Retrospective Chart Research Articles

Are Complex Skull Fractures Indicative of Either Child Abuse or Major Trauma in the Era of 3-Dimensional Computed Tomography Imaging?

The aim of the study was to determine whether complex skull fractures are more indicative of child abuse or major trauma than simple skull fractures. This is a retrospective chart and imaging review of children diagnosed with a skull fracture. Subjects were from 2 pediatric tertiary care centers. Children younger than 4 years who underwent a head computed tomography with 3-dimensional rendering were included. We reviewed the medical records and imaging for type of skull fracture, abuse findings, and reported mechanism of injury. A complex skull fracture was defined as multiple fractures of a single skull bone, fractures of more than 1 skull bone, a nonlinear fracture, or diastasis of greater than 3 mm. Abuse versus accident was determined at the time of the initial evaluation with child abuse physician team confirmation. From 2011 to 2012, 287 subjects were identified by International Classification of Diseases, Ninth Revision, code. The 147 subjects with a cranial vault fracture and available 3-dimensional computed tomography composed this study's subjects. The average age was 12.3 months. Seventy four (50.3%) had complex and 73 (49.7%) had simple fractures. Abuse was determined in 6 subjects (4.1%), and a determination could not be made for 5 subjects. Adding abused children from 2013 to 2014 yielded 15 abused subjects. Twelve of the abused children (80%) had complex fractures; more than the 66 (48.5%) of 136 accidentally injured children (P = 0.001; relative risk = 1.65 [1.21-2.24]). However, among children with a complex fracture, the positive predictive value for abuse was only 7%. Complex skull fractures frequently occur from accidental injuries. This study suggests that the presence of complex skull fractures should not be used alone when making a determination of abuse.

A novel technique for patulous Eustachian tube augmentation.

To determine the effectiveness of a soft-tissue bulking agent comparing novel approaches of Eustachian tube (ET) augmentation procedures: transpalatinatal Eustachian tube augmentation in local and general anesthesia versus an augmentation with velotraction under general anesthesia. The clinical endpoint was the resolution of symptoms related to unilateral patulous Eustachian tube dysfunction (PETD) requiring no additional revision augmentations. Combined retrospective clinical chart review. Tertiary referral center. Patients suffering from PETD underwent one of the following procedures: Group (A) transpalatinatal soft-tissue bulking agent with infiltration/augmentation under local anesthesia in a sitting position, group (B) transpalatinatal soft-tissue bulking agent infiltration/augmentation under general anesthesia in the flat position or group (C) infiltration/transoral augmentation of the ET with velotraction under general anesthesia in a flat position. The requirement to repeat the procedure due to recurrence of any PETD-related symptoms was recorded and retrospectively analyzed. A total of 50 procedures were executed in 50 patients with unilateral PETD. The necessity to perform a second procedure has analyzed a mean of 6months postoperatively (range: 6-17months). Compared to the transpalatinatal augmentation in local anesthesia (group A) (100% success rate), the 6-month failure rate was significantly higher for transpalatinatal augmentation under general anesthesia (group B) (80% success rate) and velotraction augmentation under general anesthesia (group C) (67% success rate). Patient cohort with transpalatinatal augmentation under general anesthesia required 20% and augmentation with velotraction under general anesthesia in 33% revision augmentation procedures reviewed at 6months follow-up (mean follow-up 11.2months). Although all different approaches resulted in a reduction of PETD related symptoms, the transpalatinatal ET augmentation in local anesthesia achieved a statistically significant superior clinical improvement. A complete resolution of PETD related symptoms was obtained and required additional procedures. This improvement may be related to the intraoperative "feedback" by the patients in local anesthesia in the sitting position eliminating the necessity for repeated procedures.

Surgical Outcomes of C1-2 Posterior Stabilization in Patients With Chiari Malformation Type 1.

Study Design:Retrospective chart review.Objectives:Chiari malformation (CM) is characterized by a downward displacement of the cerebellar tonsils through the foramen magnum. This tonsillar herniation may sometimes be accompanied by syringomyelia and/or basilar invagination (BI). In this study, we examined the surgical outcomes of patients by underwent C1-2 reduction + fixation (C1-2RF), which is a new method defined by Goel, in the literature.Methods:Between 2015 and 2018, 21 patients (mean age and duration of follow-up: 39 years and 20 months, respectively) with CM were treated with atlantoaxial fixation. We found syringomyelia in all patients and BI in 9 of them. In all cases, radiography, computed tomography, and magnetic resonance imaging were performed radiologically. C1-2RF was performed in all patients. Preoperative and postoperative clinical Japanese Orthopaedic Association scores were obtained. Syrinx size and cerebrospinal fluid flow rate were compared radiologically.Results:All patients were treated with C1-2RF. None of the patients underwent foramen magnum decompression or intervention for the syrinx. Occipital bone and subaxial spinal structures were not included in the fixation. In addition to significant clinical improvement, significant improvement in syringomyelia and cerebrospinal fluid flow rate was seen on the radiographs of all patients.Conclusions:Although posterior fossa decompression and/or duraplasty is a common treatment modality in CM, we propose that the C1-2RF method described by Goel is a radiologically and clinically effective treatment method, whether or not BI and/or syringomyelia in CM are present. This article is the first article of central and axial atlantoaxial dislocation, except for Goel’s writings in the literature.

