² ²Yale University School Of Medicine,Internal Medicine,New Haven, CT, USA ³Yale University School Of Medicine,General Surgery,New Haven, CT, USA ⁴University Of Texas Southwestern Medical Center,Cardiology,Dallas, TX, USA ⁵Yale University School Of Medicine,New Haven, CT, USA

Introduction: Trauma-related disorders rank among the top-five most costly medical conditions to the healthcare system. However, the impact of healthcare expenses on the families of patients suffering traumatic injury is not well studied. To address this gap in knowledge, we used nationally representative data to investigate the burden of financial hardship from out-of-pocket (OOP) health expenses for families with one or more members suffering from a traumatic injury, specifically evaluating the role of socioeconomic status and injury severity on financial burden.

Methods: This retrospective cross-sectional study used nationally representative Medical Expenditure Panel Survey data from 2010 through 2015. We identified families in which at least one member had a traumatic injury and classified this injury based on severity; socioeconomic status was based on family income. Percent of annual family income used for OOP health expenses was used to assess for the risk of excess financial burden (OOP>20% of annual income) and catastrophic medical expenses (OOP>40% of annual income) adjusting for demographic, socioeconomic, and healthcare utilization factors in a multivariable logistic regression model.

Results: We identified 7,538 individuals with injuries, represented in 7,102 families of the total 90,964 families in the cohort. Of these, 668 families were classified as severe. Families with a severe traumatic injury experienced increased OOP medical expenses, spending on average $2,784 (95% CI: $2,106-$2833). Increased severity of injury was also associated with increased proportion of excess final burden. Overall 4.4% in the uninjured cohort experienced excess financial burden, compared to 5.6% of families with a minor injury and 12.6% of families with severe injury (see Figure). In a risk-adjusted logistic regression model, families with a severe injury were significantly more likely to experience excess financial burden (OR: 2.04, 95% CI: 1.13-3.64) and catastrophic medical expenses (OR: 3.08, 95% CI: 1.37-6.9). Families below the federal poverty line had increased odds of excess financial burden (OR: 18.1, 95% CI: 15.3-21.4) and catastrophic medical expenses (OR: 47.8, 95%CI: 35.5-64.7).

Conclusions: Approximately 1 in 8 households with a severely injured family member experience financial hardship. These families are significantly more vulnerable to incurring catastrophic OOP health expenses than the non-injured population. This effect was most pronounced for families living below the poverty line. These results highlight the vulnerability of poor families to financial hardship from OOP expenses and reinforce the importance of injury prevention strategies.

38.06 The Limited Utility of Routine Culture in Pediatric Pilonidal, Gluteal, and Perianal Abscesses.

Posted on January 31, 2019

M. P. Shaughnessy¹, C. J. Park¹, L. Zhang¹, R. A. Cowles¹ ¹Yale University School Of Medicine,Department Of Pediatric Surgery,New Haven, CT, USA

Introduction:

Pilonidal, buttock, and perianal abscesses are common reasons for surgical consultation in the pediatric emergency department. When an abscess is clearly present, a bedside incision and drainage (I&D) typically includes a culture swab of the abscess fluid and patients are often discharged home with oral antibiotics. To fill a clear gap in the literature regarding culture utility and add to the existing data about antibiotic stewardship, we aimed to study abscess culture results by examining the impact of culture data on changes in management and effects on outcomes.We hypothesized that in a majority of cases, management is unaffected by culture data and therefore fluid culture from simple pilonidal, buttock, and perianal abscesses in the pediatric population may represent an unnecessary laboratory test and cost.

Methods:

With institutional review board approval, a single institution electronic medical record was searched to identify pediatric patients with a diagnosis of abscess having undergone I&D between February 1, 2013 and August 1, 2017. Two separate searches were conducted using both ICD-10 codes and CPT codes. Patients from these searches were merged, duplicates removed, and any patients with abscesses outside the gluteal region were excluded. From the resulting 317 patient encounters, 68 were excluded due to either improper coding or procedures having been performed outside of the pediatric emergency department. The final number of patient encounters was 249. Patients were divided into two different comparison groups for data analysis based upon the presence or absence of culture and recurrence or no recurrence. Data were analyzed with the support of SPSS Version 24.0 using chi-squared test or Fisher’s exact test when applicable.

