Retrospective Case-cohort Study Research Articles

Prevalence of seizures in dogs and cats with idiopathic internal hydrocephalus and seizure prevalence after implantation of a ventriculo-peritoneal shunt.

BackgroundSeizures are considered a clinical sign in dogs with internal hydrocephalus but are not found in recent studies. Seizure prevalence due to ventricular enlargement and the prevalence of postoperative seizures in animals is not known.ObjectivesTo determine seizure prevalence in dogs and cats with idiopathic internal hydrocephalus, to identify risk factors for seizure development, and to determine seizure prevalence in a 2‐year period after ventriculo‐peritoneal shunting (VPS).AnimalsRecords and MRIs of 197 animals from 2001 to December 2019 were investigated. A total of 121 animals (98 dogs and 23 cats) were included in the study.MethodsA retrospective multicenter case cohort study was conducted. Databases were searched for dogs and cats with internal hydrocephalus. MRI and CSF examinations were evaluated for signs of additional underlying disorders. Prevalence of seizures was estimated for animals showing only hydrocephalus internus. Risk factors were evaluated according to age, morphometric and morphological findings in the brain. All animals that underwent surgery were reexamined 2 years after surgery.ResultsOne hundred twenty‐one animals (98 dogs and 23 cats) with internal hydrocephalus met the inclusion criteria. Seizure prevalence in dogs and cats with internal hydrocephalus was low (1.7%; <5.8% CI 95%). Seizures were not observed in the 2‐year period after surgery.Conclusion and Clinical ImportanceSeizure prevalence in dogs and cats diagnosed with hydrocephalus internus is low. Seizures in association with VPS do not seem to be a complication of the procedure.

Patient-Reported Outcome Measures and Radiological Outcomes in Mobile-Bearing Total Ankle Arthroplasty With Varus or Valgus Deformity.

There is increasing evidence that varus deformity does not negatively affect total ankle arthroplasty (TAA) outcomes, but there is a sparsity of evidence for valgus deformity. We present our outcomes using a mobile-bearing prosthesis for neutral, varus, and valgus ankles. This is a retrospective cohort study of consecutive cases identified from a local joint registry. In total, 230 cases were classified based on preoperative radiographs as neutral (152 cases), varus greater than 10 degrees (60 cases), or valgus greater than 10 degrees (18 cases). Tibiotalar angle was again measured postoperatively and at final follow-up (mean follow-up of 55.9 months). A total of 164 cases had adequate patient-reported outcome measures data (Foot and Ankle Outcome Score, Short Form-36 [SF-36] scores, and patient satisfaction) for analysis (mean follow-up of 61.6 months). The groups were similar for body mass index and length of follow-up, but neutral ankles were younger (P = .021). Baseline scores were equal except SF-36 physical health, with valgus ankles scoring lowest (P = .045). Valgus ankles had better postoperative pain (P = .025) and function (P = .012) than neutral. Pre- to postoperative change did not reach statistical significance except physical health, in which valgus performed best (P = .039). Mean final angle for all groups was less than 5 degrees. There was no significant difference in revision rates. Our study is consistent with previous evidence that varus deformity does not affect outcome in TAA. In addition, in our cohort, outcomes were satisfactory with valgus alignment. Postoperative coronal radiological alignment was affected by preoperative deformity but within acceptable limits. Coronal plane deformity did not negatively affect radiological or clinical outcomes in TAA. Level III, retrospective comparative study.

Attributable Length of Stay, Mortality Risk, and Costs of Bacterial Health Care-Associated Infections in Australia: A Retrospective Case-cohort Study.

