High-volume Academic Medical Center Research Articles

Implementation of Thromboelastography on the Labor and Delivery Floor for Postpartum Hemorrhage [ID 2683574

INTRODUCTION: Postpartum hemorrhage (PPH) is a major cause of maternal morbidity and mortality. Thromboelastography (TEG) is a rapid test that has been shown to improve outcomes in PPH by guiding resuscitation quickly and in a targeted manner. We incorporated TEG into our hemorrhage response protocol (HRP), a robust algorithm focused on facilitating immediate response to PPH, in a pilot study at our high-volume academic medical center. The objective of this quality improvement project was to evaluate the feasibility of incorporating TEG as part of our HRP. METHODS: We identified key HRP stakeholders and appointed team leads including obstetricians, anesthesiologists, nurses, and lab/blood bank staff and developed team-appropriate education including 30-minute teaching sessions, badge reference cards, and workflow posters. We then evaluated the TEG utilization rate over time. RESULTS: Thromboelastography was utilized in 4/9 (44%) PPHs during the first week after implementation, 4/7 (57%) the second week, and 28/28 (100%) during the following 4 weeks. After an HRT was called, the median time to order TEG was 4.0 minutes (interquartile range [IQR] 13), the median time to collect TEG was 8.5 minutes (IQR 11.8), and the median time for TEG to result was 7.0 minutes (IQR 7.7). CONCLUSION: We observed 100% uptake of TEG within 3 weeks of implementation, and rapid workflow completion (<10 minutes per step). The strengths of our implementation approach were its multidisciplinary nature, structuring the workflow into the electronic health record, and appointing team leads to facilitate buy-in. Future studies are needed to assess clinical implications and provider comfort with TEG.

Prostaglandin Injection for Myoma Expulsion (PRIME): Case Series of a Novel Approach to Hysteroscopic Resection of FIGO Type 2 Myomas

Study ObjectiveTo evaluate the use of dilute carboprost tromethamine injection at the endometrium/myoma junction during hysteroscopy to facilitate myoma expulsion and removal in a single procedure. DesignCase series. SettingSingle high-volume academic medical center. PatientsSeven patients aged 32 to 51 years old with FIGO type 2 uterine myomas and symptoms of abnormal uterine bleeding or infertility undergoing hysteroscopic resection with a morcellation device from November 2022 to July 2023. InterventionDilute injection of carboprost tromethamine (10 µg/mL) at time of hysteroscopic myomectomy. Measurements and Main ResultsThe main outcome measure was ability to complete the hysteroscopic myomectomy in a single procedure using a hysteroscopic morcellator. Secondary outcomes included total operative time, fluid deficit, and postoperative pharmacologic side effects and/or surgical complications. Among our 7 patients, all had successful single procedure complete resections of myomas ranging from 0.9 to 4.6 cm in maximal diameter. Average operative time was 30 minutes, and average fluid deficit was approximately 839 mL. The carboprost dosages used ranged from 30 to 180 µg. One patient experienced prolonged postoperative nausea and vomiting that resolved with antiemetics. One patient experienced postoperative endometritis that improved with antibiotics. ConclusionIn this pilot study, injection of dilute carboprost intraoperatively facilitated one-step hysteroscopic myomectomy of FIGO 2 myomas, via enhanced extrusion of the intramural portion of the fibroid into the uterine cavity, with both short operative times and acceptable fluid deficits.

Methylated ctDNA Quantification: Noninvasive Approach to Monitoring Hepatocellular Carcinoma Burden.

Noninvasive, precision monitoring of hepatocellular carcinoma (HCC) treatment efficacy would greatly facilitate personalized therapy and improve patient outcomes. We hypothesize that quantifying methylated circulating tumor DNA (ctDNA) can be used to effectively monitor HCC burden without the need for biopsy. Blood samples were collected from 25 patients, 21 with HCC and 4 with benign liver masses, at various timepoints throughout the course of treatment at a high-volume academic medical center. Quantification of methylated ctDNA molecules assessed CpG sites on more than 550 preselected cancer-specific amplicons. The tumor methylation score (TMS) was calculated by measuring the difference between the amount of methylation in the plasma and buffy coat with a normal cutoff value of 120 or less. Among 10 patients with surgical HCC (5 surgical resections and 5 liver transplants), TMS revealed a statistically significant, rapid postoperative decline in 9. One patient who had a persistently elevated TMS on postoperative day 1 was subsequently found to have had metastatic disease. Patients in the negative control cohort all had normal-range pre- and postoperative TMS. Preoperative TMS correlated moderately with tumor burden on pathology (Spearman r = 0.54) of surgical specimens. From 11 subjects undergoing systemic therapy or Y90 radioembolization, analysis of 16 time periods demonstrated that the change in TMS (ΔTMS) was better associated with tumor progression than the change in Δalpha-fetoprotein (area under the curve 0.800 and 0.783, respectively). A composite score combining ΔTMS and Δalpha-fetoprotein further improved performance for detecting tumor progression with an area under the curve of 0.892. These findings indicate that ctDNA methylation scores can effectively evaluate changes in tumor burden without the need for tumor biopsy.

