07.12 Clinical Acuity Shorthand System (CLASS) for Surgery: A Standardized Patient Classification Tool

Posted on January 18, 2016

B. F. Gilmore1, A. K. Brys2, N. S. Nath2, K. L. Rialon1, M. E. Barfield1, G. Pomann3, L. Ding3, J. Migaly1, P. J. Mosca1 1Duke University Medical Center,Department Of Surgery,Durham, NC, USA 2Duke University School Of Medicine,Durham, NC, USA 3Duke University,Department Of Bioinformatics And Biostatistics,Durham, NC, USA

Introduction:
The handoff of medical information from one provider to another can be inefficient and error-prone, potentially undermining patient safety. Though several tools for structuring handoffs exist, none provide a concise, standardized framework for ensuring that patient acuity is efficiently and reliably communicated. This prompted the development of a novel tool, the Clinical Acuity Shorthand System (CLASS) for Surgery. This is a patient classification system that incorporates the acuity and severity of illness, phase of care, and key comorbidities into a score that can be used during transitions of care to summarize the overall wellness of the patient and convey the need for additional interventions.

Methods:
Surgical trainees at a single center were asked to complete a voluntary, anonymous exam in which a novel patient classification system would be applied to 10 theoretical patient scenarios. Responses were scored on the accuracy of classification compared to target answers. Performance was evaluated overall and between groups of trainees; time required to complete the examination was also measured. Following completion of this exercise, respondents were surveyed regarding perceived utility of the system with regard to preventing medical errors and improving efficiency.

Results:
The study task was completed by 17 participants. Mean time from first exposure to the system to completion of the application task was 10.3 ± 8.4 minutes. Interns and junior residents were able to apply the system with comparable accuracy, and in fact exceeded the accuracy of senior residents. Most respondents indicated that such a system would be feasible to institute and could prevent medical errors arising from communication breakdowns.

Conclusion:
CLASS is a novel classification system that can be learned quickly and implemented readily by trainees, and can be used to convey key patient information concisely and with acceptable fidelity regardless of level of training. Further studies are necessary to determine whether CLASS has the potential to decrease the rate of communication-related medical errors during handoff.

07.08 ACGME Duty Hour Reforms Do Not Impact Outcomes in General and Vascular Surgical Patients

Posted on January 18, 2016

N. Tehrani1, S. Wetzel1, M. John1, H. Sanfey1, S. Desai1 1Southern Illinois University School Of Medicine,Springfield, IL, USA

Introduction:

Outcomes associated with the 2003 and 2011 Accreditation Council for Graduate Medical Education (ACGME) duty hour reforms have not been evaluated for patients undergoing index general and vascular surgical procedures. The aim of this study was to evaluate the association between the 2003 and 2011 ACGME duty hour reforms with operative complications, length of stay, mortality, and cost of care. The association between month of the year and outcomes was also evaluated.

Methods:

The 1998-2012 National Inpatient Sample (NIS) was used to identify patients with acute cholecystitis who underwent laparoscopic cholecystectomy, unruptured abdominal aortic aneurysm (AAA) who underwent open repair, or right-sided colon cancer who underwent open right hemicolectomy (RHC). Only teaching hospitals were included in the sample. Patients transferred from another institution, emergency cases, and ruptured AAA were excluded. Control charts and special cause variation were utilized to identify variance in outcomes of over three standard deviations by month and year.

Results:

A total of 15,762 patients underwent laparoscopic cholecystectomy, 23,840 underwent open AAA, and 20,255 underwent RHC over the study period. The overall rate of operative complications decreased in the post-2011 duty hour reform period compared to the post-2003 and pre-duty hour reform periods (P<0.05). LOS also decreased for laparoscopic cholecystectomy and RHC (P<0.05), and also decreased for open AAA once a risk-adjusted analysis was completed (P<0.05). Inpatient mortality and cost of care were not significantly different between the various years for each surgical procedure. Special cause variations of over three standard deviations were not related to either ACGME duty hour reforms or month of the year.

Conclusion:

While there was a decrease in the rate of complications and LOS over time, there was not an association with the institution of ACGME duty hour reforms in either 2003 or 2011, indicating that these changes likely happened for other reasons (i.e. improvement in quality of care, refinement of surgical procedures, etc.). There is also no association between month of the year and patient outcomes, indicating that any positive or negative impact upon patients of interns starting their training is negligible.

07.09 Outpatient Infusion Protocol Decreases Readmission Rates in Post-operative Bariatric Patients

Posted on January 18, 2016

J. L. Salluzzo1, J. Moore2, L. Burke2, K. E. Roberts1, G. Nadzam1, A. J. Duffy1 1Yale University School Of Medicine,Gastrointestinal Surgery,New Haven, CT, USA 2Yale New Haven Hospital,Gastrointestinal Surgery,New Haven, CT, USA

Introduction:

Readmission for dehydration is a common complication of bariatric surgery. Preoperative patient education and postoperative diet plans in bariatric surgery centers emphasize strategies to optimize postoperative oral hydration. Despite this, the Metabolic and Bariatric Surgery Quality Improvement Program (MBSAQIP) national database notes readmission rates for dehydration 1.3% and 1% for Laparoscopic Roux-en-y Gastric Bypass(LRYGB), and 1.7% and 1.3% for Laparoscopic Sleeve Gastrectomy(LSG) for 2013 and 2014, respectively. Dehydration after bariatric surgery is a patient safety issue. In addition to clinical concerns, dehydration and associated inpatient medical costs present a financial burden to hospitals.

We identified dehydration readmissions as a potentially reducible complication in our institution. In 2014, we initiated a quality improvement project to develop an outpatient rehydration protocol at an infusion center.

In addition to standard post-operative follow-up, at-risk patients are identified via routine post-discharge phone calls from bariatric inpatient nurses. The patients are asked screening questions regarding hydration status and oral intake. Patients are then evaluated by bariatric practice APRN. Clinically stable dehydrated patients undergo same day lab work and outpatient fluid resuscitation. A post-infusion evaluation is performed. The patient is followed as an outpatient or admitted to the hospital, as appropriate. We hypothesized that implementation of an outpatient infusion protocol would decrease hospital readmissions related to dehydration in post-bariatric surgical patients.

Methods:

Retrospective review of patients who underwent LSG and LRYGB at an academic teaching hospital in 2013 and 2014 who presented with dehydration. The number of readmissions for dehydration in 2013 (pre protocol) and 2014 (post protocol) was determined, as was the number of patients managed via the infusion center. These data are compared to MBSAQIP national data.

