Academic Teaching Hospital Research Articles

1151: CARDIAC ARREST OUTCOMES AND TIME OF DAY: A SINGLE-CENTER STUDY

Introduction: Previous studies of in-hospital cardiac arrest have shown lower survival rates in arrests which occur during the night time hours. These statistics have held true when looking at aggregate data throughout the hospital as well as specifically in the ICU. The majority of prior analyses have been on registry data from a wide range of facilities, including both academic teaching and community hospitals. This study looks at sentinel arrests occurring in the ICU of a community hospital primarily staffed by advanced practice providers overnight with emergency physician code team backup. Methods: This retrospective, observational analysis of a Code Blue database looked at the survival to hospital discharge of adult patients who received either CPR or defibrillation while in the ICU between January 1st, 2015 – December 31st 2019 based on timing of arrest (0700 – 1859, 1900 – 0659). Binary logistic regression was utilized to assess the relationship between time of day and survival to discharge, as well as chance of ROSC. Multivariable logistic regression was performed utilizing age, gender, initial rhythm, comorbidities, use of vasoactive medications as well as ventilatory status at time of arrest. Results: Over the 5-year period there were 219 Code Blue events meeting the prespecified criteria, of these 118 (54%) occurred during the night hours while 101 (46%) occurred during the day. Survival was 23/118 (19.5%) on nights and 29/101 (28.7%) on days. After adjusting for confounders there was no significant association between an arrest occurring between the hours of 0700 – 1859 p=0.173 OR 1.69[CI 95% 0.79 – 3.6] and survival to hospital discharge. The unadjusted analysis demonstrated an OR 0.24[CI 95% 0.15 - 0.38] of survival if the arrest occurred during this timeframe. An initial shockable rhythm exhibited a positive effect on survival p=0.011 OR 3.7[CI 95% 1.36 – 10.07], while acute kidney injury p=0.012 OR 0.36 [CI 95% 0.17 – 0.8] and the use of vasoactive medications p= < 0.001 OR 0.19 [CI 95% 0.09 – 0.44] at the time of arrest were associated with a negative outcome. Conclusions: When adjusted for confounding factors there was no difference in cardiac arrest outcomes based on time of day in the ICU of a large community hospital staffed by advanced practice providers at night.

395. Impact of Racial Disparities on Clostridioides difficile Infection (CDI) Outcomes at a Southern California Academic Teaching Hospital

Abstract Background Infectious diseases are the second leading contributor to racial disparities in healthcare. Clostridioides difficile infection (CDI) is a common community/hospital acquired infection that can cause life-threatening colitis. Despite the influence that socioeconomic factors, insurance status, and access to care can have on CDI outcomes, there is a dearth of literature that evaluates the impact of racial differences. The objective of this study was to identify racial disparities in CDI and describe clinical outcomes among hospitalized adults. Methods This is an IRB approved, retrospective study of adult patients (≥ 18 years) hospitalized with initial episodes of CDI between January 2020 to June 2021. Initial CDI episodes were identified by the ICD-10 code A04.72. Medical records were reviewed for demographics, comorbid conditions, insurance, total length of stay (LOS), and need for intensive care unit (ICU) admission. Patients were dichotomized by race/ethnicity into either the racially and ethnically minoritized (REM) group or the non-Hispanic White (n-REM) group. P value of ≤ 0.05 was defined as significant. Results In total 220 patients (61.8% REM, 136/220; 38.2% n-REM, 84/220) with an initial CDI episode were included. Majority of the REM patients were Hispanic (38.2%) followed by Black (13.6%), and Asian (5%). Compared to the n-REM group, the REM patients were younger (60 vs 69 years, p =0.016) and were more likely to have underlying comorbidities (diabetes mellitus 33% vs 9.5%; p &amp;lt; 0.001 and chronic kidney disease 48.5% vs 21.3%; p &amp;lt; 0.001). The REM patients were more likely to present with fulminant CDI (21.3% vs 11.9%; p =0.1). The REM patients were also more likely to be admitted to the ICU during their stay (41.9% vs 26.2%; p =0.021) and have a longer hospital length of stay (LOS) (12 vs 7 days; p =0.02). Lastly, the REM patients were more likely to be under-insured with 91 patients (66.9%) having Medi-Cal insurance compared to 34 patients (40.5%) in the n-REM group (p &amp;lt; 0.001). Conclusion Despite being younger, REM patients were more likely to require an ICU admission, have underlying comorbidities, have a longer LOS, and be under-insured. There is a need for further studies to understand disparities between REM and n-REM patients regarding CDI. Disclosures All Authors: No reported disclosures.

Incidence and severity of thrombocytopenia associated with use of intravascular microaxial ventricular assist devices for treatment of cardiogenic shock.