Accurate protamine:heparin matching (not just smaller protamine doses) decreases postoperative bleeding in cardiac surgery; results from a high-volume academic medical center.

A multidisciplinary Quality Assurance/Performance Improvement study to identify the incidence of "heparin rebound" in our adult cardiac surgical population instead detected a thromboelastometry pattern suggestive of initial protamine overdose in 34% despite Hepcon-guided anticoagulation management. Analysis of our practice led to an intervention that made an additional lower-range Hepcon cartridge available to the perfusionists. One year later, an IRB-approved retrospective study was conducted in >500 patients to analyze the effects of the intervention, specifically focusing on the impact of the initial protamine dose accuracy and 18-h mediastinal chest tube drainage (MCTd). No differences were observed between group demographics, surgical procedures, duration of CPB or perioperative blood product transfusion. Both groups were managed using the same perfusion and anesthesia equipment, strategies, and protocols. The median initial protamine dose decreased by 19% (p < .001) in the intervention group (170 [IQR 140-220] mg; n = 295) versus the control group (210 [180-250] mg; n = 257). Mean 18-h MCTd decreased by 13% (p < .001) in the intervention group (405.15 ± 231.54mL; n = 295) versus the control group (466.13 ± 286.73mL; n = 257). Covariate-adjusted mixed effects model showed a significant reduction of MCTd in the intervention group, starting from hour 11 after surgery (group by time interaction p = .002). Though previous investigators have associated lower protamine doses with less MCTd, this study demonstrates that more accurately matching the initial protamine dose to the remaining circulating heparin concentration reduces postoperative bleeding.

Surgical Treatment at an Academic Medical Center is Associated with Statistically Insignificant Lung Cancer Survival Outcome Differences Related to ZIP Code.

Low socioeconomic status is a well-characterized adverse prognostic factor in large lung cancer databases. However, such characterizations may be confounded as patients of lower socioeconomic status are more often treated at low-volume, non-academic centers.We evaluated whether socioeconomic status, as defined by ZIP code median income, was associated with differences in lung cancer resection outcomes within a high-volume academic medical center. Consecutive patients undergoing resection for non-small cell lung cancer were identified from a prospectively maintained database (2011-18).Patients were assigned an income value based on the median income of their ZIP code as determined by census-based geographic data. We stratified the population into income quintiles representative of SES and compared demographics (chi-square), surgical outcomes, and survival (Kaplan-Meier). We identified 1,693 patients, representing 516 ZIP codes. Income quintiles were Q1: $24,421-53,151; Q2:$53,152-73,982; Q3:$73,983-99,063; Q4:$99,064-123,842; and Q5:$123,843-250,001. Compared to Q5 patients, Q1 patients were younger (median 69 vs. 73, p < 0.001), more likely male (44 vs. 36%, p = 0.035), and more likely Asian, Black, or self-identified as other than white, Asian, or Black. (67 vs. 11%, p = < 0.001). We found minor differences in surgical outcomes and no significant difference in 5-year survival between Q1 and Q5 patients (5-year: 86 vs. 85%, p = 0.886). Surgical care patterns at a high-volume academic medical center are similar among patients from varying ZIP codes.Surgical treatment at such a center is associated with no survival differences based upon socioeconomic status as determined by ZIP code.Centralization of lung cancer surgical care to high-volume centers may reduce socioeconomic outcome disparities.

The impact of race on utilization of durable left ventricular assist device therapy in patients with advanced heart failure.

Heart failure affects >6 million people in the United States aloneand is most prevalent in Black patients who suffer the highest mortality risk. Yet prior studies have suggested that Black patients are less likely to receive advanced heart failure therapy. We hypothesized that Black patients would have decreased rates of durable left ventricular assist device (LVAD) implantation within our expansive heart failure program. A retrospective single-center cohort study was conducted at a single high-volume academic medical center. Patients between 18 and 85 years admitted with a diagnosis of cardiogenic shock or congestive heart failure between 1, 2013 and 12, 2017 with a left ventricular ejection fraction < 30% and inotropic dependence or need for mechanical circulatory support were included. Patients with contraindications to durable LVAD were excluded. An adjusted logistic regression model for durable LVAD implantation within 90 days of the index admission was used to determine the effect of race on durable LVAD implantation. Among the 702 study patients (60.9% White, 34.1% Black), durable LVAD implantation was performed within 90 days of the index admission in 183 (26%) of the cohort. After multivariate analysis, Black patients were not found to have a statistically significant difference in durable LVAD implantation rates compared to White patients in our study (OR: 0.68 [95%confidence interval: 0.45-1.04; p: .074]). Black patients in our study did not have a statistically significant difference in the rate of durable LVAD implantation compared with White patients after adjustments were made for age, sex, socioeconomic, and clinical covariates. Larger prospective studies are needed to validate these findings.

Comparative study of on-label versus off-label treatment of intracranial aneurysms with the Pipeline embolization device.

