Parkland Memorial Hospital Research Articles

A validated NICU database: recounting 50 years of clinical growth, quality improvement and research.

The importance of a Neonatal Intensive Care Unit (NICU) database lies in its critical role in improving the quality of care for very preterm neonates and other high-risk newborns. These databases contain extensive information regarding maternal exposures, pregnancy complications, and neonatal care. They support quality improvement (QI) initiatives, facilitate clinical research, and track health outcomes in order to identify best practices and improve clinical guidelines. The Parkland Memorial Hospital NICU database was originally part of the Maternal and Neonatal Data Acquisition, Transmission and Evaluation project funded by the Robert Wood Johnson Foundation to assess perinatal-neonatal care in Dallas County Texas, 1977-1982. Clinical data points were defined, transcribed and validated in 1977; revalidation has occurred multiple times. Data are prospectively extracted from health records of high-risk neonates among >11,000 births annually. The database contains clinical information on >50,000 neonates, including all initially admitted to the NICU regardless of gestational age or birthweight and since 10/03/2011, all neonates admitted for observation and transferred to the term newborn nursery. The database has provided the basis for QI studies and research designed to assess and improve neonatal care. We discuss the history, evolution, administration, impact on neonatal outcomes, and future directions of our database. IMPACT: A single neonatal intensive care unit (NICU) database was designed for prospective data collection, validated and maintained for 46yrs. This database has supported quality improvement assessment, original clinical research, education and administrative requirements and impacted clinical neonatal care.

Geographic Accessibility and Completion of Initial Low-Dose CT-Based Lung Cancer Screening in an Urban Safety-Net Population.

Recent modifications to low-dose CT (LDCT)-based lung cancer screening guidelines increase the number of eligible individuals, particularly among racial and ethnic minorities. Because these populations disproportionately live in metropolitan areas, we analyzed the association between travel time and initial LDCT completion within an integrated, urban safety-net health care system. Using Esri's StreetMap Premium, OpenStreetMap, and the r5r package in R, we determined projected private vehicle and public transportation travel times between patient residence and the screening facility for LDCT ordered in March 2017 through December 2022 at Parkland Memorial Hospital in Dallas, Texas. We characterized associations between travel time and LDCT completion in univariable and multivariable analyses. We tested these associations in a simulation of 10,000 permutations of private vehicle and public transportation distribution. A total of 2,287 patients were included in the analysis, of whom 1,553 (68%) completed the initial ordered LDCT. Mean age was 63 years, and 73% were underrepresented minorities. Median travel time from patient residence to the LDCT screening facility was 17 minutes by private vehicle and 67 minutes by public transportation. There was a small difference in travel time to the LDCT screening facility by public transportation for patients who completed LDCT versus those who did not (67 vs 66 min, respectively; P=.04) but no difference in travel time by private vehicle for these patients (17 min for both; P=.67). In multivariable analysis, LDCT completion was not associated with projected travel time to the LDCT facility by private vehicle (odds ratio, 1.01; 95% CI, 0.82-1.25) or public transportation (odds ratio, 1.14; 95% CI, 0.89-1.44). Similar results were noted across travel-type permutations. Black individuals were 29% less likely to complete LDCT screening compared with White individuals. In an urban population comprising predominantly underrepresented minorities, projected travel time is not associated with initial LDCT completion in an integrated health care system. Other reasons for differences in LDCT completion warrant investigation.

Outcomes of Trainee-performed MIGS at Parkland Memorial Hospital: A Retrospective Cohort Study.

As the use of minimally invasive or microinvasive glaucoma surgery (MIGS) continues to expand, it is important to look at its outcomes in the hands of trainees. This study aims to examine the efficacy and safety of Kahook Dual Blade (KDB) goniotomy and endocyclophotocoagulation (ECP) with cataract extraction (CE) done by residents and fellows. All cases of KDB or ECP performed with CE between 2012 and 2020 at Parkland were reviewed, excluding cases with multiple MIGS procedures or other procedures. A total of 153 eyes of 136 patients who underwent KDB and 125 eyes of 124 patients who underwent ECP were included. Mean intraocular pressure (IOP) decreased from 17.2 ± 5.2 at baseline to 15.4 ± 5.5 mm Hg at postoperative (post-op) month (POM) 12 in the KDB group (p = 0.02) and from 18.6 ± 6.3 at baseline to 15.1 ± 4.9 mm Hg at POM12 in the ECP group (p < 0.001), with wide variation in IOP change among subjects for both. The mean change in IOP across all time points was statistically significant for both groups. Medication counts were reduced from baseline at POMs 1, 3, and 6, but not 12, in both the KDB and ECP groups (p = 0.43 and p = 0.35, respectively). The rate of serious complications was very low; the most common complication was cystoid macular edema (CME) (six cases) and active inflammation beyond POM1 (15 cases) for KDB and ECP, respectively. Combined CE/MIGS procedures performed by trainees were safe but less efficacious in lowering IOP and medications compared to literature reporting outcomes of attending surgeons, apart from ECP/MIGS with regards to IOP lowering, which was found to be similarly efficacious. Cataract extraction (CE) combined with KDB or ECP in the hands of trainees decreased mean IOP from baseline and was safe. IOP and medication reduction of MIGS/CE in the hands of trainees were overall lesser than reported values by attending surgeons. Da J, Gillings M, Kamat S, et al. Outcomes of Trainee-performed MIGS at Parkland Memorial Hospital: A Retrospective Cohort Study. J Curr Glaucoma Pract 2023;17(3):134-140.

