Primary Placement Research Articles

Gender Distribution of Amalgam Restoration and Treatment Pattern in Regular Attendees of a Teaching Hospital in Nigeria

ABSTRACT Background Amalgam restoration has been the main procedure carried out over the last two centuries in spite of going through 2 major wars by those opposed to amalgam; however, it has been known that several factors affect it from the stage of titration, packing and finishing of the material but studies on the effect of gender on the treatment and distribution pattern are very scarce. Materials and methods This is a 12 years cross-sectional longitudinal retrospective study of dental records of patients who had attended the Dental Centre of University College Hospital, Ibadan, a Teaching Hospital located in the South West of Nigeria, regularly for a minimum period of 5 years. Results A total of 2,094 restorations were found to meet the criteria with males accounting for 691 (33%) and females 1403 (67%). When distributed into classes of restoration, females had more class I, II and V restorations placed (69.8%, 62.7%, 63.6%) more than males (30.2%, 37.3%, 36.4%) respectively. Females also had more primary placements and replacement done for all the classes of restorations. Conclusion More female patients attended the conservative dentistry clinic regularly more than their male counterparts and more females had higher number of restorations placed, however, there is a reduced female:male ratio in the subgroup of class II amalgam restorations. It was observed that the most frequent reason given in replacement of restorations was fractured amalgam restorations. How to cite this article Olaleye AO. Gender Distribution of Amalgam Restoration and Treatment Pattern in Regular Attendees of a Teaching Hospital in Nigeria. World J Dent 2014; 5(2):109-112.

Repeated Neurological Complications during Dialysis - A Case for Echo?

A 65-year old woman presented with acute or chronic renal failure and signs of right heart failure. Renal replacement therapy—using a surgically placed dialysis catheter via the left jugular vein—was repeatedly complicated by altered flows of the dialysis unit, impaired consciousness, new onset of seizures and left-sided hemiparesis. The tip of the dialysis catheter was detected on transesophageal echocardiography within the lumen of the ascending aorta. Further imaging of the neck vessels demonstrated a primary placement of the catheter in the left common carotid artery. This incident underscores the value of ultrasound guidance for placement of intravascular catheters.

Management of subclavian artery in-stent restenosis

Stenotic and occlusive diseases of the subclavian and brachiocephalic arteries can cause a significant morbidity as it can lead to symptomatic ischemia affecting the upper extremities, brain and, in some cases, the heart. An endovascular approach with primary stenting or provisional stenting has become the primary modality of revascularization of subclavian artery stenosis. In-stent restenosis can be treated with percutaneous transluminal angioplasty or repeat stenting and although stents offer superior long-term patency over balloon angioplasty alone for de novo lesions, there are no data regarding primary versus provisional stenting in subclavian in-stent restenosis. Here we describe a case of subclavian in-stent restenosis treated with just balloon angioplasty and demonstrate that provisional stenting with angioplasty alone when the percutaneous transluminal angioplasty results are excellent is a reasonable alternative to primary stent placement for subclavian in-stent restenosis.

Interprofessional Education for Students’ in Primary Care Placements: Widening Opportunities for Accessible Interprofessional Learning

Ensuring that health care professional students’ are provided with accessible interprofessional learning within the practice placement setting can be challenging. This paper describes an interprofessional activity which enables students to experience interprofessional learning and working within the primary care setting and to consider the impact of effective teamwork on patient safety.

Combined Nerve to Masseter and Mini-Hypoglossal Nerve Transfers in the Oncologic Patient with Proximal Facial Nerve Sacrifice

