Loyola University Medical Center Research Articles

Endoscopic Endonasal Approach for Residual and Recurrent Craniopharyngioma after Transcranial Approach: A Multi-institutional Experience

Abstract Objectives While the endoscopic endonasal approach (EEA) has become a well-established surgery for resection of craniopharyngiomas (CP), the utility of this procedure following subtotal resection from open transcranial approach (TCA) surgery has yet to be explored. Here we present a multi-institutional case series of patients who underwent EEA for treatment of recurrent CP originally treated by TCA, demonstrating the viability of this approach as salvage surgery. Design Retrospective cohort. Setting Loyola University Medical Center and University of Pittsburgh Medical Center. Participants Patients who underwent EEA for recurrent CP following an initial TCA between 2003 and 2018. Main Outcome Measures Gross total resection (GTR) rate, surgical complications, visual outcomes, and endocrine outcomes Results Patients who underwent EEA for recurrent CP following a prior TCA had a GTR rate of 77%. EEA reoperation was not associated with worsening of visual outcomes as compared with the primary TCA (0% visual worsening after EEA reoperation vs. 40% after primary TCA, p = 0.055). While primary TCA resulted in worsening endocrinopathies in 100% of patients (including seven patients with permanent diabetes insipidus), subsequent EEA for re-resection of CP resulted in stable (30.8%) or improved (69.2%) endocrine function in all patients (p < 0.001). Conclusions EEA achieves reasonable GTR rates and is an effective, safe surgical option for recurrent CP postinitial TCA. This approach demonstrated stable or improved visual and endocrinologic outcomes in all patients within our two-institution series. Thus, EEA should be considered as an efficacious form of retreatment in cases of progressive and recurrent CP.

Endoscopic Endonasal Anterior Skull Base Meningoencephalocele and Cerebrospinal Fluid Leak Repair: Our Intraoperative and Postoperative Protocol and Long-term Outcomes

Abstract Objective We evaluated the long-term outcomes from a single neurosurgeon and otolaryngologist team using a specific operative protocol for repair and postoperative evaluation. Design The charts of patients undergoing endoscopic endonasal repair of meningoencephaloceles (MECs) and cerebrospinal fluid (CSF) leaks were retrospectively reviewed from 2015 to 2023. Intraoperative steps of the repair and reconstruction were analyzed. Patients' postoperative assessments and complications were analyzed. Setting Loyola University Medical Center's electronic medical record database. Participants Forty-three patients (32 female) aged between 11 and 81 years. Main Outcome Measures Long-term outcomes of patients who underwent endoscopic endonasal repair of MECs and CSF leaks by a single team and protocol. We hypothesized that there would be minimal complications and no recurrences, requiring secondary operation. Results The most common site for MECs was the cribriform plate. Lumbar drain opening pressures ranged from 10 to 35 cm H2O with 18 out of 34 patients having the lumbar drain removed immediately postoperatively. The median hospital stay was 3 days. The average length of follow-up was 3.8 years. No recurrences or secondary operations were noted in all patients. One patient had a sinonasal infection that was successfully treated. Eight patients were noted to have venous stenosis and underwent further evaluation. Conclusion This study represents one of the largest long-term analyses of outcomes by a single team. Our specific protocol for the endoscopic endonasal repair of anterior skull base MECs and CSF leaks is safe and effective. These patients should be evaluated and treated for elevated intracranial pressure following the repair.

Long-term quality of life outcomes in patients undergoing microsurgical resection of vestibular schwannoma

BackgroundWhile previous studies have assessed patient reported quality of life (QOL) of various vestibular schwannoma (VS) treatment modalities, few studies have assessed QOL as related to the amount of residual tumor and need for retreatment in a large series of patients. Objective: To assess patient reported QOL outcomes following VS resection with a focus on extent of resection and retreatment. MethodsA retrospective chart review was performed using single-center institutional data of adult patients who underwent VS resection by the senior authors between 1989-2018 at Loyola University Medical Center. The Penn Acoustic Neuroma Quality of Life (PANQOL) survey was sent to all patients via postal mail. ResultsFifty-five percent of 367 total patients were female with a mean age of 61.6 years (SD 12.63). The mean period between surgery and PANQOL response was 11.4 years (IQR: 4.74-7.37). The median tumor size was 2 cm (IQR: 1.5-2.8). The mean total PANQOL score was 70 (SD 19). Patients who required retreatment reported lower overall scores (μdiff = -10.11, 95% CI: -19.48 to -0.74; p = 0.03) and face domain scores (μdiff = -20.34, 95% CI: -29.78 to -10.91; p < .001). There was no association between extent of resection and PANQOL scores in any domain. ConclusionIn an analysis of 367 patients who underwent microsurgical resection of VS, extent of resection did not affect PANQOL scores in contrast to previous reports in the literature, while the need for retreatment and facial function had a significant impact on patient-reported outcomes.

Abstract TP252: Forward Head Posturing as a Significant Risk Factor for Posterior Circulation Infarcts

Objective: Forward head posturing (FHP) has been associated with chronic anatomic vertebral artery disturbances possibly leading to posterior circulation ischemia. The data supporting FHP as a true risk factor of posterior circulation stroke has not been well established. We aim to study if patients with severe cervical myalgias and FHP have an increased risk of posterior circulation stroke. Methods: We identified all adult patients with posterior circulation stroke and diagnosis of cervical myalgia at Loyola University Medical Center from January 2018 to January 2023. Information on demographics and comorbidities were also collected. We then identified matched pair case-controls (based on age and gender) with non-stroke cervical myalgia patients in the same 5-year period. We compared the relevant comorbidities, C2 tilt angle, and C2-C7 tilt angle of patients to their matched controls to for statistical difference. Results: 76 patients (38 cases and 38 controls) with an average age of 64 years, including 38 (50%) females met our inclusion criteria. The average C2 tilt of cases was 22.9 degrees compared to 17.7 degrees in controls, and the average C2-C7 tilt of cases was 18.9 degrees in cases compared 10.5 degrees in controls. There were no significant differences between relevant comorbidities (including hypertension, hyperlipidemia, diabetes, atrial fibrillation, hyper-coagulopathy, or body mass index) of cases and controls. There was a significant difference of 5.2 degrees higher C2 tilt and 8.1 degrees higher C2-C7 tilt in cases compared to controls respectively (p-value = 0.03). Conclusion: In this single-center retrospective analysis, we found that after controlling for age, gender, and comorbidities, patients with posterior circulation stroke were more likely to have significantly higher C2 and C2-C7 cervical tilt (worse FHP based on radiographic standards) compared to their matched control counterparts.

