Affiliated Centers Research Articles

Factors Influencing the Adjuvant Therapy Decision: Results of a Real-World Multicenter Data Analysis of 904 Melanoma Patients.

Simple SummaryAdjuvant treatment of stage III/IV melanoma patients with immune-checkpoint inhibition or targeted therapy can significantly improve recurrence-free survival. However, it is unknown how many patients with an indication for adjuvant therapy do indeed choose to receive it and what the reasons for declining are. In patients with a BRAF mutation, it is not known whether more patients prefer targeted or immunotherapy. This study investigates the real-world situation of 904 patients from 13 German Dermatologic Cooperative Oncology Group skin cancer centers with an indication for adjuvant treatment since the approval of the corresponding drugs as adjuvant treatment. Aims of this study were to investigate the patient groups who opt for or against adjuvant treatment, respectively targeted or immunotherapy, and the reasons for refusal. Findings of this study show the current acceptance and choice of adjuvant melanoma treatment and may support patients and physicians in the therapy decision-making process.Adjuvant treatment of melanoma patients with immune-checkpoint inhibition (ICI) and targeted therapy (TT) significantly improved recurrence-free survival. This study investigates the real-world situation of 904 patients from 13 German skin cancer centers with an indication for adjuvant treatment since the approval of adjuvant ICI and TT. From adjusted log-binomial regression models, we estimated relative risks for associations between various influence factors and treatment decisions (adjuvant therapy yes/no, TT vs. ICI in BRAF mutant patients). Of these patients, 76.9% (95% CI 74–80) opted for a systemic adjuvant treatment. The probability of starting an adjuvant treatment was 26% lower in patients >65 years (RR 0.74, 95% CI 68–80). The most common reasons against adjuvant treatment given by patients were age (29.4%, 95% CI 24–38), and fear of adverse events (21.1%, 95% CI 16–28) and impaired quality of life (11.9%, 95% CI 7–16). Of all BRAF-mutated patients who opted for adjuvant treatment, 52.9% (95% CI 47–59) decided for ICI. Treatment decision for TT or ICI was barely associated with age, gender and tumor stage, but with comorbidities and affiliated center. Shortly after their approval, adjuvant treatments have been well accepted by physicians and patients. Age plays a decisive role in the decision for adjuvant treatment, while pre-existing autoimmune disease and regional differences influence the choice between TT or ICI.

Clinical judgment is a cornerstone for validating and using clinical prediction rules: a head-to-head study on ambulation outcomes for spinal cord injured patients.

Retrospective comparative study. Clinical prediction rules (CPRs) are an effervescent topic in the medical literature. Recovering ambulation after a traumatic spinal cord injury (tSCI) is a priority for patients and multiple CPRs have been proposed for predicting ambulation outcomes. Our objective is to confront clinical judgment to an established CPR developed for patients with tSCI. Level one trauma center specialized in tSCI and its affiliated rehabilitation center. In this retrospective comparative study, six physicians had to predict the ambulation outcome of 68 patients after a tSCI based on information from the acute hospitalization. Ambulation was also predicted according to the CPR of van Middendorp (CPR-vM). The success rate of the CPR-vM and clinicians to predict ambulation was compared using criteria of 5% for defining clinical significance, and a level of statistical significance of 0.05 for bilateral McNemar tests. There was no statistical difference between the overall performance of physicians (success rate of 79%) and of the CPR-vM (81%) for predicting ambulation. The differences between the CPR-vM and physicians varied clinically and significantly with the level of experience, clinical setting, and field of expertise. Confronting CPRs with the judgment of a group of clinicians should be an integral part of the design and validation of CPRs. Head-to-head comparison of CPRs with clinicians is also a cornerstone for defining the optimal strategy for translation into the clinical practice, and for defining which clinician and specific clinical context would benefit from using the CPR.

Accuracy of parotid gland FNA cytology and reliability of the Milan System for Reporting Salivary Gland Cytopathology in clinical practice.