INTRODUCTION: Proximal facial nerve sacrifice during tumor extirpation poses a challenge in restoring dynamic facial expression. Primary nerve grafting is an option, but nerve grafts may require a long time to reinnervation with the likelihood of significant synkinesis and variable outcomes. Additionally, a proximal facial nerve stump may not be available in advanced cases. In the oncologic setting where life expectancy may be limited, rapid and reliable dynamic reconstruction is ideal. This study describes a new approach using combined nerve to masseter and mini-hypoglossal nerve transfers to the separate distal facial nerve target branches in order to achieve rapid reanimation while minimizing synkinesis. METHODS: A retrospective study was performed on all patients who underwent oncologic resection with proximal facial nerve sacrifice between November 2010 and March 2012. Outcomes evaluated included: time to reinnervation, speech, oral competence, tongue atrophy, mastication, and surgical complications. All patients underwent nerve-to-masseter transfer to the upper division of the facial nerve (smile and lower eyelid tone) and mini-hypoglossal transfer to the marginal mandibular nerve (lower lip animation) at the time of oncologic resection (Figure 1). Primary placement of an eyelid weight was used in all patients, and a static sling was placed in select cases to provide symmetry at rest during the period of reinnervation. Cross face nerve grafting was included in select cases.Figure 1: Nerve to Masseter and Mini-Hypoglossal Nerve Transfers.RESULTS: A total of 8 patients were identified. 7 out of 8 patients underwent adjuvant radiotherapy following tumor resection and reconstruction. All patients had evidence of dynamic recovery of smile and lower eyelid function at 3–5 months postoperatively. All patients had oral competence, intelligible speech, no evidence of hemi-tongue atrophy, and no difficulty in mastication or deglutition. All patients had the ability to close their eyes with active lower eyelid motion and no evidence of scleral show or ectropion. Separating the targets of the combined nerve transfers resulted in minimal synkinesis (Figure 2).Figure 2: Late post-operative result after combined nerve to masseter and mini-hypoglossal nerve transfers.CONCLUSION: The combined use of targeted nerve to masseter and mini-hypoglossal nerve transfers provides rapid and reliable dynamic facial reanimation. Static procedures may be performed at the same setting to provide symmetry at rest during the 3 -5 month reinnervation period. Including a cross-face nerve graft preserves the possibility for a spontaneous facial reanimation in the future.

Disc-retained tubes for radiologically inserted gastrostomy (RIG): Not up to the job?

To assess the insertion procedure and performance of disc-retained gastrostomy tubes, recording complications and accidental displacements by prospective audit, and to determine whether primary placement of the tube off-licence was feasible. Disc-retained 12F single-lumen Monarch gastrostomy tubes (Enteral UK, Selby, UK) were inserted by three gastrointestinal interventional radiologists in a supra-regional cancer centre. The 12F tubes required a 20F peel-away sheath with four-point gastropexy fixation and were placed under conscious sedation, using electrocardiogram (EEG) bispectral index monitoring. Follow-up was performed in an in-house gastrostomy drop-in clinic at 1 week and 1 month, supplemented with weekly telephone follow-up. Patients also had open access to the gastrostomy drop-in clinic for immediate advice and complication management. Eighteen patients underwent primary insertion of a Monarch gastrostomy tube over 5 months. A total of 6/18 (33%) tubes displaced; 4/18 (22%) completely, 2/18 (11%) occult into the peritoneum. Four of 18 (22%) patients developed infection at the stoma site. Due to the unexpectedly poor performance of the tube, the study was terminated early. Initial experience with the Monarch disc-retained gastrostomy tube demonstrates it unsuitable for primary placement with current protocols. In view of the potentially serious complications, the Medicines and Healthcare Products Regulatory Agency (MHRA) has been informed. A request has been made to the distributer to reassess the tube design and/or review the procedure promoted for primary placement.

Interventional Exclusion of Iliac Artery Aneurysms Using the Flow-Diverting Multilayer Stent

This study was designed to evaluate retrospectively the results of complex iliac artery aneurysm (IAA) exclusion using the Cardiatis-Multilayer-Stent. Between October 2010 and August 2012, ten IAAs were treated in eight males (mean age 75 (59-91) years) using the Multilayer Stent. All IAA exceeded a diameter of 3 cm or were symptomatic. Follow-up (FU) examinations included CT or MR angiography, sonography, and clinical assessment up to 2 years. Primary stent placement was technically successful in eight of ten cases. In two cases, severe stent retraction during deployment necessitated placement of an additional stent. Immediately after stent placement, a marked reduction of flow within the sac was observed in all cases (peri-interventional mortality 0%). During FU, there were two thrombotic stent occlusions, making reintervention necessary (primary patency rate 80%, secondary patency 100%). Four IAA were completely occluded at FU, whereas the original vessel and covered branches (n = 8) were patent. In four IAA, there was still residual perfusion. In one patient, IAA diameter decreased slightly, while it remained constant in seven (mean imaging FU 195 (range 1-695) days). There were no adverse events on clinical FU (mean FU 467 (range 101-695) days). Other studies showed the Cardiatis-Multilayer-Stent to be a technically relatively simple treatment option for complex IAA with inadequate landing zones, especially in patients with multiple comorbidities to avoid ipsilateral IIA obstruction. However, in our series complication rate was high. Incomplete sac exclusion, stent-shortening, and thrombotic occlusion can complicate treatment, making meticulous patient selection necessary. Close imaging surveillance is mandatory especially in the early postinterventional period.

