Mount Sinai Medical Center Research Articles

Development of a Social Work-Led Primary Palliative Care Model in Hospital Medicine (FR481C)

•Describe what is involved in an embedded primary palliative care program.•Describe how an embedded primary palliative care program model can improve patient outcomes. Due to palliative clinician workforce shortages and the growing number of patients with serious illness in need of palliative care, innovative primary palliative care models are essential to meet this population’s needs using the existing resources. To increase palliative care delivery, enhance appropriate hospice referral and decrease readmissions of seriously ill patients admitted to the hospitalist service. To meet unmet palliative care needs of patients admitted to the hospitalist service at Mount Sinai Medical Center, a social worker-led embedded primary palliative care model was developed. The social worker facilitated goals of care discussions, delivery of prognosis, discharge planning, and completion of advance directive documentation. In 2017, 184 patients received a primary palliative care consultation; those patients seen had an average age of 70 years, 43% were female and the median Karnofsky performance status of 40%, as compared to 20% for those seen by specialty palliative care. Overall, 51% of the patients seen met palliative care solid tumor oncology trigger criteria, 20% were triaged from the specialty palliative care team and 15% were direct referrals from hospitalists. Of those evaluated, 5% had documented goals of care in the electronic medical record before the consultation and 92% after the consultation. The hospice referral rate was 25% and the specialty palliative care referral rate was 25%. Reasons for referral to specialty palliative care were transfer to the palliative care unit (51%) and complex symptom management (49%). Of those who received the consultation, 30-day readmission rate was 5.3%, as compared to those who did not (16%). Patients seen by the social worker-led primary palliative care team were more functional, suggesting they were seen earlier in their disease course, and had fewer readmissions.

Patients' Perceptions of the Role of Physicians in Questioning and Educating in Firearms Safety: Post-FOPA Repeal Era.

In this study, we determined patients' attitudes toward discussing firearms and issues of firearms safety with emergency department physicians. We assessed whether patients feel discriminated against should physicians discuss firearms safety, and whether they believed that physician counseling may change how patients store firearms. From June to October 2017, we conducted a cross-sectional institutional review board-approved survey of 200 consenting adult patients (convenience sample) not requiring critical care presenting to the emergency department of Mount Sinai Medical Center in Miami Beach, Florida. The survey consisted of 22 questions about perceptions of physicians inquiring about firearms, demographics, firearms statistics, and firearms knowledge. Results on firearms owners and nonowners were compared with the Fisher exact test. P < 0.05 was considered significant. Ninety percent of patients said they felt comfortable discussing firearms safety with a physician (firearms vs no firearms owner, 100% vs 87.5%, P = 0.028). Ninety percent (firearms 90.7% vs no firearms owners 89.9%, P = 1.0) of patients did not believe that physicians were discriminating against patients who are firearms owners when discussing firearms safety. Seventy-six percent (firearms 76.4% vs no firearms owners 77.3%, P = 0.367) of patients believed that physicians should be educating their patients about firearms safety, and 71% (n = 142) believed that education provided by physicians will change how people store their firearms (firearms 75% vs no firearms owners 70.2%, P = 0.67). Firearms safety is a difficult but important public health matter that requires significant intervention to help prevent future firearms incidents. This study supports physicians' efforts to help educate patients about the dangers of firearms, along with proper firearms storage techniques, showing that patients are largely open to this discussion. We propose that training of physicians in strategies for initiating clinical discourse and addressing firearms safety is needed.

