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

Posted on January 31, 2019

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

Introduction:

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

Methods:

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

Results:

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

Conclusion:

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

29.07 Increased APOBEC3C-H Gene Expression is Associated with Improved Outcome in Breast Cancer

Posted on January 31, 2019

M. Asaoka1,2, S. K. Patnaik1, A. L. Butash1, E. Katsuta1, T. Ishikawa2, K. Takabe1,2  1Roswell Park Cancer Institute,Surgical Oncology,Buffalo, NY, USA 2Tokyo Medical University,Department Of Breast Surgery And Oncology,Shinjuku, Tokyo, Japan

Introduction:

APOBEC enzymes are known as strong mutagenic factors, particularly in breast cancer. APOBEC3B (A3B) gene expression is significantly increased in breast cancer and associated with tumor mutation load and intra-tumor heterogeneity. The relevance of the other APOBEC3s (A3A, C-H) is not yet clear in breast cancer. Therefore, we analyzed these genes, looking at their association with survival, mutations, and immune activity.

Methods:

We collected gene expression data for primary tumors (1091) and adjacent normal tissues (113) from The Cancer Genome Atlas (TCGA). Patients were divided into 3 equal groups by gene expression to compare high and low expressors. Tumor immune features like cytolytic activity and T cell receptor (TCR) diversity were quantified from gene expression data. Data for some of these features, mutation-related aspects, and survival were obtained from TCGA publications. Gene expression data for 55 breast cancer cell-lines was from Cancer Cell Line Encyclopedia. Cox regression and Spearman methods were used for survival and correlation analyses, resp. Welch t test was used for group comparison, with P <0.05 deemed significant. Hallmark gene-sets were used for enrichment analysis.

Results:

A3B and A3C represented 91% of A3 gene expression in breast cancer cell-lines. In patients, expression of A3B was higher in tumors compared to normal tissue (4.5x), while that of A3C was lower (0.5x). A3B or A3A levels had no effect on overall (OS) or disease-specific survival (DSS). But, higher expression for each of A3C-H was significantly associated with improved OS (HR, 0.45-0.66) or DSS (0.43-0.61). The prognostic value of high A3C-H expression was validated in two gene expression meta-datasets (KMPlot and SurvExpress). A3A and A3B expression levels correlated with both tumor mutation burden and neoantigen load (ρ = 0.28-0.34), which resp. were 2.0-2.9x more in high expressors. There was no association of tumor mutation burden or neoantigen load with A3C-H. A3C-H expression levels correlated positively with both total immune cell and lymphocyte populations in tumor (ρ = 0.29-0.70 & 0.20-0.50, resp.), whereas the correlations were poor for A3B (0.10 & -0.01, resp.). Expression of genes related to immune function like interferon response and complement activation was enriched in high A3C-H expressors, which also had significantly more CD4 and CD8 T cells, and TCR diversity (2.3-4.0x, 2.1-5.4x & 1.3-2.1x, resp.). Concordantly, for each of A3C-H, expression correlated with tumor immune cytolytic activity (ρ = 0.31-0.79), which was increased 3.1-7.9x in high expressors.

Conclusion:

APOBEC3s are DNA mutators. However, unlike A3B, whose expression is associated with poor survival, increased expression of A3C-H confers a survival benefit. Further studies are warranted to explore if the increased A3C-H expression reflects a heightened anti-cancer immune response, and if A3C-H can be used as prognostic biomarkers.

29.06 Prepectoral Direct-to-Implant Breast Reconstruction: Safety Outcomes and Delineation of Risk Factors

Posted on January 31, 2019

K. P. Nealon1, R. E. Weitzman1, N. Sobti1, A. S. Colwell1, W. G. Austen1, E. C. Liao1  1Massachusetts General Hospital,Division Of Plastic And Reconstructive Surgery,Boston, MA, USA

Introduction:  Breast cancer is among the most common cancers diagnosed in women, affecting 1 in 8 women per year. Immediate implant-based breast reconstruction is the leading technique for post-mastectomy reconstruction, trending toward direct to implant (DTI) as the preferred method when compared to the traditional tissue expander method. Although implants are generally placed beneath the pectoralis major muscle, recent developments have allowed for implant placement above the muscle in a pre-pectoral plane. This study compares the safety endpoints and risk factors in prepectoral vs. subpectoral DTI breast reconstruction cohorts. We hypothesize that prepectoral DTI breast reconstruction is a safe alternative to subpectoral DTI breast reconstruction.

Methods:  Retrospective chart review at a tertiary academic medical institution identified 107 patients who underwent prepectoral DTI reconstruction and 158 patients who underwent subpectoral DTI reconstruction. Univariate analysis was performed to compare patient characteristics between both cohorts. A penalized logistic regression identified relationships between postoperative complications and covariate variables in each group.

Results: A binomial regression model revealed that prepectoral DTI breast reconstruction is associated with lower risk of surgical site infection (p = 0.011) and lower risk of revision (p = 0.015) when compared to subpectoral DTI breast reconstruction. Prepectoral DTI breast reconstruction is also associated with lower risk of capsular contracture, trending towards significance (p = 0.064). Rates of overall complication, explant, skin necrosis and hematoma were comparable between groups.

Conclusion: This study compares the safety outcomes and risk factors in prepectoral versus subpectoral DTI breast reconstruction cases. Prepectoral DTI breast reconstruction is associated with lower rates of surgical site infection, revision, and capsular contracture. It is speculated that the significant difference in surgical site infection may be due to decreased procedure time of the prepectoral procedure, or less dissection and devascularization of the soft tissue surrounding the implant. Fewer overall complications in the prepectoral group also resulted in a decreased number of revisions. Due to lack of manipulation of the pectoralis major muscle, prepectoral implant placement reported decreased rates of capsular contracture. These results demonstrate that prepectoral DTI reconstruction is a safe alternative when compared to subpectoral DTI reconstruction. 

 

29.05 Non-Discrimination Laws and Medical Necessity Criteria for Gender Affirmation Surgery

Posted on January 31, 2019

A. Almazan1, O. Ganor1, E. Boskey2  1Harvard Medical School,Boston, MA, USA 2Boston Children’s Hospital,Department Of Plastic And Oral Surgery,Boston, MA, USA

Introduction:  A recent movement to pass state-based non-discrimination laws has led to mandatory coverage for gender-affirming surgical care in many private insurance plans. However, it is unclear whether these laws have improved access to treatment for transgender patients. While more plans may cover gender affirmation surgery, restrictive medical necessity criteria used by insurers to decide reimbursement can still delay treatment or preclude access to surgery for many patients. In this study, we examine how coverage and medical necessity criteria for gender affirmation surgeries vary between states that do and do not have laws protecting coverage of gender-affirming medical care in private insurance.

