New York Hospital Research Articles

Abstract TP182: Risk of Acute Ischemic Stroke Increases During Severe Flares of Inflammatory Bowel Disease

Introduction: Flares of inflammatory bowel disease (IBD) have been associated with venous thromboembolism, and recent studies suggest an association between IBD and myocardial infarction. The association between IBD flares and cerebral thrombotic disease is less clear. We therefore sought to evaluate the risk of cerebral venous and arterial stroke during IBD flares. Hypothesis: IBD flares are associated with an increased risk of a cerebral thrombotic event. Methods: We used data on all admissions at nonfederal acute care hospitals in California, Florida, and New York to identify patients with a primary ICD-9-CM diagnosis code for ulcerative colitis or Crohn’s disease between 2005 and 2012. Patients with a documented abdominal surgery during the index hospitalization were excluded. An IBD flare was defined as a period of 120 days from the start of the index IBD-related hospitalization. Our outcomes were ischemic stroke and cerebral venous sinus thrombosis. We used a self-controlled case series design in which we compared the risk of a thrombotic event in the 120 days after hospitalization versus the risk during the 120 days prior to hospitalization. Results: We identified 31,993 patients with IBD, of whom 98 (0.31%) developed ischemic stroke. As compared with the control period preceding the index hospitalization, the risk of stroke was significantly elevated during the 120 days after IBD-related hospitalization (incidence rate ratio [IRR] 2.0; 95% confidence interval [CI] 1.3-3.0). In subgroup analyses, this elevated risk was apparent only in the 16,280 patients older than the median age of 44 years (IRR 1.9; 95% CI, 1.27-2.95), and not in the 15,713 patients younger than 44 years of age, among whom we identified only one stroke. We found only one patient with a documented venous sinus thrombosis and thus could not estimate the risk associated with an IBD flare. Conclusion: We found an association between IBD-related hospitalization and the risk of ischemic stroke in older patients. These results build on recent studies suggesting an association between IBD and the risk of arterial thrombotic events. Further research is needed to better define the association between IBD and cerebrovascular events, especially rare events such as cerebral sinus thrombosis.

Hearing Loss in the Last Two Years of Life: A Population-Based Study (S772)

admissions while improving quality of life, yet only 37% of advanced cancer patients report having had them, and most happen near the very end of life. Research Objectives. To describe oncologists’ perspectives on facilitators of and barriers to GoC conversations with patients with advanced cancer. Methods. Semi-structured interviews with oncologists at academic, community, and municipal hospitals (n1⁄44) in New York and Connecticut. Topics include approach to GoC conversations, facilitators, barriers, and organizational influences. We analyze data using interpretive description. Results. Participants to date (n1⁄412 of 25) are 83% male, they have a mean age of 45 (range 32-66) and 18 years (range 6-40) in practice, and 50% received training in GoC. Facilitators of GoC conversations include patient characteristics of higher health literacy and poor functional status and having a supportive practice environment (e.g., palliative care resources). Barriers include patient characteristics of being young and newly diagnosed, patient-family conflict, and physicians’ emotions. Although most participants felt GoC conversations should be ongoing, some reported two distinct conversations: an early ‘‘introductory’’ conversation about cancer basics and treatment goals and a ‘‘near the end’’ conversation about risks and benefits of further treatment and DNR. These conversations had different triggers. Perceived best timing of GoC conversations varied by subspecialty. Conclusion. While data collection is ongoing, we have identified facilitators of and barriers to GoC conversations, some of which may be remediable by enabling oncologists to conduct GoC conversations despite difficult circumstances and emotional reactions, activating patients/family via increasing health literacy or peer support, advancing palliative-informed practice environments, and creating subspecialty-specific guides for timing of GoC conversations. Analyses are underway to help clarify the two distinct content conversations and connections between them. Implications for Research, Policy or Practice. By addressing findings in Oncotalk, a program to train oncologists in palliative care skills, we hope to improve content and timing of GoC conversations.

