EVENT AGENDA JUNE RD 2020 - UC Davis Health

THE31STANNUALRESEARCHDAYSYMPOSIUM| THEDEPARTMENTOFSURGERY

JUNE23, 2020 | PAGE1

EVENTAGENDA| JUNE23RD , 20207:15AM-7:30AM BREAKFAST& REGISTRATION

7:30AM-7:45AM WELCOME& INTRODUCTION

ORALPRESENTATIONSESSION1 - LECTUREHALL2222MODERATORS – DR . SEPIDEHGHOLAMI & DR . KATHLEENROMANOWSKI

7:45AM-8:00AM ALICIA G INGRICH - Comparative transcriptomics of canine and human naturalkillercellsasimmunotherapytargetintranslationalosteosarcomamodel

7:45AM-8:00AM MELISSA GRIGSBY - Upregulation of human glucocorticoid receptor isoformexpressionbygram-positivebacterialcellwallcomponents

8:15AM-8:30AM H ILA SHIMSHI-SWINDELL - Extracellular matrix mediated local delivery ofplacentalmesenchymalstemcellderivedexosomesforspinalcordregeneration

8:30AM-8:45AM JAMES CLARK - A prospective trial of intraoperative liposomal bupivacaine(Exparel)versusbupivacaine/lidocaineforthoracoscopicsurgery

8:45AM-9:00AM KATE DOYLE - The neonatal intensive care unit as a source of deceased donorkidneysfortransplantation:initialexperienceand5-yeardatareviewed

9:00AM-9:15AM CHRISTINA THEODOROU - Increased mortality in very young children withtraumaticbraininjuryduetochildabuse(presentedbyLauraGalganski)

9:15AM-9:30AM BREAK

ORALPRESENTATIONSESSION1 - LECTUREHALL2222

MODERATORS : KENTLLOYD& DR . AMANDAK IRANE

9:30AM-9:45AM KAELI JOYAMASHIRO - Fetaltoleranceofmaternalpartialresuscitativeendovascularballoonocclusionoftheaortainanovinemodel

9:45AM-10:00AM LALITHASRI RAMASUBRAMANIAN - Engineeringsyntheticextracellularvesiclemimicsforvascularregeneration

10:00AM-10:15AM SEANJUDGE - Immunephenotypeoftumorinfiltratingtandnkcellsinsofttissuesarcomasareassociatedwithclinicaloutcome

10:15AM-10:30AM DATTESHR. DAVE - Geriatricageconfersincreasedriskofpost-operativecomplicationsfollowingopenreductioninternalfixationfordistalradiusfracture:ANSQIPanalysis

10:30AM-10:45AM LAURENPERRY - Theroleofradiationtherapyinadditiontolumpectomyandhormonetherapyinmen70yearsofageandolderwithearlybreastcancer:ANCDBanalysis

10:45AM-11:00AM MATTHEWZEIDERMAN - TheOmnimaxMMFsystem:Acohortstudyforclinicalevaluation



11:00AM-11:15AM BREAK

ORALPRESENTATIONSESSION3 - LECTUREHALL2222MODERATORS : DR . L ISA BROWN& DR . DAVID COOKE

11:15-11:30AM DAKEHAO -Functionalizationofpolymericscaffoldswithhumanchorionicvillusmesenchymalstemcellderivedexosomestoimprovevascularizationandregenerationpotential

11:30AM-11:45AM KAITLINCLARK -Functionalizationofpolymericscaffoldswithhumanchorionicvillusmesenchymalstemcellderivedexosomestoimprovevascularizationandregenerationpotential

11:45AM-12:00PM T IMOTHYGUENTHER -DevelopmentofaPorcineModelofEmergencyRe-SternotomyataLowVolumeCardiacSurgeryMilitaryCenter

12:00PM-12:15PM MOUNIKABHASKARA -TherapeuticPotentialofPlacenta-derivedMesenchymalStem/StromalCellsCulturedinHumanPlateletLysateforAcquiredSpinalCordInjury

12:15PM-12:30PM SHAWNTEJIRAM -ComparingFrailtyScoresandPredictingFallsinAcutelyInjuredElderlyPatientsOverTime:AProspectiveStudy

12:30PM-12:45PM JORDANJACKSON -Post-OperativeOpioidPrescribingTrendsinAdolescentsandPainRelatedEncounters

12:45PM-1:00PM LUNCH QUICKSHOTSESSION1 - LECTUREHALL1222 MODERATORS : DR . CHETANIRWIN & DR . M IMMIE KWONG

MODERATORS : DR . ROBERTCANTER& DR . ALANABERES 1:00PM-1:10PM LUISGODOY -ComparisonofFirst25RoboticLobectomyatUCDavisforLung

CancertoContemporaneousandHistoricalVideo-AssistedThoracoscopicSurgeryLobectomy

1:10PM-1:20PM YUNFENGXUE -Panniculectomyinpreparationforrenaltransplant:Aten-yearexperience

1:20PM-1:30PM P INGSONG -DriversofIncreasedHospitalResourceUtilizationin15,510HandInfectionPatients

1:30PM-1:40PM GANESHRAJASEKAR -TrendsinPediatricDrowningfrom2000-2016:ChallengesandOpportunities

1:40PM-1:50PM ANGELAAGUIRRE -Timetodiagnostictestingandriskofamputationforpatientswithlowerextremityulcers

1:50PM-2:00PM BREAK

2:00PM-2:10PM AVNI SURI -PredictorsofUnplannedReadmissionandMortalityafterBelowKneeAmputation