BackgroundUnbiased estimates of the health and economic impacts of health care–associated infections (HAIs) are scarce and focus largely on patients with bloodstream infections (BSIs). We sought to estimate the hospital length of stay (LOS), mortality rate, and costs of HAIs and the differential effects on patients with an antimicrobial-resistant infection.MethodsWe conducted a multisite, retrospective case-cohort of all acute-care hospital admissions with a positive culture of 1 of the 5 organisms of interest (Escherichia coli, Klebsiella pneumoniae, Pseudomonas aeruginosa, Staphylococcus aureus, or Enterococcus faecium) from 1 January 2012 through 30 December 2016. Data linkage was used to generate a data set of statewide hospital admissions and pathology data. Patients with bloodstream, urinary, or respiratory tract infections were included in the analysis and matched to a sample of uninfected patients. We used multistate survival models to generate LOS, and logistic regression to derive mortality estimates.ResultsWe matched 20 390 cases to 75 635 uninfected control patients. The overall incidence of infections due to the 5 studied organisms was 116.9 cases per 100 000 patient days, with E. coli urinary tract infections (UTIs) contributing the largest proportion (51 cases per 100 000 patient days). The impact of a UTI on LOS was moderate across the 5 studied pathogens. Resistance significantly increased LOS for patients with third-generation cephalosporin-resistant K. pneumoniae BSIs (extra 4.6 days) and methicillin-resistant S. aureus BSIs (extra 2.9 days). Consequently, the health-care costs of these infections were higher, compared to corresponding drug-sensitive strains.ConclusionsThe health burden remains highest for BSIs; however, UTIs and respiratory tract infections contributed most to the health-care system expenditure.

Analysis of maternal and perinatal determinants of allergic sensitization in childhood

BackgroundNon-communicable diseases, such as allergies, are influenced by both genetic and epigenetic factors. Perinatal determinants conceivably modify the epigenetic makeup of the developing fetal immune system preventing or predisposing the development of allergies. The aim of this study therefore was to identify independent perinatal factors associated with allergic sensitization in childhood.MethodsIn a single center retrospective case-cohort study electronic obstetric medical records and available skin prick testing results of children were analyzed. For the analysis 286 skin prick test positive (sensitized) children [median (IQR): 3.47 (1.70–7.34) years] were compared with data from all remaining live births in the obstetric cohort (n = 66,583).ResultsSensitized children more frequently had a mother born in Asia (19.1% vs. 10.2%; P < 10–6). Applying backward elimination logistic regression, seven out of 23 initially entered perinatal factors remained in the model. High maternal age (> 35 years; OR: 1.912; P < 0.001), male offspring sex (OR: 1.423; P < 0.01) and assisted conception (OR: 1.771; P < 0.05) increased the risk for allergic sensitization. In contrast, maternal smoking (OR: 0.469; P < 0.005), increasing parity (OR: 0.881; P < 0.05), maternal pre-pregnancy overweight (OR: 0.742; P < 0.005) and preterm birth (OR: 0.484; P < 0.05) decreased the risk for allergic sensitization.ConclusionsIn addition to supporting previous findings, this study is first to report an increased risk of allergic sensitization after assisted conception. Beyond this finding’s potential implementation in preventative strategies, exploration of this association could further pathophysiological understanding of allergic disease.

Epidemiology of varicella among immigrants and non-immigrants in Quebec, Canada, before and after the introduction of childhood varicella vaccination: a retrospective cohort study

Many immigrants are susceptible to varicella on arrival to Canada because of different transmission dynamics in their countries of origin and scarcity of vaccination. Universal childhood vaccination programmes decrease varicella incidence rates through herd immunity, but the accumulating number of susceptible adult immigrants could remain at risk for severe varicella. Our aim was to describe the epidemiology of varicella among immigrants and non-immigrants before and after childhood varicella vaccination. We did a population-based, retrospective cohort study of all varicella cases in Quebec, Canada, diagnosed between 1996 and 2014 in administrative health databases linked to immigration data. Cases of varicella met diagnostic codes in the International Classification of Diseases, Ninth and Tenth Revision Canadian modifications. Cases with a co-occurring zoster diagnostic code and immigrants from Australia, New Zealand, the USA, and western European countries were excluded. Vaccination periods included pre-vaccination (1996-98), private vaccination (1999-2005), and public vaccination (2006-14). Incidence rate and comparative rate ratios were estimated using census data. A total of 231 339 varicella cases diagnosed between Jan 1, 1996, and Dec 31, 2014, were linked to 1 115 696 immigrants who arrived between Jan 1, 1980, and Dec 31, 2014. 1444 herpes zoster cases and 1276 immigrants from Australia, western Europe, New Zealand, and the USA were excluded. Among 228 619 varicella cases, 13 315 (5·8%) occurred in immigrants. In pre-vaccination versus public vaccination periods, varicella incidence declined in immigrants by 87% (95% CI 86·6-87·9; 324·3 cases per 100 000 person-years to 40·9 cases per 100 000 person-years) and in non-immigrants by 93% (92·4-92·7; 484 cases per 100 000 person-years to 36 cases per 100 000 person-years). Mean age at diagnosis increased in both groups (15·1 vs 19·4 years in immigrants and 8·4 vs 12·0 years in non-immigrants). In the public vaccination period, immigrants younger than 50 years had higher varicella rates than non-immigrants, with relative risk ranging from 1·53 (95% CI 1·37-1·72) to 4·64 (3·90-5·53) with the highest risk in adolescents and young adults, and people from Latin America and the Caribbean (age-specific incidence rate ratio [aIRR]I-NI pre-vaccination 2·19 and post-vaccination aIRRI-NI6·07) and south Asia (aIRRI-NI pre-vaccination 3·41 and aIRRI-NI post-vaccination 4·46) and in childbearing women (15-40 years; IRRI-NI 2·48). Immigrant adolescents, young adults, and women of childbearing age had higher age-standardised rates of varicella than non-immigrants, with increasing disparities following vaccine introduction. Immigrants younger than 50 years of age would benefit from targeted vaccination upon arrival to host countries. The Canadian Institutes of Health Research and The Department of Medicine, Jewish General Hospital, Montreal, QC, Canada.

