Chronic Steroid Use Research Articles

Risk factors for post-discharge complications and readmissions in home-discharges after elective posterior lumbar fusions

ObjectivesPrevious literature has studied overall post-operative outcomes following lumbar fusions. We examined the rates and risk factors for adverse outcomes in patients who are being discharged home. Patients and methodsThe 2012–2016 ACS-NSQIP database was used to query for patients undergoing 1- to 2-level posterior lumbar fusions (PLFs) for degenerative spinal pathology. Patients discharged to a destination other than home were removed from the database. ResultsOut of a total of 19,179 home-discharge patients, 546 (2.8%) experienced any adverse event (AAE), 276 experienced a severe adverse event (SAE) and 321 (1.7%) experienced a minor adverse event (MAE). Overall re-admission and re-operation rate in home-discharged patients was 4.4% and 2.5%. Multivariate analysis identified the following predictors for experiencing an AAE – Bleeding disorder (OR 2.25), BMI ≥ 35.0 vs. BMI < 25 (OR 1.96), chronic steroid use (OR 1.89), a LOS > 3 days (OR 1.53), insulin-dependent diabetes mellitus (OR 1.44), hypertension (OR 1.28) and female gender (OR 1.24). Patients with a pre-discharge complication (OR 2.12), bleeding disorders (OR 1.84), chronic steroid use (OR 1.55), age>75 (OR 1.49), age>65 (OR 1.26), history of severe COPD (OR 1.43), total operative time >210 min. (OR 1.26), ASA > II (OR 1.26) and undergoing a 2-level fusion (OR 1.21) were likely to be re-admitted from home. ConclusionsProviders should utilize the data to risk-stratify and better understand the need of provision of supplemental health-care services, in home-discharged patients, and/or regular clinic follow-up to minimize the rate of adverse events and reduce costs in a bundled-payment environment.

Maternal and fetal outcomes in pregnancies with long-term corticosteroid use

Purpose Long-term corticosteroids are administered in pregnant patients with an array of autoimmune and inflammatory disorders. Our objective is to determine whether long-term corticosteroid use is associated with increased maternal and neonatal adverse outcomes. Materials and methods We performed a retrospective cohort study using the Healthcare Cost and Utilization Project—national Inpatient Sample from the USA. All pregnant patients on long-term corticosteroids were identified using International Classification of Disease-9 coding from 2003 to 2015. The effect of long-term corticosteroid use on maternal and neonatal outcomes was evaluated using multivariate logistic regression. Results Out of the 10,491,798 births included in our study, 3999 were among women with long-term use of steroids, for an overall prevalence of 38 per 100,000 births. There was a steady increase in chronic steroid use from 2 to 81 per 100,000 births over the 13-year study period (p < .0001). Women on long-term steroids were more likely to have pregnancies complicated by preeclampsia, 1.72 (1.30–2.29) and were at greater risk of preterm premature rupture of membranes, 1.63 (1.01–2.44), pyelonephritis, 4.81 (1.18–19.61), and venous thromboembolisms, 2.50 (1.32–4.73). Neonates born from mothers on long-term steroids were more likely to suffer from prematurity, 1.51 (1.13–2.05), and lower weight for gestational age, 2.10 (1.34–3.30). Conclusion Long-term corticosteroids use in pregnancy is associated with maternal and fetal adverse outcomes. These patients would benefit from close follow-up throughout their pregnancy to minimize complications.

Independent Patient Risk Factors Associated With Increased Length of Hospital Stay, Unplanned Return to Operating Room, and 30-Day Readmission Rates After Posterior Cervical Fusion for Cervical Spondylotic Myelopathy

Abstract INTRODUCTION The aim of this study was to determine risk factors associated with readmissions, reoperation, and extended length of stay (LOS) following posterior cervical fusion (PCF) for spondylotic myelopathy. METHODS The National Surgical Quality Improvement Program from 2011 to 2016 was queried for all patients undergoing PCF with a diagnosis of spondylotic myelopathy. The inclusion criteria for this project were defined by the CPT code 22600 for PCF. Patients with a history of trauma, malignancy, and those with nonelective surgery were excluded. Patients without ICD9 (721.1) or ICD10 (M47.12) codes for myelopathy were also excluded. For analysis, patients were classified into 2 cohorts: patients who were readmitted, and those who were not readmitted. Patient demographics, comorbidities, intraoperative variables, and number of levels involved in surgery were collected. RESULTS A total of 893 patients with PCF for spondylotic myelopathy were identified, of which 816 (91.4%) were not readmitted and 77 (8.6%) were readmitted.The readmitted cohort was significantly older (No Readmission: 62.6 +/–10.8 vs Readmission: 65.5 +/– 10.8, P = .029). The readmitted population had a significantly higher proportion of dyspnea on exertion (No Readmission: 8.1% vs Readmission: 15.6%, P = .026) and COPD (No Readmission: 6.9% vs Readmission: 14.3%, P = .018). There were no differences in operative time (P = .762) or multilevel surgeries (P = .453) between the 2 cohorts. LOS was similar between readmitted and nonreadmitted patients (P = .640). Upon logistic regression controlling for demographics, comorbidities, surgery level, and operative time, multiple risk factors predicted extended LOS, including female gender, black race, noninsulin-dependent diabetes, chronic steroid use, and length of surgery. BMI and CHF predicted an unplanned return to the operating room. Age [OR: 1.03,95% CI (1.004-1.06), P = .025] was the single predictor of readmission. CONCLUSION Our study suggests that while there are a host of risk factors for both reoperation and extended LOS, increased age is likely the most significant risk factor for readmission following PCF.