Abstract 2312: Application of PSA screening guidelines in the clinical setting

Abstract Background: Louisiana has the 2nd highest incidence rate and the 7th highest mortality rate from prostate cancer in the United States. Overall, the incidence rates are significantly higher in African American men versus Whites. An annual prostate specific antigen (PSA) test is the standard screening for early detection, but in 2012 the U.S. Preventive Services Task Force (USPSTF) recommended against regular PSA screening testing in men of all ages. This was later revised in 2018 to recommend informed decision-making with men between the ages of 55 and 69 years old. For men older than this, it was still recommended to refrain from regular PSA screening. The purpose of this study is to characterize the clinical practices of PSA screening at LSU Healthcare Network (LSUHCN). Methods: Retrospective medical chart review of 316 randomly selected men, 55-69 years old, who were active patients within the LSUHCN clinics between August 1, 2014 and July 31, 2019. Information was extracted from their medical records to report on the total number of PSA screening received in this time frame; specialty and gender of the physician who ordered the testing; race/ethnicity of the patient; and the insurance type for the patient. To protect the privacy of the participants, patient data was de-identified and is reported in aggregate. Results: Majority of the patients were White (49%) and African American (38%) and majority of them (79%) have not had PSA screening in the last 5 years. Of those patients with PSA exams (n=67), 29 received PSA for early detection screening, 8 for follow-up of elevated PSA, 18 for prostate related conditions, and 12 for prostate cancer control. No significant differences were found between the race of patients, number of PSA screenings received, and specialty/gender of providers. However significant differences were found by race and insurance type (p=0.002), with higher percentages of Whites (16%) having private insurance than African Americans (4%). In total 19 providers (7 urologists, 1 oncologist, 4 nurse practitioners, 6 internal medicine, and 1 family medicine) ordered 183 total exams during the period (M=9.6). Although no significant differences were found by specialty of physician ordering the exams and reason to order it, most of exams were ordered by urologists (78%) followed by nurse practitioners (11%) and internal medicine (7%). Conclusion: Within the LSUHCN, the majority of male patients are not being screened for early detection of prostate cancer, which could be indicative of the LSUHCN following the 2012 USPSTF guidelines recommending no PSA screening at all. Although PSA screenings for early detection of prostate cancer should be discussed during wellness/annual checkup visits, most of the PSA exams for screening were ordered by urologists instead of primary care providers (PCPs). Considering that the updated 2018 guidelines recommend shared-decision making between patients and providers, new studies are needed to revise changes in PCP practices regarding PSA screenings in the next years. Citation Format: Elizabeth Yanes, Margarita Echeverri. Application of PSA screening guidelines in the clinical setting [abstract]. In: Proceedings of the Annual Meeting of the American Association for Cancer Research 2020; 2020 Apr 27-28 and Jun 22-24. Philadelphia (PA): AACR; Cancer Res 2020;80(16 Suppl):Abstract nr 2312.

Insights into the Clinical Management of Carbapenem-Resistant Gram-Negative Infections: An Italian Retrospective Clinical Chart Review

There is a lack of consensus regarding management of infections with carbapenem- resistant Gram-negative (CR-GN) pathogens. This study comprised a medical chart review to assess patient management in a high CR prevalence setting. Data was collated retrospectively from medical records of patients hospitalized between November 1st, 2015 and October 31st, 2016. Of 29 patients, 66% had respiratory tract infections. Median duration of hospitalization was 28 days and ~50% of patients were admitted to the intensive care unit, with 77% remaining for >2 weeks. Median time to obtain respiratory culture results was 5 days. Isolation of patients with diagnosed CR-GN infection took ≥5 days in >50% of patients. A majority (76%) of patients received ≥1 antibiotic before providing a specimen for culture; a total of 17 antibiotic treatments were used. Overall, 72% of patients, and 68% of those with respiratory infections, were discharged alive; 38% were discharged without further antibiotics. The difficulties in achieving effective management in patients with CR-GN infections are largely due to complex co-morbidities, a history of prior antibiotic treatment, and multiple referrals across health care facilities.