Neonatal Candida auris infection: Management and prevention strategies - A single centre experience.

Our aim was to identify the clinical features and outcome of multidrug resistant Candida auris (CA) infection in neonates. This is a retrospective case cohort study of 17 neonates who developed sepsis caused by CA infection in a tertiary care neonatal intensive care unit over 3 years. The risk factors, clinical features, treatment and outcome were studied. The mean gestation was 32.4 ± 4.9 weeks with overall mortality of 41%. Clinical features were indistinguishable from other causes of sepsis. CA was sensitive to micafungin but resistant to fluconazole and had variable sensitivity to voriconazole and amphotericin. Survival improved to 83% when infants were treated with a combination of micafungin and amphotericin. Non-survivors were of lower birthweights and had other risk factors. The management guidelines and infection control measures are described in this largest series of neonatal CA infection. Treatment with a combination of amphotericin and micafungin improved the outcome.

Metabolic control, cardiovascular profile, and adherence to the Mediterranean diet in a familial hypercholesterolemia cohort in a Public Health Program

Introduction and objective: familial heterozygous hypercholesterolemia (HFH) is the most common monogenic lipid metabolism disorder that associates premature cardiovascular disease. Our aim was to describe the degree of metabolic control, cardiovascular profile, and adherence to the Mediterranean diet in a cohort of HFH patients. Subjects and methods: a retrospective cohort study of the index cases and their relatives genetically diagnosed with HFH by the Endocrinology and Nutrition Service in the HCUV from 2009 to 2017. Anthropometric, clinical, laboratory, genetic, and treatment data were analyzed. Results: a total of 138 subjects were studied, with a mean age of 48.8 (17.7) years, 55.8% of them women. A gene mutation was found in 55.8%, and 10.1% had previous ischemic heart disease. At diagnosis mean total cholesterol was 281.1 (68.4) mg/dL, and LDL-C was 204 (65) mg/dL. Among family cases, at diagnosis, a lower mean age was observed [32.89 (19.2) years vs 50.3 (17.6) years, p < 0.001] as well as lower LDL values [181.9 (64.3) mg/dL vs 226.8 (52) mg/dL, p < 0.005] as compared to index cases. A positive correlation was observed between lipid-lowering treatment dose and LDL level reduction (r = 0.254, p < 0.05), although only 30% of patients reached their LDL target. Patients with HFH were highly adherent to Mediterranean diet, with an average score of 9.5 (1.9) in the Predimed test. Conclusions: early HFH detection is necessary to prevent premature cardiovascular events. A diagnosis of cases among family members anticipates the treatment of patients with HFH. Patients with HFH are more sensitive to heart-healthy diets.

Trends of tuberculosis case detection, mortality and co-infection with HIV in Ghana: A retrospective cohort study.

