University Of Pittsburgh Medical Center Research Articles

Severe complicated Clostridium difficile infection: Can the UPMC proposed scoring system predict the need for surgery?

Clostridium difficile infection (CDI) is one of the most common health care-associated infections, and it continues to have significant morbidity and mortality. The onset of fulminant colitis often requires total abdominal colectomy with ileostomy, which has a mortality rate of 35% to 57%. University of Pittsburgh Medical Center (UPMC) developed a scoring system for severity and recommended surgical consultation for severe complicated disease. The aim of this study was to evaluate if the UPMC-proposed scoring system for severe complicated CDI can predict the need for surgical intervention. This is a retrospective review of all patients who developed severe complicated CDI at Geisinger Medical Center between January 2007 and December 2012 as defined by the UPMC scoring system. Main outcomes were the need for surgical intervention and 30-day mortality. Eighty-eight patients had severe complicated CDI based on the UPMC scoring system. Fifty-nine patients (67%) required surgery and 29 did not. All patients had a diagnosis of CDI as shown by positive toxin assays. There was no difference between the groups with respect to age, sex, body mass index, or comorbidities. When comparing the surgical group to the nonsurgical cohort, the surgical cohort averaged 20 points on the scoring system compared to 9 in the nonoperative cohort. In patients with severe complicated CDI, 15 or more points predicted the need for surgery 75% of the time. Forty-two percent of the surgical cohort had respiratory failure requiring mechanical ventilation compared to 0% in the nonsurgical cohort (p < 0.0001). Forty-nine percent of the surgical cohort required vasopressors for septic shock before surgery compared to 0% in the nonsurgical cohort (p < 0.0001). Acute kidney injury was present in 92% of the surgical cohort versus 72% within the nonsurgical cohort (p = 0.026). Seventy-six percent of the surgical patients were admitted to the ICU before surgery. Within the nonsurgical cohort, only 24% of patients required ICU stay during admission. Overall, 30-day mortality in the surgical cohort was 30%, and there was no mortality in the nonsurgical cohort. The UPMC scoring system for severe complicated CDI can help us predict patients who need a surgical consult and the need for surgical intervention. In patients with severe complicated CDI, evidence of end-organ failure predicts surgical intervention. Prognostic study, level III; therapeutic study, level IV.

Free‐range apps

Free‐range apps

Bayesian Gaussian processes for identifying the deteriorating patient.

The step-down unit (SDU) is a high-acuity hospital environment, to which patients may be sent after discharge from the intensive care unit (ICU). About 1- in-7 patients will deteriorate in the SDU and require emergency readmission to the ICU. Upon readmission, these patients experience significantly higher mortality risks and lengths of stay. Gaussian process regression (GPR) models are proposed as a flexible, principled, probabilistic method to address the clinical need to monitor continuously patient time-series of vital signs acquired in the SDU. The proposed GPR models focus on the robust forecasting of patient heart rate time-series and on the early detection of patient deterioration. The proposed methods are tested with an SDU data set from the University of Pittsburgh Medical Center, comprising 333 patients, 59 of whom had at least one verified clinical emergency event. Results suggest that GPR-based heart rate monitoring provides superior advanced warning of deterioration compared to the current clinical practice of rules-based thresholding, and slightly outperforms the current state-of-the-art kernel density method, which requires 4 additional vital sign features.

Downstream consequences of melanoma screening in a community practice setting: First results.

Population-based screening for the early detection of melanoma holds great promise for reducing melanoma mortality, but evidence is needed to determine whether benefits outweigh risks. Skin surgeries and dermatology visits after screening were assessed to indicate potential physical, psychological, and financial consequences. Targeted primary care providers (PCPs) at the University of Pittsburgh Medical Center were trained to detect early melanoma using the INFORMED (INternet course FOR Melanoma Early Detection) program. The authors analyzed aggregated administrative data describing 3 groups of patients aged ≥35 years who had received an annual physical examination by PCPs: group A1 included patients of PCPs from the group with the highest percentage of INFORMED-trained providers, group A2 included patients of PCPs from the group with a lower percentage of INFORMED-trained providers, and group B included patients of PCPs without INFORMED training. INFORMED-trained PCPs screened 1572 of 16,472 patients in groups A1 or A2 and none of the 56,261 patients in group B. In group A1, there was a 79% increase (95% confidence interval, 15%-138%) in melanoma diagnoses noted; no increase was observed for the other groups, and no substantial increase in skin surgeries or dermatology visits occurred in any group. A large-scale melanoma screening using the INFORMED program was conducted in Pennsylvania. To the best of the authors' knowledge, the current study is the first analysis of downstream results and the findings indicate increased melanoma diagnoses but little impact on skin surgeries or dermatology visits. This result provides some reassurance that such efforts can be conducted without major adverse consequences, at least as measured by these parameters, and therefore should be considered for more widespread use. Cancer 2016;122:3152-6. © 2016 American Cancer Society.

