High-volume Tertiary Care Center Research Articles

Multidisciplinary Teams in the Management of Placenta Accreta Spectrum Disorders

The three-fold purpose of this review is to summarize recent evidence supporting the use of a multidisciplinary team (MDT) approach in patients with placenta accreta spectrum (PAS), to describe essential members and processes of the PAS MDT, and to highlight necessary resources for both planned and unexpected cases of PAS. Maternal outcomes in women with PAS are improved when an antenatal diagnosis occurs and referral is made to centers with MDT specialization and experience in treating PAS. New guidelines unequivocally recommend referral to higher-volume, experienced PAS centers of excellence. The diagnosis and treatment of patients with PAS are complex, resource-intensive, and pose high risk of maternal morbidity and mortality. Recent evidence suggests that stable, experienced MDTs focused on continuous systems improvement at high-volume tertiary care centers are superior to standard obstetric management for patients with PAS. Referral to a center of excellence is indicated when PAS is suspected.

PD57-08 LARGE SINGLE-INSTITUTION COMPARISON OF PERIOPERATIVE OUTCOMES AND COMPLICATIONS BETWEEN OPEN RADICAL CYSTECTOMY, INTRACORPOREAL ROBOTIC-ASSISTED RADICAL CYSTECTOMY, AND ROBOTIC CYSTECTOMY WITH EXTRACORPOREAL URINARY DIVERSION

You have accessJournal of UrologyBladder Cancer: Invasive VI (PD57)1 Apr 2019PD57-08 LARGE SINGLE-INSTITUTION COMPARISON OF PERIOPERATIVE OUTCOMES AND COMPLICATIONS BETWEEN OPEN RADICAL CYSTECTOMY, INTRACORPOREAL ROBOTIC-ASSISTED RADICAL CYSTECTOMY, AND ROBOTIC CYSTECTOMY WITH EXTRACORPOREAL URINARY DIVERSION JJ Zhang*, Kyle Ericson, Lewis Thomas, Alice Crane, Abhinav Khanna, Jacob Knorr, Michele Fascelli, Anna Zampini, Georges-Pascal Haber, and Byron Lee JJ Zhang*JJ Zhang* More articles by this author , Kyle EricsonKyle Ericson More articles by this author , Lewis ThomasLewis Thomas More articles by this author , Alice CraneAlice Crane More articles by this author , Abhinav KhannaAbhinav Khanna More articles by this author , Jacob KnorrJacob Knorr More articles by this author , Michele FascelliMichele Fascelli More articles by this author , Anna ZampiniAnna Zampini More articles by this author , Georges-Pascal HaberGeorges-Pascal Haber More articles by this author , and Byron LeeByron Lee More articles by this author View All Author Informationhttps://doi.org/10.1097/01.JU.0000557164.66800.5dAboutPDF ToolsAdd to favoritesDownload CitationsTrack CitationsPermissionsReprints ShareFacebookLinked InTwitterEmail Abstract INTRODUCTION AND OBJECTIVES: Surgical approach in radical cystectomy includes open radical cystectomy (ORC) and robotic-assisted radical cystectomy (RARC) with either intracorporeal urinary diversion (ICUD) or extracorporeal urinary diversion (ECUD). Multi-institutional studies have compared ORC to RARC or ICUD to ECUD, but comparison of all three surgical options have not been published from a single institution. The objective is to compare intraoperative outcomes, perioperative outcomes, and complication rates between open, intracorporeal, and extracorporeal diversions at a single high-volume tertiary care center. METHODS: A retrospective review was conducted of 641 patients who underwent radical cystectomy with urinary diversion at a single high-volume hospital between 2011-2018. Intraoperative outcomes, perioperative outcomes, and 90-day major complications (Clavien-Dindo classification III-V) were compared between ORC, ICUD and ECUD. Statistical analyses were performed using Pearson’s chi squared test for categorical variables and one-way ANOVA or Kruskal-Wallis for continuous variables with significance defined as p<0.05. RESULTS: 641 patients underwent radical cystectomy with urinary diversion: 231 ORC, 185 ICUD, and 225 ECUD. Estimated mean operative time was highest for ECUD (437.4 min) compared to ICUD (409.7 min) and ORC (334.8 min), p<0.0001. Median estimated blood loss (EBL) was significantly lower for ICUD (300cc) compared to ECUD (400cc) and ORC (750cc), p <0.0001. Comparing postoperative outcomes, patients undergoing ICUD had shorter hospitalization compared to ICUD and open cystectomy (7.9 v 9.5 v. 10.5 days), p<0.0001. Although there was no significant difference in rate of ileus by surgical approach, ICUD was significantly associated with lower TPN requirement rates (7.6%) compared to ECUD (12.0%) and ORC (19.5%), p=0.001. Comparing complication rates, ICUD was significantly associated with lower 90-day major complication rate compared to ECUD and ORC (14.6% v 26.2% v 27.3%, p=0.04). There was no significant difference in 90-day readmission between the three approaches. CONCLUSIONS: In our large single-institution experience, robotic intracorporeal urinary diversion demonstrated benefits of lower EBL, shorter hospital stay, lower TPN requirements, and lower major complication rates compared to both robotic extracorporeal diversion and open radical cystectomy. Source of Funding: None Cleveland, OH© 2019 by American Urological Association Education and Research, Inc.FiguresReferencesRelatedDetails Volume 201Issue Supplement 4April 2019Page: e1026-e1026 Advertisement Copyright & Permissions© 2019 by American Urological Association Education and Research, Inc.MetricsAuthor Information JJ Zhang* More articles by this author Kyle Ericson More articles by this author Lewis Thomas More articles by this author Alice Crane More articles by this author Abhinav Khanna More articles by this author Jacob Knorr More articles by this author Michele Fascelli More articles by this author Anna Zampini More articles by this author Georges-Pascal Haber More articles by this author Byron Lee More articles by this author Expand All Advertisement PDF downloadLoading ...