Impact of Acute Exacerbation of Idiopathic Pulmonary Fibrosis on Lung Transplant Outcomes.

Acute exacerbations of idiopathic pulmonary fibrosis (AE-IPF) are acute, significant respiratory deteriorations in patients with IPF and can lead to increased morbidity and mortality. It remains unclear how AE-IPF impacts lung transplant (LTX) outcomes. All adult patients who were listed for LTX between July 2005 and October 2020 at the Loyola University Medical Center with a diagnosis of IPF were included. Pretransplant characteristics and posttransplant outcomes were gathered via retrospective chart review. The primary outcome was short- and long-term survival for patients transplanted during stable IPF versus those with AE-IPF. One hundred fifty-nine patients were included in this study, 17.6% of whom were transplanted during AE-IPF. AE-IPF patients were more likely to have higher oxygen needs pretransplant, have higher lung allocation score, and were more likely to be intubated or be on extracorporeal membrane oxygenation as compared with stable IPF patients. Survival by AE status at transplant did not differ at 90 d or 1 y posttransplantation. There were also no significant differences in rates of severe primary graft dysfunction or acute rejection within 1 y. Patients with AE-IPF were more likely to have higher oxygenation requirements and higher lung allocation score at the time of LTX than those with stable IPF. Despite this, there were no differences in survival at 90 d, 1 y, or 3 y, or differences in incidence of severe primary graft dysfunction or acute cellular rejection. Transplantation of patients with AE-IPF has clinical outcomes comparable with transplantation of patients with stable IPF. This contrasts with previous studies examining LTX in patients with AE-IPF.

686. Management and Outcomes of Patients Referred to a Specialty Clinic for C. difficile Infection

Abstract Background Clostridioides difficile infection (CDI) poses an urgent threat in the United States with an estimated 223,900 cases of hospitalization and 12,800 estimated deaths in 2017. CDI manifestations range from diarrhea, pseudomembranous colitis, to fulminant colitis. Due to spores that are unaffected by current antimicrobial therapies, recurrence remains a common challenge. Patients with 2 or more episodes have an estimated 40-65% rate of recurrence. We reviewed the management and outcomes of patients referred to our specialty CDI clinic. Methods A retrospective chart review was conducted on all new patients presenting to the Loyola University Medical Center CDI clinic between 01/01/2021 and 12/31/2021. Each chart was reviewed for demographic information, comorbidities that may confound diagnosis, and characteristics that place the patient at high risk of recurrent CDI. Visits were characterized by the number of prior CDI episodes, timeline of recurrences, and prior therapies used. 30- and 60-day symptom recurrence were assessed. Results A total of 48 new patients presented to the CDI clinic. The median age was 63 years, 64.5% were white, and 64.5% were female. Patients presenting with recurrent CDI accounted for 79% of cases (38/48), with 48% (13/48) of patients having two or more recurrences. The most common decision for initial management was to not give further antimicrobials and monitor for symptoms (35%). 12% of patients only required monitoring while 23% of patients had a questionable CDI diagnosis and were referred elsewhere for further evaluation. For the 30 patients who received treatment, vancomycin or fidaxomicin tapers were selected 73% (22/30) and bezlotoxumab 20% (6/30) of the time. 8.6% (2/23) of patients with a history of two or more CD episodes had recurrence. Overall, patients experienced a subsequent recurrence rate of 12.5% (6/48) and 15% (7/48) at 30 and 60 days, respectively. The number of times each management approach was selected for initial patient appointments. The number of times each treatment regimen was selected when a patient was deemed to need antibiotic therapy. The percentage of patients who had either recurrence or resolution at 60 days after the end of therapy. Conclusion CDI is a difficult-to-treat infection with many patients suffering from multiple recurrences. Dedicated outpatient follow-up is important for monitoring therapy and excluding alternate etiologies. Expert management of CDI through a dedicated clinic results in lower recurrence for high-risk patients and spared 35% of patients further antimicrobial exposure. Disclosures Larry H. Danziger, PharmD, Ferring Pharmacetuicals: Advisor/Consultant Andrew M. Skinner, MD, Academy for Continued Healthcare Learning: Honoraria|American Society of Healthcare Pharmacists: Honoraria|Ferring Pharmaceuticals: Honoraria|MJH Life Sciences: Honoraria

Development and external validation of multimodal postoperative acute kidney injury risk machine learning models.

To develop and externally validate machine learning models using structured and unstructured electronic health record data to predict postoperative acute kidney injury (AKI) across inpatient settings. Data for adult postoperative admissions to the Loyola University Medical Center (2009-2017) were used for model development and admissions to the University of Wisconsin-Madison (2009-2020) were used for validation. Structured features included demographics, vital signs, laboratory results, and nurse-documented scores. Unstructured text from clinical notes were converted into concept unique identifiers (CUIs) using the clinical Text Analysis and Knowledge Extraction System. The primary outcome was the development of Kidney Disease Improvement Global Outcomes stage 2 AKI within 7 days after leaving the operating room. We derived unimodal extreme gradient boosting machines (XGBoost) and elastic net logistic regression (GLMNET) models using structured-only data and multimodal models combining structured data with CUI features. Model comparison was performed using the receiver operating characteristic curve (AUROC), with Delong's test for statistical differences. The study cohort included 138 389 adult patient admissions (mean [SD] age 58 [16] years; 11 506 [8%] African-American; and 70 826 [51%] female) across the 2 sites. Of those, 2959 (2.1%) developed stage 2 AKI or higher. Across all data types, XGBoost outperformed GLMNET (mean AUROC 0.81 [95% confidence interval (CI), 0.80-0.82] vs 0.78 [95% CI, 0.77-0.79]). The multimodal XGBoost model incorporating CUIs parameterized as term frequency-inverse document frequency (TF-IDF) showed the highest discrimination performance (AUROC 0.82 [95% CI, 0.81-0.83]) over unimodal models (AUROC 0.79 [95% CI, 0.78-0.80]). A multimodality approach with structured data and TF-IDF weighting of CUIs increased model performance over structured data-only models. These findings highlight the predictive power of CUIs when merged with structured data for clinical prediction models, which may improve the detection of postoperative AKI.