Frailty in Geriatric Glioblastoma Patients: A Predictor of Operative Morbidity and Outcome

Frailty is an emerging means of assessing overall health status and guiding management for geriatric patients. Frailty is associated with outcomes for many surgical indications in this age group. While half of all glioblastoma patients are 65 years old or older, frailty has not been examined in relation to surgery for glioblastoma. We performed a retrospective study of patients age 65 years and older with pathologically confirmed glioblastoma at Columbia Presbyterian Hospital from 2000 to 2012; 319 patients were identified, 243 of whom underwent craniotomy for lobar lesions. Frailty was quantified using the Canadian Study of Health and Aging Modified Frailty Index. Postoperative complications were classified according the Glioma Outcomes Project system. Systemic, regional, neurologic, and overall complications were examined in relation to age, Karnofsky performance status, frailty, comorbid disease burden, cardiovascular risk, and tumor sidedness. Frailer patients were less likely to undergo surgical resection (P= 0.0002; odds ratio [OR], 0.15; 95% confidence interval [CI], 0.05-0.40) as opposed to biopsy, had longer hospital stays (log-rank test for trend, P= 0.0061), an increased overall risk of complications (P= 0.0123; OR, 1.40; 95% CI, 1.08-1.83), and decreased overall survival (Log rank test for trend, P= 0.0028). Frailer patients with glioblastoma receive less aggressive intervention, have longer hospital stays, and experience more complications. Frailty may be an underused metric for the preoperative risk assessment of geriatric glioblastoma patients.

In memory of Marcos Vidal (1974-2016).

ABSTRACTWith the untimely death of Marcos Vidal, we have lost a good friend and a creative, brilliant colleague who made important contributions to the field of cancer biology through fruit fly research. Marcos began his research into Drosophila at Ross Cagan's laboratory in 2003, first at Washington University in St Louis and later at Mount Sinai Hospital in New York. In 2009 Marcos was appointed as Research Group Leader at the Beatson Institute for Cancer Research in Glasgow.

Medication Repurposing in Pediatric Patients: Teaching Old Drugs New Tricks.

Gaps in pediatric therapeutics often result in off-label use and specifically, novel uses for existing medications, termed "drug repurposing." Drug Information (DI) queries to a Pediatric Medication Resource Center of a large metropolitan pediatric hospital in New York and inherent difficulties in retrieving evidence-based information prompted a review of current medication repurposing for pediatric patients. The objective included characterization of innovative off-label use of medications Food and Drug Administration (FDA)-approved for 1 or more indications to treat a totally different disorder or indication in pediatric patients. A systematic literature review was conducted to retrieve publications describing repurposed medications in pediatric patients. Excluded was FDA-approved indications used off-label in pediatric patients (e.g., different dose), preclinical data, adult use only, and experimental use. Evidence quality was classified using a modified American Academy of Neurology Level of Evidence. Results were analyzed using χ(2) at p < 0.05. Over 2000 references were retrieved and reviewed. A total of 101 medications repurposed for novel off-label uses for pediatric patients were identified: 38 for neonates, 74 for children, and 52 for adolescents. Neonates and infants were least likely to receive a medication for a repurposed use. Strong or intermediate evidence existed in 80.2% of cases. The evidence was weak in 19.8%. No significant relationship was observed between the pediatric age group and strength of the literature. Most repurposed uses pertained to generic or widely used medications. Less than 5% of medications were first marketed after 2011. While not exhaustive, the present study represents the most comprehensive listing of novel uses exclusive to pediatric patients. Further research is needed to identify the frequency of repurposed uses. The valuable DI role of pharmacists in assessing repurposed uses is of expanding and increasing importance to ensure such uses are evidence-based.