Abstract WP101: Vessel Wall Enhancement Is Associated With Symptomatic Adult Moyamoya Disease And Syndrome In An American Population

Introduction: Moyamoya Disease (MMD) and Moyamoya Syndrome (MMS) are chronic progressive cerebrovascular disease characterized by bilateral or unilateral stenotic arteries around the circle of Willis with subsequent development of collateral blood vessels. MMS is associated with conditions such as Down Syndrome (DS) or sickle cell disease (SCD). The presence of vessel wall enhancement (VWE) on high resolution magnetic resonance vessel wall imaging (HR MR VWI) in MMD or MMS is controversial. Recent studies suggest VWE is associated with recent ischemic or hemorrhagic stroke. The significance of VWE in MMD or MMS in non-Asian population has not been well established. Our study aimed to investigate the prevalence of VWE in adult MMD/MMS in the United States and identify its predictive value for stenosis progression. Methods: We retrospectively reviewed patients with MMD or MMS admitted to Clements University Hospital and Parkland Memorial Hospital affiliated with University of Texas Southwestern Medical Center from January 2014 to March 2022. Patients were included if HR MR VWI was performed during workup. Patients were excluded if intracranial atherosclerosis was the suspected stroke etiology from cardiovascular risk factors. The presence of the VWE on HR MR VWI and stenosis grading were evaluated by blinded neuroradiologists and vascular neurologists. Symptomatic disease was defined as ischemic stroke, hemorrhagic stroke or transient ischemic attack within 24 months before HR MR VWI was obtained. Results: A total of 32 patients were included, of which 28 had MMD, 3 had MMS from SCD and 1 had MMS from DS. Mean age at diagnosis was 34 ± 10 years old, and 29 (90.6%) were female. VWE was seen in 22 (68.8%) patients. VWE is more common in symptomatic disease than asymptomatic disease (95% vs 20%). 24 patients had follow up MR angiogram with average time from HR MR VWI of 25.8 ± 16.7 months. Among 12 patients with 16 non-occlusive arteries, stenosis progression was seen in 67% of arteries with VWE compared to 25% of arteries without VWE. Conclusions: In a North American population with MMD or MMS, VWE on HR MR VWI was more common in symptomatic disease. The presence of VWE was associated with increased risk of stenosis progression. More studies are needed to confirm these findings.

Consumption of Pro Re Nata Inpatient Opioids Following Surgical Treatment of Severe Odontogenic Infections

<h3>Purpose</h3> The purpose of this study was to analyze the pro re nata (PRN) opioid consumption of patients with severe odontogenic infections following operating room incision and drainage using odontogenic infection severity scores. The null hypothesis was that no statistically significant difference in post-operative inpatient PRN opioid consumption exists between patients with infections of higher severity score and lower severity score. <h3>Methods</h3> This retrospective study reviewed consecutive charts of all patients admitted for severe odontogenic infections to the UTSW and Parkland Memorial hospital from January 2016 to December 2020. All patients admitted for greater than one hospital day and treated with surgical incision and drainage in the operating room with an American Society of Anesthesiologists (ASA) physical classification score of 1 or 2 as ranked by the anesthesia team prior to surgery were included. Patients with chronic pain conditions, history of substance abuse, or infections of non-odontogenic origin were excluded. Patients that required advanced airway post-surgery and intensive care unit stay or multiple operations were also excluded. Post-operative opioid doses were tabulated from the time the patient arrived on the floor as inpatient post-surgery until discharge using equianalgesic opioid tables and published conversion factors (1,2). Severity scores were assigned based on the risk to the airway and vital structures as described by Flynn et al (3). Patients with a severity score greater than or equal to five were designated as group A and less than five group B. The primary predictor variable was severity score, and the primary outcome variable was the amount of milligram morphine equivalents (MME) administered. Comparisons between Group A and Group B were conducted for age, ASA classification, hospital duration, severity score, and MME using t-tests. Values of p < 0.05 were considered statistically significant. <h3>Results</h3> A total of 93 subjects met the inclusion criteria. Group A included 40 subjects and group B included 53 subjects. The average age of subjects in group A was 38.28 years (SD=10.92), and in group B 38.03 years (SD=12.53). There was no significant difference between the groups in age (p = 0.93). The average hospital duration for patients in group A was 3.85 days (SD=1.17). Group B had an average hospital duration of 3.72 days (SD=1.08). There was no significant difference between the groups in hospital duration (p = 0.57). Group A consumed an average MME of 39.85, while group B consumed an average of 23.43. Group A consumed a significantly greater amount of PRN post-operative inpatient opioid medications (p = 0.02). <h3>Conclusion</h3> Patients with higher odontogenic infection severity scores consumed more post-operative PRN opioid analgesic medications. Given that odontogenic infections are largely preventable, it is imperative to prevent the progression of odontogenic infections to limit patient exposure to opioid medication.

Little Utility of Fungal Blood Cultures in Surgical and Burn Intensive Care Units.

