The Effect of a Hip Fragility Pathway on Outcomes of Ground Level Falls in the Elderly.

Fragility hip fractures result from low energy mechanisms and are associated with morbidity and mortality, especially in the elderly. We examined outcomes 2 years before and after implementation of a fragility fracture program. The pathway involves emergency department clearance and admission by a medical service with orthopedic consultation. Demographics include age, gender, fracture location, injury severity score (ISS), and ASA. Outcomes include DVT/PE, mortality, disposition, non-operative rate, ICU admission, time to surgery (TTS), length of stay (LOS), and admission service. 777 patients were included (383 PRE/394 POS). POS patients were slightly younger. Trauma admission decreased and LOS and TTS increased. There were no other demographic or outcome differences. Although TTS increased, it remained under 48 hours. Length of stay increase was possibly a reflection of COVID-19. Decreased trauma admission demonstrates pathway adherence. Further studies need to be conducted to verify that quality care can be maintained after initiation of a hip fragility pathway.

Rural versus urban outcomes following transcatheter aortic valve implantation: The importance of the heart team.

BACKGROUND: Rural patients face known healthcare disparities and worse cardiovascular outcomes compared to urban residents due to inequitable access and delayed care. Few studies have assessed rural-urban differences in outcomes following Transcatheter Aortic Valve Implantation (TAVI). We compared short-term post-TAVI outcomes between rural and urban patients. METHODS: We performed a retrospective analysis of n = 413 patients who underwent TAVI at our large academic medical center, between 2011 and 2020 (rural/urban patients = 93/320. Rural/urban males = 53/173). Primary outcomes were all-cause mortality and cardiovascular mortality. Secondary outcomes included stroke/transient ischemic attack, myocardial infarction, atrial fibrillation, acute kidney injury, bleeding, vascular complications, and length of stay. RESULTS: The mean age in years was 77 [IQR 70-82] for rural patients and 78 [IQR 72-84] for urban patients. Baseline characteristics were similar between groups, except for a greater frequency of active smokers and diabetics as well as a greater body mass index in the rural group. There were no statistically significant differences in all-cause or cardiovascular mortality between the groups. There was also no statistically significant difference in secondary outcomes. CONCLUSION: Rural and urban patients had no statistically significant difference in all-cause mortality or cardiovascular mortality following TAVI. Given its minimally invasive nature and quality-centric, multidisciplinary care provided by the TAVI Heart Teams, TAVI may be the preferred modality for the treatment of severe aortic stenosis in rural populations.

Thyroidectomy Outcomes in Obese Patients.

INTRODUCTION: Obese patients often have higher complication rates after elective general surgeries; however, few studies have examined the outcomes after thyroidectomy. This study examines whether increased body mass index (BMI) is associated with poor postoperative outcomes after thyroid surgery. METHODS: A retrospective review of patients who underwent thyroidectomy from 2015 to 2018 was performed. Demographics, comorbidities, pathology, and extent of resection (total versus hemithyroidectomy) were examined. Patients were classified into BMI groups according to the WHO definitions, and the incidence of surgical outcomes was determined in each group. Surgical outcomes of interest included readmission rates (RRs), length of stay, average operating room time, return to the operating room, hypocalcemia, postop infections, hematomas, and recurrent laryngeal nerve injury. Between-subjects statistics including independent samples t-test, ANOVA, and chi-square analyses were performed. RESULTS: There were n = 465 patients included with a mean BMI 32.35 (standard deviation = 8.55) and median BMI 30.78 (Q1 = 26.26, Q3 = 36.73). There were no differences between BMI groups in age, gender, smoking, heart disease. There was a positive association between increased BMI and postoperative infection (P < 0.001), pneumonia (P = 0.018), and surgical site infection (P = 0.04), which were highest for BMI > 40. Increased BMI was associated with a higher 30-d RR (P = 0.008), particularly for BMI >40 versus BMI <40 (6.2% versus 1.05%; P = 0.003). There were no significant differences between surgical outcomes for patients with increased BMI who underwent total thyroidectomy or hemithyroidectomy. CONCLUSIONS: Excellent postoperative outcomes were observed in all BMI categories. Higher postoperative infection and 30-d RRs were observed in the morbidly obese. Contrary to previous studies, operating room times were similar regardless of BMI.