 

Methods: Medical coverage guidelines for surgical treatment of gender dysphoria were taken from the websites of the largest insurer in each state by market share.

Expansiveness of coverage for each insurer was assessed by examining whether each plan offered any of the following procedures: FTM phalloplasty, MTF vaginoplasty, FTM mastectomy, MTF augmentation mammoplasty, electrolysis, and laryngoplasty.

Restrictiveness of medical necessity criteria was assessed by examining whether each plan mandated any of the following prerequisites for gender affirmation chest surgeries: proof of social transition, documentation of hormone therapy for FTM mastectomy and MTF augmentation mammoplasty, documentation of legal name change, and proof of employment/schooling/community involvement.

Each state was labeled according to whether it had a law protecting insurance coverage of gender affirmation surgery. The number of covered procedures and number of chest surgery prerequisites were compared between states that did and did not have transition-related protections.

 

Results: The mean number of procedures covered in states with legal protections is 4.81, compared to 3.92 in states without protections (t=-2.32, p=0.013). The mean number of pre-requisites for chest reconstruction surgeries in states with legal protections is 0.88, compared to 0.92 in states without protections (t=0.10, p=0.46).

 

Conclusion: Insurers in states with non-discrimination laws protecting transition-related insurance coverage tend to cover more gender-affirming surgical procedures. However, the number of requirements that must be fulfilled to deem a chest reconstruction medically necessary is effectively identical between insurers in states that do and do not have non-discrimination laws. Transition-related insurance protections are associated with enhanced coverage of gender affirmation surgery. However, they are not associated with improvements in the restrictiveness of medical necessity criteria, which may still act as a barrier to care even when coverage is nominally increased in accordance with these laws.
 

29.04 Radiation Following Autologous Breast Reconstruction – Is It Safe Practice?

Posted on January 31, 2019

L. A. Gamble1, S. Sha2, J. L. Kelly1, L. A. Jarvis4, G. L. Freed3, K. M. Rosenkranz1, C. V. Angeles1  2Stony Brook University,School Of Medicine,Stony Brook, NEW YORK, USA 3Dartmouth-Hitchcock Medical Center,Plastic Surgery,Lebanon, NEW HAMPSHIRE, USA 4Dartmouth-Hitchcock Medical Center,Radiation Oncology,Lebanon, NEW HAMPSHIRE, USA 1Dartmouth-Hitchcock Medical Center,General Surgery,Lebanon, NEW HAMPSHIRE, USA

Introduction:  The incidence of immediate breast reconstruction (IBR) following mastectomy for breast cancer has steadily been on the rise while the indications for post mastectomy radiation therapy (PMRT) have broadened. Current literature demonstrates conflicting data regarding surgical complications and timing of PMRT, while the safety of PMRT following autologous breast reconstruction (ABR) is still considered controversial. We sought to investigate the safety of PMRT in breast cancer patients who undergo ABR.

Methods:  Retrospective chart review was performed on all patients treated with mastectomy between 2000-2006 at a single, academic institution. Data collected included patient demographics, PMRT, and postoperative complications including seroma, infection, fat necrosis, and contracture documented from the time of surgery until one year post surgery. Median follow-up was 6.19 years. Chi-square analysis was performed with significance set at p <0.05.

Results: 592 patients underwent mastectomy for breast cancer treatment or prophylaxis. Only half of these patients (49%; 292/592) underwent reconstruction. The majority (83%; 240/292) received ABR, and 95% (228/240) were done at the time of mastectomy (IBR). The most common flap performed was the transverse rectus abdominis (TRAM) flap at 72.1%, followed by 24.2% latissmus dorsi (LD), and 3.7% other flaps (including superior and inferior gluteal artery perforators, and transverse upper gracilis). Of the immediate ABR patients, 57/228 received PMRT. Of these, 54% (31/57) suffered any surgical complication and 23% (13/57) were classified as Clavien-Dindo grade IIIb (CD IIIb). Comparatively, 171/228 patients did not receive PMRT with almost half (84/171) having complications, but only 26% (45/171) were classified as CD IIIb. There was no statistically significant difference in overall complication rate or CD IIIb complications between ABR patients with or without PMRT (p=0.742 and p=0.357, respectively). Additionally, we found no significant difference in overall complication rate in patients who underwent PMRT when comparing between those who had no reconstruction versus those who had ABR (p=0.0623).

Conclusion: Our data shows no statistically significant difference in the complication rate between breast cancer mastectomy patients who received PMRT after ABR versus no reconstruction.  Additionally, there is no difference in the rate of complications between ABR patients who did or did not receive PMRT. This study supports the idea that it is safe to radiate a reconstructed breast.

 

29.03 Adhering to Surgical and Oncologic Standards Improves Survival in Breast Cancer Cohorts

Posted on January 31, 2019

B. Zhao1, C. Tsai1, K. K. Hunt2, S. L. Blair1  2University Of Texas MD Anderson Cancer Center,Breast Surgical Oncology,Houston, TX, USA 1University Of California – San Diego,Surgery,San Diego, CA, USA

Introduction:
The American College of Surgeons Clinical Research Program published evidence-based surgical and oncologic standards for breast cancer in the Operative Standards for Cancer Surgery.  Recommended standards include surgical resection with negative margins, removal of all sentinel lymph nodes (SLN) and removal of >10 lymph nodes (LN) for complete axillary dissection (ALND), and the use of adjuvant therapy after surgical resection. However, the rates of adherence to these standards nationwide is unknown. 

Methods:
Using the National Cancer Database from 2004-2015, we selected distinct cohorts of breast cancer patients who underwent surgical resection: clinical T1N0M0 under age 70 (CT1), clinical T2N0M0 or T3N0M0 (CT2/3), and clinical M0, pathologic N2 or N3 (PN2/3). For CT1 and CT2/3 patients, we considered patients with negative margins, any form of adjuvant therapy, and ³2 LNs examined as meeting standards. For PN2/3 patients, we considered those with negative margins, any form of adjuvant therapy, and ³10 LNs examined as meeting standards. We compared outcomes of those who met standards versus those who did not for all cohorts. We performed Kaplan-Meier analysis with log-rank test to compare survival for patients based on achieving standards and Cox proportional hazards model for individual predictors of improved survival while controlling for patient comorbidities. 