Results:

In 2013, 3.0% of LRYGB (5 of 164) patients and 2.4% of LSG (5 of 212) patients required readmission for dehydration (2.6% overall). After implementation of the infusion center in 2014, 13 patients were identified in screening: 2 were readmitted directly, on protocol, 11 patients were referred for infusions; 7 were managed as outpatients, 4 were readmitted. 0.9% of LRYGB (1 of 110) patients and 1.7% of LSG (5 of 303) patients required readmission (1.45% overall).

Conclusion:

Implementation of a coordinated outpatient rehydration protocol for post-bariatric surgical patients reduced the readmissions at our institution by 40% (44% rate reduction). These rates of readmission compares favorably to national risk-adjusted MBSAQIP benchmarks. We anticipate institutional cost savings from adoption of this protocol.

07.10 Missed Opportunities for Intervention Prior to Fall in Elderly Patients

Posted on January 18, 2016

C. D. Minifee1,2, C. E. Wade1,2,3, J. Holcomb1,2,3, S. D. Adams1,2,3 1Center For Translational Injury Research,Houston, TEXAS, USA 2University Of Texas Health Science Center At Houston,Houston, TX, USA 3Memorial Hermann Hospital,Trauma Surgery,Houston, TX, USA

Introduction: Approximately 33% of elderly people (aged ≥ 65 years) experience a fall each year. With the rapidly aging population, the incidence of injury from ground level falls has surpassed that for motor vehicle crashes. Although most falls cause minor injuries, 20-30% are severe resulting in significant physical impairment, and elderly hospitalized for severe fall-related injuries have a 50% mortality rate. Many health and environmental factors contribute to fall risk in the elderly, however the most predictive risk factor is a prior fall. The CDC has emphasized the importance of injury prevention through identification of risk and intervention. In patients with severe injuries due to a fall, we determined the incidence of fall assessment and prevention during previous hospital encounters.

Methods: We performed a retrospective review of adult (≥65 years of age) trauma patients with severe injury (any AIS ≥ 3) admitted to our Level I center after a ground-level fall in 2014. We reviewed inpatient and clinic records to identify patients with previous admissions to our hospital, and recorded fall risk assessments and prevention efforts.

Results: Of 5448 admissions, 214 patients met the inclusion criteria. The median age was 79 (65-98), and 47% were male with an average ISS of 21 (16-42) and mortality 22%. After chart review, previous admissions were found in 39 (18%), most within 10 years. All 2014 admissions were for severe head injury (AIS > 3) and had a median length of stay of 6 days. Median age was 80 (65-98), 54% were male, and the average ISS was 22 with mortality of 10%. The 39 patients had a total of 66 prior encounters, an average of 1.7 per patient. Prior admissions were for injuries (fall, MVC, stroke) and medical illness (cardiac, cancer, infection). Fall education or intervention was not documented in 68% of the patient encounters and in 4 of the 12 patients with a known history of falls.

Conclusion: As people age, physiological changes and illness affect gate and balance, increasing the risk for falls. Patients with falls are known to be at highest risk for subsequent falls, and potentially fatal injury. We have demonstrated that our institution only documented appropriate risk identification and intervention in 46% of high risk patients. Many elderly patients presenting with a major fall-related injury had not received appropriate intervention during previous encounters, which demonstrates a missed opportunity for injury prevention.

07.06 Defect Reduction And Quality Improvement Through Lean Management Of Rigid Endoscopy Equipment

Posted on January 18, 2016

W. Stehr1, E. K. Sinclair2 1UCSF Benioff Children’s Hospital Oakland,Division Of Pediatric Surgery,Oakland, CA, USA 2UCSF Benioff Children’s Hospital Oakland,Quality Built In,Oakland, CA, USA

Introduction: Rigid bronchoscopy and rigid esophagoscopy for removal of foreign bodies, are delicate and often emergent procedures. The equipment needed for these procedures is complex and very much dependent on the size of the patients. Many hospitals encounter challenges related to the management, maintenance and emergent assembly of this equipment. For the past 30 years this equipment at our Children’s Hospital was maintained in an ‘endoscopy cart’ with 6 drawers. Similar items like lenses or graspers were collocated in the same drawer. This system was prone to problems, as the instruments in the drawers were difficult to manage. The cart was located outside of the Sterile Processing Department (SPD), which led to a lot of variability and required additional operators for maintenance. It was our goal to create a safer and more standardized way of maintaining this equipment using the Toyota Lean management principles.

Methods: As a surrogate measure of motion and possible breakage, we measured the number of drawers that needed to be opened and how many lenses and instruments needed to be touched for a setup. We also measured whether the operating room (OR) technician was able to produce a functioning setup for a patient of a certain age and weight, and the time to completion of the setup. We then performed a 2 day workshop including surgeons, staff from OR and SPD, following the Toyota Lean principles and subsequently repeated the measurements.

Results: We performed (n=7) pre-workshop measures. These showed averages of 9.7 drawers opened, 4.6 lenses touched, 9.7 instruments touched, and a time to setup of 325 seconds. None of the setups were functional. After observation of the process the system was changed to a mobile open-shelf system containing patient-age specific instrument trays. The age groups (0-6 months; over 6 months) were chosen based on our utilization over the past 2 years. Matching sizes of lenses, scopes and graspers were color labeled and collocated in the trays. Immediately after the improvement workshop, different OR technicians produced the following numbers: For a complete setup 0 drawers needed to be opened, 2 lenses touched, 4 instruments touched, and average time to setup was reduced to 105 seconds. All setups were functional. These improvements have been sustained for 2 years.

Conclusion: Despite initial hesitancy to change an established but broken system, this improvement work was made possible through engagement of the key stakeholders. We applied Toyota Lean principles (visual management, kit building, less over processing and elimination of waste) to mistake proof the management and assembly of this delicate and high-risk endoscopy equipment. Our work lead to a 3fold reduction of setup time and 100% improvement of defect free equipment assembly. The new tray system requires less time for management and setup and has reduced the defect rate, even by less experienced operators, to near zero.

07.07 Improving Quality Improvement Knowledge and Engagement Through Mentorship

Posted on January 18, 2016

R. L. Hoffman1, R. R. Kelz1 1Hospital Of The University Of Pennsylvania,Philadelphia, PA, USA

Introduction: Multiple competing priorities make integrating busy surgical residents into quality improvement (QI) activities very difficult. We sought to create a mentorship program in order to create a bi-directional forum for increasing QI awareness and knowledge and to facilitate a culture of continuous quality improvement.