The Pipeline embolization device (PED) is widely used for the treatment of intracranial aneurysms, including in off-label applications. In this work, the authors compared the real-world efficacy and safety of PED use in on-label and off-label aneurysm treatments. Clinical and angiographic data of patients who underwent PED placement at a high-volume academic medical center were retrospectively obtained. Treatments were classified as on-label if they fell within the applications approved by the United States Food and Drug Administration as of 2021. Recorded outcomes included aneurysm occlusion, procedural complications, ischemic events, in-stent stenosis, intracranial hemorrhage, postprocedural functional status, and death. In total, 416 aneurysms in 330 patients were treated with PED, comprising 256 aneurysms that received on-label treatments and 160 that received off-label treatments. The overall rate of complete aneurysm occlusion was 76.4% for on-label aneurysms and 75.6% for off-label aneurysms (p = 0.898). The risk of ischemic stroke in patients who underwent off-label treatments was 15.2%, which was higher than the 4.2% rate in patients who underwent on-label treatment (p = 0.003). All other clinical complications, procedural complications, and long-term functional status were comparable between the on-label and off-label groups. In real-world practice, off-label use of PED is common and can achieve similar efficacy as on-label use. However, in aggregate, off-label use was found to carry an increased rate of ischemic complications. With judicious attention to safety and individual patient characteristics, these results highlight the scale and general feasibility of off-label PED use by experts.

Tumor immune microenvironment and implications for progression and survival in patients with recurrent endometrial cancer (182)

Objectives: The immunologic response to cancer influences disease progression and survival in ways that are not yet completely understood. The objective of this analysis was to understand markers of immune exhaustion and mismatch repair within the tumor immune microenvironment in patients with recurrent endometrial cancer. Methods: We identified patients matched with primary and recurrent endometrial adenocarcinoma at a single high-volume academic medical center. Histologic slides were reviewed to confirm the diagnosis of primary and recurrent cancer, and formalin-fixed paraffin-embedded tissue blocks were requested from archives. Immunohistochemistry (IHC) was performed using antibodies against CD3 and immune exhaustion markers (PD1, PDL1, CTLA4, TIM3, and TIGIT) to quantify the number of tumor-infiltrating lymphocytes (TILs). Peritumoral lymphocytes (PTLs) were evaluated in a semi-quantitative manner. Kaplan-Meier method was used to estimate progression-free survival (PFS) and overall survival (OS), and the log-rank test was used to compare between groups. Conclusions: Among patients with endometrial cancer who ultimately develop recurrent disease, the number of TILs and expression of immune exhaustion markers at initial diagnosis are not associated with PFS but are associated with OS. Specifically, the higher number of lymphocytes and increased expression of exhaustion markers PD1, PDL1, and TIGIT at the time of initial diagnosis are associated with decreased OS. Further work is needed to determine the prognostic value of immune exhaustion markers for patients who develop recurrent endometrial cancer. Objectives: The immunologic response to cancer influences disease progression and survival in ways that are not yet completely understood. The objective of this analysis was to understand markers of immune exhaustion and mismatch repair within the tumor immune microenvironment in patients with recurrent endometrial cancer. Methods: We identified patients matched with primary and recurrent endometrial adenocarcinoma at a single high-volume academic medical center. Histologic slides were reviewed to confirm the diagnosis of primary and recurrent cancer, and formalin-fixed paraffin-embedded tissue blocks were requested from archives. Immunohistochemistry (IHC) was performed using antibodies against CD3 and immune exhaustion markers (PD1, PDL1, CTLA4, TIM3, and TIGIT) to quantify the number of tumor-infiltrating lymphocytes (TILs). Peritumoral lymphocytes (PTLs) were evaluated in a semi-quantitative manner. Kaplan-Meier method was used to estimate progression-free survival (PFS) and overall survival (OS), and the log-rank test was used to compare between groups. Conclusions: Among patients with endometrial cancer who ultimately develop recurrent disease, the number of TILs and expression of immune exhaustion markers at initial diagnosis are not associated with PFS but are associated with OS. Specifically, the higher number of lymphocytes and increased expression of exhaustion markers PD1, PDL1, and TIGIT at the time of initial diagnosis are associated with decreased OS. Further work is needed to determine the prognostic value of immune exhaustion markers for patients who develop recurrent endometrial cancer.

Merkel cell carcinoma: treatment and outcomes over a 10-year period at a high-volume academic center.

Merkel cell carcinoma (MCC) is a rare, highly aggressive malignancy which lacks high-level evidence-based treatment guidelines. To determine outcomes of MCC patients and assess the role of radiation in treatment, we performed a retrospective chart review of patients treated for MCC between 2006 and 2016 at a single high-volume academic medical center. The primary outcome was overall survival (OS) for the entire population and for those populations receiving specific therapies. Forty-two patients were evaluable. OS for all patients was not reached since most remain alive at time of analysis. OS for the American Joint Committee on Cancer (AJCC) stage I was not reached. OS for stages II, III, and IV was 37.3 months (6.8, -), 49.5 months (14.2, 49.5), and 14.5 months (10.8, -), respectively. OS could not be reached in the high radiotherapy (RT) dose group (biologically equivalent dose [BED] ≥ 60) and was 49.5 months (10.8, -) in the low-dose group (BED < 60). For surgical margin status, OS was 14.9158 months (6.8008, -) for positive margins and 37.3 months (10.8, -) for negative margins. No conclusive findings for OS were identified; however, trends for improved OS were associated with lower AJCC staging, negative surgical margins, and high RT doses.

