Faculty Bibliography

OBJECTIVES/UNASSIGNED:The burden of geriatric trauma continues to rise. Older trauma patients experience higher morbidity and mortality and thus benefit from early goals of care (GOC) discussions and advance care planning (ACP). The American College of Surgeons (ACS) Trauma Quality Improvement Program (TQIP) recommends holding a family meeting within 72 hours of admission when treating geriatric trauma patients. At our level I trauma center, we sought to increase early GOC discussions by implementing a new history and physical (H&P) note template for geriatric trauma patients. METHODS/UNASSIGNED:Patients (aged >65 years) admitted to the trauma surgery service (≥24 hours) were included in the study. The intervention was a change in the H&P note template to include confirmation of code status or previous ACP and identification of a healthcare proxy. Primary outcomes were the rates of recognizing a pre-existing Do-Not-Resuscitate (DNR) status/advanced directives at admission and of documentation of a GOC discussion within 72 hours. Outcomes from a 3-month period (March-May) during the pre-intervention (2021) and post-intervention (2022) periods were compared. RESULTS/UNASSIGNED:The pre-intervention and post-intervention groups had 107 and 150 patients, respectively. We observed an increase in recognition of pre-existing DNR code status at time of admission from 50% to 95% (p=0.003) and documentation of a GOC discussion within 72 hours from 17% to 83% (p<0.0001). We also observed a trend showing that new DNR orders were placed more frequently in the post-intervention period (9% vs 17%, p=0.098). The in-hospital mortality was not significantly different. CONCLUSIONS/UNASSIGNED:The importance of GOC discussions and ACP documentation for geriatric trauma patients is evident, but its completion can be challenging. Our intervention of a new H&P note template increased GOC discussions, and this implementation may be feasible in other trauma centers to comply with the ACS-TQIP Geriatric Trauma Management Guidelines. LEVEL OF EVIDENCE/UNASSIGNED:Level III.

PURPOSE: To quantify the incidence of and identify the risk factors for subsequent shoulder procedures after isolated SLAP repair. METHODS: New York's Statewide Planning and Research Cooperative System database was searched between 2003 and 2014 to identify individuals with the sole diagnosis of a SLAP lesion who underwent isolated arthroscopic SLAP repair. Patients were longitudinally followed up for a minimum of 3 years to analyze for subsequent ipsilateral shoulder procedures. RESULTS: Between 2003 and 2014, 2,524 patients met our inclusion criteria. After 3 to 11 years of follow-up, 10.1% of patients (254 of 2,524) underwent repeat surgical intervention on the same shoulder as the initial SLAP repair. The mean time to repeat shoulder surgery was 2.3 +/- 2.1 years. Subsequent procedures included subacromial decompression (35%), debridement (26.7%). repeat SLAP repair (19.7%), and biceps tenodesis or tenotomy (13.0%). After isolated SLAP repair, patients aged 20 years or younger were more likely to undergo arthroscopic Bankart repair (odds ratio [OR], 2.91; 95% confidence interval [CI], 1.36-6.21; P = .005), whereas age older than 30 years was an independent risk factor for subsequent acromioplasty (OR, 2.3; 95% CI, 1.4-3.7; P < .001) and distal clavicle resection (OR, 2.5; 95% CI, 1.1-5.5; P = .030). The need for a subsequent procedure was significantly associated with Workers' Compensation cases (OR, 2.4; 95% CI, 1.7-3.2; P < .001). CONCLUSIONS: We identified a 10.1% incidence of subsequent surgery after isolated SLAP repair, often related to an additional diagnosis, suggesting that clinicians should consider other potential causes of shoulder pain when considering surgery for patients with SLAP lesions. In addition, the number of isolated SLAP repairs performed has decreased over time, and management of failed SLAP repair has shifted toward biceps tenodesis or tenotomy over revision SLAP repair in more recent years. LEVEL OF EVIDENCE: Level III, case-control study.