Results:

Patient age distribution was bimodal with median ages of 1 and 16 years. Abscesses were more likely to occur in females (63.1%) than in males (36.9%). The most common abscess location was the gluteal cleft (46.6%), the most frequently cultured organism MRSA (26.1%), and the overall recurrence rate was 10.8%. Antibiotics were prescribed 80.3% of the time with the most commonly prescribed being Bactrim (34.5%), followed by Clindamycin (30.9%). In total, culture results were found to directly alter management in only 5 patient encounters (2.7%). When comparing groups by culture or no culture, no statistically significant difference in recurrence rate (p=0.4) was noted. When comparing groups by recurrence versus no recurrence, we found no statistically significant difference between sex (p=0.68), age (p=0.11), resident type (p=0.28), vessel loop use (p=0.2), packing use (p=0.28), or antibiotic use (p=0.17).

Conclusion:

We conclude that microbiological culture results are of limited utility in the management of pediatric pilonidal, gluteal, and perianal abscesses as they do not appear to alter treatment plans and omission of culture is not associated with failure of surgical management.

36.03 Burden, Outcomes, and Economic Benefit of Neonatal Surgery in Uganda: Results of a Five-Year Follow-up Study

Posted on January 31, 2019

S. Ullrich¹, N. Kakembo², P. Kisa³, A. Muzira⁴, M. Nabukenya⁸, J. Tumukunde³, T. Fitzgerald⁵, M. Langer⁶, M. Situma⁷, J. Sekabira², O. Doruk¹ ¹Yale University School Of Medicine,Pediatric Surgery,New Haven, CT, USA ²Mulago Hospital,Surgery,Kampala, Uganda ³Makerere University,College Of Health Sciences,Kampala, Uganda ⁴University of British Columbia,Surgery,Vancouver, BC, Canada ⁵Duke University,Department Of Surgery,Durham, NC, USA ⁶Ann & Robert H Lurie Children’s Hospital of Chicago,Pediatric Surgery,Chicago, IL, USA ⁷Mbarara Regional Referral Hospital,Surgery,Mbarara, Uganda ⁸Mulago Hospital,Anesthesia,Kampala, Uganda

Introduction: Ninety-four percent of congenital anomalies occur in low and middle-income countries (LMICs). In Uganda, only four pediatric surgeons and three pediatric anesthesiologists serve over 20 million children. This study estimates burden, outcomes, and coverage of neonatal surgical conditions in Uganda and compares them with our prior estimates. We also estimate economic benefit of neonatal surgery.

Methods: A prospectively collected database was reviewed for neonatal (age < 30 days) general surgical admissions from January 1 2012, to May 31, 2017 at the only two sites with specialist pediatric surgical coverage, one that started providing services in mid-2014. Outcomes were compared with high-income countries, and met and unmet need were estimated using disability-adjusted life years (DALYs). We estimated economic benefit using a value of a statistical life-year approach.

Results: A total of 1,177 neonatal admissions were identified, representing 25% of all pediatric surgery admissions. Mean age of presentation was 7 days and overall mortality was 36%. Mean distance travelled was 92 km. The most common conditions were anorectal malformations (18%), gastroschisis (17%), omphalocele (15%), and intestinal atresia (10%). Almost half of presenting neonates (49%) underwent surgical intervention. Post-operative mortality was 24%. Mortality for neonates was significantly associated with surgical intervention (p<0.001) and age (p<0.001). Highest mortality conditions were gastroschisis (85%) and biliary atresia (80%). Gastroschisis (42%) and anorectal malformations (42%) had the greatest reduction in mortality with surgical intervention. Met need was 3,531 DALYs/ year and 140,220 DALYS were potentially avertable (unmet need). The current met need corresponds to a $2.9 million net economic benefit to Uganda, with a potential additional benefit of $116 million if unmet need were fully addressed. Approximately 2.3% of the total need was met by the healthcare system.

Conclusions: Neonatal surgery improves survival for most conditions despite resource limitations such as lack of neonatal intensive care. Despite slight increases in workforce and infrastructure, a negligible proportion of the need for neonatal surgery is currently being met in Uganda, similar to estimates five years ago (3%). This is likely multifactorial, including lack of access to surgical care and severe shortages of workforce and infrastructure. Current and potential economic benefit to Uganda appears substantial. More advocacy is needed to increase capacity for pediatric surgical care in Uganda and similarly resourced LMICs.