Decreased Utilization of Durable Left Ventricular Assist Device Therapy in Blacks Relative to Whites with Advanced Heart Failure

Purpose Heart failure affects 6 million people in the US, and is most prevalent in Blacks who suffer the highest mortality risk[1, 2]. Yet prior studies have suggested that black patients are less likely to receive advanced heart failure therapy[3-6]. We hypothesized that black patients would have decreased rates of durable LVAD implantation within our expansive heart failure program. Methods A retrospective single center cohort study was conducted using electronic medical record data at our high-volume academic medical center. Patients between 18 and 85 years admitted with a diagnosis of cardiogenic shock or congestive heart failure between 1/2013 and 12/2017 with an LVEF Results A total of 702 patients were included, of which 60.8% were white and 34.2% were Black; 72% of the patients in the study were men. Comorbidities were similar among the racial groups with the exception of coronary artery disease (CAD), which had an increased prevalence in whites (N=248; 58%). White patients were older (65 vs 59; p Conclusion Black patients in our study had a decreased rate of durable LVAD implantation compared with white patients after adjustments were made for age, gender and clinical covariates. While this finding was likely mediated by socioeconomic factors, larger prospective studies are needed to validate these findings.

When Indirect Decompression Fails: A Review of 220 Consecutive Direct Lateral Interbody Fusions and Unplanned Secondary Decompression.

A consecutive series of patients who underwent minimally invasive spinal surgery by a single surgeon at a high-volume academic medical center were studied. The objective of this study was to identify the prevalence, radiographic features, and clinical characteristics of patients who require unplanned secondary decompressive laminectomy or foraminotomy after lateral lumbar interbody fusion (LLIF). LLIF indirectly decompresses the spinal canal, lateral recess, and neural foramen when properly performed. However, indirect decompression relies on endplate integrity, reasonable bone quality, and sufficient contralateral release so that ligament distraction can occur. Some patients have insufficient decompression, resulting in persistent axial low back pain or radiculopathy. Patients undergoing LLIF for radiculopathy or refractory low back pain were enrolled in a prospective registry. Preoperative and postoperative imaging, clinical presentation, and operative reports were reviewed from this registry. During registry collection, 122 patients were enrolled (220 lumbar levels treated), with nearly even representation between men (64/122, 52.5%) and women (58/122, 47.5%). Overall, right-sided lumbar spinal approaches (74/122, 60.7%) were more common. Ultimately, 4.1% (five of 122) of patients required unplanned direct decompressive laminectomy or foraminotomy because of refractory radiculopathy and persistent radiographic evidence of compression at the index LLIF level. All patients for whom indirect decompression failed were men who underwent stand-alone LLIF and had radiculopathy contralateral to the side of the LLIF approach. Most patients (59.8%, 73/122) had evidence of graft subsidence (grade 0 or 1) or osteoporosis. We report a 4.1% rate of return to the operating room for failed indirect decompression after LLIF for refractory radiculopathy. Graft subsidence and osteoporosis were common in these patients. All five patients who required secondary decompressive laminectomy or foraminotomy underwent stand-alone primary LLIF, and the persistent radiculopathy was consistently contralateral to the initial side of the LLIF approach.Level of Evidence: 4.

