Single Academic Center Research Articles

Apixaban versus enoxaparin to prevent venous thromboembolism in post-operative patients with gynecologic cancers at an urban academic medical center

ObjectiveA recent clinical trial demonstrated that the use of apixaban was safe and equal to enoxaparin (LMWH) in post-operative gynecologic oncology patients. This study aimed to determine if these findings are applicable in a diverse patient population at a single site urban academic medical center. MethodsThis was a retrospective cohort study of patients who underwent an exploratory laparotomy for confirmed or presumed gynecologic cancer from the years 2017–2023 at a single-site urban academic medical center. Venous thromboembolism (VTE) prophylaxis with LMWH was standard practice at our institution up until January 2021 after which apixaban became standard for post-operative prophylaxis in our division. Baseline demographic and clinical characteristics of patients receiving apixaban post-operatively were compared to the population previously receiving enoxaparin. The primary outcome was a VTE event within 90days of surgery. Secondary outcomes included major and minor bleeding events. ResultsTwo hundred fifteen patients met inclusion criteria, of which 65 were discharged on enoxaparin and 150 were discharged on apixaban. Baseline characteristics in terms of age, race/ethnicity and BMI found no significant difference between the two groups. Rates of any VTE event within 90 days of surgery were similar for apixaban and LMWH (3.33 % vs. 4.61 %, p = 0.6). Secondary outcomes demonstrated that the rate of a major bleeding event in apixaban group was 1.31 % and LMWH group was 3.08 %, (p = 0.38). Minor bleeding events in the apixaban group were comparable to the LMWH group (10.60 % vs 10.16 %, p = 0.5). ConclusionsIn this real world, urban setting, for women undergoing laparotomy for gynecologic cancer, apixaban as post-operative VTE prophylaxis showed no increase in VTE events and appeared safe with no increase in bleeding events compared to LMWH. This study adds to the literature demonstrating that apixaban is safe and effective for VTE prophylaxis in our gynecologic oncology patients.

The Impact of Balloon Use During Endobronchial Ultrasound: A Randomized Pilot Study

Introduction During endobronchial ultrasound transbronchial needle aspiration (EBUS-TBNA), a saline-filled balloon placed over the tip of the bronchoscope is used to improve coupling of the ultrasound transducer to the airway wall. However, it is unknown whether it objectively improves image quality or affects procedural outcomes. Our aim is to establish whether the use of a balloon during EBUS impacts image quality, diagnostic yield, procedure duration or complications. Methods A pilot randomized control trial of patients undergoing EBUS-TBNA of mediastinal lymph nodes was performed at a single academic centre. Patients were randomized to use of a saline-filled balloon (versus no balloon use) during EBUS-TBNA of the right lower paratracheal lymph node (station 4R). The EBUS videos were recorded and scored on a 4-point Likert scale by three blinded external reviewers. The primary outcome of this study was ultrasound image quality. Secondary outcomes included diagnostic yield, procedure duration and complications. Results Forty-six patients were randomized. In the balloon group, 61% of patients had an image quality score of “excellent” or “good,” compared to 47% in the no balloon group (p = 0.009). There was no significant difference in diagnostic yield, procedure duration or complications between the groups. Conclusion Inflation of the balloon during EBUS-TBNA at the right lower paratracheal lymph node improves ultrasound image quality but does not impact diagnostic yield, procedure duration or safety. This study provides a framework for additional studies with complete nodal assessment to determine if balloon use has a clinically meaningful benefit on procedural outcomes.

Parotidectomy Trends Toward Outpatient for Benign Disease.

We evaluate the safety of outpatient parotidectomy. We evaluate factors that lead to planned admission and compare costs. We evaluate trends toward outpatient, and the outcomes of switching admission status, total versus superficial approach, and ambulatory versus hospital site. Retrospective cohort study. Single tertiary academic center. Retrospective review of patients who underwent parotidectomy for benign tumors from 2018 to 2023. Of 370 parotidectomies performed, there were a planned 162 admissions and 208 outpatient procedures. A travel time > 60 minutes (odds ratio [OR] = 0.487, confidence interval [CI]: 0.296-0.803, P = .005) and total parotidectomy (OR = 0.448, CI: 0.226-0.89, P = .022) decreased the odds of a planned outpatient procedure. In a multivariable model, longer operative time increased the odds of switching to inpatient (n = 29, OR = 1.02, CI: 1.007-1.033, P = .002) and drain placement decreased the odds of switching to outpatient (n = 15, OR =0.035, CI: 0.004-0.298, P = .002). There was no significant difference in surgical complications, phone calls, clinic visits, readmission rates, or recurrence between outpatient and inpatient. This remained true when comparing surgical facility and superficial versus total parotidectomy. After COVID was declared an emergency, there was a trend toward outpatient parotidectomy (72.7% vs 48.9%, P < .001), but no change in complication rates. At our institution, outpatient parotidectomy saved $3838 compared to overnight admission. This study supports that outpatient parotidectomy is safe. This remained true for patients switching admission status, undergoing superficial or total parotidectomy, and having their operation at an ambulatory site. We demonstrate that institutions can safely increase outpatient parotidectomy rates and outpatient parotidectomy is cost effective.