Inequalities in Pediatric Fracture Care Timeline Based on Insurance Type.

Introduction:Socioeconomic and insurance status are often linked with limited access to health care. Despite several government-funded projects aimed at curtailing these barriers, pediatric orthopaedic patients continue to experience delays in receiving timely care for fracture treatments. This delay has been well-identified within the orthopaedic literature but, to our knowledge, has never been characterized based on timeline. Thus, the goal of this study is to evaluate the role of ethnicity, socioeconomic status, and insurance type on the timeline of pediatric patients to obtain orthopaedic care within our community.Methods:Pediatric patients presenting to our clinic for the treatment of one of 21 most common fractures were included. Patient demographics and the timeline of patient care were collected by retrospective chart review.Results:Government-funded insurance accounted for 60.6% of the 413 patients. These patients experienced significant (P < 0.001) delays in access to care when compared with commercial insurance patients; the time between injury and referral as well as the overall time from injury to orthopaedic evaluation was 2.8 and twofold greater at 4.4 days and 9.2 days, respectively. A strong correlation was established between income levels and insurance type.Discussion:Pediatric patients with a lower socioeconomic status are more likely to rely on government-funded insurance and experience delays in fracture evaluation.

Effect of Trapeziectomy on Carpal Stability.

Background: The scaphoid-trapezoid-trapezium (STT) articulation stabilizes the scaphoid and links the proximal and distal carpal rows. The purpose of the study was to determine whether trapezium excision in the treatment of trapeziometacarpal (TM) arthritis affects carpal stability. Methods: A retrospective chart and radiographic review was performed on all wrists that underwent trapeziectomy with suspensionplasty or ligament reconstruction, and tendon interposition for TM arthritis between 2004 and 2016. Radiographic outcome measures included the modified carpal height ratio (MCHR) and radioscaphoid (RS), radiolunate (RL), and scapholunate (SL) angles. Degenerative change at the TM and STT joints was classified according to the Eaton-Littler, and Knirk and Jupiter classification systems. Radiographic parameters were compared between preoperative and final follow-up time points. Results: A total of 122 wrists were included in the study with a mean follow-up of 3.5 years (range: 1.0-13.0 years). The mean RL (range: -2.2° ± 11.8° to -10.7° ± 16.5°) and RS angles (range: 52.6° ± 13.8° to 44.4° ± 17.8°) decreased significantly (<.001) without significant change in SL angle, indicating progressive lunate and scaphoid extension after trapeziectomy. The mean MCHR decreased significantly (range: 1.6 ± 0.1 to 1.5 ± 0.1) following trapeziectomy, indicating progressive carpal collapse. Progressive scaphoid-trapezoid arthrosis was observed following trapeziectomy. No other preoperative radiographic factors investigated were associated with significant differences in preoperative and postoperative values for radiographic outcome measures. Conclusions: Trapeziectomy can lead to loss of carpal height, coordinated extension of both the lunate and scaphoid, and progressive scaphotrapezoid arthrosis. As such, in wrists with dynamic or static carpal instability, trapeziectomy should be performed with caution due to the risk of carpal collapse with a nondissociative pattern of dorsal intercalated segment instability.

The Impact of Surgical Team Familiarity on Length of Procedure and Length of Stay: Inconsistent Relationships Across Procedures, Team Members, and Sites

Team familiarity has been shown to be important for operative efficiency and number of complications, but it is unclear for which types of operations and for which team members familiarity matters the most. The objective of this study is to further our understanding of familiarity in the OR by quantifying the relative importance of familiarity among all possible core team dyads, and defining the impact of team level familiarity on outcomes. Using a retrospective chart and administrative data review, five years of data from two health systems (14 hospitals) and across two procedures, (knee arthroplasty and lumbar laminectomy) were included. Multilevel modeling approach and a dominance analysis were conducted. For each previous surgery that any two members of the core surgical team had participated in together, the length of surgery decreased significantly. The familiarity of the scrub and the surgeon was the most significant relationship for knee arthroplasty across the two hospitals, and laminectomies at one hospital. The relationship between familiarity of the surgical team and surgical efficiency may be more complex than previously articulated. Familiarity may be more important for certain types of procedures. The familiarity of certain dyads may be more important for certain types of procedures.

Does Earlier Cannulation With Veno-Venous Extracorporeal Membrane Oxygenation in Adult Patients With Acute Respiratory Distress Syndrome Decrease Duration of Artificial Mechanical Ventilation?