Abstract 91: Temporal Trends in Patient Characteristics and Outcomes Among Medicare Beneficiaries Undergoing Primary Prevention Implantable Cardioverter-Defibrillator Placement in the United States: 2006-2010 Results from the NCDR ®

Background: Trends in the use and outcomes of ICDs in community practice settings are not well characterized. Our objective was to determine the temporal trends in characteristics and outcomes among patients undergoing primary prevention ICD therapy. Methods: We identified Medicare beneficiaries aged 65 years and older with an ejection fraction <35% undergoing ICD implantation for primary prevention between 2006 and 2010 in the NCDR ICD Registry™. Using a probabilistic method, eligible subjects were matched to Medicare claims data to capture outcomes using age, gender, admission date or procedure date, and hospital Medicare provider number. We tested the significance of trends in characteristics over time with χ2 tests for categorical variables and ANOVA for continuous variables. Standardized outcome rates were calculated adjusting for demographics and characteristics. Results: A total of 117,100 patients were included in the analysis. Between 2006 and 2010, small but significant increases were observed in the prevalence of hypertension, diabetes, and NYHA Class III symptoms, and decreases in the prevalence of ischemic heart disease and NYHA Class IV symptoms (Table 1). There was minimal change in age, gender, and race of patients receiving ICDs over the study period; fewer single lead and more biventricular devices were used over time. Risk-standardized six-month re-hospitalization and complication rates decreased and risk-standardized six-month all-cause mortality was stable over the study period (Table 1). Conclusions: Modest changes in patient characteristics undergoing primary prevention ICD implantation were observed between 2006 and 2010. There have simultaneously been significant improvements in outcomes after accounting for these patient trends, suggesting the possibility that there have been improvements in care of this patient population.

Educational Exhibit Abstract No. 354 - Primary placement of a constrained transjugular intrahepatic portosystemic shunt: how we do it

Learning Objectives Three methods for placement of a primary constrained transjugular intrahepatic portosystemic shunt (TIPS) will be reviewed. Background TIPS creation is often complicated by hepatic encephalopathy. Medical management fails in approximately 5-10% of cases. In those patients, TIPS revision may be required by creating a flow-limiting stent using a variety of methods. To avoid the complication of hepatic encephalopathy, however, we occasionally place primary constrained stents during the initial TIPS creation, particularly if the indication for TIPS is refractory ascites. Clinical Findings/Procedure Details We take one of three approaches to creating a primary constrained TIPS. In one approach, a self-expanding 10 mm Gore-Viatorr stent graft is deployed and a 5-0 Prolene suture is tied around the midpoint. The modified graft is then crimped into a peel-away sheath and re-sterilized. After formation of the intrahepatic tract, the graft is deployed and balloon dilated. The suture creates a flow-limiting constriction which may be dilated and/or broken as needed to improve flow. Prolene is favored due to its high elasticity, which allows for balloon expansion. Another approach involves deploying the stent graft through a balloon-expandable bare metal stent. After accessing the portal vein, we place a short 6-8 mm bare metal stent within the intrahepatic tract. Once this stent is in place, the Viatorr stent graft is deployed within it and the entire assembly is dilated to the diameter needed. The outer stent maintains a constriction in the inner stent graft due to its higher radial force, and can be dilated at a later time. In the third technique, a balloon-mounted Atrium iCast stent graft is placed on a 10-French sheath and a 4-0 absorbable suture is tied around its midpoint. This stent is then crimped onto a balloon and deployed, with the suture serving as the constriction point. Dilation can be done at a future time if needed. Conclusion and/or Teaching Points Creation of a primary constrained TIPS can be readily performed, enabling a degree of control over reduction of the portosystemic gradient both at initial TIPS creation and at follow up. Whether these techniques result in a reduction of hepatic encephalopathy requires further investigation.