Modern era surgical outcomes of elective and emergency giant paraesophageal hernia repair at a high-volume referral center.

Repair of giant paraesophageal hernia (PEH) has historically been associated with significant morbidity and mortality such that elective repair is only offered to symptomatic patients. Recent reports suggest modern era outcomes have improved such that elective repair may now be safer than historically thought. Furthermore, the morbidity of emergency surgery may still be significant. These changes may have important implications for patient selection for elective repair. The objectives of this study were to determine and compare modern era surgical outcomes after elective and emergency repair of giant PEHs at a high-volume tertiary care center. A retrospective review was conducted for all Type II-IV giant PEH repairs performed between 1 January 2012 and 31 December 2017. Type 1 hiatal hernias, fundoplication for reflux, and any co-surgery other than cholecystectomy were excluded from the final analysis. Baseline patient demographics, operative details, postoperative complications within 30 days and in-hospital or 30-day mortality were tabulated from the electronic medical record. Data were reported as median (interquartile range) unless otherwise specified. A total of 352 cases were reviewed, of which 204 met inclusion criteria (18 emergency, 186 elective). Eight had Type II PEH, 146 had Type III, and 50 had Type IV. Median length of stay was shorter in the elective group [1 (1) day elective vs. 5 (7) days emergency, p < 0.0001], and emergency patients were less likely to return directly to their original residence at discharge (13, 72% emergency vs 185, 99.4% elective, p < 0.0001). There were significantly more major complications (Clavien-Dindo score ≥ 3) in the emergency group (5, 28% emergency vs. 10, 5% elective, p = 0.005). There were no perioperative deaths in either group. Morbidity and mortality in both groups were less than historically reported. Informed consent discussions and patient selection for repair of giant PEHs should reflect modern era and institution-specific outcomes.

ERCP quality indicators: The experience of a high-volume tertiary care center in Saudi Arabia

BackgroundEndoscopic retrograde cholangiopancreatography (ERCP) is one of the most technically demanding and high-risk procedures performed by GI endoscopists. Therefore, guidelines or position statements on various aspects of quality indicators, safety indicators and credentialing for ERCP have been developed by gastroenterology associations. In this paper, we evaluate the ERCP quality in a single, high-volume, tertiary care center in Saudi Arabia using a number of measures commonly stated by these organizations, and compare the experience of that center to the previously-published standards in this regard. Patients and MethodsThis is a descriptive, retrospective chart review of a consecutive sample taken over 12 continuous months (July 2016–June 2017). Data collected included demographic characteristics, and technical/clinical details from three time periods: preprocedure, intraprocedure, and postprocedure. Measurement parameters were all taken from the ASGE/ACG guidelines. Data was represented by the percentage of which each indicator was achieved, and the 95% proportion confidence intervals (CIs) when needed. ResultsFrom July 2016 to June 2017, 281 ERCP procedures were performed. An outstanding majority of them (95.7%) was done for therapeutic purposes, whereas 4.3% were diagnostic procedures. The sample included 206 patients, of whom 83 (40.3%) were males. The age of the participants ranged between 11 and 101 years (mean age ± SD; 51 ± 19). The quality of ERCP at the center in which the study was done met the performance targets stated by the ASGE/ACG for almost all indicators. Adverse events reported in our series were lower than previous studies for pancreatitis and perforation, and slightly higher in the incidence of bleeding, cholangitis, and death. ConclusionIn a single, high-volume, tertiary care center in Saudi Arabia, the quality of ERCP met the performance targets stated by the ASGE/ACG for almost all indicators.