Acute respiratory distress syndrome (ARDS) is characterized by an acute, diffuse, inflammatory lung injury, leading to increased alveolar capillary permeability, increased lung weight, and loss of aerated lung tissue (Fan, Brodie, & Slutsky, 2018). Primary treatment for ARDS is artificial mechanical ventilation (AMV) (Wu, Huang, Wu, Wang, & Lin, 2016). Given recent advances in technology, the use of veno-venous extracorporeal membrane oxygenation (VV-ECMO) to treat severe ARDS is growing rapidly (Combes et al., 2014). This 49-month quantitative, retrospective inpatient EMR chart review compared if cannulation with VV-ECMO up to and including 48 hours of admission and diagnosis in adult patients 30 to 65 years of age diagnosed with ARDS, decreased duration on AMV, as compared to participants who were cannulated after 48 hours of admission and diagnosis with ARDS. A total of 110 participants were identified as receiving VV-ECMO during the study timeframe. Of the 58 participants who met all inclusion criteria, 39 participants were cannulated for VV-ECMO within 48 hours of admission and diagnosis with ARDS, and 19 participants were cannulated with VV-ECMO after 48 hours of admission and diagnosis with ARDS. Data collected identified no statistically significant (p < 0.579) difference in length of days on AMV between participant groups. Further studies are needed to determine if earlier initiation of VV-ECMO in adult patients with ARDS decrease time on AMV. Although the results related to length of time on AMV did not produce statistical significance, the decreased duration of AMV in the participants who were cannulated within 48 hours (21 days vs. 27 days) may support several benefits associated with this participant population including increased knowledge of healthcare providers, decreased lung injury, earlier discharge which decreases hospital and patient cost, ability for patients to communicate sooner, decreased risk of pulmonary infection, decreased length of stay, decreased cost, and improved patient and family satisfaction.

Predictors of respiratory complications in patients with C5-T5 spinal cord injuries.

Study designRetrospective chart audit.ObjectivesDescribing the respiratory complications and their predictive factors in patients with acute traumatic spinal cord injuries at C5–T5 level during the initial hospitalization.SettingHospital Vall d’Hebron, Barcelona.MethodsData from patients admitted in a reference unit with acute traumatic injuries involving levels C5–T5. Respiratory complications were defined as: acute respiratory failure, respiratory infection, atelectasis, non-hemothorax pleural effusion, pulmonary embolism or haemoptysis. Candidate predictors of these complications were demographic data, comorbidity, smoking, history of respiratory disease, the spinal cord injury characteristics (level and ASIA Impairment Scale) and thoracic trauma. A logistic regression model was created to determine associations between potential predictors and respiratory complications.ResultsWe studied 174 patients with an age of 47.9 (19.7) years, mostly men (87%), with low comorbidity. Coexistent thoracic trauma was found in 24 (19%) patients with cervical and 35 (75%) with thoracic injuries (p < 0.001). Respiratory complications were frequent (53%) and were associated to longer hospital stay: 83.1 (61.3) and 45.3 (28.1) days in patients with and without respiratory complications (p < 0.001). The strongest predictors of respiratory complications were: previous respiratory disease (OR 5.4, 95% CI: 1.5–19.2), complete motor function impairment (AIS A–B) (OR 4.7, 95% CI: 2.4–9.5) and concurrent chest trauma (OR 3.73, 95% CI: 1.8–7.9).ConclusionsRespiratory complications are common in traumatic spinal cord injuries between C5–T5. We identified previous respiratory disease, complete motor function impairment and the coexistence of thoracic trauma as predictors of respiratory complications. Identification of patients at risk might help clinicians to implement preventive strategies.

Comparative Effectiveness of Laterally Placed Expandable versus Static Interbody Spacers: A 1-Year Follow-Up Radiographic and Clinical Outcomes Study.