61. ALIF vs TLIF for isthmic spondylolisthesis: differences in radiographic outcomes

BACKGROUND CONTEXT Patients with a diagnosis of isthmic spondylolisthesis have higher sacral slope, pelvic tilt, pelvic incidence and lumbar lordosis compared to patients without isthmic spondylolisthesis. Several fusion techniques have been used to treat isthmic spondylolisthesis in adults, including anterior lumbar interbody fusion (ALIF) and transforaminal interbody fusion (TLIF). Compared to other fusion techniques, ALIF has shown better sagittal alignment outcomes, particularly restoration of segmental lordosis. PURPOSE The purpose of this study was to evaluate which fusion technique provides the better radiological outcome for adult lumbar isthmic spondylolisthesis. STUDY DESIGN/SETTING This study was a retrospective analysis of prospectively collected data from a single, high-volume academic medical center. PATIENT SAMPLE Patients who underwent lumbar fusion for isthmic spondylolisthesis from 2014 to 2019 were included in the analysis. Surgery was indicated after failure of conservative treatment to address radiculopathy and/or neurogenic claudication. Patients were excluded if they were under 18 years of age at the time of surgery, presented with a tumor or infection, or underwent revision surgery. OUTCOME MEASURES Preoperative and postoperative radiographic parameters were collected including sacral slope, pelvic tilt, pelvic incidence, lumbar lordosis, segmental lumbar lordosis, and the vertebral slip percentage. METHODS Patient and surgical characteristics including age, gender, smoking status, body mass index (BMI), Charlson Comorbidity Index (CCI), number of levels decompressed and number of levels fused were collected. Preoperative and final radiographic outcomes were obtained from an institutional electronic medical record. For analysis, patients were divided into two groups based on surgical technique: combined anterior fusion with posterior stabilization (ALIF-PLDF) or anterior and posterior fusion through a posterior approach (TLIF). RESULTS A total of 101 patients were included in final analysis, with 52 patients in the ALIF-PLDF group and 49 patients in the TLIF group. Mean age was greater in the TLIF group (p=0.017). Patients in the TLIF group were more likely to have a history of smoking (p=0.008), to have a greater CCI score (p=0.003), and to have higher number of levels decompressed. On analysis of radiographic parameters, preoperative sacral slope was higher in in the ALIF-PLDF group than the TLIF group (p=0.071). Postoperative overall lumbar lordosis was lower in the TLIF group (p=0.036). Postoperative segmental lumbar lordosis and the delta value for segmental lumbar lordosis were both lower in the TLIF group (p=0.030 and p=0.001). The TLIF group had a significant increase in PI-LL mismatch (p=0.032). Both groups had significant decrease in vertebral slip percent (p CONCLUSIONS Our data highlights that patients undergoing ALIF have a significant increase in segmental lordosis from their preoperative baseline. Interestingly, patients undergoing TLIF have significantly less postoperative change in segmental lumbar lordosis when compared to ALIF. When treating patients with isthmic spondylolisthesis, the ALIF approach has benefits not only in its capacity to restore segmental lordosis, but also by providing significant reduction in vertebral body slip. Our results suggest that, when compared to the TLIF approach, ALIF may be associated with better outcomes in terms of critical radiographic parameters. FDA DEVICE/DRUG STATUS This abstract does not discuss or include any applicable devices or drugs.

56. Minimally invasive pedicle screws provide similar clinical outcomes to open posterior fusion in the management of adult isthmic spondylolisthesis

BACKGROUND CONTEXT In adult patients undergoing anterior lumbar interbody fusion (ALIF) for the treatment of isthmic spondylolisthesis, the literature shows that posterior percutaneous pedicle screw fixation leads to shorter hospital stays, less time under anesthesia, and less intraoperative blood loss compared to open posterior fusion. However, there is conflicting evidence on whether patients undergoing posterior percutaneous fixation experience similar clinical outcomes as those undergoing open posterior fusion. PURPOSE The purpose of this study was to determine the impact of minimally invasive posterior surgery on clinical outcomes following lumbar spinal fusion for isthmic spondylolisthesis. STUDY DESIGN/SETTING This study was a retrospective analysis of prospectively collected data from a single, high-volume academic medical center. PATIENT SAMPLE Analysis of patients who underwent lumbar fusion for isthmic spondylolisthesis from 2014 to 2019 was conducted. Surgery was indicated after failure of conservative treatment to address lumbar radiculopathy and/or neurogenic claudication. OUTCOME MEASURES Patient-reported outcome measures (PROMs) were recorded at preoperative and postoperative clinical visits, and included the Visual Analog Scale back pain (VAS back) and leg pain (VAS leg), the Short-Form 12 Mental Component Score (MCS-12) and Physical Component Score (PCS-12), and the Oswestry Disability Index (ODI). Secondary measures included estimated blood loss (EBL) and length of stay (LOS). METHODS Patient and surgical characteristics including age, gender, body mass index (BMI), Charlson Comorbidity Index (CCI), number of levels decompressed and number of levels fused were recorded. Preoperative and final PROMs were obtained from an institutional query. For analysis, patients were divided into two groups based on surgical approach: ALIF with percutaneous pedicle screws (Percutaneous) and ALIF with open posterior fusion (Open). Multivariate linear regression was performed to correlate surgical approach and outcomes. RESULTS A total of 61 patients were included, with 20 patients in the Percutaneous group and 41 patients in the Open group. Patients undergoing open surgery had greater intraoperative EBL (p=0.013) and longer LOS (p=0.034). Otherwise, there were no significant differences in patient characteristics. Patients in both the Percutaneous and the Open groups had significant improvement in VAS back scores (p=0.001, p CONCLUSIONS Our results suggest that patients undergoing minimally invasive posterior fusion and patients undergoing open posterior fusion for adult isthmic spondylolisthesis have similar improvement of PROMs from preoperative to final assessment. Additionally, open surgery is significantly correlated with less improvement in VAS leg scores than minimally invasive approaches and was associated with significantly higher intraoperative blood loss and hospital length of stay. This study underscores the importance of considering surgical approach as a prognostic factor. Furthermore, the results provide additional information that can be used by physicians in preoperative discussions with patients regarding expectations of postoperative improvements in pain. FDA DEVICE/DRUG STATUS This abstract does not discuss or include any applicable devices or drugs.