Natural History of Cervical Artery Fibromuscular Dysplasia and Associated Neurovascular Events

Background and Purpose: Fibromuscular dysplasia (FMD) is a non-atherosclerotic arteriopathy most often affecting the carotid and renal arteries. In the United States Registry for FMD, 41.7% of patients experienced an aneurysm and/or dissection by the time of entry into the Registry. We sought to determine the occurrence of neurovascular events after FMD diagnosis and any changes on cervical artery imaging that may be attributable to FMD. Methods: Patients followed at the Mount Sinai Medical Center (US Registry for FMD enrollment center) with confirmed FMD and > 1 cervical artery imaging study (at least ± 6 months from the baseline carotid duplex ultrasound [CDU]) between the years 2003 and 2015 were included. Medical records and cervical artery imaging ([CDU], magnetic resonance angiogram [MRA], and computed tomography angiogram [CTA]) were reviewed. New arterial dissection, aneurysm, transient ischemic attack, stroke, or new FMD findings were recorded. Results: Among 146 FMD patients with complete information, 52 (35.6%) had an aneurysm and 52 (35.6%) had a dissection. Mean clinical follow-up was 35.3 ± 25.3 months (range 5–153 months); patients underwent 4 ± 2.7 CDU (range 1–17); 86.3% had ≥1 neck MRA or CTA. After FMD diagnosis, 3 patients (2%) experienced a new carotid artery dissection; 1 patient experienced a stroke due to concomitant atherosclerosis. No new aneurysms occurred. In patients with cervical artery FMD, imaging findings remained stable throughout follow-up. No patient developed new cervical artery FMD findings on follow-up imaging. Conclusions: No new cervical artery FMD or aneurysm was observed on subsequent imaging. New carotid dissection was uncommon over a mean follow-up period of 35.3 ± 25.3 months and was the only non-atherosclerotic vascular event observed after FMD diagnosis.

Correlation of 2-Dimensional and 3-Dimensional Echocardiographic Analysis to Surgical Measurements of the Tricuspid Valve Annular Diameter

This study sought to determine if 3-dimensional (3D) echocardiography would more closely correspond to direct surgical measurements of the maximal tricuspid valve (TV) annular diameter than 2-dimensional (2D) measurements. Prospective study. The cardiothoracic operating rooms (ORs) at Mount Sinai Medical Center in New York, NY. Fifty-nine patients over 18years of age underwent elective mitral valve surgery for severe mitral regurgitation from 2014 to 2015. None. Two-dimensional and 3D data sets and surgical TV annular dimensions were measured. Bland-Altman analysis was conducted and absolute differences were compared using paired t tests and the McNemar test. The observed mean difference between the 2D measurements by transgastric right ventricular diastolic view and the surgical measurements was 0.21cm (standard deviation [SD] = 0.36 cm); the mean difference between the 3D measurements and surgical measures was -0.03cm (SD = 0.19 cm). The McNemar test showed that the rate of highly successful measurements, defined as those within 0.2cm of the true surgical score, using the 3D technique (66%) was significantly better than the rate of highly successful measurements using the 2D technique (25%), p< 0.01, 2-sided. Three-dimensional imaging and measurement of the TV annular diameter is feasible in the OR setting. The superiority of the 3D measurements versus 2D measurements allows for greater precision and accuracy and may guide better intraoperative surgical decision-making.

Discussions in Cardiothoracic Treatment and Care: Mechanical Circulatory Support Left Ventricular Assist Device Therapy for Patients With Advanced Heart Failure

Discussions in Cardiothoracic Treatment and Care: Mechanical Circulatory Support Left Ventricular Assist Device Therapy for Patients With Advanced Heart Failure

Fulfilled: How the Science of Spirituality Can Help You Live a Happier, More Meaningful Life.

Clinical Professor Department of Psychiatry, Icahn School of Medicine, Mount Sinai Medical Center, New York City, New York

HealthPROMISE: Utilization of Patient Reported Outcomes to Measure Quality of Life in Inflammatory Bowel Disease