Results:
We identified 318,853 (65.0%) CT1 patients, 164,593 (67.3%) CT2/3 patients, and 77,626 (67.7%) PN2/3 patients who met surgical and oncologic standards. Survival data is shown in the table. For PN2/3 patients, the median survival for those who met standards was significantly longer than those who did not meet standards (109.34 months versus 72.97, p<0.001). Patients were significantly more likely to meet standards if they were treated at an academic center (p<0.001 for all cohorts). For CT1 and CT2/3 patients, ³2 LNs examined, endocrine therapy, radiation therapy, and negative margins were predictors of improved survival. For CT1 patients, chemotherapy was a predictor of worse survival, but was a predictor of improved survival in CT2/3 patients. For PN2/3 patients, ³10 LNs examined, endocrine therapy, chemotherapy, radiation therapy, and negative margins were predictors of improved survival. 

Conclusion:
Approximately a third of patients are not receiving evidence-based minimal standards as part of their surgical and oncologic treatment for breast cancer.  Adhering to surgical and oncologic standards improves survival in CT1, CT2/3, and PN2/3 breast cancer patients.  Efforts to improve knowledge of, and adherence to, these surgical and oncologic standards should be emphasized. 
 

29.02 Underinsurance and Healthcare Utilization among Working-Age Breast Cancer Patients

Posted on January 31, 2019

S. Obeng-Gyasi1, L. Timsina1, O. Bhattacharyya3, S. E. Severance1, C. S. Fisher1, D. A. Haggstrom2  1Indiana University School Of Medicine,Department Of Surgery,Indianapolis, IN, USA 2VA HSR&D Center for Health Information and Communication,Indianapolis, IN, USA 3Indiana University Purdue University,Department Of Economics,Indianapolis, IN, USA

Introduction: Breast cancer is the most common female cancer in the United States. For working-age patients, a cancer diagnosis can be financially devastating secondary to disease related reduction in work productivity, loss of employment, and subsequent increased economic burden. The objective of this study is to understand out-of-pocket costs (OOP), health care utilization costs (outpatient visits, office-based visits, ambulatory care, prescription medication cost), and the rate of underinsurance among working age breast cancer patients. 

Methods: The study data was obtained using the Medical Expenditure Panel Survey data from 2008-2012.  Self-responding patients ages 18-64 with an age at diagnosis of breast cancer within two years of the survey interviews were included. The data was divided into three groups based on insurance:  private, Medicaid, and other public.  The other public includes patients with Non-Medicaid state or local insurance or other federal programs. Bivariate intergroup analysis was conducted. A multivariable logistic regression model tested variables associated with underinsurance. Underinsurance was defined as spending at least 10% of the household income on breast cancer related OOP.

Results:The study cohort included 14,586 patients. The groups differed significantly by marital status (p=0.004), race/ethnicity (p=0.0002), education (P <0.0001), percent below the poverty level (p<0.0001), family income (P <0.0001) and employment (P<0.0001).   Mean total annual OOP costs were $2006.0 (95% CI 1705.5, 2305.5) for the privately insured, $991.0 (95% CI -160.1, 2142.3) for Medicaid, and $7420.0 (95% CI 1722.8, 13117) for other public insurance. The majority of OOP cost were on prescriptions, $706.0 (95% CI 557.7, 854.6), and office-based visits, $779. 0(95% CI 641.7, 916.3). Patients with other public insurance spent the most OOP costs on prescriptions $3258.0 (95% CI 2047.2, 4467.8) and office-based visits $3258.0 (95% CI 2047.2, 4467,8). Being divorced (OR 5.6, p=0.029), living in the Midwest (OR 18.6, p=0.001) or South (OR 7.49 p=0.015) compared to the Northwest and having other public insurance (OR 12.2, p=0.012) were all associated with an increased rate of underinsurance. Conversely, employment (OR 0.21, p=0.011) and having Medicaid (OR 0.09, p= 0.006) were associated with a reduced rate of underinsurance.

Conclusion:Breast cancer patients spend most of their OOP costs on prescriptions and office-based visits. Since Medicaid was protective against underinsurance and higher OOP costs, future longitudinal studies should monitor whether Medicaid policy changes continue to reduce the economic vulnerability among cancer patients. Fifteen states in the South and Midwest have not expanded Medicaid, and this public policy decision appears to expose breast cancer patients to substantially greater financial burdens. Medicaid expansion should be considered to mitigate financial burden among working age women with breast cancer.

 

29.01 Impact of Global Migration on Asian Breast Cancer: A Comparison between US and Taiwan

Posted on January 31, 2019

J. Wu1,2, Y. Hung2, S. M. Stapleton2, Y. Hsu2, S. T. Oseni2, C. Huang1, D. C. Chang2  1National Taiwan University Hospital,Surgery,Taipei, Taiwan 2Massachusetts General Hospital,Surgery,Boston, MA, USA

Introduction:

More than half of the Asian Americans with breast cancer were born in Asia, however it is unknown whether their disease patterns are different from Asians born in the US. We hypothesize that nativity status may have an impact on the onset and the presentation of breast cancer in the Asian population.

Methods:

A retrospective analysis was performed for Asian females³ 20 years old in the US Surveillance, Epidemiology, and End Results (SEER) Program database, and as a convenience sample from Asia, in the Taiwan Cancer Registry (TCR) for the years 2004-2010. The primary end point was proportion of patients who had early-onset breast cancer, defined as breast cancer age at onset before 50. Secondary outcome was the proportion of advanced breast cancers, defined by American Joint Committee on Cancer staging III to IV. Three groups of patients were compared: Native Asian in Taiwan (TW), Asia-born Asian American (AAA), and US-born Asian American (USAA).

Results:

We identified 13,404 patients (2,743 USAA & 10,661 AAA) in SEER and 49,322 TW in TCR. TW presented at an earlier age than AAA (median age 51vs 56) and USAA (median ­­­­­­61). TW had the highest proportion of early-onset breast cancer (44.3% vs 31.7% AAA and 23.7% USAA, p < 0.001). In addition, both TW and AAA had significantly higher rates of advanced cancer at presentation than USAA (22.8% and 17.2% vs 13.8%, respectively, p < 0.001).

