Faculty Bibliography

OBJECTIVES/OBJECTIVE:The method for drainage of exocrine secretions in pancreas transplantation remains a matter of debate. Different methods have evolved over time. Most data on these methods are from single-center studies with small sample sizes. Larger studies have yielded conflicting results. METHODS:Data from the United Network for Organ Sharing database on all adult subjects who received pancreas and kidney-pancreas transplants between 1996 and 2012 were analyzed (n = 19,934). Subjects were divided into 3 groups: enteric drainage with Roux-en-Y (n = 4308), enteric drainage without Roux-en-Y (n = 11,145), and bladder drainage (n = 4481). Primary end points were patient and graft survival at 1, 3, 5, 10, and 15 years. RESULTS:There was a patient and graft survival advantage with enteric drainage without Roux-en-Y reconstruction compared with the other methods. This was consistent at 1, 3, 5, 10, and 15 years. CONCLUSIONS:Our study demonstrated increased graft and patient survival when comparing enteric drainage of the transplanted pancreas without Roux-en-Y reconstruction to enteric drainage with Roux-en-Y and bladder drainage at 1, 3, 5, 10, and 15 years. Based on this study, we recommend enteric drainage without Roux-en-Y reconstruction as the method of choice in pancreas transplantation.

BACKGROUND:Pancreatectomies have been identified as procedures with an increased risk of readmission. In surgical patients, readmissions within 30 days of discharge are usually procedure-related. We sought to determine predictors of 30-day readmission following pancreatic resections in a large healthcare system. METHODS:We retrospectively collected information from the records of 383 patients who underwent pancreatic resections from 2004-2013. To find the predictors of readmission in the 30 days after discharge, we performed a univariate screen of possible variables using the Fisher's exact test for categorical variables and the Mann-Whitney U test for continuous variables. Multivariate analysis was used to determine the independent factors. RESULTS:Fifty-eight (15.1%) patients were readmitted within 30 days of discharge. Of the patients readmitted, the most common diagnoses at readmission were sepsis (17.2%), and dehydration (8.6%). Multivariate logistic regression found that the development of intra-abdominal fluid collections (OR = 5.32, P < 0.0001), new thromboembolic events (OR = 4.08, P = 0.016), and pre-operative BMI (OR = 1.06, P = 0.040) were independent risk factors of readmission within 30 days of discharge. CONCLUSION/CONCLUSIONS:Our data demonstrate that factors predictive of 30-day readmission are a combination of patient characteristics and the development of post-operative complications. Targeted interventions may be used to reduce the risk of readmission.

Background /UNASSIGNED:Residents and practicing physicians displaying signs of stress is common. It is unclear whether stress during residency persists into professional practice or is associated with future burnout. Objective /UNASSIGNED:We assessed the persistence of stress after residency and its correlation with burnout in professional practice. We hypothesized that stress would linger and be correlated with future burnout. Methods /UNASSIGNED:A prospective cohort study was conducted over 10 years using survey instruments with existing validity evidence. Residents over 3 academic years (2003-2005) were surveyed to measure stress in residency. Ten years later, these residents were sought out for a second survey measuring current stress and burnout in professional practice. Results /UNASSIGNED: = .028). Conclusions /UNASSIGNED:We showed emotional distress as a resident persists into individuals' professional practice 10 years later and has an association with burnout in practice.

BACKGROUND:Bethesda guidelines do not require presence of transformation zone (TZ) for a cervical Pap test to be deemed adequate. However, clinicians are concerned with specimens that are reported to lack TZ. METHODS:We analyzed 566 ThinPrep cases reported as negative for intraepithelial lesion or malignancy (NILM) with no cervical abnormality detected in previous 4 years (2007-2011). These cases were divided into two cohorts; those with TZ (ETZ) and those without TZ (NTZ). Patients' age, HPV status, time of sample collection (>14 days after last menstrual period), subsequent management, interval of subsequent Pap test (<1, 1-3, and >3 years), and result of subsequent examination were compared over a 5-year period. RESULTS:The rate of abnormal Pap test on 5 year follow-up was not statistically significant (P < .9520) between cohorts. Our data demonstrates lack of statistical significance between the variables studied. Five year follow-up of all abnormal Pap smears were analyzed (93% ETZ and 7% NTZ). Of the ETZ group, 25% ASCUS remained as ASCUS and 75% were reported as NILM in subsequent Pap smears. Additionally, 75% of the LSIL were subsequently reported as NILM and 25% reported as ASCUS. One patient reported as HSIL underwent hysterectomy. Two Pap smears performed two years after surgery were negative. Within the NTZ group, one case of ASCUS was NILM upon follow-up. CONCLUSION/CONCLUSIONS:Pap smears with NTZ were not at a higher risk for subsequent detection of cervical abnormalities, making earlier repeat testing unnecessary. Rescreening cases without TZ is neither cost effective nor necessary.