Background: Inflammatory Bowel Disease (IBD) is a chronic condition of the bowel affecting over 1.5 million people in the United States. The recurrent nature of IBD makes affected patients ideal candidates for electronic patient reported outcome (e-PRO) monitoring that centers on enhanced symptom tracking and improved communication with care teams. Objective: The study aims to understand the impact of e-PRO utilization via a prescribed mobile application, HealthPROMISE, on improving patients’ quality of life (QOL). Researchers investigated patients’ use of e-PROs to determine whether physicians change treatment in response to new patient health information, and whether patients’ quality of life changes over the course of the study. Methods: In a pragmatic randomized trial at Mount Sinai Medical Center (MSMC), baseline e-PROs were measured using online questionnaires delivered through the app that assessed health literacy, disease severity, general health status, and demographic information. Patients using HealthPROMISE could update their e-PRO information and receive a disease summary and a graph trending IBD-specific QOL scores (Figure 1). Patients could also communicate over the HealthPROMISE app and discuss results with providers. Results of e-PRO data were then compared with those collected from paper-based instruments in another institution (University of Pittsburgh Medical Center, UPMC) for triangulation (Figure 2). Results: There were 320 patients enrolled in the study. Of these, 162 were randomized to the intervention group (e-PROs), and 158 to the control group. Fatigue and tension were the two most important drivers of poor QOL in both MSMC and UPMC cohorts. Usage data showed that the majority of patients (~75%) continue to actively log into the HealthPROMISE app and update their e-PRO. Overall, QOL improved among HealthPROMISE patients over a mean follow-up of 6 months. At baseline, patients in the intervention arm reported a mean quality of life score of 30.3 ± 11.3. The last available follow-up QOL scores showed improvement among patients using HealthPROMISE to 25.3 ± 11.3 (P<0.001) (Figure 2). Conclusions: This is one of the first randomized controlled trials of app-based PRO measure in IBD patients. A significant improvement in QOL was observed. Longitudinal e-PRO collection in IBD patients is feasible with a high degree of adoption and engagement. IBD patients who participate in their own care (via PRO) and share in decision-making have appreciably improved outcomes when compared to patients who do not.

Stratifying Parkinson’s Patients With STN-DBS Into High-Frequency or 60 Hz-Frequency Modulation Using a Computational Model

High frequency stimulation (HFS) of the subthalamic nucleus (STN) is a well-established therapy for Parkinson's disease (PD), particularly the cardinal motor symptoms and levodopa induced motor complications. Recent studies have suggested the possible role of 60 Hz stimulation in STN-deep brain stimulation (DBS) for patients with gait disorder. The objective of this study was to develop a computational model, which stratifies patients a priori based on symptomatology into different frequency settings (i.e., high frequency or 60 Hz). We retrospectively analyzed preoperative MDS-Unified Parkinson's Disease Rating Scale III scores (32 indicators) collected from 20 PD patients implanted with STN-DBS at Mount Sinai Medical Center on either 60 Hz stimulation (ten patients) or HFS (130-185 Hz) (ten patients) for an average of 12 months. Predictive models using the Random Forest classification algorithm were built to associate patient/disease characteristics at surgery to the stimulation frequency. These models were evaluated objectively using leave-one-out cross-validation approach. The computational models produced, stratified patients into 60 Hz or HFS (130-185 Hz) with 95% accuracy. The best models relied on two or three predictors out of the 32 analyzed for classification. Across all predictors, gait and rest tremor of the right hand were consistently the most important. Computational models were developed using preoperative clinical indicators in PD patients treated with STN-DBS. These models were able to accurately stratify PD patients into 60 Hz stimulation or HFS (130-185 Hz) groups a priori, offering a unique potential to enhance the utilization of this therapy based on clinical subtypes.

Editorial introductions

Editorial introductions

Factors associated with success of telaprevir- and boceprevir-based triple therapy for hepatitis C virus infection.