Alphasphere as a Successful Ocular Implant in Primary Enucleation and Secondary Orbital Implant Exchange

ABSTRACTPurpose: To describe the surgical technique for a novel poly-HEMA (2-hydroxyethyl methacralate)[PHEMA] implant (Alphasphere, Addition Technology, Des Plaines, IL) in primary enucleation and placement of secondary orbital implant.Methods: Retrospective chart review of all patients receiving an Alphasphere implant for primary enucleation or secondary implant exchange from October 2009 to 2011. Interval follow-up was performed again on January 2013. Patient demographics, indications for surgery, and post-operative complications were reviewed.Results: Twelve patients received an Alphasphere implant for primary enucleation (n = 10) or secondary exchange (n = 2), with follow-up that ranged from 2 weeks to 14 months. The study included 9 adult and 3 pediatric patients with a mean age of 40 years, range 8–82 years. The indication for enucleation included: painful blind eye (n = 9), enophthalmos with difficult prosthesis fit in cases of secondary implant exchange (n = 2), and prophylaxis for sympathetic ophthalmia (n = 1). Only one patient required removal of the implant, due to a sinus infection with subsequent extrusion of the implant. Otherwise, the only other complication experienced was slight implant migration (n = 1).Conclusion: This initial report indicates that Alphasphere can be successfully used in the management of an anophthalmic socket. The advantages of the Alphasphere implant include: it does not require tissue wrapping, extraocular muscles can be directly sutured to the implant, it maintains a smooth surface to limit risk of exposure due to conjunctival breakdown, and undergoes anterior orbital fibrovascular ingrowth which optimizes prosthesis location and socket motility.

Outcome of Modified Turn in Flaps for the Lining With Primary Cartilage Support in Nasal Reconstruction

Turning in adjacent skin from the residual nose to line a full-thickness defect is still a controversial option. Text books continue to perpetuate that such flaps are poorly vascularized and may not survive if longer than 1.5 cm. The rationale of our study was to challenge the traditional thoughts about the turn-in flaps for the lining and describe our modified technique of raising these flaps so that well-vascularized thin tissue can be provided for the lining. The study was conducted at the Department of Plastic Surgery, KEMU, Lahore, from January 2007 to March 2011. Eighteen patients were included. They had posttraumatic full-thickness nasal defect of variable extent, involving the lower third of the nose. In the first stage of reconstruction, the epithelialized portion and 5-mm portion of normal adjoining skin were dermabraded. The residual skin of nasal dorsum, side walls, and alae was turned in to form inner lining of 2 nostrils. These flaps were based on healthy dermabraded skin to ensure adequate blood supply. Residual septal and conchal cartilages were used for primary support. Standard ipsilateral paramedian forehead flap with slight oblique design was used for resurfacing. Final assessment of airway patency and alar rim contour was made by the patient at 6 months as satisfactory, just satisfactory, and not satisfactory. There were 12 female and 6 male patients. There was necrosis of distal portion of the forehead flap in 1 case. Partial graft loss at the donor site with bone exposure was noted in another case. There was partial dehiscence and necrosis of turndown flap in 3cases. Mean flap size was 2.05 ± 0.28 cm. As regards airway patency, 12 patients were satisfied, 4 patients were just satisfied, and 2 patients were unsatisfied. When asked about alar rim contour, 3 patients said it to be satisfactory, 9 patients found it just satisfactory, and 6 patients declared it unsatisfactory. Nasal turndown flaps provide reliable tissue for the lining and allow primary placement of cartilage grafts.