ABSTRACTCritically ill patients are at risk for fungal infections, but there is a paucity of data regarding the clinical utility of dedicated fungal blood cultures to detect such infections. A retrospective review was conducted of patients admitted to the surgical and burn intensive care units at Parkland Memorial Hospital between 1 January 2013 and 31 December 2017 for whom blood cultures (aerobic, anaerobic, and/or fungal cultures) were sent. A total of 1,094 aerobic and anaerobic blood culture sets and 523 fungal blood cultures were sent. Of the aerobic and anaerobic culture sets, 42/1,094 (3.8%) were positive for fungal growth. All fungal species cultured were Candida. Of the fungal blood cultures, 4/523 (0.76%) were positive for growth. Fungal species isolated included Candida albicans, Aspergillus fumigatus, and Histoplasma capsulatum. All 4 patients with positive fungal blood cultures were on empirical antifungal therapy prior to results, and the antifungal regimen was changed for 1 patient based on culture data. The average duration to final fungal culture result was 46 days, while the time to preliminary results varied dramatically. Two of the four patients died prior to fungal culture results, thereby rendering the culture data inconsequential in patient care decisions. This study demonstrates that regular aerobic and anaerobic blood cultures sets are sufficient in detecting the most common causes of fungemia and that results from fungal cultures rarely impact treatment management decisions in patients in surgical and burn intensive care units. There is little clinical utility to routine fungal cultures in this patient population.IMPORTANCE This study demonstrates that regular aerobic and anaerobic blood culture sets are sufficient in detecting the most common causes of fungemia, and thus, sending fungal blood cultures for patients in surgical and burn intensive care units is not a good use of resources.

Disparities in pegasparagase-induced toxicity in Hispanic patients with acute lymphoblastic leukemia.

e18590 Background: Hispanic individuals experience the highest incidence of acute lymphoblastic leukemia of any racial or ethnic group in the United States. While Hispanic individuals are known to have disproportionately increased mortality and higher therapy-related toxicity rates in ALL, there is a paucity of data regarding ethnic differences in rates of toxicity related to pegasparagase, a backbone of ALL treatment regimens. In our safety-net hospital system, we sought to evaluate disparities in rates of pegasparagase-induced hepatotoxicity between Hispanic and non-Hispanic patients. Methods: Pegasparagase infusions administered in adult ALL patients from 2011-2020 at Parkland Memorial Hospital in Dallas, Texas, were identified using the electronic medical record. Retrospective review of demographic, clinical, and socioeconomic data was conducted. For each infusion, dosing, timing, transaminase trends, and toxicity data were gathered. Statistical analysis was completed with Excel Analysis ToolPak and R Statistical Software. Accounting for baseline characteristics (age, BMI, sex, metabolic comorbidities, and baseline hepatic function), multiple linear regression models were constructed for peak transaminase and bilirubin levels. ANOVA testing, adjusted R2 values, and AIC were utilized to compare the contribution of race, ethnicity, and socioeconomic variables to modeling. Results: 47 individual patients received pegasparagase during the study period with 196 infusions evaluated. The mean age was 30 years, 29% were female and 73.4% white Hispanic. There were 64 grade 3-4 pegasparagase-related toxicities (54 hepatotoxicity, 4 pancreatitis, 6 thrombosis). 83.3% of grade 3-4 hepatotoxicity events were in Hispanic patients, and 16.7% in non-Hispanics. The median time from infusion to grade 3-4 toxicity was 18 days. Hispanic ethnicity was significantly associated with severe hepatoxicity (P = 0.0004). An interaction was identified with insurance status and primary language which significantly strengthened the impact of ethnicity and race on hepatotoxicity severity (P = 0.005, P = 0.02). Conclusions: In our safety-net population, Hispanic ethnicity was associated with significantly higher grades of hepatotoxicity when compared to non-Hispanic patients. Uninsured status and primary Spanish language use were not only independently associated with increased toxicity but also strengthened the effect of Hispanic ethnicity on the severity of liver dysfunction related to pegasparagase. These findings propose that Hispanic patients may benefit from closer monitoring during treatment with pegasparagase-containing regimens and highlight the need for further studies to improve risk-stratification of Hispanic patients when selecting ALL therapy.

Mass Production of Compassionate Communication in the Era of COVID-19: A How-To Guide from Parkland Hospital's COVID ICU Team (TH105)

Outcomes 1. Describe and analyze a blueprint for rapid upscaling of inpatient palliative care services in the ICU, both in the context of normal operations and in the context of mass casualties, natural disasters, pandemics, and other events 2. Describe the natural history, prognosis, morbidity, and mortality associated with acute respiratory distress syndrome due to COVID-19 3. Review and simulate use of novel communication tools and scripts for communication with families of critically ill patientsIn March 2020, Parkland Memorial Hospital, Dallas County's safety net hospital and one of the busiest hospitals in the nation, opened its Tactical Care Unit, a surgical space converted into a 100-bed unit for patients suffering from the novel and rapidly spreading COVID-19. At the outset of the pandemic, the team committed to expanding access to specialty-level palliative care and maintaining a pipeline of high-quality daily communication for all families of critically ill patients admitted to the COVID ICU. In this session, members of the multispecialty and multidisciplinary Parkland COVID ICU team will present a blueprint for the novel care model that allowed them to meet these goals, even in the midst of massive surges in the summer and winter. The following components of this care model will be reviewed in detail: a clearly defined structure for efficient co-management and co-rounding between palliative care and critical care specialists; the use of volunteer communication extenders; detailed data analysis regarding natural history, prognosis, morbidity, and mortality associated with acute respiratory distress syndrome due to COVID-19; and the generation of standardized, data-driven communication tools and scripts for daily conversations with families of critically ill patients. Attendees will receive copies of said communication tools and scripts, and we will conduct case-based simulations in small groups. Afterwards, we will review lessons learned and outcomes, answer questions, and review the ways in which the strategies and tools described above are being applied in our hospital outside the context of the COVID-19 pandemic.