Risk Factors for 30-Day Readmission following Knee Arthroscopy.

This study evaluates knee arthroscopy cases in a national surgical database to identify risk factors associated with readmission. The American College of Surgeons National Surgical Quality Improvement Program database was queried from 2012 to 2016 for billing codes related to knee arthroscopy. International Classification of Diseases diagnostic codes were then used to exclude cases which involved infection. Patients were subsequently reviewed for readmission within 30 days. Univariate and multivariate analyses were then performed to identify risk factors associated with 30-day readmission. A total of 69,022 patients underwent knee arthroscopy. The overall 30-day complication rate was 1.75% and the 30-day readmission rate was 0.92%. On multivariate analysis, age > 60 years (odds ratio [OR], 1.29; 95% confidence interval [CI], 1.07-1.55), smoking (OR, 1.40; 95% CI, 1.15-1.70), recent weight loss (OR, 13.22; 95% CI, 5.03-34.73), chronic obstructive pulmonary disease (OR, 1.98; 95% CI, 1.39-2.82), hypertension (OR, 1.48; 95% CI, 1.23-1.78), diabetes (OR, 1.92; 95% CI, 1.40-2.64), renal failure (OR, 10.65; 95% CI, 2.90-39.07), steroid use within 30 days prior to the procedure (OR, 1.91; 95% CI, 1.24-2.94), American Society of Anesthesiologists (ASA) class ≥ 3 (OR, 1.69; 95% CI, 1.40-2.04), and operative time > 45 minutes (OR, 1.68; 95% CI, 1.42-2.00) were identified as independent risk factors for readmission. These findings confirm that the 30-day overall complication (1.75%) and readmission rates (0.92%) are low for knee arthroscopy procedures; however, age > 60 years, smoking status, recent weight loss, chronic obstructive pulmonary disease, hypertension, diabetes, chronic steroid use, ASA class ≥ 3, and operative time > 45 minutes are independent risk factors for readmission.

Finding the Dieulafoy’s Lesion: A Case of Recurrent Rectal Bleeding in an Immunosuppressed Patient

A Dieulafoy's lesion (DL) is rare cause of acute gastrointestinal bleeding defined as a vascular abnormality of the submucosa. With a high prevalence for the stomach and upper gastrointestinal tract, it is rarely observed in the lower gastrointestinal tract. Its prevalence is rare accounting for less than 2% of all cases of acute gastrointestinal bleeding. The etiology of DL is unknown. Common comorbidities include cardiovascular disease, kidney disease, diabetes, alcohol abuse, liver disease, and chronic NSAID use. Few cases involving chronic steroid use and immunosuppressive treatment have been reported. The most common diagnostic and treatment modality is endoscopy with refractory cases treated with arterial embolization by angiography. We present a case involving a patient with significant comorbidities on chronic immunosuppression with a life-threatening, massive lower gastrointestinal bleed from a DL in the rectum.

P074 Review of patients with inflammatory bowel disease at the university hospital of the West Indies between 1980-June 2018

