Virginia Mason Medical Center Research Articles

Intraoperative Prophylaxis with Palonosetron for Postoperative Nausea and/or Vomiting in Adults Undergoing Cardiothoracic Surgery Under General Anesthesia: A Single-Center Retrospective Study

This study assessed the efficacy of palonosetron, alone or with dexamethasone, in reducing postoperative nausea and/or vomiting (PONV) and its impact on hospitalization duration in patients who undergo adult cardiothoracic surgery (CTS) under general anesthesia. This retrospective analysis involved 540 adult patients who underwent CTS from a single-center cohort, spanning surgeries between September 2021 and March 2023. Sensitivity, logistic, and Cox regression analyses evaluated antiemetic effects, PONV risk factors, and outcomes. At the Virginia Mason Medical Center (VMMC), Seattle, WA. Adults undergoing cardiothoracic surgery at VMMC during the specified period. Patients were categorized into the following 4 groups based on antiemetic treatment: dexamethasone, palonosetron, dexamethasone with palonosetron, and no antiemetic. Primary outcomes encompassed PONV incidence within 96 hours postoperatively. Secondary outcomes included intensive care unit stay duration and postoperative opioid use. Palonosetron recipients showed a significantly lower PONV rate of 42% (v controls at 63%). The dexamethasone and palonosetron combined group also demonstrated a lower rate of 40%. Sensitivity analysis revealed a notably lower 0- to 12-hour PONV rate for palonosetron recipients (9% v control at 28%). Logistic regression found decreased PONV risk (palonosetron odds ratio [OR]: 0.24; dexamethasone and palonosetron OR: 0.26). Cox regression identified varying PONV hazard ratios related to female sex, PONV history, and lower body mass index. This single-center retrospective study underscored palonosetron's efficacy, alone or combined with dexamethasone, in managing PONV among adult patients who undergo CTS. These findings contribute to evolving antiemetic strategies in cardiothoracic surgery, potentially impacting patient outcomes and satisfaction positively.

Rudeness and civility in health care

Rudeness and civility in health care

Pagetoid Dyskeratosis of the Hand With Parallel Ridge Pattern on Dermoscopy and Expression of Bcl-10 by Immunohistochemistry.

*Department of Dermatology, Oregon Health and Science Center, Portland Oregon †Department of Dermatology, Valley Medical Center, Renton Washington; and ‡Department of Pathology, Virginia Mason Medical Center, Seattle WA. Correspondence: Steven M. Ruhoy, MD, Department of Pathology, Virginia Mason Medical Center, Seattle WA (e-mail: [email protected]). The authors declare no conflicts of interest.

Guidelines in Clinical Practice: Appraisal of Quality Metrics in the Management of Newly Diagnosed Diffuse Large B-Cell Lymphoma Based on the American Society of Hematology Practice Improvement Module