James F. Thornton, MD.

I want to thank Dr. James F. Thornton for serving as our guest editor for this edition of Seminars in Plastic Surgery and additional authors for their contributions to this very important issue on “Biologic Agents in Plastic Surgery.” James F. Thornton, MD, is a professor in the Department of Plastic Surgery at the University of Texas Southwestern Medical Center in Dallas. Dr. Thornton attended UT Southwestern for his medical degree and did his surgery internship from Parkland Memorial Hospital in Dallas. Dr. Thornton served 3 years as a United States Navy Flight Surgeon in Kaneohe, Hawaii.

Neutrophil Extracellular Trap Formation Potential Correlates with Lung Disease Severity in COVID-19 Patients.

Severe lung inflammation is common in life-threatening coronavirus disease 2019 (COVID-19). This study tested the hypothesis that polymorphonuclear (PMN, neutrophil) phenotype early in the course of disease progression would predict peak lung disease severity in patients infected with severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2). It is increasingly evident that PMN activation contributes to tissue injury resulting from extracellular reactive oxygen species generation, granule exocytosis with release of proteases, neutrophil extracellular trap (NET) formation, and release of cytokines. The current study focuses on PMN activation in response to SARS-CoV-2 infection, specifically, the association between NETs and lung disease. This is a prospective cohort study at an academic medical center with patients enrolled within 4 days of admission at 3 tertiary hospitals: Clements University Hospital, Parkland Memorial Hospital, and Children’s Health in Dallas, TX. Patients were categorized as having minimal or moderate to severe lung disease based on peak respiratory support. Healthy donor controls matched for age, sex, race, and ethnicity were also enrolled. Neutrophils from COVID-19 patients displayed greater IL-8 expression, elastase release, and NET formation as compared with neutrophils from healthy donors. Importantly, neutrophils from COVID-19 patients had enhanced NET formation in the absence of any additional stimulus, not seen in PMN from healthy donors. Moreover, PMA-elicited NET formation by circulating PMN correlated with severity of lung disease. We speculate that neutrophil immuno-phenotyping can be used to predict lung disease severity in COVID-19 patients.SUPPLEMENTARY INFORMATIONThe online version contains supplementary material available at 10.1007/s10753-021-01585-x.

Is the Low and Short Medial Horizontal Osteotomy a Predictive Factor for Postoperative Hypoesthesia in Sagittal Split Osteotomies?

Statement of the problemThe purpose of this study is to determine whether a low and short medial horizontal osteotomy is a predictive factor for determining neurosensory outcomes of the inferior alveolar nerve in non-syndromic patients undergoing sagittal split osteotomies for dentofacial disorders. Materials and methodsA retrospective cohort analysis was conducted on subjects who received orthognathic surgery from 2017 to 2019 at Parkland Memorial Hospital. Inclusion criteria were a traditional osteotomy defined by Hunsck and Epker, or a low and short osteotomy, defined by Posnick.1,2 Exclusion criteria were the diagnosis of a syndromic condition, repeat surgery, or concomitant temporomandibular joint surgery. The predictor variable was the type of osteotomy performed, defined as either a low and short or traditional osteotomy. The primary outcome variable was neurosensory testing at the pre-operative visit and at the 6-week postoperative visit utilizing the NST criteria elucidated by Zuniga et al.3 Neurosensory outcomes were scored in the following manner: passing NST-A, NST-B, and NST-C were assigned scores of 1, 2, and 3, respectively. Failing NST-C was assigned a score of 4. These outcomes were used to measure the incidence of full sensory recovery (FSR), which was defined as postoperative NST testing that returned to the patient's pre-operative baseline (NST-A). Descriptive, bivariate, and multiple logistic regression analyses were performed with P < .05 used to determine statistical significance. ResultsTwenty-nine patients met the defined inclusion criteria. The average age at the time of surgery was 23 years old. The cohort consisted of 13 males and 16 females. Nineteen patients were treated with bilateral low and short osteotomies, and 10 patients were treated with bilateral traditional osteotomies. The mean NST outcome for all pre-operative visits in both cohorts passed was 1 bilaterally. The mean NST outcome for the low and short osteotomy cohort at 6-week postoperative visit was 1.26 and 1.42 on the right and left, respectively. The mean NST outcome for the traditional osteotomy cohort was 1.2 and 1.4 on the right and left, respectively. There were no significant differences between the type of osteotomy performed and the mean pre-operative neurosensory outcome on the left (P = 1) or right (P = 1). Furthermore, there was no significant difference between the type of osteotomy performed and the mean 6-week postoperative neurosensory outcome on the left (P = .7176) or right (P = .9265). FSR was achieved in low and short osteotomy cohort in 73.68% of patients on the right and 57.89% of patients on the left. Failure to achieve FSR at the 6-week follow-up was observed in both the right (P = .0207) and left (P =.0020) sides for the low and short cohort, which was statistically significant. FSR was achieved in the traditional osteotomy cohort in 80% of patients on the right and 70% of patients on the left. Failure to achieve FSR in the traditional osteotomy group was not significant on the right (P = .1679) or left (P = .1039) side. ConclusionThe occurrence of hypoesthesia after traditional bilateral sagittal split osteotomy has been reported to range from 7.3-52%.4 To the author's knowledge, no study to date has examined the incidence of hypoesthesia after the low and short osteotomy. The results of the present study suggest the low and short osteotomy is associated with a greater duration of postoperative hypesthesia compared to the traditional osteotomy at the 6-week mark.