BACKGROUND: There are limited data on the incidence and prevalence of Inflammatory bowel disease (IBD) in Jamaica and other Caribbean countries. The aim of this study is to determine the clinical features, course and outcomes of patients with IBD in Jamaica. METHODS: A retrospective chart review of patients who were diagnosed with IBD and seen at the University Hospital of the West Indies between the period January 1980 to June 2018 was conducted. Data collected included: demographic characteristics and symptoms, endoscopic disease activity at last endoscopy, treatment and response to therapy, and surgical requirement. Descriptive statistics was computed using Stata 14 statistical software. RESULTS: We identified 115 patients with IBD during the study period. Mean age was 48.2 ± 17.7 years, 61.7% were females and mean disease duration was 12.5 ± 10.2 years. Forty-three patients (37.4%) had Crohn's disease (CD) and 72 (62.6%) had ulcerative colitis (UC). The most common presenting symptom was diarrhea (86 patients, 78.2%) and was more common in females (88% vs 62%; P value 0.001). Most patients with UC had pancolitis (54.2%), 19.4% left sided colitis and 18.1% had proctitis/proctosigmoiditis. Disease distribution in CD was mainly ileal in 37.2%, ileo-colonic in 34.9% and colonic in 23.3%. CD phenotype was inflammatory in 37.2% of patients, stricturing in 25.6% and penetrating in 32.6%. The majority of patients had moderate/high risk disease (66.1%). Eighty-nine patients (78.1%) were treated with 5-aminosalicylates, 37 (32.2%) with immunomodulators, 1 (0.9%) with a biologic agent, 48 (41.7%) were on chronic steroids and 7 (6.1%) were not on any medications. Chronic steroid use was associated with side effects in 36.4% of patients with steroid induced diabetes mellitus being the most frequent side effect occurring in 9 patients, all of whom were females (16.4% vs 0%; P value 0.007). Twenty six patients required surgical therapy for IBD. The most common indication for surgery in patients with CD was bowel obstruction (45.8%) whereas 2 patients with UC had surgery for failed medical management and spontaneous perforation respectively. Over the last 2 years patients with CD required more frequent hospital admissions for disease flares than patients with UC (0.9 ± 1.3 vs 0.3 ± 0.7; P value 0.005). Clinical remission was achieved by 75% of patients at their last clinic visit. CONCLUSION(S): Only 115 patients with IBD were identified over a 38 year period at a single referral center in Jamaica. UC was more commonly diagnosed than CD. The most common presenting symptom was diarrhea. Most patients with UC had pancolitis whereas most patients with CD had inflammatory ileal disease. A third of patients were maintained on chronic steroids. Most patients achieved clinical remission at their last clinic visit.

P095 Unusual side effects of systemic steroids in children with inflammatory bowel disease

CASE: 14 Y/M diagnosed with ileo-colonic Crohn disease at 5 Y of age. He was initially treated with oral prednisone (2 mg/kg/day) for 2 weeks and oral mesalamine. The steroids were weaned over a period of 2 months. As he continued to have persistent symptoms, he was started on infliximab infusions. After his third infliximab infusion he developed severe bilateral lower extremity pain and bilateral knee swelling requiring inpatient admission. X ray of bilateral knee joints was normal. The symptoms were attributed to an infusion reaction and he was then switched to mercaptopurine, which he did not tolerate. He was started on adalimumab, but developed antibodies within 2 months of therapy. He was also given 2–3 courses of oral steroids over 1–2 years to induce remission. The dose was 2 mg/kg/day for 1–2 weeks with weaning over 1–2 months. He developed necrosis of the left femoral head when he was 9Y. The diagnosis was based on typical x ray appearance. His BMI was 82 percentile when he developed osteonecrosis and his last course of steroid was &gt;6 months ago. He was on apriso when he developed osteonecrosis. His symptoms improved with physiotherapy over the next 1–2 years. After he failed therapy on Humira, he was started on oral budesonide (6 mg daily) as he continued to have diarrhea and his repeat colonoscopy showed worsening disease. He was on the oral budesonide for 6–7 weeks and developed typical steroid facies—moon face, supraclavicular fat pads and gained 6 lbs in 6 weeks. His blood pressure was normal. The budesonide was quickly weaned and he was switched to subcutaneous methotrexate followed by entyvio due to lack of clinical response on methotrexate. Currently he is in remission on entyvio. He continues to walk with a limp and is not complaining of any limb pain. DISCUSSION: Osteonecrosis of the femoral head (ONFH) is a disabling condition of the hip joint that primarily affects adults (avg: 36–38 Y). Risk factors for ONFH include chronic corticosteroid administration, chronic alcohol ingestion, smoking, and various chronic diseases (renal disease, hematological disease, inflammatory bowel disease (IBD), post organ transplantation, hypertension, and gout). Although ONFH is seen in children with malignancy, post stem cell transplant and sickle cell disease, it is not commonly reported in children with IBD. The exact incidence of ONFH in children on chronic steroids with IBD is unknown. In our patient, we are not sure if the ONFH was from chronic steroid use or underlying IBD. He also developed steroid facies within 6 weeks on oral budesonide which is unusual. Iatrogenic Cushing's syndrome is not expected with budesonide because a “first pass effect” removes the drug from the circulation. Multi center studies are needed in children with IBD looking at serious side effects of all types of systemic steroids as they are frequently prescribed.