Enhanced Notification of Radiographic Incidental Findings in Trauma Does Not Guarantee Follow-Up Compliance.

OBJECTIVES: Follow-up care for incidental findings (IFs) on trauma computed tomography scans is a component of comprehensive healthcare. Our objective was to assess the effectiveness of our IF predischarge disclosure practice guideline and identify factors contributing to follow-up failure. METHODS: This was a secondary analysis of a prospective observational database: 615 patients with IFs from November 2019 to February 2020. Follow-up compliance was determined by electronic medical record review and/or a telephone call after a mail-out request for voluntary participation. Volunteers answered a predetermined questionnaire regarding follow-up care. RESULTS: A total of 115 patients (19%) had computed tomography-based IFs recommending additional imaging or other follow-ups. Seventy-four (64%) patients were lost to inclusion as a result of death (12.1%), inability to contact (51.3%), or noninterest (5.2%). Of the remaining 36 patients, 19 received follow-up care (52.7%) and 17 did not (47.2%). No statistical differences existed among groups in age, sex, mechanism of injury, Glasgow Coma Scale score, whether informed by physicians or midlevel providers, or type of IF. A total of 15 (88%) nonfollow-up patients did not recall the disclosure or discharge paperwork instructions. Of 19 compliant patients: 9 had additional imaging only, 5 had biopsies and/or surgical intervention (n = 3 cancer, n = 2 benign), 3 had primary care advice against additional studies and 2 were referred to specialists. CONCLUSIONS: Predischarge disclosure of IFs can contribute significantly to overall patient health. Nonetheless, fewer than half of patients do not pursue follow-up recommendations, most often citing failure to recall verbal/written instructions. More effective communication with attention to health literacy, follow-up telephone calls, and postdischarge appointments are potential catalysts for improved patient compliance.

Obstructive Sleep Apnea as a Predictor of Inducible Atrial Flutter During Pulmonary Vein Isolation in Patients With Atrial Fibrillation: Clinical Significance and Follow-Up Outcomes.

Background: Atrial fibrillation (AF) and atrial flutter (AFL) often coexist in patients and may lead to severe symptoms and complications. Despite their coexistence, prophylactic cavotricuspid isthmus (CTI) ablation has failed to reduce the incidence of recurrent AF or new onset AFL. In contrast, the presence of inducible AFL during pulmonary vein isolation (PVI) has been shown to be predictive of symptomatic AFL during follow-up. However, the potential role of obstructive sleep apnea (OSA) as a predictor of inducible AFL during PVI in patients with AF remains unclear. Therefore, this study aimed to examine the potential role of OSA as a predictor of inducible AFL during PVI in patients with AF and reexamine the clinical significance of inducible AFL during PVI in terms of recurrent AFL or AF during follow-up. Methods: We conducted a single-center, non-randomized retrospective study on patients who underwent PVI between October 2013 and December 2020. A total of 192 patients were included in the study after screening 257 patients for exclusion criteria, which included a previous history of AFL or previous PVI or Maze procedure. All patients underwent a transesophageal echocardiogram (TEE) prior to their ablation to rule out a left atrial appendage thrombus. The PVI was performed using both fluoroscopic and electroanatomic mapping derived from intracardiac echocardiography. After the confirmation of PVI, additional electrophysiology (EP) testing was performed. AFL was classified as typical or atypical based on the origin and activation pattern. Descriptive and frequency statistics were performed to describe the demographic and clinical characteristics of the sample, and Chi-square and Fisher's exact tests were used to compare independent groups on categorical outcomes. Logistic regression analysis was performed to adjust for confounding variables. The study was approved by the Institutional Review Board, and informed consent was waived given the retrospective nature of the study. Results: Of the 192 patients included in the study, 52% (n = 100) had inducible AFL after PVI, with 43% (n = 82) having typical right AFL. Bivariate analysis showed statistically significant differences between the groups for OSA (P = 0.04) and persistent AF (P = 0.047) when examining the outcome of any inducible AFL. Similarly, only OSA (P = 0.04) and persistent AF (P = 0.043) were significant when examining the outcome of typical right AFL. Multivariate analysis showed that only OSA was significantly associated with any inducible AFL after controlling for other variables (adjusted odds ratio (AOR) = 1.92, 95% confidence interval (CI): 1.003 - 3.69, P = 0.049). Of the 100 patients with inducible AFL, 89 underwent additional ablation for AFL prior to completion of their procedure. At 1 year, the rates of recurrence for AF, AFL, and either AF or AFL were 31%, 10%, and 38%, respectively. There was no significant difference in the rates of recurrence of AF, AFL, or either AF/AFL at 1 year when accounting for the presence of inducible AFL or the efficacy of additional AFL ablation. Conclusions: In conclusion, our study found a high incidence of inducible AFL during PVI, particularly among patients with OSA. However, the clinical significance of inducible AFL in relation to the recurrence rates of AF or AFL at 1-year post-PVI remains unclear. Our findings suggest that successful ablation of inducible AFL during PVI may not provide clinical benefit in reducing AF or AFL recurrence. To establish the clinical significance of inducible AFL during PVI in various patient populations, further prospective studies with larger sample sizes and longer follow-up periods are necessary.