2:10PM-2:20PM UGURBASMACI -SurgicalandOncologicOutcomesinVascularResectionandReconstructionforAdvancedCancer:ACaseSeries



2:30PM-2:40PM SARAHMAHDAVI -OptimizedLong-termResultofNipple-AreolaComplexReconstructioninImplant-BasedBreastReconstruction

2:40PM-2:50PM LAURENCOLEMAN -MAGNesia:MagnesiumInfusionforAnalgesiaintheCriticallyIllTraumaPatient

2:50PM-3:00PM ANDREWW ISHY -SubdermalSkinClosureandTourniquetUseImprovesOutcomesAfterBelowKneeAmputation

QUICKSHOTSESSION1 - LECTUREHALL1222

MODERATORS – DR . PAYAMSAADAI & DR . ELEANORCURTIS MODERATORS – DR . JUNICHIRO SAGESHIMA & DR . ELIZABETHRASKIN

1:00PM-1:10PM AMANDAPHARES -Trauma-InformedCareandSecondaryTraumatization:Knowledge,Attitudes,andEducationofGeneralSurgeryResidents

1:10PM-1:20PM STEPHANIEKWAN -ReducingOpioidUseinEndocrineSurgerythroughPatientEducationandProviderPrescribingPatterns

1:20PM-1:30PM LEORAGOLDBLOOM-HELZNER -Optimizingtheyieldofplacentalmesenchymalstromalcell-derivedextracellularvesiclesin3Dculturesystems

1:30PM-1:40PM MOLLIEMUSTOE -Surgeryandpopulationhealth:Engagementandeffectivenessofasmokingcessationquitlineinterventioninathoracicsurgeryclinic

1:40PM-1:50PM N IKIAMCFADDEN -InjuredBehindBars:ADescriptiveStudyofPrisonersPresentingtoaLevel1TraumaCenter

1:50PM-2:00PM BREAK

2:00PM-2:10PM S IQI HE -Effectsof7,8-Dihydroxyflavoneliposomesondiabeticwoundhealing

2:10PM-2:20PM KARAKLEBER -Economic&QuantitativeAssessmentofUnanticipatedEmergencyDepartmentVisitsforRecentlyDischargedViolentlyInjuredPatients

2:30PM-2:40PM SAMM IOTKE -CausesandInjuryPatternsofElderlyBurnPatients

2:40PM-2:50PM CHARLESTONCHUA -QuantityofExtirpatedTissueDoesNotPredictPost-OperativeSeromaRates

2:50PM-3:00PM SARAHSTOKES -Determiningtheneedforpre-operativeprophylacticantibioticsinpediatricpatientsreceivingantibioticsforacuteintra-abdominalinfection



WELCOME

DianaL.Farmer,MD,FACS,FRCProfessorandChair,DepartmentofSurgeryUCDavisHealthSurgeon-in-Chief,UCDavisChildren’sHospital

TinaL.PalmieriMD,FACS,FCCMProfessorandDirector,FirefightersBurnInstituteBurnCenteratUCDavis,AssistantChiefofBurns,Shriner’sHospitalforChildren,NorthernCalifornia

WelcomefromDr.DianaFarmer,ChairofSurgery,andDr.TinaPalmieri,ViceChairofResearchWelcome to the31st AnnualDepartment of SurgeryResearch Symposiumat theUniversity ofCalifornia,Davis.Thecurrentpandemichasprovidedustheopportunitytodevelopnewresearchinitiatives,technologies,andcollaborations.ThisSymposiumcelebratesourresearchsuccessesandprovidesanopportunityfortraineestohonetheirresearchpresentationsastheysharetheirwork.ResearchisacorevalueoftheDepartmentofSurgeryandismadepossiblebythehardworkofthefacultybythehardworkofourfaculty,staff,andtrainees.Ourprogramincludesoralpresentationsandquick-shotoralposterpresentationsthathighlightthediverseresearchintheDepartment of Surgery. We will award prizes for the top clinical and basic science oralpresentationsaswellasthebestquick-shotoralpresentationtonight.ThankyouforjoiningustodaytocelebrateresearchintheDepartmentofSurgery!Sincerely,



RESEARCHCOMMITTEE

AIJUNWANG,PHDVICECHAIRFORTRANSLATIONALRESEARCH,INNOVATIONANDENTREPRENEURSHIP

TINAPALMIERI,MD,FACS,FCCMSENIORVICECHAIRFORRESEARCH,DEPARTMENTOFSURGERY

RACHAELCALLCUT,MD,MSPHVICECHAIRFORCLINICALSCIENCES

RICHARDBOLD,MD

KIHOCHO,DVM,PHD DAVIDGREENHALGH,MD

MISTYHUMPHRIES,MD,MAS,RPVI,FACS

DAVIDTOMCOOKE,MD

CLIFFORDPEREIRA,MD

RICHARDV.PEREZ,M.D.

KENTLLOYD,MD

GARTHUTTER,MD



ALICIAGINGRICH

MELISSAGRIGSBY

HILASHIMSHI-SWINDELL

JAMESCLARK

KATEDOYLE

CHRISTINATHEODOROU

MEDICALEDUCATIONBUILDING SESSION1 LECTURE2222



Comparativetranscriptomicsofcanineandhumannaturalkillercellsasimmunotherapytargetintranslationalosteosarcomamodel

GingrichA1,2,ReiterT2, JudgeS1,York,D3,YanagisawaM1,SturgillI4,BasmaciUN,BradyRV3,StoffelK3,BrownCT2,RebhunRB3,CanterRJ1.