Methods: At the start of the 2014 academic year, a natural experiment in quality education was performed. Each PGY1 categorical surgical resident in a large university-based academic program was paired with a faculty mentor who was also a representative to a unit-based clinical leadership (UBCL) team. The ACS NSQIP QITI Practical QI Curriculum was distributed to both faculty and residents and participation in QI activities was encouraged, however no additional didactics were given. A 15-point surgery-specific modified QI-Knowledge Application Tool was administered at the start and end of the year. Informal feedback on participation in QI activities was also solicited.

Results: On average, the 7 pairs met four times over a 9 month period. Fourteen participants completed the pre-program knowledge test, 10 completed the post-test. There was significant improvement over the time period (mean pre: 10.4 (2.6), post: 12.2 (1.3) p<0.05). Mentors had a higher mean pre-program score (11.3) than residents (9.4, p=0.2), but residents had higher mean post-program scores (12.6 vs 11.8, p=0.4). All participants demonstrated an improved understanding of the importance of risk-adjustment in benchmarking (57% pre, 100% post). Participant responses illustrated the fundamental need for data in the QI process, but lacked a practical understand of discrete data sources. Five of 7 residents attended UBCL meetings and had QI projects in development. Surgical trainees reported difficulty with consistent attendance at UBCL meetings given constraints on time.

Conclusion: Involvement of resident and faculty pairs has a tremendous potential to influence the development of a sustainable culture of quality within a program. By facilitating faculty-resident mentorship with a QI focus, knowledge for both parties improves, and clinically active residents can be successfully incorporated into the QI structure. Next steps will focus on building a didactic component to enhance delivery of the curriculum and validation of the assessment tool.

07.02 Are We Missing the Near Misses in the Operating Room?

Posted on January 18, 2016

E. C. Hamilton1,2, D. H. Pham1, A. N. Minzenmayer1, L. S. Kao3, K. P. Lally1,2, K. Tsao1,2, A. L. Kawaguchi1,2 1University Of Texas Health Science Center At Houston,Department Of Pediatric Surgery,Houston, TX, USA 2Children’s Memorial Hermann Hospital,Pediatric Surgery,Houston, TX, USA 3University Of Texas Health Science Center At Houston,General Surgery,Houston, TX, USA

Introduction:

Electronic hospital variance reporting systems are plagued by underreporting. Variances include near misses (unplanned events that fail to cause patient harm, but had the potential to do so) and adverse events (unplanned events cause actual patient harm). To capture as many variances as possible, we have both electronic and handwritten variance reporting systems in place. The purpose of this study is to prospectively evaluate variances that occur in our pediatric operating room and to compare these variances to the two established incident reporting systems in our hospital.

Methods:

In this prospective observational study, trained individuals directly observed pediatric perioperative patient care for six weeks to identify near misses and adverse events in domains including timeout, medication, equipment, blood bank, surgical counts, and isolation. These direct safety observations were compared to the handwritten perioperative variance reporting system and the electronic hospital variance reporting system. All observations were analyzed and categorized into an additional six safety domains (adverse event, near miss, safety process issue, non-safety issue, indeterminate, good job) and five variance categories (equipment/supplies, knowledge/attitude, policies/process, environment, operations, other). The chi-square test was used, and p-values <0.05 were considered statistically significant.

Results:

Out of 211 observed cases, 137 near misses were identified by trained observers, while 57 handwritten variance reports and 8 electronic reports were filed during the same time period. Only 2 of 137 observed events were also reported in the handwritten or electronic system. Five observed adverse events were not reported in either of the two incident reporting systems. Safety observers were more likely to recognize timeout and equipment variances (graph). Both handwritten variance cards and safety observers identified numerous policy and process issues. The electronic variance system was used infrequently and most often to report intentional incorrect counts. All systems addressed knowledge/attitude and policy/process issues most often and there were no differences for frequency of safety categories (P=0.19).

Conclusion:

Despite multiple reporting systems, near misses and adverse events are vastly underreported. By identifying and addressing near misses, the underlying causes of system and processes can be corrected before they lead to an adverse event. Efforts need to be made to lessen barriers to variance reporting in order to improve patient safety.

07.04 Resident Feedback in General Surgery Bleeds over into Trauma

Posted on January 18, 2016

B. D. Lau1,3, M. B. Streiff2, D. B. Hobson1, P. S. Kraus4, D. L. Shaffer1, V. O. Popoola1, D. T. Efron1, E. R. Haut1 1Johns Hopkins University School Of Medicine,Surgery,Baltimore, MD, USA 2Johns Hopkins University School Of Medicine,Medicine,Baltimore, MD, USA 3Johns Hopkins University School Of Medicine,Health Sciences Informatics,Baltimore, MD, USA 4Johns Hopkins University School Of Medicine,Pharmacy,Baltimore, MD, USA

Introduction: Venous thromboembolism (VTE) prevention is one of the most frequent targets for patient safety and quality improvement in hospitals. In 2013, we began providing individualized feedback to general surgery residents about their VTE prophylaxis prescribing habits which has improved VTE prevention on the general surgery services. We hypothesized that this feedback would also improve VTE prophylaxis prescription by the same residents during non-general surgery rotations. The purpose of this study was to investigate the indirect, or ‘halo,’ effect of providing individualized feedback to residents regarding prescription of appropriate VTE prophylaxis.

Methods: This retrospective cohort study compared appropriate VTE prophylaxis prescription for all patients admitted to the adult trauma service from July 1, 2012 – May 31, 2015 at a Level 1 trauma center. On October 1, 2013, we began providing monthly feedback to general surgery residents regarding their VTE prophylaxis prescribing habits while on general surgery rotations. Data were not provided about off-service practice nor to any other prescribers within the hospital. We compared performance of surgery residents rotating on the adult trauma service before and after they began receiving individualized feedback. We also compared the performance of general surgery residents to all other prescribers (e.g. non-categorical interns, rotating residents, nurse practitioners) who wrote VTE prophylaxis orders on the adult trauma service during the study period.