AIMTo evaluate new therapies for hepatitis C virus (HCV), data about real-world outcomes are needed.METHODSOutcomes of 223 patients with genotype 1 HCV who started telaprevir- or boceprevir-based triple therapy (May 2011-March 2012) at the Mount Sinai Medical Center were analyzed. Human immunodeficiency virus-positive patients and patients who received a liver transplant were excluded. Factors associated with sustained virological response (SVR24) and relapse were analyzed by univariable and multivariable logistic regression as well as classification and regression trees. Fast virological response (FVR) was defined as undetectable HCV RNA at week-4 (telaprevir) or week-8 (boceprevir).RESULTSThe median age was 57 years, 18% were black, 44% had advanced fibrosis/cirrhosis (FIB-4 ≥ 3.25). Only 42% (94/223) of patients achieved SVR24 on an intention-to-treat basis. In a model that included platelets, SVR24 was associated with white race [odds ratio (OR) = 5.92, 95% confidence interval (CI): 2.34-14.96], HCV sub-genotype 1b (OR = 2.81, 95%CI: 1.45-5.44), platelet count (OR = 1.10, per x 104 cells/μL, 95%CI: 1.05-1.16), and IL28B CC genotype (OR = 3.54, 95%CI: 1.19-10.53). Platelet counts > 135 x 103/μL were the strongest predictor of SVR by classification and regression tree. Relapse occurred in 25% (27/104) of patients with an end-of-treatment response and was associated with non-FVR (OR = 4.77, 95%CI: 1.68-13.56), HCV sub-genotype 1a (OR = 5.20; 95%CI: 1.40-18.97), and FIB-4 ≥ 3.25 (OR = 2.77; 95%CI: 1.07-7.22).CONCLUSIONThe SVR rate was 42% with telaprevir- or boceprevir-based triple therapy in real-world practice. Low platelets and advanced fibrosis were associated with treatment failure and relapse.

Fistula-Associated Anorectal Cancer in the Setting of Crohn's Disease.

Cancer arising from perianal fistulas in patients with Crohn's disease is rare. There are only a small series of articles that describe sporadic cases of perianal cancer in Crohn's disease fistulas. Therefore, there are no clear guidelines on how to appropriately screen patients at risk and choose proper management. The purpose of this study was to describe patients diagnosed with cancer in perianal fistulas in the setting of Crohn's disease. The study involved an institutional review board-approved retrospective review of medical charts of patients with perianal Crohn's disease. The data extracted from patient charts included demographic and clinical characteristics. Patients seen at the Mount Sinai Medical Center were included. We identified patients who were diagnosed with perianal cancer in biopsies of fistula tracts. We observed the number of patients with Crohn's disease who had fistulas, cancer in fistula tract, and time to diagnosis. The charts of 2382 patients with fistulizing perianal Crohn's disease were reviewed. Cancer in a fistula tract was diagnosed in 19 (0.79%) of these patients, 9 with squamous-cell carcinoma and 10 with adenocarcinoma. The majority of the 19 patients (68%) had symptoms typical of perianal fistula. The mean time from diagnosis of Crohn's disease to fistula diagnosis and from fistula diagnosis to cancer diagnosis was 19.4 and 6.0 years. In 5 patients (26%), cancer was not diagnosed in the first biopsy obtained from the fistula tract. This is a retrospective chart review of a rare outcome; the results may not be generalizable. Routine biopsies of long-standing fistula tracts in patients with Crohn's disease should be strongly considered and may yield an earlier diagnosis of cancer in the fistula tracts.

Does D-dimer Reflect Acute Exacerbation in Interstitial Lung Disease?

