58.10 Social Determinants of Falls: Are falls a disease of poor white females?

Posted on January 31, 2019

K. Sairafian2, C. Towe2,5, L. Brown1,2, L. A. Kreiner1,2, M. Crandall4, E. R. Haut3, V. P. Ho1,2  3Johns Hopkins University School Of Medicine,Baltimore, MD, USA 4University of Florida College of Medicine Jacksonville,Jacksonville, FLORIDA, USA 5University Hospitals,Thoracic And Esophageal Surgery,Cleveland, OHIO, USA 1MetroHealth Medical Center,Cleveland, OH, USA 2Case Western Reserve University School Of Medicine,Cleveland, OH, USA

Introduction:  

Falls are a leading cause of morbidity and mortality in the elderly.  It is unknown if there are racial or other disparities associated with falling. We sought to determine which social and/or demographic variables are associated with falls in the outpatient Medicare population.

Methods:

We examined data from the 2013 Medicare Current Beneficiary Survey Public Use File, a representatively sampled cross-sectional survey.  Fall was defined as at least one self-reported fall in the preceding year.  We performed a logistic regression, adjusted for survey data characteristics, to determine social/demographic factors (age, sex, race, ethnicity, income, education level, and marital status) associated with fall. In these data, patients <65 have more chronic disease than the general population to meet Medicare eligibility. Presence of physical or cognitive limitations were included in the analysis as possible confounders.  Data are presented as percent (± standard error). Adjusted odds ratios are presented with 95% confidence intervals.

Results:

13,924 Medicare beneficiaries, representing 47 million people, were included.  26.6% (±0.4) reported falling. Females, patients <65 or >74, and patients with physical/cognitive limitations were more likely to report a fall (Table).  Minority patients and males had significantly fewer self-reported falls than white patients and females (See Table, p<0.001 for each).  Low income patients (OR 1.17 [1.04-1.33]) were also significantly more likely to report a fall.

Conclusions:

Black and Hispanic Medicare patients are significantly less likely to have reported a fall than white patients. This finding differs from other health-related disparities in which minorities most commonly experience higher risk or more severe diseases.  These data may also represent differences in self-reporting, indicating disparities in self-reported data in these cohorts. Further studies on social factors related to falling are needed in this population.

58.09 Age-Related Microbiome Differences in Surgical Site Infections

Posted on January 31, 2019

R. Khatri2, T. L. Hedrick1, K. A. Popovsky1, R. G. Sawyer1,2  1University Of Virginia,Charlottesville, VA, USA 2Western Michigan University School of Medicine,Kalamazoo, MICHIGAN, USA

Introduction: Surgical site infections (SSI) contribute to overall morbidity and mortality of the surgical patient. There are numerous risk factors for the development of SSI. We propose that there are variations in the type of pathogen in SSI between different age groups.

Methods: We evaluated patients who underwent surgery at a university hospital from 1997 – 2017 that developed SSI. Patients were divided into age-related cohorts, age ≤ 45 years and age ≥65 years. We assessed immune response, disease severity, types of pathogens within wounds, mortality, and antibiotic therapy. Proportions were compared through use of chi square test and continuous variables were compared using Student’s t test.

Results: As compared to patients age ≥65 years who developed SSI (n=575), patients in age group ≤45 years (n=598) had increased leukocytosis (14.2K vs 13.4K, p=0.06), presence of fever (30.8% vs 20.9%, p<0.0001), and Tmax (37.9oC vs 37.6oC, p<0.0001) at time of diagnosis. Of those infections with positive growth on culture, patients age ≥65 years had higher percentage of Enterococcus spp (27.4% vs 17.5%; p=0.006) and P.aeruginosa (15.8% vs 9.6%; p=0.03) as primary wound pathogen as compared to those patients age ≤45 years. In addition, those patients age ≥65 had greater crude mortality rates (10.6% vs 2.7%; p<0.001). Those in age group ≤45 years had longer overall antibiotic treatment length (12.4 days vs 10.3 days, p<0.001) but were more likely to be prescribed oral antibiotics on discharge (51.3% vs 34.4%, p<0.0001).

Conclusion: Our data suggest that those in the older age group have less robust immune response and are colonized with more aggressive pathogens, which may require inpatient treatment with parenteral antibiotics. These findings may help tailor perioperative antibiotic prophylaxis according to age group and most common pathogens, and help prevent or improve overall morbidity from SSI.

 

 

58.08 Management of Blunt Kidney Injuries in Geriatric versus Non-Geriatric Trauma Patients

Posted on January 31, 2019

J. Saluck1,2, M. Crawford2, A. A. Fokin2, A. Tymchak1,2,3, J. Wycech2,3, M. Gomez3, I. Puente1,2,3,4  1Florida Atlantic University,College Of Medicine,Boca Raton, FL, USA 2Delray Medical Center,Trauma Services,Delray Beach, FL, USA 3Broward Health Medical Center,Trauma Services,Fort Lauderdale, FL, USA 4Florida International University,College Of Medicine,Miami, FL, USA

Introduction:
Nonoperative management (NOM) is the standard of care in majority of blunt kidney injuries (BKI). However, little is known about the effect of age on outcomes of NOM. The aim of this study was to assess the efficacy of NOM in BKI in geriatric vs non-geriatric patients.

Methods:
This IRB approved retrospective cohort study included 86 adult patients, admitted to a level 1 trauma center between 2012 and 2017 with computed tomography (CT) confirmed kidney injuries. 49 patients had isolated BKI, 25 BKI with other solid organ injuries, 9 BKI plus hollow viscus injury and 3 BKI plus abdominal vascular injuries. Patients were separated into 2 groups: Group I ≥65 years old (n=21) and Group II <65 years old (n=65). Age, Injury Severity Score (ISS), kidney organ injury scale (OIS) grade, comorbidities, packed red blood cells transfused within 24 hours of admission (PRBC24), rates of hemoperitoneum, angiography, embolization, Intensive Care Unit length of stay (ICULOS), hospital length of stay (HLOS) and mortality were compared.

Results:

Mean age in Group I was 82.2 vs 36.8 years in Group II (p<0.001). The two groups had similar mean ISS (19.0 vs 22.4; p=0.4) and the same mean OIS grade of 2.3 (p=0.8). Group I had statistically more comorbidities than Group II (90.5% vs 60.0%; p=0.01). Main comorbidities in Group I included hypertension, anticoagulation therapy prior to trauma (p<0.001), and cardiovascular disease. Main comorbidities in Group II included hypertension, obesity, and substance abuse.

