University-affiliated Community Hospital Research Articles

Influence of multidisciplinary teams (MDT) on breast satisfaction and sexual well-being in the immediate postoperative phase following breast-conserving surgery (BCS).

e13788 Background: Despite the recognized significance of multidisciplinary team (MDT) on patient satisfaction post-operatively, limited data exists on its overall impact. This study assessed the impact of MDT, including the surgeon, medical oncologist, and office staff, on patient breast satisfaction and sexual well-being among early-stage breast cancer patients. We examine three early time points after breast-conserving surgery (BCS): 2 weeks, 4 weeks, and 3 months. In addition, demographic and socioeconomic factors affecting patient satisfaction were also analyzed. Methods: A survey using BREAST-Q modules was conducted via telephone interviews among early-stage breast cancer patients who had BCS at a university-affiliated community hospital from October 2022 to September 2023. BREAST-Q responses were translated to Rasch scores (0=lowest, 100=highest). Patient-reported concerns were collected with open-ended questions. The correlation between variables was measured using Pearson’s correlation. A comparison of Rasch scores over time was done with repeated measures of ANOVA. SPSS 28.0 was used for statistical analysis, with a p-value<0.05 considered statistically significant. Results: Of 200 patients assessed, 61 met the study criteria, and 30 participated (mean age 66.3 years±9.9). Most were White (90%), married (55%), with stage 1 cancer (63%) and comorbidities (60%). At 2 weeks, the mean breast satisfaction score was 66.8, which increased to 71.0 at 4 weeks and 88.1 at 3 months (p<0.05), while sexual well-being remained stable (69.0 at 2 weeks, 73.1 at 4 weeks, and 68.3 at 3 months, p>0.05). Pain at the surgical site was the most cited concern at 2 and 4 weeks (30% and 41%, respectively), while dry skin (25%) was the top concern at 3 months. High patient satisfaction scores with the surgeon (mean 95.5), medical team (mean 98.3), and office staff (mean 99.3) were noted throughout the three time periods (p>0.05). Satisfaction with the surgeon was associated with better breast satisfaction and higher sexual well-being scores at two weeks after BCS (p<0.05). No other significant correlations were found between the influence of MDT on patient satisfaction at 4 weeks and 3 months. In a univariate analysis, widows reported the highest breast satisfaction at 2 weeks (94.0, p<0.05). White patients had a higher sexual well-being score than Black patients (72.4 vs. 51.5, p<0.05), while alcohol use had lower sexual well-being scores at 2 weeks (62.5 vs. 89.8, p<0.05). In a multivariable analysis, only marital status and alcohol use remained significant at 2 weeks post-BCS (p<0.05). Conclusions: The study highlights the surgeon’s critical role in achieving high level of patient satisfaction with their breasts and sexual well-being after BCS. Additionally, it reveals the significant influence of sociodemographic factors on patient outcomes.

Abstract PO1-12-04: Exploring Factors Associated with Sexual Well-being and Breast Satisfaction Among Women with Early-stage Breast Cancer

Abstract BACKGROUND: Breast cancer affects not only physical health but also psychological and emotional well-being. Among the various aspects that impact the quality of life of breast cancer patients, sexual well-being and body image in terms of breast satisfaction play a crucial role. Unfortunately, these aspects are often overlooked and undervalued in healthcare, leading to inadequate care and support for breast cancer patients. This study delved into the factors that influence breast satisfaction and sexual well-being in early-stage breast cancer patients who have recently received a cancer diagnosis. We aim to offer providers a more patient-centered and comprehensive approach to breast cancer care. METHODS: This prospective questionnaire-based study screened 175 early-stage breast cancer patients recently diagnosed at a university-affiliated community hospital in Michigan from October 2022 to June 2023. Participants with a previous history of chemoradiation and advanced-stage breast cancer were excluded. Structured telephone interviews were conducted to obtain informed consent and assess patients' breast satisfaction and sexual well-being. Participants were interviewed after their recent breast cancer diagnosis and before undergoing surgical intervention. A validated BREAST-Q questionnaire was used, and their scores were converted to equivalent Rasch scores for interpretation (0=worst, 100=best). Pre-existing medical conditions, social history, and other variables were collected through electronic medical records review and confirmed by interview. Statistical analyses were performed using SPSS version 28.0, and a p-value less than 0.05 was considered statistically significant. RESULTS: Of 175 patients initially screened, 56 met the selection criteria. 75% (N=42) participated, while 25% (N=14) were excluded as they declined to participate or were unreachable via telephone. 81% were White, 14% were Black, and 5% were Hispanics. The cancer stages of the patients were Stage 0 (29.3%), I (48.8%), II (12.2%), and III (9.8%). The mean breast satisfaction score of participants was 67.1 (N=42), and the mean sexual well-being score was 44.6 (N=36). The study found that only the type of surgery was observed to be significantly related to the breast satisfaction of patients. Interestingly, patients who chose mastectomy had higher breast satisfaction scores (75.6 vs. 62.9, p< 0.05) and were relatively younger (59 years vs. 67 years, p< 0.05) than those undergoing lumpectomy. No other demographic factors (race, education, marital status, BMI), social history (smoking), bra size, or pre-existing medical conditions (hypertension, diabetes) were found to affect breast satisfaction among these patients. On the other hand, age had a negative correlation with sexual well-being (mean age=64 years, p< 0.05), while income had a positive correlation (mean income=$ 76,170 annually, p< 0.05). No other variables were significantly associated with patients’ sexual well-being. CONCLUSION: The study revealed that the patient's sexual well-being was significantly associated with age and income, while breast satisfaction was only related to the type of surgery. These findings underscore the importance of considering multiple aspects of a patient's life when designing a comprehensive treatment plan following a cancer diagnosis. By providing additional support and resources tailored to these specific needs, healthcare providers can enhance patients' overall quality of life and promote greater satisfaction with their treatment outcomes. Citation Format: Kim Abbegail Aldecoa, Yi Lee, Lisa Deptula, Chioma Mbionwu, Ewomamobuho Eto, Esentur Salamatov, Megan Frame, Andrea Briefs Ferris, Geetha Krishnamoorthy, Amy Kirby, Judie Goodman. Exploring Factors Associated with Sexual Well-being and Breast Satisfaction Among Women with Early-stage Breast Cancer [abstract]. In: Proceedings of the 2023 San Antonio Breast Cancer Symposium; 2023 Dec 5-9; San Antonio, TX. Philadelphia (PA): AACR; Cancer Res 2024;84(9 Suppl):Abstract nr PO1-12-04.