In an era of renewed commitment to accelerate the declines in Tuberculosis (TB) incidence and mortality, there is the need for National Tuberculosis Programmes (NTPs) to monitor trends in key indicators across a geographical location and to provide reliable data for direct measurement of TB incidence and mortality. In this context, we explored the trends of TB case detection, mortality and HIV co-infection, and examined the predictors of TB deaths in Ten districts of the Volta region of Ghana. We conducted a retrospective cohort study of all TB cases registered from 2013 to 2017 in 10 districts of the Volta Region of Ghana. Case detection rate (CDR) was computed as the ratio of the number of new and relapse TB case notified to NTP to the number of estimated incident TB cases in a given year. Case fatality rates were estimated using data from 2012-2016 cohort of TB patients. Simple and multiple logistic regression were used to identify predictors of TB deaths with odds ratios and 95% confidence intervals estimated. Overall, there were 3,735 new and relapse TB patients who commenced anti-TB treatment during the period, representing the case detection rate of 40.1% with district variations. The CDR remained stable during the 5 years. Of the total cases, HIV status was documented for 3,144 (84.2%), among whom, 712 (22.6%) were HIV positive. The TB/HIV co-infection was more prevalent among children under 15 years of age (30.1%), males (30.6%), treatment after lost to follow-up patients (33.3%), and smear-negative pulmonary TB patients (29.1%). The prevalence of TB/HIV co-infection did not significantly change over the years. The overall case fatality rate was 13% (n = 486), with considerable variation among HIV-positives and HIV-negative TB patients (21.8% and 11% respectively) (p<0.001) and among districts. TB/HIV co-infection, sputum smear-negative pulmonary TB and district of anti-TB treatment predicted TB mortality. TB case detection rate was low and remained stable during the study period, whereas co-infection with HIV and mortality rates were quite high, indicating the need for feasible strategies such as active case finding to improve case detection, and improved case management to reduce mortality.

Immune Cell Associations with Cancer Risk.

SummaryProper immune system function hinders cancer development, but little is known about whether genetic variants linked to cancer risk alter immune cells. Here, we report 57 cancer risk loci associated with differences in immune and/or stromal cell contents in the corresponding tissue. Predicted target genes show expression and regulatory associations with immune features. Polygenic risk scores also reveal associations with immune and/or stromal cell contents, and breast cancer scores show consistent results in normal and tumor tissue. SH2B3 links peripheral alterations of several immune cell types to the risk of this malignancy. Pleiotropic SH2B3 variants are associated with breast cancer risk in BRCA1/2 mutation carriers. A retrospective case-cohort study indicates a positive association between blood counts of basophils, leukocytes, and monocytes and age at breast cancer diagnosis. These findings broaden our knowledge of the role of the immune system in cancer and highlight promising prevention strategies for individuals at high risk.

The Surgical Approach to Abdominal Sacrocolpopexy and Concurrent Hysterectomy: Trends for the Past Decade.

The aim of the study was to understand the surgical trends and 30-day complications of patients undergoing an abdominal sacrocolpopexy with a concurrent hysterectomy. This is a retrospective cohort study of surgical cases from the American College of Surgeons National Surgical Quality Improvement Program from 2010 to 2017 who underwent an abdominal sacrocolpopexy and a concurrent hysterectomy. There were 9327 surgical cases of an abdominal sacrocolpopexy with a concurrent hysterectomy of which 7772 (83.3%) were minimally invasive and 1555 (16.7%) were through a laparotomy. The proportion of patients undergoing a laparotomy decreased by 2.4% per year from 2010 to 2018 (R2 = 0.77). Among minimally invasive procedures, 4359 (46.7%) involved a concurrent supracervical hysterectomy and 4968 (53.3%) involved a concurrent total hysterectomy. Among minimally invasive procedures, patients who had a concurrent supracervical hysterectomy both had a longer operative time and were more likely to be admitted at least 2 days postoperatively compared with those who had a concurrent total hysterectomy (P < 0.001 for both). Patients undergoing an abdominal sacrocolpopexy and concurrent hysterectomy are increasingly likely to undergo surgery in a minimally invasive approach. The Food and Drug Administration safety communication on electric power morcellation did not impact this trend. Although complication rates are low, regardless of the type of concurrent hysterectomy, some complications, such as blood transfusions and surgical site infections, seem to be highest for those undergoing a concurrent total hysterectomy despite the fact that a concurrent supracervical hysterectomy may be associated with a longer operative time and longer hospital admission.

High-frequency electrical stimulation of the anterior thalamic nuclei increases vigilance in epilepsy patients during relaxed and drowsy wakefulness.

