Tertiary Referral Medical Center Research Articles

Impact of 2023 Ventral Hernia Repair CPT Code Changes on Work Relative Value Units in a Tertiary Hernia Referral Center

Background: CPT codes for ventral hernia repair (VHR) changed in January 2023 to address the heterogeneity of procedures with a concomitant shift from a 90-day to a 0-day global period. This study reviews a tertiary referral center’s experience with hernia coding comparing the work relative value units (wRVUs) generated for ventral hernia repair pre-2023 compared to post-2023. Study Design: CPT codes were analyzed for patients undergoing open or laparoscopic VHR before updates to the CPT hernia codes (January 2022-September 2022) and following CPT change (January 2023-September 2023). Work RVU values were assigned based on nationally published values. CPT codes in 2022, CPT codes in 2023, 8 inpatient E&M codes, and 5 outpatient E&M codes were evaluated. Results: 299 patients underwent VHR, 143 in 2022 and 156 in 2023. Average procedural VHR wRVUs increased from 9.6 in 2022 to 11.6 in 2023 (p<0.001). Procedures involving myofascial advancement flaps/component separation techniques (53.8% vs. 48.7%, p = 0.419) and wRVUs for the component separation procedures were similar between 2022 and 2023, respectively 17.7 vs 16.1 (p=0.419)]. The wRVUs associated with adjunctive procedures (mesh removal/placement) decreased from 3.3 to 0.6 (p<0.001) in the post-2023 era. Postoperative E&M wRVUs increased in 2023 for postoperative inpatient (0.48) and postoperative outpatient (0.39) services, compared to 0 wRVUs in 2022. Overall, the total management including follow-up clinic visit adjusted wRVUs for hernia repair was similar between 2022 and 2023, respectively 30.7 vs 29.2 (p=0.409). Conclusion: Procedural wRVUs for anterior abdominal hernia repair increased from 2022 to 2023 (p<0.001) at a tertiary referral medical center. However, total wRVUs, including the operation and postoperative visits, remained unchanged.

Extralaryngeal Spread in Total Laryngectomy: Comparing the Need for Thyroidectomy.

Objective: At our institution, thyroid preservation during total laryngectomy (TL) varies by surgeon, offering a distinctive dataset to compare disease outcomes in TL patients with or without thyroidectomy. Methods: This retrospective chart review study, conducted at a tertiary referral medical center, comprises patients who underwent TL for laryngeal or hypopharyngeal squamous cell carcinoma from 2014 to 2022. The study includes data on patient demographics, surgeries, pathological staging, tumor subsites, thyroid involvement, and adjuvant therapy. Results: In this study, 147 patients, mostly male (83%) and white (82%), were included. Surgeries comprised 60 hemi thyroidectomies, 35 total or completion thyroidectomies, 48 without thyroid removal, and 4 isthmusectomies. Data analysis compared these 4 groups and the cohort of no thyroid removal (NT) versus any thyroidectomy (T = 99). Among the 99 patients, 27 showed positive gland involvement, primarily due to direct disease extension (26 cases). No significant difference was found in recurrence rates or recurrence-related mortality among the 4 groups or between NT and T (P = .156). However, there was a significant difference in T staging and prognostic staging among the groups and between NT versus T (P = .043). The NT cohort showed a higher likelihood of being T3, while T was more likely to be T4. Conclusion: We found no significant difference in recurrence rates or mortality between TL patients with or without thyroid removal. However, those without thyroid removal often had lower T stages. Notably, 27% of thyroidectomy patients had gland invasion, highlighting the importance of thyroid removal in TL.

Current Demography and Treatment Strategy of Vestibular Migraine in Neurotologic Perspective.