Abstract WP351: Using Standard Work to Improve the Discharge Process on a Neurology Division

Background and Issues: Patient volume increased significantly over first half of 2011 on the Neurology Service. Bed occupancy increased by 14% over previous year and bed availability became a major constraint. Data showed, patients were discharged late in the day or sometimes stayed an extra night because discharge orders were released too late to place patients in rehab or skilled nursing facilities. Only 16% of patients were discharged by 2:00 pm due to communication barriers and inadequate information exchanged between multidisciplinary teams. There was also an issue with inconsistent acceptance criteria from primary placement facilities which resulted in a longer length of stay. Purpose: Primary goal of project was to free up capacity on the Nursing Division to accommodate the increase in patient volumes without increasing staffing or the number of available beds. Methods: In September 2011, a multidisciplinary team was assembled to understand causes of the problems and develop solutions to resolve. Solutions implemented include working with partner Rehab and Skilled Nursing Facilities to define standardized Acceptance Guidelines to ensure issues could be addressed before day of discharge. Also, processes for releasing discharge orders were redesigned so orders were more frequently written and placed “on hold” the day before expected discharge. A mobile computer was issued to physician rounding teams so orders could be released during rounds instead of batch-released in the afternoon. Additionally, team communication was significantly improved by standardizing a daily multidisciplinary team huddle and implementing a visual communication board to track key information about patients to proactively plan for discharge. Results: The overall length of stay of patients on the Neurology Service decreased from 4.26 days in 2011 to 3.69 days in 2012. Conclusions: Many variables contributed to the decrease in length of stay for patients in this study. No decisive conclusions can be made about the effectiveness of any particular variable. Other variables during this timeframe likely contributed, however the authors of this study presented the most likely factors. Although the findings are exciting, further analysis is needed to isolate the main drivers.

Failed Epidural

Summary. Failed epidural anaesthesia or analgesia is more frequent than generally recognized. We review the factors known to influence the success rate of epidural anaesthesia. Reasons for an inadequate epidural block include incorrect primary placement, secondary migration of a catheter after correct placement, and suboptimal dosing of local anaesthetic drugs. For catheter placement, the loss of resistance using saline has become the most widely used method. Patient positioning, the use of a midline or paramedian approach, and the method used for catheter fixation can all influence the success rate. When using equipotent doses, the difference in clinical effect between bupivacaine and the newer isoforms levobupivacaine and ropivacaine appears minimal. With continuous infusion, dose is the primary determinant of epidural anaesthesia quality, with volume and concentration playing a lesser role. Addition of adjuvants, especially opioids and epinephrine, may substantially increase the success rate of epidural analgesia. Adjuvant opioids may have a spinal or supraspinal action. The use of patientcontrolled epidural analgesia with background infusion appears to be the best method for postoperative analgesia.

Medical student perspectives of what makes a high-quality teaching practice

Primary care has seen increasing involvement in undergraduate medical education following recommendation from the GMC in Tomorrow's Doctors. This is also influenced by an increasing number of medical students and changing patterns of health care. The variety of practices involved in delivering undergraduate primary care placements poses a challenge for the quality of these placements. The variety of learners in primary care may also affect this. To reflect this, Cotton et al in 2009 produced a national consensus list of quality criteria for community-based education using a variety of medical education stakeholders. This paper seeks to explore the medical student perspective of what makes a high-quality teaching practice. This study uses focus group interviewing to explore student perspectives of the range of factors that can contribute towards the quality of a primary care placement. Previous research into student perspectives of teaching in primary care has revealed a strong focus on tutor quality. Students in this study again highlighted the important of good GP tutors and organisation of placements. However, one novel finding was the emphasis that students placed on involving patients in teaching and the vital role that they play in this.

Comprehensive Management of Maxillofacial Projectile Injuries at the First Operation; “Picking up the Pieces”