Abstract 4138721: Outcomes of Coronary Revascularization in Patients with Contemporaneous Abdominal Organ Transplant

Background: Clinical evaluation surrounding liver and kidney transplantation may reveal obstructive coronary artery disease (CAD). However, little is known about outcomes after revascularization in this population. Our aim was to examine coronary artery bypass grafting (CABG) and percutaneous intervention (PCI) in peri-transplant patients compared to the general CABG/PCI populations. Methods: We conducted a matched retrospective cohort study between 2014-2022 at a single academic center. Matching was done by optimal full matching of a logistic regression-based propensity score adjusting for age, chronic kidney disease, diabetes, tobacco use, chronic lung disease, hypertension, prior myocardial infarction, and valvular disease. Covariate balance was assessed as standardized mean difference &lt;0.2. The primary outcome was a composite of in-hospital death, stroke, and myocardial infarction, and a key secondary outcome was incident arrhythmia. Results: The study population comprised 2655 patients: 24 CABG/transplant (median age, 64 [IQR, 59-66]; 4 female [17%]), 1037 CABG/non-transplant (age, 66 [59-73]; 190 female [18%]), 27 PCI/transplant (age, 62 [IQR, 55-67]; 6 female [22%]), and 1567 PCI/non-transplant (age, 70 [IQR, 60-78]; 399 female [25%]). CABG/PCI preceded transplant by a median 321/324 days, respectively, and followed transplant by a median 461/36 days, respectively. For the primary outcome in CABG patients, there were no events in the transplant group and an estimated potential outcome in 6.5% of the matched non-transplant group (marginal RR, &lt;0.001; p&lt;0.001). For the primary outcome in PCI patients, there were no events in the transplant group and an estimated potential outcome in 2.4% of the matched non-transplant group (marginal RR, &lt;0.001; p&lt;0.001). For incident arrhythmia in CABG patients, the estimated potential outcome was 12% and 17.5% in the transplant and matched non-transplant groups, respectively (marginal RR, 0.98; 95% CI, 0.37-2.6; p=0.97). For incident arrhythmia in PCI patients, the estimated potential outcome was &lt;0.001% and 3.6% in the transplant and matched non-transplant groups, respectively (marginal RR, 0.89; 95% CI, 0.12-6.5; p=0.91). Conclusions: Patients with contemporaneous abdominal organ transplant undergoing coronary revascularization suffered no in-hospital mortality, stroke, or myocardial infarction, and were not at greater risk of incident arrhythmia than similar non-transplant patients.

Tibial Malalignment is an Independent Predictor of Nonunion After Intramedullary Nailing of Tibial Shaft Fractures.

This study aimed to assess the relationship between postoperative alignment and nonunion in patients with tibial shaft fractures treated with intramedullary nailing. Design: Retrospective case-control study. Single academic trauma center. Adult patients with closed or open tibial shaft fractures (42A-C) treated with intramedullary nailing from 2007 to 2018. Case patients with nonunion were compared to control patients with radiographic evidence of healing in terms of the postoperative tibial alignment measured in the coronal and sagittal planes. Of the 192 included patients (median age, 38 years; 76% male), 51 patients had a nonunion, and 141 patients had united fractures and served as the control group. A strong association between postoperative tibial malalignment in one plane and nonunion (odds ratio [OR], 3.0; 95% confidence interval [CI], 1.1 to 8.3; P = 0.03) was demonstrated. This association was even greater for malalignment in both coronal and sagittal planes (OR, 5.7; 95% CI, 2.1 to 16.1; P < 0.001) after controlling for confounders. After controlling for confounding factors, postoperative malalignment in the coronal or sagittal plane was associated with significantly increased odds of tibial shaft nonunion after intramedullary nailing. Therapeutic, Level III. See Instructions for Authors for a complete description of levels of evidence.