36.01 Pediatric Surgical Outreach Camps in Uganda: Results and Use of Guidelines for Quality Improvement

Posted on January 31, 2019

D. F. Grabski¹, N. Kakembo², M. Cheung³, I. Okello², A. Shikanda⁵, M. Langer⁷, M. Nabukenya⁴, M. Ajiko⁸, G. Villalona⁶, T. Fitzgerald⁹, G. Kateregga¹⁰, J. Tumukunde⁴, A. Muzira², P. Kisa², M. Situma⁵, J. Sekabira², D. Ozgediz³ ¹University of Virginia School of Medicine,Department Of Surgery,CHARLOTTESVILLE, VIRGINIA, USA ²Makerere University, Mulago Hospital,Department Of Surgery,Kampala, KAMPALA, Uganda ³Yale University School of Medicine,Department Of Surgery,New Haven, CT, USA ⁴Makerere University, Mulago Hospital,Department Of Anesthesia,Kampala, KAMPALA, Uganda ⁵Mbarara University of Science and Technology, Mbarara Hospital,Department Of Surgery,Mbarara, MBARARA, Uganda ⁶Saint Louis University School of Medicine,Department Of Surgery,Saint Louis, MO, USA ⁷Northwestern University School of Medicine,Department Of Surgery,Chicago, IL, USA ⁸Soroti Regional Referral Hospital,Department Of Surgery,Soroti, SOROTI, Uganda ⁹Duke University School of Medicine,Department Of Surgery,Durham, NC, USA ¹⁰Mbarara University of Science and Technology,Department Of Anesthesia,Mbarara, MBARARA, Uganda

Introduction:
Pediatric surgical resources are significantly limited in Uganda, especially in rural areas. The result is a back-log of elective cases and emergency procedures performed by general surgeons or medical officers in rural hospitals. Surgical camps run by local and international partners have historically assisted with rural service delivery. We describe the effectiveness of locally led rural pediatric surgical outreach on service delivery and training.

Methods:
We performed a retrospective review of data from rural outreach camps completed by the pediatric surgery and anesthesia teams at Mulago Hospital in collaboration with international partners from 2012-2017. Primary outcomes included surgical volume and immediate surgical outcomes. Secondary outcomes included the share of elective cases and the trainee involvement in the camps. The 2017 joint “Guidelines for Short Term Missions” (STMs) from the American Pediatric Surgery Association (APSA) were used to assess possible areas of quality improvement.

Results:
From 2012-2017, 7 surgical outreach camps ranging from 3-5 days occurred in Soroti (5/2012, 1/2013), Masaka (8/2013, 02/2015) and Mbarara (01/2016, 11/2016, 04/2017) (Table 1). 394 cases were completed, with 383 (97.2%) elective procedures. There were 4 re-operations and 2 post-operative deaths. 48 Trainees (6 from USA) in general surgery and anesthesia were involved in the camps. 6 general surgeons and 11 anesthesia officers were additionally involved in pediatric surgical and anesthesia skill transfer. Reduction of elective case backlog and clinical skill transfer in pediatric surgery and anesthesia were successes highlighted by the local team. Perceived challenges included a lack of reliable intensive care, radiology and pathology. Qualitative review by the pediatric surgery and anesthesia teams of the Day-of Surgery Checklist from published guidelines revealed several areas of potential improvement including: allergy history (specifically where language barriers exist), evaluation for clinical changes after screening, pre-operative image review, and more formal intra-operative debriefing. Participants also emphasized possible burden on local hospitals.

Conclusion:
Pediatric surgical outreach camps led by local pediatric surgeons in Uganda are safe and help to address the back-log of elective cases. Outreach camps can be closely linked with surgical training and skill transfer. Challenges vary by site and camps can stress the local system and must be well-coordinated with local teams. Lastly, the 2017 joint guidelines for STMs, adapted to the local context, may be a helpful tool for quality improvement and prospective evaluation is warranted.

32.09 Debunking the July Effect: Systematic Review and Novel Difference-in-Difference Analysis

Posted on January 31, 2019

C. K. Zogg^1,2,3, D. Metcalfe³, S. A. Hirji², K. A. Davis¹, A. H. Haider² ¹Yale University School Of Medicine,New Haven, CT, USA ²Brigham And Women’s Hospital,Center For Surgery And Public Health,Boston, MA, USA ³University of Oxford,Oxford, United Kingdom

Introduction: The arrival of new residents at the beginning of the academic year has long been associated with perceived adverse patient outcomes. Numerous studies in recent years have sought to prove/disprove the ‘July Effect.’ The objective of this study was to provide a definitive answer, combining data on mortality, morbidity, and unplanned readmission through a systematic review/meta-analysis and expanded difference-in-difference (DID) analysis of seasonal variation in outcomes for teaching vs non-teaching hospitals across seven common medical and surgical conditions.