Conclusions:

Recent immigrants to the US may be at increased risk of earlier and more aggressive breast cancers. Future studies should determine whether these differences are due to biomedical factors, access to healthcare, or poor healthcare quality affecting immigrant communities. The impact of immigration on health and disease remains an under-appreciated but important way through which we can further understand the interaction between social and biomedical factors on disease onset and progression.

23.07 Impact Of Traumatically Brain-Injured Donors On Outcomes After Heart Transplantation

Posted on January 31, 2019

A. Suarez-Pierre1, T. C. Crawford1, X. Zhou1, C. Lui1, C. D. Fraser1, E. Etchill1, K. Sharma2, R. Higgins1, G. J. Whitman1, A. Kilic1, C. W. Choi1  1Johns Hopkins University School Of Medicine,Cardiac Surgery,Baltimore, MD, USA 2Johns Hopkins University School of Medicine,Cardiology,Baltimore, MARYLAND, USA

Introduction: Heart transplant recipients of traumatically brain-injured (TBI) donors have been reported to have inferior survival and increased rates of coronary artery vasculopathy in single-center studies with limited sample sizes. This study sought to examine the impact of TBI donors on outcomes after heart transplantation. 

Methods:  We identified all adult heart transplants performed between January 2007 and December 2016 (inclusive) in the OPTN database. Patients undergoing repeat or heterotopic heart transplantation were excluded from the study. Recipients were dichotomized based on donor cause of death (TBI versus non-TBI), propensity-scored across 22 variables with known associations with mortality, and matched 1:1 without replacement. The primary endpoint was all-cause mortality at 1-, 3-, and 5-years after transplantation. Secondary endpoints were 3- and 5-year survival conditional on 1-year survival and rates of coronary artery vasculopathy at 1-, 3-, and 5- years after transplant. 

Results: In the study period, 20,244 patients underwent heart transplantation. TBI was the primary cause of death of all donors (53.4%; 10,816/20,244) and among TBI donors, blunt injury (59.6%; 6,443/10,816) and gunshot wound (35%; 3,781/10,816) were the most common mechanisms of traumatic brain injury. Propensity matching generated 6,919 pairs with adequate covariate balance (all standardized mean differences < 0.07). Risk-adjusted survival was similar between recipients of TBI donors and non-TBI donors at 1-year (90.5% vs 90.0%, log-rank p=0.32), 3-years (84.1% vs 83.3%, log-rank p=0.25), and 5-years (78.1% vs 77.5%, log-rank p=0.34). Risk-adjusted survival conditional on 1-year survival, was also similar at 3-years (92.8% vs 92.6%, log-rank p=0.57) and 5-years (86.2% vs 86.1%, log-rank p=0.74). The risk-adjusted rates of coronary artery vasculopathy did not differ either at 1-year (8.0% vs 7.7%, log-rank p=0.60), 3-years (20.6% vs 20.4%, log-rank p=0.77), or 5-years (30.6% vs 30.4%; long-rank p=0.78).

Conclusion: In the largest analysis of TBI donors in heart transplantation, we found similar survival and rates of coronary artery vasculopathy to those who received hearts from non-TBI donors out to 5 years. These findings should allay concerns over continued transplantation with this unique donor population.

23.06 Persistent Gender Disparities in Access to Kidney Transplantation

Posted on January 31, 2019

C. Holscher1, C. Haugen1, K. Jackson1, A. Kernodle1, S. Bae1, J. Garonzik Wang1, D. Segev1  1Johns Hopkins University School Of Medicine,Baltimore, MD, USA

Introduction: While national policies direct organ allocation for waitlisted candidates, the decision to list a candidate for transplantation is made at the center- and patient-level. Historically, women have had decreased access to kidney transplantation (KT). We sought to investigate if gender disparities in access to KT have improved over time. 

Methods: To explore temporal trends in access to KT, we studied 1,511,863 adults (age 18-99) with incident end-stage renal disease (ESRD) using the United States Renal Data System (USRDS) from 2000 to 2015. We divided the study period into four eras and compared characteristics of patients who were and were not listed for transplantation (Chi-square and Student’s t tests), and tested if waitlisting changed over time (Cuzick test of trend).  We used Cox regression to determine the association between era and access to transplantation while controlling for candidate factors.  As a sensitivity analysis to determine whether a differential risk of death before waitlisting impacted our inferences, we used a competing risk regression using the Fine and Gray method with a 5% random sample.

Results: The proportion of ESRD patients who were subsequently waitlisted decreased over time (13.2% in 2000-2003 to 8.7% in 2012-2015, p<0.001). Compared to those who were never waitlisted, waitlist registrants were less likely to be female (37% vs 45%, p<0.001), were younger (mean 50 vs. 66 years, p<0.001), were more likely to be African American (32% vs 28%, p<0.001), were more likely to be Hispanic (20% vs. 13%, p<0.001), and were more likely to have private insurance (38% vs. 17%) or be uninsured (13% vs 6%, p<0.001). After controlling for age, race, ethnicity, and prior insurance, men had similar access to KT over time (per 4-year era, aHR 1.00, 95% CI 1.00-1.01, p=0.6), while women had less access (aHR 0.80, 95% CI 0.20-0.81, p<0.001) that worsened with time (interaction p<0.001) (Figure). For context, in 2000-2003, women were 20% less likely to be waitlisted for kidney transplant (aHR 0.80, 95% CI 0.78-0.82, p<0.001), while in 2012-2015 this worsened to 22% less likely (aHR 0.78, 95% CI 0.76-0.80, p<0.001). Our sensitivity analysis using a competing risk regression also showed persistent gender disparities in waitlisting.

Conclusion: Despite decades of studies showing that women have less access to kidney transplantation, gender disparities in access to KT have not improved over time, rather they have worsened. Further focus and novel interventions are needed to improve access for female KT candidates. 

 

23.02 A National Survey of Sexual Harassment Among Surgeons

Posted on January 31, 2019

A. Nayyar1, S. Scarlet1, P. D. Strassle1, D. W. Ollila1, L. M. Erdahl3, K. P. McGuire2, K. K. Gallagher1  1University Of North Carolina At Chapel Hill,Department Of Surgery,Chapel Hill, NC, USA 2Virginia Commonwealth University,Department Of Surgery,Richmond, VA, USA 3University Of Iowa,Department Of Surgery,Iowa City, IA, USA

Introduction:

Emerging data suggests that experiencing sexual harassment in the workplace is a common occurrence for women across all professions, which can be harmful personally and professionally.  While recent studies have reported the incidence of sexual harassment in medicine, no study has examined the nature or scope of sexual harassment experienced by surgeons.