Juvenile Nasal Angiofibromas: A Comparison of Modern Staging Systems in an Endoscopic Era

Objectives To compare the clinical utility of four juvenile nasal angiofibroma (JNA) staging systems in a large cohort of patients. Design Retrospective case series. Setting Tertiary referral academic center. Participants Pediatric patients undergoing surgical resection of JNAs between January 2008 and June 2015. Main Outcome Measures Intraoperative blood loss and transfusions, number of staged operations, postoperative residual disease, and recurrent disease. Results In total, 34 patients were identified; all underwent preoperative embolization followed by surgery. Of the 34 patients, 33 (97%) underwent an exclusively endoscopic surgical approach, with 6 (18%) requiring planned staged operations. Ten (29%) patients had residual disease and three (9%) required further surgical resection. Using the area under the curve (AUC) of receiver operating characteristic curves, the University of Pittsburgh Medical Center (UPMC) staging system was most predictive of patients who required staged procedures, received intraoperative transfusions, and had residual postoperative disease (AUC: 0.89, 0.88, 0.86, respectively). Conclusions The UPMC JNA staging system accounts for both route of skull base extension and tumor vascularity, which are two important tumor attributes in the age of preoperative embolization and endoscopic endonasal surgery. The UPMC staging system is a reliable modern staging system that closely reflects prognostic information and aids in surgical planning.

Two-year experience with the commercial Gamma Knife Check software.

The Gamma Knife Check software is an FDA approved second check system for dose calculations in Gamma Knife radiosurgery. The purpose of this study was to evaluate the accuracy and the stability of the commercial software package as a tool for independent dose verification. The Gamma Knife Check software version 8.4 was commissioned for a Leksell Gamma Knife Perfexion and a 4C unit at the University of Pittsburgh Medical Center in May 2012. Independent dose verifications were performed using this software for 319 radiosurgery cases on the Perfexion and 283 radiosurgery cases on the 4C units. The cases on each machine were divided into groups according to their diagnoses, and an averaged absolute percent dose difference for each group was calculated. The percentage dose difference for each treatment target was obtained as the relative difference between the Gamma Knife Check dose and the dose from the tissue maximum ratio algorithm (TMR 10) from the GammaPlan software version 10 at the reference point. For treatment plans with imaging skull definition, results obtained from the Gamma Knife Check software using the measurement‐based skull definition method are used for comparison. The collected dose difference data were also analyzed in terms of the distance from the treatment target to the skull, the number of treatment shots used for the target, and the gamma angles of the treatment shots. The averaged percent dose differences between the Gamma Knife Check software and the GammaPlan treatment planning system are 0.3%, 0.89%, 1.24%, 1.09%, 0.83%, 0.55%, 0.33%, and 1.49% for the trigeminal neuralgia, acoustic neuroma, arteriovenous malformation (AVM), meningioma, pituitary adenoma, glioma, functional disorders, and metastasis cases on the Perfexion unit. The corresponding averaged percent dose differences for the 4C unit are 0.33%, 1.2%, 2.78% 1.99%, 1.4%, 1.92%, 0.62%, and 1.51%, respectively. The dose difference is, in general, larger for treatment targets in the peripheral regions of the skull owing to the difference in the numerical methods used for skull shape simulation in the GammaPlan and the Gamma Knife Check software. Larger than 5% dose differences were observed on both machines for certain targets close to patient skull surface and for certain targets in the lower half of the brain on the Perfexion, especially when shots with 70 and/or 110 gamma angles are used. Out of the 1065 treatment targets studied, a 5% cutoff criterion cannot always be met for the dose differences between the studied versions of the Gamma Knife Check software and the planning system for 40 treatment targets.PACS number(s): 87.55.Qr, 87.56.Fc

Anticipation-related brain connectivity in bipolar and unipolar depression: a graph theory approach.