Is the Low and Short Medial Horizontal Osteotomy a Predictive Factor for Bad Splits in Sagittal Split Osteotomies?

Statement of the problemThe purpose of this study is to determine whether a low and short medial horizontal osteotomy is a predictive factor for determining bad splits in non-syndromic patients undergoing sagittal split osteotomies for dentofacial disorders. Materials and methodsA retrospective cohort analysis was conducted on subjects who received orthognathic surgery from 2017 to 2019 at Parkland Memorial Hospital. Inclusion criteria were a traditional osteotomy defined by Hunsck and Epker or a low and short osteotomy defined by Posnick.1,2 Exclusion criteria were the diagnosis of a syndromic condition, repeat surgery, or concomitant temporomandibular joint surgery. The predictor variable was the type of osteotomy performed, defined as either a low and short or traditional osteotomy. The primary outcome variable was the occurrence of a bad split. Secondary predictor variables were age and sex, defined as male or female, and faculty side (right side) versus resident side (left side). Descriptive, bivariate, and multiple logistic regression analyses were performed with P < .05 used to determine statistical significance. Results and outcomesFifty-nine patients met the defined inclusion criteria. The average age at the time of surgery was 21 years old. The cohort consisted of 27 males and 32 females. Thirty-six patients were treated with bilateral low and short osteotomies, and 23 patients were treated with bilateral traditional osteotomies. Of the 118 total osteotomies performed, there were a total of 9 bad splits (7.6%). There were 3 right-side bad splits and 6 left-side bad splits. The occurrence of a right-side bad split was 3 for the low and short group and 0 for the traditional group. The occurrence of a left-side bad split was 4 for the low and short group and 2 for the traditional group. There were no significant differences between the type of osteotomy performed and the occurrence of a right-side bad split (P = .1607) or a left-side bad split (P = .7695). There was no significant difference between sex and occurrence of a right-side bad split (P = .6640) or a left-side bad split (P = .2862). There was no significant difference between age and occurrence of a right-side bad split (P = .5233) or a left-side bad split (P = .4492). There was no significant difference between faculty side and resident side with regards to bad splits (P = .4903). Discussion and conclusionThe sagittal split osteotomy (SSO) was first reported by Trauner and Obwegeser in 1955, with the horizontal medial osteotomy further modified by Hunsuck to terminate superior and posterior to lingula.1 Posnick developed an additional modification of the SSO to reduce the frequency of unfavorable splits toward the condyle by modifying the medial horizontal osteotomy to terminate below lingula at the level of the mandibular occlusal plane (low) and anterior to lingula (short).2 The occurrence of bad splits using the traditional osteotomy ranges from 1% to 23%, while the incidence of bad splits reported by Posnick in his retrospective analysis was 0%. The results of the present study suggest a low and short osteotomy is at least as reliable as the traditional osteotomy with regards to intraoperative bad splits. Future prospective studies, including split-mouth study designs by this group, will further elucidate the low and short osteotomy as a reliable alternative to the traditional osteotomy.1.The low medial horizontal osteotomy in patients with atypical ramus morphology undergoing sagittal split osteotomy2.Occurrence of a ‘bad’ split and success of initial mandibular healing: a review of 524 sagittal ramus osteotomies in 262 patients

A quality improvement initiative to increase screening for financial coverage for breast cancer patients to decrease financial toxicity.

259 Background: In April 2021, it was found that 35% of our breast cancer patients seen in the breast surgery and medical oncology clinics had no financial coverage leading to significant financial toxicity at Parkland Memorial Hospital, a safety net hospital for Dallas county in Texas. In addition, only 8% of all our breast cancer patients were financially screened in April 2021. We aimed to increase pre-visit phone calls to financially screen patients within a week of their subsequent visit with a provider from a baseline rate of 8% to 20% for all breast cancer patients in hopes of capturing more unfunded patients and providing appropriate resources. Methods: We used the Institute for Health Improvement (IHI) model as our quality improvement framework. Based on our fish bone and pareto chart analysis, it was discovered that the lack of consistent financial screening was likely due to lack of standardized training across our ancillary staff, lack of standardized processes for financial screening, and lack of education of both providers and patients regarding the financial coverage process. To address these issues, we created a standardized process of financial screening called “pre-visit planning (PVP)” involving a telephone call by our schedulers to breast oncology patients within 1 week of their next visit. Screening included checking financial application status and educating patients on methods of application submission including epic my-chart enrollment. Screening also included checking financial coverage status and if unfunded, a referral to a financial counselor was made. Formal training of staff was performed with mock trial phone calls. We initiated implementation in the breast surgery clinic initially with plans to expand to the medical oncology clinic. Results: At baseline, in April 2021, 300 patients were seen in the breast surgery clinic of which 19 were financially screened (6.3%). Implementation of PVP for all patients in the breast surgery clinic began in May 2021 with data representing 2 weeks of financial screening by our staff. Total number of patients seen over the span of 2 weeks in the breast surgery clinic was 165 of which 59 were financially screened making up 36% of patients. In addition, 8 patients in the breast surgery clinic were screened by a financial counselor increasing the rate of financial screening to 40.6%. Conclusions: We successfully implemented PVP to better assist our patients in several ways including updating their financial coverage, educating them on the financial process, as well as referring them to a financial counselor for additional aid. Increased follow up time is needed to assess the downstream effects of PVP such as increase in financial counselor visits and decrease in unfunded patients.