 

Methods:

An anonymous, electronic survey was distributed via a web-based platform to members of American College of Surgeons (ACS), Association of Women Surgeons (AWS), and through targeted social media platforms from April-July 2018. Questions pertained to workplace experiences and frequency of sexual harassment in the past 12 months. Sexual harassment was defined according to the U.S. Equal Employment Opportunity Commission. Fisher’s exact and Mantel-Haenszel tests were used to assess differences in respondent characteristics.

Results:

1,005 individuals completed the survey. 74% (n=744) identified as women, a response rate of 18% among US women surgeons. 25% (n=249) of respondents identified as men which represents 1% of male surgeons in the US – these responses were analyzed separately. Respondents reported employment by an academic institution (51%), community medical center (13%), private practice (15%), or other (19%). For both genders, the most common specialties were general surgery (34%), trauma surgery (10%), and surgical oncology (8%). Overall, 58% (n=432) of women surgeons experienced sexual harassment within the 12-month period preceding the survey, compared to 25% (n=61) of men, p<0.0001. Among women, the most common forms of harassment reported were “verbal or physical conduct (e.g. body language)” (53%), “unwanted sexual advances or physical contact” (23%), and “comments about sexual orientation” (10%). Women trainees were more than twice as likely to experience harassment as compared to attending surgeons (OR 2.52, 95% CI 1.78, 3.56, p<0.0001). The majority (84%) of incidents of harassment reported by women as part of the survey were not reported to any institutional authority. The most common reasons for not reporting was “fear of a negative impact on my career” (43%), “fear of retribution” (32%), and “fear of being dismissed and/or inaction towards perpetrator” (31%) (Figure).  

Conclusion:

Our study indicates that there is an alarming prevalence of unreported sexual harassment experienced by women surgeons in the US.   Combined with the documented sexual harassment of women physicians in other medical specialties, we believe this finding demonstrates an urgent need to improve the safety of the healthcare workplace, not just for women surgeons, but for all.
 

22.08 Setting of Care in Colon Cancer: Which Patients Benefit the Most from Care at Academic Centers?

Posted on January 31, 2019

J. K. Ewing1, J. J. Cabo1, X. Shu2, X. O. Shu2, M. Tan1, K. Idrees1, C. E. Bailey1  1Vanderbilt University Medical Center,Department Of Surgery, Division Of Surgical Oncology And Endocrine Surgery,Nashville, TN, USA 2Vanderbilt University Medical Center,Division Of Epidemiology,Nashville, TN, USA

Introduction: Some studies show that care at an academic center (AC) improves survival for patients with advanced stage colon cancer (CC). However, it remains unclear which patients have the greatest survival benefit from treatment at AC. The primary aim of this study is to determine which patients have the most improvement in overall survival (OS) from treatment at AC, relative to other treatment facilities (TF).

Methods: A retrospective cohort study of adults with histologically confirmed CC was performed using the National Cancer Database (2004-2014). TF were classified as community cancer programs (CCP; 100-500 cases/year), comprehensive community cancer programs (CCCP; >500 cases/yr), academic centers (AC; >500 cases/yr with residency training program), or integrated network cancer programs (INCP; multi-center organizations). Demographic and clinical factors were compared according to TF. Kaplan-Meier curves and log-rank tests were used for univariate survival analysis. Cox proportional hazard models were used to assess the impact of TF on OS after adjusting for patient, tumor, and treatment characteristics.  Subgroup analyses were performed stratifying by stage, age, and race.

Results:The cohort included 433,997 patients with median age of 69(Interquartile range: 59-78). Most were white(83.8%), had Medicare(55.4%) or private insurance(34.8%), and were treated at CCCP(49.1%) or AC(26.5%). Median OS was greatest for patients treated at AC(107.1 months), compared to INCP(98.5 mo), CCCP(95.9 mo), and CCP(90.2 mo) (P<0.001). On multivariate analysis, there was no significant difference in OS between patients with stage IV CC treated at CCCP or INCP relative to those treated at CCP. However, an improvement in OS was observed for patients with stage IV CC treated at AC(Hazard ratio [HR] 0.85, 95% Confidence Interval [CI] 0.83-0.87, P<0.001) (Figure 1A). Similarly, among patients younger than 70, patients treated at CCCP or INCP had similar OS relative to those treated at CCP, whereas those treated at AC had improved OS relative to those treated at CCP(HR 0.86, 95% CI 0.84-0.88, P<0.001) (Fig. 1B). Finally, for African American (AA) patients, treatment at CCCP and INCP had similar OS compared to treatment at CCP, whereas improved OS was observed for AA patients treated at AC(HR 0.88, 95% CI 0.84-.91, P<0.001). A similar pattern was observed for non-white, non-AA patients (Fig. 1C).

Conclusion:Treatment at AC is especially beneficial for patients with stage IV CC, patients younger than 70, and non-white patients. For these patients, treatment at AC was independently associated with 12-15% reduced mortality relative to treatment at CCP. Further work is needed to examine why certain groups benefit more from care at AC.

22.07 Expansion Coverage and Preferential Utilization of Cancer Surgery Among Minorities and Low-Income Groups

Posted on January 31, 2019

A. B. Crocker1, A. Zeymo1,2, J. McDermott1, D. Xiao1, T. Watson4, T. DeLeire5, N. Shara2,3, K. S. Chan1,2, W. B. Al-Refaie1,4  1MedStar-Georgetown Surgical Outcomes Research Center,Washington, DC, USA 2MedStar Health Research Institute,Washington, DC, USA 3Georgetown-Howard Universities Center for Clinical and Translational Science,Washington, DC, USA 4Department of Surgery, MedStar-Georgetown University Hospital,,Washington, DC, USA 5Georgetown McCourt School of Public Policy,Washington, DC, USA

Introduction:
Pre-Affordable Care Act (ACA) Medicaid expansions have demonstrated inconsistent effects on cancer surgery utilization rates among racial minorities and low-income Americans. Currently, it remains unknown how Medicaid expansion coverage under the ACA will impact these vulnerable populations with long standing disparities in access and outcomes of surgical cancer care. Using a quasi-experimental design, this study seeks to examine whether Medicaid expansion differentially increased the utilization of surgical cancer care for low-income groups and racial minorities in states that expanded their Medicaid program relative to states that did not.