271. Surgical technique and patient-reported outcomes in adult isthmic spondylolisthesis

BACKGROUND CONTEXT Combined anterior lumbar interbody fusion (ALIF) with posterior lumbar decompression and fusion (PLDF), and transforaminal lumbar interbody fusion (TLIF) are two procedures recommended to improve clinical outcomes in adult patients with isthmic spondylolisthesis. However, there is debate whether TLIF provides superior clinical outcomes to ALIF combined with PLDF, specifically regarding patient-reported outcome measures (PROMs). PURPOSE The purpose of this study was to compare PROMs between combined ALIF-PLDF and TLIF techniques following lumbar spinal fusion for adult isthmic spondylolisthesis. STUDY DESIGN/SETTING This study was a retrospective analysis of prospectively collected data from a single, high-volume academic medical center. PATIENT SAMPLE Patients who underwent lumbar fusion for isthmic spondylolisthesis from 2014 to 2019 were included in the analysis. Surgery was indicated after failure of conservative treatment to address radiculopathy and/or neurogenic claudication. OUTCOME MEASURES Patient-reported outcome measures were collected at preoperative and postoperative clinical visits. Metrics recorded include the visual analog scale for back pain (VAS back) and leg pain (VAS leg), the Short-Form 12 Mental Component Score (MCS-12) and Physical Component Score (PCS-12), and the Oswestry Disability Index (ODI). Secondary measures included estimated blood loss (EBL) and hospital length of stay (LOS). METHODS Patient and surgical characteristics including age, gender, body mass index (BMI), Charlson Comorbidity Index (CCI), number of levels decompressed and number of levels fused were recorded. Preoperative and final patient-reported outcome measures were obtained from an institutional query. For analysis, patients were divided into two groups based on surgical technique: combined anterior fusion with posterior stabilization (ALIF-PLDF) or anterior and posterior fusion through a posterior approach (TLIF). Multivariate linear regression was performed to correlate surgical approach and PROMs. RESULTS A total of 125 patients were included in final analysis, with 62 patients in the ALIF-PLDF group and 63 patients in the TLIF group. Patients undergoing ALIF-PLDF were more likely to be older (p=0.041) and have shorter LOS (p=0.009), while patients in the TLIF group had significantly more smoking history (p=0.007), more comorbid conditions (p=0.003), and higher number of levels decompressed (p=0.003). Patients in both the ALIF-PLDF group and the TLIF group had significant improvements in VAS back scores (p CONCLUSIONS Our results indicate that patients with isthmic spondylolisthesis treated with ALIF-PLDF approaches show significant improvements in all evaluated PROMs from initial preoperative visit to final follow-up, whereas similar patients treated with a TLIF approach have significant improvements in all PROMs except MCS-12. Our data further suggest that TLIF is more likely to be chosen for older, chronically ill patients, and those undergoing decompression at a higher number of levels. Despite these baseline differences, PROMs are similar between both fusion methods. FDA DEVICE/DRUG STATUS This abstract does not discuss or include any applicable devices or drugs.

103. Discharge to subacute rehabilitation is a predictor of wound complications after spine surgery

BACKGROUND CONTEXT A significant number of patients are discharged to inpatient care facilities after various procedures in spine surgery. However, data are limited regarding the relationship between nonhome disposition and postdischarge surgical outcomes. PURPOSE The aim of this study was to evaluate differences in wound complications and readmission among discharge settings in patients undergoing elective spine surgery for degenerative cervical and lumbar disease (radiculopathy and/or myelopathy). STUDY DESIGN/SETTING This study is a retrospective analysis of prospectively collected data from a single, high-volume academic medical center. PATIENT SAMPLE Patients undergoing one- to three-level lumbar decompression, one- to three-level lumbar decompression and fusion, or posterior cervical decompression and fusion were retrospectively identified. OUTCOME MEASURES The outcomes of interest in this study were wound complications (surgical site infections, wound dehiscence), revision surgery, 30-day readmission, and 90-day readmission. METHODS Patient characteristics, including age, gender, body mass index (BMI), Charlson Comorbidity Index (CCI), and discharge setting (home, acute rehabilitation, subacute rehabilitation) were collected. Patients were stratified into those discharged to home/self-care (home), those discharged to inpatient rehabilitation (acute), and those discharged to skilled nursing or long-term rehabilitation (subacute). A multivariate logistic regression model was developed to identify variables associated with wound complications. RESULTS A total of 623 patients were included in the final analysis, with 480 patients in the Home group, 72 patients in the Acute group, and 80 patients in the Subacute group. Acute and Subacute patients had a higher mean age compared to the Home group (p CONCLUSIONS Our results suggest that discharge to subacute rehabilitation may be associated with an increased risk of wound complications in patients’ status post elective cervical or lumbar surgery. Moreover, our analysis further supports previous reports establishing an association between increased postoperative wound complications and obesity. Patients across all groups utilized a similar amount of resources in terms of readmissions and revision surgery. Surgeons should understand the need for appropriate risk stratification, and when clinically possible and safe, design pathways aimed at home discharge to reduce the occurrence of postoperative wound complications. FDA DEVICE/DRUG STATUS This abstract does not discuss or include any applicable devices or drugs.