The use of temporary mechanical circulatory support (MCS) for patients with refractory cardiogenic shock has increased over the past decade. Impella devices (intravascular microaxial ventricular assist devices [VADs]) have become common MCS options but reportedly cause thrombocytopenia. Limited published data regarding the incidence or severity of microaxial VAD-associated thrombocytopenia exists. The goal of this study was to determine the incidence, timing, and severity of thrombocytopenia in a microaxial VAD population. A retrospective multicenter review of electronic medical records identified all patients implanted with microaxial VAD at three US academic teaching hospitals between June 2015 and August 2017. Patients were excluded for short-term procedural microaxial VAD use during percutaneous coronary intervention. Sixty-four patients underwent microaxial VAD insertion (95% for left-sided support) during the observed time period. Support was in place for a median duration of 5.2 (interquartile range [IQR]: 2.4-10.0) days. Within 7 days postinsertion, 98.5% of patients developed thrombocytopenia (platelet count <150,000/μl) and 81.3% of patients experienced a>50% platelet decrease. Average platelet count nadir was 68,200/μl or 63.9% from baseline occurring on median day 3.8 (IQR: 2.4-5.4). Twenty-four patients (38.1%) were tested for heparin-induced thrombocytopeniaby the heparin-dependent antibody (HDA) test. All HDAs were either negative or had serotonin release assay negative confirmation. Postdevice removal, platelet counts returned to baseline or >150,000/μl in 63% of patients by Day 5. Microaxial VAD-associatedthrombocytopenia is common. Practitioners should consider this when evaluating supported patients for other causes of thrombocytopenia. Platelet counts return to preimplantation levels within days of device removal.

Development and Validation of Machine Learning Models to Classify Artery Stenosis for Automated Generating Ultrasound Report.

Duplex ultrasonography (DUS) is a safe, non-invasive, and affordable primary screening tool to identify the vascular risk factors of stroke. The overall process of DUS examination involves a series of complex processes, such as identifying blood vessels, capturing the images of blood vessels, measuring the velocity of blood flow, and then physicians, according to the above information, determining the severity of artery stenosis for generating final ultrasound reports. Generation of transcranial doppler (TCD) and extracranial carotid doppler (ECCD) ultrasound reports involves a lot of manual review processes, which is time-consuming and makes it easy to make errors. Accurate classification of the severity of artery stenosis can provide an early opportunity for decision-making regarding the treatment of artery stenosis. Therefore, machine learning models were developed and validated for classifying artery stenosis severity based on hemodynamic features. This study collected data from all available cases and controlled at one academic teaching hospital in Taiwan between 1 June 2020, and 30 June 2020, from a university teaching hospital and reviewed all patients' medical records. Supervised machine learning models were developed to classify the severity of artery stenosis. The receiver operating characteristic curve, accuracy, sensitivity, specificity, and positive and negative predictive value were used for model performance evaluation. The performance of the random forest model was better compared to the logistic regression model. For ECCD reports, the accuracy of the random forest model to predict stenosis in various sites was between 0.85 and 1. For TCD reports, the overall accuracy of the random forest model to predict stenosis in various sites was between 0.67 and 0.86. The findings of our study suggest that a machine learning-based model accurately classifies artery stenosis, which indicates that the model has enormous potential to facilitate screening for artery stenosis.

The Implementation and Role of Peer Mentor Group in Advancing Clinical Skills in Inpatient Neurorehabilitation

<h3>Research Objectives</h3> To measure the effectiveness of a peer mentor group in improving clinical knowledge and application for novice occupational therapists on an adult inpatient rehabilitation unit. <h3>Design</h3> Current mentorship models were evaluated using a staff survey and available literature. Based on results, peer mentor group was established and pre/post measures were taken for each group session to evaluate effectiveness. <h3>Setting</h3> 48 bed adult inpatient neurorehabilitation unit in an academic teaching hospital in New York City. <h3>Participants</h3> Novice occupational therapists with 0-3 years experience working with the brain injury population in inpatient rehabilitation. <h3>Interventions</h3> Peer mentor group provides novice occupational therapists working with the brain injury population a safe environment to share challenges related to specific topics and administration of interventions. Each session, senior level therapists facilitate guided clinical discussions regarding specific topics/interventions and work to promote a knowledge sharing environment to support education of when interventions are clinically indicated and techniques for administration of each specific intervention. <h3>Main Outcome Measures</h3> Pre and post peer mentor group surveys are administered to staff therapists prior to each peer mentor group and the same question set is administered immediately following. This tool uses a Likert scale to measure knowledge of when interventions are clinically indicated, confidence level in administering interventions, and confidence in knowing where to locate resources. <h3>Results</h3> Results demonstrate improvements for staff therapists in knowledge of when specific interventions are clinically indicated as well as knowledge in administration of specific interventions following participation in the peer mentor group. <h3>Conclusions</h3> Improved scores on post-surveys following participation in a peer mentor group indicate participation is beneficial for novice staff therapists as a supplement to advance clinical skills in working with patients with acquired brain injury, specifically knowledge of when interventions are clinically indicated and individual confidence levels in administering interventions. Further investigation is warranted to develop a standard protocol for facilitators of each peer mentor group to determine the optimal structure of the group in order to maximize outcomes and increase efficacy of the program. <h3>Author(s) Disclosures</h3> None.