Methods:
A cohort of over 95,000 patients aged 18-64 years who underwent cancer surgery were examined in two Medicaid expansion states (Kentucky and Maryland) vs. two non-expansion states (Florida and North Carolina). This evaluation utilized merged data from the State Inpatient Database, American Hospital Association, and the Area Resource File from the Health Resources and Services Administration for the years 2012-2015. Poisson interrupted time series analysis (ITS) were performed to examine the impact of ACA Medicaid expansion on the utilization of surgical cancer care for the uninsured overall, low-income persons, and racial and ethnic minorities after adjusting for age, sex, Elixhauser comorbidity score, population- and provider-level characteristics.

Results:
Following Medicaid expansion, the share of Medicaid patients receiving surgical cancer care in expansion states increased by 56%, compared to an 11% decrease in non-expansion states (p <0.001). Simultaneously, the percentage of uninsured patients declined by 63.4% in expansion states relative to a 10% reduction in non-expansion states (p < 0.001).  For persons from low-income zip codes, Medicaid expansion was associated with an immediate 24% increase in utilization (p = 0.002), relative to no significant change in non-expansion states. However, there were no significant trends observed post ACA expansion for racial and ethnic minorities in expansion vs. non-expansion states (Figure). 

Conclusion:
In this quasi-experimental evaluation, Medicaid expansion was associated with greater utilization of cancer surgery by low-income Americans, but provided no preferential effects for racial minorities in expansion states. Beyond the availability of coverage, these early findings highlight the need for additional investigation to uncover other factors that contribute to racial disparities in surgical cancer care.
 

22.06 Post-thyroidectomy Neck Appearance and Impact on Quality of Life in Thyroid Cancer Survivors

Posted on January 31, 2019

S. Kurumety1, I. Helenowski1, S. Goswami1, B. Peipert1, S. Yount2, C. Sturgeon1  2Feinberg School Of Medicine – Northwestern University,Department Of Medical Social Sciences,Chicago, IL, USA 1Feinberg School Of Medicine – Northwestern University,Department Of Surgery,Chicago, IL, USA

Introduction:  There is a paucity of patient-reported data on thyroidectomy scar perception. The magnitude and duration of the impact of thyroidectomy scar on quality of life (QOL) is not known. We hypothesized that age, sex and race would predict scar perception, and that worse scar perception would correlate with lower?QOL. Furthermore, we hypothesized that over time, scar perception would improve.

Methods: Adults >18 years who had undergone thyroidectomy for cancer?(n=1743)?were recruited from a support group and surveyed online. Demographics, clinical characteristics, and treatment history were assessed. Scar perception was scored on a 5-point Likert scale.?QOL was evaluated via PROMIS-29. Respondents were grouped and compared based on their responses. The relationship between scar perception, patient characteristics, and QOL were?analyzed?with univariable and multivariable?models. Kruskal-Wallis, Fisher’s exact test, and cumulative logistic regression were used to compare?categorical variables. The relationship?between PROMIS domains and scar perception?were?analyzed using Spearman partial correlation coefficients?(r)?adjusted for age and years after surgery.?Holms-Bonferroni was used to correct for multiple comparisons.

Results: Increasing age?was associated with?better?scar perception (OR 0.975/year; 95% CI 0.967-0.983; p<0.001).?71% of respondents age >45?years?reported no concern over scar, compared to only 53% of respondents?<45;?p < 0.0001. Increased time since surgery?was?also associated with?improved?scar perception (OR 0.962/year; 95% CI 0.947-0.977; p<0.0001), but there was no statistically significant difference between current and baseline neck appearance >2 years after surgery. On multivariable analysis, age >45 years (OR 0.65; [0.52-0.81] p=0.0001), >2 years since surgery (OR 0.57; 95% CI 0.46-0.70; p<0.0001), and higher self-reported QOL (OR 0.77; 95% CI 0.67-0.89; p=0.0003) were independent predictors of better self-reported scar appearance. In patients <2 years after surgery (n=568), the PROMIS domains of anxiety (rs=0.19; p<0.0001), depression (rs=0.21; p<0.0001), social function (rs=-0.18; p<0.0001), and fatigue (rs=0.21; p<0.0001) had weak but statistically significant associations with worse scar appearance. Sex and race/ethnicity were not associated with scar perception.

Conclusions: This is the largest study conducted in the U.S to evaluate scar perception after thyroidectomy, and the first to use PROMIS measures.??Age >45, >2 years since surgery, and higher self-reported QOL were independent predictors of better scar perception.??There was no significant difference between perception of current and baseline neck appearance in the group of respondents >2 years after thyroidectomy. There was a weak correlation between scar perception?and?PROMIS domains in patients who had surgery within 2 years. The impact of thyroidectomy scar on QOL appears to be mild and transient and plateaus after 2 years.

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

Posted on January 31, 2019

C. K. Zogg1,2,3, D. Metcalfe3, A. Judge4, D. C. Perry3, M. L. Costa3, B. J. Gabbe5, A. H. Haider2  1Yale University School Of Medicine,New Haven, CT, USA 2Brigham And Women’s Hospital,Center For Surgery And Public Health,Boston, MA, USA 3University of Oxford,Oxford, United Kingdom 4University of Bristol,Bristol, United Kingdom 5Monash University,Melbourne, Australia

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

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

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

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

22.03 Targeted Checklist Compliance with Oral and Mechanical Prep Improves Surgical Site Infection Rates

Posted on January 31, 2019

C. L. Antonacci1, D. Armellino2, K. Cifu-Tursellino2, M. E. Schilling2, S. Dechario2, G. Husk2, M. Jarrett2, A. Antonacci2  1Tulane University School Of Medicine,New Orleans, LA, USA 2North Shore University And Long Island Jewish Medical Center,Manhasset, NY, USA

Introduction:

In addition to increased patient morbidity and mortality, National Surgical Quality Improvement Program data suggest that surgical site infection (SSI) accounts for a 9.2% increase in hospital costs above uncomplicated colectomy cases.  This project, which included 12 acute care facilities, was designed to reduce the incidence of post-colectomy SSI by implementing a system-wide standardized surgical bundle checklist, monthly communication of outcome data to practitioners and analysis of factors contributing to organ space infection, as defined by the National Healthcare Safety Network (NHSN). 

Methods:

A colectomy bundle checklist was utilized to gather information on clinical practice from 761 colectomy cases within our system from 1/1/2016 to 12/31/2017.  Data was entered into a relational database analyzing over 50 patient, procedure, SSI and bundle compliance elements at the system, hospital and surgeon level.   Documentation compliance with the checklist items was compared to surgeon specific NHSN infection rates (< 2.5% and > 2.5%) by paired Student’s t-test.