Introduction: Natural killer (NK) cells are key effectors of the innate immune system, but majordifferencesbetweenhumanandmurineNKcellshavebeenabarriertotranslation.OutbreddogsareanimportantlinkforNK-basedcancerimmunotherapystudies.WeusedRNAseqtocomparegeneexpressionprofilesofexvivodogNKcellstoinvivoNKsignaturesfromdogswithpulmonarymetastasesreceivinginhaledrecombinanthuman(rh)IL-15inaphaseIclinicaltrial.

Methods:Eightdogswithpulmonarymetastaseswereenrolledonan IACUCandclinical trials reviewboard-approvedPhaseIclinicaltrialofinhaledrhIL-15usinga3+3cohortdesignwithescalatingdosesofinhaledrhIL-15.Bloodwascollectedfromstudysubjectsimmediatelypre-treatmentandondays7,14and21 after initiation of treatment for isolation of NK cells and RNAseq.We performed differential geneexpression(DGE)comparingsubjectstohealthydonorpurifiedNKpopulations(resting),exvivoactivateddogNKcellsusingIL-15andfeederlineco-culture.Weassessedglobaltranscriptionalprofileandprincipalcomponentanalysis(PCA)forvariationbetweentreatmentgroups(FDR<0.05).

Results:Of8dogs,2demonstrated>100daysurvivalwith1stablediseaseand1partialresponsebasedonRECISTcriteria.DGErevealeddistincttranscriptionalprofilesbetweentheexvivoresting,IL-15andco-culturedcanineNKcells.Amongtreatedpatients,hierarchicalclusteringandPCArevealedinvivoNKcelltranscriptionalsignaturesgroupedbyindividualdog,andnotamountoftimeexposedtotreatment.This suggests response to therapycouldbedeterminedbybaselineNKcell characteristics rather thanchangesovertime.Keygenesinducedinvivo(>20X)postinhalationofrhIL-15includeDLA-DRA,B2M,andthymosinbeta4,whilekeygenesinducedexvivopostrhIL-15exposureincludeCD96,KLRB1,andSPP1/OPN.

Conclusion:InthefirsttranscriptomicsequencingofdogNKcells,wedemonstratedistinctgeneprofilesofexvivoactivatedNKcells fromhealthydonorscomparedtocirculatingNKcells fromdogsreceivinginhaledrhIL-15onclinicaltrial.BaselineNKcellprofilesappeartopredictresponsemorethanchangesovertime.Thesedatahighlightthestrengthoftheoutbreddogmodelinspeedingnovelimmunotherapyandbiomarkerstudies.

ALICIAGRINGRICH



Upregulationofhumanglucocorticoidreceptorisoformexpressionbygram-positivebacterialcellwallcomponents

MelissaGrigsby,TajiaGreen,DeboraLim,KihoCho,andDavidGreenhalgh

BurnDivision,DepartmentofSurgery,UCDavisandShrinersHospitalsforChildren

Introduction:Patients’variableresponsestosteroidtreatmentduringsepsismayberelatedtoalteredregulationofhumanglucocorticoid(hGR)isoformsbybacterialelements.Wepreviouslyidentifiedthatlipopolysaccharide (LPS) increased the activity of several splice variant isoforms of the humanglucocorticoidreceptor(hGR).Theseisoforms(hGR-B)containcrypticexonsinintronB,betweenexons2and3,thatresultinearlystopcodonsandtruncatedproteins.Wehypothesizethatgram-positivebacterialcellwallcomponentswillsimilarlyincreasetheactivityofthesehGRisoforms.

Methods:Peripheralbloodmononuclearcells(PMBCs)wereisolatedfromLeukopaksandtreatedwithlipoteichoicacid(LTA)orpeptidoglycan(PepG)for1,3,or13hours.RNAwasextractedfromthebuffycoats,andtheactivityof the targetedhGR isoformswasevaluatedbyqualitativeRT-PCR.Protein fromsimilarly treatedPMBCswas subjected toWesternblot analysis. The gelswere immunolabeledwith arabbitpolyclonalantibodythatrecognizedtheN-terminusofhGR.

Results: After 3 hours of treatmentwith 10 µg/mL of LTA, themRNA expression of hGR-B (54)wasincreased. Similarly, after3hoursof treatmentwith10µg/mLofPepG, expressionofhGR-B (77)wasincreased.TheexpressionofhGR-B(93)appearedtofollowasimilartrendwithbothLTAandPepG.Inpreliminaryanalysis,WesternblotshowedaprogressiveincreaseintheamountoflikelyhGRsplicevariantproteindetectedafter13hoursoftreatmentwithincreasingconcentrationsofPepG:1,10,and50µg/mL.LPSalsoincreasedtheamountofproteindetectedforwhatwebelievetobehGRsplicevariantisoforms.

Conclusions: We found that cell wall components of both gram-positive and gram-negative bacteriaincrease expression of several hGR splice variant isoforms. Both types of bacteria are responsible forcausing a septic response in patients, but the severity, timing, and length of the response often differbetweenpatients.ThepatternofhGRisoformexpressioninresponsetobacterial,viralorfungalelementsmaydetermineboththecourseofapatient’ssepticepisodeandtheroleofsteroidtreatmentinmitigatingtheinflammatorymechanism.