Navigator programme for hospitalised adults experiencing homelessness: protocol for a pragmatic randomised controlled trial

IntroductionPeople experiencing homelessness suffer from poor outcomes after hospitalisation due to systemic barriers to care, suboptimal transitions of care, and intersecting health and social burdens. Case management programmes have been...

Deprescribing Medications that Increase the Risk of Falls in Older People: Exploring Doctors' Perspectives Using the Theoretical Domains Framework (TDF).

Falls can lead to hospitalisation and death in older people. Polypharmacy is a major risk factor, and deprescribing fall-risk increasing drugs (FRIDs) is one of several possible important preventive measures. The objective of this study was to explore the factors that influence doctors when deprescribing FRIDs in a hospital setting. Semi-structured interviews were conducted with consultant geriatricians and hospital doctors experienced in dealing with patients aged 65 years or older, at a large academic teaching hospital (~ 1000 beds), Dublin, Ireland. The interviews were directed by an interview guide and audio recorded and transcribed verbatim, with subsequent thematic analysis in NVivo 12 software. A total of 18 participants were interviewed. Barriers to deprescribing included: insufficient time, incomplete patient records, changing medications initiated by other specialists and difficulties following up patients after discharge. Facilitators included: enhanced documentation through electronic patient records, the support of other healthcare professionals such as clinical pharmacists, and patients' engagement, which is considered essential for the success of the deprescribing process's outcome. Deprescribing FRIDs in older adults in the hospital setting is challenging. Implementation of the process in practice requires combined effort from stakeholders to tackle everyday work environment challenges. Future studies are required examining the clinical effect of the suggested interventions and exploring patients' involvement in deprescribing decisions.

Introduction of an internal medical trainee high-fidelity simulation course programme

The Trust felt that a targeted programme was needed to help further prepare Internal Medical Trainees’ (IMT) for their current duties and forthcoming roles as registrars. We wanted to provide them with the opportunity to boost their confidence and practice working alongside junior medical colleagues, in order to enhance patient safety [1]. These programmes could also work alongside the regional THRIVE and STRIVE sessions. A three-year programme was introduced. For IMT year 1, it is a half-day of 3 scenarios following a patient’s journey through an admission with key objectives being around difficult decision-making and communication. For IMT year 2, this includes a day of 5 challenging scenarios based around situations the IMT’s are called for. They look at non-technical aspects of their job in the context of complex clinical situations including bradycardia, supraventricular tachycardia, cardiac arrests, mental capacity, and duty of candour. IMT year 3, includes two days with the IMT3A course involving trainees working with Foundation Year Doctors over 5 scenarios where they are escalated to as the senior on call. The focus is developing skills such as prioritisation, leadership and communication. All candidates take part in the debriefing. The IMT3B course is a day of 5 extremely challenging scenarios in difficult settings such as out of hours or with limited senior presence. These scenarios are devised to push the IMT3 candidates in order to help prepare them for working under pressure. Scenarios include difficult ethical decision-making, litigation issues, and complex patients (e.g. pregnancy). The sessions were positively evaluated by the IMT who expressed how they will help change their practice and enhance patient safety (see Feedback from the internal medical trainees We feel that as the IMT work through the programme prepares them for what is a difficult transition. Over their IMT simulation training they will take part in 18 scenarios either as a candidate or in the debriefing. It has given the IMT the chance to have high quality training in a high-fidelity environment thus promoting enhanced care and patient safety. 1. Wayne D, Didwania A, Feinglass J, Fudala M, Barsuk J,McGaghie W. Simulation-based education improves quality of care during cardiac arrest team responses at an academic teaching hospital: A case controlled study. Chest. 2008;133(1):6–9.