272. Timing of preoperative surgical antibiotic prophylaxis prior to one- to three-level elective lumbar fusion

BACKGROUND CONTEXT Surgical site infections (SSIs) in patients who have undergone lumbar fusion surgery can be a devastating complication and a common indication for revision surgery. The functional decline and economic burden put on the patient as a result of infection can drastically affect postoperative outcomes. As such, studies have identified potential areas of intervention, including: optimizing patient comorbidities, thoroughly supervising the operating room, and administering antibiotic prophylaxis. Guidelines have established a goal to infuse antibiotics within one hour prior to incision. PURPOSE The aim of this study was to examine the relationship between timing of preoperative surgical antibiotic prophylaxis and adverse outcomes (e.g. SSIs, 90-day readmissions, and revision surgery) with subgroup analysis stratified by type of antibiotic. While most antibiotics are administered within one hour of surgery, certain circumstances (ie, prolonged case duration, long operating room turnover) may delay the time from antibiotic administration to incision. STUDY DESIGN/SETTING Retrospective cohort study. PATIENT SAMPLE A cohort of patients status post elective one- to three-level lumbar fusion performed between January 2013 and December 2018 was identified at a single, high-volume academic medical center using a database query via Standardized Query Language (SQL). OUTCOME MEASURES The primary outcome of interest was surgical site infections (SSIs), with secondary outcomes of interest including: 90-day readmission and revision surgery. METHODS SQL query and electronic medical record (EMR) chart reviews were used to identify patient demographics, surgical case characteristics, and postoperative complications. Patients were allocated into 5 groups based on the time period from preoperative antibiotic administration to incision (Group A = 0-15 min, Group B = 16-30 min, Group C = 31-45 min, Group D = 46 – 60 min, and Group E = 61+ min). SSIs were identified by the definition set forth by the CDC. Statistical analysis, including a logistic regression model, was used to examine the relationship between patient/case characteristics, preoperative antibiotic timing, and postoperative outcomes. RESULTS From 1,131 patients included in the final analysis, 26 SSIs were identified. Univariate analysis revealed patients in Group E had significantly longer lengths of operation (p: 0.044) and higher mean comorbidity scores (p: 0.012) compared to all other groups. Logistic regression analysis revealed that Group E patients were 1.4 times more likely to develop an SSI and 7.2 times more likely to be readmitted within 90 days compared to Group A. Furthermore, Groups B-D did not show evidence of significantly higher odds of infection compared to Group A. When stratified by antibiotic type, patients treated with Vancomycin showed the lowest incidence of SSI when administered between 16-30 minutes, however Cefazolin showed the lowest incidence when administered between 0-15 minutes. Among 26 SSIs, nine cultures showed evidence of multi-drug resistance, with two treated preoperatively with vancomycin and seven treated with cefazolin. CONCLUSIONS Our results present that preoperative antibiotic administration beyond one hour in patients who have undergone lumbar fusion is associated with higher rates of SSI. Furthermore, the utility of vancomycin to minimize the risk of SSI is optimal when administered between 16 and 30 minutes prior to incision. An effective antibiotic prophylaxis regiment depends on patient characteristics and the pharmacokinetics of antibiotic selection, while minimizing side effects and multi-drug resistant organisms. FDA DEVICE/DRUG STATUS This abstract does not discuss or include any applicable devices or drugs.

Integration of Patient-reported Outcomes in a Total Joint Arthroplasty Program at a High-volume Academic Medical Center

Introduction:Despite widely appreciated barriers to successful clinical implementation, the literature regarding how to operationalize electronic health record-integrated patient-reported outcomes (PROs) remains sparse. We offer a detailed summary of the implementation of PROs into the standard of care at a major tertiary academic medical center.Methods:Collection of four Patient-Reported Outcomes Measurement Information System computer adaptive tests was piloted in a large academic orthopaedic surgery ambulatory clinic starting in October 2016. The Patient-Reported Outcomes Measurement Information System computer adaptive tests (Physical Function, Pain Intensity, Pain Interference, and Ability to Return to Social Roles and Activities) were initially implemented as manual order sets to be administered before surgery through 2 years after surgery. Completion rate over time, mean time to completion for all PRO domains, and the overall distribution of symptom severity were used to evaluate the success of the pilot. A subsequent optimization and redesign of the pilot was conducted using tablets, automation of questionnaire deployment, and improved results review to address obstacles encountered during the pilot phase.Results:Two thousand nine distinct joint arthroplasty patients (mean age = 65) completed at least one set of PRO assessments, with overall completion rates reaching 68% and mean completion time of 3 minutes. Focal points during the implementation process included engagement and training of staff, selection of an appropriate patient population and outcome measures, and user friendly data displays for patients and providers.Conclusion:Our pilot program successfully demonstrated that PROs can be administered, scored, and made immediately available within the electronic health record to patients and their providers with minimal disruption of clinical workflows. Although considerable operational and technological challenges remain, we found that the implementation of PROs in clinical care within an ambulatory practice at an academic medical center can be achieved through a constellation of several key factors.

Is the likelihood of dysphagia different in patients undergoing one-level versus two-level anterior cervical discectomy and fusion?