NOM was attempted in 100% of Group I patients and in 76.9% of Group II patients (p=0.02). The frequency of attempted NOM was lower in Group II due to higher prevalence of other abdominal injuries. For attempted NOM patients in Groups I and II, mean ISS (19.0 vs 18.1, p=0.9) and OIS grade (2.3 vs 2.1, p=0.7) were similar, which adds to the comparability of the groups. Attempted NOM was successful in 100% of Group I patients and in 93.8% of Group II (p=0.3). Of the 3 patients that failed NOM in Group II, 2 patients failed due to a liver injury and 1 patient due to a spleen injury.

For both groups rates of PRBC24 (33.3% vs 41.5%), hemoperitoneum (52.4% vs 61.5%), angiography (9.5% vs 18.5%), embolization (4.8% vs 4.6%), ICULOS (5.9 vs 7.4 days) and HLOS (8.1 vs 10.5 days) were similar (p>0.4). Group I tended to have higher mortality than Group II (19.0% vs 10.8%; p=0.3) but it did not reach statistical significance. Concomitant traumatic brain injury was the leading cause of mortalities in Groups I and II, at 50.0% and 57.1% respectively. None of the mortality in either group was due to the kidney injury.

Conclusion:
Even with more comorbidities, the advanced age was not a contraindication for NOM and did not affect the success of NOM in geriatric patients with BKI. The severity of kidney injury in both age groups was similar and did not affect the frequency of attempted NOM.

58.07 What are the Clinical Outcomes for Damage Control Laparotomy in Patients of Advanced Age?

Posted on January 31, 2019

A. A. Smith1, C. Guidry1, P. McGrew1, J. Friedman1, R. Schroll1, C. McGinness1, J. Duchesne1  1Tulane University,Surgery,New Orleans, LA, USA

Introduction:  Damage Control Laparotomy (DCL) is an integral component in the immediate management of critically ill trauma patients to control hemorrhage and intra-abdominal contamination. Patients of advanced age have less physiologic reserve and an altered response to traumatic injuries when compared to younger patients. As the population in the United States continues to age, the number of DCLs in patients of advanced age will ultimately increase.  There is a paucity of literature on outcomes for older patients managed with DCL. The objective of this study was to provide evidence for outcomes in older population who received DCL for trauma.

Methods:  A retrospective chart review of consecutive adult patients with DCL for abdominal trauma at a Level I trauma center was conducted from 2012-2017. The patients were stratified into two groups, advanced age (AA) for patients 40 years and older and younger age (YA) for patients less than 40 years of age.

Results: A total of 149 patients with DCLs were identified with an average age of 34.0 (range, 19-81 years). In regards to patient demographics, there was no difference in ISS (p=0.16), mechanism (p=0.44), and initial INR (p=1.0). The AA group did, however, have significantly lower ED SBP (p=0.01) and significantly higher initial fibrinogen (p<0.0001). When analyzing outcomes and interventions, AA patients received MTP more frequently (p=0.03). There was a trend toward increased mortality in the AA group (23% vs 11%) when compared to YA group, though this did not reach significance (p=0.08). Of significance, the AA group had an overall shorter time to mortality (4.5+0.4 vs 8.9+1.2 days, p=0.02).

Conclusion: With an aging population, it is likely that the number of DCLs in older patients will increase. AA patients managed with DCL had decreased initial ED SBP with more utilization of MTP resources and overall shorter time to mortality. Future research should emphasize strategies that will develop optimal management and resource utilization of older trauma patients.

 

58.06 Clinical Frailty Scores Predict Re-admission for Fall Following Trauma

Posted on January 31, 2019

V. H. Hatcher1, D. Skeete1, K. S. Romanowski2  1University Of Iowa,Surgery,Iowa City, IA, USA 2University Of California – Davis,Surgery,Sacramento, CA, USA

Introduction: Falls are a significant cause of morbidity and mortality in the elderly. Frailty scales have been developed, but most cannot be utilized in retrospective studies. The Canadian Study of Health and Aging clinical frailty scale (CSHA CFS) is a 7-point clinical opinion scale validated to predict mortality and institutionalization in elderly internal medicine patients. We hypothesize that patients with higher admission frailty will be admitted more frequently with falls post-index admission.

Methods:  Charts of patients ≥50 years of age admitted for traumatic injuries from 2010 to 2015 were reviewed. Demographics, admission data, and injury severity score (ISS) were collected. Frailty scores were calculated using the CSHA CFS. Statistical analyses were performed using R.

Results: Data were collected from 804 patients (70.3 ± 13.4 years), including 380 men (47.2%). Thirty patients (3.73%) died of their injuries. Frailty scores were similar between survivors and those who died. Mean ISS was 9.83 ± 7.92 and not different between frail (CSHA CFS 5-7) and non-frail patients (CSHA CFS 1-4). One hundred and sixteen (14.4%) patients previously presented with falls. Frailty scores of patients with a history of falls were higher than those of their counterparts (4.64 ± 1.0 vs. 3.85 ± 1.13; p < 0.001). Frailty scores of patients who were readmitted with a fall after traumatic injury were higher than those of their counterparts (4.49 ± 0.97 vs. 3.89 ± 1.15; p < 0.001). The number of falls in the year post-admission of frail patients was higher than that of non-frail patients (1.31 ± 0.74 vs. 0.92 ± 0.77; p < 0.001). On multivariate linear regression analysis, CSHA CFS predicted the number of falls in the year post-admission, while controlling for age and ISS (p < 0.001).

Conclusion: Frailty predicts fall readmission post-trauma and number of falls in the year following trauma admission, but does not influence mortality. 

 

58.05 Pre-Injury Cerebral Atrophy in Traumatic Brain Injury Patients Correlates with Decreased Mortality

Posted on January 31, 2019

S. Mansour1,2, A. A. Fokin2, A. Zuviv2, J. Wycech2,3, M. Crawford2, A. Tymchak1,2,3, I. Puente1,2,3,4  1Florida Atlantic University,College Of Medicine,Boca Raton, FL, USA 2Delray Medical Center,Trauma Services,Delray Beach, FL, USA 3Broward Health Medical Center,Trauma Services,Fort Lauderdale, FL, USA 4Florida Atlantic University,College Of Medicine,Boca Raton, FL, USA

Introduction:
Geriatric patients are at increased risk for falling and sustaining traumatic brain injuries (TBI) than their non-geriatric counterparts. It has been shown that elderly patients may have cerebral atrophy that may in turn affect outcomes of intracranial hemorrhage; however this claim has not been studied adequately in TBI patients. We hypothesized that patients with pre-injury cerebral atrophy would have lower morbidity associated with TBI due to increased volume available for hematoma expansion.