SESSION TITLE: Evaluation and Treatment of ILD SESSION TYPE: Original Investigation Poster PRESENTED ON: Wednesday, October 26, 2016 at 01:30 PM - 02:30 PM PURPOSE: A prior study suggested activated intravascular coagulation disturbance occurs in acute exacerbation (AE) of idiopathic pulmonary fibrosis. Early recognition of patients with increased risk of developing AE or preclinical AE may be imperative. The aim of this study was to investigate whether abnormal serum D-dimer level (greater than or equal to 0.5 mcg/mL) can predict subsequent AE or recognize preclinical AE. METHODS: This was a single institution, retrospective study of routine D-dimer measurements in patients with interstitial lung disease (ILD) from October 2009 through September 2015 in the Advanced Lung/Interstitial Lung Disease Program at the Mount Sinai Medical Center. Subjects were aged over 18 years with idiopathic pulmonary fibrosis, the other idiopathic interstitial pneumonias, chronic hypersensitivity pneumonitis, ILD related to collagen-vascular disease, and combined pulmonary fibrosis/emphysema. The primary outcome measure was the development of AE within three months from each D-dimer measurement. The secondary outcome measures were respiratory-related hospitalization, all-cause hospitalization, venous thromboembolism (VTE), and all-cause mortality within three months. RESULTS: Nine hundred thirty nine patients were enrolled and 263 (mean age, 64.1; range, 22 to 91) with 374 D-dimer measurements (median, 0.44 mcg/mL) were included. There was a significant difference in the probability of developing AE between patients with abnormal serum D-dimer level and normal (10% vs. 1.5%, respectively; Odds Ratio [OR]: 7.88; p = 0.002, Generalized Equation Estimation, controlling for study ID, age, and gender). Patients with abnormal serum D-dimer level were at increased risk of respiratory related hospitalization, all-cause hospitalization, VTE, and all-cause mortality (OR: 5.12, 4.46, 21.47, and 11.67, respectively). The other predicting factors for AE were home oxygen therapy, increased serum LDH, decreased FVC, and decreased FEV1.0. CONCLUSIONS: Patients with abnormal serum D-dimer level are at increased risk of developing AE. CLINICAL IMPLICATIONS: Serum D-dimer may be used as a prognostic marker to predict AE or recognize preclinical AE. Anticoagulation for those with abnormal serum D-dimer level may be considered to prevent AE or improve the outcome from AE. DISCLOSURE: The following authors have nothing to disclose: Genta Ishikawa, Samuel Acquah, Mary Salvatore, Maria Padilla No Product/Research Disclosure Information

Unmet informational and supportive care needs of patients following cystectomy for bladder cancer based on age, sex, and treatment choices

PurposeAssessing the unmet needs of cancer patients can help providers tailor health care services to patients’ specific needs. This study examines whether the unmet informational and supportive care needs of the patients with muscle-invasive bladder cancer vary by the patients’ age, sex, or individual treatment choices. Methods and materialsParticipants (N = 30 survivors; 73.3% men) were recruited from the Mount Sinai Medical Center and through advertisements posted on a national Bladder Cancer Advocacy Network website between December 2011 and September 2012. Data were collected through individual interviews and electronic medical record review. A prior qualitative study of this cohort, using immersion/crystallization approach, confirmed the prevalence of unmet needs across the disease trajectory. This is a secondary quantitative analysis of the initial interview data we collected (i.e., quantitative analyses of transformed qualitative data using Chi-square and Fisher exact tests) to examine differences in unmet needs based on the patient’s age, sex, and treatment choices. ResultsYounger patients (<60y) were less satisfied with the treatment information received presurgery and more likely to report posttreatment complications, choose a neobladder, and seek and receive professional support regarding sexual function, than were older patients (P<0.05). More women than men reported difficulties with self-care and relied on themselves in disease self-management as opposed to relying on spousal support (P<0.05). Patients with neobladder were more likely to report difficulties with urinary incontinence and deterioration in sexual function, whereas patients with ileal conduit were more likely to require spousal help with self-care. Patients who received chemotherapy were significantly more likely to report changes in everyday life (P<0.05). Lastly, regardless of age, sex, or treatment choice, up to 50% of patients reported feeling depressed before or after treatment. ConclusionsUnmet informational and supportive needs of patients with muscle-invasive bladder cancer during survivorship, and vary by age, sex, and treatment choices. Educational and psychological assessments as well as clinical interventions should be tailored to a patient’s specific unmet needs, and to specific clinical and demographic characteristics.

Reducing Disparities in the LGBT Community.