Massive Quadriceps Tendon Repair Using Suture Anchors: A Case Report and Literature Review

The quadriceps tendon is the largest tendon and a fulcrum for function of the most powerful muscles in the human body and has great influence on knee function and independent walking ability. A complete rupture of quadriceps tendon is rarely reported in patients without known co morbidities. In the present case was a 65-year-old male presented with severe pain and inability to extend his right knee after missing a step while walking in his compound. His physical examination revealed the presence of a suprapatellar gap and inability to extending his right knee. Knee X rays revealed a small avulsion fracture of the medial femoral condyle. The magnetic resonance imaging (MRI) also confirmed a diagnosis of complete rupture of his right quadriceps tendon at the insertion point. He denied having systemic disease or being on chronic steroid use. The patient underwent a successful operative repair of the tendon using two arthrex suture anchors. Intraoperatively we found that the right quadriceps had ruptured transversely at the tendon insertion. During the two-month follow-up after the surgery, the patient received a full rehabilitation with a satisfactorily outcome.

Predicting surgical site infections following laparoscopic bariatric surgery: development of the BariWound tool using the MBSAQIP database

Although bariatric surgery is a safe procedure for severe obesity, incisional surgical site infections (SSI) remain a significant cause of morbidity. Bariatric surgery patients are at high risk due to obesity and diabetes. The objective of this study was to develop a predictive tool for incisional SSI within 30days of bariatric surgery. Data were retrieved from the 2015 and 2016 MBSAQIP databases. This study included patients who underwent primary laparoscopic Roux-en-Y gastric bypass (LRYGB) or laparoscopic sleeve gastrectomy (LSG). The primary outcome of interest was incisional SSI occurring within 30days. Surgeries performed in 2015 were used in a derivation cohort and the predictive tool was validated against the 2016 cohort. A forward selection algorithm was used to build a logistic regression model predicting probability of SSI. A total of 274,187 patients were included with 71.7% being LSG and 28.3% LRYGB. 0.7% of patients had a SSI in which 71.0% had an incisional SSI, and 29.9% had an organ/space SSI. Of patients who had an incisional SSI, 88.7% were superficial, 10.9% were deep, and 0.4% were both. A prediction model to assess for risk of incisional SSI, BariWound, was derived and validated. BariWound consists of procedure type, chronic steroid or immunosuppressant use, gastroesophageal reflux disease, obstructive sleep apnea, sex, type 2 diabetes, hypertension, operative time, and body mass index. It stratifies individuals into very high (> 10%), high (5-10%), medium (1-5%), and low risk (< 1%) groups. This model accurately predicted events in the validation cohort with an area under the receiver operating characteristic curve of 0.73. BariWound accurately predicted the risk of 30-day incisional SSI in individuals undergoing bariatric surgery. Stratifying low- and high-risk groups allows for customized SSI prophylactic measures for patients in various risk categories and potentially enables future research targeted at high-risk patients.

Lumbar Laminectomy in the Outpatient Setting Is Associated With Lower 30-Day Complication Rates.

Study Design:Retrospective cohort study.Objectives:To compare the incidence of complications in patients undergoing single-level and 2-level lumbar laminectomy in either the inpatient or outpatient settings.Methods:Patients who underwent single-level and 2-level lumbar laminectomy were identified in the ACS NSQIP database from the years 2006 to 2015. Independent patient variables were recorded, including demographics and preoperative health characteristics. Logistic regression was used to determine the risk of postoperative complications for both a 1- and 2-level lumbar laminectomy as well as to identify independent risk factors for a complication. Comparisons were made between 2 groups: (1) inpatient and (2) outpatient as determined by billing data.Results:A total of 18 076 single- and 2-level lumbar laminectomy cases were identified with 10 743 (59.4%) inpatient procedures and 7333 (40.6%) outpatient procedures. The incidence of any postoperative complication was significantly lower in the outpatient group than in the inpatient group among all cohorts including 1-level lumbar laminectomy (1.9% vs 6.7%), 2-level lumbar laminectomy (3.17% vs 7.38%), as well as in the combined cohort of 1- and 2-level laminectomies (2.47% vs 7.01%). Significant independent risk factors for complications after lumbar laminectomy were identified, including body mass index (BMI) >30 kg/m2, age ≥55 years, a functional status of partially dependent, chronic obstructive pulmonary disease (COPD), chronic steroid use, American Society of Anesthesiologists (ASA) class 3 or 4, and operative time >90 minutes.Conclusions:This study reports a lower overall complication rate in the 30-day postoperative period following 1- and 2-level lumbar laminectomy performed in an outpatient versus inpatient setting. Significant risk factors for complications included BMI >30 kg/m2, age ≥55 years, a functional status of partially dependent, COPD, chronic steroid use, ASA class 3 or 4, and operative time >90 minutes.

A multi-center phase Ib/II study of nal-irinotecan, 5-fluouracil and leucovorin in combination with nivolumab as second-line therapy for patients with advanced unresectable biliary tract cancer.