Methods:
This IRB approved retrospective cohort study included 346 TBI patients on pre-injury Aspirin, Clopidogrel, or both, between the ages of 17 and 101, who were delivered to a level 1 trauma center between 1/1/2015 and 3/30/2018. Patients were divided into 2 groups: Group A did not have cerebral atrophy (n=148) and Group B had cerebral atrophy documented on computed tomography (CT) reports (n=198). Patients were excluded if they were also on anti-coagulants. Age, Injury Severity score (ISS), Revised Trauma score (RTS), Glasgow Coma score (GCS), Rotterdam CT score (RCT), Marshall CT score (MCT), incidence of intracranial hemorrhage (ICH), midline shift, platelet function and status, platelet transfusion, need for neurosurgical intervention, Intensive Care Unit length of stay (ICULOS), hospital LOS (HLOS), rate of readmission and mortality were compared.

Results:

Between Groups A and B mean values for ISS (12.9 vs 12.3), RTS (7.6 vs 7.7), GCS (14.2 vs 14.3), incidence of ICH (85.5% vs 86.9%), platelet count (215.0 vs 209.8), Platelet Function Assay (PFA)-100 epinephrine (194.7 vs 188.0), PFA-100 adenosine diphosphate (ADP) (127.0 vs 160.0), Thromboelastography Platelet Mapping (TEG-PM) % inhibition ADP (39.4% vs 39.8%), TEG-PM % inhibition of arachidonic acid (60.1% vs 56.6%), Prothrombin Time (11.5 vs 11.0 seconds), Partial Thromboplastin Time (25.7 vs 26.5 seconds), platelet transfusion (37.2% vs 44.1%), neurosurgical intervention (4.7% vs 5.1%), ICULOS (3.5 vs 2.9 days), HLOS (3.8 vs 3.8 days), and readmission rate (5.5% vs 5.1%) were similar (all p>0.07).

Group B compared to Group A had significantly lower RCT (2.7 vs 2.5; p=0.002), MCT (1.2 vs 1.0; p=0.002), midline shift (12.8% vs 3.5%; p=0.001) and mortality (14.2% vs 7.6%; p=0.04) (Fig. 1).

Conclusion:
Cerebral atrophy was associated with less severe damage and lower mortality in head trauma, despite similar injury severity, when compared to patients with no atrophy. Our findings suggest that increased intracranial volume may allow TBI patients to accommodate hematoma expansion, alleviating clinical presentation and reducing the likelihood of adverse outcomes.

58.04 Sarcopenia and Frailty: Similar Yet Distinct Measurements in Geriatric Trauma and Emergency Surgery

Posted on January 31, 2019

H. K. Weiss1, M. Errea2, B. W. Stocker1, N. Weingarten1, K. E. Engelhardt3, B. Cook2, J. A. Posluszny2  1Feinberg School Of Medicine – Northwestern University,Chicago, IL, USA 2Northwestern University,Department Of Surgery,Chicago, IL, USA 3The Medical University of South Carolina,Department Of Surgery,Charleston, SC, USA

Introduction:   The diagnoses of sarcopenia and frailty are often intertwined—both identify less healthy patients with higher complication rates and worse outcomes. However, sarcopenia is a function of muscle density alone, while frailty measurements take into account a multidimensional understanding of frailty, including patient comorbidities, emotional health, nutrition, cognitive and physical function. We hypothesize that sarcopenia and frailty measure different forms of disability. The objective of our study is determine the concordance of sarcopenia and frailty in geriatric trauma and emergency general surgery (TEGS) patients.

Methods:   We reviewed our QI database of geriatric (≥65 year old) TEGS patients.  As part of this project, all geriatrics patients are screened for frailty using the validated TEGS frailty screening tool.  Patients in whom a CT of the abdomen and pelvis was obtained were identified and total psoas index (TPI) (area of right and left psoas muscle at L3/2) was calculated, with lower TPIs signifying sarcopenia.  Patients were then compared for frailty and sarcopenia.

Results:  117 geriatric TEGS patients were screened for frailty.  Of all patients, 78 (67%) had a CT of the abdomen and pelvis.  Of these 78 patients, 22 (28%) were frail.  Mean TPI for all patients was 2.34±0.77.  Mean TPI for non-frail patients was 2.34±0.81 and was 2.33±0.65 for frail patients (p=0.97).  Since 28% of our patients were frail, we then compared patients with the 28% (n=23) lowest TPI for frailty.  Only five (23%) of these patients were frail (p=0.59).  Using the lowest quintile of TPI (15 patients) to define sarcopenia, as is done in other studies, only 3 (20%) of these sarcopenic patients were frail (p=0.53).

Conclusion: Although both sarcopenia and frailty identify patients at higher risk for complications and worse surgical outcomes, sarcopenia does not specifically reflect frailty.  As such, frailty and sarcopenia are not concordant measures of illness. Further study will help elucidate the true relationship between frailty and sarcopenia and the clinical implications of sarcopenia for geriatric TEGS patients.

 

58.02 Frailty Severity Predicts Poor Outcome After First-time Lower Extremity Revascularization

Posted on January 31, 2019

L. Gonzalez1,2, M. Kassem1,2, A. Owora3, S. Cardounell1, M. Monita1, S. Brangman1, V. Gahtan1,2  1State University Of New York Upstate Medical University,Vascular And Endovascular Surgery,Syracuse, NY, USA 2Syracuse VA Medical Center,Surgery,Syracuse, NY, USA 3Syracuse University,Falk College School Of Public Health,Syracuse, NY, USA

Introduction:  Frailty severity is a predictor of poor outcome after vascular surgery. The modified frailty index (mFI) has been validated as a prognostic assessment tool in large scale databases of patients with peripheral arterial disease. Our objectives were to determine the predictive utility of the mFI after first-time lower extremity revascularization and to identify biomarkers of frailty in patients with peripheral arterial disease. Hypotheses: (1) frailty severity is associated with adverse outcome after revascularization and (2) select preoperative data may serve as biomarkers of frailty.

Methods:  A retrospective cohort study was performed of all first-time revascularizations [open surgery (OS) and endovascular surgery (ES)] in male veterans at a single institution (2003-2016). Multivariable logistic and Cox proportional hazard regression models were used to examine the relationship between the mFI and post-operative short-term (30-day morbidity, readmission, and re-intervention) and long-term (up to 2-year incidence of re-intervention, amputation, or mortality) outcomes, respectively. 