"Here's What I Wish You Knew": A Qualitative Narrative Analysis of the Adolescent Sickle Cell Pain Experience

Background Bias, stigmatizing language, and social isolation are significant barriers to the optimal care of pain for adolescents and young adults (AYA) with sickle cell disease (SCD). Qualitative studies that include first-person narratives of SCD pain are underrepresented in outcomes research but provide valuable information for clinical education and community care models. Here, we present the interim analysis of an ongoing thematic research study that analyzes narrative experiences of AYA patients with SCD and their journeys- both in and out of the healthcare system- with chronic pain. Methods In this IRB-approved study, a single semi-structured interview is administered to patients ages 13-21 with sickle cell disease (Hemoglobin SS, SC, and SBeta0Thal genotypes) living in a mid-sized metropolitan center and receiving care at an academic teaching hospital. Patients are offered the opportunity to participate from inpatient units, ambulatory continuity clinics, and community advocacy groups. Interviews are conducted either in-person or remotely, recorded, transcribed, and independently checked for accuracy. The interview includes questions about coping with pain in medical and non-medical settings, interactions with the healthcare team, impacts of pain on social and community life, and opportunities to describe what patients wish family members, teachers, friends, and healthcare providers understood about living with SCD pain. Transcripts are analyzed for thematic coding by 2 independent coders using a deductive approach with latent textual analysis (Braun & Clarke, 2013). Codes are translated into themes by key-words-in-context and indigenous categorization methods (Ryan, 2011). Thematic coders are not members of the patients' clinical care teams, and patients do not provide interviews during acute pain crises. Results At the time of submission, 8 interviews were completed and analyzed. The median patient age was 17 years. Concordant coding revealed five primary themes: the relationship between acute and chronic pain, coping with rituals and cycles of care, the unpredictable nature of pain, navigating a biased healthcare system, and social isolation. The majority of patients detailed their experiences with intense, coexistent physical and emotional pain (6/8) that creates a pervasive sense of uncertainty and foreboding (4/8) in their lives. They described navigating a healthcare system that is difficult to understand, while experiencing doubts and dismissals of their pain from healthcare providers, particularly when making the transition to adult care (4/8). Lack of education and awareness about SCD in academic settings (5/8) and "missing out" on social milestones and norms (6/8) were cited as sources of isolation and emotional fatigue. Having a family member or community-based care advocate was viewed as a critical source of support within both the health system and community (4/8). Discussion and Future Directions This ongoing qualitative research study in adolescent and young adults with SCD provides narrative data about the lived experience of sickle cell pain from the patient perspective. Interim analysis suggests several locations in the care trajectory where reports of pain may be particularly vulnerable to bias: in healthcare settings for management of acute-onset pain crisis, in schools and other academic support settings where knowledge of SCD may be incomplete, and in the transition of care from pediatric to adult care models. Particularly during acute pain management and transition care experiences, patients describe the use of stigmatizing language- in conversation and in the electronic health record- that contribute to feelings of isolation, frustration, and emotional suffering. Results of this study are being used to inform community, pastoral, and school-based sickle cell education programs as well as medical education curricula aimed at reducing stigmatizing language. Results are also being used to develop standard criteria for sickle cell patient advocates, and to improve infrastructure for the integration of patient advocates into sickle cell care teams. Future research will measure the impact of patient participation in narrative research on clinical outcomes and attitudes toward engaging the healthcare system, both for routine care and potential SCD clinical research. Figure 1View largeDownload PPTFigure 1View largeDownload PPT Close modal

Response to COVID-19 Infection and Vaccination in the CLL Population: A Large Single-Center Experience