This study aims to describe the demographic features of vestibular migraine (VM) compared to other common peripheral vestibulopathies, and to assess the efficacy of trigger management as primary VM treatment. Retrospective study. Tertiary referral medical center. A retrospective chart review was performed of patients presenting with dizziness in a tertiary neurotology clinic. Among the newly diagnosed dizzy patients, those with a diagnosis of either VM, Ménière's disease, benign paroxysmal positional vertigo, or vestibular neuritis/labyrinthitis were selected for comparisons of the disease demographics. VM patients with multiple clinic visits in the study period were included for the treatment strategy analysis. A total of 1285 patients met the study inclusion criteria. In the newly diagnosed dizzy group comprising 814 patients, VM patients accounted for the largest (25%) and youngest (mean age 47 years) cohort, showing an obvious female preponderance of approximately 3.3:1. Furthermore, prevalence of VM declined significantly with advancing age, from 69%, to 34%, to 11%, in age groups of ≤30, 31 to 60, and >60 years, respectively. Trigger management, when employed as the primary VM first-year treatment, was effective for both sexes. Notably, it was more effective for women aged over than under 45 years. In our tertiary referral neurotologic center, VM was the most common diagnosis in newly diagnosed dizzy patients aged under 60 years, especially in women. For primary VM treatment, trigger management is an effective option deserving consideration.

The Role of Temporal Bone Pneumatization on Fracture Line and Involved Cranial Structures.

Temporal bone pneumatization (TBP) is speculated to serve as a shock absorber in temporal bone fractures (TBF), directing the fracture line away from vital structures. This study correlates TBP extent with TBF patterns and preservations of vital TB structures. Retrospective cohort study. Tertiary referral medical center. All TBF patients referred to a single tertiary center 2017 to 2023 were evaluated. A pneumatization index score for each of their TBs was derived by counting automated-voxel density in a 0 to 100 scale. Results were correlated to the TBF type and the violated structure(s). The ossification index was compared to previously detailed qualitative classification systems of TBP. One hundred and forty-five patients were enrolled (mean age 43 ± 17 years). Kinematics were motor vehicle accidents (46%), scooter (15%), bicycle (14%), falls (13%), and assaults (8%). The mastoid ossification index we used showed a strong correlation to all qualitative classification systems (sigmoid = 0.829; labyrinthine = 0.849; carotis = 0.863, infralabyrinthine = 0.869, all P < .001). The pneumatization index strongly correlated with capsule-violating TBFs, with a mean of 44 ± 23 for otic capsule-sparing TBF and 61 ± 20 for otic capsule-violating (OCV) TBF (P < .001). The facial nerve was violated in 30 patients. Facial canal (FC) involvement was not correlated to the ossification index: it was 49 ± 23 for FC-sparing and 44 ± 23 for FC-violating (P = .620). TBP serves as a protective mechanism against OCV TBF. The more pneumatized the TB, the less likely the otic capsule will be violated in the event of a TBF with the exception of the carotid and FCs. TBP index is in strong agreement with qualitative TBP classification systems.

Seven Days of Voice Rest Post-phonosurgery Is Not Better than 3 days: A Prospective Randomized Short-term Outcome Study.

The aim of the study is to compare the short-term effect of 7 versus 3 days of voice rest (VR) on objective vocal (acoustic) parameters following phonosurgery. A prospective randomized study conducted at a tertiary referral medical center. Patients with vocal fold nodules, polyps, or cysts and scheduled for phonosurgery were recruited from the Voice Clinic. They were randomized into groups of 7- or 3-day postoperative VR periods and their voices were recorded preoperatively and at 4-week postoperatively. A mixed linear model statistical analysis (MLMSA) was used to compare pre- and postoperative jitter, shimmer, harmonic-to-noise ratio, and maximum phonation time between the two groups. Sixty-five patients were recruited, but only 34 fully complied with the study protocol, and their data were included in the final analysis (19 males, 20 females; mean age: 40.6 years; 17 patients in the 7-day VR group and 16 in the 3-day VR group). The groups were comparable in age, sex, and type of vocal lesion distribution. The preoperative MLMSA showed no significant group differences in the tested vocal parameters. Both groups exhibited significant (p < 0.05) and comparable improvement in all vocal parameters at postoperative week 4. A VR duration of 7 days showed no greater benefit on the examined vocal parameters than the 3-day protocol 4-week postoperatively. Our results suggest that a 3-day VR regimen can be followed by patients who undergo phonosurgery without compromising the vocal results. Larger-scale and longer-duration studies are needed to confirm our findings. 2 Laryngoscope, 2024.