Results: 431 patients met inclusion criteria (OS n=188; ES n=243), with a mean age of 66±9 years and median follow up of 16 months. Treatment groups were similar in baseline characteristics, pre-operative lab values, and polypharmacy tallies. Mean mFI was 0.39±0.16 for the OS group and0.38±0.15 for the ES group (p=0.43). 30-day complications (aOR 4.89; 95%CI: 1.67-14.33) and early readmissions (aHR 3.32; 95%CI: 1.16-9.55) were increased in the OS group compared to the ES group. Frailty severity did not predict risk of re-intervention in either group.  Kaplan Meier analysis showed an increased risk of amputation, death, and the composite outcome of amputation and/or death in both treatment groups with increasing frailty when stratified by frailty severity (p<0.005 for all).  Multivariate analysis confirms that frailty independently predicts major amputation (aHR 2.16; 1.06-4.39), mortality (aHR 2.62; 95%CI: 1.17-5.88), and the composite outcome (aHR 1.97; 95%CI: 1.06-3.68) in the cohort as a whole. Hypoalbuminemia is correlated with increased mFI in the ES group (p<0.01), but only showed a trend with mFI in the OS group (p>0.05).  Independent of treatment assignment and preoperative mFI, higher albumin concentration was associated with lower risk of amputation (aHR: 0.58; 95% CI: 0.36 -0.94) and mortality (aHR: 0.45; 95% CI: 0.25-0.83). Higher hemoglobin concentration was also independently predictive of limb salvage (aHR 0.72 95%CI: 0.62-0.84).

Conclusion: Frailty severity is predictive of short- and long-term outcomes after lower extremity revascularization. Hypoalbuminemia and anemia are associated with higher mFI and independently predicted poor outcome after revascularization, suggesting albumin and hemoglobin concentration may serve as true biomarkers of frailty in this population. 
 

58.01 Older Age Increases Mortality And Stroke Risk at One Year After Carotid Revascularization

Posted on January 31, 2019

S. J. Aitken1,2, S. J. Aitken1,2  1Concord Repatriation General Hospital,Institute Academic Surgery (Vascular),Sydney, NEW SOUTH WALES (NSW), Australia 2University Of Sydney,Concord Clinical School,Sydney, NSW, Australia

Introduction:
Cardiac and neurological complications following carotid revascularization have been associated with an increased risk of mortality, especially in older patients. This study reports mortality and stroke following carotid revascularization in Australia, comparing outcomes up to 1 year for those with and without complications within 30days and in younger and older patients.

Methods:
Routinely collected hospital data on all patients in New South Wales (NSW), Australia, were linked to state-wide mortality records. All patients who underwent carotid revascularization (endarterectomy or stenting) between 2010-2012 were selected. Primary outcomes of mortality or stroke were measured at 30days, 90days and 1 year. Secondary outcomes were complications within 30days, length of stay and hospital readmission within 90days. Differences in outcomes between younger (aged less than 75 years old) and older (aged 75 years and older) patients were evaluated. Complications were assessed at 30days, including stroke and major adverse cardiac events (MACE). Outcomes were assessed with multivariable Cox regression and Kaplan Meier survival analysis.

Results:

3008 carotid revascularization procedures were performed between 2010 and 2013; 20% for symptomatic carotid disease (n=598). Carotid endarterectomy was the most common procedure (n=2280, 76%), with 728 patients (24%) having carotid stenting. The median age was 72 years (SD 10), with more males than females having carotid revascularization (M:F ratio 69%:31%).  Mortality at 30days was 0.8% (n=26), 90days 1.4% (n=43) and 1 year 3.9% (n=112). Postoperative stroke occurred in 14 patients at 30days (0.5%), 90days 1.1% (n=32) and 1 year 1.7% (n=52).  17.3% of patients had a major complication within 30days (n=522). Median length of stay was 3 days (IQR 7). 25% of patients (n=754) had a readmission for any cause at 90days. After adjusting for age, gender and procedure type, patients aged 75 years or older were at higher mortality risk than younger patients (HR 2.7, 95%CI 2.2-3.3, P<.0001) at 1 year. After adjusting for age, gender and procedure type, older patients had a higher risk of stroke at 1 year (HR 2.4, 95%CI 1.9-2.8, P<.0001) than younger patients. Stroke risk was also associated with carotid stenting and major complications.   MACE occurring within 30days predicted 1 year stroke (HR 2.1, 95%CI 1.6-2.9, P<.0001) and death (HR 2.0, 95%CI 1.5-2.7, P<.0001). Older patients had a higher incidence of MACE (IRR 1.9, 95%CI 1.4-2.6, P<.0001) and complications (IRR 1.2, 95%CI 1.1-1.4, P.007) within 30days than younger patients.

Conclusion:

Older age increased risk for all adverse outcomes including mortality, stroke, complications, increased length of stay and readmission. Postoperative complications also increased the risk of mortality and stroke at 1 year. Targeted strategies to improve perioperative care in older patients are required to reduce complications associated with postoperative mortality.

38.10 Opioid Prescribing Practices in Pediatric Surgeons: Changing in Response to the Opioid Epidemic?

Posted on January 31, 2019

K. T. Anderson1,7, M. A. Bartz-Kurycki1,7, D. M. Ferguson1,7, M. Raval5,7, D. Wakeman4,7, D. Rothstein6,7, E. Huang2,7, K. Lally1,7, K. Tsao1,7  6University of Buffalo,Pediatric Surgery,Buffalo, NY, USA 1McGovern Medical School at UTHealth and Children’s Memorial Hermann Hospital,Pediatric Surgery,Houston, TX, USA 2University of Tennessee Health Sciences Center, Le Bonheur Children’s Hospital,Pediatric Surgery,Memphis, TN, USA 4University of Rochester School of Medicine and Dentistry,Surgery,Rochester, NY, USA 5Northwestern University, Feinberg School of Medicine,Pediatric Surgery,Chicago, IL, USA 7Pediatric Surgical Research Collaborative,USA, USA, USA

Introduction: The crisis of opioid misuse in the United States has led healthcare providers to re-evaluate their prescribing practices and pain management strategies. This study aimed to describe the perception of pediatric surgeons and their self-reported prescription practices for common general pediatric surgical procedures.

Methods: Pediatric surgeons in the Pediatric Surgical Research Collaborative and one non-member group were surveyed. Respondents were asked about their usual (>50% of the time) practices for pain management perioperatively (during or immediately after surgery) and at discharge in four common pediatric surgery operations: an infant after inguinal hernia repair, a young child after umbilical hernia repair, a school-aged child after laparoscopic appendectomy, and a teenager after laparoscopic cholecystectomy. Descriptive statistics and logistic regression were used for analysis.