BackgroundDifferentiating between malignant and benign salivary gland tumors with fine‐needle aspiration cytology (FNAC) can be challenging. This study was aimed at testing the validity of the Milan System for Reporting Salivary Gland Cytopathology (MSRSGC) and at assessing possible differences in the sensitivity and specificity of parotid gland FNAC between dedicated head and neck (H&N) centers, subdivided into head and neck oncology centers (HNOCs) and head and neck oncology affiliated centers (HNOACs), and general hospitals (GHs).MethodsThe Dutch Pathology Registry (PALGA) database was searched for patients who had undergone a salivary gland resection between January 1, 2006, and January 1, 2017, and had a preoperative FNAC result. The FNAC reports were retrospectively assigned to MSRSGC categories. The risk of malignancy (ROM) was calculated for each category. The sensitivity and specificity for diagnosing malignancy were calculated and compared among HNOCs, HNOACs, and GHs.ResultsIn all, 12,898 FNAC aspirates were evaluated. The ROMs for each category were as follows: 12.5% in MSRSGC I, 10.3% in MSRSGC II, 29% in MSRSGC III, 2.3% in MSRSGC IVa, 28.6% in MSRSGC IVb, 83% in MSRSGC V, and 99.3% in MSRSGC VI. The sensitivity of FNAC was highest in HNOCs (88.1%), HNOACs scored lower (79.7%), and GHs had a sensitivity of 75.0%.ConclusionsThe MSRSGC is a valid tool for reporting parotid gland FNAC; therefore, these results strongly advocate its use. On the basis of the higher sensitivity of FNAC in dedicated H&N centers, the authors recommend that GHs use the presented management strategies to help to minimize the chances of a preoperative misdiagnosis.

Financial toxicity, mental health, and gynecologic cancer treatment: The effect of the COVID-19 pandemic among low-income women in New York City.

BACKGROUNDNew York City (NYC) emerged as an epicenter of the COVID‐19 pandemic, and marginalized populations were affected at disproportionate rates. The authors sought to determine the impact of COVID‐19 on cancer treatment, anxiety, and financial distress among low‐income patients with gynecologic cancer during the peak of the NYC pandemic.METHODSMedicaid‐insured women who were receiving gynecologic oncology care at 2 affiliated centers were contacted by telephone interviews between March 15 and April 15, 2020. Demographics and clinical characteristics were obtained through self‐report and retrospective chart review. Financial toxicity, anxiety, and cancer worry were assessed using modified, validated surveys.RESULTSIn total, 100 patients completed the telephone interview. The median age was 60 years (range, 19‐86 years), and 71% had an annual income <$40,000. A change in employment status and early stage cancer (stage I and II) were associated with an increase in financial distress (P < .001 and P = .008, respectively). Early stage cancer and telehealth participation were significantly associated with increased worry about future finances (P = .017 and P = .04, respectively). Lower annual income (<$40,000) was associated with increased cancer worry and anxiety compared with higher annual income (>$40,000; P = .036 and P = .017, respectively). When controlling for telehealth participation, income, primary language, and residence in a high COVID‐19 prevalence area, a delay in medical care resulted in a 4‐fold increased rate of anxiety (P = .023, 95% CI, 1.278‐14.50). Race was not significantly associated with increased financial distress, cancer worry, or anxiety.CONCLUSIONSLow socioeconomic status was the most common risk factor for increased financial distress, cancer worry, and anxiety. Interventions aimed at improving access to timely oncology care should be implemented during this ongoing pandemic.

Cefazolin prophylaxis in minimally invasive gynecologic surgery – are dosage and timing appropriate? Prospective study using resampling simulation

ObjectiveCefazolin is a widely used antimicrobial prophylactic agent, however the appropriate dosage, timing, pharmacology and microbial coverage have not been well-established for gynecologic procedures. We aimed to describe serum concentrations and pharmacokinetics of Intravenous cefazolin given to women prior to scheduled minimally invasive gynecologic surgeries, and to determine whether appropriate antimicrobial coverage had been achieved in short time from prophylactic administration to surgical start time. MethodsA prospective cohort analysis study, using a resampled dataset, of women undergoing scheduled gynecological surgeries in a university affiliated tertiary medical center. IV cefazolin (1 or 2 gr) was administered prior to incision to women weighing <80 kg (Group A) and ≥80 kg (Group B), respectively. Cefazolin serum levels were obtained at the time of skin incision (Time 0) and 30 min later (Time 30), measured by high-pressure liquid chromatography (HPLC). Appropriate antimicrobial coverage was defined when cefazolin serum levels were above minimal inhibitory concentrations (MIC) for Enterobacteriaceae. ResultsOverall, 21 women were included. The mean time interval between drug administration and incision did not differ between the two groups (18 ± 10 min vs. 11 ± 10 min, respectively, p = .0.25). A hierarchical mixed linear regression model, using a simulation of multiple random bootstrap resampling (n = 1,000), revealed that cefazolin serum levels exceeded MIC, regardless of the timing of administration in the sampling intervals. Mean cefazolin serum levels in time 0 and time 30 min were not affected by BMI in patients receiving 1 gr. ConclusionA single dose of IV cefazolin given shortly prior to skin incision provides serum concentrations above minimal inhibitory concentrations for susceptible pathogens in most women undergoing scheduled minimally invasive gynecologic surgery.