The Rothman Index predicts unplanned readmissions to intensive care associated with increased mortality and hospital length of stay: a propensity-matched cohort study

BackgroundPatients with unplanned readmissions to the intensive care unit (ICU) are at high risk of preventable adverse events. The Rothman Index represents an objective real-time grading system of a patient’s clinical condition and a predictive tool of clinical deterioration over time. This study was designed to test the hypothesis that the Rothman Index represents a sensitive predictor of unanticipated ICU readmissions.MethodsA retrospective propensity-matched cohort study was performed at a tertiary referral academic medical center in the United States from January 1, 2022, to December 31, 2022. Inclusion criteria were adult patients admitted to an ICU and readmitted within seven days of transfer to a lower level of care. The control group consisted of patients who were downgraded from ICU without a subsequent readmission. The primary outcome measure was in-hospital mortality or discharge to hospice for end-of-life care. Secondary outcome measures were overall hospital length of stay, ICU length of stay, and 30-day readmission rates. Propensity matching was used to control for differences between the study cohorts. Regression analyses were performed to determine independent risk factors of an unplanned readmission to ICU.ResultsA total of 5,261 ICU patients met the inclusion criteria, of which 212 patients (4%) had an unanticipated readmission to the ICU within 7 days. The study cohort and control group were stratified by propensity matching into equal group sizes of n = 181. Lower Rothman Index scores (reflecting higher physiologic acuity) at the time of downgrade from the ICU were significantly associated with an unplanned readmission to the ICU (p < 0.0001). Patients readmitted to ICU had a lower mean Rothman Index score (p < 0.0001) and significantly increased rates of mortality (19.3% vs. 2.2%, p < 0.0001) and discharge to hospice (14.4% vs. 6.1%, p = 0.0073) compared to the control group of patients without ICU readmission. The overall length of ICU stay (mean 8.0 vs. 2.2 days, p < 0.0001) and total length of hospital stay (mean 15.8 vs. 7.3 days, p < 0.0001) were significantly increased in patients readmitted to ICU, compared to the control group.ConclusionThe Rothman Index represents a sensitive predictor of unanticipated readmissions to ICU, associated with a significantly increased mortality and overall ICU and hospital length of stay. The Rothman Index should be considered as a real-time objective measure for prediction of a safe downgrade from ICU to a lower level of care.

Increasing the Rate of Venous Thromboembolism Chemoprophylaxis Administration Using the Electronic Medical Record

Introduction: Venous thromboembolism (VTE) remains a leading cause of preventable harm among hospitalized patients. Pharmacologic VTE prophylaxis reduces the rate of in-hospital VTE by 60%, but medication administration is often missed for various reasons. Electronic medical record (EMR) prompts may be a useful tool to decrease withholding of critical VTE chemoprophylaxis medications. Methods: In August 2021, an EMR prompt was implemented at a tertiary referral academic medical center mandating nursing staff to contact a provider for approval before withholding VTE chemoprophylaxis. A pre-intervention group from August 2020 to August 2021 was compared to a post-intervention group from August 2021 to August 2022. Rates of VTE chemoprophylaxis withholding were compared between the groups with a P < .01 considered significant. Results: A total of 16,395 patients prescribed VTE chemoprophylaxis were reviewed, with 13,395 (81.7%) receiving low molecular weight heparin. Of the 16,395 patients included, 10,701 (65.3%) were medical and 5694 (34.7%) were surgical. Patients in the pre-intervention cohort (n = 8803) and post-intervention cohort (n = 7592) were similar in hospital length of stay and duration of DVT prophylaxis. In the post-intervention group, the frequency of surgical patients with at least one missed dose had increased by 4.2% (P = .002), with the trauma and acute care surgery (TACS) show an increase of 6.6% (P < .001). However, the frequency of medical patients and non-TACS patients with missed doses decreased by 3.1% (P = .002) and 1.0% (<.001), respectively. Conclusions: EMR prompts appear to be a low-cost intervention that increases the rate of VTE prophylaxis administration among medical and elective surgery patients.

Percutaneous microwave ablation for early-stage intrahepatic cholangiocarcinoma: A single-institutional cohort.