The issue of when to treat maxillofacial firearm injuries with regard to timing (early or delayed), remains an issue of debate (1-4). Although not all maxillofacial projectile injuries can be comprehensively treated at onset, many indeed may (1-4). In over 50 cases of firearm injuries to the face at our center, more than 30 were treated via early comprehensive repair and simultaneous open reduction for maxillofacial fracture fixation. These patients underwent primary debridement and arch bar placement followed by open reduction of fractures (with or without osteosynthesis) followed by primary wound closure. Primary comprehensive intervention was done when there was no gross infection, no bone comminution, no extensive soft tissue avulsion (preventing wound coverage), and when general health, concomitant injuries requiring more urgent attention, or those requiring major grafts did not preclude this. Primary management included extensive oral and extraoral irrigation (dilute hydrogen peroxide + povidone iodide), brushing, debridement of the facial wound, removal of floating fragments (teeth particles, debris, and shell fragments) excluding viable bone within the wound. Next, after access to the remaining bone stumps, we sought to find scattered bone segments; after that we put them back into place to restore bone continuity (especially in the mandible) similar to “Picking up the Pieces” and putting together a puzzle (Figure 1). This is often possible more often than not because the bone is usually shattered and scattered, rather than avulsed or pulverized (5). Figure 1 “Picking up the Pieces” and Putting Together a Mosaic Puzzle; a Similitude to Maxillofacial Reconstruction Treatment in addition to arch bars, employed titanium miniplates, recon-plates or wire osteosynthesis when necessary. All wounds were then closed primarily (using local advancement flaps); all patients were placed on antibiotics (cephalosporin + aminoglycoside or ciprofloxacin). In the acutely-treated group, few patients had complications (such as scarring and wound discharge) (6, 7). Early comprehensive intervention for projectile wounds to the face was effective in selected cases. Our main aim was to restore continuity of the mandible. The benefits include restoration of occlusion and continuity of the jaw, earlier fixation of luxated teeth, early return of function, prevention of segment displacement and tissue contracture, less scarring, and a decreased need for major bone graft reconstruction later on and shorter hospital stay. Those treated secondarily were only debrided and had arch bars placed until later; the drawbacks of delaying include: Definitive treatment of hard and soft tissue management being rendered in another subsequent operation, bone reduction more difficult because of scarring, displacement of remaining segments (i.e. mandibular ramus), longer hospital stay and greater patient anxiety (8, 9). Additionally, if scattered bone pieces are not searched for in the wound and not reduced, a defect remains and those displaced bone fragments round-off; some may be resorbed. In terms of infection or other major complications e.g. chronic osteomyelitis, no significant differences were noted between early or delayed management. Thus, today many cases of projectile injuries to the face may be treated definitively and acutely with procedures designed to repair both bone and soft tissue injuries simultaneously aiming to restore bony continuity, esthetics and function using the tissues at hand (especially in the mandible). Because then, many patients with residual defects can be treated more easily as out-patients. Early treatment is also advocated because the course of healing is not disrupted with another subsequent operation (in the same wound) and because it may also decrease anxiety and stress associated with injured patients with disfigured faces and nonfunctional jaws anticipating definitive treatment (9).

A Cross-sectional Retrospective Study of Survival of Amalgam Restoration in a Nigerian Teaching Hospital

ABSTRACT Background This is a cross-sectional retrospective study on survival of amalgam restoration in a Teaching Hospital in Nigeria. There has been no study on this particular subject in Nigeria despite the fact that there is an alarming increase in dental caries and the preferred choice of treatment for over 5 decades has been amalgam restoration. Materials and methods It is a retrospective study of dental records of the dental center over a period of 12 years setting certain criteria that must be met by such records. Those that fulfilled these criteria were then recalled for examination. Results Two hundred and ninety-four amalgam restorations were placed with primary placements forming 75.69 of all restorations carried out while replacements were 24.31%. Fractured restoration was the commonest cause of failure of restoration accounting for 66% of all replacement. Ditching formed 15.5%, recurrent caries 11.6%, dislodged restoration 5.3%. While cervical overhanging amalgam was 1.6%. 25%, 50%, 75% cumulative failure rate occurs at 4.2 and 6.9 and 9.2 years respectively. While at the same time 73.2 and 19.2% of the restorations lasted for 5 and 10 years respectively. Conclusion Primary placement is the preoccupation of the dentist's in Nigeria while replacement rate is low. However, while recurrent caries is the major cause of restoration failure in economies country in Europe and America, it is not the case in this study. How to cite this article Olaleye AO. A Cross-sectional Retrospective Study of Survival of Amalgam Restoration in a Nigerian Teaching Hospital. World J Dent 2013;4(3):149-154.