Jayne Skehan, MSN, RN, is Director of Pediatric Cardiology at Morgan Stanley Children's Hospital at New York Presbyterian Hospital in New York City. In addition to this role, she is a per diem Administrator at Mount Sinai Medical Center in Harlem. Ms Skehan received her Bachelor of Science in Nursing degree from the College of New Rochelle, New York, and her Master of Science in Nursing degree from Mercy College, Dobbs Ferry, New York. Ms Skehan has experience in Emergency Room, Pediatric Cardiology, and Operating Room management. She is currently a DNP candidate at Saint Peter's University in Englewood Cliffs, NJ. When Ms Skehan is not doing school work, she is a community advocate, donating her time to food pantries and community services. Her goal is to teach nursing upon completion of her doctoral degree. Lynn S. Muller, JD, BA-HCM, RN, CCM, is Nurse Attorney, independent case manager, and managing partner of Muller & Muller. She is Adjunct Professor in the MSN and DNP programs at Saint Peter's University of New Jersey. Lynn is a registered nurse and certified case manager with extensive nursing and case management experience. Her law practice includes defense of health care professionals before the state licensing boards, consultant on such issues as regulatory compliance and accreditation, civil litigation, Wills, Trusts and Estates, and Family law. Dr Muller is the author of numerous articles and the legal chapters of the third edition of Case Management: A Practical Guide for Education and Practice and the second edition of the CMSA Core Curriculum for Case Management (as well as the third edition, expected to be released in 2016). Dr Muller is a contributor to the CMSA Career & Knowledge Pathways Project and Standards of Practice. She is as a former commissioner for CCMC, a past president of the NJ Chapter of CMSA. Address correspondence to Jayne Skehan, MSN, RN, 15 Hudson, Irvington, NY 10533 ([email protected]). Case Management (CM) Matters is your opportunity to have your voice heard. We welcome articles some, in a less formal format than other journal departments, stories, practice tips, reflections, and revelations. How has CM changed you? How have you affected the lives of others? First-time and seasoned authors are welcome. Inquiries, questions, comments, and manuscripts should be submitted via e-mail to: [email protected] or by mail to Lynn S. Muller, 15 West Main St, Suite C, P.O. Box 164, Bergenfield, NJ 07921-0164. Do you have an idea for an article but would like to discuss it, provide your contact information in an e-mail and you will be contacted by your preferred method. The author reports no conflicts of interest

Scoring System for the Management of Acute Gallstone Pancreatitis: Cost Analysis of a Prospective Study

Predicting the presence of a persistent common bile duct (CBD) stone is a difficult and expensive task. The aim of this study is to determine if a previously described protocol-based scoring system is a cost-effective strategy. The protocol includes all patients with gallstone pancreatitis and stratifies them based on laboratory values and imaging to high, medium, and low likelihood of persistent stones. The patient’s stratification then dictates the next course of management. A decision analytic model was developed to compare the costs for patients who followed the protocol versus those that did not. Clinical data model inputs were obtained from a prospective study conducted at The Mount Sinai Medical Center to validate the protocol from Oct 2009 to May 2013. The study included all patients presenting with gallstone pancreatitis regardless of disease severity. Seventy-three patients followed the proposed protocol and 32 did not. The protocol group cost an average of $14,962/patient and the non-protocol group cost $17,138/patient for procedural costs. Mean length of stay for protocol and non-protocol patients was 5.6 and 7.7 days, respectively. The proposed protocol is a cost-effective way to determine the course for patients with gallstone pancreatitis, reducing total procedural costs over 12 %.

Abstract No. 499 - Lymphatic malformation treatment in adult and pediatric populations using real-time MRI guided percutaneous sclerotherapy