BACKGROUND CONTEXTDysphagia following anterior cervical discectomy and fusion (ACDF) is a common complication, the etiology of which has not been established. Given that one potential mechanism for dysphagia is local tissue edema, it is thought that a greater number of operative levels may result in higher dysphagia rates. However, prior reports comparing one-level to two-level ACDF have shown varying results. PURPOSETo determine if there is a difference in dysphagia between one-level and two-level ACDF. STUDY DESIGN/SETTINGRetrospective review of prospectively collected data. PATIENT SAMPLEPatients who underwent one- or two-level ACDF with a plate-graft construct by a single-surgeon at a high-volume academic medical center. OUTCOME MEASURESNeck Disability Index, Visual Analog Scale for neck pain and arm pain, Short Form-12 physical and mental health components, and Swallowing Quality of Life (SWAL-QOL) Questionnaire. METHODSPatient demographics, operative data, and patient-reported outcome measures (PROMs; Neck Disability Index, Visual Analog Scale, Short Form-12, and SWAL-QOL) of patients undergoing one- and two-level ACDF were compared using Fisher exact test for categorical variables and Student's t test for continuous variables. Regression analyses were conducted to identify factors associated with 6- and 12-week SWAL-QOL scores in order to determine whether the number of surgical levels impacts these outcomes. RESULTSFifty-eight patients (22 one-level and 36 two-level ACDF) were included. Patients undergoing two-level fusions were older (54.17+8.67 vs 48.06+10.68 years, p=.02) and had longer operative times (69.08+10.51 vs 53.5+14.35 minutes, p<.0001). There were no other significant differences in demographics or operative data. Both groups showed a statistically significant improvement in PROMs from preoperatively to 12 weeks. There was no difference in PROMs or dysphagia rates between groups at any time-point. Younger age (p=.023), male sex (p=.021), longer operative times (p=.068), and worse preoperative SWAL-QOL (p<.0001) were associated with dysphagia at 6 weeks. Preoperative SWAL-QOL was the only variable associated with dysphagia at 12 weeks (p=.003). Operative time of >61.5 minutes had a sensitivity and specificity of 62.1% for worse dysphagia scores at 6 weeks compared with baseline. CONCLUSIONSThe results of our study indicate that there is no difference in the degree of postoperative dysphagia in one- versus two-level ACDF. However, other variables associated with increased postoperative dysphagia in our population included younger age, male sex, procedural time >61.5 minutes, and worse preoperative dysphagia. Larger studies are required to confirm these findings and identify additional risk factors for postoperative dysphagia.

Robotic Pancreaticoduodenectomy Is Associated with Decreased Clinically Relevant Pancreatic Fistulas: a Propensity-Matched Analysis

BackgroundClinically relevant postoperative pancreatic fistula (CR-POPF) after pancreatoduodenectomy (PD) is a major complication that adversely affects recovery. The robotic approach may decrease the incidence of this complication. This propensity-matched analysis evaluates the impact of robotic PD (RPD) on CR-POPF. MethodsPatients undergoing PD after the learning curve at a high-volume academic medical center were reviewed. CR-POPF outcomes after open PD (OPD) and RPD were compared. Logistic regression and propensity score matching (PSM) were used to define the independent effect of RPD on CR-POPF. ResultsOf 865 PDs performed over the study period, 405 (46.8%) were OPD and 460 (53.2%) were RPD. RPD was associated with a similar overall POPF rate, but a lower incidence of CR-POPF (6.7% vs. 15.8%, p < 0.001). On multivariate analysis, RPD was an independent predictor of lower CR-POPF (OR 0.278, p < 0.001). Following propensity matching, RPD continued to be protective against the occurrence of CR-POPF (coefficient = − 0.113, p = 0.001). ConclusionsThis is the largest single-center PSM analysis to evaluate the impact of robotic approach on pancreatoduodenectomy and suggests that RPD can minimize the clinical impact of pancreatic leaks after PD.

Propensity-matched comparison of transjugular intrahepatic portosystemic shunt placement techniques: Intracardiac echocardiography (ICE) versus fluoroscopic guidance

PurposeTo compare procedure characteristics and outcomes when TIPS is performed under intracardiac echocardiography guidance (iTIPS) compared to conventional fluoroscopic guidance (cTIPS). Materials and methodsA retrospective propensity-matched study of 30 iTIPS and 30 cTIPS procedures from January 2014 to March 2017 at a single US high volume academic medical center was performed. iTIPS and cTIPS cases were propensity score matched using predictive variables: age, race, gender, etiology of liver disease, indication for TIPS, MELD score, and portal vein patency. Procedure characteristics and post- procedure outcomes were compared between propensity-matched groups including: total procedure time, technical success, radiation dose, contrast volume, complication rate, 30- day mortality, and revision rate within 3 months. ResultsRadiation dose (875.3 vs 457.4 mGY, p = 0.039) and contrast volume (141 vs 103 mL, p = 0.005) were significantly decreased in the iTIPS versus the cTIPS group. There was no significant difference in procedure time (81.5 cTIPS vs 84 min iTIPS) or rate of TIPS revisions within 3 months. Average operator experience in the iTIPs group was 4.2 years and cTIPS group 11.0 years (p = 0.0004). All procedures were technically successful with no mortalities within 30 days. ConclusioniTIPS resulted in significantly reduced radiation dose and contrast volume. However, there was no difference in total procedure time or overall outcomes despite greater operator experience in the cTIPS group.