Bipolar disorder is often misdiagnosed as major depressive disorder, which leads to inadequate treatment. Depressed individuals versus healthy control subjects, show increased expectation of negative outcomes. Due to increased impulsivity and risk for mania, however, depressed individuals with bipolar disorder may differ from those with major depressive disorder in neural mechanisms underlying anticipation processes. Graph theory methods for neuroimaging data analysis allow the identification of connectivity between multiple brain regions without prior model specification, and may help to identify neurobiological markers differentiating these disorders, thereby facilitating development of better therapeutic interventions. This study aimed to compare brain connectivity among regions involved in win/loss anticipation in depressed individuals with bipolar disorder (BDD) versus depressed individuals with major depressive disorder (MDD) versus healthy control subjects using graph theory methods. The study was conducted at the University of Pittsburgh Medical Center and included 31 BDD, 39 MDD, and 36 healthy control subjects. Participants were scanned while performing a number guessing reward task that included the periods of win and loss anticipation. We first identified the anticipatory network across all 106 participants by contrasting brain activation during all anticipation periods (win anticipation + loss anticipation) versus baseline, and win anticipation versus loss anticipation. Brain connectivity within the identified network was determined using the Independent Multiple sample Greedy Equivalence Search (IMaGES) and Linear non-Gaussian Orientation, Fixed Structure (LOFS) algorithms. Density of connections (the number of connections in the network), path length, and the global connectivity direction ('top-down' versus 'bottom-up') were compared across groups (BDD/MDD/healthy control subjects) and conditions (win/loss anticipation). These analyses showed that loss anticipation was characterized by denser top-down fronto-striatal and fronto-parietal connectivity in healthy control subjects, by bottom-up striatal-frontal connectivity in MDD, and by sparse connectivity lacking fronto-striatal connections in BDD. Win anticipation was characterized by dense connectivity of medial frontal with striatal and lateral frontal cortical regions in BDD, by sparser bottom-up striatum-medial frontal cortex connectivity in MDD, and by sparse connectivity in healthy control subjects. In summary, this is the first study to demonstrate that BDD and MDD with comparable levels of current depression differed from each other and healthy control subjects in density of connections, connectivity path length, and connectivity direction as a function of win or loss anticipation. These findings suggest that different neurobiological mechanisms may underlie aberrant anticipation processes in BDD and MDD, and that distinct therapeutic strategies may be required for these individuals to improve coping strategies during expectation of positive and negative outcomes.

Diagnostic accuracy of somatosensory evoked potential and electroencephalography during carotid endarterectomy

Background and Purpose: Perioperative stroke risk following carotid endarterectomy (CEA) is reported to be approximately 2–3%. The diagnostic accuracies of intraoperative EEG and SSEP monitoring during CEA have been studied separately. However, to date, the effectiveness of simultaneous EEG and SSEP monitoring during CEA has only been evaluated in small study populations. This study examined the diagnostic accuracy of combined EEG and SSEP monitoring in a large (N = 1165) patient population.Methods: This study included 1165 patients who underwent CEA from 2000 to 2012 at the University of Pittsburgh Medical Center. The sensitivities, specificities, and diagnostic odds ratio of EEG and SSEP monitoring methods were examined separately and together. Receiver operating characteristic curves were plotted to assess sensitivity and specificity of single and combined Intraoperative monitoring (IONM) methods.Results: Maximum sensitivity was obtained with multimodality monitoring with an IONM change in either EEG or SSEP of 50.00 (95% CI, 30.66–69.34). The specificity of simultaneous EEG and SSEP changes was 93.95 (95% CI, 92.28–95.35%). Maximum area under ROC curve obtained for IONM change in either EEG or SSEP was 0.660 (95% CI, 0.547–0.773, p-value 0.004).Conclusion: The diagnostic accuracy of multimodality IONM during CEA is higher than an approach using single modality IONM. Simultaneous EEG and SSEP monitoring improves the likelihood of detecting periprocedural strokes after CEA. Neuro protective therapies to prevent periprocedural strokes can be based on changes in SSEP and EEG during CEA.

Journal Digest

Journal Digest

Endoscopic Endonasal Optic Nerve Decompression for Fibrous Dysplasia.

Objective To evaluate visual outcomes and potential complications for optic nerve decompression using an endoscopic endonasal approach (EEA) for fibrous dysplasia. Design Retrospective chart review of patients with fibrous dysplasia causing extrinsic compression of the canalicular segment of the optic nerve that underwent an endoscopic endonasal optic nerve decompression at the University of Pittsburgh Medical Center from 2010 to 2013. Main Outcome Measures The primary outcome measure assessed was best-corrected visual acuity (BCVA) with secondary outcomes, including visual field testing, color vision, and complications associated with the intervention. Results A total of four patients and five optic nerves were decompressed via an EEA. All patients were symptomatic preoperatively and had objective findings compatible with compressive optic neuropathy: decreased visual acuity was noted preoperatively in three patients while the remaining patient demonstrated an afferent pupillary defect. BCVA improved in all patients postoperatively. No major complications were identified. Conclusion EEA for optic nerve decompression appears to be a safe and effective treatment for patients with compressive optic neuropathy secondary to fibrous dysplasia. Further studies are required to identify selection criteria for an open versus an endoscopic approach.