Results: During the study period, 931 patients were admitted to the adult trauma service and assessed using the trauma-specific risk assessment tool. During the 15-month pre-feedback period, surgery residents wrote appropriate VTE prophylaxis orders for 78.5% trauma patients and other prescribers wrote appropriate orders for 75.4% patients, p=0.441. Surgery residents’ ordering practice for trauma patients significantly improved during the 20-month post-feedback period (94.5% vs 78.5%, p<0.001). Practice significantly improved among other prescribers during the post-feedback period, as well (84.3% vs 75.4%, p=0.036); however, practice was significantly better among surgery residents compared with other prescribers (94.5% vs 84.3%, p=0.001).

Conclusion: Individualized resident feedback has been shown to directly improve VTE prescribing practice. We found a beneficial ‘halo’ effect for other patients treated by those residents. There is a secondary, albeit smaller, ‘halo’ effect for patients treated by prescribers who may be aware of the feedback project despite not directly receiving feedback. Individualized feedback regarding practice habits should be implemented for all providers.

07.05 What’s Wrong with the Surgical Safety Checklist? Thinking Outside the Checkbox

Posted on January 18, 2016

A. A. Hildebrandt1, L. R. Putnam1,2, M. B. Diffley1, K. M. Caldwell1, S. E. Covey1, A. N. Mizenmayer1, K. T. Anderson1,2, A. L. Kawaguchi1,2, L. S. Kao3, K. P. Lally1,2, K. Tsao1,2 1University Of Texas Health Science Center At Houston,Pediatric Surgery,Houston, TX, USA 2Children’s Memorial Hermann Hospital,Pediatric Surgery,Houston, TX, USA 3University Of Texas Health Science Center At Houston,General Surgery,Houston, TX, USA

Introduction: Three-phase (pre-induction, pre-incision, debriefing) surgical safety checklists (SSC) have been widely adopted as an effective tool for decreasing postoperative morbidity and mortality. However, checklist effectiveness has recently been questioned. We aimed to identify potential flaws in the execution of a local, stakeholder-derived SSC, which could lead to its ineffectiveness.

Methods: From May to July 2015, five trained observers directly observed the completion of 11 pre-induction, 19 pre-incision, and 9 debriefing checkpoints during the three-phase SSC for pediatric operations. All checkpoints were assessed for adherence (checking the box). Of the 19 pre-incision checkpoints, 10 were assessed for high fidelity performance (meaningful completion). These fidelity checkpoints represent complex measurable tasks relying on a high-level of team cohesion and communication for meaningful completion. Inter-rater reliability and chi-squared tests were performed; p-values <0.05 were considered significant.

Results: 212 pediatric operations were observed representing 35 surgeons and 9 surgical subspecialties. At least one phase of the SSC was conducted in 100% of cases. 174 pre-induction, 212 pre-incision, and 199 debrief checklists were evaluated with an average adherence to each checklist of 56%, 95%, and 76%, respectively. For the pre-incision phase, adherence to checkpoint completion ranged from 85-100% and averaged 95%, yet high fidelity performance ranged from 36-98% and averaged 75%. Three pre-incision checkpoints (induction concerns, anticipated case duration, and site marking) were performed most consistently with associated meaningful completion. However, 7 checkpoints were performed at a high frequency (range 85-99%) but had a significantly lower rate of fidelity (range 36-86%, p<0.05). Inter-rater reliability kappa values for pre-induction, pre-incision, and debriefing were 0.68, 0.70, and 0.89, respectively.

Conclusion: Although surgical safety checklists are routinely performed, meaningful execution of each and every step remains suboptimal. Monitoring of implementation fidelity can identify specific processes and checkpoints upon which to focus improvement efforts.

07.01 Creating Confusion: Publically Reported Surgeon Ranking Systems are Inconsistent

Posted on January 18, 2016

L. E. Johnston1, R. K. Ghanta1, B. D. Kozower1, C. L. Lau1, J. M. Isbell1 1University Of Virginia,Division Of Thoracic And Cardiovascular Surgery,Charlottesville, VA, USA

Introduction: Measurement of healthcare quality is rapidly moving from the hospital level to the provider level, with two recent initiatives presenting surgeon rankings based on Medicare data. Previous studies have demonstrated significant differences between hospital ranking systems. We hypothesize that there will be similar differences between surgeon ranking systems, and that hospital specialty ranking will not correlate with the average ranking of its surgeons in a particular specialty.

Methods: The U.S. News & World Report (USNWR) hospital scores in orthopedics, urology, gastroenterology & GI surgery, and cardiac care areas were selected as the basis for comparison. The USNWR scores were averaged, and the top 10 hospitals in each specialty were ranked based on the mean score. Hospitals included in this list were identified in ProPublica’s (PP) Surgeon Scorecard and Consumer’s Checkbook’s (CC) SurgeonRatings.org websites. Both sites analyze physician outcomes based on Medicare billing data from 2009-2013 (PP) or 2009-2012 (CC), and USNWR scores incorporated Medicare data from the same time-frame. For each website we recorded each surgeon's score by specialty area, and these scores were then averaged to generate the mean surgeon score at an institution. The mean surgeon score was then used to rank institution-level performance in order to examine the correlation between the PP and CC rating systems, as well as between each of the two rating systems and USNWR.

Results: Compared to averaged USNWR institution rankings in orthopedics and urology, PP rankings had correlation coefficients of 0.33 (p=0.4) and -0.59 (p=0.1). CC ranking correlations were -0.15 (p=0.7) for orthopedics, -0.31 (p=0.4) for urology, -0.01 for GI surgery (p=1.0), and 0.36 (p=0.3) for cardiac care compared to USNWR (Figure, panel A). Comparing PP rankings to CC rankings in orthopedics and urology, the correlation coefficients were 0.47 and 0.56 respectively (Figure, panel B). There was no consistent relationship between number of surgeons/procedures ranked and the institutional rankings.

Conclusion: Medicare data used to generate surgeon rankings produces inconsistent estimates depending on methodology. Average surgeon rankings in a specialty do not correlate well with hospital rankings using either of the publicly available surgeon ranking tools. Current ranking systems produce highly variable results that may confuse rather than inform healthcare consumers, and may inappropriately incentivize surgeons to operate only on lower-risk patients in order to improve their ratings.