Background: The National Comprehensive Cancer Network (NCCN) has issued well-established guidelines for the management and treatment of non-Hodgkin's lymphoma (NHL), in particular for diffuse large B-cell lymphoma (DLBCL). In 2014, the American Society of Hematology established practice improvement module (ASH PIM) incorporating quality metrics in six areas: pathologic diagnosis, staging, hepatitis B testing, use of growth factors, vaccination, and fertility counseling. Currently, such practice improvement modules have allowed physicians to monitor the quality of care in their practice, and reiterating the significance of these clinical guidelines. In an appraisal of quality metrics undertaken at Virginia Mason Medical Center (VMMC), Seattle, Washington, we sought to review four of the ASH PIM metrics and several other metrics to assess adherence to treatment guidelines for Diffuse Large B-Cell Lymphoma (DLBCL) and examine the need for institutional improvement.Methods: A longitudinal cohort of all patients who were diagnosed with DLBCL and received treatment at VMMC between January 1st, 2005 to December 31st, 2016 was identified using VMMC's Tumor Registry. Utilizing the electronic medical records, each patient's chart was reviewed for these quality metrics: pathologic diagnosis, staging of lymphoma, hepatitis and HIV serology testing, echocardiogram (ECHO) prior to starting treatment, clymphoma recurrence risk categorization, chemotherapy education, use of Rituximab therapy, G-CSF use, and post-therapy CT or CT-PET scan. Parameters for pathological diagnosis included assessment of expression of CD20, germinal center vs non-germinal center phenotype based on reporting of MUM1, CD10 and BCL-6, fluorescence in-situ hybridization (FISH) and IHC studies for the presence of traslocation/overexpression of c-Myc, BCL-2 or BCL-6, and EBV assessment by EBV-encoded small RNA1 (EBER1) in-situ hybridization. Staging was evaluated based on imaging in the form of a CT or PET-CT scan prior to treatment initiation and if a bone marrow biopsy (BMB) was also obtained. Serology testing for hepatis B (HBV) and hepatitis C (HCV), and HIV was reviewed. Patients receiving anthracycline-based treatments were assessed for having undergone an ECHOcardiogram prior to initiation of treatment. Post-treatment PET-CT was noted based on the presence of an internal report or outside records.Results: A total of 179 patients were included in this analysis. The median age of this cohort was 67 years (range 24 -91 years) and 54% of these patients were male. Pre-treatment viral serologic screening was performed in 87% of patients for HBV, 78% for HCVFISH f and 92% for HIV. All the specimen were uniformly tested for expression of CD20, and the germinal center vs. non-germinal center phenotype was determined in 97% of patients. c-Myc and BCL2/BCL6 data was available in only 32% of patients. For staging, all patients had imaging (CT/PET-CT), while bone marrow was obtained in only 72% of patients. Post-treatment imaging was available in 97% of cases. Additional data analysis of treatment-related quality metrics is underway, and shall be presented at the ASH annual meeting.Conclusion: Performing regular quality assessments by employing standardized metrics provide opportunities to improve the institutional quality of care for patients with newly diagnosed DLBCL, and allows to build and ensure better adherence to evolving NCCN patient-care guidelines ASH PIM. However, performance on the metrics relying on clinical documentation may not be as high as for those relying on objective testing. Whether such quality metrics affect real-time treatment-decisons and patient outcomes needs further evaluation. DisclosuresNo relevant conflicts of interest to declare.

Editorial Comment.

No AccessJournal of UrologyAdult Urology1 May 2021Editorial CommentThis article comments on the following:Measuring Bladder Health: Development and Cognitive Evaluation of Items for a Novel Bladder Health Instrumentis a letter which has replyReply by Authors Una J. Lee Una J. LeeUna J. Lee Female Pelvic Medicine and Reconstructive Surgery, Section of Urology and Renal Transplantation, Virginia Mason Medical Center, Seattle, Washington More articles by this author View All Author Informationhttps://doi.org/10.1097/JU.0000000000001581.01AboutFull TextPDF ToolsAdd to favoritesDownload CitationsTrack CitationsPermissionsReprints ShareFacebookLinked InTwitterEmail "Editorial Comment." The Journal of Urology, 205(5), p. 1414

Prevalence of Urinary Incontinence among a Nationally Representative Sample of Women, 2005-2016: Findings from the Urologic Diseases in America Project.

Urinary incontinence is frequently underreported and underdiagnosed in the clinical setting. We analyzed 12 years of data from a large, nationally representative sample of women in the United States to assess the prevalence, severity, and daily impact of urinary incontinence and its subtypes at the population level. We analyzed data from 15,003 women aged ≥20 years who participated in the 2005-2016 National Health and Nutrition Examination Survey. We estimated the prevalence of urinary incontinence in the prior year, overall and by subtype (stress, urgency or mixed). Among women with urinary incontinence, we additionally assessed symptom severity using the validated 4-level Incontinence Severity Index, as well as impact on daily activities. The 2005-2016 prevalence of any urinary incontinence was 53%; 16% of women had mixed urinary incontinence, 26% had stress only and 10% had urgency only. While urgency urinary incontinence and mixed urinary incontinence were highest among women aged ≥60 years, stress urinary incontinence was highest among women aged 40-59 years. NonHispanic Black women had higher prevalence of urgency urinary incontinence and lower prevalence of stress urinary incontinence compared to other racial/ethnic groups. Of women with urinary incontinence, 30% reported moderate or severe symptoms, which were more common among older than younger women. In addition, 24% of women with urinary incontinence reported that the condition affected their daily activities. Our study demonstrates a high prevalence of urinary incontinence among a nationally representative population of women in the United States, with many reporting that urinary incontinence affected their daily activities. Age and racial/ethnic trends varied by urinary incontinence subtype.