QOL-22. VACILLATING EMOTIONS AND SHIFTING INFORMATION PREFERENCES: A QUALITATIVE ANALYSIS OF CAREGIVER DISTRESS IN FACING A MALIGNANT GLIOMA DIAGNOSIS

Abstract BACKGROUND Caregivers of patients with malignant gliomas (MG) experience considerable psychological distress as they contend with the implications of their loved one’s terminal illness. However, caregivers’ specific reactions to the patient’s diagnosis/prognosis and optimal ways to support caregivers in the months following diagnosis remain poorly understood. METHODS At a single academic medical center, we enrolled English-speaking adults identified by patients with newly diagnosed MG as their primary caregiver. Using a semi-structured interview guide, we conducted in-depth interviews with caregivers at the conclusion of concurrent chemoradiation exploring their experiences learning about the patient’s diagnosis and their prognostic information preferences. We used rapid qualitative analysis to analyze interview data. RESULTS We interviewed 7 caregivers (female: 5/7; spouse/partner: 6/7, sibling: 1/7) of MG patients (glioblastoma: 5/7). Caregivers described the time following diagnosis as tumultuous and difficult as they struggled to cope with their distress related to navigating the practical burdens of cancer treatment while also managing the emotional burden (e.g. fear, sadness) of living amidst uncertainty. Caregivers vacillated between feeling devastated by the patient’s poor prognosis and wanting to remain hopeful (e.g., by seeking out inspiring survivorship stories). Caregivers also reported varying and often evolving preferences regarding the manner, timing, and context in which they received information about the patient’s MG. Many caregivers desired more prognostic information (e.g., to facilitate planning for their future and for the patient’s eventual demise) while some chose to focus on the present (e.g., to avoid “dwelling” on potential negative outcomes), in light of inherent uncertainty about the patient’s trajectory. CONCLUSIONS Caregivers experience significant distress in the context of vacillating emotions and shifting information needs as they adapt to life in the aftermath of a MG diagnosis. These results highlight the need for tailored prognostic information and support for caregivers during this stressful, emotionally fraught time.

QOL-09. “I’VE DEFINITELY CHANGED WHO I AM”: A THEMATIC ANALYSIS OF CHALLENGES FACED BY PATIENTS WITH IDH-MUTANT GLIOMAS

Abstract BACKGROUND Despite their more favorable prognosis, patients with isocitrate dehydrogenase (IDH)-mutant gliomas experience significant psychological distress across their disease trajectory. The specific drivers of distress in this population are poorly understood, and interventions to support these patients are lacking. We sought to better characterize drivers of distress and ways to enhance support for patients with IDH-mutant gliomas as they confront potentially prolonged but ultimately unpredictable survival with an incurable, progressive brain tumor. METHODS Eligible individuals were English-speaking adults ages 65 and younger diagnosed with an IDH-mutant glioma at a single academic medical center. We conducted semi-structured interviews (N=20) to better understand the distress patients experience as they progress along their illness trajectories. We audio-recorded and transcribed interviews and analyzed interview content using reflexive thematic analysis. RESULTS Distress among participating patients (female = 7/20; age &amp;lt;40 years = 10/20) was linked to their struggles to maintain a coherent sense of identity while adapting to 1) neurocognitive changes and 2) altered life plans amidst prognostic uncertainty. Patients described feeling self-conscious and distrustful of their cognitive capacities, frequently comparing their current performance to their premorbid functioning (e.g. by checking their symptoms and indexing perceived deficits against scan results). Patients felt overwhelmed by the need to make decisions and set priorities (e.g., regarding family planning, retirement) due to the uncertain timing of their tumor’s progression and its unclear impact on their future functioning. Patients identified the transition from treatment to surveillance as a time of heightened worry, as they shifted their focus from the logistics of cancer care to the task of planning – financially, occupationally, socially – for an uncertain future. CONCLUSION These findings highlight the need for tailored supportive care to help patients with IDH-mutant gliomas cope with the distress caused by significant changes to identity and ongoing uncertainties regarding their future.

Higher BMI Is Associated With Wound Breakdown Following Resection of Haglund Deformity.