Hand-assisted Laparoscopic Surgery for Colorectal Liver Metastasis: Analysis of Short-term and Long-term Results.

There is scant data regarding the outcomes of hand-assisted laparoscopic surgery (HALS) for colorectal liver metastasis (CRLM). The aim of this study is to report our experience and analyze the short-term and long-term results. Retrospective study of patients undergoing HALS for CRLM in 2 university affiliated medical centers. Two hundred and thirty-eight liver procedures were performed on 145 patients including 205 parenchymal sparing resections and 33 anatomic resections. The median number of metastases was 1 (range: 1 to 8), 38 patients (26.2%) had 3 or more metastases, and 41 patients (28.3 had a bi-lobar disease. The tumor size was 20 (2 to 90) mm, and 52 patients (36.6%) had a tumor larger than 30 mm. Nighty-nine patients (67.8%) received neoadjuvant chemotherapy. In 8 patients (5.5%) the laparoscopic liver resection was combined with ablation, and 16 patients (11%) underwent a synchronous resection of colorectal cancer. The median operative time, blood loss during surgery, and postoperative hospital stay were 163 minutes, 300 mL, and 4 days, respectively. The median modified Iwate complexity score was 4 (0 to 10) and the conversion rate to open surgery was 5.5%. The overall and major complication rates were 23.8% and 3.6%, respectively. The mortality rate was 0.7%. R0 resections were achieved in 91% of patients. Median overall survival for all the cohort (intend to treat) was 59 months, and the 8- and 10-year overall survival rates were 47.3% and 24.9%, respectively. This study shows that HALS is a safe and efficacious treatment for selected patients with CRLM.

A Novel Stimulation Protocol for Poor-Responder Patients: Combining the Stop GnRH-ag Protocol with Letrozole Priming and Multiple-Dose GnRH-ant: A Proof of Concept

Objective: The objective of this study was to examine whether the combined Stop GnRH-agonist (GnRH-ag), letrozole priming, and multiple-dose GnRH-antagonist (GnRH-ant) protocol may improve in vitro fertilization/intracytoplasmic sperm injection cycle in poor ovarian responders (PORs). Design: This was a historical cohort, proof of concept study under tertiary setting at University affiliated Medical Center. Patients: Five PORs fulfilling the POSEIDON Group 4 criteria were included. Main Outcome Measures: Number of oocytes retrieved, number of top-quality embryos (TQEs), and controlled ovarian hyperstimulation (COH) variables were the main outcome measures. Results: The combined Stop GnRH-ag, letrozole priming, and multiple-dose GnRH-ant COH protocol revealed significantly higher number of follicles >13 mm on the day of hCG administration and higher number of oocytes retrieved, with non-significantly more TQEs and a reasonable clinical pregnancy rate. Conclusions: The combined Stop GnRH-ag, letrozole priming, and multiple-dose GnRH-ant COH protocol is a valuable tool in the armamentarium for treating POSEIDON Group 4 patients. Further large prospective studies are needed to elucidate its role in POR and to identify the specific characteristics of women (before initiating ovarian stimulation) that will aid both fertility specialists’ counseling and their patients in adjusting the appropriate COH protocol.