MELISSAGRIGSBY



Extracellularmatrixmediatedlocaldeliveryofplacentalmesenchymalstemcellderivedexosomesforspinalcordregeneration

HilaShimshi1DakeHao1,PriyaKumar1AijunWang1,2

1SurgicalBioengineeringLab,DepartmentofSurgery,2DepartmentofBiomedicalEngineering,UCDavis

Introduction:Researchsuggeststhatregenerationofthespinalcordcanoccurifthemicroenvironmentatthelesionsiteispro-regenerative.Mesenchymalstemcells(MSCs)possessregenerativepotentialfortissuerepairandwoundhealing.ThecurrentrationalisthatMSCselicittheirtherapeuticeffectsprimarilyviaparacrinemechanisms.Exosomeswerefoundtobevaluableparacrinesignalingfactorsfordeliveringpro-regenerativemolecules. Exosomes adhere to extracellularmatrix (ECM) in an integrin-dependentmanner and influence cell migration, proliferation, apoptosis, differentiation and other physiologicalactivities.ArecentproteomicandRNAsequencinganalysisofplacentalMSC-derivedexosomes(PMSC-exos)revealedseveralproteinsandRNAsknowntobeinvolvedinneuronalsurvivalanddevelopment.Thus, inthisstudy,weconstructeddeliverysystemsbyusingtwotypesofscaffolds for localsustainedreleaseofPMSC-exostoserveasastemcell-derived,cell-freetherapytoprotectandregenerateneurons.Methods:We isolated and immobilized PMSC-exos onto two representative ECM scaffolds, injectablecollagenhydrogelandsmallintestinalsubmucosa(SIS)patchmaterial.WepreviouslyidentifiedLLP2A,anintegrinα4β1ligandbyone-beadone-compoundcombinatorialtechnologyandshowedthatLLP2Acanspecifically bind to PMSCs and PMSC-exos. We couple a collagen-binding peptide, SILY, to LLP2A togenerate a bifunctional peptide SILY-LLP2A, and use this bifunctional peptide to conjugate LLP2A tocollagen-based scaffolds to thus immobilize PMSC-exosomes to the scaffolds via their α4β1 integrin.Binding affinity of PMSC-exos on SILY-LLP2Amodified scaffolds were examined in vitro via scanningelectronmicroscopy(SEM).Thecontrolledreleaseofexosomeswasanalyzedusingnanotrackinganalysis(NTA).NeurorescueandneurogenesisassayswillbefurtherconductedtotestthefunctionofimmobilizedPMSC-exos.Results:SEMshowedspecificmechanismofexosomesbindingwhenmodifiedwithSILY-LLP2Aligand.Acontrolreleaseanalysisshowedastrongerbindingaffinityandslowerreleaseofexosomesfromcollagen-basedscaffoldsmodifiedwithSILY-LLP2A.Conclusion:Inthisstudywedevelopedascaffoldbasedcontrolledreleasesystemtoprovidesustainedreleaseofexosomeswhichholdspromisingforneurorescueandneurodegenerationandcanbewidelyusedforothertissueregenerationapplications.

HILASHIMSHI-SWINDELL


JUNE23, 2020 | PAGE10

Aprospectivetrialofintraoperativeliposomalbupivacaine(Exparel)versusbupivacaine/lidocaineforthoracoscopicsurgery

JamesM.Clark,MD,LuisA.Godoy,MD,AnnaXue,MD, SarahHolmesPA-C, JohnAnconaPA-C,LisaM.Brown,MD,MAS,DavidT.Cooke,MD

Section of General Thoracic Surgery, Department of Surgery, University of California, Davis Health,Sacramento,CA

Introduction:Given theworsening opioid crisis, enhanced recovery protocols utilizing intraoperativeliposomal bupivacaine (LipoB) have been implemented in a variety of surgical specialties to improvepatientrecovery.NostudytodatehasexaminedtheeffectofLipoBonpatientreportedoutcomes(PROMs),andthereisapaucityofdataontheeffectoflong-termopioidusageupto2monthspostoperatively.Method: Through a prospective cohort trial we enrolled 20 patients to receive 1:1 0.25%bupivacaine:1.0%lidocaine(control)followedby20patientstoreceiveLipoBviaintraoperativeposteriorintercostalnerveblock.Eligiblepatientswerethoseundergoingplannedvideo-assistedorrobot-assistedthoracoscopic lung resection, lung biopsy, or pleural biopsy. Patient postoperative opioid usage inmorphineequivalentdoses(MEDs)wascalculated,andPROMswererecordedviaavalidatedsurveyinthepreoperativearea,ondayofdischarge,atpostoperativemonth1,andatpostoperativemonth2.Results:Therewerenodemographicdifferencesbetweentreatmentgroups.Controlpatientshada2.3xhigher opioid need postoperatively while inpatient compared to LipoB patients (MEDs 296±227 vs130±123mg,p=0.006),andweremorelikelytostillrequireopioidsattimeofdischarge(65.0vs30.0%,p=0.03).Onmultivariable analysis, use of LipoB compared to Control decreased inpatient opioidMEDrequirementsby125mg(β-125,95%CI-222to-29,p=0.013).Eachadditional10mgofinpatientMEDsrequiredpostoperatively increased theoddsof continuedopioidusageatdischargeby6.6%(OR1.07,95%CI1.01to1.13,p=0.03)andat1monthby10.4%(OR1.10,95%CI1.02to1.20,p=0.02).PROMsdidnotdifferatdischarge,1month,or2monthspostoperatively.Conclusion: LipoB significantly reduces the need for postoperative inpatient opioids after thoracicsurgery,andmayreducetheneedforopioidprescriptionsatthetimeofdischarge.TherewasnodifferenceinlongtermpostoperativePROMs,suggestingthatLipoBisnotmaskingshorttermsymptomsbutprovidesdurablelong-termpainreliefandpatientrecovery.Accordingly,theUCDavisPharmacyandTherapeuticsCommitteehasapprovedLipoBforuseinthoracicsurgeryproceduresinclinicalsettings.