Impact of Bleeding on Myocardial Infarction, Stroke, and Death During 12 Months Dual Antiplatelet Therapy After Acute Coronary Syndrome.

BACKGROUND: Bleeding remains a complication during dual antiplatelet therapy (DAPT) for acute coronary syndrome (ACS). Some data suggest a link between bleeding and worsened vascular outcomes. However, this association is unclear, due to omitting of minor bleedings when applying conservative scales. In contrast, the Platelet Inhibition and Outcomes (PLATO) trial classification used broad realistic capturing of all bleedings. METHODS: Access was gained to the Food and Drug Administration-issued adjudication data set on which post hoc analyses of bleeding, myocardial infarction (MI), stroke, and death were conducted. Bleeding was defined as minimal, minor, major, and life-threatening or fatal (LTOF) as per the original PLATO scale. RESULTS: Among 18,624 enrollees, 10,705 adjudicated events occurred across 7171 patients. There were 618 minimal, 1412 minor, 1216 major, and 536 LTOF bleedings for the total of 3782 events reported in 3387 patients. There were 938 deaths, 2751 MIs and 359 strokes. The overall bleeding was 20.3%, exhibited in 19.2% patients. Total bleeds were associated with less deaths (odds ratio [OR]: 0.55, 95% confidence interval [CI]: 0.47-0.63) and MI (OR: 0.47, 95% CI: 0.41-0.54; P < .001 for both). There were no differences in deaths (OR: 1.11, 95% CI: 0.93-1.34; P = .24), but less MIs (OR: 0.72. 95% CI: 0.59-0.86; P < .001), and more strokes (OR: 2.17, 95% CI: 1.64-2.88; P < .001) after LTOF. Major, minor, and minimal bleeds were associated with less deaths and MI but not strokes. CONCLUSION: These large uniformly adjudicated data reveal that within 12 months of dual antiplatelet therapy, 1 out of 5 patients experiences bleeding. Overall, bleeding was associated with diminished incidence of death and MI but not strokes.

Acanthosis Nigricans Is a Strong Predictor of Low Blood Calcidiol Levels in Children and Adolescents.

Background: Clinical consensus differs as to when blood vitamin D (VD) levels should be measured in children. Obesity and metabolic syndrome are risk factors for low VD levels and are also associated with acanthosis nigricans (AN). Objectives: To test whether the clinical diagnosis of AN is a strong predictor for vitamin D deficiency (VDD) in children. Methods: Within the study period (2015-2020), we identified 677 consecutive individuals (age <18 years) with available calcidiol measurements and compared those with (n = 273) and without (n = 404) AN. Bivariate associations and the occurrence of AN were tested using the chi-squared test. Multivariate logistic regression was performed to control for confounding variables, and adjusted odds ratios with 95% confidence intervals (CI) were reported. Multiple regression analysis was performed, and unstandardized beta coefficients, standard errors, and standardized beta coefficients were reported. Results: Individuals with AN had 3.6 times higher odds of VDD than those without (95% CI: 1.38-9.51, P = 0.009). Males had 0.41 times lower odds of having AN than females (95% CI: 0.21-0.79, P = 0.008). Individuals with vitamin D sufficiency (VDS) were much less likely to be diagnosed with metabolic syndrome compared with those who were vitamin D deficient (P = 0.011), even after adjusting for body mass index z-scores. Conclusion: Children and adolescents with AN are at a higher risk of VDD and should likely be tested for low calcidiol levels.