Analysis of anastomotic urethroplasty for pelvic fracture urethral distraction defect: Decadal experience from a high-volume tertiary care center.

Context:Pelvic fracture urethral distraction defect (PFUDD) may be challenging for the treating urologist. Anastomotic urethroplasty is the established surgical procedure for the treatment of PFUDD. Few studies in literature focus purely on PFUDD, and majority of the studies include anterior urethral stricture as well. The period of these studies is relatively short. We conducted a retrospective analysis of patients who underwent primary or redo anastomotic urethroplasty for PFUDD over a period of 12 years at a tertiary care center in northern India.Aims:The aim is to study anastomotic urethroplasty for pelvic fracture urethral distraction defect with regard to long-term success rate and complications.Settings and Design:This was a retrospective study. Subjects andMethods:This retrospective study was conducted in the Department of Urology, King George's Medical University, Lucknow, India, from August 2004 to July 2016. All patients who underwent progressive perineal anastomotic repair of PFUDD were included in this study. Demographic findings, type of pelvic fracture, length of distraction defect as per retrograde urethrography (RUG) and micturating cystourethrography, any history of erectile dysfunction in the preoperative or postoperative phase, and urinary incontinence in postoperative phase were analyzed. Decision regarding catheter removal was taken after pericatheter RUG at 4 weeks. Follow-up was done at 3 and 6 months in postoperative period.Results:A total of 226 anastomotic repairs were done in 221 patients. Of the 221 patients, 51 (23%) were redo urethroplasty. The mean age of patients was 27.6 years. The mean length of distraction defect was 2.7 cm. The mean duration of hospital stay was 6 days. Primary urethroplasty was successful in 163 (93.14%) of 175 patients and redo urethroplasty in 44 (86.27%) of 51 patients. Out of 165 patients, 18 (10.9%) patients reported occasional incontinence while 6 (3.63%) patients reported mild incontinence.Conclusions:Anastomotic urethroplasty is the definitive procedure for PFUDD. Our success rate for primary deferred anastomotic urethroplasty is 93.14% and for redo anastomotic urethroplasty is 86.27%.

291: Racial disparities in postpartum pain management

Multiple studies have demonstrated racial/ethnic minority individuals receive less treatment for similar levels of pain than non-Hispanic white (NHW) individuals. Whether this association exists in the postpartum setting remains unknown. We sought to evaluate racial/ethnic differences in women’s postpartum pain scores, inpatient opioid administration, and discharge opioid prescribing. Retrospective cohort study of all deliveries at a single, high-volume tertiary care center (12/2015-16). Women were included if they self-identified as NHW, non-Hispanic black (NHB), or Hispanic. Medical records were queried for three outcomes: 1) patient-reported postpartum pain score at discharge (dichotomized <5 or ≥5); 2) inpatient opioid dosing during postpartum hospitalization (reported as morphine milligram equivalents [MME] per postpartum day); and 3) receipt of an opioid prescription at discharge. The associations between each of these outcomes and maternal race/ethnicity were assessed using multivariable logistic regression models with random effects to account for clustering by discharge physician. Of 9,900 women eligible for analysis, 68.4% identified as NHW, 21.0% as Hispanic, and 10.6% as NHB. On bivariable analyses, Hispanic and NHB women were more likely to report postpartum pain scores ≥5 (p<0.001), but received less inpatient MME/day (p<0.001) and were less likely to receive an opioid prescription at discharge than NHW women (p<0.001) (Figure). On multivariable analyses, these findings remained statistically significant (Table). Specifically, compared to NHW women, Hispanic women had significantly greater odds of reporting a pain score of ≥ 5 (aOR 1.69; 95% 1.33-2.15), but received significantly less inpatient MME/day (aβ -4.77; 95% CI -6.59 to -0.62) and were significantly less likely to receive an opioid prescription at discharge (aOR 0.81; 95% CI 0.68-0.97). Similarly, NHB women had significantly greater odds of reporting a pain score ≥5 (aOR 2.66; 95% 2.05-3.45), but received significantly less inpatient MME/day (aβ -2.79; 95% CI -4.95 to -0.62) and were significantly less likely to receive an opioid prescription at discharge (aOR 0.81; 95% CI 0.65-0.99). Hispanic and NHB women experience disparities in pain management in the postpartum setting that cannot be explained by less perceived pain.View Large Image Figure ViewerDownload Hi-res image Download (PPT)