Cholangiocarcinoma (CCA) is the second-most common primary hepatic malignancy with an increasing incidence over the past two decades. CCA arises from the epithelial cells lining the bile ducts and can be classified as intrahepatic, perihilar, or distal based on the site of origin in the biliary tree. Surgical resection is the definitive curative therapy for early-stage intrahepatic CCA; however, only a minority of patients may be ideal surgical candidates. Percutaneous microwave ablation (MWA) is a minimally invasive procedure widely used for hepatocellular carcinoma and colorectal cancer metastases to the liver. Growing evidence suggests MWA can play a role in the management of patients with early-stage intrahepatic CCA. In this study, we aim to describe the safety and efficacy of MWA for the management of intrahepatic CCA. A retrospective review of patients with intrahepatic CCA treated with MWA at our tertiary referral medical center was performed. Eight patients were treated between 2014 and 2019. Diagnosis of CCA was made based on histopathological studies of samples obtained by surgical resection or percutaneous liver biopsy. All procedures were performed under computed tomography (CT) guidance using a high-power single antenna MWA system. General anesthesia was used for all procedures. Patient medical history, procedural technical information, outcomes, and follow-up data were reviewed. Progression-free survival was estimated with a Kaplan-Meier curve. A total of 25 tumors with an average size of 2.2 ± 1.7 cm (range 0.5-7.8) were treated with MWA. Our cohort consisted of eight patients (4 males and 4 females) with an average age of 69.3 ± 5.7 years (range 61-79). Three out of eight (3/8, 37.5%) patients were treated initially with surgical resection. NASH-related cirrhosis was documented in 3/8 (37.5%) patients, while 1/8 (12.5%) had alcoholic cirrhosis; the remaining 4 patients (4/8, 50%) did not have cirrhosis. All patients were discharged within 24 h after ablation. Average total follow-up time was 10.6 ± 11.8 months (range 0-41). The incomplete ablation rate and local recurrence rate were 4% (1/25 lesions) and 12% (3/25 lesions), respectively. In patients who do not qualify for surgical resection, MWA is a safe alternative therapy for the treatment of intrahepatic CCA.

Agreement between Fetal Brain Ultrasonography and Magnetic Resonance Imaging in the Measurements of the Corpus Callosum and Transverse Cerebellar Diameter.

As the use of magnetic resonance imaging of the fetal brain has evolved, the need to understand its efficiency in the biometry of the fetal brain has broadened. This study aimed to assess the level of agreement and correlation between the two cardinal imaging methods of fetal neuroimaging, ultrasonography (US) and magnetic resonance imaging (MRI), by measuring the corpus callosum (CC) and transverse cerebellar diameter (TCD) in terms of length and percentile. Measurements of CC and TCD length and percentile were documented over a 7-year span in a tertiary referral medical center. All US and MRI examinations were performed in the customary planes and subcategorized by valid reference charts. Exclusion and inclusion criteria were set before the collection and processing of the data. A total of 156 fetuses out of 483 were included in the study. A positive, strong correlation and agreement were found (r = 0.78; ICC = 0.76) between US and MRI in TCD measurements. For CC length measurement, a moderate correlation and moderate agreement (r = 0.51; ICC = 0.49) between US and MRI was observed. TCD and CC percentiles had lower levels of correlation and agreement compared with the length variables. Our study indicates good agreement between MRI and US in the assessment of TCD measurement as a part of antenatal neuroimaging. Furthermore, while the two techniques are not always compatible, they are complementary methods.

P947 medical cannabis increases appetite but not body weight in patients with inflammatory bowel diseases

Abstract Background Medical cannabis (MC) is prescribed to improve appetite and nutritional status in patients with inflammatory bowel diseases (IBD) despite no supporting evidence. We aimed to describe the effect of MC on appetite and dietary intake among patients with IBD. Methods An observational prospective cohort study, among patients with IBD, initiating treatment with MC for disease related symptoms, at the IBD clinic of a tertiary referral medical center. Patients' demographics, anthropometric measurements, medical history, cannabis use history, and medical treatment were documented and an appetite questionnaire (SNAQ), and food frequency questionnaire (FFQ) were filled before MC initiation and throughout 6 months of treatment. Results Of patients enrolled in the study (n=149, age 39.0±14.1 years, 42.3% female) and treated with MC for disease related symptoms, on top of their routine therapy regimen, while 33.6% received MC for increasing appetite and improving nutritional status. Among patients treated for raising appetite and improving nutritional status, 34.0% experienced a significant increase in appetite after 3 months. None the less, all patients experienced a modest increase in appetite (P&amp;lt;0.05), a trend which was more profound among patients treated with high THC/CBD ratio (SNAQ score 27.0±4.1 at 3 months vs. 25.2±3.6 at baseline, P=0.021). Nonetheless, this increase in appetite throughout the study did not result in increased energy, macronutrient intake or in BMI following MC treatment. Among patients without a significant increase in appetite by 3 months of MC therapy, a significant decrease in BMI was noticed at 6 months (24.1±3.7 at baseline vs. 23.4±3.6 at 6 months, Pv=0.010). Conclusion Use of MC, and specifically THC, may be a potential strategy to improve appetite among some patients with IBD. This increase in appetite was not associated with an increase in caloric intake or in BMI at follow-up.