Study DesignRetrospective chart review.PurposeThis study compared the clinical and radiographic outcomes of patients treated with expandable and static interbody spacers following minimally invasive lateral lumbar interbody fusion (MIS-LLIF) with 12-month follow-up.Overview of LiteratureA common surgical option for the treatment of degenerative disk disease (DDD) is MIS-LLIF using static or expandable spacers to restore disk height (DH), neuroforaminal height (NH), and segmental lordosis. Static spacers may require excessive trialing and aggressive impaction, potentially leading to endplate disruption and subsidence. Expandable spacers allow for in situ expansion to help address complications associated with static spacers.MethodsThis is an Institutional Review Board-exempt review of 69 patients (static, n=32; expandable, n=37) diagnosed with DDD who underwent MIS-LLIF at 1–2 contiguous level(s) using static or expandable spacers. Radiographic and clinical outcomes were collected and compared at pre- and postoperative time points up to 12 months.ResultsThe expandable group had a significantly higher mean change in Visual Analog Scale (VAS) scores at 6 weeks, 6 months, and 12 months vs. static (∆VAS at 12 months: expandable, 6.7±1.3; static, 5.1±2.6). Mean improvement of Oswestry Disability Index (ODI) scores at 3, 6, and 12 months were significantly better for the expandable group vs. static (∆ODI at 12 months: expandable, 63.2±13.2; static, 29.8±23.4). Mean DH and NH significantly increased at final follow-up for both groups, with no significant difference in DH improvement between groups. The expandable mean NH improvement at 6 weeks and 6 months was significantly greater vs. static. Segmental lordosis significantly improved in the expandable group at all time intervals vs static. Subsidence rate at 12 months was significantly lower in the expandable group (1/46, 2.2%) vs. static (12/37, 32.4%).ConclusionsExpandable spacers resulted in a significantly lower subsidence rate, improve segmental lordosis, and VAS and ODI outcomes at 12 months vs. static.

0923 Doxepin in Children and Adolescents With Symptoms of Insomnia: A Single Center Experience

Abstract Introduction Pediatric insomnia is a widespread problem and especially difficult to manage in children with neurodevelopmental disorders. There are currently no FDA- approved medications for pediatric patients to use once first line therapy fails. Doxepin is FDA-approved at low doses for use in transient or chronic sleep maintenance insomnia in adults. The objective of this study is to determine the tolerability and efficacy of doxepin in the pediatric population. Methods This is a retrospective single center chart review of children and adolescents (2-17 years of age) whose sleep failed to improve with behavioral intervention and melatonin who were then trialed on doxepin. Treatment was initiated at a median starting dose of 2mg and slowly escalated to a median maintenance dose of 10mg. Improvement in sleep was recorded using a 4-point Likert scale reported by parents on follow up visits. Results Total of 29 patients were included in analysis. Mean follow-up duration was 6.5 months (±3.5). Out of 29 patients, 4 (13.8%) patients discontinued doxepin due to lack of efficacy or side effects. 8 (27.6%) patients showed significant improvement of their insomnia, 8 (27.6%) showed moderate, 10 (34.5%) showed mild and 3 (10.3%) showed minimal to no improvement on treatment with doxepin (P&amp;lt;0.05) Only two patients (6.8%) experienced adverse effects in the form of behavioral side effects (aggression) and enuresis. Conclusion Our data suggests that doxepin is effective, safe and well-tolerated in the treatment of sleep initiation and maintenance insomnia as well as psychophysiological insomnia in child and adolescents with Ausitsm specutrm disorder, other neuro-developmental disorders and attention deficit hyperactivity disorder. It is also an effective, safe, and well-tolerated alternative in children suffering from chronic persistent insomnia. The results of this study suggests a promising emerging therapy for the treatment of insomnia in the pediatric population. Support None

Sensitivity of High-Resolution Computed Tomography in Otosclerosis Patients undergoing Primary Stapedotomy.

To determine the incidence of abnormal otospongiotic or otosclerotic findings on high-resolution computed tomography (HRCT) as read by local radiologists in patients with surgically-confirmed otosclerosis. Retrospective chart review. Tertiary-referral private otology-neurotology practice. Adults (>18 years old) with surgically-confirmed otosclerosis between 2012 and 2017 with a HRCT performed preoperatively. Preoperative HRCT then stapedotomy. Positive identification and location of radiographic otosclerosis as reported by the local radiologist. We then correlated the CT with surgical location as documented at time of surgery. Audiometry, demographic data, intraoperative findings, and surgical technique were secondarily reviewed. Of the 708 stapes surgeries were performed during the study time frame. Preoperative HRCT scans were available for 68 primary stapedotomy surgeries performed in 54 patients. Otosclerosis was reported in 20/68 (29.4%). Following a negative report by the local radiologist, a re-review by the surgeon and/or collaborating neuroradiologist confirmed otosclerosis in 12/48 additional cases (25.0%). There was an overall sensitivity of 47.1%. Intraoperatively, cases with negative reads tended to have more limited localization at the ligament (8.7%) or anterior crus (39.1%), compared with positive reads, which demonstrated more extensive involvement, with bipolar foci (30.0%) or diffuse footplate manifestations (20.0%) more common. Acoustic reflexes were characteristically absent. While HRCT may aid in the diagnosis of otosclerosis and rule out concomitant pathology in certain cases of clinical uncertainty or unexplained symptoms, its sensitivity for otosclerosis remains low. HRCT should not be relied upon to diagnose routine fenestral otosclerosis.