09.11 Age and Anti-Thyroid Drug Intolerance Predict Definitive Therapy in Pediatric Graves Disease

Posted on January 18, 2016

E. J. Graham1, J. Malinowski1, C. A. Dinauer1, E. R. Christison-Lagay1, C. E. Quinn1, T. Carling1, R. Udelsman1, G. G. Callender1 1Yale University School Of Medicine,Department Of Surgery,New Haven, CT, USA

Introduction: Graves disease (GD) is an autoimmune disease of the thyroid with an incidence of 0.79 cases per 100,000 person-years in children aged 0-14 years. In the United States, the pediatric GD population has not been well characterized due to its low prevalence and lack of comprehensive follow up. The American Thyroid Association recommends anti-thyroid drugs (ATD) for primary treatment of GD in pediatric patients, but no clear recommendation exists for definitive treatment, i.e. radioactive iodine (RAI) or thyroidectomy. This study aimed to characterize demographics and predictors of treatment selection in pediatric patients with GD at a tertiary referral center.

Methods: Retrospective review was performed of all patients diagnosed with GD at age ≤18 years from 2000-2015 at a tertiary care center. Neonatal GD patients and patients whose primary follow up was not performed at our center were excluded. The effect of race/ethnicity (non-Hispanic white, non-Hispanic black, Hispanic, other), insurance status (public, private, none), intolerance to ATD, presence of ophthalmopathy, age at diagnosis, and age at definitive treatment on election of definitive treatment and likelihood of remission was determined using ANOVA and logistic regression.

Results: Overall, 103 patients (81% female) were diagnosed with GD from 2000-2015 at median age 13 (range 2-18) years. Age at diagnosis did not differ between racial/ethnic groups or by insurance status. After primary ATD treatment, 11 (10.7%) patients entered remission at median 22 (range 3-126) months; 16 (15.5%) underwent RAI at median age 11 years; 34 (33.0%) underwent total thyroidectomy at median age 12 years; 45 (43.7%) continued ATD treatment only, with 23 (51.1%) of these continuing beyond 2 years. Type of treatment elected was independent of age at diagnosis, ophthalmopathy, insurance status and race/ethnicity. The likelihood of pursuing definitive treatment increased with age (OR: 2.6, p=0.01) and intolerance to ATD (OR: 174, p=0.01); patients with an earlier age at diagnosis trended toward greater likelihood of pursuing definitive treatment (OR: 1.8, p=0.06). Likelihood of remission was independent of all tested variables.

Conclusion:The management of pediatric GD is heterogeneous. Age at diagnosis and type of treatment elected were not impacted by socioeconomic status. Less than 50% of patients undergo definitive therapy (RAI or surgery) in spite of the low incidence of remission with ATD therapy alone. Increasing age and intolerance to ATD therapy increase the likelihood of pursuing definitive treatment. As pediatric GD is relatively rare, a prospective multicenter trial would be ideal to determine the optimal treatment algorithm for this patient population.

09.12 Surgeons as Agents of Change: Community Outreach and Provider Engagement

Posted on January 18, 2016

R. L. Hoffman1, K. O’Neill2, J. Olsen1, S. R. Allen1, M. K. Lee1, C. B. Aarons1, R. R. Kelz1 2Yale University School Of Medicine,New Haven, CT, USA 1Hospital Of The University Of Pennsylvania,Philadelphia, PA, USA

Introduction: Community outreach is a powerful tool for improving public knowledge of issues related to cancer care and decreasing disparities. Surgery is the only curative treatment of many types of cancer, therefore we developed a community outreach program to increase surgeon presence within the community.

Methods: In partnership with a large urban university cancer center, the Agnew society surgical interest group organized two community health outreach events focused on cancer prevention, screening and treatment in the surrounding community. Volunteers included medical students, surgical residents and faculty. The event consisted of free time for networking and engagement with participants. A survey instrument was used to gauge participant beliefs about cancer topics prior to the educational portion. The main event consisted of a presentation on colon cancer, followed by survivor and caregiver testimony and a question and answer session. Descriptive statistics were used to analyze survey results and to compare the demographics of the university to the community participants.

Results: Faculty are 69% male, 77% White, 3.5% African American and 14% Asian. Twenty-two surgical volunteers participated in the events and 2 of 6 faculty member panelists were African American. A total of 265 community members attended. Participants were 20% male and 96% African American. The survey response rate was 71% (188/256). Thirty-two percent endorsed mistrust in what doctors told them, 22% found it difficult to talk to doctors, and 25% felt that surgical treatment caused cancer to spread. After the first event, all medical professionals voluntarily continued participation in the second event and committed to future participation.

Conclusion: There was a clear difference between the demographic profiles of the university staff and the community that they served. Negative perceptions of physicians and the role of surgery in cancer treatment were prevalent within the community. Surgeon interest in community outreach is largely underappreciated. Surgeon engagement in community outreach can be easily expanded to other urban centers and may provide an opportunity to reduce surgical disparities.

06.19 Dialysis Status as a Predictor of Hemodialysis Access Failure: Do We Need to be More Proactive?

Posted on January 18, 2016

E. Benrashid1, L. M. Youngwirth1, J. Kim1, D. N. Ranney1, J. C. Otto1, J. F. Lucas2, J. H. Lawson1 1Duke University Medical Center,Division Of Vascular Surgery, Department Of Surgery,Durham, NC, USA 2Greenwood Leflore Hospital,Greenwood, MS, USA

Introduction:

Current guidelines encourage early hemodialysis (HD) access placement in the chronic kidney disease (CKD) and end stage renal disease (ESRD) population. A variety of patient and operative factors (i.e. preoperative target vein diameter) have been proposed as predictors for access success or failure, although the current literature is conflicting. The objective of this study was to determine whether there were any predictors for HD access failure in this population.

Methods:

The Society for Vascular Surgery Vascular Quality Initiative database was queried to identify all new HD access cases performed by a single surgeon from January 2011 – December 2013. The primary outcome of interest was access failure as defined at follow-up. Secondary outcomes included necessity for access revision via surgical or interventional (percutaneous) techniques. Multivariable logistic regression was used to determine factors associated with access failure and need for revision. Age, gender, race, smoking status, diabetes, BMI ≥ 30, presence of a central venous catheter, dialysis status, and access type were included in the model.

Results:

During the study period, 1,354 HD access cases were performed, with n = 1,238 (91.4%) of these autogenous arteriovenous fistulae (AVF), and the remainder prosthetic (n = 57; 4.2%) or biologic (n = 59, 4.4%) arteriovenous grafts (AVG). Overall mean age was 56.6 ± 14.3 years, black race was 77.0%, and male gender was 48.2%, which was not significantly different among the groups. The total proportion of patients actively on dialysis was 66.7%, which differed significantly amongst the three access types (p < 0.001). On multivariable logistic regression analysis, active dialysis status was associated with a significantly higher probability of access failure [adjusted odds ratio (AOR), (95% confidence interval [CI]): 1.91 (1.17, 3.11); p = 0.010]. Additionally, the presence of a biologic AVG was associated with a significantly higher probably for the need for access revision [AOR (95% CI): 2.26 (1.32, 3.86); p = 0.003].