Medical Cannabis Increases Appetite but Not Body Weight in Patients with Inflammatory Bowel Diseases.

We aimed to elucidate the effect of Medical Cannabis (MC) on appetite and nutritional status among patients with inflammatory bowel disease (IBD). A case series of patients with IBD were initiating treatment with MC for disease-related symptoms, at the IBD clinic of a tertiary referral medical center. Patients' demographics, anthropometrics, medical history and treatment and MC use were systematically recorded. An appetite and food frequency questionnaire (SNAQ and FFQ) were filled before, and at 3 and 6 months of treatment. Patients with IBD initiating MC were enrolled (n = 149, age 39.0 ± 14.1 years, 42.3% female), and 33.6% (n = 50) were treated for improvement of nutritional status. A modest increase in appetite after 3 months was detected among all patients enrolled (Pv = 0.08), but there were no significant differences in energy or macronutrient intake, and in patients' body mass index (BMI). A significant appetite improvement after 3 months was detected among 34.0% (n = 17) of patients, but this was not associated with increased caloric intake or BMI at 3 or 6 months. Among patients without increased appetite after 3 months of MC therapy, BMI decreased at 6 months (24.1 ± 3.7 vs. 23.4 ± 3.6, Pv = 0.010). MC may be a potential strategy to improve appetite among some patients with IBD, but not caloric intake or BMI.

Efficacy and Safety of Activated Prothrombin Complex Concentrate for Reversal of the Anticoagulant Effect of Apixaban and Rivaroxaban in Patients with Major Bleeding.

The use of activated prothrombin complex concentrate (aPCC) to treat direct oral anticoagulant (DOAC)-associated bleeding is off-label and clinical experience is limited. We aimed to assess the efficacy and safety of aPCC in reversing the anticoagulant effect of apixaban and rivaroxaban in patients presenting with major bleeding. A retrospective cohort study of adult non-randomized patients was conducted at a tertiary referral medical center in the United States (US) to investigate the use of aPCC for the reversal of the anticoagulant effect of apixaban and rivaroxaban in patients presenting with major bleeding. The primary outcome was achieving clinical hemostasis according to prespecified criteria. Safety outcomes included the occurrence of thrombotic events during hospitalization. A total of 217 patients were included in the study. Intracranial hemorrhage (ICH) was the most common site of bleeding (n = 100, 46.1%), followed by gastrointestinal bleed (n = 87, 40.1%). Clinical hemostasis was achieved in 170 patients (78.3%), and the risk of not achieving hemostasis with ICH-related bleeding was significantly higher than that of non-ICH-related bleeding (2.5, 95% confidence interval [CI] 1.44-4.34; p < 0.001). Eight patients not achieving hemostasis died during hospitalization, all of whom were suffering from ICH, and mortality associated with non-ICH-related bleeding was significantly lower compared with ICH-related bleeding (0.91, 95% CI 0.86-0.97; p < 0.001). Thromboembolic events during hospitalization occurred in one patient (0.5%). The use of aPCC for the management of apixaban- or rivaroxaban-related major bleeding is effective in most cases and is associated with a low risk of thromboembolism.

Are Commonly Used Geographically Based Social Determinant of Health Indices in Orthopaedic Surgery Research Correlated With Each Other and With PROMIS Global-10 Physical and Mental Health Scores?

Are Commonly Used Geographically Based Social Determinant of Health Indices in Orthopaedic Surgery Research Correlated With Each Other and With PROMIS Global-10 Physical and Mental Health Scores?

Surgical Versus Noninvasive Manual Repositioning After Cochlear Implant Partial Magnet Dislocation.