High-frequency deep brain stimulation (DBS) of anterior thalamic nuclei (ANT) reduces the frequency and intensity of focal and focal to bilateral tonic-clonic epileptic seizures. We investigated the impact of high-frequency ANT-DBS on vigilance in epilepsy patients during relaxed and drowsy wakefulness, to better understand the effects and the mechanisms of action of this intervention in humans. Four patients with different structural epileptic pathologies were included in this retrospective case-cohort study. Short- and long-term electroencephalography (EEG) was used to determine states of relaxed or drowsy wakefulness and the vigilance changes during stimulation-on and stimulation-off intervals. In relaxed, wakeful patients with eyes closed, the eyelid artifact rate increased acutely and reproducibly during stimulation-on intervals, suggesting an enhanced vigilance. This effect was accompanied by a slight acceleration of the alpha rhythm. In drowsy patients with eyes closed, stimulation generated acutely and reproducibly alpha rhythms, similar to the paradoxical alpha activation during eyes opening. The occurrence of the alpha rhythms reflected an increase in the vigilance of the drowsy subjects during ANT-DBS. This is the first demonstration that ANT-DBS increases the vigilance of wakeful epilepsy patients. Our results deliver circumstantial evidence that high-frequency ANT-DBS activates thalamocortical connections that promote wakefulness.

Enhanced recovery care versus traditional non-ERAS care following osteotomies in developmental dysplasia of the hip in children: a retrospective case-cohort study

BackgroundEnhanced recovery after surgery (ERAS) has been shown to shorten the length of hospital stay and reduce the incidence of perioperative complications in many surgical fields. However, there has been a paucity of research examining the application of ERAS in major pediatric orthopaedic surgeries. This study aims to compare the perioperative complications and length of hospital stay after osteotomies in children with developmental dysplasia of the hip (DDH) between ERAS and traditional non-ERAS group.MethodsThe ERAS group consisted of 86 patients included in the ERAS program from January 2016 to December 2017. The Control group consisted of 82 DDH patients who received osteotomies from January 2014 to December 2015. Length of hospital stay, physiological function, postoperative visual analogue scale (VAS) score, and postoperative complications were compared between the two groups.ResultsThe mean duration of hospital stay was significantly reduced from 10.0 ± 3.1 in the traditional care group to 6.0 ± 0.8 days in the ERAS(P < 0.001). The average VAS score in the first 3 days was significantly lower in the ERAS group (2.9 ± 0.8) than the traditional non-ERAS group (4.0 ± 0.8) (P < 0.001). However, there was no significant difference in the frequency of break-out pain (VAS > 4) between two groups (29.5 ± 6.3 times vs.30.6 ± 6.5 times, P = 0.276). The frequency of postoperative fever was lower in the ERAS group. The frequency of urinary tract infection in both groups were not noticeable because the catheter was removed promptly after the surgery.ConclusionThe ERAS protocol is both safe and feasible for pediatric DDH patients undergoing osteotomies, and it can shorten the length of hospital stay without increasing the risk of perioperative complications.

Autopsy and postnatal follow-up of prenatally diagnosed ventricular outpouchings.

Prenatal ventricular outpouchings (VOs), which include congenital ventricular aneurysms (CAs) and congenital ventricular diverticula (CD), are very rare. We describe the features and outcomes of prenatal VOs diagnosed over a 4-year period. Retrospective cohort study of cases of prenatal diagnoses of CAs and CD at our center between June 2014 and January 2018. The prenatal and postnatal echocardiogram data were reviewed, and telephone follow-up was conducted of liveborn cases. A total of 25 VOs were identified. Two were lost to follow-up, 15 chose termination of pregnancy, and eight resulted in livebirths. Only two cases underwent autopsy: Histopathology showed that the CA wall was substituted by collagen fibers. At follow-up, none of the eight liveborn babies experienced adverse events, and three VOs near the tricuspid annulus almost disappeared, though one was extremely large. In our center, all liveborn babies with VO had good prognoses. We hypothesize that VOs located near the right ventricular annulus may be caused by prenatally unbalanced pressure, given their decrease in size after birth when the right heart pressure declines.

Facial Nerve Arterial Arcade Supply in Dural Arteriovenous Fistulas: Anatomy and Treatment Strategies.