Conclusions:

Active dialysis status is associated with a higher incidence of access failure, with biologic AVG in particular associated with a greater need for revision. This data suggests that patients with CKD who are ‘pre-dialysis,’ in which there is any suspicion for progression to ESRD requiring renal replacement therapy (RRT), should receive more aggressive surgical referral and proactive placement of AVF prior to initiating any form of RRT. Additionally, given the > 2X likelihood for reintervention, patients that receive biologic AVG may be better suited with other access modalities. However, this cohort in particular may have specific anatomical limitations or have expended other access options, which may preclude AVF creation or the use of more conventional synthetic graft materials.

06.20 Aspirin Use is Associated with Decreased Thrombus Sac Volume in Abdominal Aortic Aneurysms

Posted on January 18, 2016

L. E. Trakimas1, C. I. Aghaie1, D. S. Mix1, K. Rasheed1, J. L. Ellis1, R. J. Glocker1, A. J. Doyle1, M. C. Stoner1 1University Of Rochester,Vascular Surgery,Rochester, 14642, USA

Introduction: Data suggest that pro-inflammatory mediators play a key role in the formation and enlargement of abdominal aortic aneurysms (AAA). Formation and renewal of intramural thrombus is also associated with inflammation, and is known to contribute to the complexity of aneurysm repair. Current cardiovascular pharmacotherapy includes a number of inflammatory modulators such as aspirin (ASA), Plavix (clopidogrel), statins, and angiotensin-converting enzyme inhibitors (ACE-I). The purpose of our study was to investigate the effect of these inflammatory modulators on radiographically-determined thrombus sac volume (TSV).

Methods: Patients who underwent elective infrarenal aortic repair were identified. Pre-operative CT scans were reviewed, and TSV was obtained using a Hounsfield Unit (HU) restricted region growth algorithm. Receiver-operator characteristic curves were systematically generated for TSV and various cardiovascular pharmacotherapies. Additional co-morbid conditions such as diabetes mellitus (DM) and post-operative complications were also evaluated versus TSV.

Results: A total of 210 patients (mean age = 72.0, SE 0.63 years; mean TSV = 81.9, SE 5.83 cm3) were identified. ASA use was associated with a decreased thrombus sac volume ≤ 50 cc (AUC = 0.616, p= 0.013) (figure) whereas statins (p= 0.258), ACE-I (p= 0.455), and Plavix (p= 0.622) had no correlation to thrombus sac volume. DM was not associated with TSV (p= 0.311). Post-operative bleeding was also not associated with TSV (p = 0.120).

Conclusion: ASA use is associated with decreased TSV in a patient population undergoing elective AAA repair. The effect of ASA over other anti-inflammatory and anti-platelet agents is possibly attributable to its distinct mechanism of cyclooxygenase-1 (COX-1) inhibition. These data suggesting a key role of COX-1 in aneurysm thrombus modulation. DM, a known correlate of aneurysm incidence, is not related to thrombus burden. The potential to alter aneurysm thrombus volume affecting aneurysm morphology may yield a more favorable aneurysmal repair.

06.16 The Effect Of Use And Timing Of Venous Thromboembolism Chemoprophylaxis After Major Vascular Surgery.

Posted on January 18, 2016

D. C. Horne1, P. Georgoff1, M. A. Healy1, N. H. Osborne1 1University Of Michigan,Department Of Surgery,Ann Arbor, MI, USA

Introduction:

Venous thromboembolism (VTE) has been reported to occur in as much as 2-33% of patients undergoing major open vascular surgery. Despite this relatively high incidence, patients inconsistently receive chemoprophylaxis. The true incidence of VTE among patients receiving chemoprophylaxis is unknown. We sought to explore the effect of not only administration, but timing of administration of chemoprophylaxis on risk of VTE and post-operative bleeding among patients undergoing major open vascular surgery.

Methods:

Patients undergoing major open vascular surgery (defined as open abdominal aortic aneurysm repair, aorto-femoral bypass, mesenteric bypass) and infrainguinal bypass were identified from the Michigan Surgical Quality Collaborative (MSQC) between 2008 and 2012. Rates of VTE (deep venous thrombosis and/or pulmonary embolism) were compared between patients receiving and not receiving routine VTE chemoprophylaxis using univariate and multivariate statistics. Delay in the initiation of chemoprophylaxis was defined as initiation of therapy greater than 1 day following surgery. Among patients receiving VTE chemoprophylaxis, the effect of the timing of initiation of chemoprophylaxis upon development of VTE was determined using multivariate statistics. Post-operative complications were compared among all groups using univariate and multivariate analysis.

Results:

A total of 8776 patients underwent major open vascular surgery, including 1068 open AAA repairs, 958 aorto-femoral bypass and 6483 infrainguinal bypass procedures. The overall incidence of 30-day VTE was 1.4%, ranging from 0.99% among patients undergoing infrainguinal bypass and 2.62% among patients undergoing open abdominal procedures. Among all patients who received VTE chemoprophylaxis anytime during their admission, the rate of VTE was 1.45% as compared to 1.38% among those who did not receive chemoprophylaxis. However, accounting for the timing of chemoprophylaxis initiation, delay in the administration of VTE chemoprophylaxis was associated with a significantly higher risk of VTE (OR 3.92, p<0.01), controlling for pre-op risk of VTE. There was no increased risk of post-operative transfusion among patients receiving routine chemoprophylaxis compared those who did not (16.28% vs. 17.43%, p=0.197).

Conclusions:

Although patients undergoing major open vascular surgery appear to have a low risk of VTE at baseline, there is a significantly higher risk of developing VTE among patients who have a delay in the administration of VTE chemoprophylaxis. Bleeding complications were no higher among patients who routinely receive chemoprophylaxis. Surgeons should consider routinely initiating chemoprophylaxis in the early post-operative setting following major open vascular surgery.