Objectives: To compare surgical magnet repositioning (SMR) and noninvasive manual magnet repositioning (MMR) as treatments for partial magnet dislocation (PMD) of the internal magnet in a cochlear implant (CI) caused by magnetic resonance imaging (MRI). The primary objective was the success rate, while the secondary objectives were total postinterventional CI downtime and complications. Methods: This single-center retrospective study was conducted at a tertiary referral medical center. Patients with CI treated for PMD between January 1, 2007 and September 30, 2022 were included. SMR served as primary treatment until June 2019 and as secondary treatment after the introduction of MMR. Results: A total of 51 cases of PMD were observed in 42 patients and 43 devices (18 ♀; 24 ♂; 12 with bilateral CI). MMR was performed successfully in 19 out of 20 cases (95%), while 32 cases were managed successfully by SMR. The median age at first magnet repositioning was 53.8 years (minimum 19 years, maximum 93 years). When MMR was performed, the mean time from diagnosis to treatment (0.5 ± 1.5 days vs 9.8 ± 7.6 days; P < .01), the mean time from repositioning to CI reactivation (1.4 ± 4.3 days vs 13.1 ± 6.7 days; P < .01), and the mean total CI downtime (1.9 ± 4.8 days vs 22.9 ± 11.9 days; P < .01) were significantly shorter compared to SMR. Significantly fewer complications were experienced with MMR [n = 0 (0%) vs n = 8 (25%); P = .04]. Conclusion: In case of PMD caused by MRI, noninvasive MMR shows a high success rate with a shorter total CI downtime as well as a lower complication rate compared to SMR. Therefore, MMR should be considered as first line treatment with SMR as a second option in case of failure.

Fetal brain volumes and neurodevelopmental outcome of intrauterine growth restricted fetuses

ObjectiveThis study aims to investigate the correlation of MRI measured fetal brain volumetrics with long-term neurodevelopmental outcome, among intrauterine growth restricted (IUGR) and apparently healthy fetuses. Study designA historical cohort study at a single tertiary referral medical center during 6 years period, of fetuses diagnosed with IUGR due to placental insufficiency, and apparently healthy fetuses, who had fetal brain MRI scan. The volumes of the supratentorial brain region, both hemispheres and the cerebellum were measured by 3D MRI semi-automated volume measurements. The cerebellar to supratentorial ratio (CER/ST) was calculated. Volumes were plotted on normal growth curves. 17 IUGR fetuses, and 53 apparently healthy fetuses adhered to participate in the VABS-II questionnaire, evaluating neurodevelopmental outcome. Results70 patients (mean age at conducting VABS-II questionnaire 4.4 ± 2.1 years, 38 males) were evaluated. Among fetuses born in a gestational age of 36 weeks or later, IUGR fetuses demonstrated a significantly larger number of abnormal results in the VABS-II communication domain (p =.049). No significant differences were found in other domains or in overall neurodevelopmental outcome. The CER/ST ratio correlated with the overall neurodevelopmental outcome of the total study population (r = 0.40, p <.001), and of the IUGR group separately (ρ = 0.58, p =.02). ConclusionCER/ST ratio measured using fetal brain MRI was found to be correlated with long term neurodevelopmental outcome. This result may aid in clinical interpretation of biometric data obtained by fetal brain MRI, linking it with long term neurodevelopmental outcome.

Increasing Trend and Effects of Pediatric Palliative Care on Children With Noncancer Diagnoses.

Pediatric palliative care (PPC), especially among noncancer pediatric patients, faces challenges including late referral, limited patient care, and insufficient data for Asian patients. This retrospective cohort study used the integrative hospital medical database between 2014 and 2018 to analyze the clinical characteristics, diagnoses, and end-of-life care for patients aged less than 20 who had died in our children's hospital, a tertiary referral medical center implementing PPC shared-care. In our cohort of 323 children, 240 (74.3%) were noncancer patients who a younger median age at death (5 vs. 122 months, P < 0.001), lower rate of PPC involvement (16.7 vs. 66%, P < 0.001), and fewer survival days after PPC consult compared to cancer patients (3 vs. 11, P=0.01). Patients not receiving PPC had more ventilator support (OR 9.9, P < 0.001), and less morphine use on their final day of life (OR 0.1, P < 0.001). Also, patients not receiving PPC had more cardiopulmonary resuscitation on the last day of life (OR 15.3, P < 0.001) and died in the ICU (OR 8.8, P < 0.001). There was an increasing trend of noncancer patients receiving PPC between 2014 and 2018 (P < 0.001). High disparities exist between children receiving PPC in cancer versus noncancer patients. The concept of PPC is gradually becoming accepted in noncancer children and is associated with more pain-relief medication and less suffering during end-of-life care.