Incidence of Skin and Respiratory Immune-Related Adverse Events Correlates With Specific Tumor Types in Patients Treated With Checkpoint Inhibitors

Checkpoint inhibitors (CPIs) increase antitumor activity by unblocking regulators of the immune response. This action can provoke a wide range of immunologic and inflammatory side effects, some of which can be fatal. Recent studies suggest that CPI-induced immune-related adverse events (irAEs) may predict survival and response. However, little is known about the mechanisms of this association. This study was undertaken to evaluate the influence of tumor diagnosis and preexisting clinical factors on the types of irAEs experienced by cancer patients treated with CPIs. The correlation between irAEs and overall survival (OS) was also assessed. All cancer patients treated with atezolizumab (ATEZO), ipilimumab (IPI), nivolumab (NIVO), or pembrolizumab (PEMBRO) at Virginia Mason Medical Center between 2011 and 2019 were evaluated. irAEs were graded according to the Common Terminology Criteria for Adverse Events (Version 5) and verified independently. Statistical analyses were performed to assess associations between irAEs, pre-treatment factors, and OS. Of the 288 patients evaluated, 59% developed irAEs of any grade, and 19% developed irAEs of grade 3 or 4. A time-dependent survival analysis demonstrated a clear association between the occurrence of irAEs and OS (P < 0.001). A 6-week landmark analysis adjusted for body mass index confirmed an association between irAEs and OS in non-Small Cell Lung Cancer (NSCLC) (P < 0.03). An association between melanoma and skin irAEs (P < 0.01) and between NSCLC and respiratory irAEs (P = 0.03) was observed, independent of CPI administered. Patients with preexisting autoimmune disease experienced a higher incidence of severe irAEs (P = 0.01), but not a higher overall incidence of irAEs (P = 0.6). A significant association between irAEs and OS was observed in this diverse patient population. No correlation was observed between preexisting comorbid conditions and the type of irAE observed. However, a correlation between skin-related irAEs and melanoma and between respiratory irAEs and NSCLC was observed, suggesting that many irAEs are driven by a specific response to the primary tumor. In patients with NSCLC, the respiratory irAEs were associated with a survival benefit.

Building a Culture of Respect for People

Summary The delivery of safe, effective, and efficient health care requires both technical ability and an enduring culture of respect within the institution. Respect for People is Virginia Mason Medical Center’s comprehensive effort to foster an organizational culture of respect. This multiyear endeavor has engaged every employee through a series of workshops and ongoing communication. As part of this effort, we sought to evolve the artifacts, norms and values, and underlying beliefs that constitute our organizational culture. Implementing and sustaining Respect for People has redefined the health care environment at Virginia Mason, to the betterment of patients and staff.

Incidence and Significance of Biliary Stricture in Chronic Pancreatitis Patients Undergoing Extracorporeal Shock Wave Lithotripsy for Obstructing Pancreatic Duct Stones