06.17 Temporal Variability of Mortality & Readmission Determinants in Peripheral Vascular Surgery Patients

Posted on January 18, 2016

M. J. Lin1, F. Baky2, B. Housley2, N. Kelly2, M. Chowdhury2, D. B. Tulman2, E. Pletcher1, J. D. Balshi1, S. P. Stawicki1, D. C. Evans2 1St. Luke’s University Health Network,Department Of Surgery,Bethlehem, PA, USA 2Ohio State University,Department Of Surgery,Columbus, OH, USA

Introduction: Vascular surgery patients constitute a population subset that has traditionally been considered "high-risk" for readmissions and mortality. Although various studies report factors associated with readmission or mortality in this population, data continue to be limited regarding the temporal risk profile for readmissions and mortality during the initial postoperative year. We set out to determine the relationship between various clinical determinants, hospital readmissions, and mortality in a sample of vascular surgical patients. We hypothesized that factors independently associated with hospital readmission and mortality will gravitate from traditional "short-term" indicators toward the more established "long-term" outcome determinants at 90, 180, and 360-day postoperative cut-off points.

Methods: Medical records of peripheral vascular surgery patients at two institutions (2008-2014) were retrospectively reviewed. Abstracted data included demographics, procedural characteristics, the American Society of Anesthesiologists (ASA) Physical Status, Goldman Criteria for postoperative cardiac complications, Charlson Comorbidity Index, morbidity, readmission data (30-day, 180-day, 360-day), and mortality (30-day, 180-day, 360-day). Univariate analyses were performed for both readmissions and mortality at each specified time point. Variables reaching statistical significance of p<0.20 were included in subsequent multivariate analyses for factors independently associated with readmission/mortality.

Results: A total of 450 patients were included in the current analysis. Most patients underwent either a bypass or endarterectomy revascularization (406/450) or non-catheter dialysis access procedure (44/450). There were 188 males and 262 females (mean age 61.1±13.8, 14% emergent procedures, median operative time 177 minutes). Median hospital length of stay (index admission) was 4 days (25%-75% IQR 2-8 days). Cumulative readmission rates at 30, 180, and 360 days were 12%, 27%, and 35%. For mortality, the corresponding figures were 3%, 7%, and 9%, respectively. Table 1 shows factors independently associated with 30-day, 180-day, and 360-day readmissions and mortality.

Conclusion: We noted important patterns in temporal variability regarding the risk of hospital readmission and mortality in peripheral vascular surgery patients. Previous readmissions, frailty/acuity indices, and cardiovascular morbidity were all independently associated with subsequent risk of readmission and mortality. The knowledge of temporal trends described herein may be helpful in guiding readmission reduction approaches — a consideration of increasing importance in the evolving paradigm of value-based healthcare.

06.18 A Time Based Risk Model To Screen Post EVAR Patients

Posted on January 18, 2016

C. M. Png1, R. O. Tadros1, P. L. Faries1, S. Kim1, W. Beckerman1, M. R. Torres1, Z. M. Feldman1, M. L. Marin1 1Mount Sinai School Of Medicine,New York, NY, USA

Introduction: Follow up computed tomography angiography (CTA) scans add considerable post implantation costs to endovascular aneurysm repairs (EVAR) of abdominal aortic aneurysms (AAA). By building a risk model, we hope to identify patients at low risk for postoperative complications in order to minimize unnecessary CT scans.

Methods: 557 consecutive patients were reviewed. Probit models were created for four outcomes: aneurysm sac enlargement, reintervention, type I/III endoleaks and type II endoleaks, using preoperative aneurysm morphology, patient demographics and operative details as covariates. Patients with an abnormal 30 day post operative CT scan were excluded. Time points chosen for analysis were 1-year, 2-year, 3-years and 10-year post EVAR. A combined model including three outcomes was also created.

Results: Individual models that showed most significance were aneurysm sac enlargement at 1-year post EVAR (n=411; Sensitivity=1; Specificity=0.47; Accuracy 0.48) and reintervention at 2-year post EVAR (n=494; Sensitivity=1; Specificity=0.42; Accuracy=0.45). Notably, our models reported that increasing iliac artery diameter and increasing aortic neck angle increased the risk for a reintervention, while increasing iliac artery tortuosity increased the risk for a type I/III endoleak. Similarly, almost all statistically significant covariates were qualitatively supported by prior literature. Our final combined model would prevent the need for post-EVAR CTA in 59 patients (16%) at 1 year, 26 (7%) patients at 2 years and 6 (2%) patients at 3 years with 100% sensitivity. (Table 1)

Conclusion: Our model is a robust predictor of patients at low risk for post AAA EVAR complications. With additional validation and refinement, it could be applied to practices to cut down on the overall need for post-implantation CTA. Reducing the number of CT scans will reduce post-implantation cost and radiation exposure.

06.14 Predictors Of 30-Day Post-Operative Outcomes Following Carotid Revascularization Procedures

Posted on January 18, 2016

B. J. Nejim1, I. Arhuidese1, C. Hicks1, T. Obeid1, S. Wang1, J. Canner1, M. Malas1 1Johns Hopkins University School Of Medicine,Surgery,Baltimore, MD, USA

Introduction: The aim of our study is to compare the postoperative outcomes of Carotid Endarterectomy (CEA) with Carotid Artery Stenting (CAS) using the Procedure-targeted American College of Surgeons National Surgical Quality Improvement Program (ACS-NSQIP) database.

Methods: Patients who underwent CEA or CAS were identified in ACS-NSQIP for the years 2011 – 2013. Mean difference estimates and chi-square tests were used as appropriate. Univariate and multivariate logistic regression analysis were performed to evaluate the predictors of post-operative outcomes (any stroke or death and myocardial infarction (MI)) adjusting for age, gender, comorbidities, symptomatology, degree of stenosis and emergency surgical status.