Capecitabine therapy in recurrent/metastatic nasopharyngeal cancers.

e18515 Background: A wide range of chemotherapeutic agents have demonstrated antitumor activity in patients with recurrent or metastatic Nasopharyngeal Cancers (NPC). These therapeutic agents have different efficacy and toxicity profile. Capecitabine monotherapy had activity in recurrent/metastatic NPC based on small previous retrospective studies. The primary objective is to evaluate the overall response rate and tolerability of capecitabine in recurrent/metastatic NPC. Methods: A retrospective electronic chart review performed for 51 cases of recurrent/metastatic NPC patients who received capecitabine 1000-1,250 mg/m² twice daily two weeks on, one week off between 2011 to 2019 at King Faisal Specialist Hospital &amp; Research Center (KFSH&amp;RC). The Common Terminology Criteria for Adverse Events (CTCAE) Version 5.0 was used. Results: The median age at diagnosis was 42 years. 98% had a non-keratinized undifferentiated squamous cell carcinoma (Grade III). The most common sites for metastases were Bone (58.3%), Lung (50.0%), and liver (45.8%). 95% of patients received platinum-based chemotherapy and radiation therapy as the primary treatment. Capecitabine was used as the second or third line of treatment in the metastatic setting 45.1% and 43.1%, respectively. The patients tolerated the standard dose for a median of 6 cycles; only 20.0% of patients required a 25% dose reduction. The best response for capecitabine was complete response in 8 patients (15.7%), partial response in 14 patients (27.5%), stable disease in 10 patients, (19.6%), with a clinical benefit achieved in 32 patients (62.7%), and progressive disease in 16 patients (31.4%). The overall response rate to capecitabine was 43.2%, which was consistent regardless of the site of metastasis. The median progression-free survival was seven months (95%.CI: 5.3 -8.8). The one and three-year survival rates were 79% and 53%, respectively. Capecitabine was generally tolerated, the most common grade I &amp; II adverse events were hand-foot syndrome (HFS) in 9 patients (20.5%), fatigue in 8 patients (15.7%), Diarrhea in 6 patients (11.7%), anemia in 5 patients (9.8 %), thrombocytopenia in 4 patients (7.8%) and neutropenia in 2 patients (4.0%). The most common grade III &amp; IV was HFS in 3 patients (6%) and fatigue in one patient (2%) that led to treatment discontinuation after the first cycle. Conclusions: Capecitabine in Recurrent/Metastatic NPC is an effective and well-tolerated oral agent; however, a randomized prospective trial to evaluate capecitabine efficacy in this setting still recommended.

A multicenter chart review study of patients with metastatic pancreatic ductal adenocarcinoma receiving liposomal irinotecan after gemcitabine-based therapy.

e16733 Background: Real-world data allows healthcare decision-makers to assess and manage therapeutic and economic options for patients, including those who would and would not have met eligibility criteria for randomized control trials (RCT) and are instead managed under usual care. This retrospective multi-academic center chart review study describes real-world characteristics and outcomes of US patients receiving liposomal irinotecan for the management of metastatic pancreatic ductal adenocarcinoma (mPDAC). Methods: Patients with mPDAC treated with liposomal irinotecan were eligible. Initiation of liposomal irinotecan defined index date; covariates assessed included clinical characteristics and treatment patterns; real-world overall survival (rwOS) was assessed via Kaplan-Meier methodology. The target enrollment is 300 patients. The study centers included were Memorial Sloan Kettering Cancer Center, Cedars-Sinai Medical Center, Emory Winship Cancer Institute, Houston Methodist Cancer Center, Henry Ford Cancer Institute, and University of Pittsburgh Medical Center. Results: Data on 26 patients were available for initial analyses. Mean age was 68 years; 58% were female and 65% Caucasian. 54% of patients had stage IV disease at first diagnosis, and 17%, 65%, and 17% had index ECOG score of 0, 1, and 2, respectively. Common genetic mutations include KRAS (40%) and TP53 (40%). Prior to liposomal irinotecan, treatments received for metastatic disease include gemcitabine+nab-paclitaxel (77%) and fluorouracil (5-FU)/leucovorin (LV)+irinotecan+oxaliplatin (19%). Patients had received 0 (12%), 1 (23%), and ≥2 (65%) lines of therapy in the metastatic setting prior to liposomal irinotecan. Mean duration of liposomal irinotecan use was 3.0 months; liposomal irinotecan was mostly received with 5-FU (23%) or 5-FU/LV (69%). Median rwOS was 4.9 months (95% CI: 3.0, 6.3). Conclusions: Real-world data of the first 26 patients in this study show patients treated with liposomal irinotecan are older, sicker, and have had more lines of therapy than previously reported in RCT data.