Endovascular treatment of petrous dural AVFs may carry a risk of iatrogenic facial nerve palsy if the facial nerve arterial arcade, an anastomotic arterial arch that supplies the geniculate ganglion, is not respected or recognized. Our purpose was to demonstrate that the use of a treatment strategy algorithm incorporating detailed angiographic anatomic assessment allows identification of the facial nerve arterial arcade and therefore safe endovascular treatment. This was a retrospective cohort study of consecutive petrous dural AVF cases managed at Toronto Western Hospital between 2006 and 2018. Our standard of care consists of detailed angiographic assessment followed by multidisciplinary discussion on management. Arterial supply, primary and secondary treatments undertaken, angiographic outcomes, and clinical outcomes were assessed by 2 independent fellowship-trained interventional neuroradiologists. Fifteen patients had 15 fistulas localized over the petrous temporal bone. Fistulas in all 15 patients had direct cortical venous drainage and received at least partial supply from the facial nerve arterial arcade. Following multidisciplinary evaluation, treatment was performed by endovascular embolization in 8 patients (53%) and microsurgical disconnection in 7 patients (47%). All patients had long-term angiographic cure, and none developed iatrogenic facial nerve palsy. By means of our treatment strategy based on detailed angiographic assessment and multidisciplinary discussion, approximately half of our patients with petrous AVFs were cured by endovascular treatment, half were cured by an operation, and all had preserved facial nerve function.

Validating the management paradigm for pediatric spinal aneurysmal bone cysts to optimize long-term outcomes: an institutional experience.

The optimal clinical management and outcomes of rare pediatric spinal aneurysmal bone cysts (spABC) is largely anecdotal. Current practice is based on bigger adult series, although given the disparities in spine growth of adults versus children, what impact this difference may have on long-term outcomes has yet to be substantiated. Correspondingly, the aim of this study was to describe the clinical course of all pediatric spABC cases managed at our institution to better understand this. A retrospective cohort study of all pediatric spABC cases presenting to our institution between 1993 and 2017 was performed using a predetermined set of selection criteria. Primary outcomes of interest were treatment modalities and their outcomes, recurrence status, and functional status. A total of 24 pediatric spABC cases satisfied all criteria. Median age of diagnosis was 13.5years, with 15 females and 9 males. Radicular pain was the presenting symptom in 21 (88%) cases. Diagnostic biopsy was pursued in 9 (38%) cases, pre-operative embolization in 8 (33%) cases, surgical intervention in 23 (96%) cases, and sclerotherapy in 2 (8%) cases. In terms of surgery, there were no intraoperative complications, and gross total resection (GTR) was achieved in 14 of the 23 (61%) cases. Overall, there were 5 (21%) cases which experienced recurrence by a median time of 8months after initial surgery, all of which had initial subtotal resection. Median follow-up was 5years, by which all patients demonstrated excellent functional status. There are a number of feasible therapeutic modalities and combinations that can be utilized to maximize control of pediatric spABCs and optimize long-term function similar to that of adults, irrespective of developing versus developed spines. The incidence of recurrence is not negligible, and therefore, rigorous long-term surveillance is highly encouraged, particularly within the first post-operative year following mono-modal non-GTR treatment.

06: Supracervical or total hysterectomy at the time of a laparoscopic colpopexy: national trends in surgical practice

To assess national trends and associated morbidity in the preferred route of hysterectomy for patients undergoing a concurrent laparoscopic colpopexy and to determine if the 2014 FDA safety communication about power morcellation impacted these national trends. A retrospective cohort study of surgical cases from The American College of Surgeons National Surgical Quality Improvement Program was conducted from 2010 to 2017. Patients were included if they underwent a laparoscopic colpopexy and a concurrent hysterectomy. Surgical cases were identified using CPT codes. Patients who underwent concomitant surgery for a gynecologic cancer were excluded. To assess the effect of the 2014 FDA safety warning, an interrupted time-series analysis was conducted comparing the time period from the first quarter of 2010 to the first quarter of 2014 with the time period from the second quarter of 2014 to the fourth quarter of 2017. We identified 7729 surgical cases of which 4292 (55.0%) involved a total hysterectomy and 3480 (45.0%) involved a supracervical hysterectomy. Demographics and comorbidities were similar between the two groups. Overall patients were a mean of 56.5 ± 11.7 years of age at the time of surgery and had a mean BMI of 28.4 ± 5.9 kg/m2. The proportion of patients undergoing an abdominal colpopexy with a concurrent total hysterectomy remained relatively unchanged from 64.2% in 2010 to 52.5% in 2017. In the interrupted time series analysis, we did not see a significant change in the type of hysterectomy performed before and after the 2014 FDA safety communication about the electric power morcellator (p=0.37 in the first quarter after the FDA warning and p=0.26 for the remaining time period). Patients undergoing a concurrent total hysterectomy had similar postoperative morbidity when compared to those undergoing a concurrent supracervical hysterectomy, although patients undergoing total concurrent hysterectomy had higher organ space surgical site infections (0.6% vs. 0.2%, p=0.006). Overall 11.7% of patients undergoing a concurrent total hysterectomy were admitted to the hospital for at least two days following surgery and 17.0% of patients undergoing a supracervical hysterectomy were admitted for at least two days following surgery. Patients undergoing a laparoscopic colpopexy and concurrent hysterectomy are as likely to undergo a concurrent supracervical hysterectomy as a concurrent total hysterectomy and there was no significant changed in this trend from 2010 to 2017. There does not appear to have been a change in the national trends despite the challenges with tissue extraction brought about by the FDA safety communication on power morcellation. The perioperative risks were similar between groups although patients with a concurrent supracervical hysterectomy were more likely to have a hospital admission of at least two days.