No. 500 Transfemoral vs. transradial access: patient preference assessment using iPad technology J. Horn, A. Fischman, R. Patel, N. Tabori, E. Kim, F. Nowakowski, R. Lookstein; Icahn School of Medicine at Mount Sinai, New York, NY; Mount Sinai Medical Center, New York, NY; N/A, New York, NY; Mount Sinai Hospital, New York, NY Purpose: Transradial access (TRA) has been shown to be less costly, safer, and preferred by patients for coronary interventions as compared to transfemoral access (TFA). The purpose of this study was to determine differences in patient preference for access site during non-coronary arterial interventions using survey based iPad technology. Materials: From 1/2014 to 9/2015, retrospective review of all patients undergoing arterial interventions at a high volume academic medical center was performed. These patients were given a post-procedure survey (Surveymonkey.com) via a bedside iPad in the IR PACU. Surveys were available in English, Spanish and Mandarin. Questions related to pain at access site, preference for access site, procedure type and demographics was recorded. TRA and TFA procedures were all performed from the left wrist and right groin, respectively. Results: Survey respondents (n1⁄4126) (82% male) included the following procedures: TACE (n1⁄422, 23%), Y90 delivery (n1⁄434, 35%), and planning (n1⁄428, 29%), UFE (n1⁄48, 8%) and renal intervention (n1⁄46, 6%). Access sites included: TFA (n1⁄431, 25%) and TRA (n1⁄495, 75%). 67 patients reported having had both TRA and TFA in the past. Of those patients, 53/67 (79%) preferred TRA, 4/67 (6%) preferred TFA and 10/ 67 (15%) had no preference. Conclusions: Post-procedure survey data acquired via iPad is feasible in a PACU setting. A strong patient preference for TRA over TFA was noted in patients who had undergone both types of access.

Abstract P6-10-04: Factors determining underutilization of core biopsy prior to breast surgery

Abstract BACKGROUND: The American College of Surgeons National Accreditation Program for Breast Centers, Standard 2.9, requires a palpation-guided or image-guided needle biopsy as the initial diagnostic approach for breast cancer rather than an open biopsy. In replacing excisional biopsies, this minimally invasive technique demonstrates accuracy and precision in determining tumor characteristics and allows for more optimal breast cancer care. Recent studies have suggested that needle biopsy is underused in the United States. In a recently published analysis of U.S. Medicare data from 2003-2007, needle biopsy was used in 68.4% of all patients with breast cancer surgery. In this single-institution study, we analyzed the utilization of image-guided preoperative breast biopsies and which patient and system related factors contributed to the underutilization of image-guided breast biopsies and clinical outcomes. MATERIALS AND METHODS: In this retrospective study, we analyzed all breast cancer cases diagnosed over a four year period at Mount Sinai Medical Center (MSMC) from January 1, 2009 to December 31, 2013 (n=485). We performed a detailed chart review of the surgical cases that did not meet breast biopsy standards to identify contributing patient and surgeon level factors. Descriptive statistics and univariate analysis were used to characterize breast biopsy patterns and outcomes as well as delineate the associations between patient and surgical covariates with needle biopsy receipt. RESULTS: Needle biopsy was used in 86% (n=419) of all breast cancer surgeries. The median age for the cohort of patients without needle biopsy was 68.0 years (range 35-94). There was no significant variation in utilization of needle biopsy by race or surgeon. The proportion of patients without needle biopsy decreased significantly over time from 2009-2013. The most common reason for the lack of preoperative breast biopsy was the surgeon's preference to proceed with surgery because of very suspicious imaging studies (including mammograms and MRI) (n=9). There were an additional nine cases where the biopsy was attempted but was non-diagnostic. The most common patient-related factors for lack of needle biopsy were advanced age, use of anticoagulation and noncompliance due to a psychiatric diagnosis and patient discomfort. Other factors identified include lack of surgeon consultation before biopsy, biopsy of axillary lymph nodes as a means of diagnosis and patient's inpatient status. CONCLUSIONS: In this single institution, the rate of needle biopsy for breast cancer diagnosis was above national benchmarks. The most common reason for lack of a preoperative breast biopsy was the surgeon's preference to proceed with surgery because of very suspicious imaging studies. Patients with advanced age, psychiatric history, and inpatient workup were also more likely to lack a preoperative breast biopsy. Citation Format: Fan T, Paramo J, Mesko T, Poppiti R, Ruiz A, Rodriguez E. Factors determining underutilization of core biopsy prior to breast surgery. [abstract]. In: Proceedings of the Thirty-Eighth Annual CTRC-AACR San Antonio Breast Cancer Symposium: 2015 Dec 8-12; San Antonio, TX. Philadelphia (PA): AACR; Cancer Res 2016;76(4 Suppl):Abstract nr P6-10-04.