Accuracy of the Diagnosis of Subsegmental Pulmonary Embolism Among General Radiologists

Background: Diagnosis and treatment of subsegmental pulmonary embolism (SSPE) are challenging. Contrary to segmental PE, little is known about the accuracy of the diagnosis of SSPE Methods A retrospective matched cohort study was conducted at a university-affiliated community hospital. Computed tomographic angiography (CTAs) were reviewed from August 2018 to December 2021. Patients who were 18-year-old or older with the diagnosis of SSPE were included. Patients with a concurrent segmental PE or deep venous thrombosis (DVT) were excluded. Another radiologist reviewed each CTA. Results Total of 43 patients with SSPE without segmental PE were identified. The mean age of subjects was 67 years. 24 (56%) patients were males, and 41 (95%) were white. 42 (97%) of CTAs were performed for suspected PE. One case was found incidentally. Forty patients (93%) received therapeutic anticoagulation. Three patients (7%) were discharged from the Emergency Department (ED) without therapeutic anticoagulation. The average duration of anticoagulation therapy was four-months. Another radiologist's review of the CTA on admission revealed a discordant diagnosis: 13 out of 43 (30%) cases were reported negative for SSPE. One case was reported for segmental PE Conclusion The accuracy of the diagnosis of SSPE is low as the discordance rate by different radiologists is high.More studies are needed to establish the diagnosis and guide treatment of SSPE.

Are preoperative sexual well-being and breast satisfaction associated with the decision making in patients with early-stage breast cancer undergoing oncologic surgery?

e12573 Background: Early-stage breast cancer is treated with lumpectomy with radiation therapy or mastectomy in the absence of medical contraindications. Patients have the autonomy to pursue the surgery of their choice. However, the associations between patients’ decisions on surgery (lumpectomy vs. mastectomy) and their preoperative sexual wellbeing and breast satisfaction remain largely unknown. We investigated early-stage breast cancer patients’ preoperative sexual wellbeing and breast satisfaction who underwent lumpectomy vs. mastectomy using the validated and widely used BREAST-Q questionnaire. Secondary aim described the expectations and concerns through qualitative methods. Methods: This is a study using BREAST-Q to investigate early-stage breast cancer patients’ preoperative sexual wellbeing and breast satisfaction at a university-affiliated community hospital between October 2022 and February 2023. Structured telephone interviews with open-ended questions conducted. All patients received preoperative teaching regarding current guideline-directed treatment. Multivariate logistic regression analysis examined factors predictive of surgery and two-sample t-test for baseline characteristics. Statistical analyses were performed using Stata/IC 16.1. Results: A total of 109 patients were screened, 6 patients declined, and 22 patients were eligible for enrollment. 90.1% were White, 9.1% were Black. We identified 68.8% of patients agreed to undergo lumpectomy; 87.5% expressed that the decision was based on total trust for the multidisciplinary team, whereas 12.5% based on personal decision. 70% underwent lumpectomy and 20% mastectomy, among which two were recommended mastectomy by physicians' clinical judgement, two elected mastectomy in the hope for no cancer recurrence. Preoperative sexual wellbeing score (48.4 vs 53, p = 0.74) and breast satisfaction score (60.2 vs 69.2, p = 0.39) showed no difference in lumpectomy vs mastectomy. The multivariate logistic regression model adjusted for baseline demographics (age, race, BMI, bra size), relationship status, and socioeconomic status (education and annual personal income) indicated that no independent factors predictive of decisions. Patients reported answers to open-ended questions revealed the following most common expectations were 42.8% cancer free, 28.5% fast recovery, meanwhile concerns were 38.1% cancer recurrence, 28.6% surgical complications, 9.5% breast appearance. Conclusions: Our study shows that most patients made trust-based decisions despite available information and preoperative teaching. Patients' preoperative sexual wellbeing and breast satisfaction had no association with patients' decisions in lumpectomy vs. mastectomy. No social determinants associated with patients' decision making were identified.

No prostate? No problem: robotic inguinal hernia repair after prostatectomy.