JAMESCLARK

Table1.DemographicsandnarcoticusageofcontrolandLipoBpatients.


JUNE23, 2020 | PAGE11

Theneonatalintensivecareunitasasourceofdeceaseddonorkidneysfortransplantation:Initialexperienceand5-yeardatareviewed

Kathleen Doyle, MD, Andrew Perry, MD, Jakub Woloszyn, MD, Chandrasekar Santhanakrishnan, MD,ChristophTroppmann,MD,JunichiroSageshima,MD,JohnMcVicar,MDandRichardPerez,MD.

SponsoringDepartment:UCDavisDepartmentofTransplantSurgery

Introduction:TheorgandonationgapbetweenpatientswaitingfortransplantandavailableorgansintheUnitedStatesisexpanding.KidneydonationfromtheNeonatalIntensiveCareUnit(NICU)israrethoughthepotentialissignificant.Wedevelopedanapproachfortransplantingneonatalkidneysandreportourexperienceincluding5-yearpatientfollowup.

Methods:Aretrospectiveanalysiswasperformedofallrecipientsofkidneysfromneonataldonorsfrom2011to2014atasinglecenter.AllkidneyswereprocuredenblocandimplantedintotheiliacfossawiththedonoraortaandIVCanastomosedtorecipient iliacvessels. Recipientswereprimarilysmalladultswithlowimmunologicrisk.Patientandallograftoutcomeswerereviewed.Results:28patientswere included in the studywith 64% (19/28) female, average age of 50.7 years;averageweightof54.7kgandaveragepercentreactiveantibodyof2.9±1.3%.Donoragewas9days,andweight3.4±0.2kg(range:1.9-5.0kg).71%weredonorsaftercardiacdeath(DCD)and96%wereimportedfromoutsideourlocalorganprocurementarea.Allkidneyswerepreservedwithhypothermicpulsatileperfusion.Patientsurvivalwas96%withonefatalitywithafunctioninggraftafter2years.One-yeargraftsurvivalwas86%with4earlygraftfailures.Therewerenoothergraftlossesafterthefirstyear.Allgraftshadearlyhematuriaandproteinuria;mostresolvedwithin1year.5-yearfollowupdatawasavailablefor22patientsandshowedprogressiveimprovementofkidneyfunction.Serumcreatinineat6months,1,2,3,4,and5yearswasasfollows:1.26±0.14,1.0±0.09,0.90±0.08,0.88±0.09,0.82±0.07,and0.75±0.07mg/dL,respectively.EstimatedGFRnormalizedinallpatients.Conclusion:Successfulneonatalkidneytransplantationisfeasiblewiththeknownrisksofhigherearlygraft failure rateanduniversal evidenceof earlyhyperfiltration injury.However,kidney functiondoesrecover and improves up to 5 years.Morewidespread experiencewith these graftswill undoubtedlyimprovetheseoutcomes.Webelieveneonatalkidneydonationshouldbeconsideredasaviableoptiontoaddressthenationalorganshortage.

KATEDOYLE


JUNE23, 2020 | PAGE12

IncreasedmortalityinveryyoungchildrenwithtraumaticbraininjuryduetochildabuseCMTheodorou,MNuño,KJYamashiro,SCStokes,JEJackson,DLFarmer,SHirose,ALBeres,PSaadai,EGBrown,DepartmentofPediatricSurgeryIntroduction:Traumaticbraininjury(TBI)istheleadingcauseofdeathanddisabilityinchildrenandyoungerageisassociatedwithworseoutcomes.Theimpactofmechanismonoutcomeshasnotbeenfullyevaluated.WehypothesizedthatchildrenwithTBIduetochildabusewouldhavehighermortalityratesthanchildrenwithTBIduetomotorvehiclecollisions(MVC).Methods:WeperformedaretrospectivereviewofthenationalKids’InpatientDatabaseofallchildren<2yearsoldwithTBIduetochildabuseorMVCfrom2000-2012.Theprimaryoutcomewasmortality.Secondaryoutcomeswerelengthofstay(LOS)andtotalhospitalcharges.Amultivariableregressionmodelwascreatedtodeterminepredictorsofmortality.Results:Of5964patientsidentified,65.04%ofpatientshadTBIduetochildabuse.Abusedchildrenweremorelikelytobelessthan1yearoldthanchildrenwithMVC(85.7%vs54.63%,p<0.0001).Overallmortalitywas9.98%.ComparedtochildrenwithTBIduetoMVC,abusedchildrenhadahighermortality(10.72%vs8.59%,p=0.0086),longerLOS(6.0vs4.0days,p<0.0001)andhigherhospitalcharges($18,706vs$67,312,p<0.0001).Onmultivariableregression,childrenwithTBIduetochildabusehad47%increasedoddsofmortalitycomparedtochildrenwithTBIduetoMVC(OR1.47,95%CI1.16-1.88,p=0.0017)whenadjustingforage,race,sex,insurance,hospitalregion,andhospitalteachingstatus.Onsubgroupanalysisbyage,mechanismwasnotassociatedwithmortalityinchildrenaged0-1yearsold,butoddsofmortalityweresignificantlyincreasedinchildrenaged1-2yearsoldwithTBIduetochildabuse(OR3.9,95%CI2.53-6.03,p<0.0001).Conclusion:ChildrenwithTBIduetochildabuseareyounger,havelongerhospitalLOS,higherhospitalcharges,andincreasedmortalitycomparedtochildrenwithTBIduetoMVC.Giventhedireoutcomesforthesevulnerablechildren,resourcesmustbedirectedatpreventingchildabuse.