Methods: 1) Systematic review and meta-analysis of studies published prior to July 31, 2018. 2) DID analysis of adult patients, ≥18y, with primary diagnosis/procedure codes for AMI, CVA, pneumonia, elective CABG, elective colectomy, craniotomy, or hip fracture contained within the 2012-2015 Nationwide Readmissions Database. Weighted models compared disease-specific differences in 30- and 90-day mortality, readmission, and median index hospital length of stay (LOS) between patients admitted to teaching vs non-teaching hospitals in July-August vs September-June and April-May.

Results: A total of 85 studies met inclusion criteria. Of these, 12 (14.1%) reported evidence in support of a July Effect for any outcome (1/13 high-quality studies). An additional 14 (16.5%) suggested that evidence was mixed (3/13 high-quality studies). 57/85 assessed mortality, of which 25 were eligible to be included in the random effects meta-analysis (Figure), OR(95%CI): 1.00(0.97-1.03). 48/85 assessed major morbidity, of which 26 were included in the random effects meta-analysis, 1.02(0.99-1.05). One met inclusion for readmission, 0.90(0.80-1.23). Data assessment similarly revealed no significant differences in 30- or 90-day mortality when comparing teaching vs non-teaching hospitals in July-August vs April-May (e.g. absolute 30-day DID[95%CI] hip fracture: +0.1[-0.7 to +0.9] percentage-points). When compared relative to September-June, AMI showed a slight 30-day difference, +0.4(0.1-0.8) percentage-points, that was not significant for p<0.001. Similar results were observed for 30- and 90-day readmission (e.g. 30-day hip fracture: -0.2[-2.0 to +1.6] percentage-points) and median index hospital LOS (0.0[0.0-0.0] days).

Conclusion: An influx of recent studies has challenged pre-existing notions of the July Effect for major adverse outcomes: mortality and morbidity. While evidence refuting the July Effect in readmission is scarcer, DID assessment of common medical and surgical conditions demonstrated that the July Effect does not exist. Taken together, the results suggest that fears surrounding the July Effect are unfounded and that further studies might be unwarranted.

29.08 Shared Decision-making for Unilateral Breast Cancer Patients Choosing between CPM and UM

Posted on January 31, 2019

J. Huang¹, A. Chagpar¹ ¹Yale University School Of Medicine,New Haven, CT, USA

Introduction:

Choosing between contralateral prophylactic mastectomy (CPM) and unilateral mastectomy (UM) is a personal decision, but the patient’s surgeon may influence this. We sought to determine how different patient-doctor communication strategies play into the decision-making process.

Methods:

Female unilateral breast cancer patients who had a mastectomy at a large academic institution were approached to participate in a survey regarding patient-physician communication and their decision between CPM and UM. Patient satisfaction with decision was measured using the 5-point Satisfaction with Decision (SWD) scale (higher = more satisfied). Non-parametric statistics were performed using SPSS version 24.

Results:

100 (91.7%) of 109 patients approached completed the survey and were included in this cohort; the median age was 49.5 years (range 29-82). 54 patients chose to undergo CPM (54%). 33 patients (33%) reported being recommended UM, 6 patients (6%) reported being recommended CPM, and 61 patients (61%) reported that their doctors employed shared decision-making (SDM), i.e., made no strong recommendation either way. The majority of patients who stated their doctors recommended UM chose UM (78.8%); similarly, 83.3% of those who stated their doctors recommended CPM chose CPM. Of the 39 patients whose doctors recommended a surgery, 8 patients (20.5%) did not follow their doctor’s advice. These patients were equally as satisfied with their decision as those who did follow their doctor’s advice (p=0.441). Compared to patients that followed their doctor’s advice, patients who did not tended to use a 2^nd physician’s opinion (38.7% vs. 0%, p=0.042) as well as photos of cosmetic results (37% vs. 6.5%, p=0.049) in their decision-making process. There was no difference in age, race, education, insurance type, or income between patients who followed their doctor’s advice versus those who did not (p>0.05). Patients who reported engaging in SDM tended to choose CPM (68.3% vs. 30.8%, p<0.001). The mean SWD score of the entire cohort was 4.80 out of 5.00 (range 3.17-5.00). Patients who did not engage in SDM were similarly satisfied with their decision as those who did engage in SDM (mean SWD score 4.77 vs. 4.83, p=0.286). In terms of patient reported preferences for patient-physician communication, 12 patients (12%) preferred the doctor to provide a recommendation, 7 (7%) preferred to make the decision on their own, and 81 (81%) preferred to engage in SDM. Race, education, insurance type, income, and age did not differ between types of preferred communication strategies (p>0.05).