Traditional teaching suggests that prior pelvic operations, including prostatectomy, are a contraindication to laparoscopic inguinal hernia repair. Despite the growing use of robotic platforms in inguinal hernia repair, there are few studies describing robotic-assisted inguinal hernia repairs (RIHR) in this patient population. This study aims to demonstrate that RIHR is safe and effective in repairing inguinal hernias in patients who had previously undergone prostatectomy. We retrospectively reviewed RIHR cases performed from March 2017 to October 2021 by a single surgeon at our university-affiliated community hospital. Cases were reviewed for preoperative considerations, operative times and complications, and postoperative outcomes. A total of 30 patients with prior prostatectomy underwent transabdominal preperitoneal (TAPP) RIHR with mesh. Sixteen of the 30 patients had undergone robot-assisted laparoscopic prostatectomy (RALP), while 14 patients underwent open resection. Seven of the patients had received post-resection radiation and 12 had previous non-urologic abdominal operations. When compared to all RIHRs performed over the same period, duration of surgery was increased. There were no conversions to open surgery. Postoperatively, one patient developed a repair site seroma which resolved after 1month. Mean follow-up time was 8.0months. At follow-up, one patient reported experiencing intermittent non-debilitating pain at the repair site and one patient developed an inguinoscrotal abscess of unknown relation to the repair. No patients reported hernia recurrences nor mesh infection. This review suggests that TAPP RIHR can be a safe and effective approach to inguinal hernia repair in patients who have previously undergone prostatectomy, including those who received radiation and those who underwent either open or robotic resections.

Point-of-care ultrasound: impact on emergency department length of stay for suspected lower extremity DVT.

Point-of-care ultrasound (POCUS) has demonstrated excellent sensitivity and specificity for the diagnosis of DVT in the emergency department (ED). Before POCUS became widespread, patients underwent radiology department comprehensive lower extremity venous duplex ultrasounds (RADUS) which may be associated witha prolonged length of stay. The goal of this study is to evaluate the impact of POCUS on ED arrival to disposition (ATD) time for patients presenting to the ED with suspected lower extremity DVT. This is a retrospective chart analysis of ED visits to an urban, university-affiliated community hospital from January 2019 to December 2020. This study compared ATD between patients who underwent POCUS by an emergency medicine physician and RADUS by the radiology department. In total, 1204 patients underwent POCUS, and 1582 patients were evaluated with RADUS. The POCUS mean ATD was 313 ± 16.8min compared to the RADUS arm average of 323 ± 57.9min (p = 0.56). Order to disposition time (OTD) was prolonged among the RADUS group relative to POCUS. ATD was significantly reduced in the POCUS subgroup of patients presenting during night shift when RADUS was not available, 326 ± 28.2min versus 630 ± 109min (p < 0.05). ED POCUS scans decrease the amount of time between order placement and disposition when compared to RADUS. POCUS significantly decreases length of stay in the ED when RADUS is not available.

1206. Epidemiological interaction of MRSA, ESBL E.coli and C. difficile between ICU/Step-down Unit of University-affiliated Community Hospital and LTACs in Japan: Utility of Molecular Epidemiology Analysis by PCR-based ORF Typing (POT method)

Abstract Background Epidemiological interaction of drug resistant organisms between ICU and surrounding health facilities including LTACs have been of interest in the era of antimicrobial resistance (AMR) and aging society. In addition, conventional molecular epidemiology methods such as pulsed-field gel electrophoresis, and multilocus sequence typing are time-consuming and difficult to perform in a standard microbiology laboratory. Methods Patients admitted to a university-affiliated community hospital in Japan was recruited if their cultures collected clinically during admission grew the following target pathogens: Methicillin-resistant Staphylococcus aureus (MRSA), Vancomycin Resistant Enterococci (VRE), ESBL Gram negative rods (GNR), carbapenem-resistant Enterobacteriaceae (CRE), multi-drug resistant Pseudomonas (MDRP) and Clostridioides difficile (C. diff). Their clinical information including admission to ICU/step-down unit vs regular wards and disposition was analyzed with chi-square test for binary outcomes. For the isolates of MRSA, ESBL E. coli, and C. diff, further molecular epidemiology analysis was made, using PCR-based open-reading frame (ORF) Typing (POT method), a more resource-friendly and time-efficient technology originally developed in Japan. Results Among total 9639 hospital admissions in 2018-2019, the above-mentioned target pathogens grew from 233 patients (2.4%). There were 96 MRSA isolates (41.2%, out of 233), followed by 93 ESBL GNR (39.9%), 21 C. diff (9.0%), 13 CRE (5.6%), 10 MDRP (4.3%), and no VRE, respectively. Patients admitted to ICU/step-down unit were more likely to grow the target pathogens (117/1605 vs 116/7801, RR 4.90, 95% CI 3.81-6.30, p&amp;lt; 0.001), and to be discharged to LTACs than patients admitted to regular wards (70/113 vs 32/116, RR 2.17, 95% CI 1.56-3.02). Molecular epidemiology analysis with POT method identified 5, 3 and 3 common strains across 20, 11, and 7 patients with MRSA, ESBL E.coli, C. diff, respectively. Conclusion The study suggests the pathogens of higher priority were more prevalent in ICU/step-down unit and that the discharge from ICU/step-down unit to LTACs could impact on further transmission in the surrounding region. POT method can be utilized for more efficient molecular epidemiology analysis in the era of AMR. Disclosures All Authors: No reported disclosures.