Evolution of Robot-assisted Partial Nephrectomy: Techniques and Outcomes from the Transatlantic Robotic Nephron-sparing Surgery Study Group

BackgroundRobot-assisted partial nephrectomy (RAPN) is considered a feasible minimally invasive alternative to open partial nephrectomy (OPN) for the surgical treatment of renal tumors. ObjectiveTo provide further evidence supporting the effectiveness of RAPN in a contemporary patient population treated at one of three tertiary care centers for robotic surgery and to describe the evolution of RAPN-based technical improvements. Design, setting, and participantsThe Transatlantic Robotic Nephron-sparing Surgery (TRoNeS) study group prospectively collected data from 635 patients subjected to RAPN for clinically localized kidney cancer between 2010 and 2016 at three high-volume tertiary care centers. Surgical procedureRAPN was performed using methods outlined in the supplementary video using either the da Vinci Si or Xi surgical system (Intuitive Surgical, Sunnyvale, CA, USA). MeasurementsClinical data were collected within a prospectively maintained multi-institutional database. Intra- and postoperative data as well as surgical outcomes were assessed. Descriptive statistical analysis was performed and multivariable logistic regression models were fitted to determine the predictors of surgical outcomes. Results and limitationsMean patient age was 60.7yr and mean preoperative tumor size was 33mm. According to the PADUA score, 202 (31.8%) patients had a low-, 235 (37.0%) had an intermediate-, and 198 (31.2%) had a high-complexity tumor. In the majority of patients, a transperitoneal approach was used (n=447; 70.4%). Mean operative time was 156.3min and mean estimated blood loss was 171ml. Overall, 25 (3.9%) patients experienced a significant (Clavien-Dindo >2) complication after surgery. No statistically significant differences between pre- and postoperative creatinine values were observed (p≤0.823). Finally, optimal surgical outcomes defined according to the margin, ischemia, and complication score were achieved in 459 (72.3%) individuals. At a mean follow-up of 26mo, only two local and two distant recurrences of the disease were observed. Finally, in multivariable logistic regression models, tumor complexity was associated with the risk of not achieving optimal surgical outcomes. ConclusionsRAPN represents an effective minimally invasive alternative to OPN in the treatment of clinically localized renal tumors. Patient summaryWe reported contemporary experience with RAPN for the treatment of kidney cancer. RAPN appears to be a safe and effective procedure, resulting in optimal outcomes in the majority of individuals despite tumor complexity.

Predictive value of hematological parameters in testicular torsion: retrospective investigation of data from a high-volume tertiary care center.

ObjectiveTo investigate the use of hematological parameters in the differential diagnosis of testis torsion and epididymo-orchitis, and to determine the predictive value of these parameters in the diagnosis of testis torsion.MethodsThis study retrospectively reviewed the medical data of patients who presented to our institute with the complaint of acute scrotal pain. Eighty-five patients who had undergone orchiectomy or surgical detorsion due to testis torsion and 72 patients with epididymo-orchitis were included in the study. The control group comprised 78 healthy males. The groups were compared with respect to age, hematological parameters, neutrophil to lymphocyte ratio (NLR), monocyte to eosinophil ratio (MER), and platelet to lymphocyte ratio (PLR).ResultsThe monocyte count significantly differed between testis torsion and epididymo-orchitis, and was useful in the differential diagnosis. The mean neutrophil, platelet, and white blood cell counts, and the NLR, MER, and PLR values in the control group were significantly lower than those in the torsion and epididymo-orchitis groups.ConclusionThe sensitivity and specificity of NLR in predicting testis torsion were as high as the sensitivity and specificity of doppler ultrasonography, suggesting the possible use of this parameter in the diagnosis of testis torsion.