Advancing diagnosis and management of liver disease in adults through exome sequencing

Whole-exome sequencing (WES) is an effective tool for diagnosis in patients who remain undiagnosed despite a comprehensive clinical work-up. While WES is being used increasingly in pediatrics and oncology, it remains underutilized in non-oncological adult medicine, including in patients with liver disease, in part based on the faulty premise that adults are unlikely to harbor rare genetic variants with large effect size. Here, we aim to assess the burden of rare genetic variants underlying liver disease in adults at two major tertiary referral academic medical centers. WES analysis paired with comprehensive clinical evaluation was performed in fifty-two adult patients with liver disease of unknown etiology evaluated at two US tertiary academic health care centers. Exome analysis uncovered a definitive or presumed diagnosis in 33% of patients (17/52) providing insight into their disease pathogenesis, with most of these patients (12/17) not having a known family history of liver disease. Our data shows that over two-thirds of undiagnosed liver disease patients attaining a genetic diagnosis were being evaluated for cholestasis or hepatic steatosis of unknown etiology. This study reveals an underappreciated incidence and spectrum of genetic diseases presenting in adulthood and underscores the clinical value of incorporating exome sequencing in the evaluation and management of adults with liver disease of unknown etiology. S.V. is supported by the NIH/NIDDK (K08 DK113109 and R01 DK131033-01A1) and the Doris Duke Charitable Foundation Grant #2019081. This work was supported in part by NIH-funded Yale Liver Center, P30 DK34989.

Safety and Efficacy of Metabolic Surgery in Patients with Type 2 Diabetes in the Middle East and North Africa Region: An Analysis of Primary Roux-en-Y Gastric Bypass and Sleeve Gastrectomy Outcomes.

Type 2 diabetes (T2D) is a chronic medical condition that results in significant health implications and reduced life expectancy. The International Diabetes Federation (IDF) estimated that in 2021, 51.8% of all deaths of people under 60 years old in the Middle East and North Africa (MENA) region were related to diabetes. Bariatric surgery has been demonstrated to be a safe and effective treatment for T2D in different populations worldwide, though few specific data exist on outcomes of procedures in the MENA region. The aim of this study was to compare the safety and postoperative outcomes between patients with and without T2D undergoing primary bariatric surgery at a tertiary referral academic medical center in the United Arab Emirates. All patients who underwent primary metabolic surgery between September 2015 and July 2020 were retrospectively reviewed from a prospective database. Group 1 included patients with T2D, and Group 2 included patients without T2D. Patients undergoing revisional or correctional operations were excluded. The procedure performed was based on surgeon discretion in discussion with a multidisciplinary team and the patient. Demographics as well as perioperative and postoperative results were examined. Our study included 542 patients, 160 (29.5%) with T2D and 382 (70.5%) with non-T2D. Mean age was 44.5 years (range 16-70) in the T2D group and 33.3 years (range 15-63) in the non-T2D group; median BMI was 41.8 ± 7.3 and 43.2 ± 7.2, respectively. The T2D group was 37.5% male and 62.5% female, and the non-T2D group was 38.7% male and 61.3% female. There were no significant differences in comorbidities. In the T2D group, 45.6% of patients underwent Roux-en-Y gastric bypass and 54.4% sleeve gastrectomy. In the non-TD2 group, 42.7% of patients received Roux-en-Y gastric bypass and 57.3% sleeve gastrectomy. There were no statistically significant differences in postoperative ED visits (21.8% vs. 24.3%, p = 0.21), minor complications within 30 days (4.3% vs. 5.2%, p = 0.67), readmission rates (5.6% vs. 4.9%, p = 0.77), re-operation rates (3.7% vs. 1.5%, p = 0.11), median hospital stay (2.0 days vs. 3.0, p = 0.05), or complications after 30 days (6.2% vs. 11.2%, p = 0.07). There were no deaths either group. In this cohort of patients from the MENA region, bariatric surgery in T2D patients is safe and effective, with perioperative outcomes comparable to those of non-T2D patients. To the best of our knowledge, our postoperative findings, which are the first report in the MENA region, are consistent with studies published in North America and Europe.

