Faculty Bibliography

OBJECTIVE:To determine the incidence of fallopian tube endometriosis in patients undergoing laparoscopic surgery with a preoperative diagnosis of endometriosis, pelvic pain, infertility, or cystic adnexal mass. DESIGN/METHODS:Retrospective cross-sectional study. SETTING/METHODS:Gynecologic oncology and minimally invasive surgery practice. PATIENT(S)/METHODS:All patients who underwent surgery for endometriosis from July 2015 to June 2018 were included. Exclusion criteria were age ≥55 years, diagnosis of cancer, laparotomy, previous bilateral salpingectomy, and preoperative diagnosis other than endometriosis, pelvic pain, infertility, or cystic adnexal mass. INTERVENTION(S)/METHODS:Subjects were divided by those who did and those who did not have a salpingectomy at the time of surgery. MAIN OUTCOME MEASURE(S)/METHODS:Diagnosis of tubal endometriosis was based on macroscopic evidence of endometrial implants on the fallopian tube(s) noted within the operative report and microscopic evidence of endometriosis noted within the pathology report. RESULT(S)/RESULTS:A total of 444 surgeries were performed and 185 met the study criteria. Among those, 153 (82.7%) had histologically diagnosed endometriosis within the abdominopelvic cavity. The incidence of tubal endometriosis was 11%-12% macroscopically and 42.5% microscopically after salpingectomy. Patients with tubal endometriosis were more likely to have severe disease. CONCLUSION(S)/CONCLUSIONS:Among patients with endometriosis, the incidence of microscopic tubal endometriosis was significantly greater than that of macroscopic disease.

OBJECTIVE:The primary objective was to evaluate hydrocortisone's efficacy for decreasing respiratory support in premature infants with developing bronchopulmonary dysplasia (BPD). Secondary objectives included assessment of the impact of intrauterine growth restriction (IUGR), maternal history of chorioamnionitis, side effects and route of administration associated with hydrocortisone's efficacy. Dexamethasone as second-line treatment to decrease respiratory support was reviewed. METHODS:Retrospective chart review of preterm infants requiring respiratory support receiving hydrocortisone. RESULTS:A total of 48 patients were included. Successful extubation was achieved in 50% of intubated patients after hydrocortisone treatment with no major complications. In our small study, history of maternal chorioamnionitis, IUGR or route of administration did not affect the response. Rescue dexamethasone after hydrocortisone therapy was ineffective in the ten patients who failed extubation following hydrocortisone. CONCLUSION/CONCLUSIONS:Hydrocortisone is effective in decreasing respiratory support in patients with developing BPD without major complications. Randomized studies are warranted to confirm our findings.

OBJECTIVE:Obstetric hypertensive emergency is defined as having systolic blood pressure ≥160 mmHg or diastolic blood pressure ≥110 mmHg, confirmed 15 min apart. ACOG recommends that acute-onset, severe hypertension be treated with first line-therapy (IV labetalol, IV hydralazine or PO nifedipine) within 60 minutes to reduce risk of maternal morbidity and mortality. Therefore, our objective was to identify barriers that lead to delayed treatment of obstetric hypertensive emergency. STUDY DESIGN/METHODS:A retrospective cohort study was performed comparing women appropriately treated within 60 minutes versus those with delay in first line therapy. We identified 604 patients with discharge diagnoses of chronic hypertension, gestational hypertension or preeclampsia using ICD-10 codes and obstetric antihypertensive usage in a pharmacy database at one academic institution from January 2017 - June 2018. 267 subjects (44.2%) experienced obstetric hypertensive emergency in the intrapartum period or within two days of delivery. 213 subjects were used for analysis. We evaluated maternal characteristics, presenting symptoms and circumstances, timing of hypertensive emergency, gestational age at presentation, and administered medications. Chi square, Fisher's exact, Wilcoxon ran-sum and sample t-tests were used to compare the two groups. Univariable logistic regression was applied to determine predictors of delayed treatment. Multivariable regression model was also performed, C-statistic and Hosmer and Lemeshow goodness-of-fit test were used to assess the model fit. A result was considered statistically significant at p<0.05. RESULTS:Of the 213 women, 110 (51.6%) had delayed treatment vs. 103 (48.4%) who were treated within 60 min. Patients who had delayed treatment were 3.2 times more likely to present with an initial BP in the non-severe range vs those who had timely treatment (OR=3.24, 95% CI:1.85-5.68). Timeliness of treatment was associated with presence or absence of preeclampsia symptoms-- patients without pre-eclampsia symptoms were 2.7 times more likely to have delayed treatment (OR=2.68, 95%CI:1.50-4.80). Patients with HTN emergencies that occurred overnight between 10pm-6am were 2.7 times more likely to have delayed treatment vs. those that occurred between 6am-10pm (OR 2.72, 95% CI: 1.27-5.83). Delayed treatment also had an association with race, with Caucasian patients being 1.8 times more likely to have delayed treatment (OR=1.79; 95% CI: 1.04-3.08). Patients treated under 60 min had a lower gestational age at presentation vs those with delayed treatment (34.6±5wk vs. 36.6±4wks, respectively, p <0.001). For every 1 week increase in gestational age at presentation, there was a 9% increase in the likelihood of delayed treatment (OR 1.11; 95%CI:1.04-1.19). Another factor associated with delay of treatment was presenting complaint of labor symptoms, which made patients 2.2 times as likely to experience treatment delay (OR=2.17; 95%CI: 1.07-4.41). CONCLUSION/CONCLUSIONS:Initial blood pressure in non-severe range, absence of preeclampsia symptoms, presentation overnight, Caucasian race, presenting complaint of labor symptoms, and increasing gestational age at presentation are barriers that lead to delay in treatment of obstetric hypertensive emergency. Quality improvement initiatives targeting these barriers should be instituted to improve timely treatment.