Utilization of 4T score to determine the pretest probability of heparin-induced thrombocytopenia in a community hospital in upstate New York

BackgroundThrombocytopenia is common in hospitalized patients. Heparin-induced thrombocytopenia (HIT) is a life-threatening condition which can lead to extensive thrombosis. Diagnosis of HIT relies on clinical suspicion determined by 4T score and immunoassays through testing for anti-PF4/heparin antibodies. Clinical practice guidelines published by the American Society of Hematology in 2013 recommended use of the 4T score before ordering the immunoassays as a measure of pretest probability. The purpose of this study was to evaluate the utilization of 4T score before ordering anti-PF4/heparin antibodies at Unity Hospital.MethodsWe did a retrospective chart review for patients who are 18 years or older, admitted to Unity Hospital between July 1, 2013, and December 31, 2014, and had anti-PF4/heparin antibodies ordered. Subjects who had prior history of HIT or had end-stage renal disease on hemodialysis were excluded. After calculating 4T score retrospectively, we calculated the proportion of patients who had 4T score documented prior to ELISA testing and proportion of ELISA tests, which were not indicated due to a 4T score less than or equal to 3 using Minitab 16.ResultsReview of 123 patients, with an average age of 69.4 years, showed that testing was indicated in 18 patients. Six subjects had positive results, and testing was indicated in all of them. 4T score was documented in three patients. This quality improvement study showed that 4T score documentation rate at Unity Hospital is 2.4%. Anti-PF4/heparin antibody testing was indicated in 14.6%. This test is being overused in thrombocytopenia work up at Unity Hospital, costing $9,345. The topic was reviewed for residents. A prompt and calculator for 4T score were added to electronic medical records before ordering the test as a step to improve high value care.

Temporal Trends in Anesthesia-related Adverse Events in Cesarean Deliveries, New York State, 2003-2012.

Cesarean delivery (CD) is associated with significantly increased risks of anesthesia-related adverse events (ARAEs) and nonanesthetic perioperative morbidity compared with vaginal delivery. Temporal trends in these adverse outcomes remain unknown despite efforts to improve maternal safety. This study examines temporal trends in ARAEs and nonanesthetic perioperative complications in CDs in New York hospitals. Data are from the State Inpatient Database for New York, 2003-2012. ARAEs, including minor and major ARAEs, and nonanesthetic perioperative complications were identified through International Classification of Diseases, Ninth Revision, Clinical Modification codes. Statistical significance in time trends was assessed using the Cochran-Armitage test and multivariable logistic regression. Of the 785,854 CDs studied, 5,715 (730 per 100,000; 95% CI, 710 to 750) had at least one ARAE and 7,040 had at least one perioperative complication (890 per 100,000; 95% CI, 870 to 920). The overall annual rate of ARAEs decreased from 890 per 100,000 in 2003 to 660 in 2012 (25% decrease; 95% CI, 16 to 34; P < 0.0001). The rate of minor ARAEs decreased 23% (95% CI, 13 to 32) and of major ARAEs decreased 43% (95% CI, 23 to 63). No decrease was observed in the rate of ARAEs for CDs performed under general anesthesia. The rate of nonanesthetic complications increased 47% (95% CI, 31 to 63; P < 0.0001). Anesthesia-related outcomes in cesarean deliveries appear to have improved significantly across hospitals in New York in the past decade. Perioperative nonanesthetic complications remain a serious healthcare issue.

An Update on the Cardiovascular Risks Associated With NSAIDs

•Nonsteroidal anti-inflammatory drugs (NSAIDs) increase the risk of myocardial infarction and stroke •The FDA revised the labeling explaining the cardiovascular risks associated with NSAIDs •Risks and benefits should be weighed for patients, with or without heart disease or risk factors for heart disease, when deciding to recommend a NSAID treatment course Both authors are affiliated with The Mount Sinai Hospital in New York, NY. Jason Babby, PharmD, BCPS, is a drug information clinical pharmacist. He can be reached at . Archna Lall, PharmD, BCPS, CGP, is a pharmacist.