Pain after Arteriovenous Access Creation.

OBJECTIVES: Dialysis access creation is a common outpatient procedure that can be completed using general, regional, or local anesthetic techniques. There are few endorsed guidelines regarding opioid-based pain control following fistula creation. The purpose of this study was to determine whether utilization of regional anesthesia (RA) is associated with the decreased use of narcotics postoperatively. METHODS: We performed a prospective cohort study including all patients undergoing arteriovenous fistula creation with one vascular surgeon from August 2019 to February 2020. Patients were selected for regional versus general anesthesia. Selection for anesthesia type was determined by the primary anesthesiologist. Patients selected for RA underwent supraclavicular brachial plexus block with 30 cm3 of 0.5% ropivacaine. Patients were seen in clinic follow-up and completed a questionnaire regarding their postoperative opiate use and pain control. RESULTS: In the study period, 52 patients underwent arteriovenous fistula creation and completed the follow-up questionnaire. Forty patients received RA. Seventy-five percent of patients sent home with a narcotic prescription filled the prescription. There was a significant difference in postoperative opioid use between the two study groups. Patients who received regional block took on average 3.3 pills totaling 16.5 morphine milligram equivalents, whereas patients who received general anesthesia took on average 6.64 pills totaling 33.2 morphine milligram equivalents (P = 0.04). CONCLUSIONS: Morbidity and mortality related to opiate use continues to be a public health issue in the United States. This study demonstrates that regional anesthetic techniques in comparison to general anesthesia can result in a significant decrease in postoperative opiate consumption.

Intravenous Lidocaine for Rib Fractures: Effect on Pain Control and Outcome.

BACKGROUND: Multimodal analgesia in rib fractures (RFs) is designed to maximize pain control while minimizing narcotics. Prior research with intravenous lidocaine (IVL) efficacy produced conflicting results. We hypothesized IVL infusion reduces opioid utilization and pain scores. METHODS: A retrospective review of RF patients at an ACS-verified Level I trauma center from April 2018 to 2/2020 was conducted. Patients (pts) stratified as receiving IVL vs no IVL. Initial lidocaine dose: 1 mg/kg/hr with a maximum of 3 mg/kg/hr. Duration of infusion: 48 h. Pain quantified by the Stanford Pain Score system (PS). Bivariate and multivariate analyses of variables were performed on SPSS, version 21 (IBM Corp). RESULTS: 414 pts met inclusion criteria: 254 males and 160 females. The average age for the non-IVL = 67.4 ± 15.2 years vs IVL = 58.3 ± 17.1 years (P < .001). There were no statistically significant differences between groups for ISS, PS for initial 48 h, and ICU length of stay (LOS). There was a difference in morphine equivalents per hour: non-IVL = 1.25 vs IVL = 1.72 (P = .004) and LOS non-IVL = 10.2+/-7.6 vs IVL = 7.82+/-4.94. By analyzing IVL pts in a crossover comparison before and after IVL, there was reduction in opiates: 3.01 vs 1.72 (P < .001) and PS: 7.0 vs 4.9 (P < .001). Stanford Pain Score system reduction in the IVL = 48.3 ± 23.9%, but less effective in narcotic dependency (27 ± 22.9%, P = .035); IVL pts had hospital cost reduction: $82,927 vs $118,202 (P < .01). DISCUSSION: In a crossover analysis, IVL is effective for reduction of PS and opiate use and reduces hospital LOS and costs. Patient age may confound interpretation of results. Our data support IVL use in multimodal pain regimens. Future prospective study is warranted.

Continued Relevance of Initial Temperature Measurement in Trauma Patients.