Conclusion:

When the physician provides an initial recommendation between UM and CPM, patients tend to follow it, while patients who engaged in SDM tend to choose CPM. While most patients state that they prefer to have physicians engage in SDM, patients were equally as satisfied with their surgical decision whether they engaged in SDM or not.

28.10 EphB4 regulates mechanical properties of mouse arteriovenous fistulae

Posted on January 31, 2019

S. Lee¹, K. Brownson¹, R. Khosravi¹, K. Goldstein¹, T. Isaji¹, J. Humphrey¹, A. Dardik¹ ¹Yale University School Of Medicine,New Haven, CT, USA

Introduction:
Veins are typically thin-walled and compliant at low pressures, optimal for their dual roles as conduits for blood returning to the heart and reservoirs for holding most of the blood volume. Surgically connecting a vein to the arterial system as an arteriovenous fistula (AVF) exposes the vein to higher pressure, flow magnitudes and frequencies, triggering a set of molecular pathways that result in venous remodeling, such as dilatation and thickening. Recent work showed that the venous identity marker EphB4 is upregulated and required for the venous remodeling that occurs during AVF maturation. However, it is not known how EphB4 function or fistula creation affects the mechanical properties of veins; we hypothesize that increased EphB4 function during fistula remodeling enhances venous compliance.

Methods:
C57BL/6 wild type (WT) and Ephb4^+/- (heterozygous) mice were treated with sham surgery or abdominal aortocaval fistulae creation via needle puncture (n=4-6 per group). The thoracic IVC were harvested at post-operative day 21 for uniaxial mechanical testing and subsequent histology. Veins were axially stretched to their in vivo length, then cyclically distended from 1 to ~20 mmHg with phosphate buffered saline while simultaneously recording outer diameter with a side-mounted video camera. Compliance was calculated as the change in cross-sectional luminal area per unit pressure. Veins were sectioned at 5 μm with wall (intima-media) thickness measured manually. Statistical analyses were performed with one-way ANOVA, using the Tukey post-hoc test for multiple comparisons.

Results:
WT AVF distended to a greater maximal diameter compared to WT control veins (1290±35μm vs. 986±55μm; p = 0.04). Similarly, Ephb4^+/- AVF distended to a greater diameter compared to Ephb4^+/- control veins (1231±75μm vs. 878±77μm, p = 0.007). At physiologic venous pressures (0-5 mmHg), Ephb4^+/- veins were less compliant than WT veins (<ΔC_WT,EphB4> = -0.05 mm²/mmHg, p = 0.015). Veins became more compliant with fistula creation in both WT (<ΔC_WT,F> = 0.17 mm²/mmHg, p = 0.01) and Ephb4^+/- (<ΔC_EphB4,F> = 0.12 mm²/mmHg, p = 0.006) mice, with Ephb4^+/- fistulae remaining less compliant than WT fistulae (<ΔC_EphB4F,WTF> = 0.1 mm²/mmHg, p = 0.01). Ephb4^+/- veins were significantly thicker than WT veins with (73.2±5.9μm vs 41.9±1.6μm, p = 0.03) or without (81.5±12μm vs 46.3±4.5μm, p = 0.01) fistula creation.

Conclusion:
Although creation of an AVF results in more distensible and circumferentially compliant veins in both WT and Ephb4^+/-mice, veins from Ephb4^+/- mice are thicker and stiffer than veins in WT mice both at baseline and after AVF creation. These results suggest that the structural changes of EphB4-regulated venous remodeling are accompanied by functional changes that support venous adaptation to the fistula environment.