Communication with fertility patients during the COVID-19 pandemic- let's talk about it

ObjectiveTo assess the impact of the COVID-19 pandemic on the activity of a tertiary fertility service and compare telemedicine and face-to-face meetings during this time. MethodsThis was a retrospective cohort study conducted in a university affiliated tertiary medical center. Included were patients scheduled for an appointment in the in-vitro fertilization (IVF) unit between March 18th and April 15th. A comparison was made between patients who chose telemedicine as opposed to face-to-face meetings. Additionally, the population of patients who chose to cancel their appointment was characterized. IVF cycle outcomes were additionally compared between the groups. ResultsOverall, 90 IVF clinic appointments were scheduled during the study period. Thirty-four (37.8 %) patients chose to arrive to the clinic in spite of the COVID 19 pandemic and partial quarantine, 27 (30.0 %) patients chose to avoid in person meeting and scheduled a telemedicine appointment and 29 (32.2 %) patients cancelled their appointment. On comparison between patients who chose telemedicine vs. face-to-face meeting, the telemedicine group had lower prevalence of primary infertility (20.0 % vs. 47.1 %, p = 0.037) and higher rates of preimplantation genetic testing indication for in-vitro fertilization (48.2 % vs. 20.6 %, p = 0.026). Rate of a first-ever clinic visit was higher in patients that arrived for a face-to-face meeting, as compared to telemedicine encounter (55.9 % vs. 28.0 %, respectively; p = 0.036). Patients that opted to avoid attending the clinic or meeting via telemedicine had higher rates of medical comorbidities compared to patients who chose to attend their appointment (51.7 % vs. 29.5 %, p = 0.016). Rate of appointments that led to fresh or frozen-thawed embryo transfer and these transfers' outcomes (clinical pregnancy rate) were similar in the telemedicine and face-to-face meeting groups (72.2 % vs. 88.0 % and 30.8 % vs. 31.8 %, p = 0.73 and p = 1.00; respectively). ConclusionTelemedicine is a valuable tool for delivering fertility care during the COVID-19 pandemic. There is need to determine which patients will benefit most from this modality.

Impact of location of inpatient cancer care on patients with Ewing sarcoma and osteosarcoma-A population-based study.

Ewing sarcoma (EWS) and osteosarcoma (OS) require multidisciplinary treatment. Care at specialized cancer centers (SCC: Children's Oncology Group affiliated and/or National Cancer Institute-designated cancer center) has been found to improve outcomes in patients with leukemia, but studies have not considered location of care and outcomes in EWS and OS patients, an ideal group to evaluate given their specialized multidisciplinary treatment needs. Patients hospitalized with primary EWS and OS (2000-2014) were identified using the California Cancer Registry linked with hospitalization data. Patients were divided into age groups (0-18, 19-39, ≥40years), and classified on whether they received all versus part/none of their inpatient treatment at a SCC within 1year of diagnosis. Multivariable Cox proportional hazards regression identified factors associated with survival. There were 531 ES and 959 OS patients. Five-year overall survival was better for patients with EWS (all: 63% vs. part/none: 42%) and OS (all: 64% vs. part/none: 47%) who received all of their treatment at a SCC. After adjusting for sociodemographic and clinical factors, receiving all inpatient cancer treatment at a SCC was associated with superior overall survival (EWS HR: 0.49, CI 0.37-0.67; OS HR: 0.78, CI 0.63-0.97). Our results suggest that treatment for EWS and OS at a SCC is associated with significantly improved survival even after adjustment for known prognostic factors. The superior survival among those treated at SCCs may be due to having greater access to clinical trials and services at SCCs.

African American Pediatric Liver Transplant Recipients Have an Increased Risk of Death After Transferring to Adult Healthcare

To analyze the long-term outcomes in pediatric liver transplant recipients after they have transferred to an adult provider and assess for racial disparities in health outcomes. This is a single-center, retrospective review of pediatric patients who underwent liver transplantation between July 1990 and August 2015 at a tertiary healthcare system with a large transplant center. Patient mortality and retransplantation were assessed after transfer to adult care. There were 120 patients who were transferred, of whom 19 did not meet the inclusion criteria. Of the remaining 101 patients, 64 (63%) transferred care to a nearby affiliated tertiary adult facility, 29 (29%) were followed by other healthcare systems, and 8 (8%) were lost to follow-up. Of the patients followed at our affiliated adult center, 18 of the 64 (28%) died. Of those 18 deaths, 4 (22%) occurred within the first 2years after transfer, and 10 (55%) within 5years of transfer. Four patients were retransplanted by an adult provider, of whom 2 eventually received a third transplant. African Americans had higher rates of death after transfer than patients of other races (44% mortality vs 16%, representing 67% of all cases of death; P=.032), with nearly 50% mortality at 20years from time of transplantation. Death is common in pediatric liver transplant recipients after transfer to adult care, with African Americans having disproportionately higher mortality. This period of transition of care is a vulnerable time, and measures must be taken to ensure the safe transfer of young adults with chronic health care needs.

