Faculty Bibliography

Background: Individuals with decompensated cirrhosis (DC) experience uncertain illness trajectories and significant healthcare burden towards the end of life (EOL) Advance care planning (ACP) has been associated with improved EOL outcomes in patients with serious illnesses We implemented a quality improvement (QI) intervention from November 2018 to March 2020 that aimed to increase advance directive (AD) completion among patients with DC seen in a once-weekly hepatology clinic staffed by transplant hepatology fellows, gastroenterology fellows, and attending hepatologists The goal of this study was to evaluate the effect of our QI intervention on EOL care, including the hospital length of stay (LOS) and concordance between documented preferences and care received Methods: We performed a retrospective chart review of adult patients with DC seen in our clinic during the QI intervention We followed patients from the time of their first appointment through June 2020, or until date of death We collected data on whether an AD was completed, along with contents of the most recent document Among decedents, we collected data on location of death, goals of care discussions (GCDs), LOS, and receipt of comfortfocused care Descriptive statistics were calculated and Wilcoxon rank sum tests were performed to compare LOS All analyses were conducted using STATA 14 2 Results: A total of 95 patients were seen during the follow-up period Our cohort consisted mostly of men (60%), of Latinx origin (60%), Medicaid-insured (69%) and with a mean age of 56 (standard deviation [SD]: 12) years The primary cause of cirrhosis was alcohol use (36%) Most patients had history of ascites (71%) or hepatic encephalopathy (57%). At first visit, the mean Model of End-Stage Liver Disease-Sodium (MELDNa) score was 13 9 (SD: 6 0), and most patients were never evaluated for transplant (77%) or declined for listing (11%) AD completion improved from 9 to 40% Nine (9%) patients died during follow-up, of which 8 were hospitalized Among decedents, 5 (56%) had a prior AD, of which all designated a healthcare proxy (HCP) and 4 designated care preferences at the EOL The care of 5 decedents (56%) involved GCDs, of which 4 (80%) included specialty palliative care (SPC) services All patients previously opting for limits to care received comfort care at the EOL and experienced shorter hospitalizations compared to patients with fully aggressive or unreported preferences (median LOS: 11 vs 14 days), though this difference was not statistically significant (p=0.30) (Table 1)
Conclusion(s): AD completion significantly improved over the follow-up period All patients who previously documented limits to care received goal-concordant care at the EOL and tended to have shorter hospitalizations Future iterations of this quality improvement project will involve more patients, longer follow up periods, and formal assessments of patient and family satisfaction at the EOL. (Table Presented)

Background: During the novel coronavirus-2019 (COVID-19) pandemic, physicians in residency and fellowship training programs are serving as essential healthcare workers while also attempting to continue their preparation for eventual independent practice in their field. We aimed to determine how level of exposure patients with COVID-19 affected the experience of graduate medical trainees in terms of their safety, professional development, and well-being during March and April 2020 Methods: We administered an anonymous, voluntary, web-based survey to physicians enrolled in residency or fellowship training programs in any specialty worldwide A convenience sampling of trainees was obtained through distribution of the survey by email and social media posts from April 20th to May 11th, 2020 To investigate the impact of burden of exposure to COVID-19 the trainee experience, we categorized respondents according to their self-reported estimate of the number of patients with COVID-19 that they provided care for in March and April 2020 (0, 1-30, 31-60, >60). Descriptive statistics were performed and the chi square test was used to evaluate for statistical significance. A multivariable logistic regression analysis was conducted to determine independent predictors of physician burnout Results: Surveys were completed by 1420 trainees, of whom 1031 (73%) were residents Most of the fellows who responded to the survey were training in gastroenterology/ hepatology (27%, 85/280) Trainees who cared for a greater number of COVID-19 patients were more likely to report limited access to PPE and COVID-19 testing and more likely to report testing positive for COVID-19 (Figure 1A) Compared to trainees who did not take care of COVID-19 patients, those who took care of 1-30 patients (adjusted odds ratio [AOR] 1 80, 95% CI 1 29-2 51), 31-60 patients (AOR 3.30, 95% CI 1.86-5.88) and >60 patients (AOR 4.03, 95% CI 2 12-7 63) were increasingly more likely to report burnout More than half (835, 58%) of trainees reported concern about their future preparedness for independent practice Trainees who cared for >60 COVID-19 patients compared to those who did not care for any COVID-19 patients reported similar levels of concern about their preparedness for independent practice (56%, 372/636 vs 58%, 71/125 respectively, p-value 0 57, Figure 1B)
Conclusion(s): Physician trainees who were involved in the care of patients with COVID-19 were more likely to report unsafe working conditions and suffered from higher rates of physician burnout Trainees were concerned about the effects of lost training opportunities on their professional development irrespective of the number of COVID-19 patients they cared for