Long-Term Outcomes After Bariatric Surgery

To describe the long-term outcomes after laparoscopic adjustable gastric banding (LAGB) and compare these with the published literature on bariatric surgery. Because obesity is a chronic disease, any proposed obesity treatment should be expected to demonstrate long-term durability to be considered effective. Yet for bariatric surgery, few long-term weight loss data are available. We report our 15-year follow-up data after LAGB and provide a systematic review of the peer-reviewed literature for weight loss at 10 years or more after bariatric surgical procedures. We performed a prospective longitudinal cohort study of LAGB patients using an electronic database system (LapBase) to track progress, measure weight changes, and document revisional procedures. The evolution of the LAGB procedure was recognized, and revisional rates for 3 separate periods between September 1994 and December 2011 were described. In addition, we performed a systematic review of the peer-reviewed published literature collecting all reports that included weight loss data at or beyond 10 years. A total of 3227 patients, with a mean age of 47 years and a mean body mass index of 43.8 kg/m, were treated by laparoscopic adjustable gastric band placement between September 1994 and December 2011. Seven hundred fourteen patients had completed at least 10 years of follow-up. Follow-up was intact in 81% of patients overall and 78% of those beyond 10 years. There was no perioperative mortality for the primary placement or for any revisional procedures. There was 47.1% of excess weight loss (% EWL) at 15 years [n = 54; 95% confidence interval (CI) = 8.3] and 62% EWL at 16 years (n = 14; 95% CI = 13.6). There was a mean of 47.0% EWL (n = 714; 95% CI = 1.3) for all patients who were at or beyond 10 years follow-up. Revisional procedures were performed for proximal enlargement (26%), erosion (3.4%), and port and tubing problems (21%). The band was explanted in 5.6%. The need for revision decreased as the technique evolved, with 40% revision rate for proximal gastric enlargements in the first 10 years, reducing to 6.4% in the past 5 years. The revision group showed a similar weight loss to the overall group beyond 10 years. The systematic review of all bariatric procedures with 10 or more years of follow-up showed greater than 50% EWL for all current procedures. The weighted mean at maximum follow-up for LAGB was 54.2% EWL and for Roux-en-Y gastric bypass was 54.0% EWL. The LAGB study from 1 center demonstrates a durable weight loss with 47% EWL maintained to 15 years. This weight loss occurred regardless of whether any revisional procedures were needed. A systematic review shows substantial and similar long-term weight losses for LAGB and other bariatric procedures.

798: Pregnancy outcome after placement of a reinforcement cerclage

of a reinforcement cerclage Jesse Woo, Pedro Arrabal, Geralyn O’Reilly, David Schwartz, Stephen Contag Sinai Hospital of Baltimore, Obstetrics and Gynecology, Baltimore, MD OBJECTIVE: Determine the pregnancy outcome after placement of a reinforcing transvaginal cerclage for ultrasound confirmed cervical shortening among women whom underwent an initial prophylactic, therapeutic or rescue cerclage. STUDY DESIGN: This is a retrospective cohort study. We included patients who underwent a primary cerclage placement between January of 2006 and May of 2012 at Sinai Hospital of Baltimore. The pregnancy outcomes including cervical length, placement of a subsequent reinforcing cerclage and gestational age at delivery were abstracted from electronic medical records. The time to delivery after initial cerclage placement was compared between women who received one or two cerclage using Kaplan Meier survival analysis. Student T-test and chi square was used to compare continuous and non-continuous variables. A P-value of 0.05 was used to establish a statistically significant difference. RESULTS: We identified a total of 158 women with singleton pregnancies who underwent cerclage placement. Prophylactic cerclage was placed in 66, therapeutic cerclage in 31 and rescue cerclage in 61 women. The average gestational age from initial cerclage to delivery was 20.5, 15.7 and 12.5 weeks gestation for prophylactic, therapeutic and rescue cerclage respectively. The main indication for placement of a reinforcing cerclage was ultrasound diagnosed cervical shortening. The median cervical length prior to placement of reinforcing cerclage was 1.0 cm. At 24 weeks gestational age the median cervical length among 87 of 138 patients who did not receive a reinforcing cerclage was 2.7 cm. (41% had a cervical length less than 2.5 cm.) The difference in gestational age at delivery was not significant between patients who received (30.4 7.0 wk) and did not receive (34.4 6.4 wk) a reinforcing cerclage regardless of the indication for the cerclage (P 0.19) (Figure and Table). CONCLUSION: Placement of a reinforcement cerclage after initial cerclage did not prolong the pregnancy regardless of the indication for the initial cerclage. 799 Is vaginal delivery of a macrosomic infant after cesarean section really so dangerous? Joel Baron, Adi Weintraub, Ruslan Sergienko, Eyal Sheiner, Reli Hershkovitz Faculty of Health Sciences, Soroka University Medical Center, Ben-Gurion University of the Negev, Department of Obstetrics and Gynecology, BeerSheva, Israel, Faculty of Health Sciences, Ben-Gurion University of the Negev, Department of Epidemiology and Health Services Evaluation, BeerSheva, Israel OBJECTIVE: To determine whether women with a previous uterine scar and a macrosomic fetus have a higher risk of uterine rupture. STUDY DESIGN: A retrospective comparison of all singleton vaginal births after a cesarean delivery (VBAC) of a macrosomic infant (birthweight above 4000 gr) to those of normal weighing infants ( 4000 gr) during the years 1988-2011 was conducted. Receiver operating characteristic (ROC) curves were used to determine an association between birthweight and the risk for uterine rupture. RESULTS: Of 31,310 VBAC that occurred during the study period, 5.3% (n 1644) were of macrosomic infants. No significant association was found between VBAC of a macrosomic infant and uterine rupture (Table). Likewise the rates of post partum hemorrhage, and peripartum hysterectomy were comparable between the groups. The ROC curve did not demonstrate a significant association between Outcomes after placement of reinforcing cerclage www.AJOG.org Clinical Ob, Epidemiology, ID, Intrapartum Fetal, Operative Ob, Med-Surg-Diseases, Ob Quality & Safety, Public & Global Health Poster Session V