Computed tomography: The optimal imaging method for differentiation of ischemic vs non-ischemic cardiomyopathy

Case history: 57-year-old woman presents with 8 month history of shortness of breath on exertion. She has no chest pain. She has history of hypertension and type 2 diabetes and both are well controlled with oral medications. The HR is 74 bpm and regular, BP140/ 85 mm Hg. The cardiac examination is normal. The ECG shows NSR and voltage criteria of LVH. The renal function is normal. TTE shows mildly enlarged LV, EF of 35%, and mild diffuse wall motion abnormality with trivial MR. The RV is normal. The PAS pressure is estimated at 35 mm Hg. Cardiomyopathies are diseases of the heart muscle and represent a heterogeneous group of disorders affecting the myocardium and ultimately resulting in heart failure. The primary diagnostic strategy is to determine the underlying cause of cardiomyopathy. Notably, there are causes that are treatable and may to some extent be reversible. Ischemic cardiomyopathy is the most common cause of dilated cardiomyopathy in the Western world and is associated with a worse adverse outcome. The differentiation between ischemic and non-ischemic cardiomyopathy is challenging, and has both important therapeutic and prognostic implications as patients with ischemia may benefit from coronary revascularization. In those patients with extensive coronary atherosclerotic disease (CAD), the cardiomyopathy is likely ischemic in etiology. Therefore, a diagnostic strategy for the differentiation between ischemic and non-ischemic cardiomyopathy relies primarily on the evaluation of coronary anatomy for the presence of coronary atherosclerosis. Coronary artery calcium (CAC) is a marker of vascular injury and its presence is pathognomonic for the presence of coronary atherosclerosis. A non-contrast coronary CT, referred to as a CAC scan, allows for the visualization and quantification of calcium in the coronary arteries. The deposit of coronary calcium is highly correlated to the extent and severity of the coronary atherosclerotic burden. As such, CAC-scanning has been used to identify those patients at high risk for obstructive disease. The complete absence of coronary calcium deposits rules out obstructive CAD with near to absolute certainty, implying a non-ischemic etiology to the cardiomyopathy. Of note, Budoff et al found an accuracy of 92% to differentiate between ischemic and non-ischemic cardiomyopathy by using a non-contrast CT scan, obviating the need of invasive procedures in those patients with a negative CAC-scan. Nevertheless, the presence of coronary calcium deposits warrants further testing, since the CAC-score has poor predictive values for obstructive CAD. In this regard calcium scoring may serve as a gatekeeper to CT-based coronary angiography. In contrast to conventional coronary angiography, coronary computed tomography angiography (CCTA) provides a non-invasive alternative for visualizing coronary anatomy. There is a large body of literature on the diagnostic performance of CCTA, unambiguously portraying the same picture of an unequaled high sensitivity and negative predictive value (NPV) of 96% and 94%, respectively. Notably, studies have demonstrated that its accuracy remained high even in patients with tachycardia and/or irregular heart rhythms, recipients of heart transplants, and dilated cardiomyopathy of Reprint requests: ames K. Min, MD, FACC, FSCCT, Dalio Institute of Cardiovascular Imaging, Weill Cornell Medical College and The NewYork-Presbyterian Hospital, 413 East 69th Street, Suite 108, New York, NY 10021; jkm2001@med.cornell.edu J Nucl Cardiol 2015;22:961–7. 1071-3581/$34.00 Copyright 2015 American Society of Nuclear Cardiology.

Epidemiology of bloodstream infections caused by methicillin-resistant Staphylococcus aureus at a tertiary care hospital in New York

In the United States, bloodstream infections (BSIs) are predominated by Staphylococcus aureus. The proportion of community-acquired methicillin-resistant S aureus (MRSA) BSI is on the rise. The goal of this study is to explore the epidemiology of BSI caused by S aureus within Staten Island, New York. This is a case-case-control study from April 2012-October 2014. Cases were comprised of patients with BSI secondary to MRSA and methicillin-sensitive S aureus (MSSA). The control group contained patients who were hospitalized during the same time period as cases but did not develop infections during their stay. Two multivariable models compared each group of cases with the uninfected controls. A total of 354 patients were analyzed. Infections were community acquired in 76% of cases. The major source of BSI was skin-related infections (n = 76). The first multivariable model showed that recent central venous catheter placement was an independent infection risk factor (odds ratio [OR] = 80.7; 95% confidence interval [CI], 2.2-3,014.1). In the second model, prior hospital stay >3 days (OR = 4.1; 95% CI, 1.5-5.7) and chronic kidney disease (OR = 3.0; 95% CI, 1.01-9.2) were uniquely associated with MSSA. Persistent bacteremia, recurrence, and other hospital-acquired infections were more likely with MRSA BSI than MSSA BSI. Most infections were community acquired. The presence of a central venous catheter constituted a robust independent risk factor for MRSA BSI. Patients with MRSA BSI suffered worse outcomes than those with MSSA BSI.