BACKGROUND: Patients with chronic lymphocytic leukemia (CLL) are at increased risk of morbidity and mortality after infection with severe adult respiratory syndrome coronavirus 2 (SARS-CoV-2) and illness with coronavirus disease 2019 (COVID-19). Vaccination is of crucial importance in this patient population yet CLL patients demonstrate impaired vaccination responses with decreased ability to produce neutralizing anti-SARS-CoV-2 antibodies. COVID-19 boosters increase response rates in most patients with CLL, but their impact on "real-word” disease-related outcomes warrants further study. Therefore, we evaluated the outcomes of COVID-19 infection and response to COVID-19 vaccination and boosters in patients with CLL. METHODS: This was a retrospective cohort study conducted in a single-center, North American academic teaching hospital in a large, urban area. Data was collected from January 2020 to December 2021. This time period coincided with SARS-CoV-2 Alpha and Delta variant predominant waves of infection in New York City, with Omicron (BA.1) dominating the last two weeks of December 2021. Patients with a diagnosis of CLL were evaluated for inclusion based on retrospective chart review. In total, 338 patients with CLL were included. RESULTS: Of 338 patients with CLL, 252 patients (74.6%) underwent testing for COVID-19, of whom 57 (16.9%) had evidence of active or resolved infection. 10 patients tested positive by ECLIA, 38 by RT-PCR, and 9 by both detection methods. Characteristics of patients with documented infection are depicted in Figure 1A. 51 patients (89.5%) were symptomatic, and 6 (10.5%) were asymptomatic. 24 patients (42.1%) required hospitalization and 9 deaths were recorded (15.6% case fatality rate). 7 of 32 patients (21.8%) who had received CLL therapy died, versus 2 of 25 (8.0%) who never received therapy. Mortality was 19.6% in patients > 60 years compared to 0% in those ≤ 60 years. 269 patients were vaccinated against COVID-19, and 127 patients received a booster vaccination (third vaccine dose). The response rate in 114 evaluable patients who were tested for antibody response after 2 doses of vaccine was 66.6% (76/114, median assessment at 160 days [range, 1-253 days] after dose #2). 77 patients had antibody response evaluated only after receiving booster vaccination. In these patients, 70.1% had an antibody response at a median of 42 days (range, 5-145 days). In patients with both pre- and post-booster data (n=28), the response rate increased from 46.2% (13/28) to 85.7% (24/28) after receiving a third vaccination. Across the entire cohort, 74.3% (142/191) of evaluable patients responded to vaccination either on initial evaluation or on serial testing (Figure 1B-C). 11 COVID-19 infections occurred following at least one vaccination, and one patient died 2 days after receiving a second vaccination. Receipt of prior or current CLL-directed therapy differed between the antibody-positive and negative groups (53.5% vs 77.6%), although both groups had received a median of 2 lines of therapy. BTK inhibitors and combination venetoclax/anti-CD20 antibody were the most commonly used treatments in both groups. Median IgG (740 vs 504 mg/dL) and the proportion of patients with an IgG level < 700 mg/dL (43.0% vs 75.5%) differed between the antibody-positive and negative groups, respectively. The case-fatality rate was 9.1% (1/11) in the vaccinated group compared to 17.8% (8/45) in the unvaccinated group. There were 6 documented COVID infections in patients who had a documented vaccination response and none in patients without documented response. No deaths occurred in the former group. CONCLUSIONS: Serologic response to COVID-19 vaccination occurred in three-quarters of patients with CLL. This antibody response to vaccination compares very favorably to earlier, large studies that reported a response rate of 40-50%. A significant improvement in serologic response in patients between second and third vaccinations offers real-world evidence to support the efficacy of booster vaccination in this population. An additional expanded analysis including subsequent data from the Omicron variant predominant BA.1, BA.2, and BA.4/5 waves is in progress and will be presented. Figure 1View largeDownload PPTFigure 1View largeDownload PPT Close modal

Circulating dihydrotestosterone, testosterone, and free testosterone levels and dihydrotestosterone-to-testosterone ratios in healthy women across the menstrual cycle

To characterize the circulating androgen levels across the menstrual cycle in healthy women using highly sensitive and accurate methods and report sex differences in the relative levels of dihydrotestosterone (DHT) to testosterone (T) levels. Prospective cohort study. Research clinic, academic teaching hospital. Twenty-one healthy premenopausal women, aged 19-40 years, with regular menstrual cycles. Not applicable. Serum total T and DHT levels measured using liquid chromatography-tandem mass spectrometry, free T levels measured using a standardized equilibrium dialysis method coupled with measurement of the T levels in the dialysate using liquid chromatography-tandem mass spectrometry, and comparison of the DHT-to-T ratio between healthy women and age-matched healthy men. The serum total and free T levels increased across the follicular phase and peaked at midcycle (total T, 43.6 ± 16.2 ng/dL; free T, 15.6 ± 11.9 pg/mL) and gradually declined in the luteal phase. The DHT level did not significantly change across the menstrual cycle. The DHT-to-T ratios were 1:4 and 1:13 in women and men, respectively. In healthy premenopausal women, the total and free T levels varied significantly across the menstrual cycle, whereas the DHT levels did not change; the peak total and free T levels in the midcycle period were higher than previously reported, underscoring the importance of establishing menstrual phase-specific reference ranges to avoid misdiagnosis of hyperandrogenism. Women have significantly higher DHT levels relative to total T than men; the significance of this sex difference in the DHT-to-T ratio needs further investigation.

A Comparison Study Quantifying Environmental Impact of All Surgical Modalities of Hysterectomies