The effect of prenatal docosahexaenoic acid supplementation on infant outcomes in African American women living in low-income environments: A randomized, controlled trial

ImportanceAfrican American women living in urban, low-income environments are at high risk for poor nutrition during pregnancy and birth complications. ObjectiveTo test the effectiveness of prenatal docosahexaenoic acid (DHA) supplementation on birth outcomes and infant development in a sample of African American women with Medicaid insurance and living in the city of Pittsburgh. DesignThe Nutrition and Pregnancy Study (NAPS) is a double-blind, randomized controlled trial of prenatal DHA supplementation conducted between 2012 and 2014. SettingParticipants were recruited from obstetric clinics at the University of Pittsburgh Medical Center. ParticipantsSixty-four pregnant, African American women were enrolled at 16–21 weeks of gestation and randomized to either 450mg/day of DHA (22:6n-3)(n=43) or a soybean placebo (n=21). Four women (6.3%) withdrew from the study: two participants from each study arm; complete data were obtained for 49 infants (76.5%) at the 3-month assessment. InterventionsSupplementation with DHA or placebo continued from the beginning of enrollment through delivery. Main outcome and measuresData on birth outcomes were collected from medical records. At approximately 3 months post-partum, mothers brought their infants to the laboratory where the Bayley Scales of Infant Development (BSID-III) were administered and cortisol response to the Face-to-Face Still-Face (FFSF) paradigm was assessed. ResultsInfants of mothers who received DHA supplementation had higher birth weight (3.174g versus 2.890g) than infants of mothers receiving placebo (F [2.40]=6.09, p=0.018, eta=0.36), and were more likely to have a 1-min Apgar score greater than 8 (OR=5.99 [95% CI=1.25–28.75], p=0.025). Infants of mothers who received DHA compared with infants of mothers receiving placebo had lower levels of cortisol in response to the FFSF paradigm (F [1.32]=5.36, p=0.018, eta=0.36). None of the scores on the BSID-III differed as a function of active supplement versus placebo. ConclusionsInfants of women living in urban, low-income environments who received DHA supplementation had more optimal birth outcomes and more modulated cortisol response to a stressor. DHA supplementation may be effective in attenuating the negative effects of prenatal stress on offspring development.

Kidney Transplant Outcomes After Primary, Repeat and Kidney After Nonrenal Solid Organ Transplantation: A Single-Center Experience.

BackgroundImprovements in renal allograft outcomes have permitted kidney transplantation after prior kidney allograft failure as well as after nonrenal solid organ transplantation. This study compares renal allograft outcomes in the 3 groups, that is, primary, repeat, and kidney after nonrenal solid organ transplantation, where transplant group was coded as a time-dependent variable.MethodsWe retrospectively reviewed registry data for kidney transplant recipients at University of Pittsburgh Medical Center from January 2000 to December 2011. We compared overall graft survival between the 3 groups using Cox regression modeling. We calculated 1-, 3-, and 5-year graft survival and half-lives for each group where feasible.ResultsThe study cohort (N = 2014) consisted of group A (primary kidney transplant, n = 1578, with 7923.2 years of follow-up time), group B (repeat kidney transplant, n = 314, with 1566.7 years of follow-up time) and group C (kidney post-nonrenal solid organ transplant, n = 176, with 844.8 years of follow-up time). Of the 1578 patients in the primary kidney transplant group, 74 later received a repeat transplant and thus also have follow-up counted in the repeat kidney transplant group. The median follow-up was 56, 53, and 55 months, respectively. The 5-year actuarial and death-censored graft survival was 68.69%, 68.79%, and 66.48% and 65.53%, 67.68%, and 62.92%, respectively (P = 0.70). There was no difference in overall graft survival in the Cox-adjusted analysis (group B: odds ratio, 1.02; 95% confidence interval, 0.84-1.26; P = 0.79; group C: odds ratio, 0.96; 95% confidence interval, 0.75-1.23; P = 0.76).ConclusionsThe adjusted kidney graft survivals in the 3 groups were similar.

Changes in Hysterectomy Trends and Patient Outcomes Following the Implementation of a Clinical Pathway [7

INTRODUCTION: The goal of this project is to describe the development and implementation of an evidence-based hysterectomy clinical pathway to reduce unnecessary variations in care and to promote improved patient outcomes at a reduced cost. This study characterized the longitudinal impact of hysterectomy pathway implementation on the number of total abdominal hysterectomy (TAH) procedures performed between fiscal years (FY) 2012 to 2014. METHODS: All noncancerous hysterectomy surgeries performed at University of Pittsburgh Medical Center (UPMC) hospitals from FY 2012 to FY 2014 were identified through various systems including Medipac and EpicCare. We analyzed the cases by surgical approach (TAH vs minimally invasive hysterectomy), age, and surgical indication. Changes over time were analyzed using Cochran-Armitage test for linear trends. RESULTS: A total number of 6,544 patients were included in this study (mean age 48.6 years, SD 11.69). The three most common indications for hysterectomy were: leiomyoma, menstruation disorders, and endometriosis. In FY 2012, 28.59% of hysterectomies performed due to noncancerous conditions were TAH, however, this number declined in FY 2013 to 23.35%, and further declined in FY 2014 to 17.86%. Overall, there was a significant reduction in the rate of TAH procedures, from 28.59% in FY 2012 to 17.86% in FY 2014 (P for trend<.001). In addition, there was a trend for reduction in wound infections, hospital readmissions, and complications. CONCLUSION/IMPLICATIONS: Implementation of a hysterectomy pathway has been associated with a decrease in the number of TAH hysterectomy procedures, reduced costs to the healthcare system, and improvements in patient outcomes.