Preoperative assessment of microvascular invasion risk using gadoxetate-enhanced MRI for predicting outcomes after liver transplantation for single hepatocellular carcinoma within the Milan criteria.

To compare therapeutic outcomes after liver transplantation (LT) between hepatocellular carcinomas (HCC) with low and high risk for microvascular invasion (MVI) within the Milan criteria evaluated preoperatively. Eighty patients with a single HCC who underwent LT as the initial therapy between 2008 and 2017 were included from two tertiary referral medical centers in a HBV-predominant population. A preoperative MVI-risk model was used to identify low- and high-risk patients. Recurrence-free survival (RFS) after LT between the two risk groups was compared using Kaplan-Meier curves with the log-rank test. Prognostic factors for RFS were identified using a multivariable Cox hazard regression analysis. Eighty patients were included (mean age, 51.8 years +/- 7.5 [standard deviation], 65 men). Patients were divided into low-risk (n = 64) and high-risk (n = 16) groups for MVI. The RFS rates after LT were significantly lower in the MVI high-risk group compared to the low-risk group at 1 year (75.0% [95% CI: 56.5-99.5%] vs. 96.9% [92.7-100%], p = 0.048), 3 years (62.5% [42.8-91.4%] vs. 95.3% [90.3-100%], p = 0.008), and 5 years (62.5% [42.8-91.4%] vs. and 95.3% [90.3-100%], p = 0.008). In addition, multivariable analysis showed that MVI high risk was the only significant factor for poor RFS (p = 0.016). HCC patients with a high risk of MVI showed significantly lower RFS after LT than those without. This model could aid in selecting optimal candidates in addition to the Milan criteria when considering upfront LT for patients with HCC if alternative treatment options are available. High risk for microvascular invasion (MVI) in hepatocellular carcinoma patients lowered recurrence-free survival after liver transplantation, despite meeting the Milan criteria. Identifying MVI risk could aid candidate selection for upfront liver transplantation, particularly if alternative treatments are available. • A predictive model-derived microvascular invasion (MVI) high- and low-risk groups had a significant difference in the incidence of MVI on pathology. • Recurrence-free survival after liver transplantation (LT) for single hepatocellular carcinoma (HCC) within the Milan criteria was significantly different between the MVI high- and low-risk groups. • The peak incidence of tumor recurrence was 20 months after liver transplantation, probably indicating that HCC with high risk for MVI had a high risk of early (≤ 2 years) tumor recurrence.

Prediction of surgical outcomes in severe encapsulating peritoneal sclerosis using a computed tomography scoring system

Encapsulating peritoneal sclerosis (EPS) is a rare and potential lethal complication of peritoneal dialysis characterized by bowel obstruction. Surgical enterolysis is the only curative therapy. Currently, there are no tools for predicting postsurgical prognosis. This study aimed to identify a computed tomography (CT) scoring system that could predict mortality after surgery in patients with severe EPS. This retrospective study enrolled patients with severe EPS who underwent surgical enterolysis in a tertiary referral medical center. The association of CT score with surgical outcomes including mortality, blood loss, and bowel perforation was analyzed. Thirty-four patients who underwent 37 procedures were recruited and divided into a survivor and non-survivor group. The survivor group had higher body mass indices (BMIs, 18.1 vs. 16.7kg/m2, p=0.035) and lower CT scores (11 vs. 17, p<0.001) than the non-survivor group. The receiver operating characteristic curve revealed that a CT score of ≥15 could be considered a cutoff point to predict surgical mortality, with an area under the curve of 0.93, sensitivity of 88.9%, and specificity of 82.1%. Compared with the group with CT scores of <15, the group with CT scores of ≥15 had a lower BMI (19.7 vs. 16.2kg/m2, p=0.004), higher mortality (4.2% vs. 61.5%, p<0.001), greater blood loss (50 vs. 400mL, p=0.007), and higher incidence of bowel perforation (12.5% vs. 61.5%, p=0.006). The CT scoring system could be useful in predicting surgical risk in patients with severe EPS receiving enterolysis.