#2724 THROMBO-INFLAMMATORY BIOMARKERS OF CARDIORENAL SYNDROME IN PATIENTS UNDERGOING MAINTENANCE HEMODIALYSIS IN END STAGE RENAL DISEASE

Abstract Background and Aims Cardiovascular disease is a highly common complication in patients with end stage renal disease (ESRD) on maintenance hemodialysis. In the ESRD patient population, cardiovascular mortality is 20 times higher compared to the general population. The strong relationship of both illnesses can be explained through cardiorenal syndrome (CRS). CRS encompasses a spectrum of disorders involving both the heart and kidneys in which acute or chronic dysfunction in one organ may induce similar effect in the other organ. The diagnosis, prognosis and risk stratification of CRS is poorly understood. Current literature reveals that inflammation and thrombosis are integral to CRS development and key cardiac and renal biomarkers are elevated in CRS patients. Hence, this study aims to demonstrate that thrombo-inflammatory biomarkers and laboratory parameters give a telling narrative of ESRD progression to CRS. Method Plasma samples were collected from 95 ESRD patients which were recruited with an approved IRB protocol at Loyola University Medical Center hemodialysis unit. Normal human plasma (NHP) was obtained from a commercial source (George King Biomedical, Overland Park, KS). Thrombo-inflammatory biomarkers, including Annexin V, MPO, Troponin, L-FABP, VEGF, D-dimer, TNF-alpha, IL-6, CRP, eNOS, Nitrotyrosine, MDA, NEFA, NO, vWF and MCP-1 were measured using commercially available ELISA methods. Cardiovascular comorbidities and laboratory parameters were obtained from EPIC chart analysis. Results were then statistically analyzed using GraphPad Prism v.9; the results were compiled into mean ± SEM, percent change comparison to NHP, analyzed for significance. Results Several cardiovascular comorbidities were seen in the 95 ESRD patient samples including AF (22%), PAD (29%), HF (24%), CAD (22%), DVT (15%), COPD (6.5%), and PE (5.3%). Overall, 25% of the ESRD patients have CRS. Laboratory parameters, ferratin (521.99 ±289.33) and PTH (442.91 ± 1.50) were elevated in ESRD patients. Most of the thrombo-inflammatory CRS biomarkers were elevated in ESRD patients. Biomarkers including Annexin V (ESRD 7.57 ± 5.24, 23.64% vs. 6.125 ± 8.29, p&amp;lt; 0.001), L-FABP (106599.43 ± 176728.97, 1983% vs. 5116.33 ± 1767.88, p&amp;lt;0.0001), D-dimer (ESRD 1447.01 ± 2103, 650.53% vs. 192.8 ± 212.9, p&amp;lt;0.0001), TNF-alpha (ESRD 2.52 ± 1.06, 35.87% vs. 1.85 ± 1.20, p&amp;lt;0.0001), IL-6 (ESRD 5.211 ± 10.36, 317.21% vs. 1.25 ± 1.24, p &amp;lt;0.0001), CRP (ESRD 14.53 ± 14.11, 2214.43% vs. 0.63 ± 0.99, p&amp;lt; 0.0001), NO (ESRD 34.74 ± 19.74, 151.74% vs. 13.8 ± 5.60, p&amp;lt;0.0001), vWF (ESRD 200.7 ± 25.89, 183.03% vs. 70.91 ± 23.13 p&amp;lt; 0.0001) and MCP-1 (148.4 ± 56.09, 67.49% vs. 88.6 ± 27.25, p&amp;lt;0.0001) showed significant increase when compared to NHP. Conclusion This study suggests that thrombo-inflammatory biomarkers and laboratory parameters may be helpful in indicating CRS in ESRD patients. Ultimately, these biomarkers can now be readily used to correlate against other biomarker findings and studied further to determine their accuracy in prognosis and diagnosis of CRS.

Defining risk of central nervous system relapse in acute myeloid leukemia following allogeneic stem cell transplantation.

e19009 Background: Relapse following allogeneic stem cell transplant (AlloSCT) for acute myeloid leukemia (AML) remains the commonest cause of death post-transplant. Central nervous system (CNS) relapse is a devastating complication. With an estimated incidence of 2-8%, defining those patients at high risk and the management following CNS relapse remains controversial. We sought to identify demographic, clinical, molecular, and laboratory risk factors that would predispose AML patients to CNS relapse. Methods: This was a single institution retrospective study at Loyola University Medical Center. Inclusion criteria were adult patients with AML undergoing first AlloSCT from January 2012 to June 2021. Diagnosis of CNS relapse following AlloSCT was defined as leukemic blasts detected in spinal fluid analysis in accordance with established criteria. Chi-square tests were used to test the association between the experiencing of relapse and the categorical variables recorded. Wilcoxon Rank Sum test were used to assess the relationship between relapse experience and each of the demographic variables. Due to the low count of patients with CNS relapse and in order to avoid a poor estimation of confidence limits of any effect size, we limited our analyses to descriptive statistics and univariable analyses. Results: 198 patients met inclusion criteria with 8 cases (4.0% total) identified with CNS relapse following AlloSCT. Our analysis initially characterized 44 variables including age, race, HCT-CI risk, and day 100 chimerism. Univariate analysis is shown in the table below. Of note, it revealed that 62.50% of patients with CNS relapse had a chimerism value ≤98% at day 100 post-transplant as compared to 22.58% of patients without CNS relapse (p-value 0.02). Additionally, 87.50% of the CNS relapse group versus 51.38% of the group without relapse had favorable to intermediate AML risk scores (p-value 0.07). Conclusions: We observed a 4.0% rate of CNS relapse, which is consistent with what has been repored in the literature. Our results suggest that day 100 chimerism and disease risk index may be predictive of CNS relapse. Since there is a 10.6% incidence (5/47) of eventual CNS relapse amongst those with ≤98% chimerism at day 100, these patients could be considered for a lumbar puncture and bone marrow biopsy to prevent full relapse. Further research in this topic would be valuable to provide additional AML guidance in managing this uncommon complication, such as which patients may benefit from prophylactic strategies. [Table: see text]