Results:

Compared to 2016, elective post-colectomy SSIs for our health system in 2017 were reduced by 33% with a 45.3% reduction in intrabdominal infections, a 71.4% reduction in deep space infections and a 6.1% reduction in superficial site infections.  Bundle checklist compliance was analyzed with respect to pre-operative use of oral antibiotics, mechanical bowel prep, and intra-operative re-dosing of IV antibiotics. Of 540 elective colectomy cases, 420 (77.78%) were in compliance with regard to oral antibiotics, 468 (86.67%) with mechanical bowel prep, and 441 (81.67%) with re-dosing IV antibiotics. Of 39 surgeons with checklist data and NHSN reported infections, 4 (10.26%) had infection rates less than 2.5%, while 35 (89.74%) had infection rates greater than 2.5%.  Statistically significant differences were observed in checklist compliance between surgeons with infection rates <2.5% and >2.5%, respectively, for: (1) oral antibiotics 186/217 (85.7%) v. 87/134 (64.9%), p < 0.002; and (2) mechanical bowel prep 194/217 (89.4%) v. 36/65 (55.5%), p<0.006.  The use of intra-operative re-dosing of IV antibiotics 171/217 (78.8%) v. 113/130 (86.9%) was not significantly different.

Conclusion:

These data suggest that implementing a system-wide standardized surgical bundle checklist  and  relational database system can significantly reduce the incidence of elective colectomy SSIs. Analysis of bundle checklist compliance between low infection rate surgeons (<2.5%) and high infection rate surgeons (>2.5%) demonstrates significantly lower utilization of pre-operative oral antibiotic and mechanical bowel preps in high infection rate surgeons. These data further suggest that target compliance rates may need to be set in the 85% to 90% range for these bundle items to achieve optimal reductions in elective colectomy SSIs. 

 

22.02 The Impact of Prehospital Whole Blood on Arrival Physiology, Shock, and Transfusion Requirements

Posted on January 31, 2019

N. Merutka1, J. Williams1, C. E. Wade1, B. A. Cotton1  1McGovern Medical School at UT Health,Acute Care Surgery,Houston, TEXAS, USA

Introduction: Several US trauma centers have begun incorporating uncrossmatched, group O whole blood into civilian trauma resuscitation. Our hospital has recently added this product to our aeromedical transport services. We hypothesized that patients receiving whole blood in the field would arrive to the emergency department with more improved vital signs, improved lactate and base deficit, and would receive less transfusions following arrival when compared to those patients receiving pre-hospital component transfusions. 

Methods: In Novemeber 2017, we added low-titer group O whole blood (WB) to each of our helicopters, alongside that of existing RBCs and plasma. We collected information on all trauma patients receiving prehospital uncrossed, emergency release blood products between 11/01/17 and 07/31/18. Patients were divided into those who received any prehospital WB and those who received only RBC and or plasma (COMP). Initial field vital signs, arrival vital signs, arrival lbaoratory values, and ED and post-ED blood products were captured. Statistical analysis was performed using STATA 12.1. Continuous data are presented as medians (25th-75th IQR) with comparisons performed using Wilcoxon ranksum. Categorical data are reported as proportions and tested for significance using Fisher’s exact test. Following univariate analyses, a multivariate model was created to evaluate post-arrival blood products, controlling injury severity score, field vital signs, and age. 

Results: 174 patients met criteria, with 98 receiving prehospital WB and 63 receiving COMP therapy. 116 WB units were transfused in the prehospital setting. Of those receiving WB prehospital, 84 (82%) received 1 U, 14 (12%) received 2U. There was no difference in age, sex, race, or injury severity scores between the two groups. While field pulse was similar (WB: median 117 vs. COMP: 114; p=0.649), WB patients had lower field systolic pressures (median 101 vs. 125; p=0.026) and were more likely to have positive field FAST exam (37% vs. 20%; p=0.053). On arrival, however, WB patients had lower pulse and higher systolic pressures than COMP patients (TABLE). There was no difference in arrival base excess and lactate values (TABLE). However, WB patients had less ED and post-ED blood transfusions than the COMP group. A multivariate linear regression model demonstrated that field WB was associated with a reduction in ED blood transfusions (corr. coef. -10.8, 95% C.I. -19.0 to -2.5; p=0.018).

Conclusion: Prehospital WB transfusion is associated with improved arrival physiology with similar degrees of shock compared to COMP treated pateints. More importantly, WB pateints received less transfusions after arrival than their COMP counterparts. 

18.21 Is Protocolized FFP Reversal truly inferior to the PCC for Patients with Warfarin associated ICH?

Posted on January 31, 2019

J. Butz1, Y. Shan1, R. Shadis1, T. Vu1, O. Kirton1  1Abington Hospital, Jefferson Health,Surgery,Abington, PA, USA

Introduction:  The Neurocritical Care Society and Society of Critical Care medicine are recommending the Prothrombin Complex Concentrate (PCC) as the preferred method of reversal for patient with warfarin related intracranial hemorrhage (ICH). The recommendation is based on studies, in which trauma patients are excluded. In trauma patients, protocol-based fresh frozen plasma (FFP) reversal may not be inferior.

Methods:  Our institution utilized a FFP reversal protocol for warfarin related traumatic ICH. The trauma registry (2010 – 2017) was surveyed for patients with ICH, who underwent warfarin reversal. Primary outcome was mortality. Secondary outcomes included ICH progression based on Stockholm score, neurological deterioration, need for surgical intervention, fluid overload, VTE complication, and re-admission. We compared the data to the previous published large population studies (n > 100) referenced in the Neurocritical Care Guideline.

Results: Total of 140 patients underwent FFP reversal protocol. Demographics were of the following: average age 80.8 ± 8.3 years, male 53.6%, female 46.4%, BMI 27.0 ± 6.0 kg/m2, fall 68%, Initial SBP 157 ± 32, Initial HR 80 ± 19, and Initial GCS of 13-15 96.4%. Average time to reversal (INR ≤ 1.5) was 6.1 ± 3.8 hours. Morality was 17.1%, ICH progression was 32.4%, and neurological deterioration was 18.6%. These were lower or comparable to previously published results after PCC reversal of 32-37% (1,2), 35.3% (3), and 20% (2) respectively. In these same studies, results from FFP reversal were 45.6-54%, 45.4%, and 11% respectively. Surgical intervention was done in 7.1% of patients. Fluid overload was 2.9%. VTE complication was 3.6%. Re-admission rate for ICH was 6.4%.