Intraoperative Inferior Alveolar Nerve Location following Low Medial Horizontal Sagittal Split Osteotomy

PurposeThe purpose of this study is to evaluate the intraoperative location of the inferior alveolar nerve (IAN) after completion of a sagittal split osteotomy using a low medial horizontal (low and short) sagittal split osteotomy. MethodsThe authors designed and implemented a retrospective cohort study of patients who received orthognathic surgery from 2017 to 2019 at Parkland Memorial Hospital. Inclusion criteria was a traditional osteotomy defined by Hunsuck and Epker1,2 or a low and short osteotomy defined by Posnick.3 Exclusion criteria were the diagnosis of a syndromic condition, repeat surgery, or concomitant temporomandibular joint surgery. The predictive variable was the type of osteotomy performed, defined as either a low and short or traditional osteotomy. The primary outcome variable was the location of the IAN in either the proximal or distal segment, following completion of split. Statistical analysis was performed with P < .05 used to determine statistical significance. ResultsFifty-one patients met the defined inclusion and exclusion criteria. The average age at the time of surgery was 21 years. The cohort consisted of 26 males and 25 females. Thirty-six patients were treated with bilateral low and short osteotomies, and 15 patients were treated with bilateral traditional osteotomies. Of the 36 low and short osteotomies on the right side, 11 were located in the distal segment (30.5%) and 25 in the proximal (69.5%). Of 36 low and short osteotomies on the left side, 12 were located in the distal segment (33%) and 24 in the proximal (66%). Of the traditional osteotomies on the right side, 8 were located in the distal segment (53%) and 7 in the proximal (46%). Of 15 traditional osteotomies on the left side, 8 were located in the distal segment (53%) and 7 in the proximal (46%) There was no significant difference between the osteotomy performed and the location of the IAN on the right side (P = .1304) or the left side (P = .1897). DiscussionThere have been many modifications to the sagittal split osteotomy since the initial description by Trauner and Obwegeser in 1955. With each modification, the medial horizontal osteotomy has consistently remained superior to the lingula of the ramus. The more recent modification developed by Posnick places the medial horizontal osteotomy below and anterior to the lingula.3 With this modification, it makes anatomic sense that the IAN would be contained within the proximal segment. When the IAN is located within the proximal segment following traditional sagittal osteotomy, it is often teased out in an effort to prevent excessive stretching and damage to the nerve or limitation in the movement of the distal segment. The results of this present study show there is no significant difference in intraoperative nerve location after sagittal split when comparing the low and short osteotomy to the traditional osteotomy. Further prospective studies, including nerve testing following low and short osteotomy with the IAN located within the proximal segment, will further elucidate the low and short osteotomy as a viable alternative to the traditional osteotomy.

Does Liposomal Bupivicaine Injection Decrease Postoperative Opioid Usage following Bimaxillary Surgery?

PurposeAmong patients undergoing bimaxillary surgery, does the use of liposomal bupivacaine injection reduce the use of opioid analgesics and/or length of hospital admission in the postoperative period? MethodsA retrospective cohort analysis was conducted on subjects who received orthognathic surgery from 2017 to 2019 at Parkland Memorial Hospital. Inclusion criteria were a maxillary Le Fort I procedure and simultaneous bilateral sagittal split osteotomy. Exclusion criteria were a syndromic condition, repeat surgery, concomitant genioplasty or temporomandibular joint surgery, or single-jaw surgery. The predictor variable was the administration of a standard dosage of 266mg (20mL) of liposomal bupivacaine distributed equally among all 4 surgical sites. The primary outcome variable was the total milligram morphine equivalent (MME) of opioids administered to the subject in the immediate postoperative period. Secondary predictor variables were postoperative hospital stay length, defined in days, age, and sex, defined as male or female. Statistical analysis was performed with P < .05 used to determine statistical significance. ResultsNineteen patients met the defined inclusion criteria. The age at the time of surgery ranged from 17 to 51, with the average age being 26 years old. The cohort consisted of 8 males and 11 females. Ten subjects received an injection of 266mg of liposomal bupivacaine, divided equally among all 4 surgical sites (2 maxillary and 2 mandibular) at the completion of surgery, and 9 subjects received no liposomal bupivacaine.Postoperatively, subjects received varying combinations of PRN opioids, including: codeine, hydrocodone, oxycodone, fentanyl, and hydromorphone. MME for each of these medications was then calculated. Patients in the group who received a liposomal bupivacaine injection required a mean of 9.3 MME during their postoperative course, while the group who did not receive liposomal bupivacaine required a mean of 25 MME. Statistical analysis revealed a significant difference in MME usage between the 2 groups (P =.0243). The average postoperative hospital admission duration was 1.32 days, with no significant difference between the 2 study groups (P = .884). There was no significant difference between sex or age and postoperative MME usage (P = .566 and P = .381, respectively). DiscussionManagement of postoperative pain is not only vital to patients’ surgical experiences, but is imperative in preserving hospital resources, decreasing hospital stay, and decreasing readmission rates. In total, 20-80% of patients experience moderate to severe pain during their postoperative course. Opioids remain the leading modality to manage postoperative pain, but the recent opioid epidemic has motivated clinicians to pursue other pathways, including liposomal bupivacaine for pain management to mitigate the use of large doses of opioids. The results of the present study suggest that administration of 266mg of liposomal bupivacaine, given equally in all 4 surgical sites following bilateral Le Fort I and sagittal split osteotomies, leads to a statistically significant decrease in postoperative opioid usage. Future prospective studies utilizing liposomal bupivacaine and standard multimodal pain control regimens following orthognathic procedures will further explore the efficacy of liposomal bupivacaine in opioid reduction and management of postsurgical pain.