Background/AimsThis study assessed the significance of biliary stricture in symptomatic chronic pancreatitis patients requiring extracorporeal shock wave lithotripsy (ESWL) and endoscopic retrograde cholangiopancreatography (ERCP) to remove obstructing pancreatic calculi.MethodsA total of 97 patients underwent ESWL followed by ERCP to remove pancreatic calculi between October 2014 and October 2017 at Virginia Mason Medical Center. Significant biliary stricture (SBS) was defined as a stricture with upstream dilation on computed tomography scan or magnetic resonance cholangiopancreatography scans accompanied by cholestasis and/or cholangitis. SBS was initially managed by either a plastic stent or fully covered self-expandable metallic stent (fcSEMS). If the stricture did not resolve, the stent was replaced with either multiple plastic stents or another fcSEMS. Data were collected by retrospectively reviewing the medical records.ResultsBiliary strictures were noted in approximately one-third of patients (34/97, 35%) undergoing ESWL for pancreatic calculi. Approximately one-third of the biliary strictures (11/34, 32%) were SBS. Pseudocysts were more frequently found in those with SBS (36% vs 8%, p=0.02), and all pseudocysts in the SBS group were located in the pancreatic head. The initial stricture resolution rates with fcSEMSs and plastic prostheses were 75% and 29%, respectively. The overall success rate for stricture resolution was 73% (8/11), and the recurrence rate after initial stricture resolution was 25% (2/8).ConclusionsAlthough periductal fibrosis is the main mechanism underlying biliary stricture development in chronic pancreatitis, inflammation induced by obstructing pancreatic calculi, including pseudocysts, is an important contributing factor to SBS formation during the acute phase.

History and evolution of regional anesthesiology and acute pain medicine fellowship training

IntroductionIn 2016, individual training programs in regional anesthesiology and acute pain medicine (RA/APM) became eligible for accreditation by the Accreditation Council for Graduate Medical Education (ACGME), thereby culminating a process...

Transduodenal sphincteroplasty for sphincter of Oddi dysfunction

Presenter: Morgan Bonds MD | Virginia Mason Medical Center Background: Sphincter of Oddi dysfunction is a rare condition resulting in the non-calculous obstruction of pancreatic and biliary secretions at the pancreaticobiliary junction. Most cases are treated via endoscopic sphincterotomy. However, when this fails, surgical intervention is necessary. We present a video of transduodenal sphincteroplasty, an uncommon procedure in the modern era. Methods: A 64 year old woman presented to our institution after 10 years of recurrent epigastric pain and nausea after previous cholecystectomy. She was diagnosed with type III sphincter of Oddi dysfunction. Initially, she underwent two years of endoscopic interventions including endoscopic sphincterotomy, biliary and pancreatic stents, and botulinum toxin injections. She responded to these treatments for 3-4 months before her symptoms returned. Given that she responded to botulinum toxin injections, it was felt she had an incomplete sphincterotomy due to a long Sphincter of Oddi and, for this reason, she was evaluated for a transduodenal sphincteroplasty to complete her sphincterotomy. Results: The video demonstrates the key steps to completing a sphincterotomy via transduodenal sphincteroplasty. The Ampulla of Vater was identified through a lateral duodenotomy. Full thickness sutures were placed at the one o’clock and eleven o’clock position between the duodenal mucosa and the bile duct. Cautery completed the sphincterotomy between these stitches, dividing a band of scar tissue. Pancreatogram confirmed the pancreatic duct remained patent and choledochoscopy ensured there were no retained stones within the bile duct. Unfortunately, the patient's symptoms returned 3 months postoperatively. Conclusion: Transduodenal sphincteroplasty is a procedure that is rarely performed in the era of endoscopic sphincterotomy. This video demonstrates the key steps for successfully performing this procedure. It also presents the challenges of managing patients with type III sphincter of Oddi dysfunction. While the operation described is a safe and effective way of completing a long biliary sphincterotomy, the long term benefits can be difficult to predict.

IR-guided endoscopic pancreaticojejuostomy for post-whipple pancreaticocutaneous fistula