TPS4154 Background: Patients (pts) with advanced biliary tract cancers (BTC) have poor prognosis despite systemic chemotherapy, and treatment beyond first-line platinum doublet remains investigational. The immunomodulatory properties of conventional cytotoxic therapy, particularly in regard to the upregulation of PD-L1 expression rendering tumor cells more sensitive to T cell-mediated lysis and neoantigen production, rapid emergence of chemotherapy resistance, and known modest efficacy of single agent PD-1 antibody in BTC provide a rationale for combining chemotherapy and immunotherapy. This multi-center, phase Ib/II, single-arm study is designed to investigate the role of nal-irinotecan, 5-FU and leucovorin in combination with nivolumab as second-line therapy in pts with advanced BTC. Methods: Key eligibility criteria include histologically confirmed advanced, unresectable biliary carcinoma (intra- or extra-hepatic and gallbladder) with progression or intolerance of first-line systemic therapy (excluding irinotecan and PD-1/PD-L1 antibody), measurable disease per RECIST v1.1, ECOG PS 0-1, Child Pugh A or B7, and absence of autoimmune disease or chronic steroid use. Primary objective of the phase Ib portion is to determine the recommended phase 2 dose, and of the phase II portion is to evaluate the median progression-free survival. Secondary objectives include evaluation of objective response rate per immune related (ir)RECIST, median OS and safety in this patient population. Exploratory objectives include identification of biomarker predictors of response and mechanisms of resistance through serial biopsies and blood collection (pre, on and post therapy), including sequential whole exome/transcriptomic analysis and immune cell subset analysis (tissue and blood). Therapy includes nal-irinotecan 70 mg/m2, leucovorin 200 (dose level -1) or 400 mg/m2 (dose level 0), 5-fluouracil 2400 mg/m2 IV over 46 hours, and nivolumab 240 mg on day 1 every 2 weeks for 6 months. In the absence of disease progression, pts may continue therapy for up to 2 years. Accrual goal is 30 evaluable pts. Using a null hypothesis value of median PFS of 2.9 months, and an alternative hypothesis of 5.0 months, this ongoing study has &gt; 80% power, with a two-sided alpha of 0.05 to identify treatment efficacy of study arm. Clinical trial information: NCT03785873.

A multicenter phase II trial of rucaparib in combination with nivolumab as maintenance therapy for patients with advanced biliary tract cancer.

TPS4153 Background: Patients (pts) with advanced biliary tract cancers (BTC) have a poor prognosis with a median overall survival (OS) less than 12 months. Using whole exome NGS, 26 (49%) pts in a 53 pt cohort had either DNA damage repair (DDR) pathway mutations (somatic and/or germline, n = 18), or isocitrate dehydrogenase 1 (IDH1) mutations (n = 8), and may have potentially benefited from PARP inhibition. Further, disruption of the mutated DDR pathways with a PARP inhibitor may result in increased mutational burden and neoantigens leading to immunogenicity, thus providing the rationale for combination with a PD-1 antibody. This phase 2 trial is designed to investigate the role of a PARP inhibitor in combination with a PD-1 antibody in pts with advanced BTC. Methods: Key eligibility criteria include histologically confirmed advanced, unresectable biliary adenocarcinoma (intra- or extra-hepatic, and gallbladder) without progression after 4-6 months of 1st line platinum-based systemic chemotherapy, measurable disease per RECIST v1.1, ECOG PS 0-1, Child-Pugh A or B7, and absence of autoimmune disease or chronic steroid use. Primary objective is to evaluate progression-free survival (PFS) rate at 4 months. Secondary objectives include evaluation of objective response rate per immune related (ir)RECIST criteria, median PFS and OS, and safety in this patient population. Exploratory objectives include identification of predictive biomarkers of response and mechanisms of resistance through serial biopsies and blood collection (pre, on and post therapy), including sequential whole exome/transcriptomic analysis with immune cell subset analysis. Treatment includes rucaparib 600 mg PO BID on days 1-28 with nivolumab 240 mg on days 1, 15 Q4 weeks. In absence of disease progression, pts may continue therapy up to 2 years. Accrual goal is 32 evaluable pts. Using a null hypothesis value of a 63% PFS rate at 4 months, and an 85% alternative hypothesis, this ongoing study has 80% power, with a one-sided alpha of 0.05 to identify treatment efficacy in the study arm. Clinical trial information: NCT03639935.

Short-Term Risk Factor Profile of Pediatric Choanal Atresia Repair Using ACS-NSQIP National Database.