OBJECTIVE:Tricuspid regurgitation (TR) severity has known adverse implications, its impact on patients undergoing non-cardiac surgery (NCS) remains unclear. We sought to determine the impact of TR on patient outcomes after NCS. METHODS:We performed a retrospective cohort study in patients undergoing NCS. Outcomes in patients with moderate or severe TR were compared with no/trivial TR after adjusting for baseline characteristics and revised cardiac risk index (RCRI). The primary outcome was defined as 30-day mortality and heart failure (HF), while the secondary outcome was long-term mortality. RESULTS:Of the 7064 patients included, 312 and 80 patients had moderate and severe TR, respectively. Thirty-day mortality was higher in moderate TR (adjusted OR 2.44, 95% CI 1.25 to 4.76) and severe TR (OR 2.85, 95% CI 1.04 to 7.79) compared with no/trivial TR. There was no difference in 30-day HF in patients with moderate TR (OR 1.48, 95% CI 0.90 to 2.44) or severe TR (OR 1.42, 95% CI 0.60 to 3.39). The adjusted HR for long-term mortality in moderate TR was 1.55 (95% CI 1.31 to 1.82) and 1.87 (95% CI 1.40 to 2.50) for severe TR compared with no/trivial TR. CONCLUSION:Increasing TR severity has higher postoperative 30-day mortality in patients undergoing NCS, independent of RCRI risk factors, ejection fraction or mitral regurgitation. Severity of TR should be considered in risk stratification for patients undergoing NCS.

Background: High quality preventative care has the potential to improve health outcomes in patients with cirrhosis; however, most quality improvement initiatives focus on hospitalized patients. We aimed to evaluate the quality of care (QOC) provided by gastroenterology (GI) and hepatology providers to patients with cirrhosis by measuring eleven evidence-based quality indicators (QIs) focusing on outpatient preventative care and the factors associated with higher QOC.
Method(s): We conducted a retrospective study of outpatients with cirrhosis seen by GI or hepatology providers at a single tertiary care liver transplant center in the United States between 1/1/2013 and 1/30/2018. We used ICD-9 and ICD-10 codes to identify patients with cirrhosis and then performed a manual chart review to confirm a clinical diagnosis of cirrhosis, presence of a primary care provider in our health system, and receipt of care by a GI or hepatology provider. We excluded patients who received a liver transplant prior to 2013. We performed chart abstraction for sociodemographic, laboratory, imaging, procedure, and counseling data. QI pass rates for the 11 QIs were calculated as the proportion of patients eligible for a QI who received that QI during the study period. We performed logistic regression to determine predictors of high-quality care, defined as an overall pass rate >=75%.
Result(s): In total, 149 patients met inclusion criteria. Median age was 61, 66% were male, and 20% were Hispanic. The most common etiology of cirrhosis was viral hepatitis C (40%), followed by alcoholic liver disease (23%). Median initial MELD-Na score was 10, and 36% were decompensated at their index visit (Table). QI pass rates ranged from 4% (received prophylaxis for spontaneous bacterial peritonitis (SBP)) to 91% (received counseling on alcohol abstinence) (Figure). Overall, 6% (9/149) of patients achieved all eligible QIs. On average, patients received 48% (95% CI:19%-76%) of the QIs for which they were eligible. More frequent outpatient GI or hepatology visits were associated with higher QOC, but the association did not reach statistical significance in multivariable regression analysis (Table).
Conclusion(s): In a large liver transplant center, receipt of evidence-based preventative QIs for patients with cirrhosis was low overall and varied across individual indicators. Quality gaps exist for driving counseling, SBP prophylaxis, and secondary prophylaxis after esophageal variceal hemorrhage. Future studies should examine the association between preventative QIs and patient reported outcomes. As patient factors were not significantly associated with QOC, future studies should also evaluate the role of provider and system-level factors in designing interventions that reduce practice variability, standardize care, and translate evidence-based practices from guidelines to clinical practice. [Figure presented] [Figure presented]
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Trigeminal neuralgia, also known as tic douloureux, is a disorder characterized by pain in the distribution of the trigeminal nerve. Chronic pain secondary to this condition can have a significant negative impact on a patient's quality of life. We present an educational case of refractory trigeminal neuralgia responsive to a novel pain-alleviating procedure. An 80-year-old man with recurrent trigeminal neuralgia presented with episodic pain refractory to multimodal pharmacologic treatment, as well as interventional pain procedures. Radiofrequency ablation (RFA) to the mandibular and maxillary branches of the trigeminal nerve was attempted, but deemed unsuccessful. In an attempt to relieve the patient's pain in the mandibular region, an inferior alveolar nerve block with radiofrequency ablation was performed. The patient reported a significant long-term reduction of his pain and improved ability to perform activities of daily living.
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Aims & Objectives: Patients with Ehlers-Danlos syndrome (EDS) have abnormal collagen production or secretion leading to hyperextensibility of the skin, hypermobility of the joints, and increased tissue fragility. Although uncommon, respiratory manifestations of EDS have been described. The typical causes of death in patients with EDS are viscus rupture and arterial hemorrhage. Some deaths have been attributed to pulmonary hemorrhage. We report a case of acute pulmonary hemorrhage as the presenting finding of granulatomatosis with polyangiitis in a child with EDS. Methods Case Report Results A 14-year-old female with EDS presented with a 2-month history of fever, fatigue, unintentional weight loss, arthralgias, myalgias, and progressive dyspnea. Chest radiography revealed diffuse alveolar opacities and laboratory evaluation revealed anemia and thrombocytopenia. Chest computed tomography (CT) showed pulmonary hemorrhage. Anti-neutrophil cytoplasmic antibodies targeting proteinase 3 were positive for granulomatosis with polyangiitis. She was admitted on highflow nasal cannula oxygen therapy and given pulse-dose intravenous methylprednisolone. Subsequent improvement in respiratory status was observed; she was treated with rituximab and weaned off oxygen. Patient was discharged home in stable condition on hospital day #5 and remained on oral prednisone, with a 4-week course of rituximab, and was started oral azathioprine. (Figure prsented). Conclusions To our knowledge this is the first reported case of polyangiitis with granulomatosis presenting with pulmonary hemorrhage in a child with EDS. An increased index of suspicion may improve outcomes