Impact of body mass index (BMI) and weight changes on hematopoietic stem cell transplant (HSCT) outcomes in the elderly population.

e19058 Background: HSCT remains the only curative treatment for high-risk hematologic malignancies. Reduced intensity conditioning (RIC) has increasingly allowed transplant of elderly patients. However, maximizing outcomes in this population remains a challenge. We examine the influence of BMI and weight changes on HSCT outcomes in the elderly. Methods: This was a retrospective review of 216 patients ≥60 years of age who underwent first HSCT at the Loyola University Medical Center between 8/30/2000-6/15/2017. Pearson Chi-square tests for independence evaluated the associations between categorical variables and timing of recurrence. Fisher’s exact test were used where expected frequencies were &lt;5. Independent two-sample t-tests and ANOVA assessed differences in numerical variables. Results: BMI at time of transplant, defined as underweight (BMI&lt;18), normal weight (BMI 18-25), overweight (BMI 25-30), and morbidly obese (BMI&gt;30), did not impact incidence of cardiac dysfunction, pulmonary complications (Cx’s), renal Cx’s, graft versus host disease (GVHD), paraenteral nutrition (TPN) use, changes in albumin, or mortality. However, there was a trend towards increased disease relapse in those who were not normal weight (p=.08). Normal weight (BMI 18-25) at Day 100 was associated with decreased cardiac dysfunction (p=.02), days of hospitalization (p = .03), and mortality (p = .02) compared to non-normal BMI (BMI &lt; 18 or BMI &gt; 25). But there appeared no difference in rates of renal Cx's, GVHD, TPN use, or relapse. Having &gt;10% weight change at discharge from transplant admission was associated with increased renal Cx’s (p = .007), infectious Cx’s (p = .03), use of TPN (p = .006), length of hospital stay (p = .0002), and mortality (p = .009). However, it was not associated with cardiac dysfunction, pulmonary Cx’s, readmissions by 6 months, GVHD, or relapse. Having &gt;10% weight change at Day 100 was associated with increased risk of acute (p = .01) and chronic GVHD (p = .002) and readmissions by 6 months (p = .01), but not with other Cx’s, relapse, or mortality. Conclusions: Patients who were underweight or overweight at key timepoints may impact complications and HSCT outcomes. Furthermore, maintaining a stable weight during transplant admission and the first 100 days was associated with decreased rates of complications and adverse HSCT outcomes. These findings warrant further evaluation into age-related weight and nutritional targets to improve understanding and optimize HSCT outcomes in this vulnerable population. [Table: see text]

A Retrospective Analysis of Tear Film and Blink Parameters in Patients With Ocular Surface Disease.

We had two objectives: (1) to investigate differences in tear film and blink parameters in patients with six ocular surface diseases (OSD): ocular graft versus host disease (oGVHD), Stevens-Johnson syndrome (SJS), lax eyelid syndrome, meibomian gland dysfunction (MGD), obstructive sleep apnea, and dry eye disease; and (2) to characterize the relationships between lipid layer thickness (LLT), meiboscore, Schirmer I test, and three blink parameters: partial blink rate (PBR), interblink interval (IBI), and interpalpebral fissure height (IPFH) in this group of patients. This is a single-site retrospective analysis of 228 patients (456 eyes) with six different primary OSD at Loyola University Medical Center between January 2018 and July 2020. Objective parameters included: LLT, IBI, PBR, IPFH, Pult meiboscore, and Schirmer I score. Linear mixed effects models were used to analyze the relationships between these parameters. The meiboscore was highest in patients with SJS compared with the other five groups. There was significant variability in IPFH across different groups, with patients with oGVHD having the smallest height. An increase in IPFH was associated with increases in IBI, PBR, and Schirmer score. Patients with no partial blinks demonstrated a statistically significant higher IBI than patients who showed 1%-50% partial blinks. Finally, no statistically significant relationship was found between the following: (1) meiboscore and LLT, (2) OSDI and IPFH, (3) Schirmer score and IBI, or (4) LLT and IBI. There were fewer than anticipated differences in objective tear film and blink parameters between patients with six different OSD. A statistically significant association was found between IPFH and Schirmer score and IPFH and IBI, representing new findings in tear film research. Further investigation of the relationship between IPFH and IBI is needed.

Editorial Commentary.

No AccessUrology PracticeHealth Policy1 May 2023Editorial CommentaryThis article comments on the following:eConsult Provides a Novel Opportunity to Evaluate Hematuria Referrals for Medicaid Patients in the “Real-World” Community Nicholas Lanzotti and Kristin G. Baldea Nicholas LanzottiNicholas Lanzotti Department of Urology, Loyola University Medical Center, Maywood, Illinois More articles by this author and Kristin G. BaldeaKristin G. Baldea Department of Urology, Loyola University Medical Center, Maywood, Illinois More articles by this author View All Author Informationhttps://doi.org/10.1097/UPJ.0000000000000391.01AboutFull TextPDF ToolsAdd to favoritesDownload CitationsTrack CitationsPermissionsReprints ShareFacebookLinked InTwitterEmail "Editorial Commentary." Urology Practice, 10(3), p. 243

Editorial Commentary.