The goal of this study is to describe the 30-day postoperative sequelae of pediatric choanal atresia repair and identify predictive factors for adverse events. The American College of Surgeons' National Surgery Quality Improvement Program-Pediatric (NSQIP-P) database was searched between January 2012 and December 2015 to identify pediatric patients status post choanal atresia repair. Postoperative outcomes included surgical site complications, readmissions, and total length of stay. A total of 178 children underwent choanal atresia repair. The overall complication rate was 6.2%, while the 30-day readmission rate was 15%. Patients with CHARGE had a longer mean duration of hospitalization (26.91 days vs 8.05 days, P = .013). Additionally, patients ≤10 days of age had longer duration of hospitalization (17.84 days vs 9.24 days, P ≤ .001) and higher readmission rates (33.30% vs 10.1%, P = .001). Among the nonsyndromic cohort, ventilator dependence was a predictor of postoperative complications (odds ratio [OR] = 16.08, P < .001), higher readmission rates (OR = 5.46, P = .002), and a longer hospital stay (OR = 18.69, P < .001). Analysis of the 2012-2015 NSQIP-P data set reveals that patients with a diagnosis of CHARGE and those ≤10 days of age have a longer duration of hospitalization. Increased risk of postoperative complications and longer duration of hospitalization were both influenced by chronic steroid use and ventilator dependence.

Maternal and Fetal Outcomes in Pregnancies with Long-term Corticosteroid Use: Retrospective Cohort Study [13OP

INTRODUCTION: Long-term corticosteroids is administered in pregnant patients with an array of autoimmune and inflammatory disorders. Our objective is to determine whether long-term corticosteroid use is associated with increased maternal and neonatal adverse outcomes. METHODS: We performed a retrospective cohort study using the Healthcare Cost and Utilization Project - National Inpatient Sample from the United States. All pregnant patients on long-term corticosteroids were identified using International Statistical Classification of Disease-9 coding from 2003 to 2015. The effect of long-term corticosteroid use on maternal and neonatal outcomes was evaluated using logistic regression. RESULTS: Out of the 10,491,798 births included in our study, 3,999 were on chronic steroids, for an overall prevalence of 38 per 100,000 births. There was a steady increase in chronic steroid use from 2 to 81 per 100,000 births over the 12-year study period (P&lt;.0001). Women on chronic steroids were more likely to have pregnancies complicated by gestational diabetes mellitus, 1.61 (1.46-1.79) and preeclampsia, 2.50 (2.26-2.77). They were also more likely to have caesarean sections, 1.73 (1.62-1.84), premature preterm rupture of membranes, 2.29 (2.06-2.54), sepsis, 1.77 (0.66-4.73), venous thromboembolisms, 5.25 (4.12-6.69) and uterine rupture, 3.39 (2.10-5.46). Neonates born from mothers on chronic steroids were more likely to suffer from prematurity, 3.02 (2.79-3.28) and congenital malformations, 2.42 (1.88-3.12). CONCLUSION: Long-term corticosteroids use in pregnancy is associated with maternal and fetal adverse outcomes. These patients would benefit from close follow-up throughout their pregnancy to minimize complications.

MON-495 Hypophosphatasia: A Rare Cause of Osteoporosis in a Young Adult Male

Introduction: Secondary osteoporosis is due to an identifiable cause of osteoporosis. Hypophosphatasia is a rare cause of secondary osteoporosis and needs to be considered when evaluating osteoporosis in young people. We present a case of secondary osteoporosis initially thought to be a result of malabsorptive disorder and chronic steroid use, with eventual diagnosis of autosomal dominant hypophosphatasia as the primary underlying cause. Clinical Case: A 24 year old male who was seen for evaluation of osteoporosis. He reported an extensive history of fractures about 26 in total, including wrist, shoulders, nose, and metatarsals. Past history was also significant for bowed legs at birth requiring osteotomies and spontaneous loss of several teeth with root intact, requiring extractions. He was also diagnosed with Crohn’s disease at 17 years old and history of steroid use, however was not on steroids at time of initial evaluation. He was diagnosed with bilateral avascular necrosis at age 18 years and needed bilateral hip replacement at age 20 years. There was no family history of skeletal disorders. DEXA scan obtained for the assessment of bone density revealed a Z score of -2.6 in the lumbar spine and -2.1 in the distal forearm. Further evaluation for secondary causes of osteoporosis revealed a normal TSH, PTH, tryptase, vitamin D and testosterone levels. Bone turnover markers were normal except for a low alkaline phosphatase. It was noted that the patient had a persistently low alkaline phosphatase for the last 6 years despite his frequent fractures. Hypophosphatasia was suspected given the history and the low alkaline phosphatase levels. Pyridoxal 5-phosphate was elevated at 77mcg/L (normal 5-50mcg/L). Genetics evaluation revealed a heterozygous, missense mutation in ALPL gene, confirming diagnosis of autosomal dominant hypophosphatasia. He was started on enzyme replacement therapy with asfotase alpha. Conclusion: Hypophosphatasia is a rare metabolic bone disease due to a deficiency of alkaline phosphatase which may present from infancy to adulthood. Diagnosis is made by finding a low alkaline phosphatase level and elevated 5 pyridoxal phosphate. Enzyme replacement therapy with asfotase alpha is the mainstay of treatment. It is probably underdiagnosed secondary to its rarity and therefore must be considered in any young patient who presents with osteoporosis.