28.05 Rapamycin Improves Adaptive Venous Remodeling and Decreases Arteriovenous Fistula Wall Thickening

Posted on January 31, 2019

A. Fereydooni^1,2, X. Guo^2,3, H. Hu², T. Isaji², N. Nassiri⁴, L. Zhang³, A. Dardik^2,4 ¹Howard Hughes Medical Institute,Chevy Chase, MD, USA ²Vascular Biology And Therapeutics Program,Yale School Of Medicine,NEW HAVEN, CT, USA ³Renji Hospital, Shanghai Jiaotong University,Department Of Vascular Surgery,Shanghai, SHANGHAI, China ⁴Yale University School Of Medicine,Department Of Surgery, Section Of Vascular And Endovascular Surgery,New Haven, CT, USA

Introduction: Arteriovenous fistulae (AVF) continue to be the most common access created for hemodialysis, but up to 50% of AVFs fail to mature, suggesting a need to improve AVF maturation. In a mouse model, Akt1 expression increases during AVF maturation and reduced Akt1 expression in vivo reduces fistula wall thickness and diameter and improves long-term patency. Mammalian target of rapamycin (mTOR) is a key regulatory protein that integrates signals from the Akt pathway to coordinate cell growth and proliferation. We hypothesized that inhibition of the Akt1-mTORC1 axis reduces pathologic venous remodeling that is associated with failure of AVF maturation.

Methods: A C57BL6/J mouse aortocaval fistula model was used (male, 9–12 weeks). Mice were injected with 0 or 100 μg of rapamycin (intraperitoneal) daily. The AVF (venous limb) of control- and rapamycin-injected mice were harvested at days 0, 3, 7 and 21 and for comparison analysis. Post-operative vessel remodeling was assessed using serial ultrasound measurements of the AVF diameter and computer morphometry to measure vessel wall thickness. AVF were compared for leukocyte, M1 and M2 macrophage surface markers and expression level of Akt1 signaling proteins using Western blot and immunofluorescence (IF) intensity.

Results: Rapamycin reduced AVF wall thickness (day 3, 4.4 μm vs 7.6 μm; day 7, 4.7 μm vs 17.8 μm; day 21, 6.2 μm vs 42.2 μm; p<0.01; n=4), without any change in AVF diameter (1-11% reduction in relative diameter; p>0.5 for day 21; n=6). Rapamycin decreased PCNA expression (day 3 and 7, p< 0.05; n=3), but did not increase cleaved caspase-3 expression (day 3, 7, and 21 p>0.05; n=3) in AVF. Deposition of collagen I, collagen III and fibronectin also decreased in AVF of rapamycin-treated mice, compared to control mice (41-63% reduction in IF intensity of all three markers at day 21, p< 0.05 for collagen I and III day 7 and 21; n=4; p< 0.01 for fibronectin day 3, 7 and 21; n=5). Rapamycin treatment was associated with diminished phosphorylation of the mTORC1 pathway: Akt1, 4EBP1 and p70S6K (p<0.001; n=5-7), but not of the mTORC2 pathway: PKC-α and SGK1 (p>0.4; n=4). Both leukocyte CD45+ and macrophage CD68+ protein expression increased in AVF compared to sham-operated vein (days 3, 7 and 21; p<0.05). Macrophage depletion with clodronate liposomes reduced AVF wall thickness compared to control veins (p< 0.01, day 21; n=3). Rapamycin also reduced macrophage CD68+ protein expression as well as both M1 and M2 macrophage activity in AVF (iNOS, TNF-α, IL-10 and CD206, day 7, p<0.04; n=4).

Conclusion: Rapamycin reduces inflammation and wall thickening during AVF maturation through the Akt1-mTORC1 signaling pathway. Rapamycin may be a translational strategy to improve AVF patency.

22.10 Rapamycin Improves Adaptive Venous Remodeling and Decreases Arteriovenous Fistula Wall Thickening

Posted on January 31, 2019

Conclusion: Rapamycin reduces inflammation and wall thickening during AVF maturation through the Akt1-mTORC1 signaling pathway. Rapamycin may be a translational strategy to improve AVF patency.