Patient and Health Care Provider Factors Associated With Prescription of Opioids After Delivery

To identify patient and health care provider characteristics associated with receipt of a high amount of prescribed opioids at postpartum discharge. This was a retrospective case-control study of all opioid-naïve women delivering at a single, high-volume tertiary care center between December 1, 2015, and November 30, 2016. Inpatient, outpatient, pharmacy, and billing records were queried for clinical, prescription, and health care provider (training, age, gender) data. The discharging health care provider, whether an opioid prescription was provided, and the details of any opioid prescription were determined. A high amount of prescribed opioids was defined as morphine milligram equivalents greater than the 90th percentile (determined as 300 morphine milligram equivalents for vaginal and 500 morphine milligram equivalents for cesarean delivery). Multivariable logistic regression models with random effects were used to identify patient and health care provider factors independently associated with receipt of a high amount of prescribed opioids at discharge. Findings were analyzed separately by mode of delivery. The analysis included 12,362 women. High amounts of opioids were prescribed for 636 of 9,038 (7.0%) women who delivered vaginally and 241 of 3,288 (7.3%) of those delivering by cesarean. In multivariable analysis, patient factors associated with receipt of a high amount of prescribed opioids at discharge after a vaginal delivery included nulliparity, intrapartum neuraxial anesthesia, major laceration, and infectious complication. Discharge by a trainee physician was associated with decreased odds of receiving a high amount of opioids (8.5% vs 1.9%; adjusted odds ratio [OR] 0.08, 95% CI 0.01-0.53). For women who underwent cesarean delivery, the only patient factor associated with receipt of a high amount of prescribed opioids was hemorrhage. Discharge by a trainee physician was associated with decreased odds of being provided a high-amount opioid prescription (7.9% vs 0.4%; adjusted OR 0.01, 95% CI 0.00-0.36). Even after adjusting for patient factors, discharge by a trainee physician is significantly associated with decreased odds of a high amount of prescribed opioids at postpartum discharge.

To admit or not to admit? Experience with outpatient thyroidectomy for Graves’ disease in a high-volume tertiary care center

BackgroundOutpatient thyroidectomy is increasingly performed. Thyroidectomy for Graves' disease, however, has greater risk of periprocedural complications, limiting use of same-day procedures. We sought to demonstrate that these patients may be managed with ambulatory surgery. MethodsThe experience of one endocrine surgeon with thyroidectomy for Graves' was examined from January 2016–November 2017. Forty-one patients met criteria. Patient demographics, perioperative parameters, and postoperative outcomes including emergency department utilization and readmission were recorded. ResultsMean age was 31.5 ± 17.0 years, with 80% females. Mode ASA score was 3, and median operative time was 77 minutes (43–132). Complications included transient hypocalcaemia in 12%, and temporary laryngeal nerve palsy in 9.7%, with no permanent complications. Two patients were admitted immediately postoperatively for non-medical reasons. Thirty-day emergency rdepartment visits were noted in 9.7%, with subsequent readmission of 7%. ConclusionsOutpatient total thyroidectomy is safe and effective with acceptable morbidity in the Graves' patient.

Baseline NIH Stroke Scale is an inferior predictor of functional outcome in the era of acute stroke intervention.

Background and aims Baseline National Institutes of Health Stroke Scale (NIHSS) scores have frequently been used for prognostication after ischemic stroke. With the increasing utilization of acute stroke interventions, we aimed to determine whether baseline NIHSS scores are still able to reliably predict post-stroke functional outcome. Methods We retrospectively analyzed prospectively collected data from a high-volume tertiary-care center. We tested strength of association between NIHSS scores at baseline and 24 h with discharge NIHSS using Spearman correlation, and diagnostic accuracy of NIHSS scores in predicting favorable outcome at three months (defined as modified Rankin Scale 0-2) using receiver operating characteristic curve analysis with area under the curve. Results There were 1183 patients in our cohort, with median baseline NIHSS 8 (IQR 3-17), 24-h NIHSS 4 (IQR 1-11), and discharge NIHSS 2 (IQR 1-8). Correlation with discharge NIHSS was r = 0.60 for baseline NIHSS and r = 0.88 for 24-h NIHSS. Of all patients with follow-up data, 425/1037 (41%) had favorable functional outcome at three months. Receiver operating characteristic curve analysis for predicting favorable outcome showed area under the curve 0.698 (95% CI 0.664-0.732) for baseline NIHSS, 0.800 (95% CI 0.772-0.827) for 24-h NIHSS, and 0.819 (95% CI 0.793-0.845) for discharge NIHSS; 24 h and discharge NIHSS maintained robust predictive accuracy for patients receiving mechanical thrombectomy (AUC 0.846, 95% CI 0.798-0.895; AUC 0.873, 95% CI 0.832-0.914, respectively), while accuracy for baseline NIHSS decreased (AUC 0.635, 95% CI 0.566-0.704). Conclusion Baseline NIHSS scores are inferior to 24 h and discharge scores in predicting post-stroke functional outcomes, especially in patients receiving mechanical thrombectomy.