<h3>Study Objective</h3> Compare carbon dioxide emissions generated from operating room waste from all types of hysterectomies. Improving provider awareness on the environmental impact of hysterectomies may facilitate interventions to minimize our carbon footprint. <h3>Design</h3> A prospective cohort study was conducted, including patients who had a hysterectomy for any indication. Surgical waste in pounds (lbs), procedure data, and patient demographics was collected for each case. The formula below was used to identify the emissions generated for each procedure: <i>CO2 emissions = Waste in pounds (lbs) x 1 short ton/2000 lbs x EPA emission factor (kg CO2 per short ton) x global warming potential</i> <h3>Setting</h3> A 305-bed Level II Trauma center and academic teaching hospital, 11/2021 – present. <h3>Patients or Participants</h3> A total of 81 women ≥ 18 years of age underwent a scheduled hysterectomy (robotic assisted, laparoscopic, vaginal, abdominal) for benign or malignant indications at one institution. We excluded women < 18 years of age and emergent hysterectomies (i.e., postpartum hysterectomy). Data collection is ongoing with the goal of reaching a sample size of 100. <h3>Interventions</h3> Waste that was generated for every hysterectomy was weighed by the Primary Investigator. <h3>Measurements and Main Results</h3> Among the 81 cases analyzed, there was no significant difference between groups in age, ethnicity, and BMI. The total waste generated by each type of hysterectomy ranges from lowest (vaginal, 3 lbs.) to highest (robotic, 46 lbs.). CO2 emissions was significantly higher for robotic hysterectomies (57%, <0.0001) when compared to the other types. 100% of robotic hysterectomy waste contributed more than the mean CO2 emission of our sample. There was no significant association between duration of surgical case and amount of waste generated. Additional analysis in progress. <h3>Conclusion</h3> Robotic hysterectomies were found to generate a statistically significant majority of CO2 emissions. Additional studies are needed to determine the environmental impact and strategies to reduce our carbon footprint.

8761 Batwing Endometriosis: Radiographic Findings and Surgical Approach

<h3>Study Objective</h3> To present radiographic findings suggestive of deep infiltrating endometriosis of the uterosacral ligaments and posterior torus uterinus (referred to as batwing endometriosis) and review surgical considerations and approach to excision of disease. <h3>Design</h3> Description of imaging findings and surgical technique. <h3>Setting</h3> Academic teaching hospital. <h3>Patients or Participants</h3> Patients with batwing endometriosis on preoperative pelvic magnetic resonance imaging (MRI) and concordant intraoperative findings. <h3>Interventions</h3> Preoperative pelvic MRI and laparoscopic or robotic excision of endometriosis with and without hysterectomy. <h3>Measurements and Main Results</h3> Batwing endometriosis can often be associated with an obliterated posterior cul-de-sac and present significant challenges during laparoscopy. Here we review a systematic approach to aid with restoration of this space and focus on relevant anatomy to consider. The following important steps are discussed: methods for navigating ureterolysis, ways to shave disease and preserve neurovascular and ligament support, and finally, techniques to consider with vaginal cuff closure for concurrent hysterectomy. In addition to highlighting batwing endometriosis on MRI, key pelvic structures are identified including the ureter, uterine vessels, and pararectal space which all aid in dissection. <h3>Conclusion</h3> Identification of batwing endometriosis on preoperative pelvic MRI may improve surgical planning. Knowledge of important anatomic considerations and surgical steps allows for safe and effective excision for patients with batwing endometriosis.

8557 Laparoscopic Resection of Involuting Cesarean Scar Pregnancy after Failed Multidose Methotrexate and KCl Treatment

<h3>Study Objective</h3> To describe the workup, treatment, and follow up of a cesarean-section scar ectopic pregnancy (CSP) that failed medical management and to demonstrate a laparoscopic resection of a cesarean section scar ectopic pregnancy that has failed medical management. <h3>Design</h3> Surgical video. <h3>Setting</h3> An academic teaching hospital and tertiary care center. <h3>Patients or Participants</h3> 36-year-old G2P2022, with a persistent cesarean scar ectopic pregnancy, who failed medical management with a multi-dose Methotrexate protocol and intrasac KCl injection and presented 3 months later for infertility evaluation. <h3>Interventions</h3> After failing medical management, the patient consented for a laparoscopic resection of CSP with revision of the previous scar. During surgery, the patient was found to have an involuting ectopic pregnancy at the site of the previous scar, which was successfully resected. The uterine incision was repaired in two layers. <h3>Measurements and Main Results</h3> The laparoscopic repair was completed successfully. Pathology showed fibrotic and necrotic chorionic villi with an adjacent decidual reaction consistent with a pregnancy. The patient's beta-hcg trended down to non-pregnant levels and she had a normal postoperative visit with no concerns. <h3>Conclusion</h3> Recommended treatment for CSP includes surgical resection, as medical management alone is unlikely to be successful. Key strategies for laparoscopic excision include use of backfilling the bladder to delineate borders, avoidance of excessive thermal energy, and closure of the defect in multiple layers.

Does Leuprolide Acetate Predict Successful Pain Relief after Hysterectomy and BSO in Endometriosis Patients?