Evidence-Based Recommendations for Referral and Consultation to a Minimally Invasive Gynecologic Surgeon: A Systematic Review

Study Objective Minimally invasive gynecologic surgery (MIGS) is a subspecialty focus of obstetrics and gynecology with focused expertise on complex benign gynecologic pathology. To date, no formal recommendations have been made in defining a referral system for MIGS. This systematic review investigates the evidence regarding common pathologies and procedures including leiomyomatous uteri, endometriosis, and complex hysterectomies and their outcomes, and posits a basis for MIGS referral. Design Systematic Review. Setting University-Affiliated Community Hospital. Patients or Participants A PubMed literature search of pertinent research published within the preceding 5 years from January 2017 - Dec 2021. 1435 titles and abstracts were identified, and of these 372 full articles screened. 26 retrospective studies were eligible and included in this systematic review. Interventions The following PubMed MeSH terms were used for literature review: Leiomyomas - fibroids, myomectomy, complications, outcomes; Endometriosis - endometriosis, minimally invasive gynecologic surgery fellowship; and Complex Hysterectomy - complex MIS, Hysterectomy, obesity, outcomes, high volume, high volume gynecologic surgeon. Measurements and Main Results In instances where intraoperative and perioperative features may pose clinical challenges to the surgeon and ultimately the patient, the literature suggests the following scenarios may have adverse outcomes and therefore benefit from the skills of MIGS subspecialists: Fibroids - ≥5 myomas, myoma size ≥9cm, and suspected myoma weight ≥500g; Endometriosis - presence of endometrioma(s), suspected stage III/IV endometriosis, and requirement for advanced adjunct procedures; and Complex Hysterectomy - uteri ≥250g or 12 weeks estimated size, ≥3 prior laparotomies, obesity, and complex surgical history with suspected adhesive disease. Conclusion A referral system for MIGS subspecialists has proven benefits for both the gynecologic surgical community as well as the patients and their outcomes. This article provides evidence for collaboration with MIGS especially as it relates to leiomyomatous uteri, endometriosis, and complex hysterectomies. Minimally invasive gynecologic surgery (MIGS) is a subspecialty focus of obstetrics and gynecology with focused expertise on complex benign gynecologic pathology. To date, no formal recommendations have been made in defining a referral system for MIGS. This systematic review investigates the evidence regarding common pathologies and procedures including leiomyomatous uteri, endometriosis, and complex hysterectomies and their outcomes, and posits a basis for MIGS referral. Systematic Review. University-Affiliated Community Hospital. A PubMed literature search of pertinent research published within the preceding 5 years from January 2017 - Dec 2021. 1435 titles and abstracts were identified, and of these 372 full articles screened. 26 retrospective studies were eligible and included in this systematic review. The following PubMed MeSH terms were used for literature review: Leiomyomas - fibroids, myomectomy, complications, outcomes; Endometriosis - endometriosis, minimally invasive gynecologic surgery fellowship; and Complex Hysterectomy - complex MIS, Hysterectomy, obesity, outcomes, high volume, high volume gynecologic surgeon. In instances where intraoperative and perioperative features may pose clinical challenges to the surgeon and ultimately the patient, the literature suggests the following scenarios may have adverse outcomes and therefore benefit from the skills of MIGS subspecialists: Fibroids - ≥5 myomas, myoma size ≥9cm, and suspected myoma weight ≥500g; Endometriosis - presence of endometrioma(s), suspected stage III/IV endometriosis, and requirement for advanced adjunct procedures; and Complex Hysterectomy - uteri ≥250g or 12 weeks estimated size, ≥3 prior laparotomies, obesity, and complex surgical history with suspected adhesive disease. A referral system for MIGS subspecialists has proven benefits for both the gynecologic surgical community as well as the patients and their outcomes. This article provides evidence for collaboration with MIGS especially as it relates to leiomyomatous uteri, endometriosis, and complex hysterectomies.

Major Perioperative Complications of Benign Gynecologic Procedures at a University-Affiliated Hospital

Background: With the increasing use of minimally invasive techniques for gynecologic procedures, women are at a low risk for peri-operative complications. The purpose of this study was to determine the incidence of and risk factors for major intra or postoperative complications among women undergoing benign gynecologic surgeries. Methods: We conducted a retrospective observational study of all women who underwent benign gynecologic surgery in 2016-2017 at a University-Affiliated community hospital. Pregnant women, malignancy cases, and hysteroscopic or minor vulvar procedures were excluded. Primary outcome was composite intraoperative and/or 30-day postoperative complications requiring medical or surgical management. Logistic regression identified significant patient, peri-operative and surgeon risk factors associated with complications. Results: Of 975 patients included, 53 patients experienced major intra or postoperative complications (5.4%). Mean age was 47.7 ± 13.8 years. Mean BMI was 27.1 ± 5.8 kg/m2. Prior abdominal surgery (laparotomy or laparoscopy) (adjusted odds ratio [OR]= 2.01, 95%CI 1.05-3.83) and emergency surgery (adjusted OR= 19.54, 95%CI 2.99-127.54) were significantly associated with major complications. Surgeon volume of 1-2 operative days per month (adjusted OR=0.30, 95%CI 0.10 - 0.87) and age 40-64 years (adjusted OR=0.24, 95%CI 0.11- 0.56) had a protective effect on the risk of major complications. Conclusions: Among patients in our sample, 5.4% experienced major complications from a benign gynecologic surgery. Complications from benign gynecologic surgery are rare, even in the absence of robotic equipment. Center-specific data and a discussion of the increased morbidity associated with with prior abdominal surgery and emergency surgery should be considered for pre-operative patient counselling.