STUDY OBJECTIVE/OBJECTIVE:The objective of this study was to analyze the characteristics of pediatric patients transferred from a hospital-based general emergency department (ED) to an acute care facility. METHODS:Study data were abstracted from the 2010 Healthcare Cost and Utilization Project Nationwide Emergency Department Sample database. A multivariate logistic regression was constructed for pediatric patients (<18 years old) who require a transfer to an acute care facility from a general ED. Independent variables included in the model were age (<1, 1-4, 5-9, 10-14, 15-17 age in years), sex, insurance/payment method, and diseases/body systems using International Classification of Diseases, Ninth Revision, coding. RESULTS:In the Healthcare Cost and Utilization Project/Nationwide Emergency Department Sample, 5.5 million ED visits were for children less than 18 years. About 1.5% of visits resulted in transfer. Children younger than 1 year had higher transfer rates as compared with 15 to 17 year old group (odds ratio [OR], 1.17; 95% confidence interval [CI], 1.089-1.146). Patients with Medicaid and self-pay compared with private insurance/health maintenance organization had 4% (OR, 0.96; 95% CI, 0.944-0.976) and 9% (OR, 0.91; 95% CI, 0.886-0.945), respectively, lower likelihood of being transferred. Patients with circulatory (OR, 8.43; 95% CI, 7.8-9.1), endocrine (OR, 5.9; 95% CI, 5.6-6.2), mental (OR, 5.44; 95% CI, 5.3-5.6), nervous system (OR, 5.2; 95% CI, 4.9-5.5), congenital anomalies (OR, 5.14; 95% CI, 4.5-5.9), hematology-oncology (OR, 4.49; 95% CI, 4.2-4.8), digestive, (OR, 1.52; 95% CI, 1.5-1.6), and other disorders (OR, 1.33; 95% CI, 1.3-1.4) had a higher odds of being transferred as compared with trauma/injury and poisoning, whereas patients with disorders related to genitourinary (OR, 0.96; 95% CI, 0.91-1.0), respiratory (OR, 0.79; 95% CI, 0.77-0.81), musculoskeletal (OR, 0.63; 95% CI, 0.58-0.68), skin (OR, 0.47; 95% CI, 0.45-0.50), infectious and parasitic (OR, 0.23; 95% CI, 0.22-0.25), and eyes/ears/nose/throat (OR, 0.09; 95% CI, 0.079-0.094) had a lower odds of being transferred as compared with trauma/injury and poisoning. CONCLUSIONS:Children younger than 1 year had relatively higher transfer rates. Patients covered by Medicaid and self-pay had the lowest likelihood of transfer. Transfer rates varied significantly by condition and the high-transfer diagnostic categories were related to circulatory, endocrine, nervous, hematology-oncology, and mental disorders as well as congenital anomalies, which may be related to a lack of ED or inpatient resources to care for children with problems that require more complex care.