57: Age is just a number: in older patients, risk of postoperative admission, readmission and complications after sling procedures for stress incontinence is low

To determine preoperative factors associated with postoperative hospital admission, readmissions, and complications amongst older patients undergoing sling procedures for stress urinary incontinence (SUI). This is a retrospective cohort study of surgical cases from The American College of Surgeons National Surgical Quality Improvement Program which is a nationally validated, multicenter database that contains preoperative, intraoperative and 30-day postoperative data from over 700 hospitals within the United States. We conducted a secondary analysis of surgical cases from 2012 through 2017. Patients were included if they were 65 years of age or greater. Patients undergoing concurrent procedures were excluded from this study. Comorbidities included obesity, diabetes, hypertension, bleeding disorder, steroid use, severe chronic obstructive pulmonary disease, congestive heart failure, ascites, ventilator dependence, dialysis, or acute renal failure. We identified 2692 eligible patients who underwent a sling procedure for SUI. Patients were more likely to be 65-74 years old (71.4%), white (68.4%) and non-Hispanic (66.3%). Comorbidities were common and included obesity (47.7%), hypertension (61.6%), and diabetes (18.1%). There were 454 (16.9%) post-operative admissions, and 48 (1.8%) readmissions. There was no association between the three age groups studied (ages 65-74, 75-84, 85 and over) with overnight admission or readmission. An ASA classification of III or IV was associated with an increased risk of overnight admission (risk ratio (RR) 1.4, 95% confidence interval (CI) 1.2-1.7) and readmission (RR 2.1, 95% CI 1.2-3.6). There appears to be an increased risk in admission and readmission in patients with multiple comorbidities, although our sample size is small. These findings are reflected in Table 1. There were 155 complications (5%), including 65 serious complications (2.4%) such as death, cardiac complication, stroke, renal failure, pulmonary embolism, ventilator use, reintubation, return to the operating room, readmission, or sepsis. There was an association between the number of comorbidities and the overall incidence of complications, serious complications, cardiac arrest and death (p<0.001 for all) as well as incidence of postoperative urinary tract infections (p<0.03). Overall, the risk of inpatient hospitalization and readmission is low in older patients, but patients with multiple comorbidities may be at higher risk. Serious complications are rare, although more likely to present in patients with multiple comorbidities. Older patients with few medical comorbidities who are undergoing a sling procedure for stress urinary incontinence may be reassured that they are not more likely to need postoperative hospitalization nor readmission.

15: National trends in the surgical approach to an abdominal colpopexy with a concurrent hysterectomy

To understand the national trends in laparotomy compared to laparoscopy for patients undergoing an abdominal colpopexy with a concurrent hysterectomy and to more fully characterize the 30-day complications for this subset of patients. This is a retrospective cohort study of surgical cases from The American College of Surgeons National Surgical Quality Improvement Program of female patients who underwent an abdominal colpopexy and concurrent hysterectomy from 2010 through 2017. Patients were classified as having either a laparoscopic abdominal colpopexy with a concurrent hysterectomy or an open abdominal colpopexy with concurrent hysterectomy (laparotomy). We identified 9327 surgical cases, of which 1555 (16.7%) of surgical cases were performed through a laparotomy while 7772 (85.3%) were performed laparoscopically. There were no clinically significant differences in baseline patient characteristics between those who underwent a laparotomy and those had laparoscopy. Patients were a mean of 56.6 ± 11.7 years of age at the time of surgery and had a mean BMI of 28.3 ± 5.9 kg/m 2. The proportion of patients undergoing a laparotomy decreased by 2.4% per year from 2010 through 2018 (R2=0.77) (Figure 1). Patients undergoing a laparoscopic colpopexy had from similar postoperative morbidity compared to patients undergoing a laparotomy; however, those undergoing a laparotomy were more likely to stay in the hospital 2+ days postoperatively (14.1% vs 68.0%), were more likely to need a blood transfusion (1.9% vs 0.6% p<0.01) and more likely to have a surgical site infection (2.8% vs 1.1%, p<0.01, Table 1). A laparoscopic approach is the most common for patients undergoing a colpopexy and concurrent hysterectomy. As we become increasingly adept at minimally invasive surgery, it is possible that laparotomy will become increasingly rare. We should feel reassured by the lower morbidity associated with minimally invasive surgery despite the longer operative time.View Large Image Figure ViewerDownload Hi-res image Download (PPT)