BACKGROUND:Older adults account for more than half of all admissions to intensive care units; most remain alive at 1 year, but with long-term sequelae. OBJECTIVE:To explore geriatric-focused practices and associated outcomes in older intensive care survivors. METHODS:In a 1-year, retrospective, cohort study of patients admitted to the medical intensive care unit and subsequently transferred to the medicine service, adherence to geriatric-focused practices and associated clinical outcomes during intensive care were determined. RESULTS:= .003) were significantly associated with longer hospital stays. Bladder catheters were associated with hospital-acquired pressure injuries (odds ratio, 8.9; 95% CI, 1.2-67.9) and discharge to rehabilitation (odds ratio, 8.9; 95% CI, 1.2-67.9). Nothing by mouth (odds ratio, 3.2; 95% CI, 1.2-8.0) and restraints (odds ratio, 2.8; 95% CI, 1.4-5.8) were also associated with an increase in 30-day readmission. Although 95% of the patients were assessed at least once by using the Confusion Assessment Method for the Intensive Care Unit (overall 2334 assessments documented), only 3.4% had an assessment that indicated delirium; 54.6% of these assessments were inaccurate. CONCLUSION/CONCLUSIONS:Although initiatives have increased awareness of the challenges, implementation of geriatric-focused practices in intensive care is inconsistent.

OBJECTIVES/OBJECTIVE:To explore the effect of the presence and timing of a do-not-resuscitate (DNR) order on short-term clinical outcomes, including mortality. DESIGN/METHODS:Retrospective cohort study with propensity score matching to enable direct comparison of DNR and no-DNR groups. SETTING/METHODS:Large, academic tertiary-care center. PARTICIPANTS/METHODS:Hospitalized medical patients aged 65 and older. MEASUREMENTS/METHODS:Primary outcome was in-hospital mortality. Secondary outcomes included discharge disposition, length of stay, 30-day readmission, restraints, bladder catheters, and bedrest order. RESULTS:Before propensity score matching, the DNR group (n=1,347) was significantly older (85.8 vs 79.6, p<.001) and had more comorbidities (3.0 vs 2.5, p<.001) than the no-DNR group (n=9,182). After propensity score matching, the DNR group had significantly longer stays (9.7 vs 6.0 days, p<.001), were more likely to be discharged to hospice (6.5% vs 0.7%, p<.001), and to die (12.2% vs 0.8%, p<.001). There was a significant difference in length of stay between those who had a DNR order written within 24 hours of admission (early DNR) and those who had a DNR order written more than 24 hours after admission (late DNR) (median 6 vs 10 days, p<.001). Individuals with early DNR were less likely to spend time in intensive care (10.6% vs 17.3%, p=.004), receive a palliative care consultation (8.2% vs 12.0%, p=.02), be restrained (5.8% vs 11.6%, p<.001), have an order for nothing by mouth (50.1% vs 56.0%, p=.03), have a bladder catheter (31.7% vs 40.9%, p<.001), or die in the hospital (10.2% vs 15.47%, p=.004) and more likely to be discharged home (65.5% vs 58.2%, p=.01). CONCLUSION/CONCLUSIONS:Our study underscores the strong association between presence of a DNR order and mortality. Further studies are necessary to better understand the presence and timing of DNR orders in hospitalized older adults.