Combining Aesthetic Septorhinoplasty With Bioabsorbable Implants for Nasal Valve Insufficiency

This case report demonstrates the usage of a bioabsorbable nasal implant (BNI) in conjunction with an aesthetic septorhinoplasty. The authors uniquely chose to use this allograft due to inadequate autologous tissue secondary to previously performed temporomandibular joint arthroplasties. In addition to evaluating our case of a 22-year-old woman who received a BNI with an aesthetic septorhinoplasty, the authors performed a comprehensive literature review on the topic. Spanning 3 databases (Scopus, PubMed, and Cochrane), this review revealed 4 primary studies, totaling 349 patients. Each utilized nasal obstruction symptom evaluation (NOSE) scores to subjectively measure symptomatic improvement. We chose to use the NOSE questionnaire on our patient both preoperatively and postoperatively, in order to help demonstrate subjective improvement. The patient’s functional and aesthetic concerns were addressed in the operating room at Parkland Memorial Hospital under general anesthesia. Notably, the patient had previously had conchal cartilage harvested bilaterally, had insufficient septal cartilage for adequate grafting, and did not desire to undergo costal cartilage harvest. Therefore, all parties agreed to use a BNI to complete the functional component of the patient’s septorhinoplasty. This day-surgery first focused on the aesthetic septorhinoplasty followed by the placement of the BNI bilaterally. Following an uneventful postoperative course, our patient endorsed not only an aesthetic improvement but also an 88% functional improvement based on her NOSE score within 4 months of surgery. The authors were able to successfully integrate functional as well as aesthetic septorhinoplasty techniques under the constraints of having both limited autologous tissue and limited accepted options from the patient. For the patient and provider team, this newer allograft was confirmed to be effective and efficient. With the correct patient selection, this is an excellent adjunct procedure that can be quickly and safely performed either in conjunction with surgical rhinoplasty or as a standalone procedure by facial surgeons.

MP54-09 TRENDS IN THE INFLUENCE OF GENDER, RACE, AND ETHNICITY ON THE PREVALENCE OF KIDNEY STONES: A MULTI-INSTITUTIONAL AND CLAIMS ANALYSIS

You have accessJournal of UrologyStone Disease: Epidemiology & Evaluation II (MP54)1 Sep 2021MP54-09 TRENDS IN THE INFLUENCE OF GENDER, RACE, AND ETHNICITY ON THE PREVALENCE OF KIDNEY STONES: A MULTI-INSTITUTIONAL AND CLAIMS ANALYSIS Joseph Crivelli, Naim Maalouf, Phyllis Yan, Amy Hughes, Ryan Hsi, Noah Canvasser, Naveen Kachroo, David Leavitt, Kyle Wood, Gabriela Oates, John Hollingsworth, and Dean Assimos Joseph CrivelliJoseph Crivelli More articles by this author , Naim MaaloufNaim Maalouf More articles by this author , Phyllis YanPhyllis Yan More articles by this author , Amy HughesAmy Hughes More articles by this author , Ryan HsiRyan Hsi More articles by this author , Noah CanvasserNoah Canvasser More articles by this author , Naveen KachrooNaveen Kachroo More articles by this author , David LeavittDavid Leavitt More articles by this author , Kyle WoodKyle Wood More articles by this author , Gabriela OatesGabriela Oates More articles by this author , John HollingsworthJohn Hollingsworth More articles by this author , and Dean AssimosDean Assimos More articles by this author View All Author Informationhttps://doi.org/10.1097/JU.0000000000002084.09AboutPDF ToolsAdd to favoritesDownload CitationsTrack CitationsPermissionsReprints ShareFacebookLinked InTwitterEmail Abstract INTRODUCTION AND OBJECTIVE: Significant increases in kidney stone prevalence have been reported for Black and Hispanic individuals in the US, but the gender-specific contribution to this trend is unclear. We evaluated the distribution of prevalent stone disease by gender, race, and ethnicity in contemporary cohorts. METHODS: We identified patients with a kidney stone diagnosis between 2010-2019 from three centers (University of Alabama at Birmingham [UAB, n=32,745], University of Texas Southwestern [UTSW, n=51,354], and Parkland Memorial Hospital [PMH, n=22,967]). We also utilized a claims database (Optum Clinformatics Data Mart) to identify working-age adults with a kidney stone diagnosis from 2010-2019 (n=68,594). Differences in male-to-female ratio between groups across all datasets were assessed with the Mann-Whitney U test. In the Optum cohort, temporal trends in male-to-female ratio were modeled with linear regression. RESULTS: In each cohort, most Black stone formers were female, most White stone formers were male, and most non-Hispanic stone formers were male; in two of the four cohorts, most Hispanic stone formers were female (Figure 1). We observed a significant difference in male-to-female ratio between Black vs. White stone formers, but not between Hispanic vs. non-Hispanic stone formers (Figure 1). In the Optum cohort, a significant linear decline in male-to-female ratio was observed in White and non-Hispanic stone formers, but not in Black and Hispanic stone formers (Figure 2). CONCLUSIONS: An analysis of multi-institutional and claims data showed that most Black stone formers were female, whereas most White stone formers were male, demonstrating a significant difference in gender distribution. Based on insurance claims, the male-to-female ratio decreased in all groups over time, but most consistently among White and non-Hispanic patients. Further evaluation of these findings and their association with comorbidities and socioeconomic factors is needed to understand disparities in stone disease. Source of Funding: National Institutes of Health 1R01DK121709-01A1 © 2021 by American Urological Association Education and Research, Inc.FiguresReferencesRelatedDetails Volume 206Issue Supplement 3September 2021Page: e952-e952 Advertisement Copyright & Permissions© 2021 by American Urological Association Education and Research, Inc.MetricsAuthor Information Joseph Crivelli More articles by this author Naim Maalouf More articles by this author Phyllis Yan More articles by this author Amy Hughes More articles by this author Ryan Hsi More articles by this author Noah Canvasser More articles by this author Naveen Kachroo More articles by this author David Leavitt More articles by this author Kyle Wood More articles by this author Gabriela Oates More articles by this author John Hollingsworth More articles by this author Dean Assimos More articles by this author Expand All Advertisement Loading ...