A simple method to establish antegrade cerebral perfusion during hemiarch reconstruction.

ObjectiveWe describe a novel and safe technique using a 12F–14F pediatric arterial cannula to establish unilateral, selective, antegrade cerebral perfusion (ACP) during open hemiarch reconstruction.MethodsBetween January 2015 and September 2018, 42 patients underwent elective aortic aneurysm repair requiring an open distal anastomosis and at least a hemiarch replacement via hypothermic circulatory arrest by 2 surgeons. All distal reconstructions were performed at moderate hypothermia (22°C–26°C) with direct cannulation of the innominate artery (IA) using a pediatric arterial cannula to allow ACP at 10–15 mL/kg/min. Data were collected by retrospective chart review.ResultsThirty-one of the 42 patients (74%) were male. The mean patient age was 65 ± 13 years, and the mean body surface area was 2.1 ± 0.3 m2. Proximal repairs included a modified Bentall with a valve-graft composite (n = 17), valve-sparing root replacement (n = 2), and aortic valve replacement (n = 15). Perioperative mortality was 2% (n = 1), and the incidence of stroke was 0%. The mean lowest core body temperature reached during circulatory arrest was 23.8 ± 2.7°C with a mean ACP time of 21.8 ± 3.6 minutes. The mean aortic cross-clamp and cardiopulmonary bypass times were 160.6 ± 55.5 minutes and 204.7 ± 57.5 minutes, respectively. There were no cases of IA injury.ConclusionsDirect IA cannulation with a pediatric arterial cannula is a safe and efficient method to allow ACP in aortic surgery requiring hypothermic circulatory arrest and may circumvent the potential complications of axillary cannulation.

PEDIATRIC ORTHOPEDIC RADIOGRAPH REDUCTION: A QUALITY IMPROVEMENT INITIATIVE

Background:Children are more vulnerable to ionizing radiation which increases health risks later in life including cancer. An interdepartmental team developed an algorithm to guide providers ordering extremity radiographs in pediatric patients with musculoskeletal (MSK) injuries.Purpose:Reduce unnecessary pediatric radiation/extremity radiographs through development and implementation of an interdepartmental designed algorithm. Determine utility, safety, and efficacy of the algorithm through retrospective and prospective analysis.Methods:Our study was performed at an academic pediatric trauma center. An interdepartmental committee including pediatric orthopedic surgery, emergency medicine, trauma, and radiology providers created a MSK injury imaging algorithm (Figure 1). We retrospectively validated the algorithm for efficacy and safety through chart review of pediatric patients seen in the ED with MSK extremity injury, identified through CPT code, from 6/24/2016 through 8/31/2016. We determined the number of extra radiographs per patient and identified if injuries would be missed utilizing our protocol. After retrospective validation, guideline implementation was undertaken through multidisciplinary education. The imaging guideline was prospectively implemented in the pediatric ED from 6/24/2018 through 8/31/2018. We continued to prospectively evaluate through selecting one week every month over the following eight months to determine sustainability of the implemented algorithm.Results:Our interdepartmental team in 2016 developed a pediatric MSK radiograph protocol (Figure 1). A retrospective chart and radiograph review of 295 pediatric patients between 6/24/2016 through 8/31/2016 was analyzed correlating physical examination to appropriate radiographs. Utilizing the protocol, the review revealed an average of 2.75 extra radiographs per patient. No injuries were missed. Providers including orthopedic and emergency medicine attendings, mid-levels, and residents were educated through meetings, emails, and having the protocol posted and easily accessible. Our protocol was implemented 6/24/18 and underwent prospective enrollment and review through 8/31/18 which revealed a reduction to 0.72 radiographs per patient (P-value <0.001) (Figure 2). Eight month follow up revealed a sustainable reduction in extra radiographs per patient (Figure 3).Conclusion:Reduction of unnecessary radiation to pediatric patients with MSK extremity injuries was accomplished through development and implementation of a safe and effective imaging algorithm. The multidisciplinary approach combined with widespread education of pediatric providers improved buy-in driving a sustainable system improvement.Figure 1.Pediatric Extremity Injury AlgorithmFigure 2.Average number of radiographs per pediatric patient not indicated by imaging algorithms before and after protocol implementation. (P<0.001)Figure 3.Eight month follow up of average number of extra radiographs per patient

Evaluation of Sedation Outcomes Following Increased Dexmedetomidine Use in the ICU.