A Descriptive Analysis of Occult Gynecologic Malignancy in a Large Series of Supracervical Hysterectomy with Sacrocolpopexy

<h3>Study Objective</h3> The incidence of occult malignancy in patients with pelvic organ prolapse (POP) undergoing a supracervical hysterectomy (SCH) at the time of robotic-assisted laparoscopic sacrocolpopexy (RA-SCP) is not well documented in the medical literature. This has clinical implications as discovery would entail further operative management to perform staging, remove oncologic burden, and possibly revise the approach to pelvic reconstructive surgery. This study aims to detect the prevalence of oncologic pathology and ability of diagnostic preoperative work-up to detect such disease. <h3>Design</h3> Retrospective descriptive analysis. <h3>Setting</h3> University-affiliated community hospital. <h3>Patients or Participants</h3> All women undergoing a RA-SCP with SCH by one surgeon between March 2017 and March 2020 without symptoms of abnormal or postmenopausal bleeding. <h3>Interventions</h3> N/A. <h3>Measurements and Main Results</h3> A total of 425 women were included in this study. Of these, 19 (4.2%) patients were found to have uterine pathology of either pre-malignancy (n=14, 3.5%) or malignancy (n=5, 1.2%). Transvaginal ultrasonography (TVUS) had lower cases of missing pathology compared to EMB in the case of endometrial cancer (EC) (0% vs. 1.2%), endometrial hyperplasia +/- atypia (EH) (2.4% vs. 3%), or in combination EC and EH (2.4% vs 4.2%). EC and EH collectively were undiagnosed by either TVUS or EMB until final pathology in 4.2% of cases. <h3>Conclusion</h3> A small subset of asymptomatic postmenopausal women who undergo a SCH at the time of RA-SCP for POP will have underlying gynecologic malignancy or premalignant conditions. EMB or TVUS in these patients have inadequate sensitivity to rule out endometrial pathology and patients should be counseled appropriately regarding the small but possible necessity to remove the cervix in its entirety. Patients may be offered an intraoperative pathology assessment of the SCH prior to attachment of SCP mesh material to the cervix when appropriate.

Robotic-Assisted Laparoscopic Sacrocolpopexy in the Extreme Elderly: Safety and Feasibility

<h3>Study Objective</h3> Robotic-assisted laparoscopic sacrocolpopexy (RA-SCP) has evolved to be the standard of care for advanced stage pelvic organ prolapse (POP) repair in many women. Due to the variety of patients that undergo pelvic reconstructive surgery (PRS), it is important to identify risk stratification tools in the aging population in order to ensure positive outcomes in those undergoing RA-SCP for POP repair based on demographic risk factors. <h3>Design</h3> Retrospective cohort study. <h3>Setting</h3> University-affiliated community hospital. <h3>Patients or Participants</h3> All women undergoing a RA-SCP by one surgeon (n=1078) between March 2017 and March 2020 were included. <h3>Interventions</h3> Four groups were compared based on age: <40 years of age (n=23), ≥40 but <60 (n=304), ≥60 but <80 (n=723), and ≥80 years of age (n=28). <h3>Measurements and Main Results</h3> Intraoperative complications including bladder, ureteral, or bowel injury, and blood transfusions were not statistically different between groups, as were rates of presentation within 90 days to the emergency department or for readmission to the hospital. Postoperatively, greater age groups presented with greater incidence of incontinence (0%, 5.3%, 9.1%, 14.3%, p<0.05). There were no statistically significant differences in acute urinary retention (p=0.90) or need for home catheterization (p=0.80) between groups. Greater age groups underwent less operative time (231, 229, 221, and 204 mins respectively, p<0.05), and required less morphine milligram equivalents (MME) during their hospital stay (30.3, 25.6, 18.1, and 15.6 MME respectively, p<0.05). <h3>Conclusion</h3> RA-SCP is a highly tolerable procedure. Surgeons should counsel patients that advancing age does not appear to increase the rate of complications or readmissions both during and after surgery. Decreased operative time for advancing age groups due to concern for anesthesia, prolonged Trendelenburg positioning, and patient frailty may help to decrease pain medication needs postoperatively.

Perioperative Outcomes Following Opportunistic Bilateral Salpingo-Oophorectomy at the Time of Sacrocolpopexy