OBJECTIVES: Hypothermia occurs in 30-50% of severely injured trauma patients and is associated with multiple metabolic derangements and worsened outcomes. However, hypothermia continues to be under-diagnosed which leads to inadequate triage and treatment in trauma patients. Our study set out to determine if hypothermia is an independent predictor of mortality in trauma patients. METHODS: We retrospectively reviewed data of all trauma activation patients over a 5-year period. Data were collected on patient demographics, initial core temperature, Glasgow Coma Scale (GCS) on presentation, and injury severity score (ISS). Patients were then stratified into groups based on presenting temperature, ISS, and GCS. Outcomes compared were mortality, blood products received, and intensive care unit (ICU) length of stay. Correlations and logistic regression were used to test the hypotheses. RESULTS: Survival and temperature data were reviewed on 15,567 patients. Initial temperature was not significantly associated with ICU length of stay or blood products transfused (P = .21 and P = .08, respectively). However, odds ratio of mortality in hypothermic patients (<35°C) compared to normothermic patients (35-39°C) was 3.95 (95% CI 2.90-5.41). When controlling for GCS and ISS, separately, temperature remained an independent predictor of mortality. CONCLUSIONS: Hypothermia is an independent risk factor for mortality in trauma patients. It remains crucial to obtain accurate presenting temperatures in trauma patients in order to triage and treat hypothermia. Based on our data, obtaining core temperatures and rapidly treating hypothermia continues to be a vital part of the secondary survey of trauma patients.

Thromboembolic Rates Are Similar Between Intensive Care Unit and Nonintensive Care Unit Hospitalized Patients With Severe Acute Respiratory Syndrome Coronavirus 2 (SARS-CoV-2): A Retrospective Cohort Study.

High rates of thromboembolic events have been described in intensive care unit (ICU) patients. Data regarding thromboembolic events in all hospitalized patients has been less frequently reported, raising concerns that thromboembolic events in non-ICU may be underrecognized. In addition, optimal anticoagulation type and dose is still unsettled at this time. This is a retrospective cohort study of 159 hospitalized patients with coronavirus disease 2019 (COVID-19) pneumonia during a 9-month period to determine an association between the frequency of thromboembolic rates and hospitalized patients with COVID-19. Secondary outcomes sought to investigate association of thromboembolic events with relation to place of admission, risk factors, anticoagulation, mortality, hospital length of stay, and discharge disposition. Among the cohort of 159 hospitalized patients who met criteria, 16 (10%) were diagnosed with a thromboembolic event. There were a total of 18 thromboembolic events with 12 venous and 6 arterial. Admission to the ICU was not associated with a higher frequency of thromboembolic events compared with non-ICU patients (37.5% vs 62.5%), p = .71. Patients with a thromboembolic event had a significantly higher mortality compared with those with no thromboembolic event (37.5% vs 13.3%), p = .012. Patients hospitalized with COVID-19 have increased rates of thromboembolic events, both venous and arterial, which contribute to a significant increase in mortality. However, the frequency of thromboembolism in patients admitted to the ICU was similar to events in non-ICU patients. We hope to increase awareness of the increased risk of hypercoagulability in all hospitalized patients with COVID-19 including non-ICU patients.

Old Is (Not) Gold: Midazolam Monotherapy versus Midazolam Plus Fentanyl for Sedation during Cardiac Catheterization.

OBJECTIVE: We aimed to study the differences in perception of pain during cardiac catheterization with midazolam monotherapy compared to the current standard of midazolam plus fentanyl. BACKGROUND: Procedural sedation is important to ensure comfort and safety in patients undergoing left heart catheterization. Despite the widespread use of midazolam and fentanyl for procedural sedation, the effectiveness of this dual agent approach to sedation has never been studied in comparison to midazolam monotherapy. METHODS: A total of 129 patients undergoing sedation for outpatient elective cardiac catheterization were randomly assigned to either midazolam monotherapy (n = 69) or combination of midazolam and fentanyl (n = 60). The primary outcome was assessment of pain perception prior to discharge by patient completion of a pain questionnaire. Participants were asked if they experienced any pain during their procedure (yes/no) and, if yes, asked to rate their overall pain level using a 10-point Likert scale that ranged from 1 (minimal pain) to 10 (worst pain imaginable). RESULTS: Most patients (n = 94, 73%) reported no pain during their procedure. Patients sedated with midazolam monotherapy reported similar average pain scores compared to patients sedated with the combination of midazolam and fentanyl (1.1 vs. 1.1, p=0.95). CONCLUSIONS: Among patients undergoing elective cardiac catheterization, no significant differences in pain scores were noted between sedation with midazolam alone compared to midazolam and fentanyl. Due to fentanyl's unfavorable interaction with P2Y12 agents, increased costs, and addiction potential, it is imperative that cardiologists revisit the role of effective procedural sedation with a single agent and avoid the use of fentanyl.