A 20-Year Review of 75 Cases of Salivary Duct Carcinoma.

Salivary duct carcinoma is a rare, aggressive malignancy of the salivary glands. Owing to its rare nature, clinical data are limited, and only a few clinical studies comprise more than 50 patients. To review the University of Pittsburgh Medical Center's experience with salivary duct carcinoma over a 20-year period, focusing on demographics, presentation, treatment, and outcome. This investigation was a retrospective cohort study in a multihospital institution with tertiary referral. A pathology database was reviewed for all cases of histopathologically diagnosed salivary duct carcinoma from January 1, 1995, to October 20, 2014. Patients who were referrals for pathology review only and were never seen at the institution were excluded. In total, 75 study patients were identified. The electronic medical record was reviewed for details regarding demographics, presentation, treatment, and outcome, including overall survival (OS) and disease-free survival (DFS). This study was supplemented with a review of the institution's Head and Neck Oncology Database for further clinical details. Primary outcome measures consisted of OS and DFS. The study sample comprised 75 participants with a mean age at diagnosis of 66.0 years (age range, 33-93 years), and 29% (n = 22) were female. Most primary tumors were from the parotid gland (83%), with the next most frequent site being the submandibular gland (12%). Overall, 41% of the cases were carcinoma ex pleomorphic adenoma. Rates of other histologic features included the following: perineural invasion (69%), extracapsular spread (58%), ERBB2 (formerly HER2) positivity (31%) (62% of those who were tested), and vascular invasion (61%). The median OS was 3.1 years, and the median DFS was 2.7 years. Univariate Kaplan-Meier survival analyses demonstrated that facial nerve sacrifice and extracapsular spread were associated with lower OS (2.38 vs 5.11 years and 2.29 vs 6.56 years, respectively) and DFS (2.4 vs 3.88 years and 1.44 vs 4.5 years, respectively). Although underpowered, multivariable analysis demonstrated significantly worse OS in patients with N2 and N3 disease (hazard ratio [HR] 8.42, 95% CI, 1.84-38.5) but did not show significantly worse DFS or OS for facial nerve sacrifice or extracapsular spread. There was no association between ERBB2 positivity and survival and no difference in survival between patients receiving radiation therapy vs radiation therapy plus chemotherapy. No patients had recurrence or distant metastasis after 5 disease-free years. Salivary duct carcinoma is an aggressive disease. A large number of cases in this review were carcinoma ex pleomorphic adenoma and had classic negative prognostic indicators, such as perineural invasion, vascular invasion, and extracapsular spread. ERBB2 positivity was not associated with any difference in survival. Facial nerve involvement appears to indicate worse prognosis, as does nodal stage higher than N1. Recurrence and metastasis after 5 years are rare.

211 Genetic variants in the Wnt pathway genes NFATC1 and PLCB1 predict melanoma survival

208 Multiple primary melanomas: Prevalence and outcomes A Nosrati, S Goel, J McGuire, B Grimes, RK Singh, K Lee, VB Morhenn, A Griffin and ML Wei 1 University of California, San Francisco, CA and 2 Veterans Affairs Medical Center, San Francisco, CA We investigated the characteristics and outcomes of individuals with multiple primary melanomas (MPM) compared with individuals with a single primary melanoma (SPM) to identify risk factors for developing MPM and whether outcomes differed between these groups. 7,268 individuals diagnosed with melanoma from 1983-2013 were identified at a tertiary referral academic center for a retrospective observational study. 6963 individuals (95.8%) had a SPM and 305 (4.2%) had MPM. Mean follow-up interval was 17 y (median 14.6, CI 95%13.715.4). MPM patients were more likely to be older (mean age 60.2 vs 55.8 y; P 1 mm. Overall survival was significantly better for patients with MPM when calculated by designating the index tumor as either the first occurring tumor (HR1⁄40.73, 95%CI 0.599-0.891) or the first invasive tumor (HR1⁄40.8, 95%CI 0.652-0.992). Overall survival was also increased when the thickest tumor was designated as the index tumor (HR1⁄40.86, 95%CI 0.7-1.06), however this did not reach significance. Melanoma specific survival was increased in MPM patients, but not significantly. In summary, MPM patients are more frequently older, white, male individuals with family history of melanoma. MPM patients have an increased rate of selected internal malignancies and overall survival but similar melanoma-specific survival rate compared with those with SPM. 209 No psychological harm from melanoma screening by PCPs: Preliminary results PM Risica, L Dionne, J Mello, LK Ferris, G Alan, M Saul, J Kirkwood and MA Weinstock 1 Brown University, Providence, RI, 2 VA Med CTR, Providence, RI, 3 University of Pittsburgh, Pittsburgh, PA and 4 Harvard University, Cambridge, MA Screening for melanoma may save lives, but may also cause patient distress. In January 2014, the University of Pittsburgh Medical Center launched a melanoma screening program for primary care providers (PCPs) offering INFORMED, a validated web-based training for detection of skin cancers, especially melanoma, to all PCPs and promoting annual skin screening of all patients age 35. We report the results of the first 139 telephone surveys of UPMC patients indicated by e medical record to having been screened to identify potential effects of the screening process. Measures of anxiety, depression and other distress were queried in addition to questions about screening activities, resources provided, and future intentions regarding skin cancer prevention. Patients surveyed were mostly white, non-Latino, female, with college or higher education, and of higher household income. Of those surveyed 42% were determined to have been thoroughly screened by their PCP as indicated by selfreport (35%) or by report of level of undress and skin areas examined consistent with thorough examination (6%). The remaining 58% were unaware the PCP screening, but may have been screened by another provider. Low numbers of participants reported potentially concerning anxiety (5 PCP screened of 7 overall) and depression (1 PCP screened of 2 overall). No differences in distress measures were found between screening groups. However, those with PCP screening were more likely to have been counseled to perform regular skin selfexamination (53%) and have been provided with written information (33%) compared to those not screened (27, 6% respectively, all p<.01). These data are subject to limitations including the several months’ time lag between screening and the survey. However, they suggest that screening for melanoma by PCPs occurred without increasing psychological symptoms. The sample will be enlarged to over 200 patients to better understand the impact of PCP screening.