Risk of Surgical Site Infection and Mortality Following Lumbar Fusion Surgery in Patients With Chronic Steroid Usage and Chronic Methicillin-Resistant Staphylococcus aureus Infection.

A retrospective database analysis among Medicare beneficiaries OBJECTIVE.: The aim of this study was to determine the effect of chronic steroid use and chronic methicillin-resistant Staphylococcus aureus (MRSA) infection on rates of surgical site infection (SSI) and mortality in patients 65 years of age and older who were treated with lumbar spine fusion. Systemic immunosuppression and infection focus elsewhere in the body are considered risk factors for SSI. Chronic steroid use and previous MRSA infection have been associated with an increased risk of SSI in some surgical procedures, but their impact on the risk of infection and mortality after lumbar fusion surgery has not been studied in detail. The PearlDiver insurance-based database (2005-2012) was queried to identify 360,005 patients over 65 years of age who had undergone lumbar spine fusion. Of these patients, those who had been taking oral glucocorticoids chronically and those with a history of chronic MRSA infection were identified. The rates of SSI and mortality in these two cohorts were compared with an age- and risk-factor matched control cohort and odds ratio (OR) was calculated. Chronic oral steroid use was associated with a significantly increased risk of 1-year mortality [OR = 2.06, 95% confidence interval (95% CI) 1.13-3.78, P = 0.018] and significantly increased risk of SSI at 90 days (OR = 1.74, 95% CI 1.33-1.92, P < 0.001) and 1 year (OR = 1.88, 95% CI 1.41-2.01, P < 0.001). Chronic MRSA infection was associated with a significantly increased risk of SSI at 90 days (OR = 6.99, 95% CI 5.61-9.91, P < 0.001) and 1 year (OR = 24.0, 95%CI 22.20-28.46, P < 0.001) but did not significantly impact mortality. Patients over 65 years of age who are on chronic oral steroids or have a history of chronic MRSA infection are at a significantly increased risk of SSI following lumbar spine fusion. 3.

Perioperative outcomes of bariatric surgery in the setting of chronic steroid use: an MBSAQIP database analysis

BackgroundChronic steroids are a treatment option for many chronic diseases but predispose patients to both weight gain and surgical complications. They therefore represent a unique interface between obesity, chronic disease, and surgical risk. As the benefits of bariatric surgery for controlling metabolic disease become more apparent, patients with chronic illnesses on corticosteroids are increasingly being referred for surgery despite an unclear safety profile. The Metabolic and Bariatric Surgery Accreditation Quality Improvement Program database represents the largest bariatric-specific clinical data set for comparing outcomes in this complex patient population. ObjectiveTo compare perioperative outcomes following bariatric surgery in the setting of chronic steroid/immunosuppression. SettingUniversity Hospital, United States. MethodsUsing the Metabolic and Bariatric Surgery Accreditation Quality Improvement Program MBSAQIP database, we identified patients on chronic corticosteroids who underwent laparoscopic sleeve gastrectomy or laparoscopic gastric bypass in 2015 or 2016. Unmatched as well as propensity-score and case-controlled matched cohort analyses were performed of patients on corticosteroid therapy compared with those without. ResultsOf the 302,140 patients who underwent sleeve gastrectomy or laparoscopic gastric bypass in 2015–2016, a total of 4947 (1.63%) were on chronic steroids/immunosuppressive drugs. Patients using steroids were older with significantly higher rates of co-morbid conditions. Hospital length of stay, intensive care unit admission, reoperation, readmission, bleeding, leak, and infectious complications were significantly higher in steroid users; however, in a propensity and case-control matched analysis of 8710 patients and 6598 patients, respectively, steroids were not found to be independent risk factors for poorer outcomes except for an increased rate of leak. ConclusionsGenerally, steroid use does not independently predict poorer outcomes among bariatric surgery patients except for an increased leak rate. With appropriate patient selection based on associated co-morbid factors, primary bariatric surgery is safe in patients using corticosteroids, with an acceptable 30-day postoperative risk profile.