The Impact of Professional Development and Student and Teacher Characteristics on the Quality of Postsecondary Goals

This study examined (a) the main effects of professional development on the quality of postsecondary goals in employment and postsecondary education/training, (b) the main effects of student and teacher characteristics on goal quality, and (c) whether professional development moderated the relationship between the impact of these characteristics and goal quality. Individual Education Program (IEP) documents were gathered from 18 teachers before and after professional development totaling 137 IEPs. Hierarchical linear modeling methods were used to account for the fact that student IEPs were nested within teachers. Results indicated professional development significantly improved goal quality for both goal areas. Teachers whose primary placement and caseload was within self-contained classrooms and those with more years of experience had higher quality employment goals than teachers with less experience and those in resource rooms or general education settings. Implications are discussed regarding the continued need to align the content of IEPs for transition-age students with practice.

Temporary Right Ventricular Support in Left Vetricular Assist Device Recipients

Objectives: Right ventricular failure (RVF) remains a major early postoperative complication after left ventricular assist device (LVAD) placement despite attempts to identify patients (pts) at risk. We describe our experience with temporary right ventricular assist device (RVAD) support with CentriMag (Levitronix LLC, Waltham, MA) after LVAD placement. Methods: Between 01/2008 and 06/2011, 45 LVAD recipients (8 f; age 53.4±9.1, range: 25-70 years) with preoperative evidence of moderate to severe RVF (Pennsylvania University score >50 and Michigan University score >5) received a temporary CentriMag RVAD at our institutions. Etiology of cardiomyopathy was: idiopathic (n=24, 53%), ischemic (n=14, 31%) and valvular (n=7, 16%). In 34 pts the RVAD was inserted simultaneously with LVAD placement (primary) and in 11 others within 48 hours after LVAD placement (secondary). Results: During daily echocardiographic examinations a progressive improvement of RV function was documented in 29 (64.4%) pts (n=24, primary placement; n=5, secondary pl.). After an average of 12.1 postoperative days (POD) weaning from RVAD was carried out by reducing the flow by 10% every 12 h and after 16.2 POD it was successfully removed. All pts had RVEF of 38-40%, CVP of 10-15 mmHg and stable LVAD flow. RVAD removal was performed by a minimally invasive approach without re-sternotomy in 10 pts. Three (6.6%) pts required permanent support with an implantable centrifugal RVAD (HeartWare Inc., Miramar, FL). Ten (22.2%) pts died on temporary RVAD support. Overall 26 (57.7%) pts were discharged home (n=25, permanent LVAD support; n=1, permanent BVAD support) and 3 (6.6%) received successful heart transplantation. Conclusions: Implantation of an LVAD in pts with high risk for RVF is a feasible and effective therapy option if RV function is closely monitored. Once RVF is identified, immediate temporary RVAD placement improves the outcome. Weaning from and removal of the RVAD support allows pts to be on LVAD support only, thus providing good quality of life and enabling long-term mechanical support.