Presenter: Elliot Scott MD | Virginia Mason Medical Center Background: A 67yF presented with biliary obstruction and computed tomography (CT) suggested a distal bile duct tumor. She underwent an ERCP with brushings for stenting and to but unfortunately developed severe acute pancreatitis (SAP). Although technically resectable after complete staging without evidence of distant disease, she was not felt to be a surgical candidate and was referred for neoadjuvant chemotherapy while. Unfortunately, after one cycle of gemcitabine and cisplatin, her SAP progressed to walled-off necrosis (WOPN) requiring percutaneous and endoscopic drainage. Therefore, after a period of recovery, she was taken to the operating room for an attempt at curative resection. A pylorus-preserving pancreaticoduodenectomy (PD) was performed, however, the pancreas was scarred without a visible duct and adherent to a thrombosed splenic vein with sinistral portal hypertension form WOPN. Decision was made to suture the pancreatic remnant without an anastomosis. The patient did well until POD#4 when a CT performed for abdominal pain revealed a large fluid collection. This was drained percutaneously and was consistent with a pancreatic leak. The patient convalesced from her operation but was left with a pancreaticocutaneous fistula. Methods: Since transgastric internalization was not feasible post-PD, a combined interventional radiology (IR) and gastroenterology (GI) rendezvous approach was utilized. An endoscopic ultrasound (EUS) scope was passed into the afferent limb while a balloon catheter was passed through the drain tract. The balloon was visualized by EUS and punctured in order to grab an IR wire and pass it into the afferent jejunal limb. Two pigtail stents were then deployed in order to create a pancreaticojejunostomy (See Figure). Results: The patient did well post procedure and deemed ready for adjuvant therapy for her T2N1 distal cholangiocarcinoma. Conclusion: This challenging case highlights the multidisciplinary strategy required not only for optimal oncologic treatment of biliary tumors but also to manage the complications of therapy.

Laparoscopic Common Bile Duct Exploration For Stone Associated With Surgical Foreign Body

Presenter: Morgan Bonds MD | Virginia Mason Medical Center Background: Choledocholithiasis is a common problem that presents to hepatopancreatobiliary surgeons. As more patients undergo procedures that alter the anatomy of the proximal gastrointestinal tract, common bile duct exploration emerges as one of the few options to treat these patients. Laparoscopic common bile duct exploration has been shown to shorten hospital length of stay in these situations. In this video we present a patient who has undergone a cholecystectomy and roux-en-y gastric bypass and presented with choledocholithiasis that appeared to be associated with a surgical clip. Methods: Our patient is a 61 year old woman who presented with acute onset epigastric pain. On computed tomography, a stone was visualized within the distal common bile duct. This stone appeared to be surrounding a hyperdense foreign body consistent with a surgical clip. She had previously undergone a cholecystectomy and roux-en-y gastric bypass that was complicated by an ulcer perforation requiring resection of the gastric remnant. Double balloon endoscopy was attempted to access the common bile duct but was not successful. Surgery was consulted for laparoscopic common bile duct exploration. Results: The video presents the key steps for performing laparoscopic common bile duct exploration which includes choledochotomy, performing choledochoscopy to locate the pathology, stone extraction and closure of the choledochotomy. We were able to identify the offending stone on choledochoscopy and it was removed. No foreign body or mucosal erosion was seen within the duct. The choledochoscopy was closed primarily without a drain as an internal drain would not be retrievable with her altered anatomy. She had a bile leak controlled by her peritoneal drain in the immediate postoperative period but this resolved within the first week and her drain was removed on postoperative day 7. Conclusion: Laparoscopic common bile duct exploration is a safe and effective method of treating choledocholithiasis in patients with altered anatomy in the setting of a suspected foreign body within the duct. Closure of the choledochotomy should be individualized to the patient and clinical scenario. This technique should be considered to shorten the length of stay for all patients with choledocholithiasis.

Latin American hepatopancreatobiliary fellowships accreditation: Assessing desire and barriers