No AccessUrology PracticeHealth Policy1 May 2023Editorial CommentaryThis article comments on the following:Outcome Measures and Inclusion/Exclusion Criteria in Benign Prostatic Hyperplasia Trials on ClinicalTrials.govis a letter which has replyReply by Authors Kevin T. McVary Kevin T. McVaryKevin T. McVary Center for Male Health, Department of Urology, Stritch School of Medicine, Loyola University Medical Center, Maywood, Illinois More articles by this author View All Author Informationhttps://doi.org/10.1097/UPJ.0000000000000397.01AboutFull TextPDF ToolsAdd to favoritesDownload CitationsTrack CitationsPermissionsReprints ShareFacebookLinked InTwitterEmail "Editorial Commentary." Urology Practice, 10(3), p. 259

Spotlight in Plastic Surgery: April 2023.

“Spotlight in Plastic Surgery” provides a quarterly overview of articles from non–plastic surgery high-impact journals and Plastic and Reconstructive Surgery Global Open. This month, we review key articles of relevance to plastic surgeons from The Lancet, New England Journal of Medicine, Nature, Annals of Surgery, JAMA Surgery, and Plastic and Reconstructive Surgery Global Open. Our goal is to enlighten Journal readers with clinical and basic science literature relevant to our specialty that they otherwise may not be read. We continue to thank the Plastic and Reconstructive Surgery resident advisors and advisory board members who volunteer to help us identify these articles and provide brief synopses. Should any readers have specific suggestions of articles to review in recent issues of high-impact journals, please contact us by email at [email protected] We wish to remain responsive to the needs of our readers in keeping all of us up to date as to key developments relative to plastic surgery. Association between Gender-Affirming Surgeries and Mental Health Outcomes. By Almazan AN, Keuroghlian AS. JAMA Surg. 2021;156: 611–618.1 This study aimed to investigate the associations between gender-affirming surgery and mental health outcomes (psychological distress, substance use, and suicide risk). The study was a secondary analysis of the 2015 US Transgender Survey (n = 27,715). Results suggest that patients who underwent gender-affirming surgery were associated with lower psychological distress, past-year smoking, and suicidal ideation when compared with transgender patients with no history of gender-affirming surgery. The authors adjusted for sociodemographic factors and exposure to other types of gender-affirming care. The findings of this study may aid plastic surgeons in counseling patients who are planning to undergo gender-affirming surgery. Ronald K. Akiki, MD Brown University Providence, RI A Randomized Trial of Enteral Glutamine for Treatment of Burn Injuries. By Heyland DK, Wibbenmeyer L, Pollack JA, et al. N Engl J Med. 2022;387:1001–1010.2 This was an international, multicenter, doubleblind, randomized, placebo-controlled trial including 1209 patients with deep second or third degree burns (≥10% to ≥20% total body surface area). Patients were randomized to receive glutamine 0.5 g/kg/day (delivered enterally) or placebo. A total of 1200 patients were included in the analysis, with 596 patients in the glutamine group and 606 in the placebo group. There was no significant difference between groups in the median time to discharge (40 days in the glutamine group and 38 days in the placebo group) or mortality rate at 6 months (17.3% in the glutamine group and 16.2% in the placebo group). Amanda Fazzalari, MD Massachusetts General Hospital/Brigham and Women’s Hospital Boston, MA A Prospective Study on the Safety and Efficacy of Vascularized Lymph Node Transplant. By Brown S, Mehrara BJ, Coriddi M, et al. Ann Surg. 2022;276:635–653.3 The authors assessed the safety and efficacy of vascularized lymph node transplantation for the management of lymphedema, through a prospective study evaluating two patient-reported outcome metrics, limb volume, bioimpedance, need for compression, and incidence of cellulitis in a postoperative follow-up, including 89 patients with different donor sites. They demonstrated a significant improvement at 2 years postoperatively in all outcome measures with a low complication rate, establishing vascularized lymph node transplantation as a safe procedure with good results. As lymphedema is a common problem, vascularized lymph node transplantation should be considered by surgeons to offer an innovative, safe, and effective management alternative. Tomás Mestre García, MD Universidad Militar Nueva Granada Bogotá, Colombia Neoadjuvant Cemiplimab for Stage II to IV Cutaneous Squamous-Cell Carcinoma. By Gross ND, Miller DM, Khushalani NI, et al. N Engl J Med. 2022;387:1557–1568. E-published ahead of print September 12, 2022.4 This study describes a phase 3 double-blind, multicenter, single-group, nonrandomized trial assessing the efficacy of cemiplimab, an anti–programmed cell death 1 monoclonal antibody for neoadjuvant immunotherapy in cutaneous squamous cell carcinoma. Seventy-nine patients with stage III and IV cutaneous squamous cell carcinoma (no metastasis) received cemiplimab intravenously at a dose of 350 mg every 3 weeks for up to four doses. A pathological complete response was observed 51%, and 6% had a complete response on imaging. Thus, cemiplimab can be considered a neoadjuvant treatment before resection in advanced squamous cell carcinoma. Knowing this will greatly help plastic surgeons in making decisions. Majid Kalbasi Gharavi, MD Isfahan University of Medical Sciences Isfahan, Iran Reoperation through a Prosthetic-Reinforced Abdominal Wall and Its Association with Postoperative Outcomes and Longitudinal Health Care Utilization. By Rios-Diaz AJ, Cunning JR, Talwar AA, et al. JAMA Surg. 2022;157:908–916.5 The aim of this study was to investigate the association of prior incisional hernia repair with mesh with postoperative outcomes and health care utilization after common abdominal operations. Rios-Diaz et al. conducted a retrospective cohort study using five statewide databases. Results of this study suggested that reoperation through a previously prosthetic-reinforced abdominal wall was associated with increased surgical complications and health care utilization. This risk is independent of prior abdominal surgical history and is magnified by the mesh footprint. This