Results: Of the 10,169 patients who underwent carotid revascularization, 9,817 (96.5%) underwent CEA while 352 (3.5%) underwent CAS during the study period. Sixty one percent of the cohort were males. Patients who underwent CEA were older than those undergoing CAS [mean age (SD): 71.3 (9.4) vs. 69.1 (9.7) years, p <0.001]. However, patients who underwent CAS had a greater prevalence of diabetes (38.4% vs. 29.2%, p<0.001), hypertension (88.1% vs. 84.9%, p=0.104), congestive heart failure (4.8% vs. 1.4%, p<0.001) and COPD (17.3% vs. 10.2%, p<0.001). The risk of post-operative stroke/death was 92% higher with CAS (Adjusted odds ratio: 1.92; 95% Confidence Interval: 1.04-3.52), receiving blood transfusion 72 hours prior to surgery was associated with 5-fold increase of mortality odds (aOR: 5.47; 95%CI: 1.79-16.73), other significant predictors of stroke/death were symptomatic status (aOR: 1.60 ,95%CI:1.19-2.16) and emergency surgery status (aOR: 2.35 ,95%CI: 1.31-4.23). No significant association was found between the type of procedure and odds of unplanned reoperation (aOR: 0.60; 95%CI: 0.22-1.63). Thirty-day post-op myocardial infarction was mostly related to patient’s age and being on hypertension medication whereas the type of procedure was found not to be significantly associated with post-op MI (aOR: 0.84; 95%CI: 0.26-2.67). Although readmission odds was higher for CAS, this association was not significant (aOR: 1.23; 95%CI: 0.82-1.85)

Conclusion: Carotid stenting is associated with higher odds of both post-operative mortality and stroke. The adverse impact of pre-procedural blood transfusion on outcomes is a call for caution and deserves further elucidation. Carotid procedure type is not a predictor of post-op MI or readmission, suggesting that these outcomes are a function of other patient factors. Further studies are warranted to evaluate the ability of the administrative dataset models to predict postoperative outcomes following carotid revascularization.

06.15 A 30 Year Experience with Tibial/Peroneal Arterial Revascularization using Polytetrafluoroethylene.

Posted on January 18, 2016

N. J. Gargiulo1, F. J. Veith3, E. C. Lipsitz4, N. S. Cayne3, G. S. Landis2 1The Brookdale Hospital And Medical Center,Vascular Surgery,New York, NY, USA 2Northwell Health System,New Hyde Park, NY, USA 3New York University,Surgery,New York, NY, USA 4Montefiore Medical Center,Surgery,Bronx, NY, USA

Introduction: Polytetrafluoroethylene (PTFE) tibial and peroneal arterial bypasses without vein cuffs, patches or arteriovenous fistulas have been advocated for critical limb ischemia in circumstances when autologous saphenous vein is not available. This reviews a 30-year experience.

Methods: A retrospective analysis was performed on a group of 377 patients with critical limb ischemia facing immediate amputation requiring revascularization between July 1977 and June 2011. These 377 patients had no autologous vein on duplex examination and operative exploration and underwent 411 PTFE bypasses to a tibial or peroneal artery (the only patent outflow vessels) without any adjunctive procedure. The majority of these patients had two or more prior ipsilateral infrainguinal bypasses. Tourniquet control of the tibial or peroneal was used in the majority of cases (85%). Cumulative life table primary and secondary patency and limb salvage rates were calculated for these bypasses. These results were compared to those infrapopliteal bypasses performed with alternate autologous vein conduits or PTFE in conjunction with an adjunctive procedure (i.e. cuff, patch or av fistula).

Results: The 5- and 10-year cumulative primary graft patency rates for tibial and peroneal arterial PTFE bypasses were 39% +/- and 28% +/-, respectively. Secondary graft patency rates were 55% and 51% at 5 and 10 years, respectively. Limb salvage rates were 71 % at 5 years and 66% at 10 years. Several effective surgical strategies employed over the last 3 decades included meticulous attention to the distal anastomosis, mandatory completion arteriography, initial pharmacologic treatment of distal anastomotic or runoff pseudodefects, thrombectomy and/or graft extension for those defects that failed to resolve, and postoperative anticoagulation.

Conclusions: PTFE bypasses without adjunctive procedures to infrapopliteal arteries is an acceptable alternative option for those patients without autologous vein facing imminent amputation in this small cohort of patients. Several important perioperative strategies may help improve PTFE graft patency and overall limb salvage.

06.11 Gender Differences in Mortality Following Ischemia-Reperfusion Injury in Diabetic Animals

Posted on January 18, 2016

N. N. Rizk1, E. Abbott1, M. Rizk2, A. Fischer1,2, J. Dunbar2 1Beaumont Health System Research Institute,General Surgery,Royal Oak, MI, USA 2Wayne State University,Physiology,Detroit, MI, USA

Introduction: The physiologic differences between men and women are well characterized so their clinical manifestations in pathologic states should potentially exhibit differences. Much of preclinical research utilizes male animal models to develop treatment modalities for clinical applications assumed to extrapolate to both genders. In this study we evaluated normal and diabetic female rats response to stroke and reperfusion injury and compared to our previously characterized outcomes in male rats.

Methods: We utilized middle cerebral artery occlusion (MCAO) and reperfusion model in normal and diabetic Wistar female animals. Following 24-hour MCAO and 2-hour MCAO followed by 24-hour reperfusion interval, several CNS parameters were examined, lesion volume (Triphenyltetrazolium Chloride), up regulation of apoptosis [TUNEL immunoreactivity in the sensori-motor cortex (layers-5 and 6) and the hippocampal pyramidal cell layers (CA1 and CA3 sectors)], as well as the percent survival.

Results: The two parameters in which the female animals differed significantly from their male counter parts were i) in lesion volume following restoration of blood flow with 2-hour MCAO and ii) in mortality following 24-hour MCAO and in following restoration of blood flow with 2-hour MCAO. Restoration of blood flow following 2-hour MCAO significantly decreased lesion volume in the normal and diabetic female animals (13.95 ± 8.16* and 20.32 ± 6.85*, respectively). In comparison to the male counterparts, lesion volumes following reperfusion were significantly less for normal male rats and significantly more for the diabetic male animals (3.8 ± 2.36# and 31.25 ± 2.5#, respectively). Twenty-hour MCAO and restoration of blood flow with 2-hour MCAO proved to be significantly more detrimental to the female animals with lower survival (normal 65%, diabetic 55% survival, p<0.05) in comparison to the male animals (normal 90%, diabetic 65% survival, p<0.05). There was a significant increase in TUNEL immunoreactive cells in the diabetic animals following reperfusion injury compared with the control counterpart. There were no appreciable differences in TUNEL immunoreactivity between male and female diabetic animals following reperfusion.

Conclusion:This paper highlights the dramatically different outcomes and metrics in different genders in animal models. Thus one gender alone may not translate into clinically relevant data applicable to both genders. We have demonstrated that both male and female diabetic animals have an exaggerated response to stroke and to restoration of blood flow but differ in their outcome with a significantly more detrimental outcome for the female sex. Understanding the exaggerated vascular response to injury in the female animal model is important in developing gender specific treatment modalities.

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