Presenter: Morgan Bonds MD | Virginia Mason Medical Center Background: Hepatopancreatobiliary (HPB) surgery is a challenging field, both clinically and technically. Latin America has a significant burden of HPB disease which has fostered a number of fellowships. However, despite belonging to the Americas Hepatopancreatobiliary Association (AHPBA), there are no Latin American HPB fellowship programs participating in AHPBA fellow certification through Fellowship Council program accreditation. The purpose of this study is to assess whether interest in this process exists among Latin American fellowship program directors and what barriers exist to their participation. Methods: This was a prospective mixed-methods study. Initially, a 20 item survey was constructed to assess the demographics of Latin American HPB fellowships and attitudes toward the accreditation process. The survey was validated by consensus of 2 North American and 2 Latin American HPB fellowship directors. Latin American HPB fellowship directors were identified through the International Hepatopancreatobiliary Association website or by contacting local AHPBA chapters. Surveys were administered electronically. Statistical analysis was performed on the survey responses. An interview was requested of all participants to further assess attitudes and barriers to fellowship accreditation. Interview responses were analyzed using a validated qualitative thematic network technique. Results: Nineteen Latin American fellowship program directors were identified, and 13 (68.4%) responded to the survey. All program directors were members of AHPBA. Most programs reported having 3 or more clinical fellows each year. Five (38.5%) programs had an adequate number of pancreas cases per fellow for certification, 9 (69.2%) had adequate major liver cases, and 7 (53.8%) had adequate biliary cases. Laparoscopic HPB was practiced by 69.2% of the programs. The majority of program directors were interested in AHPBA certification (10/13) and the other respondents reported neutral feelings toward the process. All participants reported that certification and accreditation would be beneficial to the fellowship program and the fellows. Interviews were conducted with 8/13 (61.5%) survey respondents. The interviews revealed there was a desire among Latin American HPB fellowship directors to pursue certification because outside critique provides structured quality improvement for their program. They also felt the fellows would benefit from the international recognition and collaboration that the North American HPB fellows experience. Benefits to HPB societies were also identified as a positive consequence of accrediting Latin American fellowships. No negative consequences were identified. The primary barriers to meeting certification requirements were financial as well as concerns regarding clinical case volumes. Conclusion: Latin American HPB fellowship program directors show a high level of interest in AHPBA certification through Fellowship Council accreditation. Several positive outcomes of participating in this process were identified and align with previous research on the benefits of accreditation. Strategies should be developed to reduce the barriers to Latin American HPB programs that seek to participate in this process.

Oral rimegepant increased freedom from pain and from most bothersome symptom at 2 h in acute migraine.

ACP Journal Club19 November 2019Oral rimegepant increased freedom from pain and from most bothersome symptom at 2 h in acute migraineLucas McCarthy, MD, MSLucas McCarthy, MD, MSVirginia Mason Medical Center, Seattle, Washington, USA (L.M.)Search for more papers by this authorAuthor, Article, and Disclosure Informationhttps://doi.org/10.7326/ACPJ201911190-059 SectionsAboutFull TextPDF ToolsAdd to favoritesDownload CitationsTrack CitationsPermissions ShareFacebookTwitterLinkedInRedditEmail Source CitationLipton RB, Croop R, Stock EG, et al. Rimegepant, an oral calcitonin gene-related peptide receptor antagonist, for migraine. N Engl J Med. 2019;381:142-9. https://pubmed.ncbi.nlm.nih.gov/31291516Clinical Impact RatingsGIM/FP/GP: Neurology: References1 Ferrari MD, Goadsby PJ, Roon KI, Lipton RB. Triptans (serotonin, 5-HT1B/1D agonists) in migraine: detailed results and methods of a meta-analysis of 53 trials. Cephalalgia. 2002;22:633-58. [PMID: 12383060] Google Scholar2 Marcus R, Goadsby PJ, Dodick D, et al. BMS-927711 for the acute treatment of migraine: a double-blind, randomized, placebo controlled, dose-ranging trial. Cephalalgia. 2014;34:114-25. [PMID: 23965396] Google Scholar3 Deen M, Correnti E, Kamm K, et al; European Headache Federation School of Advanced Studies (EHF-SAS). Blocking CGRP in migraine patients - a review of pros and cons. J Headache Pain. 2017;18:96. [PMID: 28948500] Google Scholar Author, Article, and Disclosure InformationAffiliations: Virginia Mason Medical Center, Seattle, Washington, USA (L.M.)This article was published at Annals.org on 5 November 2019. PreviousarticleNextarticle Advertisement FiguresReferencesRelatedDetailsSee AlsoOrally disintegrating rimegepant increased freedom from pain and from most bothersome symptom at 2 h in acute migraine Lucas McCarthy Metrics 19 November 2019Volume 171, Issue 10Page: JC59KeywordsAdverse eventsCalcitoninMigraineNauseaNumber needed to treatPhase 2 trialsProtease inhibitorsSafetySerious adverse eventsVasodilation ePublished: 19 November 2019 Issue Published: 19 November 2019 Copyright & PermissionsCopyright © 2019 by American College of Physicians. All Rights Reserved.PDF downloadLoading ...