Lateral frontal galeal-cutaneous flap for reconstruction after orbital exenteration for advanced periorbital skin cancer.

Background/aimOrbital exenteration (OE) is one of the most disfiguring procedures leading to significant deformity. Defect reconstruction is challenging, especially in elderly patients. Herein, experiences with orbital exenteration and primary reconstruction with lateral frontal galeal-cutaneous flap based on superficial temporal artery were reviewed.Materials and methodsData on patients treated for nonmelanoma skin cancer invading the orbit during a 10-year period were analyzed. The patient demographics, tumor features, reconstructive techniques used, complications, and survival were recorded with a median follow-up of 27.5 months.ResultsIncluded in the study were 26 patients in whom OE was performed, comprising 14 males and 12 females, with a mean age of 75.29 years (range: 61–87). The majority of the patients were treated for basal cell carcinoma with medial cantus as the primary site. All of the defects were closed using a lateral frontal galeal-cutaneous flap based on the superficial temporal artery, and in 2 patients, a temporalis muscle pedicle flap was used as an additional flap for reconstruction of the orbital roof in order to separate the brain from the empty orbit, and it was then covered with the same galeal-cutaneous flap. In 19 patients, the frontal area was closed primarily, and in 7 patients, skin graft was used for the secondary defect. There was no flap loss. Tumor-related death was registered in 3 patients (inoperable recurrent tumors) (11.5%), 7 died from complications that were unrelated to the tumors (2 were operated for recurrent orbital tumors), and 16 survived.ConclusionThe preferred method for reconstruction after OE at our university affiliated center is lateral frontal galeal-cutaneous flap based on the superficial temporal artery. Flap harvesting is simple, safe, and obtains enough tissue to cover the defects, even after extended exenteration. The complication rate is low. The simultaneous use of this flap with pedicle temporalis muscle flap is suggested only for reconstruction of the scull base after anterior cranial fossa resection.

Feasibility of Remote Occupational Therapy Services via Telemedicine in a Breast Cancer Recovery Program.

Access to perioperative breast surgery occupational therapy services remains limited in remote areas. To assess the feasibility and acceptance of occupational therapy services using a "hub-and-spoke" telemedicine model. Prospective study using videoconferencing to connect the occupational therapist, located at the hub site, with the patient, located at the spoke site. National Cancer Institute Comprehensive Cancer Center (hub site) and affiliated community cancer center (spoke site). The sites are 75 mi apart. Female breast cancer patients (N = 26) scheduled for breast surgery were asked to participate in telemedicine occupation therapy sessions. Patients lived in a geographically remote region and travelled a mean of 16 miles (range = 3-85) to the hub site. The majority (56%) of the patients had public insurance. Perioperative occupational therapy sessions completed through videoconferencing. Outcome measures were participation in and completion rate for the sessions, number of sessions required to return to baseline, and time interval from surgery to return to baseline function. Patient satisfaction was assessed with a questionnaire. Of the patients who enrolled in the study, 18 completed all postoperative sessions in which functional assessments, exercises, and education were provided. Patients regained baseline function within a mean of 42.4 days after surgery and after an average of three sessions. Patients reported high satisfaction with the sessions. Videoconference telemedicine in breast perioperative rehabilitation is feasible, effective, and acceptable to patients. This study adds to the emerging use of telemedicine for rehabilitative services. This study, by demonstrating the acceptability, practicality, and efficacy of breast perioperative occupational therapy services offered through a videoconferencing platform, supports continued research to evaluate the value of telemedicine. Issues with access to medical care may be mitigated through creative use of technology.

Special Convening and Listening Session on Health Equity and Community Outreach and Engagement at National Cancer Institute-Designated Comprehensive Cancer Centers.