Abstract TP230: Ischemic Strokes in Anti-Coagulated Patients - Treatment Failure or Alternate Etiology?

Background: Patients experiencing ischemic strokes while already on therapeutic anti-coagulation are often considered anti-coagulant failures if they are compliant with treatment, and pose a management challenge. Stroke etiology in such patients is also often overlooked and they are routinely switched to alternate anticoagulant or combined with an anti-platelet therapy, although evidence is lacking if doing so prevents future ischemic strokes. Objective: To identify determinants and mechanisms of strokes in patients who experience ‘breakthrough ischemic strokes’ while already on therapeutic anticoagulation. Methods: We conducted a retrospective case-cohort study of patients presenting to Cleveland Clinic Akron General between January 2013 - December 2017. Patients were included if they had an ischemic stroke diagnosis on admission and were already on therapeutic anticoagulation at the time, who were then compared against a matched cohort from the same time period. Treatment compliance was determined using manual chart review. Stroke etiology was determined and dichotomized into embolic stroke (ES) vs Non-embolic stroke (NES) etiology based on their history, imaging and ancillary findings. Results: We identified 64 patients who were true breakthrough strokes with complete data and compared them to 119 matched controls. Both groups were similar in age (72±13 years among cases vs 72±16 among cohorts, p=0.795) and sex (Females 69 (58%) among cases vs 30 (47%) among cohorts, p=0.150). History of auto-immune disease was the only co-morbid condition not dependent on anticoagulation status which was significantly higher among cases (9(14%) vs 4(3%), p=0.013). Stroke etiology was similar among both groups, with the anti-coagulated group not necessarily showing a trend towards higher incidence of ES (49 (77%) in cases vs. 83 (70%) in cohort, p=0.327). Conclusion: Ischemic strokes among patients on therapeutic anticoagulation do not necessarily differ in stroke mechanisms compared to routine ischemic strokes, and require a thorough, individualized approach to prevent future stroke risks.

Concordance between clinical diagnosis of pulmonary thromboembolism at hospital discharge and anatomopathological diagnosis.

Half of the cases of pulmonary thromboembolism (PTE) are not diagnosed because of its unspecific clinical presentation; in Mexico, autopsy data reveal a similar incidence to that of developed countries. The objective of this work was to know the concordance between the clinical diagnosis of PTE at hospital discharge and its autopsy diagnosis. The method used was a retrospective cohort study of cases with PTE diagnosis who attended from January 2005 to December 2013. Information was obtained from the autopsies registry and clinical charts. From 177,368 hospital discharges, there were 412 (6.74%) with PTE diagnosis. There were 13,559 deaths, with PTE diagnosis in 139 (1%) patients. There were 479 autopsies, and in 66 (14%) of whom PTE diagnosis was documented, the mean age was 55 years (range, 18–89 years). The premortem diagnosis of PTE at discharge was confirmed in 412 cases. Postmortem diagnosis of principal disease was medical in 49 (74%) and medical-surgical in 17 (26%) patients. We found that nine patients had the clinical diagnosis of PTE, unlike the postmortem diagnosis, which was reported in 66 autopsies. The above allows establishing a 1:7 ratio that represents 14%. D-dimer was determined in 11 cases (16%) and was positive in 8 (73%). Thromboprophylaxis was applied in 15 cases (23%). The study of necropsies and identification of discrepancies is needed to improve the diagnostic accuracy and healthcare quality. The evaluation of hemostasis biomarkers besides D-dimer can better describe the pro-thrombotic state, the risk of thrombosis, and its association with morbidity and mortality.