Continuous Transversus Abdominis Plane Block for Primary Open Inguinal Hernia Repair: A Randomized, Double-Blind, Placebo-Controlled Trial.

Patients undergoing open inguinal hernia repair may experience moderate to severe postoperative pain. We assessed opioid consumption in subjects who received a continuous transversus abdominis plane block in addition to standard multimodal analgesia. Randomized, double-blind, placebo-controlled. Tertiary academic medical center. Adult patients undergoing open inguinal hernia repair at Virginia Mason Medical Center. A total of 90 patients were enrolled. Subjects presenting for surgery were randomized to receive either a continuous transversus abdominis plane block or a subcutaneous sham block. The primary outcome was opioid consumption within the first 48 hours after surgery. Secondary outcomes included pain scores, activities assessment scores, and opioid-related adverse events. Multimodal analgesia utilized in both groups included acetaminophen, nonsteroidal anti-inflammatory drugs, and surgical local anesthetic infiltration. Eighty-two subjects, 42 from the block group and 40 from the sham group, completed the study, per protocol. The intention-to-treat analysis demonstrated no difference in 48-hour postoperative oxycodone equivalent consumption between the block and sham groups (27.8 mg ± 26.8 vs 32 mg ± 39.2, difference -4.4 mg, P = 0.55). There was a statistically significant reduction in pain scores at 24 hours in the block group. There were no other differences in secondary outcomes. Continuous transversus abdominis plane blocks provide modest improvements in pain after open inguinal hernia repair but fail to significantly reduce opioid consumption or improve functional activity levels in the setting of multimodal analgesia use.

Application of standardized hemodynamic protocols within enhanced recovery after surgery programs to improve outcomes associated with anastomotic leak and conduit necrosis in patients undergoing esophagectomy.

Esophagectomy for cancer is associated with high risk for postoperative morbidity. The most serious regularly encountered complication is anastomotic leak and the most feared individual complication is conduit necrosis. Both of these complications affect the length of stay, mortality, quality of life, and survival for patients undergoing esophageal resection. The maintenance of conduit viability is of primary importance in the perioperative care of patients following esophageal resection. It has been shown that restrictive fluid management may be associated with improved postoperative outcomes in abdominal and other types of surgery, but many factors can affect the incidence of anastomotic leak and the viability of the gastric conduit. We have performed a comprehensive review with the aim to give an overview of the available evidence for the use of standardized hemodynamic protocols (SHPs) for esophagectomy and review the hemodynamic protocol, which has been applied within a standardized clinical pathway (SCP) at the Department of Thoracic surgery at the Virginia Mason Medical Center between 2004-2018 where the anastomotic leak rate over the period has been 5.2% and the incidence of conduit necrosis requiring surgical management is zero. The literature review demonstrates that there are few high quality studies that provide scientific evidence for the use of a SHP. The evidence indicates that the use of goal-directed hemodynamic monitoring might be associated with a reduced risk for postoperative complications, shortened length of stay, and decreased need for intensive care unit stay. We propose that the routine application of a SHP can provide a uniform infrastructure to optimize conduit perfusion and decrease the incidence of anastomotic leak.