In recent years, the cancer research and care community has been more attuned to health equity, increasingly pursuing coordinated and comprehensive action to achieve equitable health outcomes. In addition to its support of a joint research agenda for health disparities in 2017, the National Cancer Institute (NCI) has demonstrated its commitment to addressing health inequities with its 2012 requirement for cancer centers to define and address the needs of a local “catchment area” and the 2016 mandate for Community Outreach and Engagement (COE). With several years of experience with the COE requirements, there is an opportunity to reflect on the experience to-date and identify opportunities to bolster the impact of COE on equitable cancer outcomes for the future. To do so, the Bristol Myers Squibb Foundation (BMSF) hosted a special convening and listening session in April 2019. The session agenda was cocreated by BMSF and NCI leaders and staff. It brought together 41 individuals, including representatives from the NCI Cancer Centers Program, Division of Cancer Control and Population Health and Center to Reduce Cancer Health Disparities, 22 NCI-designated, emerging or affiliated comprehensive cancer centers, and the broader cancer community. This article captures key themes from that meeting, including an overview of current COE efforts, with a deeper look at how four cancer centers are embedding health equity and COE efforts into their institutions and work, and the successes and challenges they have encountered.

379 The association between congenital uterine anomalies and perinatal outcomes – canalization vs. unification defects

To evaluate the association between congenital uterine anomalies (CUA) and adverse perinatal outcomes stratified by type of anomaly. A retrospective cohort study of all women delivered in one university affiliated medical center between 2010-2017 with CUA. Multiple pregnancies and pregnancies complicated by fetal anomalies were excluded. Arcuate and T-shaped uterus were also excluded as they represent only minimal deviation from the normal anatomy. Maternal and short-term neonatal outcomes were evaluated and compared between women with unification defects (including unicornuate, bicornuate or uterus didelphys), and canalization defects represented by septate uterus. P <0.05 was considered significant. Among 167 pregnancies with CUA, 92 (55.1%) had bicornuate uterus, 32 (19.2%) septate uterus, 26 (15.6%) didelphys uterus and 17 (10.2%) unicornuate uterus. Maternal demographics and obstetric characteristics were similar between women with unification and canalization defects. Rate of adverse pregnancy outcome was high for the entire cohort (Fig 1). There was one case of anterpartum death in the canalization defects group. In comparison to unification defects (unicornuate, bicornate and didelphys uterus), pregnancies in women with canalization defects (septate uterus), had increased risk for preterm delivery <32 weeks (12.5% vs 3%, p=0.02), and placental abruption (12.5% vs. 3%, p=0.02), however, a lower overall rate of cesarean delivery (46.9% vs. 67.4%, p=0.03). There were no differences in neonatal outcomes between the groups. Overall, women with CUA have a high prevalence of adverse pregnancy outcomes. Compared to unification defects, canalization defects represented by septate uterus have a higher rate of PTD <32 weeks and placental abruption, but overall lower rates of CD, probably due to a lower prevalence of malpresentation.View Large Image Figure ViewerDownload Hi-res image Download (PPT)

368 Predictors and adverse outcome of uterine extension at the time of cesarean delivery

To identify risk factors and perinatal adverse outcomes related to unintended lower segment uterine extension during cesarean delivery (CD). A retrospective cohort analysis in a single, university affiliated medical center between January 1st 2018 to December 31st 2019. All singleton pregnancies delivered by CD were included. Univariate and multivariate analysis were performed to identify maternal and obstetrical predictors for uterine extension during CD. For secondary outcomes, we assessed correlation between uterine extension and any adverse maternal or neonatal outcome. ROC statistics was utilized to measure predictors prediction performance for uterine extension. Overall, 1,746 (19.3%) CDs were performed during study period. Of them, 121 (6.9%) CDs were complicated by unintended uterine extension. Uterine extensions were more common following induction of labor, intrapartum fever, premature rupture of membranes, trial of labor after cesarean, advanced gestational age, urgent CD and in particular during second stage of labor (37.2% vs. 6.5%) and after failed vacuum extraction (6.6% vs. 1.1%), p<0.05 for all. Using a multivariable analysis, the only factor that remained significant was CD at second stage of labor (aOR 54.2, 95% CI 4.5-648.9, p=0.002), with area under the ROC curve 0.653 (95% CI 0.595-0.712, p<0.001). For secondary outcomes, unintended uterine extension was associated with longer operation time, higher estimated blood loss, greater pre- to post CD hemoglobin difference, increased blood products transfusion, puerperal fever and longer hospital stay. No clinically significant neonatal adverse outcomes were observed. In out cohort, second stage CD was the strongest predictor for unintended uterine extension. Following uterine extension, women had increased infectious and blood loss morbidity.