Results: There were 171 respondents (61% response rate) with a median of 10 years in practice (IQR 4.5-20). The majority of pediatric surgeons responded that the opioid epidemic is an issue in pediatric surgery (61%), their prescribing practices matter (79%) and that they have changed their opioid prescribing patterns (80%). Almost ¼ of surgeons had witnessed opioid abuse problems in their practice, with 17% reporting treating pediatric patients with opioid abuse problems. Most surgeons prescribed opioids in the treatment of surgical pain perioperatively and at discharge for school age children undergoing a laparoscopic appendectomy or a teenager undergoing laparoscopic cholecystectomy (Table). Opioid prescribing was less common in younger children. Presence or use of a hospital or state prescription monitoring system was not associated with opioid prescribing. Increasing years in practice, however, was associated with greater odds of opioid prescribing at discharge in infants (OR 1.07, 95% CI 1.02-1.12).

Conclusions: Most pediatric surgeons believe that opioid misuse is an important issue and have changed their practices to address it. Nevertheless, a majority of surgeons prescribe opioids to school age and older children after common surgical procedures. 
 

38.09 National Perspective Of Firearm Violence In Pediatric Population: Does The Type Of Firearm Matter?

Posted on January 31, 2019

M. Zeeshan1, M. Hamidi1, A. Tang1, E. Zakaria1, L. Gries1, T. O’Keeffe1, N. Kulvatunyou1, A. Northcutt1, B. Joseph1  1University Of Arizona,Trauma And Acute Care Surgery,Tucson, AZ, USA

Introduction:
Firearm injuries are the second leading cause of death in the US. There is paucity of data regarding firearm injuries in pediatric population. The aim of our study was to assess the prevalence of firearm injuries, the type of firearm used and its impact on mortality in pediatric trauma patients.

Methods:
All patients aged <18 years who were admitted secondary to a firearm injury in the ACS Pediatric-TQIP (2014-16) were included. Data were recorded regarding demographics, ED vitals, injury parameters, intent of injury, type of firearm used and in-hospital mortality. We performed Cochrane Armitage trend analysis and regression analysis.

Results:
We analyzed 123,835 pediatric trauma patients, of which 3221 (2.6%) patients were admitted secondary to a firearm injury. Mean age was 13±4 years, 83.3% were male, and 58% were African-American. A total of 64% patients were shot in an act of violence, 23% had self-inflected injuries while 7.7% patients had accidental injuries. There was no difference in the incidence of violent crimes between males and females. However, accidental injuries were more common in females (30% vs 20%, p=0.01) while self-inflected injuries were more common in males (10% vs 5%, p=0.04). Overall mortality rate was 12.8% (<2y: 21.6%, 2-12y: 11.4% and 13-17y: 10.8%). The number of firearm related admissions (200/10,000 to 300/10,000 trauma admissions, p<0.001) and mortality (10% to 14%, p=0.03) increased over the study period.  The most common weapon used was handgun (45%) followed by machine gun (21%), and shot gun (16%). On sub analysis based on type of firearm, patients who were shot by machine gun were more likely to die (p=0.03) Table 1. On regression analysis, self-inflicted gunshot wounds (OR: 2.7[1.8-3.9]), use of machine gun (OR: 3.1[1.9-5.1]), and head injury (OR: 4.1[3.7-6.5]), were independent predictors of mortality after firearm injuries.

Conclusion:
Firearm injuries are becoming more prevalent among pediatric trauma patients. Handguns are the most commonly used weapon in firearm injuries. Self-inflicted gunshots and use of automatic weapons like machine guns are associated with higher mortality. Injury prevention should focus on men and women equally. Stricter gun laws and a focused national intervention targeting both small and automatic guns may prevent civilian injuries in pediatrics.
 

38.08 Impact of Hydroxyurea Therapy on Surgical Splenectomy Rates in Sickle Cell Disease Patients

Posted on January 31, 2019

M. Verla1, G. Airewele2, C. Style1, H. Sriraman1, O. Olutoye1  1Baylor College of Medicine, Michael E. DeBakey Department of Surgery,Division Of Pediatric Surgery, Texas Children’s Hospital,Houston, TX, USA 2Baylor College Of Medicine,Department Of Pediatrics, Section Of Hematology-Oncology, Texas Children’s Hospital,Houston, TX, USA

Introduction:  Sickle cell disease (SCD) is typically associated with auto-splenectomy from splenic infarction. Surgical splenectomy is performed on those with sequestration crises or hypersplenism. Hydroxyurea therapy decreases the frequency and severity of sickle cell crises and thus the auto-splenectomy associated with sickle cell disease.. The purpose of this study was to determine if hydroxyurea therapy is associated with 1) an increase in the incidence of surgical splenectomy and 2) a later age at surgical splenectomy.

Methods:  We performed a retrospective review of children with SCD who underwent a surgical splenectomy at our children’s hospital between January 1990 and December 2017. Patient demographics, type of SCD, hydroxyurea use, and peri-operative data were collected. Patients were further stratified into two groups, pre-2005 and post-2005, based on the year when hydroxyurea use steadily increased at our institution. Data were analyzed using chi-square analysis and two-way multivariate analysis of variance. A p-value < 0.05 was considered statistically significant.

Results: Over the 27-year period, a total of 2,910 patients with SCD were identified and 125 children had a splenectomy. Of these, 20% (n=21) received hydroxyurea for at least 6 months prior to surgical splenectomy. Splenic sequestration and hypersplenism were the most common indications (96%) for splenectomy at a median age of 5 years (IQR: 2.6 – 9.9). The cumulative incidence of splenectomy was 4.9% pre-2005 versus 3.5% post-2005. Ninety-four children (78%) had HbSS, of whom 18 had hydroxyurea therapy for at least 6 months. Those who had a long-term history of hydroxyurea therapy had a splenectomy at a median age of 6 years (IQR: 3.4–8.9) versus 3 years (IQR: 2.2–6.4) for those who did not have a long-term history of hydroxyurea use (p=0.03, Figure 1). Regardless of the pre- or post-2005 stratification, all HbSS patients on hydroxyurea therapy had their splenectomy at a later age.

Conclusion: Although the incidence of surgical splenectomy does not appear to have increased with the introduction of hydroxyurea therapy, patients receiving hydroxyurea long-term are undergoing surgical splenectomy at an older age.
 