OBJECTIVES/OBJECTIVE:Inappropriate antibiotic use for respiratory tract infection (RTI) is an ongoing problem linked to the emergence of drug resistance and other adverse effects. Less is known about the prescribing practices of individual physicians or the impact of physician prescribing habits on patient outcomes. We studied the prescribing practices of providers for acute RTIs in an integrated health system, identified patient factors associated with receipt of an antibiotic and assessed the relation between providers' adjusted prescribing rates and a number of patient outcomes. METHODS:This was a retrospective analysis of adults with an RTI visit to any primary care providers across the Cleveland Clinic Health System in 2011-2012. Patients with a history of chronic obstructive pulmonary disease or immunocompromised status were excluded. Logistic regression was used to examine patient factors associated with receipt of an antibiotic. RESULTS:< 0.001). Emergency department visits for respiratory complications were rare and not associated with antibiotic receipt. CONCLUSIONS:Antibiotic prescribing for RTI varies widely among physicians and cannot be explained by patient factors. Patients prescribed antibiotics for RTI were more likely to return for RTI.

AIMS: Patients seeking cervical spine surgery are thought to be increasing in age, comorbidities and functional debilitation. The changing demographics of this population may significantly impact the outcomes of their care, specifically with regards to complications. In this study, our goals were to determine the rates of functionally dependent patients undergoing elective cervical spine procedures and to assess the effect of functional dependence on 30-day morbidity and mortality using a large, validated national cohort. PATIENTS AND METHODS: A retrospective analysis of the American College of Surgeons National Surgical Quality Improvement Program data files from 2006 to 2013 was conducted to identify patients undergoing common cervical spine procedures. Multivariate logistic regression models were generated to analyse the independent association of functional dependence with 30-day outcomes of interest. RESULTS: Patients with lower functional status had significantly higher rates of medical comorbidities. Even after accounting for these comorbidities, type of procedure and pre-operative diagnosis, analyses demonstrated that functional dependence was independently associated with significantly increased odds of sepsis (odds ratio (OR) 5.04), pulmonary (OR 4.61), renal (OR 3.33) and cardiac complications (OR 4.35) as well as mortality (OR 11.08). CONCLUSIONS: Spine surgeons should be aware of the inherent risks of these procedures with the functionally dependent patient population when deciding on whether to perform cervical spine surgery, delivering pre-operative patient counselling, and providing peri-operative management and surveillance. Cite this article: Bone Joint J 2017;99-B:824-8.

Statement of Problem: Traditionally, pediatric craniomaxillofacial reconstruction was driven by nonvascularized bone grafts and then later, distraction osteogenesis. Although beneficial, these techniques were prone to problems, particularly relapse and graft resorption. Oftentimes, patients reconstructed primarily with costochondral grafts required multiple subsequent operations to reconstruct the mandible and temporomandibular joint secondary to near total graft resorption. We propose the use of the free fibula flap in conjunction with adjunctive procedures (orthognathic surgery, temporomandibular joint reconstruction or maxillofacial prosthetics) to successfully treat young patients with complex craniofacial asymmetries who have failed previous operations. Methods: A retrospective chart review at NYU Langone Medical Center was completed to identify patients under 18 years of age who underwent free fibula flap reconstruction for congenital or acquired asymmetric craniofacial deformities from 2010-2013. All patients were previously treated with non-vascularized grafts prior to free tissue transfer. A total of seven patients were treated for hemifacial microsomia, Pruzansky III (HFM) (n=4), Treacher Collins syndrome (n=1), Ectodermal dysplasia (n=1), and orbital osteoradionecrosis (n=1). Computer aided design and virtual surgical planning was implemented in all cases. For the four patients with HFM, reconstruction of the hypoplastic mandible with the fibula flap was performed in conjunction with maxillary and/or mandibular orthognathic surgery. One of those patients also underwent concomitant total prosthetic replacement of the contralateral TMJ. Five patients underwent concomitant dental implant placement into the fibula, while one patient received a post operative orbital prosthesis. Frameless stereotaxy was used in three cases to aid in placement of the proximal fibula. Postoperative physical examination and computed tomography was used to evaluate flap position and correction of asymmetry. R!