Retrospective evaluation of frozen section use for thyroid nodules with a prior fine needle aspiration diagnosis of Bethesda II-VI: The Weill Cornell Medical College experience.

ObjectiveTo evaluate the Weill Cornell Medical College (WCMC)/New York Presbyterian Hospital (NYPH) experience with intraoperative frozen (IOF) section in the management of thyroid nodules with a fine needle aspiration (FNA) diagnosis of Bethesda II–VI and to analyze the cost and pathology benefit it provides.MethodsThe surgical and cytopathology files at WCMC/NYPH were searched within the time period of January 2008 to May 2013. A total of 435 thyroid specimens were identified for which both an FNA and subsequent IOF section was performed. The FNA was correlated with the locations of the resected nodule and the nodule frozen for intraoperative diagnosis. The results of the FNA were compared to the IOF section diagnosis and final diagnosis (FD).ResultsAmong 435 cases, the FNA diagnosis was Bethesda II: 149 cases, Bethesda III: 170 cases, Bethesda IV: 91 cases, Bethesda V: 19 cases, and Bethesda VI: 6 cases. There were a total of 83 carcinomas identified on FD, which included 69 papillary thyroid carcinomas (PTCs), 12 follicular carcinomas, and 2 poorly differentiated carcinomas. The preoperative FNA diagnosis for these carcinomas was as follows: Bethesda II, 11/149 (7.4%), Bethesda III, 24/170 (14%), Bethesda IV, 26/91 (29%), Bethesda V, 16/19 (84%), and Bethesda VI, 6/6 (100%). IOF section contributed to the diagnosis of malignancy in 16/429 (4%) cases: 1/149 (0.7%) Bethesda II, 5/170 (3%) Bethesda III, 2/91 (1.1%) Bethesda IV, and 8/19 (42%) Bethesda V. The diagnosis of malignancy was confirmed in the 6 Bethesda VI cases by IOF section. There were no false positives on IOF section. IOF had a sensitivity and specificity of 26% and 100%, respectively.ConclusionThe role of IOF section is limited in the evaluation of thyroid nodules. IOF section is most useful for nodules with an FNA diagnosis of Bethesda V lesions. The diagnosis of follicular variant of PTC remains difficult on frozen section.

Electronic Cigarettes: An Evidence-Based Analysis.

Kochurani S. Joseph, MSN, ANP-C, has been with Columbia-Presbyterian Medical Center in New York, NY, for 15 years, first as a clinical nurse in the Interventional Cardiology Unit and for the last 5 years as a nurse practitioner in the Internal Medicine Clinic managing patients on anticoagulation. Her extensive experience includes work in medical centers in Bahrain, Arabian Gulf, and Bombay, India. She is licensed as a registered professional nurse in both New York and New Jersey. Ms. Joseph received her bachelor of science degree from the College of Nursing, Kottayam, Kerala, India, and her master of science in Nursing-Adult Nurse Practitioner Degree at Saint Peter's University in Jersey City, NJ, and is presently a Doctor of Nursing Practice Candidate at the Englewood Cliff's campus. Ms. Joseph can be contacted by e-mail at: [email protected] Address correspondence to Lynn S. Muller, RN, BA-HCM, CCM, JD, Muller & Muller, 15 West Main Street, Suite C, P.O. Box 164, Bergenfield, NJ 07621 ([email protected]). Disclaimer: The information contained in this department is for educational purposes only. It is not legal advice, which can only be given by an attorney admitted to practice in the jurisdiction/state(s) in which you practice. Do you have a question or issue you would like addressed here? Questions are always welcome. We encourage ALL readers to submit questions and/or manuscripts, as well as topics they would like to see addressed in this department. Questions and other inquiries are accepted by e-mail at: [email protected]. The author reports no conflicts of interest.