Conclusion: Studies on reversal of warfarin in hemorrhagic stroke patients may not be generalized to warfarin associated traumatic ICH patients. Dedicated studies on trauma patients are needed to evaluate the benefit of warfarin reversal with PCC.

1. Parry-Jones, AR. Napoli, MD. Goldstein, JN. et al. Reversal Strategies for Vitamin K Antagonists in Acute Intracerebral Hemorrhage. Annals of Neurology. 2015 78(1): 54-62

2. Majeed, A. Meijer, K. Larrazabal, R. et al. Mortality in Vitamin K antagonist-related intracerebral bleeding treated with plasma or 4-factor prothrombin complex concentrate. Thrombosis and Haemostasis. 2014; 111:233-239

3. Kuramatsu JB, Gerner ST, Schellinger PD, et al. Anticoagulant reversal, blood pressure levels, and anticoagulant resumption in patients with anticoagulation-related intracerebral hemorrhage. JAMA 2015; 313:824–836.

18.20 Central venous catheter-related DVT in the pediatric CVICU: causes and complications

Posted on January 31, 2019

E. H. Steen1, J. J. Lasa3, T. C. Nguyen3, S. G. Keswani2, P. A. Checchia3, M. M. Anders3  1Baylor College Of Medicine,Department Of Surgery,Houston, TX, USA 2Texas Children’s Hospital,Division Of Pediatric Surgery, Department Of Surgery,Houston, TX, USA 3Texas Children’s Hospital,Section Of Critical Care Medicine, Department Of Pediatrics,Houston, TX, USA

Introduction: Central venous catheter (CVC) use is common in the management of critically ill children, especially those with congenital or acquired heart disease (CHD). Prior reports suggest that the presence of a CVC augments the risk of deep vein thrombosis (DVT). How CVC-associated DVTs contribute to morbidity and mortality in this high risk patient population is unknown. Taken together, the aim of this study is to identify the factors associated with DVT and thrombus propagation in the pediatric cardiovascular intensive care unit (CVICU) population.

Methods: The PC4 database and a radiologic imaging database for patients admitted to Texas Children’s Hospital were retrospectively reviewed. During the one year study period (January – December 2017), there were 1215 unique central lines placed in 851 admissions. Information gathered included demographics and outcomes of patients requiring central line placement in the TCH CVICU, as well as the incidence of DVT and complications. Data shown as OR [95% CI] by univariate linear regression; p value < 0.05 considered significant.

Results: DVT was diagnosed in 8% of admissions with a CVC. Almost 30% of these patients demonstrated thrombus extension into the inferior vena cava (IVC). The diagnosis of DVT is a highly significant risk factor for mortality in these patients (p=.0001, OR 6.1 [2.8, 13.1]). In a univariate regression model, the risk factors most significantly associated with DVT include the presence of more than one line and higher total line hours (defined as the sum of all lines multiplied by the number of hours each line was in place), as well as longer duration of intubation and extended CVICU admission times. A diagnosis of low cardiac output syndrome (LCOS), sepsis, UTI, CLABSI, and cardiac catheterization during admission are also significant risk factors. Of these, only longer catheter dwell times (p=.0001) and cardiac catheterization (p=.002) are significantly associated with the diagnosis of DVT on multivariate analysis. Interestingly, both LCOS and CLABSI (p<0.0001 in each) are significantly associated with propagation of the thrombus into the IVC. Of note, cardiac surgery with cardiopulmonary bypass appears to be protective of clot development (p=0.001, OR 0.38 [0.22, 0.67]). 

Conclusion: We have defined risk factors for CVC-associated DVT in the pediatric CVICU population, as well as specific factors associated with clot propagation into the IVC. CVC-associated DVTs impart a significant risk of morbidity and mortality in critically ill children, highlighting the need for well-designed studies to determine the best preventive and therapeutic strategies and to establish guidelines for appropriate monitoring and follow up of these patients.

18.19 Circumstances of Gunshot Injury: Understanding a Population

Posted on January 31, 2019

A. McGreal1, B. Tracy2, K. Williams2, R. Smith2,3  1Mercer University School of Medicine,Department Of Surgery,Savannah, GEORGIA, USA 2Emory University School of Medicine,Department Of Surgery,Atlanta, GEORGIA, USA 3Rollins School of Public Health,Atlanta, GEORGIA, USA

Introduction:  National surveillance provides data regarding the incidence and prevalence of gun-related injuries (GRIs), yet little is known about the circumstances surrounding these events.  We believe an understanding of how GRIs occur will better inform patient outreach and violence prevention. This study seeks to characterize the contexts and clinical impact of GRIs.

Methods:  In 2018, we performed a 4-month prospective review of patients who presented to our Level 1 trauma center because of a GRI.  We analyzed patient demographics, injury details, disposition, operations performed, and length of stay.  We then surveyed the patients regarding the context of the event, i.e. whether it was intentional, the immediate circumstances, or who was the owner of the gun.

Results: There were 186 patients sustaining GRIs during the study, of which 79 were included in analysis.  Most patients were black males in their third decade of life.  Patients presented with an average of 2.63 missile wounds with the most affected body region being the lower extremities.  Men had more missile wounds than females (2.76 vs 1.92, p= 0.05) and more retained ballistics (57 vs 7, p=0.03).  Sixty percent (n=47) of patients received an operation during their hospitalization with a mean of 5 procedures.  Most operations were orthopedic (53%, n=25), followed by general surgery interventions (45%, n=21).  Intentional injuries accounted for 76% (n=60) of GRIs, with 42% (n=25) of these events related to interpersonal altercations and 36% (n=22) related to robberies.  Unintentional injuries represented 24% (n=19) of GRIs of which the majority of patients (47%, n=9) were uninvolved bystanders.  Regarding gun ownership, 8 patients knew the owner, 9 owned the gun, and the remaining 62 were unknown.  

Conclusion: Our patient population largely sustained GRIs from intentional, interpersonal altercations and robberies.  These etiologies may shed light on the economic plight and desperation plaguing our city.  Interestingly, despite the number of intentional injuries, little is known or shared about ownership of the associated gun.  Furthermore, the volume of procedures per patient is high, which imparts a significant financial burden.  Ultimately, we still must better understand the circumstances that surround GRIs in order to effectively treat the survivors of these injuries and create effective outreach programs aimed at violence prevention.

« Previous Page
Next Page »