22.04 Learning from England’s Best Practice Tariff: Process Measure Pay-for-Performance Can Improve Outcomes

Posted on January 31, 2019

C. K. Zogg^1,2,3, D. Metcalfe³, A. Judge⁴, D. C. Perry³, M. L. Costa³, B. J. Gabbe⁵, A. H. Haider² ¹Yale University School Of Medicine,New Haven, CT, USA ²Brigham And Women’s Hospital,Center For Surgery And Public Health,Boston, MA, USA ³University of Oxford,Oxford, United Kingdom ⁴University of Bristol,Bristol, United Kingdom ⁵Monash University,Melbourne, Australia

Introduction: Since passage of the Patient Protection and Affordable Care Act in 2010, Medicare has renewed efforts to improve the quality of older adult health through the introduction of an expanding set of outcome-based readmission and mortality pay-for-performance (P4P) measures. Among trauma patients, potential P4P has met with mixed success given concerns about the heterogeneous nature of patients that trauma providers treat and resultant variations in outcome measures. A novel approach taken by the National Health Service in England could offer a viable alternative plan. The objective of this study was to assess the effectiveness of the 2007-2010 English provider consensus-driven, process measure-based P4P Hip Fracture Best Practice Tariff (BPT) on improving trauma outcomes.

Methods: Quasi-experimental interrupted time-series and difference-in-difference analysis of 2000-2014 death certificate-linked data from England (Hospital Episode Statistics), Scotland (Scottish Morbidity Records), and the United States (100% Medicare all-payer claims). The study compared before-and-after differences in English temporal trends relative to those of Scotland and the US. Outcomes included: 30/90/365-day mortality, readmission, index hospital length of stay, and time to surgery. The study also assessed projections for the number of lives saved and readmissions averted were the BPT to be implemented in Scotland and the US.

Results: A total of 878,860 English, 97,487 Scottish, and 2,994,748 US index fractures were included among adults ≥65y. Following BPT introduction in England, 30-day mortality decreased instantaneously by an absolute value of -2.6 (95%CI -3.5, -1.7) percentage-points and continued to drop by an average of -0.2 (-0.4, -0.1) percentage-points per year (DID-Scotland: -1.6; DID-US: -2.2). 90-day mortality decreased more precipitously, dropping by an absolute value of -5.6 (-7.1, -4.2) percentage-points and an annual average thereafter of -0.2 (-0.5, 0.0) percentage-points per year (DID-Scotland: -1.9; DID-US: -2.9). Similar improvements were observed in readmission (e.g. 30-day ITSA: -1.4 [-2.3, -0.5]), time to surgery, and length of stay. Projections suggest that were the BPT to be implemented in Scotland and the US (Figure), by 2030, as many as 1,377 Scottish and 11,434 US lives could be saved.

Conclusion: In contrast to outcome-based P4P, process measure P4P such as that implemented through the English Hip Fracture BPT could result in significant improvements in outcomes for US patients while remaining more applicable to heterogeneous trauma populations and acceptable to trauma providers. As efforts to improve older adult health continue to increase, there are important lessons to be learned from initiatives like the BPT

20.01 Correlation Between Burnout, Stress, Work-Family Conflict, and Self-Efficacy in Surgical Faculty

Posted on January 31, 2019

M. R. Smeds¹, M. Harlander-Locke², H. K. Sandhu³, S. Allen⁴, K. Amankwah⁵, P. Ansari⁶, K. Charlton-Ouw³, D. Hess⁷, P. Jackson⁸, M. Johnson⁹, M. K. Kimbrough¹⁰, D. Knight¹¹, G. M. Longo¹², B. Shames¹³, J. Shelton¹⁴, P. Yoo¹⁵, M. Smeds¹ ¹Saint Louis University School Of Medicine,Division Of Vascular And Endovascular Surgery,St. Louis, MO, USA ²Lake Erie College of Osteopathic Medicine,Bradenton, FL, USA ³McGovern Medical School at UTHealth,Houston, TX, USA ⁴Penn State Hershey Medical Center,York, PA, USA ⁵State University Of New York Upstate Medical University,Syracuse, NY, USA ⁶Lenox Hill Hospital,New York, NY, USA ⁷Boston University,Boston, MA, USA ⁸Medstar Georgetown University Hospital,Washington, DC, USA ⁹University of South Dakota,Vermillion, SD, USA ¹⁰University of Arkansas for Medical Sciences,Little Rock, AR, USA ¹¹Waterbury Hospital,Waterbury, CT, USA ¹²University Of Nebraska College Of Medicine,Omaha, NE, USA ¹³University of Connecticut School of Medicine,Farmington, CT, USA ¹⁴University Of Iowa,Iowa City, IA, USA ¹⁵Yale University School Of Medicine,New Haven, CT, USA

Introduction:
Burnout is a work-related syndrome involving emotional exhaustion, depersonalization, and a sense of reduced personal accomplishment that has become prevalent in all areas of medicine. We sought to understand factors associated with burnout in surgical faculty including self-efficacy, perceived stress, work-family relationship and depression.