The Preventive Effect of Endovascular Treatment for Recurrent Hemorrhage in Patients with Spinal Cord Arteriovenous Malformations.

Spinal cord AVMs represent rare and insufficiently studied pathologic entities. Embolization is thought to play an important role in the management of spinal cord AVMs. Factors for recurrent hemorrhage and the impact of endovascular treatment on prevention of recurrent hemorrhage remain to be confirmed. We aimed to assess recurrent hemorrhagic incidence of spinal cord AVMs and its prevention by endovascular treatment. We reviewed 80 patients with spinal cord AVMs by spinal cord angiography who had hemorrhage before the first endovascular treatment at New York University Medical Center, Beth Israel Medical Center, or Roosevelt Hospital in New York. We compared the baseline and radiologic characteristics of patients with and without recurrent hemorrhage by the log-rank test and the Cox proportional hazards model. We observed recurrent hemorrhage in 35 (44%) patients (1/41 patients with endovascular treatment and 34/39 patients without endovascular treatment). The median length of total follow-up was 659 days (interquartile range, 129-2640 days), and the median length from first-to-recurrent hemorrhage was 369 days (interquartile range, 30-1596 days). The log-rank test revealed that endovascular treatment and venous thrombosis reduced recurrent hemorrhage, and associated aneurysm was related to recurrent hemorrhage. Even in multivariate analysis, the endovascular treatment reduced (hazard ratio, 0.027; P < .0001) and associated aneurysm increased (hazard ratio, 3.4; P = .044) the risk of recurrent hemorrhage. Endovascular embolization is the first choice of treatment for spinal cord AVMs and is effective in preventing recurrent hemorrhage.

Editorial introductions

Editorial introductions

Abstract 4770: Levels of 5-methyl-cytosine and 5-hydroxymethyl-cytosine in hepatocellular carcinoma prognosis

Abstract Hepatocellular carcinoma (HCC) is the third most common cause of cancer death in the world. The US incidence of HCC has tripled between 1975 and 2005 and has been accompanied by improved long term survival rates, but as a result of HCC ‘s poor prognosis, 1-year survival remains lower than fifty percent. Therefore, a better understanding of the molecular mechanisms underlying the disease process is currently needed. Epigenetic alterations have been linked to HCC and global genomic hypomethylation is a well known hallmark of the disease. Less is understood about the role hydroxymethylation plays in HCC carcinogenesis. Here, we conducted a study to determine 5-methylcytosine (5mC) and 5-hydroxymethylcytosine (5hmC) levels by UPLC/MS/MS in HCC tumor (T) and non-tumor (NT) adjacent tissue DNAs of sixty six individuals treated at Columbia Presbyterian Medical Center in New York. We analyzed the association between demographic and clinicopathological characteristics and 5mC and 5hmC levels, as well as performed a Cox-survival analysis to determine which factors better predicted survival. Mean levels of 5mC (5mCT = 3.15±0.49% vs.5mCNT = 3.80±0.12% (p&amp;lt;0.0001) and 5hmC (5hmCT = 0.11±0.04% vs. 5hmCNT = 0.23±0.07%, p&amp;lt;0.0001) in tumor tissues were statistically significantly lower than in non-tumor tissues. Older age was associated with lower 5mC content (5mC&amp;lt;60y = 3.32±0.43% vs. 5mC≥60y = 3.00±0.50%, p = 0.001), while tumor DNA of transplant (LT) patients had higher 5hmC levels compared to surgical resection (LR) patients (5hmCLR = 0.10±0.04% vs. 5hmCLT = 30.13±0.04%, p = 0.0053). However, survival was predicted by whether transplant or resection were performed (Hazard ratio LT vs. LR, 3.54 (95% confidence interval:1.34-9.29), p = 0.01). Our study had a limited sample size, but suggests that future studies of 5hmC might be informative concerning HCC prognosis. Citation Format: Lissette Delgado-Cruzata, Hui Chen Wu, Tiffany Thomas, Abby B. Siegel, Jing Shen, Yu-Jing Zhang, Abhishek Goyal, Christine C. Hsu, Helen Remotti, Regina M. Santella. Levels of 5-methyl-cytosine and 5-hydroxymethyl-cytosine in hepatocellular carcinoma prognosis. [abstract]. In: Proceedings of the 106th Annual Meeting of the American Association for Cancer Research; 2015 Apr 18-22; Philadelphia, PA. Philadelphia (PA): AACR; Cancer Res 2015;75(15 Suppl):Abstract nr 4770. doi:10.1158/1538-7445.AM2015-4770