449 Fetal head station at second stage dystocia- does it predict subsequent TOLAC success rate?

The factors associated with successful trial of labor after cesarean (TOLAC) among women with prior cesarean delivery (CD) for second-stage dystocia remain largely unestablished. We aimed to determine whether fetal head station at the index CD predicts the success rate of subsequent trial of labor among primiparous women. A retrospective cohort study conducted at two tertiary, university affiliated medical centers, including all primiparous women with subsequent delivery after CD for second-stage dystocia during 2009-2019. Overall, 481 primiparous women with prior CD for second-stage dystocia, had a subsequent delivery during study period. Of them, 171 (35.6%) women had an elective repeat CD and 310 (64.4%) attempted a TOLAC. Those undergoing TOLAC were younger (P<0.001), with lower rates of hypertensive disorders (P=0.005) and gestational diabetes (P=0.003) at the subsequent pregnancy. Of those undergoing TOLAC (n=310), 222 (71.6%) successfully delivered vaginally. The rate of successful TOLAC was significantly higher in those with fetal head station below the ischial spines at the index CD as compared to those with higher head station (79.0% vs. 60.5%, P<0.001). The proportion of infants weighing >3,500 grams in the subsequent delivery was lower in those with successful compared with failed TOLAC (29.7% vs. 43.2%, OR [95% CI]: 0.56 (0.33-0.93), P=0.03). In a multivariable analysis, lower fetal head station at the index CD was the only independent factor associated with TOLAC success (aOR [95% CI]: 2.38 (1.43, 3.96), P=0.001). Lower fetal head station at the index CD for second-stage dystocia was independently associated with higher VBAC rate, with an overall acceptable success rate. These findings should improve patient counseling and reassure those who wish to delivery vaginally after prior second-stage arrest.

454 Pregnancy outcome after cesarean section following a failed vacuum attempt

To compare pregnancy outcome of women who underwent cesarean section (CS) in second stage of labor, with or without a following failed vacuum extraction attempt (VE). A retrospective cohort study of women who underwent cesarean section during the second stage of labor in a single tertiary university affiliated medical center (2012-2019). Pregnancy outcome was compared for women who underwent cesarean section following a failed vacuum extraction to women who had cesarean section during the second stage of labor with no vacuum extraction attempt. Neonatal outcomes included umbilical artery pH less than 7.1, Apgar at 5 minutes < 7, hypoxemic ischemic encephalopathy and NICU admission. Maternal outcomes included duration of hospitalization, need for blood transfusion and need for re-surgery in 45 days. Overall, 88,375 women delivered during the study period. Of them, 120 women had a cesarean section following failed vacuum (study group). Another 551 women underwent cesarean section in the second stage of labor without VE attempt (control group). The groups were similar with regard to obstetrical and demographic characteristics. The rates of umbilical artery pH<7.1 (17.50% vs 6.53%, p<0.001), NICU admission (13.33% vs 2.90%, p<0.001), hypoxemic ischemic encephalopathy (5.83% vs 0.18%, p<0.001) and epicranial sub-aponeurotic hemorrhage (16.67% vs 2.18%, p<0.001) were significantly higher in the study group. No significant differences were found in maternal outcomes. In a sub-analysis including only labor with reassuring fetal heart tracing, failed vacuum attempt was associated with higher rate of NICU admission and epicranial hemorrhage (16.67% vs 3.13%, p=0.009, 27.78% vs. 3.41, p=0.001, respectively). Failed vacuum attempt is associated with a significant increased neonatal morbidity, but not increased maternal morbidityView Large Image Figure ViewerDownload Hi-res image Download (PPT)

Analysis of Mechanical Thrombectomy for Acute Ischemic Stroke on Nights and Weekends Versus Weekdays at Comprehensive Stroke Centers