Haglund deformity is characterized by an enlarged posterosuperior calcaneus, often with inflammation of the retrocalcaneal bursa and Achilles tendon. This study aims to determine if obesity is associated with an increased rate of complications after Haglund resection. A retrospective review was conducted on patients who underwent surgical resection for Haglund deformity from January 2015 to December 2023 at a single academic center. The patient cohort was initially stratified by body mass index (BMI) into normal (BMI < 25), overweight (25 ≤ BMI < 30), and obese (BMI ≥ 30). For those classified as obese, further subclassification was performed using the standard system: obesity class I (mild obesity) = BMI 30.0-34.9; obesity class II (moderate obesity) = BMI 35.0-39.9; and obesity class III (severe obesity) = BMI ≥40.0. Data on demographics, surgical techniques, and weightbearing were collected and analyzed. Postoperative complications were compared between groups. Of the 370 patients included in this study, 20 (5.4%) were classified as normal, 77 (20.8%) were overweight, and 273 (73.8%) were obese. Within the cohort of patients with obesity, 96 (35.2%) were classified as obesity class I, 96 (35.2%) as obesity class II, and 81 (29.7%) as obesity class III.The obese group had a higher proportion of females (70.0%) and Black/African American race (24.5%), and a higher prevalence of diabetes mellitus (22.0%) and American Society of Anesthesiologists scores compared with other groups. Additionally, analysis within the obesity subclassifications revealed significant differences in smoking status, with a higher proportion of nonsmokers as obesity class increased (58.3% in class I, 76.0% in class II, and 79.0% in class III; P = .01). Follow-up duration averaged 10.5 months, with wound breakdown rates significantly higher in the obese group vs the overweight or normal groups (11.0% vs 2.6% vs 0.0%, P = .02). No significant differences in wound complications or outcomes were observed between patients based on different obesity subclassifications. Our findings demonstrate that after Haglund resection, obese patients have a higher risk of complications, particularly wound breakdown. This underscores the necessity of careful patient selection and perioperative optimization.

Census growth and challenges of a novel Hospital at Home program: A retrospective cohort study.

Hospital at Home (HaH) is a growing care model requiring significant investments. Critical to starting a program is estimating census and enrollments. The objective of this study was to compare expected versus actual consults, enrollments, and barriers in a novel HaH program. This was an observational, retrospective cohort study at a single urban academic medical center. Adult inpatients considered for enrollment to HaH were included. Demographic data, diagnoses and outcomes data were extracted for HaH patients. Volume and outcomes of HaH consults were recorded, including reasons for ineligibility or a patient declining to enroll. Over the first year of implementation, 248 patients enrolled. The average daily census (ADC) grew over months 1-6, then plateaued at a mean of 4.4 patients during month 10, with an overall ADC range from 0 to 7 patients. From months 7 to 12, there were 724 consults for a home hospital assessment, of which 22.5% (163/724) of patients were enrolled, 21.8% (158/724) declined to enroll, 29.3% (212/724) were ineligible for the program, and 26.4% (191/724) had consults that were deferred until the time of discharge and never explicitly consented or refused. The most common reasons for program ineligibility were complex care needs, insurance status, and not meeting inpatient status. The most common reasons patients declined to enroll were a preference to remain in the brick-and-mortar hospital and home conditions not suitable for HaH. This retrospective, cohort study defines the challenges of enrolling patients in an HaH program and provides areas for other programs to examine as they start or grow a program.

EXPRESS: Normal Saline Versus Balanced Intravenous Fluids in Acute Ischemic Stroke: A Retrospective Study.

Background While some studies have suggested better outcomes for critically ill patients with balanced solutions over normal saline, the best type of intravenous fluid to use for stroke patients remains unknown.Objective To determine if balanced solutions or normal saline are associated with risk of hemorrhagic transformation or 90-day disability in patients with acute ischemic stroke treated with intravenous thrombolysis.Methods This was a retrospective review of the 2015-2019 Get with the Guidelines® data at a single academic medical center. Exposure was type of intravenous fluid and outcomes were modified Rankin scale (mRS) ≤2 at 90 days and hemorrhagic transformation. Multivariate analysis controlled for age, demographics, medical history, time to tPA, and admission stroke scale.Results We included 302 patients who received thrombolysis, of which 166 patients had mRS data at 90 days. In univariate analysis, exposure to any balanced solution was associated with increased 90-day disability (OR 4.3, 95% CI 3.8-4.9) and hemorrhagic transformation (OR 2.0, 95% CI 1.3-2.2). In multivariate analysis, exposure to a balanced solution at any time was associated with increased 90-day disability (OR 6.3, 95% CI 2.4-17.0, p<0.01), but not hemorrhagic transformation.Conclusion This observational trial demonstrated that exposure to balanced solutions is associated with increased risk of disability at 90 days and possibly hemorrhagic transformation in patients with acute ischemic stroke treated with intravenous thrombolysis. This data would suggest that normal saline is a preferred solution in these patients, though larger future trials are needed.