I am a critical care nurse.

Kevin Xuereb, RN, is a staff nurse in the burn intensive care unit at New York Presbyterian-Weill Cornell Hospital in New York.

Impact of the Centers for Medicare and Medicaid Services Hospital-Acquired Conditions Policy on Billing Rates for 2 Targeted Healthcare-Associated Infections.

The 2008 Centers for Medicare & Medicaid Services hospital-acquired conditions policy limited additional payment for conditions deemed reasonably preventable. To examine whether this policy was associated with decreases in billing rates for 2 targeted conditions, vascular catheter-associated infections (VCAI) and catheter-associated urinary tract infections (CAUTI). Adult Medicare patients admitted to 569 acute care hospitals in California, Massachusetts, or New York and subject to the policy. DESIGN We used an interrupted times series design to assess whether the hospital-acquired conditions policy was associated with changes in billing rates for VCAI and CAUTI. Before the policy, billing rates for VCAI and CAUTI were increasing (prepolicy odds ratio per quarter for VCAI, 1.17 [95% CI, 1.11-1.23]; for CAUTI, 1.19 [1.16-1.23]). The policy was associated with an immediate drop in billing rates for VCAI and CAUTI (odds ratio for change at policy implementation for VCAI, 0.75 [95% CI, 0.69-0.81]; for CAUTI, 0.87 [0.79-0.96]). In the postpolicy period, we observed a decreasing trend in the billing rate for VCAI and a leveling-off in the billing rate for CAUTI (postpolicy odds ratio per quarter for VCAI, 0.98 [95% CI, 0.97-0.99]; for CAUTI, 0.99 [0.97-1.00]). The Centers for Medicare & Medicaid Services hospital-acquired conditions policy appears to have been associated with immediate reductions in billing rates for VCAI and CAUTI, followed by a slight decreasing trend or leveling-off in rates. These billing rates, however, may not correlate with changes in clinically meaningful patient outcomes and may reflect changes in coding practices.

Sa1697 Effects of Sitagliptin, a Dipeptidyl Peptidase 4 Inhibitor, on Tumor Progression and p62/SQSTM1 Subcellular Localization in a Mouse Model of Non-Alcoholic Steatohepatitis-Related Hepatocellular Carcinoma