CHRISTINATHEODOROU


JUNE23, 2020 | PAGE13

KAELIJOYAMASHIRO(PRESENTEDBYLAURAGALGANSKI)

LALITHASRIRAMASUBRAMANIAN

SEANJUDGE

DATTESHR. DAVE

LAURENPERRY

MATTHEWZEIDERMAN



JUNE23, 2020 | PAGE14

Fetaltoleranceofmaternalpartialresuscitativeendovascularballoonocclusionoftheaortainanovinemodel

KaeliYamashiro,LauraGalganski,DianaFarmer,LucasNeff,DanielFong,SoheilGhiasi,JacobStephenson,ShinjiroHirose,TimothyWilliams,M.AustinJohnson

Introduction:Hemorrhageistheleadingcauseofmaternalmortality.Resuscitativeendovascularballoonocclusion of the aorta (REBOA) is used to decrease post-partum hemorrhage only after the fetus isdelivered.PartialREBOA(pREBOA)priortodeliverymayimproveoutcomesbuttheeffectsonthefetusareunknown.WeaimedtoevaluatehowprogressivelevelsofpREBOAeffectthefetus.Methods:AREBOAcatheterwasplacedinZone3ingravidewesattermandfetalcarotidarterialaccesswasobtained.TheREBOAballoonwasinflatedtoattenuatemeanarterialpressureattheplacenta(pMAP)by5-10mmHgin10minintervalsuntilafetalSaO2of<15%.Thefetuswasrecoveredfor10minandthiswasrepeatedtwice.Fetalarterialbloodgasses,heartrate(HR)andmeanarterialpressure(MAP)wereobtained.Results:Duringthefirstround,fetal(n=3)changesfrombaselinefirstoccurredatpMAP40mmHgwithadecreaseinSaO2(59.0±12.1vs37.6±14.8%,p=0.0009),followedbyadecreaseinfetalMAPandpHatpMAP35mmHg(51.3±5.8vs56.1±10.1mmHg,p=0.04and7.20±0.08vs7.17±0.07,p=0.01)andanincreaseinlactateatpMAP30mmHg(2.0±0.5vs2.4±0.4mmol/L,p=0.02).HRdidnotdifferfrombaseline,evenatthelowestpMAPof25mmHg.ThebaselineSaO2improvedfromround1toround2(59.0±12.1vs70.6±6.6,p=0.02),lactateworsenedbyround(2.0±0.5vs4.7±0.4vs5.6±0.9,p=0.007)andtherewasnodifferenceinfetalMAPorHRbetweentherounds.Conclusion:PhysiologicchangesinthefetusfrommaternalpREBOAfirstoccurredatpMAP40mmHg.ThefetustoleratedhighlevelsofpREBOAanddemonstratedanabilitytorecover.pREBOApriortodeliverymaybepossiblewithoutinjuringthefetus.

KAELIJOYAMASHIRO


JUNE23, 2020 | PAGE15

Engineeringsyntheticextracellularvesiclemimicsforvascularregeneration

LalithasriRamasubramanian,PriyadarsiniKumar,DianaL.Farmer,AijunWang

SurgicalBioengineeringLaboratory

Introduction:Extracellular vesicles (EVs) derived from endothelial progenitor cells (EPCs) have beenshowntofacilitatevascularizationviadeliveryofmiRNA-126(miR126).However,therapeutictranslationhasbeengreatlyhinderedby the inherentdisadvantages inEV isolationandstandardization.Here,wesoughttoovercometheseshortcomingsbyengineeringabiomimeticsyntheticEVthatcanrecapitulatetheproangiogenic properties of native EPC EVs and can also bemass producedwith a greater degree ofstandardizationandspecification.WeproposethatEPCEVmimics(EMs)canbesynthesizedbycoatingamiR126-loaded poly (lactic-co-glycolic acid) (PLGA) core with SILY (a collagen-binding peptide)-conjugatedEPC-plasmamembrane(PM)shellinordertomimicthefunctionalcharacteristicsofnativeEPCEVs.

Methods:miR126-loadedPLGAcoresweresynthesizedusingamodifiednanoprecipitationmethodandmechanically coatedwithplasmamembrane fractions isolated fromEPCs.Clickchemistrywasused toconjugate SILY onto particle surfaces. Fluorescent microscopy and transmission electron microscopy(TEM) were used to visualize morphology and confirm coating. miR126 loading and release werequantifiedalongsideEMstabilityovertwoweeks.EPCmigrationandproliferationwereassessedusingascratchwoundassayandMTSassay,respectively,todeterminetheangiogenicpotentialoftheEMs.Progress:WesternblottingconfirmedretentionofEVsurfacemarkers(CD9,CD63,CD81,Alix)onisolatedPMwhile fluorescencemicroscopyandTEMshoweduniformPMcoatingonto thePLGAcores.SurfacemodificationofthePMwithSILYpeptideswassuccessfulviaClickchemistry.EMswereseentoexhibithigh stability (~115nm)over2weeks.miR126encapsulation efficiencywas46.4%±3.72,with~60%cumulativereleaseoveraweek.PreliminarystudiesshowthatboththemiRNA-126andPMcomponentsoftheEMsystemplayfunctionalrolesinpromotingEPCmigrationandproliferation.Conclusion: Thus far, a relatively stable biomimetic EV structure has been synthesized to broadlyrecapitulatethephysicalstructureofEPC-derivedEVsandpromoteangiogenicprocessesinEPCs.FutureworkwillfocusonassessingandoptimizingtheEMfunctionalpropertiesfordownstreaminvitroandinvivoangiogenicmodels.