38.07 Pediatric Colorectal Surgery: A Collaborative Approach from a Single Institution

Posted on January 31, 2019

C. Pisano1, I. Sapci1, P. Karam1, M. M. Costedio1, A. L. DeRoss1  1Cleveland Clinic,Digestive Disease Institute/Department Of Pediatric Surgery And Colorectal Surgery,Cleveland, OH, USA

Introduction: Inflammatory bowel diseases (IBD) such as Crohn’s disease and ulcerative colitis are relapsing gastrointestinal disorders commonly presenting in pediatric patients. Due to the chronic nature of these diseases, children with IBD need life-long follow-up, often requiring surgical management. While presenting symptoms are similar, the needs and expectations of treatment may differ between adult and pediatric patients. Patients initially require operations performed by pediatric surgeons, but are then followed by adult colorectal surgeons after the age of 18. The varied age of this population may cause difficulties in surgical management and continuity of care is not always well established. This may create frustration for patients and healthcare providers. There have been models in other fields establishing transitional care from the pediatric to the adult patient. However, there has been little mention of similar efforts in surgery. A collaborative system involving both pediatric and colorectal surgeons may add expertise and improve the overall experiences for pediatric colorectal patients.  We hypothesized that surgeries performed in partnership with both pediatric and adult colorectal surgeons may lead to better outcomes for these patients.

Methods: Data was gathered retrospectively from patients 18 years old or younger who underwent colorectal resections for inflammatory bowel disease between 2010 and 2017 at a single institution. Data included patient demographics (age, gender, BMI, disease, steroid or biologic agent use), type of procedure, surgical approach, specimen extraction site, surgeon involvement (pediatric, colorectal or collaboration), operative time, and estimated blood loss. We analyzed days until passage of flatus and bowel movement, length of stay, type of surgical procedure, and surgical complications.

Results: A total of 117 patients were included in our study. Our data showed that days until flatus (2.27±0.47, p=0.049), first bowel movement (2.64±0.67, p=0.006) and length of stay (4.45±1.51, p=0.006) were the least in collaboration group. Single-incision laparoscopic surgery (SILS), compared to other laparoscopic techniques, was utilized most commonly in collaborative group (77.8% p=0.002). We did not see differences in surgical complication rates when comparing any of the groups.

Conclusion: Our results show improved outcomes in pediatric patients with inflammatory bowel disease when there was collaboration between pediatric and colorectal surgeons in comparison to surgeries performed by pediatric surgeons or adult colorectal surgeons alone. Such structured cooperation may benefit transition of care and other aspects of long-term management in this patient population.

 

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. 

38.05 Practitioner Perceptions Surrounding the Desire of Families to Participate in Fertility Preservation

Posted on January 31, 2019

J. Vaught1,2, K. S. Corkum2,3, C. J. Harris2,3, E. E. Rowell2,3  1Feinberg School Of Medicine – Northwestern University,Chicago, IL, USA 2Ann & Robert H. Lurie Children’s Hospital of Chicago,Pediatric Surgery,Chicago, IL, USA 3Feinberg School Of Medicine – Northwestern University,Surgery,Chicago, IL, USA

Introduction:

With increasing survival of childhood cancer patients, the long-term consequences of medical therapy, including impaired fertility from gonadotoxic therapy, have become an important consideration in a child’s treatment plan. Given this concern, there is growing interest in fertility preservation (FP) consultation for high-risk patients, yet referral can be inconsistent even in centers with a FP program. This study aimed to assess practitioner perceptions surrounding families’ interest in FP and the desire of parents to discuss FP if their child was deemed to be at significant risk of infertility from their planned therapy.

Methods:

A survey was administered to parents of non-oncology patients and practitioners across all medical and surgical subspecialties. Parent surveys were administered in outpatient clinics; and practitioner surveys were distributed via email. Questions focused on demographics, family history and FP, specifically related to willingness to participate, cost and attitudes toward the consultation.  

Results:

A total of 164 practitioners (95.9%) and 101 parents (96.2%) completed the full survey. Compared to practitioners, parents were younger (44 years vs. 37 years, p<0.001), non-white (79.5% vs. 51.4%, p<0.001), single parents (6.2% vs. 18.1%, p<0.001) and had a total household income less than $131,201 (11.8% vs. 68.6%, p<0.001). There was no difference between parents and practitioner’s perceived parent willingness to participate in FP (90.7% vs. 96.8%, p=0.07). Practitioners grossly overestimated the amount of distress having a FP discussion would cause parents (77.5% vs. 32.7%, p<0.001) and underestimated the parent’s feeling of hope provided by a FP discussion (67.1% vs. 84.7%, p<0.001). Practitioners significantly underestimated a parent’s willingness to pay for FP (median [IQR] $500 [200-1000] vs. $1000 [300-5000] per year, p=0.03). In consultation, practitioners incorrectly perceived that parents would want to learn about infertility risk from a third party fertility preservation consultant (62.6% vs. 39%, p<0.001), when in fact parents preferred discussion with their pediatrician (14.6% vs. 45.7%, p<0.001) or oncologist (73.1% vs. 64.8%, p=0.183).

Conclusion: 

Parents feel less distress and more hope with an FP consultation than practitioners perceived. Moreover, they are willing to pay more for these services than presumed. These misperceptions could hinder referral for FP consultation and suggest that a standardized process for evaluating infertility risk may best serve patients and families.

38.04 Decolonization Protocols Do Not Decrease Recurrence of MRSA Abscesses in Pediatric Patients

Posted on January 31, 2019

S. T. Papastefan1,3, C. T. Buonpane1,2, G. Ares1,2,3, B. Benyamen1, I. Helenowski1,2, C. J. Hunter1,2  1Ann & Robert H. Lurie Children’s Hospital of Chicago,Pediatric Surgery,Chicago, IL, USA 2Feinberg School Of Medicine – Northwestern University,Surgery,Chicago, IL, USA 3University Of Illinois At Chicago,Surgery,Chicago, IL, USA

Introduction: Methicillin-resistant staphylococcus aureus (MRSA) nasal colonization is associated with the development of future skin and soft tissue infection in children. While MRSA decolonization protocols are effective in eradicating MRSA colonization, they have not been shown to prevent recurrent MRSA infections. This study analyzed the prescription of decolonization protocols, rates of MRSA abscess recurrence, and factors associated with recurrence.  We hypothesized that decolonization would decrease MRSA abscess recurrences after incision and drainage. 

 

Methods: This study is a single institution retrospective review of patients ≤ 18 years of age diagnosed with MRSA culture-positive abscesses who underwent incision and drainage from January 2007 to December 2017 at a tertiary care children’s hospital. The primary outcome was MRSA abscess recurrence. MRSA decolonization protocols (for the patient and all family members) included daily mupirocin nasal ointment and sodium hypochlorite baths or chlorhexidine towel washes two to three times per week for two weeks.