Complications of total knee arthroplasty in patients with prior anterior cruciate ligament reconstruction compared to a matched cohort

BackgroundCurrent literature reports a 500 % increase in reoperation in total knee arthroplasty (TKA) after anterior cruciate ligament reconstruction (ACLR). The purpose of this study is to determine the effect of ACLR on subsequent TKA. MethodsThis retrospective case control study included 30 patients that underwent TKA following an ACLR who were matched 3:1 to a control cohort at a single tertiary academic center between January 1, 2011 and January 1, 2021. The electronic medical records were queried for demographics, complications, history of ACLR, and range of motion (ROM) preoperatively and postoperatively at 3 months and 1 year. Student's t-tests and Fisher's exact tests were used for analysis (α = 0.05). ResultsThe mean ROM between the ACLR and control groups preoperatively, at 3 months and at 1 year postoperatively were 108.2° v 104.8° (p = 0.42), 114.0° v 111.8° (p = 0.51), and 115.3° v 115.8° (p = 0.88). At 1 year, 9 of 30 (30 %) ACLR patients decreased ROM versus 14 of 90 (15.6 %) control patients (mean loss of 21.4° v 11.9°, p = 0.076). No difference in complication rate was found (10 % v 11.1 %, p = 1). Complications in the ACLR group included open debridement and capsular release for stiffness after 2 failed manipulations under anesthesia (MUA), lysis of adhesions for patellar clunk, and revision surgery for flexion instability. No control patients required MUA. ConclusionThis study demonstrated that TKA following ACLR is without an increased risk of complications. However, ACLR patients should be followed closely since loss of ROM can be large.

Obstetric Life Support Education for Maternal Cardiac Arrest: A Randomized Clinical Trial.

Management of maternal cardiac arrest (MCA) requires understanding the unique physiology of pregnancy and modifications to life support. Health care professionals have historically demonstrated inadequate knowledge and skills necessary to treat MCA. To evaluate the effect of Obstetric Life Support (OBLS) education on health care professionals' cognitive performance, skills, and self-efficacy in managing MCA. In this single-masked randomized clinical trial, 46 health care professionals, including emergency medical service and hospital staff representing diverse specialties, were randomized to intervention or control groups at a single academic medical center in Farmington, Connecticut between May 1, 2022, and July 23, 2023. The intervention group received OBLS education, which included a blended learning curriculum with simulation-based training on common maternal medical emergencies that lead to MCA. Participants were assessed for knowledge, confidence, and skills (eg, megacode scores as team leaders during MCA simulations). Intervention participants were compared with control group participants who received no OBLS education. The primary outcome was cognitive scores. Secondary outcomes included megacode scores rated by experienced OBLS instructors masked to assignment groups, combined assessment pass rates, and cognitive and confidence scores at baseline and 6 and 12 months after education. Data were analyzed from January 2024 to May 2024. Forty-six participants (mean [SD] age, 41.1 [16.2] years; 24 [52%] women) were randomized. Despite most participants holding certification in basic and advanced cardiac life support, significant between-group differences were identified in knowledge, skills, and confidence. Mean (SD) cognitive scores were 79.5% (9.4%) in the intervention group vs 63.4% (12.3%) in the control group (P < .001). Mean (SD) megacode skills were higher in the intervention vs control group (91.0% [5.0%] vs 61.0% [12.0%], P < .001), as were confidence scores (72.7 [13.3] vs 56.2 [17.9] points, P = .002). Combined assessment pass rates were 90% in the intervention group compared with 10% in the control group (P < .001). In this randomized clinical trial, OBLS education significantly improved health care professionals' knowledge, skills, and confidence in managing MCA. These findings underscore the urgent need for implementation of a standardized MCA curriculum nationwide, especially as the US continues to face unacceptably high maternal mortality rates. ClinicalTrials.gov Identifier: NCT05355519.

Disease recurrence in patients undergoing mastectomy for ductal carcinoma in situ.

With DCIS incidence on the rise, up to 30% of patients undergo mastectomy for Ductal carcinoma in situ (DCIS) (Nash and Hwang, in: Ann Surg Oncol 30(6):3206-3214, 2023). Local recurrence rates after mastectomy for DCIS are reportedly low, but risk factors for recurrence are not known (Kim et al., in: J Cancer Res Ther 16(6):1197-1202, 2020). We aim to define risk factors associated with ipsilateral breast cancer recurrence in patients undergoing mastectomy for DCIS. We aimed to identify risk factors that may contribute to recurrence of breast cancer following mastectomy for pure DCIS. We hypothesized that close or positive mastectomy margins, age at diagnosis, extent of breast disease and mutation carriers would be associated with increased risk of recurrence. We performed a retrospective chart review of patients who underwent unilateral or bilateral mastectomies for pure DCIS at a single academic tertiary referral center from 2013 to 2023. There were 165 patients who met inclusion criteria with an average length of follow-up of 39.9months. On final surgical pathology, the average span of DCIS was 33.7mm (± 24.6mm). Hormone receptor positive disease was identified in 80.6% of the patient cohort. For margin status, 23 patients (14%) had < 1mm margins on final pathology and of those, 1 received adjuvant radiation therapy and 4 returned to the OR for re-excision. Only 1 (0.6%) patient had ipsilateral disease recurrence during the study period. Recurrence after mastectomy for pure DCIS is a rare event and in our study sample, only one recurrence occurred. Risk factors for recurrence appear unrelated to margin status, age, extent of DCIS, or pathogenic mutation (ElSherif et al., in Am J Surg 226(5):646-651, 2023).