LALITHASRIRAMASUBRAMANIAN


JUNE23, 2020 | PAGE16

DifferencesinNKandMemoryCD8T-cellresponsestoantigen-nonspecificstimulationbyinterleukin-15Sean J. Judge*, Cordelia Dunai, Catherine T. Le, Lam T. Khuat, Logan V. Vick, KevinM. Stoffel, ArtaM.Monjazeb,WilliamJ.Murphy,RobertJ.Canter*

*DivisionofSurgicalOncology,UniversityofCalifornia,Davis.Introduction:Naturalkiller(NK)cellsareinnatelymphoidcellsthatexertimmediatefunctionswhichcanbe further augmented and sustainedwith immunostimulatory cytokines. Memory CD8 T cells, due toexpressionofCD132andCD122,canbeactivatedbysimilarcytokinesintheabsenceofTCRengagement(termed“bystander”activation).Thisresultsinactivationandproliferationbutnecessitateshighamountsofcytokineashigh-affinityIL2Rcomplexes(CD25)arenotinduced.Interestingly,bothcelltypescanthenelicitsimilareffectorfunctionsviaNKG2D-mediatedtargetcellrecognition.Asthesecelltypescanfillasimilarimmunologicniche,wesetouttocompareNKandmemoryCD8TcellresponsesfollowingIL-15exposureinvitrofromhealthyhumandonors.

Methods:CellanalysiswasperformedbyflowcytometryandqRT-PCR.Atbaseline,CD25expressionwasnegligibleat<5%onbothhumanNKandmemoryCD8Tcells.CulturewithrhIL-15(10ng/mL)for4-6daysresultedinmarkedCD25upregulationonCD56+CD3-NKcellsbutnotbystander-activatedCD45RA-CD95+ CD8 T cells (72±9.2% vs 11±3.8%, P=0.003) despite comparable proliferation. Additionally,cytokine-activated NK cells expressed higher levels of inhibitory receptor TIGIT (85±4% vs 57±2%,P=0.01)andactivationmarkerCD69(99±1%vs27±9%,P=0.008).Functionally,NKcellshadincreasedexpressionofgranzymeBcomparedtobystanderactivatedCD8Tcells.Conclusion:AlthoughNKandbystanderCD8Tcellscanfillasimilarimmunologicnicheregardingtargetcellkilling,therearesignificantdifferencesinexpressionofcriticalmarkersfollowingactivation.Thesedifferencesmayhaveconsequences in theregulationof thesecell typesand impactanti-viralandanti-tumorresponses,aswellastheimmunopathologicresponseduringhighlyinflammatory,non-infectiousstates.

SEANJUDGE


JUNE23, 2020 | PAGE17

Geriatricageconfersincreasedriskofpost-operativecomplicationsfollowingopenreductioninternalfixationfordistalradiusfracture:AnNSQIPanalysisDatteshRDave,MD,MSc,MatthewRZeiderman,MD,CoreyMBascone,MD,MPH,MBA,AndrewILi,MD,ChetanSIrwin,MD,CliffordTPereira,MDDivisionofPlasticSurgery,UniversityofCalifornia,Davis,Sacramento,CA

Introduction:Open reduction internal fixation of distal radius fractures is one of the most commonfracturesurgeriesforHandsurgeons.Fewstudieshaveevaluatedopenreductioninternalfixationwithinthegeriatricpopulation.Thisstudyhypothesizesthatgeriatricpatientsareatgreaterriskofpost-operativecomplicationsrelativetonon-geriatricsfollowingdistalradiusfracturefixation.

Methods: The American College of Surgeons National Surgical Quality Improvement Project (NSQIP)databasewasreviewedforopenreductioninternalfixation(ORIF)fordistalradiusfractures(DRFs)from2005 – 2017. Hypothesis testing for demographics, co-morbidities, and post-operative complicationsbetweengeriatricandnon-geriatricpatientswasperformed.Statisticallysignificantdifferenceswerethenevaluatedwithmulti-variatelogisticregressionanalysis.

Results:Atotalof17,097ORIFforDRFswerecollectedbyNSQIP2005-2017,with5,654patientsolderthan64years(33.2%).AverageageforgeriatricpatientsundergoingORIFforDRFwas73.7yearsversus46.7 years for non-geriatric patients. Rates of pre-operative risk factors including body mass index,albuminlevel,diabetes,dialysisdependence,smokingstatus,andoperativetimewerestatisticallydifferentbetween the groups (p<.001). Geriatric age confers a 1.5-times increased risk for any post-operativecomplicationfollowingORIFfordistalradiusfractureadjustingforpre-operativeriskfactors(ORa1.5p=.04). Within the geriatric cohort, dialysis dependence was singularly predictive of returning to theoperativeroomwitha14.5-timesincreasedrisk(ORa14.5p<.01).Predictorsforany30-daypost-operativecomplicationwithinthegeriatriccohortincludeprolongingoperativetimeby45-minuteincrementsafter80minutes(ORa1.3p<.001).Conclusion: Geriatric age confers an adjusted increased risk of 30-day post-operative complication.Geriatric patients who are dialysis dependent carry a significant increased risk for returning to theoperative room within 30 days. Prolonging operative time increased the risk for any post-operativecomplicationwithin the geriatric cohort.Hand surgeons can use these findings to guide pre-operativediscussionswiththeirgeriatricdistalradiusfracturepatients.