Epidemiology and outcomes of electric burn injury: a study of 768 patients in a high volume tertiary care centre of North India

Background: Electrical burn injuries (EBI) comprise a small proportion of the total burn admissions but they inflict significant morbidity. The objective of this study was to analyse recent epidemiologic data and identify prevention measures.Methods: A retrospective study was conducted by reviewing the medical records of all burn admissions from April 2016 to March 2018 and data was analysed for demographic characteristics and outcomes and patterns of electric burn injury.Results: A total of 3136 admissions were made. Male to female ratio was 1.5:1.0. Rural: urban ratio was 2:1. Mode of injury was accidental (79%), suicidal (12%) and homicidal (9%). Flame burn (64.47%) topped the list of etiologic factors. Electric burn represented 24.49% which was quite significant when compared to other parts of the world. 1042 patients expired (33.22%). Out of the total electric burn admissions, 768 (24.49%) patients were of electric injury. 207 (27.01%) patients sustained low voltage (&lt;1000 kv) injuries while 561 (73.04%) patients had high voltage (&gt;1000 kv) injury. Most of the injuries were work related. There was a rise in serum creatine phosphokinases, myoglobinuria, renal failure, abnormal cardiac events and other concomitant injuries in the high voltage group. Reconstructive surgeries performed in both high and low voltage group was high. A total of 71 (9.24%) fasciotomy and 123 (16.01%) amputations were done. The mortality rate was 10.5%.Conclusions: EBI has a devastating influence on burn survivors. We advocate a low threshold for managing associated injuries, educating safety principles and improving infrastructure by the state to curb this preventable danger.

Analyzing candidemia guideline adherence identifies opportunities for antifungal stewardship.

Candidemia epidemiology varies significantly by region; thus, local data are essential for evidence-based decision-making in prophylaxis and treatment. Current management strategies are derived from large randomized controlled trials mostly executed in large high-volume tertiary care centers. Results may not be entirely transferable to smaller hospitals. This study investigates epidemiology, diagnosis, and treatment standards in six hospitals in the Cologne metropolitan area (number of inhabitants approx. one million). We assessed adherence to the current guideline of the European Society for Clinical Microbiology and Infectious Diseases (ESCMID) and the Infectious Diseases Society of America (IDSA) using the EQUAL Candida Score of the European Confederation of Medical Mycology (ECMM). Data were documented by trained medical students as part of an integrated research and teaching concept at the University of Cologne. Between January 2014 and June 2017, 77 patients had candidemia, corresponding to an incidence of 0.2 cases/1000 admissions. While 55 patients were enrolled, 22 patients were excluded due to incompletely retrievable health records. Fluconazole monotherapy was the preferred first-line treatment in cases with Candida albicans infection (21/29). A central vascular catheter was present in 40 patients and was removed in 17 (43%) during treatment. Overall mortality at 30days was 44%. Patients reached a mean EQUAL Candida Score of 9.9 (range 8-14), which was well below the maximum score of 22 for perfect guideline adherence. In summary, management of candidemia differed from current European recommendations. It remains unclear to what extent enhanced adherence would improve patient outcome. Larger prospective studies need to answer that question.