Medical Decision-Making and Bereavement Experiences After Cardiac Arrest: Qualitative Insights From Surrogates.

Surrogates of incapacitated patients in the intensive care unit (ICU) face decisions related to life-sustaining treatments. Decisional conflict is understudied. To compare experiences of ICU surrogates by reported level of decisional conflict related to treatment decisions after a patient's cardiac arrest preceding death. Convergent mixed methods were used. Bereaved surrogates recruited from a single northeastern US academic medical center completed surveys including the low-literacy Decisional Conflict Scale (moderate-to-high cut point >25) and individual interviews about 1 month after the patient's death. Interview data were analyzed by directed and conventional content analysis. Surrogates were stratified by median total survey score, and interview findings were compared by decisional conflict level. Of 16 surrogates, 7 reported some decisional conflict (median survey score, 0; range, 0-25). About two-thirds decided to withdraw treatments. Three themes emerged from interviews: 2 reflecting decision-making experiences ("the ultimate act"; "the legacy of clinician communication") and 1 reflecting bereavement experiences ("I wish there was a handbook"). Surrogates reporting decisional conflict included those who first pursued but later withdrew treatments after a patient's in-hospital cardiac arrest. Surrogates with decisional conflict described suboptimal support, poor medical understanding, and lack of clarity about patients' treatment preferences. These findings provide insight into bereaved ICU surrogates' experiences. The low overall survey scores may reflect retrospective measurement. Surrogates who pursued treatment were underrepresented. Novel approaches to support bereaved surrogates are warranted.

The impact of prior levonorgestrel intrauterine device use at the time of embryo transfer.

To investigate whether infertile women with a history of levonorgestrel intrauterine device (LNG IUD) use have impaired pre-transfer endometrial thickness and pregnancy rates after embryo transfer. Retrospective cohort study at a single academic medical center of infertile women ages 18-44 with a history of LNG IUD use undergoing their first embryo transfer cycle between January 2019 and January 2021 compared to controls with a history of no prior birth control use (NONE) or only prior oral contraceptive use (OCP). The primary outcome is endometrial thickness prior to embryo transfer. Secondary outcomes include embryo transfer results. We analyzed data from a total of 616 patients (197 NONE, 357 OCP, 62 LNG IUD). Women with a history of LNG IUD use had thinner endometrial stripes than women with a history of no prior birth control use (LNG IUD 8.93mm, NONE 10.32mm [aRR 0.88, 95% CI 0.80-0.97]), but not when compared to women with a history of OCP use (OCP 9.61mm [aRR 0.92, 95% CI 0.84-1.01]). Women with a history of LNG IUD use had slightly higher implantation rates than those with no birth control use history (LNG IUD 43.37%, NONE 24.17% [RR 1.79, 95% CI 1.21-2.45]), though not when compared to prior OCP users (OCP 38.72% [RR 1.12, 95% CI 0.86-1.47]). The remainder of the embryo transfer outcomes were similar between the three groups. Prior LNG IUD users have reduced endometrial thickness at the time of embryo transfer but do not have worse pregnancy outcomes.

Maternal body mass index, maneuvers, and neonatal morbidity associated with shoulder dystocia