Methods:
Anonymous electronic surveys consisting of demographic information as well as validated scales for burnout, depression, perceived stress, self-efficacy, social support, and work-family conflict were sent to all surgical faculty at 14 general surgery residency programs. Respondents were grouped into quartiles based on burnout level, and predictors of burnout were determined using univariate and multivariate analysis comparing those in the highest quartile to all others.

Results:
Of 731 invitations sent, 240 (33%) surgeons responded. Those in the highest quartile of burnout were younger (45.5 vs. 48.1, p=0.049), more likely to have higher perceived stress (p<0.001), work-family conflict (p<0.001), and moderate or severe depression (p<0.001) and lower perceived social support (p<0.001) and self-efficacy (p<0.001). Amount of educational debt, years out from training, gender, marital status, proximity of immediate family, and having children did not correlate with burnout, nor did work-related factors of frequency of call, number of hospitals covered, percent clinical involvement, number of cases performed per week, attainment of divisional/departmental leadership roles or overall compensation. On multivariate logistic regression analysis, higher perceived stress (OR 1.51, p<0.001), depression (OR 2.730, p=0.004), and work-family conflict (OR 1.2, p=0.012) were related to higher levels of burnout while self-efficacy was protective against burnout (OR 0.89, p=0.046). Those with the highest levels were unlikely to select surgery as a career if they could do it all over again (OR 0.093, p=0.001).

Conclusion:
Burnout in surgical faculty is associated with depression, high perceived stress, increased work-family conflict, and low self-efficacy. Improving work-family balance and self-efficacy and decreasing stress may improve levels of burnout in surgical faculty.

19.20 Measuring Uncertainty Intolerance in Surgical Residents Using Standardized Assessments

Posted on January 31, 2019

L. Ying¹, R. Assi¹, A. Harrington¹, C. Thiessen¹, M. Hubbard¹, G. Nadzam¹ ¹Yale University School Of Medicine,New Haven, CT, USA

Introduction: Due to ambiguities inherent to medical and surgical practice, a physicians’ intolerance for uncertainty (uncertainty intolerance, UI) can significantly impact the quality of their practice and their own mental well-being. Many residency programs, including our own, have introduced new education initiatives aimed at improving UI in our residents. However, currently there is no standard protocol to measure the effectiveness of such interventions, and there are no established methods for identifying the residents who would most benefit from the training. In this study, our goal is two-fold: 1. To validate the use of the Physician Reaction to Uncertainty (PRU) and Physician Risk Attitude (PRA) scales assessments for uncertainty intolerance, and 2. To determine if Myers-Briggs Type Indicator (MBTI) personality factors are associated with PRU and PRA scores and can be used to identify residents who are more likely to have higher UI.

Methods: The PRU and PRA scales, and the MBTI assessment were administered to a total pool of 71 general surgery residents. In addition to the survey questions, residents were asked to provide information regarding their gender (Male or Female), and stage of training (Junior or Senior).

Results: In total, 45 male residents and 25 female residents responded to the survey and completed the PRA and PRU scales (98.6%). There were no statistically significant differences found when comparisons were made between Junior versus Senior residents or Male versus Female residents. 37 male residents and 18 female residents also completed the MBTI assessment (80.4% and 72%, respectively). PRU and PRA scores were analyzed with respect to personality factors to determine if certain dichotomies are associated with increased uncertainty intolerance. Individuals identifying as Perceiving had significantly higher scores in the PRU category of “Concern about Bad Outcomes” (J: 8.76±3.39, P: 10.47±3.08; p<0.05), and on the PRA scale (J: 22.55±3.58, P: 20.71±2.34; p<0.05). Additionally, individuals identifying as Sensing had significantly higher scores on the PRU category of “Reluctance to Disclose Mistakes to Physicians” (S: 4.68±1.36, N: 3.74±2.40; p<0.05).

Conclusion: In this study, we have validated a new assessment for measuring the success of our education initiatives aimed at improving uncertainty tolerance. We found that the PRU and PRA assessments were simple to administer, and had a high completion rate due to buy-in from the residents. We have also demonstrated for the first time that specific personality factors are linked to higher uncertainty intolerance in surgical residents. These results will allow us to better identify residents who would benefit most from uncertainty intolerance training and to monitor their progress.

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