Opioid prescribing patterns among postpartum women

Women commonly receive opioid prescriptions following hospitalization. The rise of the opioid epidemic in the United States underscores the importance of a better understanding of prescribing patterns. Although delivery is the most frequent reason for hospitalization in the United States, there is inadequate knowledge regarding opioid prescribing at postpartum hospital discharge. We sought to describe opioid prescribing patterns at the time of discharge following delivery in a large, diverse cohort, and to describe the relationship of these patterns with objective and subjective measures of pain prior to discharge. This is a retrospective cohort study of all deliveries at a single, high-volume tertiary care center over a 1-year period. Women were excluded from analysis if they had evidence of recent opioid use, or their labor, delivery, or postpartum course was notable for rare, nonroutine events anticipated to increase pain. Medical records were queried for demographic and clinical data, including whether an opioid prescription was provided at discharge, and if so, details of that prescription. The primary outcome was amount of opioid morphine milligram equivalents prescribed at discharge, described separately for women after vaginal and cesarean deliveries. Among women who received a prescription, we additionally assessed associations between prescription quantity and subjective (patient-reported pain score) and objective (inpatient opioid requirement during the final 24 hours of hospitalization) assessments of pain. Descriptive and bivariable analyses were performed. Of the total 12,611 women, 12,326 were eligible for inclusion. Of 9038 women postvaginal delivery and 3288 women postcesarean delivery, 30.4% and 86.7% received an opioid prescription at discharge, respectively. Of women receiving discharge opioid prescriptions, median morphine milligram equivalents received was 200 (interquartile range: 120-300) following vaginal and 300 (interquartile range: 200-300) following cesarean delivery. Nearly half (45.7%) of women postvaginal delivery and 18.5% of women postcesarean delivery who received an opioid prescription used 0 morphine milligram equivalent during the final hospital day. Similarly, 26.5% and 18.5% of women after vaginal and cesarean delivery, respectively, reported a pain score of 0 of 10 prior to discharge. Regardless of delivery mode, the amount of opioids prescribed did not differ between those who reported a pain score of 0 of 10 and those who reported a pain score of >0 of 10 immediately prior to discharge. Similarly, for women who underwent cesarean delivery, the morphine milligram equivalents prescribed did not differ between those who used 0 morphine milligram equivalents and those who used >0 in the 24 hours prior to hospital discharge. Postpartum women are commonly prescribed opioids at the time of postpartum hospital discharge. There is a wide range of morphine milligram equivalents prescribed at hospital discharge following delivery, highlighting a lack of standardization. Furthermore, regardless of objective and subjective measures of pain prior to discharge, women received similar amounts of prescription morphine milligram equivalents following either vaginal or cesarean deliveries.

LONG-TERM FOLLOW-UP IN 1501 PATIENTS AFTER EXTRACORPOREAL MEMBRANE OXYGENATION THERAPY FOR REFRACTORY CARDIOGENIC SHOCK

The aim of the study was to evaluate the clinical outcome, 30 day- and longterm follow up in patients undergoing extracorperal membrane oxygenation (ECMO) for refractory postcardiotomy cardiogenic shock at our high volume tertiary care center. We analyzed all patients undergoing ECMO-Therapie (n=

LONG-TERM FOLLOW UP AFTER CORONARY ARTERY BYPASS GRAFT OPERATION WITH REFRACTORY CARDIOGENIC SHOCK AND EXTRACORPOREAL MEMBRANE OXYGENATION THERAPY

The aim of the study was to evaluate the clinical outcome, 30 day- and longterm follow up in patients undergoing extracorperal membrane oxygenation (ECMO) after coronary artery bypass graft operation (CABG) and refractory postcardiotomy cardiogenic shock at our high volume tertiary care Center. We

Appropriate Use of Venous Imaging and Analysis of the D-Dimer/Clinical Probability Testing Paradigm in the Diagnosis and Location of Deep Venous Thrombosis

The D-dimer (DD) level combined with the pretest Wells criteria probability (WCP) score can safely exclude deep venous thrombosis (DVT). The objective of this study was to examine the correlation between DD results alongside WCP score with findings on venous duplex ultrasound (VDU). The hypothesis is that VDU remains overutilized in low-risk patients with negative DD and that higher DD levels may correlate with thrombus burden and location. Patients who presented to a high-volume tertiary care center with lower limb swelling with or without associated pain were retrospectively examined through June and July for 4 consecutive years (2012 to 2015). After calculating WCP, patients were divided into low-, moderate-, and high-risk categories. Electronic DD results utilizing enzyme linked immunosorbent assay, WCP data, and VDU analysis data were merged and analyzed based on receiver operator characteristic curve to determine the DD cutoff point for each WCP. Abnormal DD with an average value≥0.6mg/L fibrinogen equivalent units (FEUs) was correlated to positive DVT to differentiate proximal DVT (above popliteal vein) from distal DVT (below popliteal vein). Data of 1,909 patients were analyzed, and 239 (12.5%) patients were excluded secondary to serial repeat visits or follow-ups, surveillance screens, and if they had a previous history of DVT. The average age was 62.1±16.3years with more women (55.7%) and the majority presented with limb pain and edema (87%). DD studies were ordered and completed in 202 patients and correlated with all positive and negative DVT patients (100% sensitivity and negative predictive value, with specificity and positive predictive value of 14.9% and 15.9%, respectively). Twenty-six of 202 patients had DD that were in the normal range 0.1-0.59mg/L (FEU), all of which were negative for DVT (100% sensitive). Fifty one of 202 patients had DD values of 0.6-1.2mg/L FEU, of which only 3 DVTs were recorded, and all of them were distal DVTs. In addition, 685 patients with WCP <1 and negative DD were sent for VDU. Thus, 762 patients had an unnecessary immediate VDU (Wells ≤1 and -DD) study during their initial presentation. Potential charge savings for VDU for all patients are 762×$1,557=$1,186,434 and DD for all patients are 762×$182=$138,684, with total potential savings of $1,047,750 (USD 2016). This study suggests that DD is still underutilized, and DD in conjunction with WCP could significantly reduce the number of unnecessary immediate VDUs. Higher value of DD (>1.2mg/L FEU) may raise concern for proximal DVT. Concern on cost-effectiveness exists and raises the demand for a proposed algorithm to be followed.