<h3>Study Objective</h3> Surgeons commonly opt to perform an opportunistic bilateral salpingo-oophorectomy (BSO) for peri- and postmenopausal women who undergo pelvic reconstructive surgery (PRS) in order to prevent future development of malignancy. The prevalence of underlying gynecologic malignancy amongst this population is not well defined in medical literature. There is also limited information on the impact of an opportunistic BSO on perioperative outcomes. This study aims to investigate the oncologic incidence and perioperative outcomes for those undergoing robotic-assisted laparoscopic sacrocolpopexy (RA-SCP) for pelvic organ prolapse (POP) with and without a concomitant BSO. <h3>Design</h3> Retrospective descriptive analysis. <h3>Setting</h3> University-affiliated community hospital. <h3>Patients or Participants</h3> Cases of patients who underwent a RA-SCP without hysterectomy (n=283) by one surgeon between March 2017 and March 2020. <h3>Interventions</h3> RA-SCP with concomitant BSO (n=150) versus without BSO (n=133). <h3>Measurements and Main Results</h3> A total of 2 patients (0.7%) were found to have malignant adnexal pathology: 2 high grade serous cancers of the fallopian tube with no ovarian cancers detected. Cases with concomitant BSO required statistically significant longer operative times (215 vs 197 mins, p<0.05). Morphine milligram equivalents (MME) used in the post-anesthesia care unit (PACU) and the recovery floor were comparable between with and without BSO groups (2.95 and 20.09 MME, vs 3.14 and 22.55 MME, p=0.59, p=0.49), respectively. Quantitative blood loss was similar amongst both groups (-2.12 and -2.31 g/dL, p=0.08). Demographics were without statistical differences between groups. <h3>Conclusion</h3> Performing opportunistic BSOs at the time of PRS with a RA-SCP is a well-tolerated procedure. A small subset of patients were found to have gynecologic cancer. Surgeons should counsel patients regarding the safety profile of opportunistic BSO and the potential to detect cancer in patients with POP who otherwise have no suspicion for adnexal malignancy.

244 Effect of Physician Burnout on Perception of Physician Empathy

Physician burnout is an ongoing health crisis effecting up to 50% of the physicians in the United States. Resident physicians are at a particularly high risk for burnout due to the rigorous demands of resident training. It has been assumed provider empathy could be protective against burnout. We aim to determine the strength and direction of correlation between provider burnout and patient perception of empathy as well as self-perception of empathy. We hypothesize that physician burnout is negatively associated with patient perception and self-perception of physician empathy and communication We conducted a correlational study measuring relationship of provider burnout and perception of empathy. Our participants included emergency medicine residents training at an urban, university-affiliated community hospital. Resident burnout rates were measured by responses to a validated survey administrated through an anonymous platform. Burnout was defined using the Maslach Burnout Inventory (MBI), a 22-item rating scale designed to assess three aspects of the burnout syndrome: emotional exhaustion (EE), depersonalization (DP), and lack of personal accomplishment (PA). A score of greater than 27 in EE, greater than 10 in DP, and less than 33 in PA was considered high risk for burnout. Empathy was self-measured by provider as well as reported by patients they cared for in the emergency department via a survey conducted by research assistants at conclusion of interaction with the provider. Self-empathy scores were measured with an Interpersonal Reactivity Index (IRI) focusing on empathic concern (EC). Patient perception of the resident’s empathy was quantified with the Consultation and Relational Empathy (CARE) Measure. Descriptive statistics and percent of respondents with burnout determined by their scores in each of 3 MBI domains are reported. Results for each domain were compared with self-perception and patient perception of empathy scores using linear and logistic regression analysis. Thirty-two of the 39 eligible residents completed the survey and took care of patients who perceived their empathy during the study period. Logistic regression model demonstrated that for every point increase of self-empathy score, the odds for DP burnout were less likely (Odds 0.69, 95% CI 0.49-0.86, p=0.01). For every point increase of patient perception of empathy, the odds for DP burnout were also less likely (Odds 0.71, 95% CI 0.49-0.95, p=0.04). Residents at high risk for burnout using the DP domain (less than 10 in DP) had lower empathy scores by patients (Effect -.3.30, 95% CI -6.60 to -0.55, p =0.03) and lower self-empathy scores (Effect -5.70, 95% CI -9.09 to -2.21, p < 0.01). Burnout remains a concern for resident physicians in the US. Identifying those at risk and investigating protective characteristics are of crucial importance to combat this epidemic. We found a correlation between residents’ empathy and the level of DP. An increase in empathy decreased the level of DP, making them at less risk for burnout. Our evidence also suggests that higher empathy scores can make DP less likely.

For Residents, by Residents: Developing a Physician Handoff Tool at a University Affiliated Community Hospital.

The 80-hour per week work limit resulted in an increased number of patient handoffs. A satisfactory handoff system should optimize the exchange of vital patient information while concisely minimizing error. This project describes our experience and lessons learned in successfully developing and implementing an Electronic Health Record (EHR)-integrated handoff system based on the I-PASS model. The handoff system, termed Physician Handoff, was refined through end-user feedback. End-users were evaluated on the quality of handoff in the following categories: Illness Severity, Patient Summary, Action List, and Situational Awareness. Resulting survey showed high adoption and satisfaction rate with Physician Handoff. Success can be attributed to interdepartmental collaboration, credentialing the users, and recognizing the importance of end-user feedback.

1607P Trends in cancer imaging by indication, care setting, and hospital type during the COVID-19 pandemic and recovery