<h3>Study Objective</h3> Evaluate whether patients with endometriosis-associated pelvic pain who achieve pain relief with leuprolide acetate are more likely to achieve pain relief after hysterectomy and oophorectomy (BSO). <h3>Design</h3> Retrospective chart review. <h3>Setting</h3> Academic teaching hospital. <h3>Patients or Participants</h3> Patients who underwent trial of leuprolide acetate prior to hysterectomy and BSO for endometriosis. <h3>Interventions</h3> We performed a retrospective chart review of patients from 2015-2021 who had a diagnosis of endometriosis and underwent a trial of leuprolide acetate prior to hysterectomy with BSO for pelvic pain (n=31). We reviewed pre-operative records, operative notes, and postoperative records to assess whether patients achieved pain relief following ovarian suppression with leuprolide acetate or definitive surgical management with hysterectomy and oophorectomy. Patients who achieved complete pain relief with leuprolide acetate or hysterectomy with oophorectomy were considered having achieved "complete pain relief". <h3>Measurements and Main Results</h3> 31 patients underwent a trial of leuprolide acetate prior to hysterectomy and BSO for endometriosis. Fifteen patients reported "complete pain relief" with leuprolide acetate therapy and 16 did not. The groups were similar in age, ethnicity, race, BMI, parity, number of past treatments for pelvic pain, mode of hysterectomy, blood loss during surgery, presence of adhesions, and surgical complications. There was a significant difference between the two groups as to whether they achieved complete pain relief after hysterectomy with BSO. Among patients with complete pain relief after leuprolide acetate therapy, 73.7% reported complete pain relief after surgery. In patients who did not experience complete pain relief with leuprolide acetate therapy, only 37.5% reported complete pain relief after surgery (p=.045). <h3>Conclusion</h3> Patients who had complete preoperative pain relief using leuprolide acetate were more likely to achieve pain relief with hysterectomy and BSO. A trial of leuprolide acetate prior to surgery may be helpful to predict which patients will benefit from hysterectomy and BSO for endometriosis-related pelvic pain.

8400 Distal Ureteral Resection with Ureteroneocystotomy; A Case of Robotic Assisted Laparoscopic Management of Ureteral Endometriosis

<h3>Study Objective</h3> Video presentation showing distal ureterectomy and reimplantation. <h3>Design</h3> Case presentation with showing procedural techniques in detail. <h3>Setting</h3> Tertiary academic teaching hospital. <h3>Patients or Participants</h3> 39-y.o. G6P3033 with past medical history of upper extremity deep venous thrombosis and surgical history of tubal ligation as well as endometrial ablation for menorrhagia, presented to the emergency room with right lower quadrant pain and was found to have right hydronephrosis and a 1.6 cm right ureterovesical junction mass on CT scan. She underwent a cystoscopy and right ureteric balloon dilation with stent placement with no evidence of bladder endometriosis. MRI showed a 1.6cm nodule at a low-intensity signal in T2-weighted sequences, suspicious for ureteral endometriosis. <h3>Interventions</h3> She underwent diagnostic laparoscopy with total hysterectomy and bilateral salpingectomy, robotic assisted distal ureterectomy with ureteroneocytotomy and stent placement. Her anticoagulation was held 48h prior to the surgery and re-initiated the day after her surgery. <h3>Measurements and Main Results</h3> The stent was discounted at 8 weeks post-operative. At 12 weeks post-operative she had an ultrasound done with normal fin dings and resolved hydronephrosis. <h3>Conclusion</h3> Preoperative planning and multidisciplinary team approach to management of severe endometriosis affecting the ureter is of paramount importance. While medical management is often the first-line therapy for endometriosis, urinary tract involvement often represents advanced stage of the disease, thereby timely diagnosis and appropriate surgical intervention is required to avoid permanent kidney injury.

Optimizing Surgeon Longevity: Ergonomics in Robotic Surgery

<h3>Study Objective</h3> To describe the risk of physical injury to robotic surgeons and review optimal set up of the robotic console, bedside assistant, and uterine manipulator that decrease risk of a work-related injury. <h3>Design</h3> Video demonstration with narrated description. <h3>Setting</h3> Tertiary care academic teaching hospital. <h3>Patients or Participants</h3> Surgeons trained in robotic surgery. <h3>Interventions</h3> Ergonomically favorable operating room set up for the robotic console, bedside assistant, and uterine manipulator. <h3>Measurements and Main Results</h3> Per the US Labor Department, the highest incidence of work-related injuries is in healthcare. Prior research suggests robotic surgery is more ergonomically favorable in the upper back, shoulders, arms and wrists and mentally less stressful than conventional laparoscopy. However, over 50% of robotic surgeons have work related pain with less than 20% of all robotic surgeons having received formalized ergonomic training. This video reviews appropriate operating room set up for the robotic console, bedside assistant, and uterine manipulator along with common positioning and postural errors that may lead to physical strain. <h3>Conclusion</h3> In order to maximize career longevity and minimize work-related injuries, surgeons must understand the ergonomically correct set up that is recommended for the robotic console, bedside assistant, and uterine manipulator. Early adoption of these recommendations can help prevent physical injuries and should be an essential foundation of trainees' operative skills.