HIT-It or Quit It: Heparin-Induced Thrombocytopenia Testing Appropriateness Using 4T Scoring and Inappropriate Testing Cost Analysis.

OBJECTIVES: The American Society of Hematology's 4T scoring system is a validated tool to assess a patient's probability of having heparin-induced thrombocytopenia (HIT) before testing is performed. There is no benefit to testing patients with a low probability 4T score for HIT. This study aimed to assess for inappropriate HIT testing at our institution based on 4T scoring. METHODS: We retrospectively reviewed 201 patient charts and calculated 4T scores and testing costs to assess for inappropriate testing and the economic impact of such testing. RESULTS: HIT testing often occurred in the least appropriate patients and resulted in tens of thousands of dollars of waste for unnecessary testing. CONCLUSIONS: Inappropriate testing for HIT is still a prevalent issue despite literature supporting the 4T score for guidance in testing appropriateness.

Double Mandibular Osteotomy for Access to High-Carotid Pathology.

BACKGROUND: Anecdotal experience demonstrates the existence of patients with superiorly located carotid stenosis, neoplasms, or aneurysms where the mandible obstructs effective surgical access using standard techniques. As carotid pathology extends anatomically beyond the limits of standard operative technique, additional exposure becomes paramount to safely and effectively address the lesion. Double mandibular osteotomy (DMO) is one of several techniques to obtain additional exposure to high-carotid pathology; however, there is no large series to address the outcomes of patients undergoing this procedure. METHODS: A retrospective case series was performed for all patients undergoing surgery for carotid pathology from 2011-2019 that could not be approached with standard cervical incision. The primary predictor variable was high-anatomic carotid pathology necessitating DMO. The primary outcome variable was early and late complications sustained by patients. RESULTS: Fifteen patients met study criteria and underwent 16 DMOs to access high-carotid pathology including carotid stenosis (n = 8 patients), carotid aneurysm (n = 2 patients), and carotid body tumor (n = 8 patients). Two patients had dual ipsilateral pathology with one patient having both carotid artery stenosis and aneurysm, and the other patient diagnosed with carotid artery stenosis and carotid body tumor. One patient had bilateral carotid artery stenosis, each requiring high anatomic exposure for treatment. Early complications occurred in 8 patients. Five patients experienced significant dysphagia requiring enteral feeding, and 2 patients developed malocclusion directly related to the double mandibular osteotomy. One patient experienced contralateral cortical watershed infarcts. Late complications included one patient developing osteomyelitis of the mandible, and this patient also developed distal mandibular segment screw exposure. The comparison of the outcome groups for categorical predictor variables using Fisher's exact test detected no statistically significant differences for gender, hypertension, hyperlipidemia, type 2 diabetes, chronic obstructive pulmonary disease, tobacco use, chronic kidney disease, or cerebrovascular disease. For the continuous variable comparisons, independent-samples t-tests detected no difference between the complication groups for age, operative time, or years of follow-up. No significant differences were found between the groups for body mass index or intraoperative blood loss. CONCLUSIONS: The double mandibular osteotomy provides excellent exposure and surgical access to the distal internal carotid artery for repair of vascular pathology with acceptable outcomes and long-term complications compared with previously reported techniques. Because of the early complications realized with the DMO, we recommend the procedure for symptomatic patients with a high risk of failing medical therapy alone and not appropriate for endovascular treatment as well as those patients with tumors requiring surgical intervention.

Elevated troponin level as a predictor of inpatient mortality in patients with infective endocarditis in the Southeast United States.