BackgroundShoulder dystocia is associated with neonatal morbidity. Higher maternal prepregnancy body mass index is an established risk factor for shoulder dystocia, yet the relationship between maternal prepregnancy body mass index and resulting neonatal morbidity after shoulder dystocia is not well studied. ObjectivesWe assessed the association between body mass index and neonatal adverse outcomes following shoulder dystocia. The frequency and type of maneuvers used to resolve shoulder dystocia by maternal body mass index was compared. Study DesignWe conducted a retrospective cohort study of pregnant individuals who experienced a shoulder dystocia at delivery from June 2012-July 2021 at a tertiary care center. We included singleton non-anomalous livebirths ≥36 weeks’ gestation at a single academic medical center in the Midwestern US. The primary exposure was prepregnancy body mass index categorized as: <30 kg/m2 [referent], 30-34.9 kg/m2, and ≥35 kg/m2. The primary outcome was a composite neonatal morbidity including birth injury (brachial plexus injury or fracture), seizures, hypoxic ischemic encephalopathy, and 5-minute Apgar < 7. Secondary outcomes were neonatal intensive care unit admission and neonatal acidemia (cord arterial pH < 7.10). Shoulder dystocia duration and the number and types of maneuvers were compared by body mass index group. Multivariable logistic regression was used and adjusted for nulliparity, diabetes, operative vaginal delivery, and gestational age. ResultsAmong 872 individuals who experienced a shoulder dystocia at delivery, 602 (69.0%) had a body mass index <30 kg/m2, 160 (18.3%) had a body mass index between 30-34.9 kg/m2, and 110 (12.6%) had a body mass index ≥35 kg/m2. The median duration of shoulder dystocia was 40 seconds (interquartile range 30, 60 seconds) and did not vary by maternal body mass index. Deliveries complicated by body mass index ≥35 kg/m2 required a greater number of maneuvers compared to those with lower maternal body mass index (p<0.01). McRoberts (96.0%), suprapubic pressure (90.2%) and delivery of the posterior arm (41.1%) were the most frequent maneuvers in all body mass index groups. Rubin’s maneuver was more frequently used with body mass index ≥35 kg/m2 compared with body mass index <30 kg/m2 (34.6% versus 22.4%, p = 0.02, adjusted odds ratio 1.63, 95% CI 1.04-2.57). Composite neonatal morbidity did not differ by body mass index. Neonatal injury was more frequent with body mass index ≥35 kg/m2 compared with body mass index <30 kg/m2 (adjusted odds ratio 1.97, 95% CI 1.06-3.68). Interaction between body mass index and number of maneuvers was not statistically significant (p=0.94). ConclusionsAmong pregnant individuals who experienced a shoulder dystocia, increased prepregnancy body mass index was associated with an increased number of maneuvers performed during a shoulder dystocia, but not longer duration. Risk of neonatal injury following shoulder dystocia, but not the composite neonatal adverse outcome, was increased with body mass index ≥35 kg/m2.

Ten-Year Outcome After Supracricoid Partial Laryngectomy in cT3M0 Laryngeal Squamous Cell Carcinoma-A STROBE Analysis.

The aim of this study was to document 10-year outcomes after supracricoid partial laryngectomy (SCPL) in selected cT3M0 laryngeal squamous cell carcinoma (SCC) patients. This real-life retrospective observational study analyzed an inception cohort of 168 patients with isolated, untreated, selected cT3M0 laryngeal SCC, that were consecutively managed by SCPL during the period 1973-2013, and followed up until death or for a minimum of 10 years in 92% of cases at a single French academic and tertiary referral care center. Prior induction chemotherapy, arytenoid cartilage removal, level II-IV neck dissection, and postoperative radiation therapy were performed on 148, 77, 136, and 27 patients, respectively. The main objective was to determine 10-year actuarial local control and laryngeal preservation estimates. Secondary objectives included 10-year actuarial survival and cause-of-death analysis, and assessment of correlations between endpoints and clinical variables. The significance threshold was set at p < 0.005. Ten-year actuarial local control, laryngeal preservation, and survival estimates were 90%, 85%, and 52%, respectively. Salvage treatment resulted in an overall 99% local control rate. Metachronous second primary cancer, intercurrent disease without evidence of SCC, SCPL-related death, and uncontrolled local recurrence accounted for 31%, 26%, 7%, and 2% of causes of death. On univariate analysis, overall local recurrence and laryngeal preservation rates varied significantly, from 5% to 54% and 90% to 46% when resection margins were R0 and R1, respectively. The present study highlighted successful 10-year outcomes after SCPL, providing further evidence in favor of its integration into the conservative armamentarium for endolaryngeal cT3 SCC. 4 Laryngoscope, 134:4557-4563, 2024.