8397 Metroplasty; A Case of Bicornuate Uterus

<h3>Study Objective</h3> Video presentation showing laparoscopic metroplasty. <h3>Design</h3> Case presentation with showing procedural techniques in detail. <h3>Setting</h3> Tertiary academic teaching hospital. <h3>Patients or Participants</h3> 29-yo G3P0 with history of a 16 and an 18 weeks pregnancy losses leading to evaluation and diagnosis of bicornuate uterus with no other identifiable cause of recurrent second trimester loss. Her past medical history is significant for polycystic ovarian syndrome, otherwise healthy with no surgical history. US showed equal cavities in size and there is a small indentation about 2 cm at the top of the uterus. <h3>Interventions</h3> Hysteroscopy, followed by laparoscopic metroplasty. <h3>Measurements and Main Results</h3> Uncomplicated procedure with 3 months follow-up hysteroscopy showing normal cavity with no evidence of polyp, both ostia visualized, and secretory endometrium appreciated with no adhesions seen. <h3>Conclusion</h3> Surgical correction of bicornuate uterus is only recommended in patients with a history of poor pregnancy outcome after other potential causes have been ruled out. It is crucial to resect only the inter cavity segment to preserve normal size uterine cavity. Multi-layer myometrial closure is recommended.

Systematic Approach to Using Magnetic Resonance Imaging for the Patient with Deep Infiltrating Endometriosis

<h3>Study Objective</h3> To demonstrate systematically how to identify deep infiltrative endometriosis (DIE) on MRI and compare preoperative MRI imaging to intraoperative laparoscopic findings. <h3>Design</h3> Video demonstration of MRI images and surgical footage with narrated description. <h3>Setting</h3> Tertiary care academic teaching hospital. <h3>Patients or Participants</h3> Patients with deep infiltrative endometriosis in the anterior, middle, and posterior compartments. <h3>Interventions</h3> Preoperative MRI was completed for patients with suspected DIE due to reported symptoms or examination findings to confirm DIE presence and extension. <h3>Measurements and Main Results</h3> The diagnosis and evaluation of DIE is difficult with physical examination and laparoscopic exploration alone. MRI is easily reproducible and surveys the anterior, middle, and posterior compartments of the pelvis in single study even if lesions are obscured by adhesions. This video reviews how to systematically identify DIE on preoperative MRI and provides specific tips for each pelvic compartment. This video shows how appropriate preoperative planning allows for one step laparoscopy with subspecialty surgeons (e.g.: case 1 with General Surgery, case 3 with Colorectal Surgery). <h3>Conclusion</h3> Because successful treatment of DIE requires surgical excision, preoperative confirmation of DIE presence and extension is extremely important. Surgeons should understand how to evaluate MRI images for DIE and use these findings to guide preoperative surgical planning and intraoperative exploration.

Compliance with a novel hand hygiene protocol tailored to non-sterile healthcare workers in the operating theatre

Observing hand hygiene compliance (HHC) among non-sterile healthcare workers (HCWs) in the operating theatre (OT) is challenging as there are no tailored protocols or observation tools. To develop and test a hand hygiene protocol tailored to non-sterile HCWs in the OT. In this prospective observational study, nine hospitals in the Rotterdam-Rijnmond region provided input on a draft protocol on hand hygiene in the OT, resulting in a new consensus protocol for the region. An observation tool based on the protocol was developed and tested. HHC rates with 95% confidence intervals (CI) were calculated by type of hospital and type of HCW. The protocol has three sections: (1) written general hand hygiene rules; (2) written hand hygiene rules specific for anaesthesia and surgery; and (3) visual representation of the OT, divided into four hand hygiene areas. Hand hygiene should be applied when changing area. Average HHC of 48.0% (95% CI 45.2-61.2%) was observed in OTs across all hospitals. HHC was highest in the two specialized hospitals (64.0%, 95% CI 30.6-89.8%; 76.7%, 95% CI 62.8-84.5%) and lowest in the academic teaching hospital (23.1%, 95% CI 0.0-45.8%). In terms of type of HCW, HHC was lowest among anaesthesiologists (31.6%, 95% CI 19.2-62.4%) and highest among OT assistants (57.4%, 95% CI 50.1-78.2%). This uniform way of observing HHC in the OT enables evaluation of the effectiveness of interventions in the OT and facilitates friendly competition. In the Rotterdam-Rijnmond region, HHC in the OT was below 50%; this needs to be addressed, particularly in teaching hospitals and among physicians.