A study of clinicopathological characteristics of thyroid carcinoma at a Tertiary Care Center.

To share clinicopathological data of thyroid carcinoma from a high volume Tertiary Care Centre in East India. To share the epidemiology and clinicopathological presentation of thyroid cancer at a high volume Tertiary Care Center in East India. Retrospective observational study. Forty-two consecutive patients of thyroid neoplasm diagnosed by fine needle aspiration cytology (FNAC) and primarily underwent surgical treatment from July 2005 to June 2012 were included. Retrospective data analyses of patient's records were done. The statistical analysis was performed using Epi Info version 3.5.3. Forty-two patients underwent surgery for thyroid neoplasm. Median age of diagnosis was 39 years. It was 6 times more common in females (female:male - 6:1). Papillary carcinoma consists of 63.15%, follicular carcinoma consists of 23.68%, and medullary carcinoma and anaplastic carcinoma each consist of 5.26% of malignant cases. Out of them, lymph node metastases were seen in 17 patients (44.73%). FNAC shows positive predictive value of 89.74%. In our study, differentiated thyroid cancers were found to be more common in younger age group. Cervical lymph node metastases occur in a large number of patients. Central compartment lymph node dissection with exploration of lateral neck and modified neck dissection whenever needed is helpful in all cases of thyroid carcinoma for proper pathological staging. FNAC is rapid and efficient procedure with high positive predictive value in diagnosing thyroid neoplastic lesions.

137: Provider characteristics are associated with prescription of opioids after delivery

Patient factors are associated with patterns of opioid prescribing after hospitalization, yet factors in the postpartum setting, and in particular the contribution of provider characteristics, are unclear. The objective of this study was to identify provider and patient characteristics associated with postpartum opioid prescribing patterns at discharge. This was a retrospective case control study of all deliveries at a single, high volume tertiary care center (12/2015-16). Inpatient, outpatient, pharmacy, and billing records were queried for clinical, prescription, and discharging provider (training, academic position, age, and gender) data. We determined whether the discharging provider prescribed an opioid and, if so, the prescription details. Multivariable logistic regression with random effects was utilized to identify patient and provider factors independently associated with a) receipt of any opioid prescription at discharge post-vaginal delivery (VD) and b) receipt of a high amount of opioids (morphine milligram equivalents [MME] >90%ile) on discharge post-cesarean delivery (CD). 12,318 women were eligible for analysis. Of 9,054 women post-VD, 2,748 (30.3%) received an opioid prescription at discharge, and of 3,264 women post-CD, 1,497 (45.9%) received a high MME prescription. In multivariable analysis, patient factors associated with receipt of any opioid prescription at discharge post-VD included older age, white race, nulliparity, prior CD, operative VD, neuraxial analgesia use, postpartum hemorrhage (PPH), longer postpartum hospitalization, and higher discharge pain score. Discharge by a mid-level provider (aOR 0.42, 95% CI 0.23-0.77) or an academic faculty (aOR 0.44, 95% CI 0.22-0.90) was associated with decreased odds of receiving an opioid prescription. For women post-CD, the only patient factor associated with receipt of high MME was PPH, although several provider characteristics (discharge by a trainee [aOR 0.06, 95% CI 0.01-0.27], older provider [aOR 1.11, 95% CI 1.05-1.16], or female [aOR 3.48, 95% CI 1.13-10.70]) were associated with odds of being provided a high MME prescription at discharge. Although patient factors account for some variation in postpartum prescribing of opioids at discharge, multiple provider characteristics also are significantly associated with prescribing patterns.

915: Implementation of an antenatal late preterm steroids protocol at a high volume tertiary care center

915: Implementation of an antenatal late preterm steroids protocol at a high volume tertiary care center