Objective:To evaluate sedation practices following a dexmedetomidine guideline update in the ICU.Design:Single-center, retrospective chart review.Setting:Tertiary academic medical center.Patients:Patients were included in this analysis if they were admitted to the ICU and were ordered for continuous infusion sedatives or opioids from September to November 2016 (PRE) and from September to November 2017 (POST). Patients were excluded from this analysis if they met any of the following criteria: mechanical ventilation less than 12 hours, admitted with acute neurologic injury, burn of greater than 20% total body surface area, chronic tracheostomy, admitted to the neuroscience or cardiac surgery ICU, on extracorporeal membrane oxygenation support, or received an infusion of neuromuscular blockers.Interventions:Patients admitted during a restricted dexmedetomidine prescribing guideline were compared with patients admitted during an expanded prescribing guideline.Measurements and Main Results:Of the 1,426 patients evaluated for inclusion, 427 patients met the criteria in this analysis. Of these, 217 patients were in the PRE and 210 patients in the POST. A majority of patients were excluded for admission to neuroscience or cardiac surgery ICU. Dexmedetomidine was used in 13.8% of encounters in the PRE and 51.9% of encounters in the POST (p < 0.001). The median duration of mechanical ventilation was 49 hours (24–110 hr) in the PRE and 47.5 hours (26–98 hr) in the POST (p = 0.8). ICU length of stay was a median of 136 and 121 hours in the PRE and POST, respectively (p = 0.2). The median hospital length of stay was 296 and 326 hours in the PRE and POST, respectively (p = 0.35). After controlling for possible confounders, ventilation time remained unchanged between the PRE and POST (p = 0.98).Conclusions:The expansion of a hospital dexmedetomidine prescribing guideline resulted in an increased use of dexmedetomidine but was not associated with a difference in length of mechanical ventilation.

Opioid overdoses: Emerging clinical challenges.

Analysis of a large consecutive case series of cases brought to an Emergency Department (ED). Retrospective chart review. Emergency Department in Broward County, Florida. Medical records of patients with registered diagnoses of opioid overdose in 2016 and 2017. Demographics, toxicology results, mental-health comorbidities, use/response to naloxone, and hospital disposition. Seven hundred and seventy nine opioid-overdose cases were identified (35 percent female, 65 percent male; age 36.2). Her-oin intoxication was registered in 77 percent of discharge diagnoses, and 17.7 percent were prescription pain medications. Urine sam-ples were collected in 39 percent and 81.5 percent of patients received naloxone (mean dose 4.0 mg ± 2.2). Sixty-five percent of cases were discharged home, 17.5 percent left the ED against medical advice, and 17.5 percent were admitted to the hospital/intensive care unit/behavioral unit. There is an alarming number of visits to the ED due to opioid overdoses with differences in age and gender. Clinicians are facing diagnostic, treatment and follow-up challenges for the management of these cases.

Neuro R2 score: Predicting high-risk neurologic readmissions within 30 days.

To evaluate clinical and demographic factors of patients with neurologic disorders to determine which patient characteristics are significant for predicting 30-day hospital readmissions to develop a readmission risk predictor specific to patients with neurologic disorders. We performed a retrospective single-center chart review for all patients admitted to the Department of Neurology or neurologic intensive care unit from January 1, 2013, to December 31, 2017. Clinical and demographic factors were analyzed to determine the association with readmission. Multivariable logistic regression analysis was performed and validated to develop a simple tool (Neuro R2 score) for predicting patients with neurologic disorders at high risk for hospital readmission. After removal of planned readmissions and patients who died in the hospital, the records of 4,876 patients with 314 (6.4%) readmission events were analyzed. The strongest predictors for readmission were Charlson disease count (odds ratio [OR] 1.20, 95% confidence interval [CI] 1.06-1.35, p = 0.005), urgent or emergent admission (OR 1.50, 95% CI 1.04-2.17, p = 0.031), discharge to rehabilitation (OR 1.66, 95% CI 1.16-2.35, p = 0.005), cancer (OR 1.70, 95% CI 1.15-2.50, p = 0.007), brain tumor (OR 1.82, 95% CI 1.08-3.09, p < 0.03), cerebrovascular disease (OR 2.18, 95% CI 1.53-3.11, p < 0.001), and discharge to skilled nursing facility (OR 2.43, 95% CI 1.65-3.57, p < 0.001). The Neuro R2 score was developed to predict readmission risk, specifically in patients with neurologic disorders. Future research could include further validation of this readmission risk tool and strategies to reduce readmission in patients with the highest risk.