important information can aid plastic surgeons in counseling patients undergoing abdominal wall surgery after prior incisional hernia repair with mesh. Francis D. Graziano, MD Icahn School of Medicine at Mount Sinai New York, NY Tissue-Engineered Grafts Exploit Axon-Facilitated Axon Regeneration and Pathway Protection to Enable Recovery after 5-cm Nerve Defects in Pigs. By Smith DH, Burrell JC, Browne KD, et al. Sci Adv. 2022;8:eabm3291.6 When one considers the shortcomings of the current peripheral nerve repair techniques, repair of long segmental nerve defects still constitutes a challenge for plastic surgeons. The authors developed tissue-engineered nerve grafts (TENGs) to bridge the long nerve gaps. TENGs are mechanobioreactor generated via axonal “stretch growth” of the embryonic murine or swine sensory dorsal root ganglion neurons. In a porcine long (>5 cm) nerve gap model, TENGs demonstrated a level of electrophysiological recovery and axonal regeneration comparable or superior to that of autografts. Therefore, successful clinical translation of TENGs, an off-the-shelf product, may cause a paradigm shift in the management of long-segment defects. Gunel Guliyeva, MD The Ohio State University Columbus, OH Does Fitzpatrick Score Predict Flap Loss? Microsurgical Breast Reconstruction Outcomes of Varying Skin Color. By Perez K, Steppe C, Teotia SS, Haddock NT. Plast Reconstr Surg Glob Open. 2022;10:e4637.7 In this study, the authors aimed to evaluate the influence of Fitzpatrick skin tone on flap loss due to unsalvaged vascular compromise in patients who underwent autologous breast reconstruction. Perez et al. identified 56 patients from their institution who met the inclusion criteria. The Cochran-Armitage test showed a statistically significant linear trend (P = 0.006), with darker skin tones in the Fitzpatrick score indicating higher percentage of flap loss. The current study highlighted that these patients had a higher rate of flap loss after vascular injury. The authors recommend that more aggressive flap monitoring be considered in the immediate postoperative period. Samarth Gupta, MBBS, MS, MCh St Andrew’s Center of Plastic Surgery and Burns Chelmsford, United Kingdom Functional and Psychosocial Outcomes following Innervated Breast Reconstruction: A Systematic Review. By Abbas F, Klomparens K, Simman R. Plast Reconstr Surg Glob Open 2022;10:e4559.8 In this study, the authors conducted a systematic review to gain insight into the efficacy of nerve coaptation during breast reconstruction. Twenty-three studies were included—seven for DIEP flaps, nine for TRAM flaps, two for implant reconstruction, and five for other reconstruction. Monofilament testing was the most common modality to test sensation, and various tools were used to assess the psychosocial impact, including the BREAST-Q. Even though the methods in the studies were heterogeneous, the studies showed improved outcomes following neurotization, both clinically and psychosocially. This highlights the need to further explore neurotization in a multicenter study with a standardized methodology. Ayush K. Kapila, MD Brussels University Hospital (UZ Brussel) Brussels, Belgium A Statewide Approach to Reducing Re-excision Rates for Women with Breast-Conserving Surgery. By Schumacher JR, Lawson EH, Kong AL, et al. Ann Surg. 2022;276:665–672.9 This study retrospectively assessed the effect of statewide implementation of a quality improvement (QI) initiative on re-excision rates after breast-conserving surgery using discharge data through a difference-in-difference statistical approach. The QI initiative involved (1) benchmarked performance reporting, (2) a collaborative learning environment for surgeons to share experiences, and (3) education on evidence-based practices. Authors demonstrated reduced re-excision rates in patients operated on at hospitals participating in the QI initiative compared with those from nonparticipating hospitals (odds ratio, 0.69). Implementation of this breast QI initiative can help surgeons better manage resources such as operative time and avoid delays in starting adjuvant therapy. Ann-Sophie Lafreniere, MD University of Calgary Calgary, Alberta, Canada Routine Sterile Glove and Instrument Change at the Time of Abdominal Wound Closure to Prevent Surgical Site Infection (ChEETAh): A Pragmatic, Cluster-Randomised Trial in Seven Low-Income and Middle-Income Countries. By NIHR Global Research Health Unit on Global Surgery. Lancet 2022;400:1767–1776.10 In the ChEETAh study, a pragmatic, clustered, randomized trial, the authors aimed to evaluate whether routine change of gloves before abdominal wound closure reduced surgical site infection (SSI) rates within 30 days of operation. A total of 13,301 patients at 81 hospitals in seven low-income countries were included in the study. Routine change of gloves and instruments before abdominal wound closures reduced the rate of SSI by 13%. SSI remains the most common health care–associated infection. This valuable information allows plastic surgeons all over the world to implement a simple routine that leads to a lower incidence of SSI. M. Diya Sabbagh, MD Loyola University Medical Center Maywood, IL Aqueous Skin Antisepsis before Surgical Fixation of Open Fractures (Aqueous-PREP): A Multiple-Period, Cluster-Randomised, Crossover Trial. By PREP-IT Investigators. Lancet 2022;400:1334–1344.11 In a multiperiod, cluster-randomized, crossover trial involving 14 hospitals in the United States, Spain, and Canada, 1683 patients with open extremity fractures were randomized 1:1 to receive either 10% povidone-iodine or aqueous 4% chlorhexidine gluconate for skin preparation before surgical incision. Overall, the odds of surgical site infection (SSI) did not differ between patients assigned aqueous 10% povidone-iodine (7% SSI rate) or aqueous 4% chlorhexidine gluconate (7% SSI rate) for skin antisepsis. On the basis of this study, hand surgeons treating open extremity fractures may choose either povidone-iodine or chlorhexidine for skin preparation without significant effects on SSI rates. Amanda R. Sergesketter, MD Duke University Hospital Durham, NC

Coronavirus Disease 2019 (COVID-19) Pandemic’s Effect on Child and Adolescent Mental Health: Analysis of Pediatric Intensive Care Unit and Consultation-Liaison Psychiatry Service