Predictors of reoperation and noninfectious complications following craniotomy for cerebral abscess

ObjectivesThere is a paucity of literature that examines predictors of reoperation and noninfectious complications following treatment of cerebral abscess with craniotomy. The goal of the present study is to identify predictors for each of these outcomes. Patients and methodsThe American College of Surgeons National Surgical Quality Improvement Program (NSQIP) database 2012–2016 file was the data source. Patients were identified using a combination of CPT and ICD-9/10 codes. Exclusions included missing age/gender, secondary surgery, and absent length of stay information. Univariate followed by multivariable analysis using logistic regression was used to identify significant predictors of reoperation and noninfectious postoperative complications (p < 0.05). Results166 patients met the above criteria. Median age was 56 (IQR 44–65) and 68.1% of patients were men. The 30-day reoperation rate was 18.1% and increasing white blood cell count (WBC) was identified as a significant risk factor for reoperation (odds ratio [OR] 1.10, 95% CI 1.02–1.19, p = 0.013). Noninfectious complications occurred at a rate of 20.5% at 30 days. Significant predictors were ASA classification ≥4 (OR 4.13, 95% CI 1.74–9.81, p = 0.001), smoking (OR 3.04, 95% CI 1.18–7.78, p = 0.020), and increasing WBC count (OR 1.11, 95% CI 1.03–1.20, p = 0.007). Emergency case status, abscess location (supratentorial versus infratentorial), nor chronic steroid use demonstrated a significant relationship with the studied outcomes. ConclusionIncreasing preoperative WBC count predicts both reoperation and noninfectious complications following craniotomy for cerebral abscess. Less modifiable predictors for noninfectious complications which may help anticipate operative risk are smoking and high ASA classification.

Risk factors for 30-day readmission following hip arthroscopy.

Hip arthroscopy is known to be safe with low rates of postoperative complications. The purpose of this study is to evaluate hip arthroscopy cases in a national surgical database to identify risk factors associated with readmission. The American College of Surgeons National Surgical Quality Improvement Program database was queried from 2012 to 2016 for current procedural terminology billing codes related to hip arthroscopy. International Classification of Diseases diagnostic codes were used to exclude cases involving infection, fracture, or open procedures. Univariate and multivariate analyses were performed to identify risk factors associated with 30-day readmission. 1493 patients were identified who had undergone hip arthroscopy. The most common procedures were labral resection or chondroplasty (n = 589, 39.5%) and femoroplasty (n = 527, 35.3%). The 30-day complication rate was 1.7% and the most common complications following the procedure were bleeding (n = 12, 0.8%) superficial infections (n = 5, 0.3%), and returning to the operating room (n = 4, 0.3%). The 30-day readmission rate was 1.3%. On multivariate analysis, hypertension requiring anti-hypertensive medication (odds ratio [OR], 3.5; 95% confidence interval [CI], 1.4-8.7) and chronic corticosteroid or immunosuppressant use (OR 7.2; 95% CI 1.9-26.7) were identified as independent risk factors for readmission. There was no difference in complication rates when hip arthroscopy was performed with isolated femoroplasty (n = 340), isolated acetabuloplasty (n = 103), both (n = 187) or neither (n = 863). These findings confirm that the 30-day readmission (1.3%) and complication rate (1.7%) are low for isolated hip arthroscopy procedures; however, hypertension and chronic steroid use are independent risk factors for readmission. Retrospective comparative study, Level III.

The Effects of Preoperative Steroid Therapy on Perioperative Complications After Elective Anterior Lumbar Fusion

To examine the effects of chronic preoperative steroid therapy on 30-day perioperative complications after anterior lumbar fusion (ALF). We retrospectively analyzed data from the American College of Surgeons National Surgical Quality Improvement Program between 2008 and 2015. Adult patients who underwent ALF were included and divided into 2 groups: steroids and no steroids. We compared baseline patient demographics, comorbidities, and operative variables between these 2 groups and then performed a multivariate regression analysis to determine complications that were independently associated with chronic steroid therapy. We also performed a subgroup analysis of the steroid group to identify additional risk factors that further predispose these patients to postoperative complications. A total of 9483 patients were included, of whom 289 (3.0%) were on chronic steroid therapy. Univariate analysis showed that chronic steroid use was independently associated with 4 perioperative complications, including deep surgical site infection (odds ratio [OR], 2.78; confidence interval [CI], 1.09-7.10; P= 0.033), pulmonary complications (OR, 1.98; CI, 1.02-3.86; P= 0.044), blood transfusion (OR, 1.60; CI, 1.15-2.23; P= 0.005), and extended length of stay (OR, 1.58; CI, 1.17-2.16; P= 0.003). In patients on chronic steroid therapy, pulmonary comorbidity and extended operative time were additional risk factors that further predisposed to perioperative complications, including deep surgical site infection, blood transfusion, and extended length of stay. Chronic preoperative steroid therapy is associated with perioperative complications after ALF. Decisions about the discontinuing or holding steroid therapy preoperatively should be determined through an interdisciplinary approach between the medical and surgical teams.