ObjectiveThe “weekend effect” has been shown to affect outcomes in acute ischemic stroke. We sought to compare metrics and outcomes of emergent stroke thrombectomy at three affiliated comprehensive stroke centers on weekdays versus nights/weekends for a three-year period beginning in 2015, when thrombectomy became common practice for large vessel occlusion acute ischemic stroke. MethodsWe performed a retrospective analysis of all stroke thrombectomy patients treated from 2015 to 2018 to compare standard thrombectomy metrics and outcomes in patients presenting during weekdays or nights/weekends. ResultsTwo hundred-sixteen mechanical thrombectomy cases were evaluated, with 50.9% of patients presenting on weekdays and 49.1% presenting on nights/weekends. There were no statistical differences in baseline characteristics in demographics, stroke risk factors, or stroke severity, but patients presenting on nights/weekends had longer times from last known normal to presentation (130 versus 72.5 minutes, p=0.03). Door-to-groin times were delayed in patients presenting on nights/weekends compared to weekdays (median 104.5 versus 86 minutes, respectively; p=0.007) but groin-to-reperfusion times were similar (51.5 versus 48 minutes, respectively; p=0.4). Successful reperfusion was similar in both groups (90.6% nights/weekends versus 90% weekdays; p=1.0) as were the incidence of symptomatic intracerebral hemorrhage (10.4% nights/weekend versus 7.3% weekdays; p=0.48) and 90-day good functional outcomes based on the modified Rankin Scale did not differ between the two groups in a shift analysis (p=0.545). ConclusionsDespite delays in door-to-groin puncture times in acute ischemic stroke patients presenting on nights/weekends compared to weekdays, we did not identify significant differences in successful reperfusion or functional outcomes in this cohort. Further studies are warranted to continue to evaluate differences in stroke care on nights/weekends versus weekdays.

Evaluation of antibiotic escalation in response to nurse-driven inpatient sepsis screen.

To determine the frequency and predictors of antibiotic escalation in response to the inpatient sepsis screen at our institution. Retrospective cohort study. Two affiliated academic medical centers in Los Angeles, California. Hospitalized patients aged 18 years and older who had their first positive sepsis screen between January 1, 2019, and December 31, 2019, on acute-care wards. We described the rate and etiology of antibiotic escalation, and we conducted multivariable regression analyses of predictors of antibiotic escalation. Of the 576 cases with a positive sepsis screen, antibiotic escalation occurred in 131 cases (22.7%). New infection was the most documented etiology of escalation, with 76 cases (13.2%), followed by known pre-existing infection, with 26 cases (4.5%). Antibiotics were continued past 3 days in 17 cases (3.0%) in which new or existing infection was not apparent. Abnormal temperature (adjusted odds ratio [aOR], 3.00; 95% confidence interval [CI], 1.91-4.70) and abnormal lactate (aOR, 2.04; 95% CI, 1.28-3.27) were significant predictors of antibiotic escalation. The patient already being on antibiotics (aOR, 0.54; 95% CI, 0.34-0.89) and the positive screen occurred during a nursing shift change (aOR, 0.36; 95% CI, 0.22-0.57) were negative predictors. Pneumonia was the most documented new infection, but only 19 (50%) of 38 pneumonia cases met full clinical diagnostic criteria. Inpatient sepsis screening led to a new infectious diagnosis in 13.2% of all positive sepsis screens, and the risk of prolonged antibiotic exposure without a clear infectious source was low. Pneumonia diagnostics and lactate testing are potential targets for future stewardship efforts.

Characteristics and Outcomes of Hip Fracture Patients Hospitalized in an Orthogeriatric Unit Versus an Orthopedic Department: A Retrospective Cohort Study

Introduction:Hip fractures are a significant health risk in older adults and a major cause of morbidity, functional decline and mortality. Our aim was to compare clinical outcomes of older patients hospitalized in an ortho-geriatric (OG) unit to those hospitalized in an orthopedic department (OD) for surgical treatment of a hip fracture.Methods:A retrospective cohort study of hip fractured patients hospitalized between 2015-2016 in a single tertiary university-affiliated medical center. Included were patients aged 65 and older who had undergone hip fracture surgery and were admitted to either a geriatric or orthopedic ward.Results:441 patients met the inclusion criteria (195 in the OG unit, 246 in the OD); 257 were transferred to an affiliated geriatric center hospital (107 from the OG unit and 127 from the OD) for rehabilitation. Patients in the OG unit were older, more cognitively and functionally impaired and with more comorbidities. The 1-year mortality rate was significantly lower in the OD group (OR 0.32, CI 95% 0.19-0.53, p < 0.001), however, after propensity matching, the 30-day and 1 year mortality rates were similar in both groups. No difference was found in the rehabilitation length of stay between the groups. The functional independence measure improvement was similar in both groups, with a non-significant trend toward better functional improvement among OG unit patients.Conclusions:Despite the higher complexity of patients, worse baseline functional capacity in the OG unit, improvement after rehabilitation was similar in both groups. These results demonstrate the advantages of the OG unit in treating and stabilizing frail older adults, thus maximizing their chances for a successful recovery after hip fractures.Level of Evidence:Level IV