What is the Resident Perception of Physician Assistants in an Oral and Maxillofacial Training Program?

Physician assistants (PAs) are not employed in a widespread manner in the academic oral and maxillofacial surgery setting despite being able to assist with resident workload. We aim to measure residents' perception of PAs employed by an academic oral and maxillofacial surgery department after the addition of 2 PAs to the department. The investigators conducted an anonymous cross-sectional survey study addressing resident perception of PA's on reducing their working hours, the scope of PA's role, and the positive and negatives of working with a PA. The survey was distributed to current oral and maxillofacial surgery residents, non-categorical interns, and recent graduates at Parkland Memorial Hospital and John Peter Smith Hospital between November 1, 2020 and January 31, 2021. A follow-up survey to collect demographic data was distributed between May 20, 2021 and June 10, 2021. Descriptive statistics were used to summarize the results, with bootstrapping techniques to calculate 95% confidence intervals (CI). Investigators contacted 54 residents and recent alumni, and 31 (57%) responded to the original survey and 32 responded to the follow-up survey. All respondents agreed that the addition of PAs decreased resident workload (100%; 95% CI). The majority stated PAs should assist with rounding on inpatients (61%; 95% CI), in hospital consultations (52%; 95% CI), clinic appointments (74%; 95% CI), and patient care coordination (97%; 95% CI). Only 29% (95% CI) stated that PAs should be assisting in the operating room. The results of this study suggest that residents perceive the addition of PAs to the academic oral and maxillofacial surgery program to be beneficial when it comes to reducing overall workload and increasing potential educational opportunities, by assisting with care coordination, outpatient appointments, and inpatient rounding.

Validation of two predictive models designed to aid clinicians in identifying Stevens-Johnson syndrome/toxic epidermal necrolysis: A single institution retrospective review

Validation of two predictive models designed to aid clinicians in identifying Stevens-Johnson syndrome/toxic epidermal necrolysis: A single institution retrospective review

Antibiotic exposure and growth patterns in preterm, very low birth weight infants

BackgroundAntibiotic exposure in term infants has been associated with later obesity. Premature, very-low-birth-weight (birth weight ≤ 1500 g) infants in the neonatal intensive care unit frequently are exposed to antibiotics. Our hypothesis was that in preterm infants, there is a positive linear and dose-dependent relationship between antibiotic exposure and growth from birth through 12 months’ corrected age.MethodsRetrospective analysis of prospectively collected data of all antibiotic use among inborn, preterm (≤32 weeks’ gestation), very-low-birth-weight infants admitted to the neonatal intensive care unit at Parkland Memorial Hospital and followed in the Low Birth Weight Clinic at Children’s Medical Center, Dallas, TX. Antibiotic use was quantified by days of therapy which was compared with weight and length parameters at birth, 36 weeks’ postmenstrual age, and 2, 4, 6, and 12 months’ corrected age. The change in weight and length z-scores from birth to all subsequent age points was calculated. Stepwise multivariate regression analysis was performed to determine predictors of weight, length, and weight-for-length delta z-scores from birth to each subsequent age point.ResultsDuring the 18-month study, 161 infants received a median of 11 (IQR, 5.5–19.5) antibiotic days of therapy which was not associated with weight or length delta z-scores from birth through 12 months’ corrected age.ConclusionAssociation of prolonged antibiotic use and neonatal morbidities and mortality may override the potential association with increased weight gain in the NICU and beyond.