BACKGROUND:Behavioral emergencies endanger hospital staff and patients. The objective of this study was to identify patient characteristics that could be used to predict and prevent these incidents. METHODS:We analyzed a one-year consecutive series of behavioral emergencies that triggered the rapid response team at a general hospital, comparing study patients with controls who did not trigger a rapid response. Standard parametric or nonparametric tests, as appropriate, were used to compare the 2 groups in univariate analyses, and multivariable logistic regression analysis was used to identify the best combination of variables for stratifying the risk of such an event. RESULTS:There were 109 behavioral emergencies involving 83 patients. Comparison of patients who did (n = 83) or did not (n = 22,849) trigger a rapid response revealed marked differences between the two groups with respect to age, sex, and the prevalence of psychiatric comorbidities and various conditions that can diminish cognitive function. Substance use disorder was the most frequent principal diagnosis in the study group, accounting for 10.8% (9/83) of study patients vs. 0.6% (132/22849) of controls (p < 0.0001). The presence of a condition that can impair cognition (substance intoxication and withdrawal, epilepsy, cerebrovascular disease, traumatic brain injury, delirium, dementia) was associated with a 13-fold increase in the risk of a behavioral disturbance (95% CI, 8 to 22-fold). CONCLUSIONS:Brief cognitive assessment of patients susceptible to cognitive impairment, along with diligent prophylaxis and management of substance withdrawal and delirium, may facilitate prevention of behavioral emergencies.

OBJECTIVE:To determine whether delaying oral feeding until coming off NCPAP will alter feeding and respiratory-related morbidities in preterm infants. DESIGN/METHODS:In this retrospective pre-post analysis, outcomes were compared in two preterm infant groups (≤32 weeks gestation). Infants in Group 1 were orally fed while on NCPAP, while infants in Group 2 were only allowed oral feedings after ceasing NCPAP. RESULTS:Although infants in Group 2 started feeds at a later postmenstrual age (PMA), they reached full oral feeding at a similar PMA compared with Group 1. Interestingly, there was a positive correlation between the duration of oral feeding while on NCPAP and the time spent on respiratory support in Group 1. CONCLUSIONS:Delayed oral feeding until ceasing NCPAP did not contribute to feeding-related morbidities. We recommend caution when initiating oral feedings in preterm infants on NCPAP without evaluating the safety of the infants and their readiness for oral feedings.

STUDY OBJECTIVE/OBJECTIVE:A gap analysis of emergency departments' (EDs') pediatric readiness across a health system was performed after the appointment of a service line health system pediatric emergency medicine (PEM) quality director. METHODS:A 55-question survey was completed by each eligible ED to generate a weighted pediatric readiness score (WPRS). The survey included questions regarding volume, ED configuration, presence of a pediatric emergency care coordinator (PECC), quality initiatives, policies and procedures, and equipment. Surveys were completed from June 1 to November 12, 2016.Analysis of variance was used to compare the 4 groups of EDs based upon their annual pediatric volume as a continuous measure (low, <1800 visits; medium, 1800-4999 visits; medium-high, 5000-9999 visits; high, >10,000 visits). The Fisher exact test was used to compare the 4 groups for the remaining categorical variables represented as frequencies and percentages. A result was considered statistically significant at the P < 0.05 level of significance. RESULTS:There were a total of 16 hospitals (after the exclusion of the children's hospital, the hub for pediatric care in the health system, and 1 adult-only hospital) with the following pediatric capability: 7 basic (no inpatient pediatrics), 7 general (inpatient pediatrics, with/without a neonatal intensive care unit), and 2 comprehensive (inpatient pediatrics, pediatric intensive care unit, and a neonatal intensive care unit). In 12 EDs, adults and children are treated in the same space. These EDs see a total of 800,000 annual visits including 120,000 pediatric visits. Two low pediatric volume EDs had a median WPRS of 69, range of 62 to 76 (national median, 61.4); 6 medium pediatric volume EDs had a median WPRS of 51, range of 42 to 81 (national median, 69.3); 4 medium-high pediatric volume EDs had a median WPRS of 69.3, range of 45 to 98 (national medium, 74.8); 4 high pediatric volume EDs had a WPRS score of 84.5, range of 58 to 100 (national medium, 89.8). There were 4 sites with PECCs: 1 medium-high volume and 3 high volume, with a median WPRS of 98.5, range of 81 to 100 (national medium, 89.8). Two low-volume EDs have Neonatal Resuscitation Program training for nurses (P < 0.0083). One medium-high volume ED requires specific pediatric competency evaluations for advanced level practitioners staffing the ED. Pediatric-specific quality programs are present in the 2 low volume EDs, 3 of the 6 EDs in the medium group, 3 of 4 EDs in the medium-high group, and all 4 high volume hospitals. After the implementation of the health system PEM quality director, all EDs have a doctor and nurse PECC with a median WPRS of 81. In additiona, a committee was formed with the following key stakeholders: PECCs, pediatric nursing educators, pediatric quality, pharmacy, obstetrics, behavioral health, and neonatology. The committee is part of the health system quality program within both pediatrics and emergency medicine and is spearheading the standardization of code carts and medications, dissemination of pediatric clinical guidelines, and the development of a pediatric quality program across the health system. CONCLUSIONS:Pediatric emergency care coordinators play an important role in ED readiness to care for pediatric patients. In a large health system, a service line PEM quality director with the support of emergency medicine and pediatrics, a committee with solid frontline ED base, and a diverse array of stakeholders can foster the engagement of all EDs and improve compliance with published guidelines.