Laparoscopic antrectomy: a safe and definitive treatment in managing type 1 gastric carcinoids

BackgroundTreatment for type 1 gastric carcinoid (T1GC) includes esophagogastroduodenoscopy (EGD), polypectomy, and antrectomy, but few studies compare outcomes. This study assessed risk-benefit ratio to determine the most effective treatment for T1GC. MethodsA retrospective review of 52 T1GC patients (ages 30 to 88 years; 77% female) presenting to Mount Sinai Medical Center between 2004 and 2012 was conducted. Patient demographics, procedures, and outcomes were reviewed, and patient satisfaction was assessed using a phone-administered validated questionnaire. Data were analyzed using SPSS version 20 software. ResultsAverage EGDs needed per follow-up year was significantly lower for antrectomy than polypectomy or EGD surveillance (.395 vs 1.038 vs 1.380, P = .002). Antrectomy patients exhibited decreased recurrence risk than polypectomy patients (11% vs 44%, P = .049), despite longer follow-up time (6.10 vs 4.39 years, P = .023). ConclusionsAntrectomy treats T1GC with lower recurrence risk and less postintervention monitoring, whereas allowing patients to avoid the discomfort of repeated EGD surveillance and anxiety over a lingering condition.

Impact of inpatient radiation on length of stay and health care costs.

Health care costs are rising. Identifying areas for health care utilization savings may reduce costs. To identify oncology patients receiving inpatient radiotherapy with the purpose of measuring length of stay (LoS) and hospital charges. During July 2013 the oncology service physicians at Mount Sinai Medical Center in New York City were surveyed daily to identify patients receiving inpatient radiation. Actual LoS, acuity LoS were determined from the chart review. Expected LoS was calculated using the University Healthsystem Consortium database. Charges associated with actual LoS, acuity LoS, and expected LoS were then reported. Actual and expected LoS were compared for inpatient radiotherapy and nonradiotherapy groups. 7 patients were identified as having remained in the hospital to receive radiation treatment. In that cohort, the average actual LoS and charges per patient were 40.1 and $48,724, compared with acuity LoS and charges of 25.6 days and $34,089 and expected LoS and charges of 7.7 days and $10,028. Mean LoS and charges attributed to radiation alone amounted to 11 days and $12,514. The mean actual LoS of oncology patients admitted during the same time period who did not receive radiation was 6.7 days, compared with 40.1 days for patients who received radiation (𝑃 < .0001). Inability to access actual reimbursement data prevented exact cost calculations, small sample size, and single-institution focus. Delivery of radiation therapy during inpatient hospitalization extends LoS and contributes to higher health care costs. Methods to facilitate the delivery of outpatient radiotherapy may result in cost savings.

The Patient With Probable Obstructive Sleep Apnea Who Needs Postoperative Pain Relief

Dr. Dr. Frost is Professor of Anesthesiology, Icahn School of Medicine at Mount Sinai, Mount Sinai Medical Center, KCC 8th Floor, One Gustave L. Levy Place, Box 1010, New York, NY 10029; E-mail: [email protected]. The author and all staff in a position to control the content of this CME activity have disclosed that they and their spouses/life partners (if any) have no financial relationships with, or financial interests in, any commercial companies pertaining to this educational activity. Lippincott Continuing Medical Education Institute, Inc., is accredited by the Accreditation Council for Continuing Medical Education to provide continuing medical education for physicians. Lippincott Continuing Medical Education Institute, Inc., designates this enduring material for a maximum of 1.5 AMA PRA Category 1 Credits™. Physicians should only claim credit commensurate with the extent of their participation in the activity. To earn CME credit, you must read the CME article and complete the quiz and evaluation assessment survey on the enclosed form, answering at least 70% of the quiz questions correctly. This activity expires on October 31, 2016.