 

Results: Three hundred ninety-nine patients with MRSA culture-positive abscesses who underwent incision and drainage were identified. Mean age was 3.44 ± 4.45 years, 45% were male and 94.5% had community acquired MRSA infections.  119 (29.8%) patients were prescribed the MRSA decolonization protocol. Patients with prior history of abscesses or cellulitis (32% vs 17%, p=0.002), prior MRSA infection (17.6% vs 4.6%, p<0.0001), groin/genital region abscesses (30% vs 18%, p=0.01), and incision and drainage by a pediatric surgeon (34.0% vs. 10.0%, p<0.0001) were more likely to be prescribed decolonization. Additionally, patients with a higher number of family members with a history of abscess/cellulitis (0.45 vs. 0.20, p<0.0001) or MRSA infection (0.27 vs 0.05, p<0.0001) were more likely to be prescribed decolonization. 62 patients (15.6%) had a MRSA abscess recurrence. Decolonized patients did not have lower rates of recurrence (18.5% vs 14.3%, p=0.29).  Recurrence was more likely to occur in patients with prior abscesses (p=0.004), prior MRSA infection (p=0.04), family history of abscesses (p=0.002), family history of MRSA infection (p=0.0003), Hispanic ethnicity (p=0.018), and those with fever on admission (p=0.047). In a subgroup analysis of patients with these significant risk factors, decolonization did not decrease the rate of recurrence. 

 

Conclusion: Contrary to our hypothesis, MRSA decolonization did not decrease the rate of recurrence of MRSA abscesses in our patient cohort. We found significant variability in decolonization prescription between practitioners. Patients at high risk for MRSA recurrence such as personal or family history of abscess or MRSA infection, Hispanic ethnicity, or fever on admission did not benefit from decolonization. Future study of methods to reduce recurrence in patients at high risk are indicated.

38.03 Optimal Predictor of Gonadal Viability in Testicular Torsion: Time to Treat vs Duration of Symptoms

Posted on January 31, 2019

O. A. Morin1, M. G. Carr1, S. D. Bhattacharya1  1University of Tennessee Chattanooga,General Surgery,Chattanooga, TN, USA

Introduction:  Little published evidence has been presented that drastically minimizing the “time-to-treat” in testicular torsion results in fewer orchiectomies. However, the current ACS NSQIP benchmark is a time-to-treat <2h. Duration of symptoms (DoS) may serve as a more accurate predictor. We evaluated testicular salvage rates based on patient presentation with <24h versus >24h total DoS. We hypothesize that time-to-treat has little impact on testicular salvage rates and patients’ DoS better correlates with predicting testicular viability. 

Methods:  Medical records of all male pediatric patients treated for suspected diagnosis of testicular torsion in the emergency department from January 1, 2016 to September 30, 2017 were retrospectively evaluated. Twenty-three patients met inclusion criteria. Statistical analysis compared testicular viability based on both time-to-treat, DoS, and patients originating in our system versus transfers from outside hospitals.

Results:

Testicular salvage rates for patients presenting directly to the ED was 50% with an average time-to-treat of 2.6h. Testicular salvage rates in patients transferred from an outside ED was 88.9% with an average time-to-treat of 5.1h. Overall testicular survival was not statistically impacted by decreasing the time-to-treat by an average of 3h (p<0.189).

When comparing DoS, a 77.8% testicular salvage rate (DoS <24 hours) versus a 16% salvage rate (DoS >24 hours) was shown in patients presenting directly to the ED (p<0.041). Within the total population (N=23), a significant difference was shown (p<0.023) when comparing overall testicular salvage rates in patients presenting with <24h versus >24h total DoS.

Conclusion: In this case series, it appears that a better predictor of ultimate outcomes and increased testicular salvage rates is a duration of symptoms <24h rather than a shortened time-to-treat. This is a meaningful metric when providing accurate pre-operative counselling to parents and may better focus quality improvement efforts surrounding this topic. 

38.02 Household Chronic Opioid Use Increases Risk of Persistent Opioid Use after Surgery among Teens

Posted on January 31, 2019

C. M. Harbaugh1,5, J. S. Lee1, K. Chua3,6, B. Kenney5, T. J. Iwashyna2,5, M. J. Englesbe1,5, C. M. Brummett5,7, A. S. Bohnert4,5, J. F. Waljee1,5  1University Of Michigan,Department Of Surgery,Ann Arbor, MI, USA 2University Of Michigan,Department Of Internal Medicine, Division Of Pulmonary Critical Care Medicine,Ann Arbor, MI, USA 3University Of Michigan,Department Of Pediatrics And Communicable Diseases,Ann Arbor, MI, USA 4University Of Michigan,Department Of Psychiatry,Ann Arbor, MI, USA 5University Of Michigan,Institute For Healthcare Policy And Innovation,Ann Arbor, MI, USA 6University Of Michigan,Child’s Health Evaluation And Research Center,Ann Arbor, MI, USA 7University Of Michigan,Department Of Anesthesia, Division Of Pain Medicine,Ann Arbor, MI, USA

Introduction:  Opioid-naïve teens prescribed opioids after surgery have a substantial risk of developing prolonged opioid use. Prior work has shown that this risk is associated with individual-level factors such as mental health disorders and prior substance use. It is unknown whether the risk of persistent use varies with exposure to chronic opioid use among family members.

Methods:  We performed a retrospective analysis of 2010-2016 Truven MarketScan Commercial Claims including opioid-naïve patients aged 13–21 years who had surgery without subsequent procedure or anesthesia, perioperative opioid prescription, and dependent status with ≥1 family member on the same insurance plan (N=257,550). The dependent variable was new persistent opioid use (NPOU, ≥1 prescription 91–180 days after surgery). The main independent variable was household chronic opioid use (≥120 days or ≥3 prescriptions within 90 days in the year before surgery among any family member). We used generalized estimating equations with robust standard errors at the family level to model NPOU as a function of household chronic use, controlling for patient demographics; patient mental health and chronic pain conditions; and household mental health and chronic pain conditions. Sensitivity analysis evaluated the association with the number of adult (primary insurance holder/spouse) and youth (other dependent) family members with chronic opioid use. Average marginal effect for the primary outcome was calculated using observed values.