Introduction: Orthotopic liver transplantation (OLT) is a life-saving procedure for children with end-stage liver disease. Advances in surgical techniques have made OLT in children younger than one year of age increasingly feasible. Previous studies have suggested that infants may experience high operative complications, difficult post-operative courses, and poor graft and patient survival. Many transplant centers have required infants to reach a specific weight or age prior to OLT to minimize morbidity and mortality. As a result, many children have died or experienced significant decompensation while awaiting the required weight or age, thereby making them worse candidates for the procedure. Aim: To review our single center experience with OLT in children younger than one year of age at the time of transplantation. Methods: We retrospectively reviewed the charts of patients 365 days of age and younger that underwent OLT at Morgan Stanley Children's Hospital of NewYork Presbyterian from 1998 to 2014. We specifically reviewed data related to intraoperative course, length of hospitalization, duration of stay in intensive care unit (ICU), duration of mechanical ventilation, post-transplant complications within 90 days and 90-day and 1year patient and graft survival. Results: Data for 65 of 116 eligible patients were included in this interim analysis (median age:240 days, range:21-365 days; median weight:5.9 kg, range:2.0-8.5 kg). The most common indications for OLT were biliary atresia (n= 51, 78.5%) and cryptogenic cirrhosis (n=5, 7.7%). Forty-three patients (66.2%) received deceased donor grafts, of which 55.8% were whole organs. Mean duration of transplant surgery was 7.2 hours. Intra-operatively, 53 patients (89.8%) required blood transfusions (mean:72 mL/kg), 32 patients (55.2%) required fresh frozen plasma (mean:48 mL/kg) and 6 patients (11.8%) required platelet transfusions (mean:13 mL/kg). Median post-transplant hospitalization was 17 days, ICU stay was 8 days, and mechanical ventilation duration was 2 days. Posttransplant complications included bile leak (26.2%), acute rejection (18.5%), hepatic artery thrombosis (13.8%), portal vein thrombosis (13.8%), wound dehiscence (13.8%), abdominal compartment syndrome (9.2%), and bleeding (9.2%). The reoperation rate was 49.2%. Four patients required re-transplantation, 2 of whom died. Patient survival was 93.8% at both 90 days and 1 year. Graft survival was 90.8% at 90 days and 89.2% at 1 year. Conclusion: Infants can have excellent outcomes after OLT with acceptable operative complications and high survival rates in a center of excellence. The use of partial or whole grafts can yield patient and graft survivals approaching that of children greater than 1 year of age. OLT should not be delayed in infants merely because of low weight or young age, reducing pretransplant morbidity and mortality.

Procedure-specific surgical site infection incidence varies widely within certain National Healthcare Safety Network surgery groups

The National Healthcare Safety Network (NHSN) classifies surgical procedures into 40 categories. The objective of this study was to determine surgical site infection (SSI) incidence for clinically defined subgroups within 5 heterogeneous NHSN surgery categories. This is a retrospective cohort study using the longitudinal State Inpatient Database. We identified 5 groups of surgical procedures (amputation; bile duct, liver or pancreas [BILI]; breast; colon; and hernia) using ICD-9-CM procedure codes in community hospitals in California, Florida, and New York from January 2009-September 2011 in persons aged ≥18 years. Each of these 5 categories was classified to more specific surgical procedures within the group. The 90-day SSI rates were calculated using ICD-9-CM diagnosis codes. There were 62,901 amputation surgeries, 33,358 BILI surgeries, 72,058 breast surgeries, 125,689 colon surgeries, and 85,745 hernia surgeries in 349,298 people. The 90-day SSI rates varied significantly within each of the 5 subgroups. Within the BILI category, bile duct, pancreas, and laparoscopic liver procedures had SSI rates of 7.2%, 17.2%, and 2.2%, respectively (P < .0001 for each) compared with open liver procedures (11.1% SSI). The 90-day SSI rates varied widely within certain NHSN categories. Risk adjustment for specific surgery type is needed to make valid comparisons between hospitals.

Herbert Rackow and Ernest Salanitre: the emergence of pediatric anesthesia as a specialty in the United States.

Herbert Rackow and Ernest Salanitre were pediatric anesthesiologists at Babies Hospital at the Columbia-Presbyterian Medical Center in New York whose work spanned three decades beginning in the early 1950s. Their pioneering research included studies of the uptake and elimination of inhalational anesthetics and of the risk of cardiac arrest in infants and children. They were actively involved in the development of pediatric anesthesia as a specialty, and their efforts contributed to inter-disciplinary collaboration and to the formation of the Section on Anesthesiology of the American Academy of Pediatrics. Their 1969 review article, 'Modern Concepts in Pediatric Anesthesiology', provides a fascinating view of pediatric anesthesia 50years ago. In 1990, they were jointly awarded the Robert M. Smith award by the Section on Anesthesiology of the American Academy of Pediatrics.