208 Multiple primary melanomas: Prevalence and outcomes

208 Multiple primary melanomas: Prevalence and outcomes A Nosrati, S Goel, J McGuire, B Grimes, RK Singh, K Lee, VB Morhenn, A Griffin and ML Wei 1 University of California, San Francisco, CA and 2 Veterans Affairs Medical Center, San Francisco, CA We investigated the characteristics and outcomes of individuals with multiple primary melanomas (MPM) compared with individuals with a single primary melanoma (SPM) to identify risk factors for developing MPM and whether outcomes differed between these groups. 7,268 individuals diagnosed with melanoma from 1983-2013 were identified at a tertiary referral academic center for a retrospective observational study. 6963 individuals (95.8%) had a SPM and 305 (4.2%) had MPM. Mean follow-up interval was 17 y (median 14.6, CI 95%13.715.4). MPM patients were more likely to be older (mean age 60.2 vs 55.8 y; P 1 mm. Overall survival was significantly better for patients with MPM when calculated by designating the index tumor as either the first occurring tumor (HR1⁄40.73, 95%CI 0.599-0.891) or the first invasive tumor (HR1⁄40.8, 95%CI 0.652-0.992). Overall survival was also increased when the thickest tumor was designated as the index tumor (HR1⁄40.86, 95%CI 0.7-1.06), however this did not reach significance. Melanoma specific survival was increased in MPM patients, but not significantly. In summary, MPM patients are more frequently older, white, male individuals with family history of melanoma. MPM patients have an increased rate of selected internal malignancies and overall survival but similar melanoma-specific survival rate compared with those with SPM. 209 No psychological harm from melanoma screening by PCPs: Preliminary results PM Risica, L Dionne, J Mello, LK Ferris, G Alan, M Saul, J Kirkwood and MA Weinstock 1 Brown University, Providence, RI, 2 VA Med CTR, Providence, RI, 3 University of Pittsburgh, Pittsburgh, PA and 4 Harvard University, Cambridge, MA Screening for melanoma may save lives, but may also cause patient distress. In January 2014, the University of Pittsburgh Medical Center launched a melanoma screening program for primary care providers (PCPs) offering INFORMED, a validated web-based training for detection of skin cancers, especially melanoma, to all PCPs and promoting annual skin screening of all patients age 35. We report the results of the first 139 telephone surveys of UPMC patients indicated by e medical record to having been screened to identify potential effects of the screening process. Measures of anxiety, depression and other distress were queried in addition to questions about screening activities, resources provided, and future intentions regarding skin cancer prevention. Patients surveyed were mostly white, non-Latino, female, with college or higher education, and of higher household income. Of those surveyed 42% were determined to have been thoroughly screened by their PCP as indicated by selfreport (35%) or by report of level of undress and skin areas examined consistent with thorough examination (6%). The remaining 58% were unaware the PCP screening, but may have been screened by another provider. Low numbers of participants reported potentially concerning anxiety (5 PCP screened of 7 overall) and depression (1 PCP screened of 2 overall). No differences in distress measures were found between screening groups. However, those with PCP screening were more likely to have been counseled to perform regular skin selfexamination (53%) and have been provided with written information (33%) compared to those not screened (27, 6% respectively, all p<.01). These data are subject to limitations including the several months’ time lag between screening and the survey. However, they suggest that screening for melanoma by PCPs occurred without increasing psychological symptoms. The sample will be enlarged to over 200 patients to better understand the impact of PCP screening.