BACKGROUND:While elevated second trimester maternal serum alpha fetoprotein (msAFP) has been associated with adverse pregnancy outcomes, the utility of first trimester msAFP in predicting these outcomes is limited. Some laboratories have been including msAFP as part of the first trimester analyte screening for aneuploidy and preeclampsia, offering its potential utility in predicting pregnancy outcomes. OBJECTIVE:Our primary objective was to determine the association between elevated first trimester msAFP and preeclampsia, as well as ischemic placental disease (a composite of preeclampsia, fetal growth restriction and/or placental abruption). Secondary outcomes included early onset preeclampsia requiring delivery at <34 weeks gestation, fetal growth restriction, placental abruption, preterm delivery, fetal demise, and spontaneous abortion. STUDY DESIGN/METHODS:An IRB-approved multi-site retrospective cohort study was performed including all patients with first trimester msAFP as part of routine first trimester aneuploidy screening from April 2015-January 2017. Pregnancies with multiple gestations, known structural or chromosomal abnormalities, known malignancy, and incomplete delivery records were excluded. Delivery records were reviewed for baseline characteristics and adverse pregnancy outcomes. The optimal cut-off point for first trimester msAFP to predict these outcomes was assessed and an elevated msAFP was considered > 2.0 MoM. Fisher exact test and odds ratios were used to determine the association between elevated first trimester msAFP and adverse pregnancy outcomes. Spearman correlation coefficient assessed the relationship between first and second trimester msAFP. RESULTS:Of 1478 patients with first trimester msAFP, 1280 had complete records available for review (86.6%). There was no association demonstrated between elevated first trimester msAFP (> 2.0 MoM) and the primary outcome, overall preeclampsia (5.8% vs. 4.6%, OR 1.29, 95% CI 0.58, 2.91). However, there was an increased incidence of ischemic placental disease, 15.8% vs 7.7% (OR 2.26, 95% CI 1.33-3.87) in those with an elevated AFP. Also, elevated first trimester msAFP was associated with a higher incidence of fetal growth restriction (7.5% vs 2.3%, OR 3.40, 95% CI 1.56-7.42) and preterm birth (18.3% vs 10.3%, OR 1.95, 95% CI 1.18-3.21). Also, a positive correlation between first and second trimester msAFP was demonstrated (rho = 0.46, P< 0.0001). CONCLUSIONS:Elevated first trimester msAFP is associated with ischemic placental disease, fetal growth restriction, and preterm birth. This suggests that elevated msAFP may help to identify high risk pregnancies as early as the first trimester of pregnancy. Future studies are necessary to determine if addition of first trimester msAFP to existing algorithms can improve the early detection of ischemic placental disease.

Introduction/UNASSIGNED:Positioning-related neural injuries are an inherent risk in surgery, particularly in robotic-assisted abdominal wall reconstruction because of unique patient positioning and increased operative times. The implementation of intraoperative neurophysiological monitoring should be considered in such cases. Methods/UNASSIGNED:This was a two-armed study with one prospective intervention group and one retrospective control group. All patients underwent robotic abdominal wall reconstruction at an academic center. The prospective arm underwent robotic reconstruction from January through July 2019. The retrospective database reviewed patients who underwent the same procedure from August 2015 through July 2018. Factors assessed included: demographics (age, gender, body mass index, comorbidities), surgical details (American Society of Anesthesiologists class, procedure, operative time, positioning), outcomes (length of stay, 30-d readmission, reoperation), and any new-onset intraoperative or postoperative neuropathy. Patients were seen in the clinic postoperatively at weeks 1 and 6. Results/UNASSIGNED:Ten patients were included in the prospective arm. All received intraoperative neurophysiological monitoring using somatosensory evoked potentials. They were compared with 47 patients in the retrospective arm who underwent surgery without intraoperative neurophysiological monitoring. One position-related neural response from baseline was detected intraoperatively in the prospective arm; however, there were no peripheral neurological symptoms present postoperatively. Two patients in the control group developed transient peripheral neuropathies that resolved within 6 weeks. Demographics, surgical procedures, and length of surgery were similar in both groups. The prospective group had a higher rate of preoperative neuropathy and intraoperative use of vasopressors. Conclusion/UNASSIGNED:Incorporation of neurophysiological monitoring in robotic surgery is feasible and may lead to the prevention and reduction in positioning-related injuries.