PURPOSE/OBJECTIVE:The purpose of this retrospective study was to determine clinical and imaging factors on computed tomography (CT) associated with clinically worrisome pneumatosis intestinalis (PI) that may aid in the decision to provide conservative management or urgent surgical intervention. METHODS:Informed consent was waived in this IRB approved study. Imaging features assessed included the presence, location, and pattern of PI, bowel dilatation, thickening, enhancement, stranding, portal venous (PV) and mesenteric venous gas, mesenteric edema, free air, and ascites. Two radiologists retrospectively evaluated 167 patients with CT reports containing the text "PI" between 1/1/11 and 12/31/13. Clinical data collected included serum lactate, malignancy, bowel disease, operative findings, and death during admission. Clinically, worrisome PI was tabulated by summation of surgical diagnosis of dead bowel and/or death during admission. Chi-square test or Fisher's exact test was used when appropriate to compare subjects with benign or worrisome PI for categorical variables and the Mann-Whitney test used to compare continuous measures. RESULTS:Clinically, worrisome PI was present in 44 cases. Benign PI was diagnosed in 97 cases, and these patients were followed conservatively. There was a statistically significant association between clinically worrisome PI and imaging features: location in small bowel (p < 0.0001), bowel dilatation (p = 0.0003), stranding (p = 0.0002), bowel enhancement (p = 0.0384), PV gas (p < 0.0001), mesenteric venous gas (p = 0.0141), and moderate mesenteric edema (p = 0.0036). Location of PI in the small bowel exhibited a statistically significant association with benign PI (p < 0.0002). Statistical significance was found between worrisome PI and the following clinical features: elevated serum lactate (p = 0.0003), underlying bowel disease (p = 0.0004), and mechanical cause of bowel obstruction (p = 0.0497). CONCLUSION/CONCLUSIONS:CT imaging characteristics and clinical features can help predict clinically worrisome PI and guide crucial management decisions.

BACKGROUND/AIMS/OBJECTIVE:Opiate use for inflammatory bowel disease (IBD), particularly high-dose (HD) use, is associated with increased mortality. It's assumed that opiate use is directly related to IBD-related complaints, although this hasn't been well defined. Our goal was to determine the indications for opiate use as a first step in developing strategies to prevent or decrease opiate use. METHODS:A retrospective cohort was formed of adults who were diagnosed with IBD and for whom outpatient evaluations from 2009 to 2014 were documented. Opiate use was defined if opiates were prescribed for a minimum of 30 days over a 365-day period. Individual chart notes were then reviewed to determine the clinical indication(s) for low-dose (LD) and HD opiate use. RESULTS:=0.0071) was more common among HD than among LD. CONCLUSIONS:Our findings show that most IBD patients using opiates, particularly HD users, used opiates for IBD-related complaints. Future research will need to determine the degree to which these complaints are related to disease activity and to formulate non-opiate pain management strategies for patients with both active and inactive IBD.

BACKGROUND:Medicare patients account for approximately 50% of hospital days. Hospitalization in older adults often results in poor outcomes. OBJECTIVE:To test the feasibility and impact of using Assessing Care of Vulnerable Elders (ACOVE) quality indicators (QIs) as a therapeutic intervention to improve care of hospitalized older adults. DESIGN:>Post-test only prospective intervention with a nonequivalent retrospective control group. SETTING:Large tertiary hospital in the greater New York Metropolitan area. PATIENTS:Hospitalized patients, 75 years and over, admitted to medical units. INTERVENTION:A checklist, comprised of four ACOVE QIs, administered during daily interdisciplinary rounds: venous thrombosis prophylaxis (VTE) (QI 1), indwelling bladder catheters (QI 2), mobilization (QI 3), and delirium evaluation (QI 4). MEASUREMENTS:Variables were extracted from electronic medical records with QI compliance as primary outcome, and length of stay (LOS), discharge disposition, and readmissions as secondary outcomes. Generalized linear mixed models for binary clustered data were used to estimate compliance rates for each group (intervention group or control group) in the postintervention period, along with their corresponding 95% confidence intervals. RESULTS:Of the 2,396 patients, 530 were on an intervention unit. In those patients not already compliant with VTE, compliance rate was 57% in intervention vs 39% in control (𝑃 < .0056). For indwelling catheters, mobilization, and delirium evaluation, overall compliance was significantly higher in the intervention group 72.2% vs 54.4% (𝑃 = .1061), 62.9% vs 48.2% (𝑃 < .0001), and 27.9% vs 21.7% (𝑃 = .0027), respectively. CONCLUSION:The study demonstrates the feasibility and effectiveness of integrating ACOVE QIs to improve the quality of care in hospitalized older adults.