Background: The delivery of cancer care has been greatly affected by the COVID pandemic. We aim to investigate the effect of the pandemic on computed tomography (CT) imaging of cancer. Methods: Cancer-related CT exams were retrospectively analyzed during three periods of 2020: pre-COVID (1/5/20-3/14/20), COVID peak (3/15/20-5/2/20) and post-COVID peak (5/3/20-11/14/20). Volumes were assessed by 1) Imaging indication: cancer screening, initial workup, active cancer, surveillance;2) Care setting: outpatient, inpatient, ED;3) Hospital type: quaternary academic center (QAC), university-affiliated community hospital (UACH), sole community hospitals (SCHs). Results: During the COVID peak, a significant drop in CT volumes was observed (-42·2%, p<0·0001), with cancer screening, initial workup, active cancer and cancer surveillance experiencing declines by 81·7%, 54·8%, 30·7% and 44·7% respectively (p<0·0001, Figure 1). The emergency department (ED) was the only setting with stable cancer-related CT volumes. In the post-COVID peak period, CT volumes for cancer screening and for initial workup did not recover (-11·7%, p=0·037;-20·0%, p=0·031), with the outpatient setting particularly affected. CT volumes for active cancer recovered post-peak, but inconsistently across hospital types with the QAC experiencing a 9·4% decline (p=0·022) and the UACH a 41·5% increase (p<0·001). Outpatient CTs recovered during the post-peak period, but a shift in utilization away from the QAC (-8·7%, p=0·020) toward the UACH (+13·3%, p=0·013) was observed. Inpatient and ED-based cancer-related CTs increased post-peak (+20·0%, p=0·004 and +33·2%, p=0·009, respectively). Conclusions: COVID severely impacted cancer imaging care. CTs for cancer screening and initial workup did not recover to pre-COVID levels well into 2020, a finding that suggests higher numbers of patients with advanced cancers may present in the future. A redistribution of imaging utilization away from the QAC and outpatient settings, toward the community hospitals and inpatient setting/ED was observed. The ED has remained a dependable healthcare delivery setting for patients with cancer throughout the pandemic. Legal entity responsible for the study: The authors. Funding: Has not received any funding. Disclosure: J. Brink: Financial Interests, Institutional, Member of the Board of Directors: Accumen, Inc. All other authors have declared no conflicts of interest.

The Transitional Year internship: Five classes of former interns reflect on their first clinical year

Objective: The clinical internship (postgraduate year-1), which precedes many advanced residency training programs, are traditionally fulfilled by a transitional year (TY) or preliminary year of training in medicine or surgery. TY programs can take place in a variety of settings, ranging from community hospitals to large academic medical centers. In the present study, we sought to evaluate if resident physicians who completed a community hospital-based TY internship felt prepared for their subsequent specialty residency training. Methods: A cross-sectional survey was adapted and distributed to resident physicians who completed their TY internship at a university-affiliated community hospital in Baltimore, Maryland, between 2015 and 2019. The survey was composed of seven questions, utilizing a 5-point Likert-type scale, and assessed the perceived value of internship in preparing for advanced residency training, their professional development, and their willingness to choose the TY training experience again. Results: Thirty-seven responses were received out of a total of 53 resident physicians who trained in the program over a five-year period (70% response rate). After completing the TY internship, most residents subsequently trained in Diagnostic Radiology 16/37 (43%) and Ophthalmology 11/37 (30%). Of all respondents, 33/37 (89%) agreed that the internship training experience was necessary for their development as a physician. Regarding preparedness, 22/37 (59%) reported that the TY internship had advanced their procedural skills. Most respondents, 32/37 (86%), would choose the TY experience again to fulfill the internship requirement. No significant difference was seen when responses were stratified by year of internship completion. Conclusion: This single-center study of resident physicians who completed a community hospital-based Transitional Year internship revealed that the majority of participants found their training to adequately prepare them for their respective residencies across specialties and that they would select this route again to fulfill the internship requirement.

Trends in cancer imaging by indication, care setting, and hospital type during the COVID-19 pandemic and recovery at four hospitals in Massachusetts.

BackgroundWe aimed to investigate the effects of COVID‐19 on computed tomography (CT) imaging of cancer.MethodsCancer‐related CTs performed at one academic hospital and three affiliated community hospitals in Massachusetts were retrospectively analyzed. Three periods of 2020 were considered as follows: pre‐COVID‐19 (1/5/20–3/14/20), COVID‐19 peak (3/15/20–5/2/20), and post‐COVID‐19 peak (5/3/20–11/14/20). 15 March 2020 was the day a state of emergency was declared in MA; 3 May 2020 was the day our hospitals resumed to non‐urgent imaging. The volumes were assessed by (1) Imaging indication: cancer screening, initial workup, active cancer, and surveillance; (2) Care setting: outpatient and inpatient, ED; (3) Hospital type: quaternary academic center (QAC), university‐affiliated community hospital (UACH), and sole community hospitals (SCHs).ResultsDuring the COVID‐19 peak, a significant drop in CT volumes was observed (−42.2%, p < 0.0001), with cancer screening, initial workup, active cancer, and cancer surveillance declining by 81.7%, 54.8%, 30.7%, and 44.7%, respectively (p < 0.0001). In the post‐COVID‐19 peak period, cancer screening and initial workup CTs did not recover (−11.7%, p = 0.037; −20.0%, p = 0.031), especially in the outpatient setting. CT volumes for active cancer recovered, but inconsistently across hospital types: the QAC experienced a 9.4% decline (p = 0.022) and the UACH a 41.5% increase (p < 0.001). Outpatient CTs recovered after the COVID‐19 peak, but with a shift in utilization away from the QAC (−8.7%, p = 0.020) toward the UACH (+13.3%, p = 0.013). Inpatient and ED‐based oncologic CTs increased post‐peak (+20.0%, p = 0.004 and +33.2%, p = 0.009, respectively).ConclusionsCancer imaging was severely impacted during the COVID‐19 pandemic. CTs for cancer screening and initial workup did not recover to pre‐COVID‐19 levels well into 2020, a finding that suggests more patients with advanced cancers may present in the future. A redistribution of imaging utilization away from the QAC and outpatient settings, toward the community hospitals and inpatient setting/ED was observed.