Productive errors Transforming learning experiences in healthcare

Sandra L. Warner is an EHR systems analyst at the University of Pittsburgh Medical Center in Pittsburgh, Pa. The author has disclosed no financial relationships related to this article.

Convergence Science Arrives: How Does It Relate to Psychiatry?

Acad Psychiatry DOI 10.1007/s40596-016-0496-0 IN DEPTH ARTICLE: COMMENTARY Convergence Science Arrives: How Does It Relate to Psychiatry? Harris A. Eyre 1 & Helen Lavretsky 2 & Malcolm Forbes 3 & Cyrus Raji 4 & Gary Small 2 & Patrick McGorry 5 & Bernhard T. Baune 1 & Charles Reynolds III 6 Received: 28 February 2015 / Accepted: 25 January 2016 # Academic Psychiatry 2016 Convergence (from the Latin convergere, to “incline togeth- er”) encompasses the juncture between diverse industries, cul- tures, departments, and disciplines. It is the node where tradi- tional concepts meld, intersect, clash, and cross-pollinate. Convergence is the point from which novel insights arise, which has been termed the Medici Effect, for its role in cata- lyzing the Renaissance [1]. Convergence science was recently defined and promoted in two large reports [2, 3]. It was defined as “an approach to problem solving that cuts across disciplinary boundaries. It integrates knowledge, tools, and thought strategies from var- ious fields for tackling challenges that exist at the interfaces of multiple fields” ([2], p. 13). In the context of medical science, convergence involves integration of computer science, phys- ics, mathematics, engineering, medicine, the arts, chemistry, and biology; synergy between government, academia, and industry is also vital. Convergence, or transdisciplinary * Harris A. Eyre Harris.eyre@gmail.com University of Adelaide, Adelaide, South Australia, Australia Semel Institute for Neuroscience and Human Behavior, UCLA, Los Angeles, California, USA James Cook University, Townsville, Queensland, Australia UCLA, Los Angeles, California, USA University of Melbourne, Melbourne, Victoria, Australia University of Pittsburgh Medical Center, Pittsburgh, Pennsylvania, USA science, is suggested to surpass interdisciplinary and multi- disciplinary science via a more comprehensive integration. After single disciplinary approaches, multi-disciplinarity jux- taposes two or more disciplines focused on a question, prob- lem, topic, or theme. The disciplines remain distinct, and existing knowledge is not questioned. Interdisciplinarity in- volves more comprehensive integration, again, whereby a blending of diverse perspectives offers more than the sum of the parts. Transdisciplinarity offers an even more comprehen- sive intellectual and social integration of paradigms, systems, theories, disciplines with problem-oriented research, and de- velopment. Convergence is uniquely characterized by the cre- ation of these novel conceptualizations and methodologic ap- proaches. Convergence is also unique because it explores op- portunities at the interface of scientific disciplines, but it is not the only way to advance science [2]. Convergence aims to foster mutual learning, innovative collaborations, and a trans- disciplinary language and knowledge integration to solve spe- cific problems [2]. A diagrammatic overview of the differ- ences between uni-, multi-, inter-, and transdisciplinary sci- ences are outlined in Fig. 1. Importantly, there are still ongoing debates around the differentiation between inter- and transdis- ciplinary approaches to science and medical innovation [4]. Modern psychiatric research problems are characterized by their complexity, multi-systemic nature, and broad societal impact, hence making them poorly suited to siloed approaches of thinking and innovation. Psychiatry involves the integra- tion of insights from the mind, the brain, and behavior. The promotion of convergent approaches to psychiatry is thus im- portant for improving mental health. Convergence psychiatry is a novel term and refers to the expressed embedding of convergence science into the clinical psychiatric context, which may occur by engaging clinicians, researchers, and

Abstract No. 505 - Battery-powered electrified conductive vascular access device minimizes fibrin sheath adhesion