OBJECTIVES: To examine the variables affecting outcomes for sequential bilateral cochlear implantation patients in the adolescent population. STUDY DESIGN: Retrospective chart review at tertiary care center. METHODS: Main outcome measures were open set speech recognition tests at the word (Consonant-Nucleus-Consonant/Phonetically Balanced Kindergarten List Test [CNC/PBK]) and sentence levels in noise (Hearing in Noise Test-Noise [HINT-N]) in different test conditions with respect to the age at first and sequential implantation, as well as the interval between implants. RESULTS: Despite a mean age at sequential implantation of 13.5 years, sequential bilateral implanted adolescents revealed significant improvement in the sequential cochlear implant (CI2) ear. The mean time interval between implants was 8.2 years. A wide range of performance was noted, and age at implantation and interval between first cochlear implant (CI1) and CI2 did not predict outcome. Mean CNC/PBK score with CI1 alone was 83.0%, with the CI2 alone was 56.5%, and with bilateral implants was 86.8%. Sentence scores (HINT-N) were 89.5% for CI1, 74.2% for CI2, and 94.4% for bilateral CI condition. The clinical relevance of these enhanced perception abilities requires attention to individual device use, performance with the first implant, and subjective benefits reported by patients. CONCLUSIONS: Bilateral sequential cochlear implantation leads to improved speech perception in the adolescent population and should be considered in this population, even after a long period of deafness and despite a prolonged interval between implants. Numerous factors affect the ability to predict performance, but age at implantation and interimplant interval were not correlated with performance measures. Extensive preoperative counseling and individualized evaluation are critical to ensure that patients and families understand the range of possible outcomes. LEVEL OF EVIDENCE: 6. Laryngoscope, 2015.

The purpose of this study was to analyze the effect of hospital volume and charges on the rate of surgical site infections for total hip replacements (THRs) in New York State (NYS). In NYS, higher volume hospitals have higher charges after THR. The study team analyzed 93 620 hip replacements performed in NYS between 2008 and 2011. Hospital charges increased significantly from $43 713 in 2008 to $50 652 in 2011 (P < .01). Compared with lower volume hospitals, patients who underwent THR at the highest volume hospitals had significantly lower surgical site infection rates (P = .003) and higher total hospital charges (P < .0001). The study team found that in the highest volume hospitals, preventing one surgical site infection was associated with $1.6 million dollars in increased charges.

Background. Uterine leiomyosarcoma (LMS) is a rare diagnosis, which is seldom cured when it recurs with metastatic disease. We evaluated patients who present with first time recurrence treated surgically to determine prognostic factors associated with long-term survival. Methods. Over a 16-year period, 41 patients were operated on for recurrent uterine sarcoma. Data examined included patient age, date of initial diagnosis, tumor histology, grade at the initial diagnosis, cytopathology changes in tumor activity from the initial diagnosis, residual tumor after all operations, use of adjuvant therapy, dates and sites of all recurrences, and disease status at last followup. Results. 24 patients were operated for first recurrence of metastatic uterine LMS. Complete tumor resection with histologic negative margins was achieved in 16 (67%) patients. Overall survival was significantly affected by the FIGO stage at the time of the initial diagnosis, the ability to obtain complete tumor resection at the time of surgery for first time recurrent disease, single tumor recurrence, and recurrence greater than 12 months from the time of the initial diagnosis. Median disease-free survival was 14 months and overall survival was 27 months. Conclusion. Our findings suggest that stage 1 at the time of initial diagnosis, recurrence greater than 12 months, isolated tumor recurrence, and the ability to remove ability to perform complete tumor resection at the time of the first recurrence can afford improved survival in selected patientsat the time of the first recurrence can afford improved survival in selected patients.

BACKGROUND: Rotator cuff repairs (RCRs) have become increasingly common. Several studies have shown variation in the indications for this procedure. We chose to track the incidence of RCRs in New York State (NYS) from 1995 to 2009. We hypothesized that after the introduction of the Current Procedural Terminology (CPT) code 29827 for arthroscopic RCR, there would be a significant increase in the rate of RCRs performed in NYS. MATERIALS AND METHODS: The NYS Department of Health's Statewide Planning and Research Cooperative System (SPARCS) database was queried for reported RCRs between the years 1995 and 2009. Using the International Classification of Diseases, Ninth Revision, Clinical Modification procedural code 83.63 and CPT codes 23410, 23412, 23420, and 29827, we collected and analyzed data on RCR procedures. RESULTS: A total of 168,780 RCRs were performed in NYS from 1995 to 2009. In 1995, the population incidence of RCRs was 23.5 per 100,000. In comparison, in 2009, the population incidence was 83.1 per 100,000, an increase of 238% (P < .0001). The percentage of individuals aged between 45 and 65 years undergoing RCR increased from 53.0% to 64.2% during this same period. CONCLUSIONS: There has been a notable increase in the volume of RCRs performed in NYS. In addition, after the introduction of CPT code 29827 in 2003, the increase in the incidence of RCRs became significantly more pronounced.