Use of a standardized discharge checklist with daily post-operative C-reactive protein monitoring does not impact readmission rates after colon and rectal surgery.

Elevated CRP has been associated with infectious complications after colorectal surgery but has not been evaluated in a prospective fashion as part of a discharge checklist. The objective of this study was to evaluate the effectiveness of a multi-component "discharge criteria checklist" that included daily use of CRP in decreasing hospital readmission rates after colorectal surgery. This is a prospective before and after study design that included consecutive patients undergoing major colorectal operations at a single university-affiliated community hospital over a 2-year period. The primary outcome was inpatient or emergency department readmission after 30 days. Selected pre- and peri-operative factors associated with readmissions were then examined in a multivariate analysis model. The study included a total of 1546 patients. Surgical indications were inflammatory bowel disease (15%), colorectal cancer (24%), and benign disease (60%); 9.5% were emergencies. The readmission rates for each group were similar, 17.3% and 17.0%, for the control and discharge checklist groups, respectively (p=0.88). On multivariate analysis of the discharge checklist group dataset, only age, sex, surgical acuity and operating time were statistically significant risk factors. The difference of median CRP values on the day of discharge of those readmitted compared to those not readmitted (35 vs 32 mg/L) was not statistically significant (p=0.28). The institution of a "discharge checklist" did not impact post-operative hospital readmissions. Not only were readmissions unchanged by the use of a CRP threshold at discharge, but CRP levels at the time of discharge were not associated with readmissions.

Enhanced Recovery Protocols Reduce Mortality Across Eight Surgical Specialties at Academic and University-affiliated Community Hospitals.

To determine if implementation of a simplified ERP across multiple surgical specialties in different hospitals is associated with improved short and long-term mortality. Secondary aims were to examine ERP effect on length of stay, 30-day readmission, discharge disposition, and complications. Enhanced recovery after surgery and various derivative ERPs have been successfully implemented. These protocols typically include elaborate sets of multimodal and multidisciplinary approaches, which can make implementation challenging or are variable across different specialties. Few studies have shown if a simplified version of ERP implemented across multiple surgical specialties can improve clinical outcomes. A simplified ERP with 7 key domains (minimally invasive surgical approach when feasible, pre-/intra-operative multimodal analgesia, postoperative multimodal analgesia, postoperative nausea and vomiting prophylaxis, early diet advancement, early ambulation, and early removal of urinary catheter) was implemented in 5 academic and community hospitals within a single health system. Patients who underwent nonemergent, major orthopedic or abdominal surgery including hip/knee replacement, hepatobiliary, colorectal, gynecology oncology, bariatric, general, and urological surgery were included. Propensity-matched, retrospective case-control analysis was performed on all eligible surgical patients between 2014 and 2017 after ERP implementation or in the 12 months preceding ERP implementation (control population). A total of 9492 patients (5185 ERP and 4307 controls) underwent ERP eligible surgery during the study period. Three thousand three hundred sixty-seven ERP patients were matched by surgical specialty and hospital site to control non-ERP patients. Short and long-term mortality was improved in ERP patients: 30 day: ERP 0.2% versus control 0.6% ( P = 0.002); 1-year: ERP 3.9% versus control 5.1% ( P < 0.0001); 2-year: ERP 6.2% versus control 9.0% ( P < 0.0001). Length of stay was significantly lower in ERP patients (ERP: 3.9 ± 3.8 days; control: 4.8 ± 5.0 days, P < 0.0001). ERP patients were also less likely to be discharged to a facility (ERP: 11.3%; control: 14.8%, P < 0.0001). There was no significant difference for 30-day readmission. All complications except venous thromboembolism were significantly reduced in the ERP population (P < 0.02). A simplified ERP can uniformly be implemented across multiple surgical specialties and hospital types. ERPs improve short and long-term mortality, clinical outcomes, length of stay, and discharge disposition to home.

Feasibility of robotic-assisted minimally invasive inguinal hernia repair in patients with urologic considerations including artificial urinary sphincters and bladder herniation.

Robotic surgical technology has the potential to broaden the applicability of minimally invasive approaches into more complex, technically challenging inguinal hernia repairs. A unique patient population requiring inguinal hernia repair are those patients who either have artificial urinary sphincters (AUS) or inguinal bladder herniation (IBH). Traditionally, these patients have not been considered candidates for minimally invasive inguinal hernia repairs. Through this retrospective series, we aim to contribute to the growing body of literature on robotic-assisted inguinal hernia repair (RIHR) by describing our experience with RIHR in this patient subset. We performed a retrospective chart review of RIHR cases performed from June 2017 to April 2019 by a single surgeon at our university-affiliated community hospital. Charts were reviewed for preoperative considerations, operative complications, and postoperative outcomes. A total of three patients with an AUS and six patients with IBH were included, all of whom were male. All the patients received transabdominal preperitoneal (TAPP) approaches, and all received placement of mesh. There were no intraoperative complications and no conversions to open surgery. Postoperatively, one patient with IBH had persistent surgical site pain that resolved after 3weeks and one patient, also with IBH, had a surgical site seroma that resolved without further intervention. Mean follow-up time was 10.71 and 12.13months for patients with AUS and IBH, respectively. No patients reported hernia recurrence during this time. This review suggests that the use of robotic assistance for laparoscopic inguinal hernia repair is safe and effective and may provide additional benefits for patients with concurrent urological considerations such as AUS and IBH.