BACKGROUND: Despite recent improvement in management, infective endocarditis (IE) continues to be associated with considerable risk of morbidity and mortality. Early identification of predictors of inpatient mortality is key in improving patient outcomes in IE. The aim of our study was to evaluate the role of serum troponin levels measurements as a marker of increased mortality. METHODS: A case-control study included adult patients with IE admitted to a tertiary care hospital in east Tennessee between December 2012 and July 2017. Cases were defined as patients with definitive IE who died in-hospital; controls were patients who did not die in hospital. First patient admission was included only. Data collected included the patients' demographic and baseline clinical information, microbiological data, injection drug use status, elevated serum troponins levels. RESULTS: Two hundred eighty three patients with definitive IE were included; median (IQR) age was 41 (30-57) years, and 153 (54%) patients were men. One-hundred sixty-four (58%) were injection drug users. The most frequent IE type was: 167 (59%) right-sided, 86 (30%) left-sided, 24 (9%) both left and right-sided, and 10 (4%) device related. The most commonly isolated organism was Staphylococcus aureus (n = 141), and 64% were methicillin-resistant. Two-hundred twelve (75%) patients had a troponin level obtained, and 57 (27%) had an elevated troponin value. Thirty-six (13%) patients died in-hospital; in-hospital mortality was associated elevated troponin values (adjusted odds ratio [adjOR], 7.3; 95%CI, 3.3-15.9), and methicillin-resistant S. aureus IE (adjOR 2.6; 95%CI, 1.2-5.8). Forty-four (16%) patients received IE valve surgery, and none of these patients died in the hospital. CONCLUSION: Inpatient mortality was higher in patients with IE and elevated cardiac troponin levels compared to patients with normal levels.

Cohesive Round Implants and the Risk of Implant Flipping.

Fifth-generation, round, form-stable implants have a higher cohesive gel, a higher fill volume, and distinct anterior and posterior profiles. Due to these implant features, anterior-posterior (AP) flipping of round, form-stable implants is discernible, but little is known of this complication of implant reconstruction. METHODS: Patients who underwent skin- or nipple-sparing mastectomy followed by direct-to-implant reconstruction with round, cohesive, smooth implants were included in this retrospective study. Implants were placed submuscularly or prepectorally. Incidence of flipping was retrieved from patient records. Patients were stratified by presence or absence of flipping; data on patient demographic characteristics, neoadjuvant/adjuvant treatment, mastectomy characteristics, and acellular dermal matrix (ADM) type (AlloDerm or FlexHD) and coverage technique (inferior pole, tenting, or wrapping) were compared between the groups to identify risk factors associated with flipping. RESULTS: A total of 117 patients (230 breasts) were evaluated. Sixteen cases of implant flipping were documented for a flip rate of 7.0%, all occurring in patients with prepectoral implants. On univariate analysis, prepectoral implant placement, highly cohesive implants, use of AlloDerm, and ADM wrapping/tenting were found to be significantly associated with AP flipping. On logistic regression analyses, ADM type and ADM coverage technique were no longer significant predictors of AP flipping. CONCLUSIONS: Patients who undergo prepectoral implant reconstruction with highly cohesive round implants appear to be at an increased risk of AP flipping. Subpectoral reconstruction is not associated with AP flipping.

Evaluating effectiveness of cognitive behavioral therapy within multimodal treatment for chronic groin pain after inguinal hernia repair.

INTRODUCTION: The development of chronic groin pain after inguinal hernia repair is a complex problem with many potential factors contributing to its development. Surgical options for alleviation of symptoms are limited and only performed by a few centers dedicated to its treatment. Opportunities to apply the principles of a prehabilitation program, including Cognitive Behavioral Therapy (CBT), aim to improve the surgical outcomes for this condition. METHODS AND PROCEDURES: A multi-disciplinary hernia team has implemented a clinical quality improvement (CQI) effort in an attempt to better measure and improve outcomes for patients suffering with chronic groin pain after inguinal hernia repair. Between April 2011 and August 2018, 129 patients (157 groins) underwent surgical treatment for chronic groin pain after inguinal hernia repair. Data were collected to compare outcomes for those undergoing preoperative CBT and patients who did not have CBT prior to their operation. RESULTS: Of 129 total patients, baseline demographics were similar in terms of gender, age, and BMI. In total, 27 patients (32 groins) underwent prehabilitation with CBT (20.93%). We found none of the patients who underwent preoperative CBT had new postoperative pain and all patient procedures were able to be performed on an outpatient basis. Overall, 15 (14.7%) patients had no improvement in symptoms after surgery from the non-CBT group, whereas there was improvement in chronic pain for all patients who underwent CBT. CONCLUSION: This attempt at process improvement demonstrated beneficial effects for patients who had CBT as part of a prehabilitation program prior to a surgical procedure to attempt to relieve groin pain after inguinal hernia repair. As with any CQI analysis, other factors may have contributed to these outcomes and these results may be different in another local environment.