The Coronavirus Disease (COVID-19) pandemic has contributed to a co-occurring psychiatric epidemic. Children and adolescents have been particularly impacted, with disruptions in continuity of learning and healthcare. Psychological stressors such as fear of infection, boredom, decreased socialization, supply shortages, and incomplete information have contributed to low mood, irritability, insomnia, and emotional exhaustion. Our study contributes to this research by quantifying the devastating psychiatric toll that the COVID isolation period and virtual schooling had on the mental health of children. The Loyola University Medical Center (LUMC) Consultation-Liaison Psychiatry Service (CLP) (Maywood, IL) designed a study to identify and analyze data regarding the total number of CLP consult requests, patient presentations to the emergency department (ED), and admissions to the Pediatrics floor and Pediatric Intensive Care Unit (PICU) during the COVID pandemic. IRB approval was obtained for this retrospective chart review study. ED visits and Pediatric floor/PICU admissions of all pediatric patients (6-18 years old), specifically those related to mental health, were identified using ICD-9 diagnostic coding for the dates of March 2019 through February 2022. The total number of admissions and encounter diagnoses were analyzed and compared between 3 pandemic periods: Pre-pandemic phase (March 2019-February 2020), acute pandemic phase: isolation/virtual schooling (March 2020-February 2021), and chronic pandemic phase: post-isolation/virtual schooling (March 2021-February 2022). During the chronic pandemic phase, ED visits and Pediatric floor/PICU admissions of all pediatric patients were identified via manual chart review of existing CLP patient lists. The total number of admissions, along with diagnoses during encounters, were compared between the 3 periods and psychiatric admissions were further subcategorized into intentional drug overdoses. In the pre-pandemic phase, there were 39,304 total encounters for children (6-18 years), with 11,189 ED-only visits, and 3,043 inpatient admissions. In the acute pandemic phase, total encounters fell to 15,779, with 4,631 ED-only visits, and 2,578 inpatient admissions. Pre-pandemic, 0.55% of all pediatric encounters required psychiatry consults compared to 1.32% after the onset of the pandemic. During the pre-pandemic phase, there were 27 PICU admissions for psychiatric-related conditions (i.e. intentional ingestion) or 4.52% of all PICU admissions. During the acute pandemic period, there were 57 PICU admissions for psychiatric-related conditions or 11.19% of all PICU admissions. Specifically, there was a rise in intentional ingestion cases from 25 prior to the pandemic to 44 after the onset of the pandemic. During the chronic pandemic period, there were 43 PICU admissions for psychiatric-related conditions. Of those 43 admissions, 33 were intentional drug overdoses. Total encounters during this phase were comparable to the pre-pandemic phase (39,304 encounters pre-pandemic vs. 32,544 encounters in chronic pandemic phase).At this large academic medical center, the pandemic has had a clear impact on total pediatric encounters, with a rise in the number of PICU admissions for psychiatric-related conditions. Findings from this study can be used to inform public policy and develop guidelines in preparation for future pandemics. Safeguards should be put in place to address the significant effects that social isolation and virtual schooling have on the mental health of children, including but not limited to widespread therapy sessions incorporated into the virtual school day and socially distanced in-person activities when safe.

Microbiome in Lower Urinary Tract Symptoms (LUTSs): Mapping the State of the Art with Bibliometric Analysis.

The main objective of this study is to provide the first characterization of the current research field of the clinical microbiome in LUTSs. First-of-its-kind scientometric insight into the historical development and structural state of the discipline is provided by a field analysis, mapping, and sub-analysis of articles for future research. On 22 December 2022, the entire Scopus database was searched without language or date restrictions. Search terms included "Chronic prostatitis", OR "Interstitial cystitis", OR "Lower urinary tract symptoms", OR "Lower urinary tract dysfunction", OR "Overactive bladder", OR "Incontinence", OR "Urolithiasis", OR "Urothelium", OR "Urine", OR "Urology", OR "urinary disorder", OR "Pathophysiology", OR "Benign prostatic hyperplasia", OR "Benign prostatic enlargement", AND "Microbiota", OR "Microbiome", OR "Urobio-ma", OR "Urobiota; microflora". The author and institutional data were transformed using the analytical tool Biblioshiny (a Shiny app for Bibliometrix), which took into account variations in author spelling as well as institutional naming and subgroups. The specified search strategy was able to locate 529 documents from 267 sources published from 1981 to 2022. The average number of years from publication was 4.59 years. The authors with the most publications were Wolfe AJ and Brubaker I. The top three most collaborative networks were Loyola University Chicago, Loyola University Medical Center, and the University of California San Diego. The most frequently occurring words among the 50 nodes were: human, humans, nonhuman, female, adult, article, microbiology, microflora, microbiota, and controlled study. Frontiers in Cellular and Infection Microbiology and the International Urogynecology Journal, followed by Nature Reviews Urology, were the top three most relevant sources in microbiome research in urology. One of the most crucial requirements for developing research policies and anticipating the scientific requirements of researchers is paying attention to the evolution of various scientific fields. Understanding research gaps and future needs in microbiome research in urology can be effectively understood by paying attention to the models, maps, and visualizations used in this research, which are the results of systematic analysis of scientific products in the most esteemed scientific journals in the world.

Relationship Between Worst Pattern of Invasion and Extranodal Extension in Oral Tongue Squamous Cell Carcinomas.

Oral tongue squamous cell carcinoma (OTSCC) is a common malignancy of the oral cavity with poor survival rates. The aim of this project is to investigate the relationship between certain histopathological factors such as Worst Pattern of Invasion (WPOI) and Extranodal Extension (ENE) in patients with oral tongue squamous cell carcinoma (OTSCC) who underwent surgical resection at Loyola University Medical Center. This was a retrospective cohort study at a tertiary care academic medical center. All patients that underwent primary surgical resection of OTSCC between 1/1/2015 and 1/1/2022 were reviewed. Patients were identified using the Cerner CoPath Laboratory Information System. A total of 82 patients met inclusion criteria and were included in the study. Higher grades of WPOI (WPOI 5) were not significantly associated with the presence of ENE in our study (P = 0.82), regardless of the presence of major or minor ENE. WPOI 5 was associated with a higher incidence of local recurrence (P = 0.011). Higher grades of WPOI were not found to correlate with the presence of ENE, a common histopathological factor that is used as an important prognostic indicator in OTSCC. It is important for clinicians to consider these factors separately when determining whether a patient is high-risk and would benefit from aggressive multimodal treatment.