Report of cardiac electronic device implant complications over a 7-year study period

Abstract Background The global placement of cardiac implantable electronic devices (CIEDs) is on the rise. Complications linked to device implantation present a substantial burden on healthcare systems and patients alike. It is imperative to comprehend the complication rates associated with CIED procedures, enabling informed decision-making and strategic planning for patients, thereby enhancing the overall quality of care. Purpose We sought to determine post CIED implantation complication rates and provide operator specific complication data for quality assurance at our institution. Methods A comprehensive audit of all procedures completed between April 2016 to March 2023 by 14 high volume operators at a single academic center was completed. Complications and device data were extracted using electronic medical records. Complications evaluated include pneumothorax, infections, hematomas, venous thrombosis, lead perforation, and dislodgement using standardized definitions. Results During the 7-year period, a total of 9,467 procedures were completed. Among the cohort, 62% were male, with an average age of 74.6 ± 15.2 years. The procedural breakdown comprised 60% pacemakers, 19% ICDs, 16% CRTs and 3% ILRs. A total of 11,616 leads were implanted (3,644 RA leads and 1,110 LV leads). The overall complication rate was 3.1% (n=316): device pocket infection 0.68%, superficial infection 0.19%, lead dislodgement 0.53%, lead perforation 0.24%, pericardial effusion 0.1%, pneumothorax 0.15%, pocket hematoma 0.83%, DVT 0.36%, and hemothorax 0.02%. Complication rates per operator are shown in Figure-1. Conclusion Our findings indicate that the overall complication rates for CIED implants are lower than previously reported rates, and there is no significant difference between operators in overall rates of complication. This observation can be attributed to operator experience, advancements in peri-operative care and guideline-directed post-operative protocols. However, notable variations exist among operators in rates of pocket infection. The ongoing monitoring of CIED complications as a quality indicator remains a crucial benchmark, meriting annual assessments for ongoing evaluation.

Pupillary Peaking & Presence of Dysphotopsias Following Glaucoma Tube Shunt Surgery

ABSTRACT Purpose To describe the presence of pupillary peaking and dysphotopsias in a sample of eyes following glaucoma drainage device (GDD) surgery. Methods Cross-sectional analysis of 68 glaucoma patients with GDD, 45 patients with glaucoma and no GDD, and 50 control patients was conducted in a single academic center. Patients with an appropriate diagnosis that met the inclusion criteria were asked to enroll in the study. All patients received an 8-item dysphotopsia questionnaire and were age-matched. Photographs of pupils were taken to assess pupillary peaking. One-way analysis of variance (ANOVA) testing was performed for statistical analysis. Results Of the 68 patients with GDD, 25 (36.76%) had pupillary abnormalities with peaking most commonly occurring in the direction of the tube entry superotemporally, and 50 (73.53%) had reported one or more dysphotopsias. In patients reporting one or more dysphotopsias, the rate of lines, crescents, ghost images, and shadows was significantly higher when compared to glaucoma patients without GDD and control patients (p < .01). This corresponded to a lower best-corrected visual acuity in the GDD group compared to the glaucoma and control groups (p < .001). Conclusions Over a third of glaucoma patients receiving GDD had pupillary abnormalities, and nearly 3 out of 4 patients with GDD reported one or more dysphotopsias when compared to glaucoma patients without GDD and an age-matched control group. Glaucoma specialists and patients should be aware of these complications when proceeding with GDD surgery.

Outcomes for Female Physicians Compared With Nonphysicians After Assisted Reproductive Technology.

To evaluate outcomes of female physicians after assisted reproductive technology (ART). We conducted a retrospective cohort study using data from 248 physician patients and 3,470 nonphysician patients who underwent a total of 10,095 fresh or frozen ART cycles at a single academic center in an insurance-mandated state between January 2015 and March 2022. The primary outcome was live-birth rate. The secondary outcomes were implantation rate, early pregnancy loss rate, and time to pregnancy. Models were adjusted for confounders where appropriate. Both groups were similar in age (mean physician age 36.29 years; mean nonphysician age 35.96 years, P=.35). Physicians had lower body mass index (BMI) (mean physician BMI 23.51, mean nonphysician BMI 26.37, P<.01), and a higher proportion were diagnosed with unexplained infertility (physician 33.9%, nonphysician 25.9%, P<.01) and used preimplantation genetic testing for aneuploidy (physician 21.5%, nonphysician 12.7%). Physicians and nonphysicians had similar live-birth rates (physician 39.3%, nonphysician 38.2%; adjusted relative risk [aRR] 1.01 95% CI, 0.91-1.13), implantation rates (physician 34.7%, nonphysician 33.7%; relative risk 1.03 95% CI, 0.94-1.14), and early pregnancy loss rates (physician 21.9%, nonphysician 19.8%; aRR 1.18 95% CI, 0.99-1.41) per transfer. Physicians had a shorter time from initial ART cycle to pregnancy (physician 21.82 weeks, nonphysician 25.16 weeks; aRR 0.86, 95% CI, 0.83-0.89). There was no difference between female physicians and nonphysicians in assisted reproduction cycle outcomes. Physicians become pregnant slightly faster than nonphysicians.