Clinical Characteristics and Outcome of Staphylococcus aureus Prostate Abscess, Ten-Year Experience at a Tertiary Care Center.

BACKGROUND: Prostatic abscess (PA) is an uncommon infection that is generally secondary to Escherichia coli and other members of the Enterobacteriaceae family. In recent years, although rare, more reports of Staphylococcus aureus (S. aureus) PA have been reported, especially with increasing reports of bacteremia associated with injection drug use (IDU). METHODS: This was a retrospective review of adult patients admitted to a tertiary care hospital between 2008 and 2018 and who had a diagnosis of S. aureus PA. RESULTS: Twenty-one patients were included. Average age was 46 years. Fourteen (67%) presented with genitourinary concerns. Main risk factors included concurrent skin or soft tissue infections in 52%, history of genitourinary disease or instrumentation in 48%, IDU in 38%, and diabetes mellitus in 38%. Methicillin-resistant staphylococcus aureus (MRSA) was identified in 57% and concomitant bacteremia in 81% of patients. Surgical or a radiologically guided drainage was performed in 81% of patients. Antibiotic treatment duration ranged from 3 to 8 weeks. Six patients were lost to follow-up. Clinical resolution was observed in the remaining 15 (81%) patients who had follow-up. CONCLUSIONS: S. aureus prostate abscess (PA) continues to be a rare complication of S.aureus infections. MRSA is the culprit in most published reports. In high risk patients with persistent bacteremia physicians need to consider the prostate as a site of infection.

Laparoscopic Ventral Hernia Repair with a Non-Woven Hernia Mesh.

INTRODUCTION: Laparoscopic ventral hernia repair is a commonly performed procedure with a variety of mesh options. A relatively new mesh option is a non-woven polypropylene mesh with a silicone barrier designed for intraabdominal placement. This non-woven randomly oriented polypropylene microfiber hernia mesh may have benefits with potentially better biocompatibility compared with other ventral hernia repair mesh options. MATERIALS AND METHODS: A clinical quality improvement (CQI) program was initiated for ventral hernia patients to better measure and improve outcomes. From March 2013 to September 2015, 62 laparoscopic ventral hernia repairs were performed with this non-woven polypropylene mesh on 61 patients (one patient had two separate hernia repairs). Attempts were made to obtain long-term (> 2 years) follow up. RESULTS: There were 36 females and 25 males. The average age was 58.7 years (range 21-85). The average body mass index (BMI) was 36.2 (range 21.4-62.4). There were 51 (82%) incisional hernias and 11 (18%) primary hernias. There were 29 (47%) recurrent hernias. Mean hernia size was 83.4cm2 (range 1-400) and mean mesh size was 508.5cm2 (range 144-936). The mean operating room (OR) time was 108.2 minutes (range 38-418). The mean length of hospital stay was 2.7 days (range 0-13). There was one intraoperative complication-an injury to an inferior epigastric vessel that had a minor postoperative bleed that was self-limiting and required no treatment. There was one postoperative death due to aspiration on postoperative day #4. There has been one recurrence (1.6%) with long-term follow up. There were two patients (3.2%) with suture site pain postoperatively that resolved with suture site injections of local anesthetic in the clinic. There were no patients that required rehospitalization within 30 days after surgery. There were no mesh-related complications and no incidence of mesh removal was required. CONCLUSION: The results for laparoscopic ventral hernia repair, using a relatively new non-woven randomly oriented polypropylene microfiber mesh, are good with long-term follow up completed in the majority of patients. More experience with this type of mesh could generate evidence for the benefits of this mesh material in laparoscopic ventral hernia repair.