1125. Reduced Time to Pathogen Identification and Antibiotic Prescription Using Multiplex Molecular Testing for Gastrointestinal Infections

BackgroundA variety of microbial pathogens causes diarrhea which remains a significant global concern. The ability to rapidly identify the pathogen impacts the decision to treat, promotes antimicrobial stewardship, and assists with infection control and prevention. The objective of the study was to compare the time it took for rapid identification of microbial pathogens via a stool-culture based testing vs. real-time PCR using a Verigene Enteric Pathogens (EP) test.MethodsThe study was performed at Virginia Mason Medical Center, a tertiary medical center in Seattle. A retrospective chart review included the diagnosis of microbial pathogen, antibiotics prescribed (if any), time of prescription, duration of antibiotics course and patients’ outcome if they were hospitalized. Stool specimens from 136 patients in 2015 were analyzed via a stool-culture based method. The results were compared with a molecular-based method used to study specimens from 225 patients in 2017. Years 2015 and 2017 were chosen as in 2016 the culture-dependent testing was replaced by culture independent. T-test was used to examine the difference in time to identification of the pathogen and time to prescription between 2015 and 2017. SAS 9.4 was used for the analysis.ResultsIn 2015, 2,194 stool specimens were tested and 136 (6.2%) were positive. In 2017, 2,037 stool specimens were examined and 225 (11%) returned positive. The median time to prescription in 2015 was 53.84 hours in comparison to 21.96 hours in 2017 (P < 0.0001). The time to identification of the pathogen was 60.05 hours in 2015 vs. 22.53 hours in 2017 (P < 0.0001). The TAT (turnaround time), defined as the time from the specimen being received in the laboratory to the finalized result, was 167.92 hours vs. 156.35 hours, respectively (P = 0.75).ConclusionMultiplex PCR assays for enteric pathogens showed higher sensitivity when compared with standard culture-based methods. When the clinician felt antibiotics were indicated, there was a significantly shorter time to antibiotics prescription. Aside from a shorter time to microbial identification, molecular assays detect an increased number of pathogens from a single specimen that has an important impact on infection prevention and appropriate treatment.Disclosures All authors: No reported disclosures.

Erratum.

Stachler RJ, Francis DO, Schwartz SR, et al. Clinical practice guideline: hoarseness (dysphonia) (update). Otolaryngol Head Neck Surg. 2018;158:S1-S42. (Original DOI: 10.1177/0194599817751030) Stachler RJ, Francis DO, Schwartz SR, et al. Clinical practice guideline: hoarseness (dysphonia) (update) executive summary. Otolaryngol Head Neck Surg. 2018;158:409-426. (Original DOI: 10.1177/0194599817751031) Krouse HJ, Reavis CW, Stachler RJ, Francis DO, O'Connor S. Plain language summary: hoarseness (dysphonia). Otolaryngol Head Neck Surg. 2018;158:427-431. (Original DOI: 10.1177/0194599817751137) In the March 2018 clinical practice guideline and associated articles David O. Francis and Seth R. Schwartz's affiliations were listed incorrectly. Dr Francis should have been affiliated with University of Wisconsin, Madison, Wisconsin, USA. Dr Schwartz should have been affiliated with Virginia Mason Medical Center, Seattle, Washington, USA. Additionally, in the Plain Language Summary the location of Wayne State University was listed as Allen Park, Michigan; it should have been Detroit, Michigan. These have been updated in the online issues.

Etiology unknown: Qualitative analysis of patient attributions of causality in scleroderma

Questions about the etiology of disease can concern patients living with any chronic disease and may impact disease-related adjustment. These causal attributions may be of particular interest when individuals are living with diseases for which etiologies have not been definitively identified, such as scleroderma. This study qualitatively explored patient attributions of causality for scleroderma. Patients with confirmed diagnoses of scleroderma responded to an open-ended prompt. The cross-sectional sample of scleroderma patients (N = 114) was recruited through registries maintained at the University of California, Los Angeles and University of California, San Diego Schools of Medicine and the Virginia Mason Medical Center. Content analysis was used to analyze the qualitative data and group the responses via an inductively derived codebook using the text analysis tool Dedoose Version 4.5. Patients provided a variety of possible causes for scleroderma, which grouped into seven themes: (1) stress, (2) environment, (3) genetics, (4) medical conditions or surgeries, (5) diet, (6) medications or substance use, and (7) spirituality. Patients' causal attributions for scleroderma were varied, but many patients identified stress as a cause of scleroderma, often focusing on acute or chronic stressors that were present before disease onset. Identifying patient theories of causality for scleroderma can contribute to an increased understanding of disease-related behaviors and adjustment.