Abstract TP108: Early Palliative Care Consultation In Patients With Disabling Stroke

Severe disability and critical illness due to stroke can be burdensome to patients, caregivers, and resource intensive, particularly in the elderly. Management of these patients is multifaceted and includes optimizing quality of life through palliative care (PC). PC in stroke patients can improve comfort while reducing overutilization of resources unlikely to prolong life or contribute meaningful quality. We investigated the impact of early PC involvement in disabled stroke patients, which we defined as NIH Stroke Score ≥ 5 and ICU admission. A screening program was implemented in 2019 at the Loyola University Medical Center for automatic PC consults in disabling stroke (ischemic or hemorrhagic) patients over age 70 or who require a ventilator. We hypothesized that early PC consultation via this protocol reduced resource consumption without compromising patient care. This pilot study gathered data prospectively for patients with a positive screen from 2020 to 2021 (“screening”, n=71), and retrospectively for those who met screening criteria in 2017 and 2018 prior to its application (“control”, n=193). Comparing the screening and control groups, there was no significant difference in age (75.9 ± 2.7 vs 72.1 ± 1.1, p&gt;0.1), NIH stroke score (16.6 ± 0.5 vs 17.5 ± 0.9, p=0.2), stroke type (61% vs 69% ischemic, p&gt;0.2), or proportion who expired (22% vs 18%, p=0.4). However, the screening group had more frequent code status change from full to DNR/DNI (42% versus 19%, p&lt;0.01) and more frequent discharges to home (20% vs 8%, p&lt;0.01) when compared to the control. These findings suggest that our samples were similar in stroke severity and screening did not affect mortality. More frequent code status changes with PC screening implies better early identification of patient centered goals of care during admission. Increased discharges to home among these patients may reduce overall long term health care utilization with clear future directives. In conclusion, our pilot study demonstrates that early palliative care involvement in patients with disabling stroke is feasible and expedites establishing goals of care without affecting the quality of care patients receive. We plan to further investigate resource utilization including ICU length of stay and cost.

Editorial Commentary.

No AccessUrology PracticeClinical Research23 Jan 2023Editorial CommentaryThis article comments on the following:Stent Omission in Prestented Patients Undergoing Ureteroscopy Decreases Unplanned Health Care Utilization Kristin G. Baldea Kristin G. BaldeaKristin G. Baldea * E-mail Address: [email protected] Department of Urology, Loyola University Medical Center, Maywood, Illinois More articles by this author View All Author Informationhttps://doi.org/10.1097/UPJ.0000000000000376.01AboutFull TextPDF ToolsAdd to favoritesDownload CitationsTrack Citations ShareFacebookLinked InTwitterEmail "Editorial Commentary." Urology Practice, Publish Ahead of Print, pp. – Reference 1. Surgical management of stones: American Urological Association/Endourological Society guideline, part II. J Urol.2016; 196(4):1161–1169. Link, Google Scholar © 2022 by American Urological Association Education and Research, Inc.FiguresReferencesRelatedDetailsRelated articlesUrology Practice23 Jan 2023Stent Omission in Prestented Patients Undergoing Ureteroscopy Decreases Unplanned Health Care Utilization Advertisement Copyright & Permissions© 2022 by American Urological Association Education and Research, Inc.MetricsAuthor Information Kristin G. Baldea Department of Urology, Loyola University Medical Center, Maywood, Illinois * E-mail Address: [email protected] More articles by this author Expand All Advertisement PDF downloadLoading ...

602. Clinical Outcomes of Ertapenem in Patients with Hypoalbuminemia

Abstract Background Infections caused by extended-spectrum ß-lactamase (ESBL) producing organisms pose a unique challenge for infection control. The preferred agents for treatment of infections due to ESBL-producing bacteria are carbapenems. Data from prior studies suggest that hypoalbuminemia may have a profound effect on the pharmacodynamic properties of ertapenem. Our hypothesis is that ertapenem usage in patients with hypoalbuminemia will lead to negative clinical outcomes such as infection recurrence, hospital readmission, and mortality when compared to subjects with higher albumin levels. Methods This was a retrospective, observational, single-centered, cohort study of hospitalized patients at Loyola University Medical Center between January 2010 and August 2020. Patients were divided into 2 groups to include those who received ertapenem with serum albumin &amp;gt;2.5 g/dL and those who received ertapenem with serum albumin &amp;lt; 2.5 g/dL. The primary outcome of interest was 30-day all-cause mortality. Baseline characteristics that were collected included age, sex, nutrition status, patient comorbidities. Data regarding predictors of mortality within 24 hours of initiation of ertapenem including the Acute Physiology and Chronic Health Evaluation (APACHE) II score and the Charlson Comorbidity Index (CCI) was also collected. Study Criteria Results Of the 146 subjects that were included, 73 patients had serum albumin levels of &amp;lt; 2.5 g/dL during treatment with ertapenem. 30 day all-cause mortality was 19.7% for subjects with low albumin and 9.6% for subjects with normal albumin levels (p=0.09). Our study found that although not statistically significant, there is potentially a clinical significance between hypoalbuminemia and our primary endpoint, 30-day all-cause mortality, with higher rates of mortality in the low albumin group and a 9.6% between group difference. This data suggests that in subjects with hypoalbuminemia, treatment with once-daily ertapenem may lead to suboptimal outcomes regarding patient mortality. Outcome Data Conclusion The present study data suggests that in subjects with hypoalbuminemia, treatment with ertapenem dosed as a once-daily intravenous infusion may be associated with suboptimal clinical outcomes that may include an increased mortality, hospital readmission, and length of stay. Disclosures All Authors: No reported disclosures.