Results: In this cohort, 4.3% of patients (11,087) have a household member with chronic opioid use with an unadjusted NPOU rate of 2.5% overall. Patients and family members with household chronic opioid use were more likely to have chronic pain, mental health, and opioid use disorders compared to families without any chronic opioid use. The adjusted odds of NPOU were 57% higher among patients with any household chronic use (aOR 1.57, 95% CI 1.42 – 1.74). The adjusted rate of NPOU was 2.4% for patients with no household chronic use compared to 4.1% for patients with household chronic use (Figure). On sensitivity analysis, NPOU was significantly associated with chronic opioid use among adults in a dose-dependent manner (one adult: aOR 1.55, 95% CI 1.40 – 1.72; two adults: aOR 1.63, 95% CI 1.12 – 2.37), but not other youth (aOR 1.49, 95% CI 0.89 – 2.49). 

Conclusion: The risk of persistent opioid use after surgery was significantly higher among adolescents who had family members with chronic opioid use. This suggests that household opioid use patterns should be assessed to determine which patients might require closer monitoring and heightened anticipatory guidance when opioids are prescribed.

 

15.20 The Limited Role of Ultrasound in the Assessment of Solid Pediatric Breast Lesions

Posted on January 31, 2019

C. J. Granger2, E. L. Ryon3, A. R. Hogan1, H. L. Neville1, C. M. Thorson1, E. A. Perez1, J. E. Sola1, A. Brady1  1University Of Miami,Division Of Pediatric And Adolescent Surgery/Department Of Surgery/Miller School Of Meidcine,Miami, FL, USA 2University of Miami,Leonard M. Miller School Of Medicine,Miami, FL, USA 3University of Miami,Division Of Surgical Oncology/Department Of Surgery/Miller School Of Medicine,Miami, FL, USA

Introduction: Ultrasound (US) imaging is an adjunct to clinical exam (CE) in the assessment of pediatric breast lesions.  We sought to investigate the accuracy of CE and US in determining maximum diameter (Ø) of breast lesions versus final pathology (P).

 

Methods: A single institutional retrospective analysis of patients < 25 years of age who underwent breast mass resection (CPT 19120, 19301) from Feb 2011 to Sept 2015 was performed.  Data was collected and analyzed using SPSS.  

 

Results: 67 patients underwent breast resection with a mean age of 16 ± 2 years.  The mean PØ (MPØ) for all lesions was 4.2 ± 2.7 cm.  Lesions encountered were fibroadenoma (88%, MPØ 3.8  ± 1.8 cm), juvenile fibroadenoma (7.5%, MPØ 8.1 ± 6.8 cm), low-grade phyllodes sarcoma (3%, MPØ 7.5 ± 3.5 cm), and fibrous hamartoma of infancy (1%, the only male patient).  51% of lesions were right sided, 37% were left sided, and 12% were bilateral.  34% of patients had no surgical indication documented.   Documented indications included: 28=increasing size, 11=mastodynia, 8=large size, 1=malignant US findings, and 1=recommended by primary physician. 13% of patients developed recurrent and/or new lesions.  The complications from surgery included: 3=mastodynia, 2=seromas, 3=local skin reactions, and 1=numbness.  Of the two patients with low-grade phyllodes sarcoma, one was lost to follow-up and the other underwent re-excision for a positive margin.

50 patients had documented CE measurements while 48 patients underwent US imaging.  Of these, 28 patients had both CE and US measurements and were included in the sub-group analysis.  Both groups were normally distributed by Shapiro-Wilk’s test (p=0.107 for CEØ; p=0.373 for USØ). Paired t-test comparing PØ to CEØ found the groups to be the same with an underestimation on CE of 0.4 ± 1.2 cm, p=0.87. When comparing PØ to USØ there was a statistically significant underestimation on US of 0.6 ± 1.2 cm, p=0.01.  The difference between CEØ and USØ was not statistically significant (0.2 ± 0.8 cm, p=0.227).  

 

Conclusion: In this single institutional retrospective study, CE estimates were equivalent to final P, while US significantly underestimated the size of breast lesions. The underestimation in each case was between 0.4 cm for CE and 0.6 cm for US which is likely not clinically significant and possibly biased by time to surgery.  Nevertheless, given the accuracy of CE, the utility of US in measurement of pediatric breast lesions is limited and should be individualized. 

15.19 Methotrexate Use In Patients With Granulomatous Mastitis

Posted on January 31, 2019

B. Caballero2, J. Sugandi1,2, R. K. Viscusi1,2  1Banner- University of Arizona,Department Of Surgery,Tucson, AZ, USA 2University Of Arizona,College Of Medicine,Tucson, AZ, USA

Introduction:  Granulomatous mastitis (GM) is a rare, benign, chronic inflammatory disease of the breast that usually affects women of child bearing age. The most common clinical symptoms are a palpable breast mass associated with overlying erythema, induration, pain or drainage. Imaging is non-specific and histopathology is needed for confirmative diagnosis. The etiology is unclear, but an autoimmune reaction is favored and it has been linked to prior contraceptive use, a history of pregnancy and breastfeeding. Given the limited knowledge of etiology, initial treatment of this benign, yet locally aggressive disease remains controversial. Observation alone, antibiotics, surgical excision, steroids alone, and immunosuppressive agents have all been described in the literature. There is no consensus on treatment but knowing GM is generally a self-limited disease and surgery can be associated with poor cosmetic outcomes, a non-invasive alternative such as methotrexate (MTX) is a viable option. 

Methods:  A retrospective chart review of patients with histologically confirmed GM between January 2013 and December 2017 was analyzed to identify response to MTX treatment. Eight adult female patients, age range 29-57, were diagnosed with GM via excisional or core breast biopsy. Methotrexate treatment was planned for all 8 patients with confirmed GM. Liver function tests and a full blood count were evaluated during treatment course. Treatment protocol included MTX administered at 2.5-10 mg orally together with folic acid in one dose, once a week. 

 

Results: On physical exam, a palpable breast mass was detected on 8 patients. All patients underwent ultrasound examination and after diagnosis of GM was confirmed, MTX + folic acid treatment was initiated. Treatment was administered for 3-15 months. One patient discontinued MTX due to plans to conceive. None of the patients developed complications from MTX and no recurrence was observed during follow up periods. Patients noted relief of symptoms including, erythema, breast tenderness and nipple discharge following 30-60 days of MTX treatment. 

Conclusion: Evidence in most literature has shown most patients with GM have a troublesome course of recurrence. There is no consensus on treatment but non-invasive alternatives such as steroids and methotrexate are good options. More cases using methotrexate alone or in combination with corticosteroids are needed to confirm those results. Ultimately, treatment depends on the size of the lesions and symptom severity. Prompt diagnosis and treatment with methotrexate can often treat the disease or provide symptomatic improvement without subjecting patients to multiple trials of medications that could pose risks of adverse effects. 
 

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