No. 505 Battery-powered electrified conductive vascular access device minimizes fibrin sheath adhesion D. Choi, A. Negussie, R. Seifabadi, N. O’Grady, L. Jiang, J. Lozier, H. Amalou, R. Chang, B. Wood; National Institutes of Health, Bethesda, MD; Johns Hopkins University School of Medicine, Baltimore, MD; National Institutes of Health, Ellicott City, MD Purpose: Vascular access devices (VADs) are widely used in acute and chronic high-risk settings such as for dialysis or therapies in hyper-coagulable patients. VADs are associated with a range of complications including thrombosis, central venous stenosis, infection, and development of fibrin sheaths with astronomical costs to the health care system. A fibrin sheath is a heterogeneous matrix of cells and debris that forms a circumferential sleeve around the surface of VADs and often remains intact within the lumen of the vein after removal of the catheters. Therapeutic options include endoluminal thrombolytic therapy and percutaneous mechanical stripping, and prophylactic options like flushing do not guarantee avoiding development of fibrin sheath encasement. The purpose of this study is to study the ability of micro electric current in a custom conductive catheter to minimize fibrinsheath adhesion on VAD surfaces. Materials: A novel vascular catheter with a conductive distal tip was designed, custom fabricated, and used for this study. The catheters were incubated with human fibrinogen protein solution (1.0 mg/mL) for 2 hours at 37oC either with or without electric current (8μA). The catheters were washed and further incubated with Sheep Anti-Human Fibrinogen FITC antibody solution at 4oC overnight to visualize the fluorescence signals of fibrinogen. The catheter tips were qualitatively evaluated for protein adhesion using a Fluorescence Imaging System. For quantitative analysis, the catheter tips were sonicated in 7 mL of PBS buffer after washing the tips to detach loosely adhered fibrinogen protein. Signal intensities of fibrinogen adhered to electrified catheter and control were blindly compared using fluorescence spectroscopy at λexc/λemi of 490/520 nm. Results: Use of electric current to the conductive catheter reduced adherent fibrinogen by 39% compared to control. Qualitative analysis using fluorescent microscopy demonstrated catheter exposed to electric current had less signal compared to the control. Conclusions: In line with the inhibition of bacterial colonization previously reported, the electrification of the conductive VAD with a battery reduced fibrin adhesion in an in vitro model. Educational Exhibit Abstract No. 506 Novel anticoagulants: navigating the periprocedural course and previewing the new horizon for reversal agents A. Klobuka, M. Krosin, N. Amesur, F. Bontempo; University of Pittsburgh Medical Center, Pittsburgh, PA; University of Pittsburgh Medical Center, Pittsburgh, PA Learning Objectives: Describe the current clinical use and relevant pharmacokinetics of both the direct oral thrombin and factor Xa inhibitors including dabigatran, rivaroxaban, apixaban, and edoxaban. Illustrate the effects, or lack thereof, on commonly monitored anti-coagulation parameters. Review guidelines regarding when to withhold and resume these medications when planning low, moderate, and high risk procedures. Describe current, if any, available techniques for emergent reversal. Preview three agents currently under development, idarucizumab, andexanet alfa, and PER977 for the reversal of both direct thrombin and factor Xa inhibitors. Background: Dramatic growth in the utilization of novel oral anticoagulant agents is supplanting warfarin in the treatment of a number of conditions including non-valvular atrial fibrillation and deep venous thrombosis, as well as for venous thromboembolism prophylaxis. Clinical Findings/Procedure Details: The direct thrombin inhibitor dabigatran as well as the direct factor Xa inhibitors rivaroxaban, apixaban, and edoxaban are compared in terms of their current approved clinical indications, onset of action, effect on common coagulation parameters, time course for witholding periprocedurally (as dependent on creatinine clearance), and amenability to indirect strategies for emergent reversal including hemodialysis and the use of clotting factor concentrates. Three potential reversal agents, idarucizumab, andexanet alfa, and PER977 are all within various stages of the FDA approval pipeline and will be discussed in terms of their mechanisms of action, proposed use, and anticipated market release timeline. Conclusions: Given the frequent coincidence of the conditions for which novel anticoagulants are used among the particular subset of patients requiring common interventional procedures, knowledge of their use and comfort with the guidelines for their periprocedural management are crucial skills for any practicing Posters and Exhibits ’ JVIR S224 P os te rs an d Ex hi bi ts

“We Will Gladly Join You in Partnership in Harrisburg or We Will See You in Court”

In 1990, Mayor Sophie Masloff warned large not-for-profits, like the University of Pittsburgh Medical Center (UPMC), that unless they started making an increased financial contribution in the form of payments in lieu of taxes, or PILOTs, the City of Pittsburgh would take them to court to recoup what municipal officials perceived to be their “fair share” of the local tax pie. Masloff’s threat represented only one potential strategy employed by city officials since the late 1960s to address the growing imbalance of power between large not-for-profit employers and local government. This study uses the debate over PILOTs, and the 1997 passage of the Insitutions of Purely Public Charity Act, or Act 55, to examine the changing role of large not-for-profits in the City of Pittsburgh from the late 1960s to the present. It argues that more attention must be paid to the emergence of large not-for-profits, especially hospital systems, as major economic actors and as a focal point for Pittsburgh’s current reinvention narrative. This decision has had real financial consequences for the city’s revenue collection stream. It has also placed elected officials into an uncomfortable role as an arbiter between sometimes-warring parties, as the growing rift between the large health care not-for-profits UPMC and Highmark Blue Cross Blue Shield has dramatically illumined. A more careful consideration of the role of large not-for-profits allows historians and policymakers to better understand the financial consequences of the “eds and meds” economy for the postindustrial American city.