DATTESHR. DAVE


JUNE23, 2020 | PAGE18

Theroleofradiationtherapyinadditiontolumpectomyandhormonetherapyinmen70yearsofageandolderwithearlybreastcancer:AnNCDBanalysisLaurenM.Perry,MD*,SarahB.Bateni,MD*,XiaoZhao,MD,MiliArora,MD,MeganE.Daly,MD,SusanL.Stewart,PhD,RichardJ.Bold,MD,RobertJ.Canter,MD,CandiceA.M.Sauder,MDDivisionofSurgicalOncology,DepartmentofSurgery*LaurenPerryandSarahB.Batenicontributedequallytothiswork.Introduction:Currenttreatmentguidelinesformalebreastcancerareguidedbyfemale-onlytrialsdespitedatasuggestingdistinctclinicopathologicdifferencesbetweensexes.Wesoughttoevaluate ifradiationtherapy(RT)afterlumpectomywasassociatedwithequivalentsurvivalamongmen>70yearsofagewithStageI,estrogenreceptor(ER)positivetumors,asseeninwomenfromtheCancerandLeukemiaGroupB(CALGB)9343trial.Methods:Weperformedaretrospectiveanalysisof752stageI,ER-positivemalebreastcancerpatients≥70yearswhoweretreatedwithhormonetherapyandsurgery,withorwithoutRT,fromtheNationalCancerDatabasebetween2004-2014.PatientswerecategorizedbasedonsurgeryandRT(lumpectomyalone,lumpectomywithRT,andmastectomyalone).MultivariableCoxproportionalhazardsregressionanalysiswasusedtocompareoverallsurvivalbetweentreatmentgroups.Results:Mostpatientsunderwenttotalmastectomy,withonly32.6%treatedwithlumpectomy.Ofthosewhounderwentlumpectomy,72.7%receivedadjuvantRT.Inmultivariateanalysis,therewasnostatisticaldifference in overall survival when comparing lumpectomy alone to lumpectomy with RT (aHR 0.72[95%CI0.38-1.37],p=0.31),orwhencomparing lumpectomy(aloneorwithRT)andmastectomy(aHR1.28[95%CI0.88-1.87],p=0.20).

Conclusion: In this national sample of elderlymenwith ER-positive early-stage disease treated withendocrinetherapy,therewerenosignificantdifferencesinoverallsurvivalwhencomparinglumpectomyalonetolumpectomywithRT,orlumpectomy(aloneorwithRT)tomastectomy.Theseresultssuggestthatlessaggressivetreatmentmaybeappropriateforasubsetofmalebreastcancerpatients.

LAURENPERRY


JUNE23, 2020 | PAGE19

TheOmniMaxMMFSystem:Acohortstudyforclinicalevaluation

MatthewZeidermanMD,DouglasKendrickDDS,KyleSteinDDS,MichaelS.WongMD,GrangerB.WongMD,DMD,WilliamMorioDDS,M.KinonLecholopDMD,MartinSteedDDS

DivisionofPlastic&ReconstructiveSurgery

Introduction:Hybridmaxillomandibularfixation(MMF)systemsarecomposedofanarchbarfixatedtothealveoluswithscrews.Perceivedproblemsofthesesystemsincluderiskofdamagetotoothrootsandperiodontalstructures.ThisstudypresentstheresultsofaclinicaltrialevaluatingthesafetyandefficacyoftheOmniMaxMMFsystem(ZimmerBiomet),appliedtopatientsundergoingrepairofuncomplicatedmandibularfracture(s).

Methods:Thismulti-center,prospective,uncontrolled,singlecohortstudyincluded39adultpatients(31males,8females) with one or more mandibular fractures repaired within10days usingtheOmniMaxMMFsystem.Open-reductioninternalfixationoffractureswerecompletedasindicatedandMMFplacedfor4-8weeks.Datawascollectedprospectivelyatbaseline,intra-operativedeviceplacement,and removal. Outcome measures included tooth root damage from screw insertion, time for deviceimplantationandremoval,incidenceofsurgeongloveperforationorsharpsexposure,incidenceofmucosalovergrowthandgingivalnecrosis,patientqualityoflifemetrics,andadverseevents.Results:AveragelengthofMMFwas49.6±11days.Averagetimefordeviceimplantationwas14.6±5.0minutes. All removalswere completedinanoutpatientsetting in an average 3.2±2.2 minutes.Meanpatient-reported pain score (0-10 scale) was 5.1±1.6beforedeviceapplication and 1.9±2.2priortoremoval.605rootsurfacescouldbeaffectedbyscrews.515(85.6%)hadnocontact,84(13.9%)hadminorcontact,6(1.0%)hadrootcontact.Noscrewcontactrequiredfurthertreatment.Adverseeventsatfinalvisitincluded3cases(7.7%)ofinjury/damagetoperiodontalstructure.38/39(97.4%)hadadequatefracture healing.37/39 (94.9%) had satisfactoryfinalocclusion.No glove perforations or accidentalpuncturesoccurred.Conclusion:ResultsofthisstudysupportsafeandeffectiveuseoftheOmniMaxMMFsystemfortreatinguncomplicatedmandibularfractures.

MATTHEWZEIDERMAN


JUNE23, 2020 | PAGE20

DAKEHAO

KAITLIN CLARK

T IMOTHYGUENTHER

MOUNIKABHASKARA

SHAWNTEJ IRAM

JORDAN JACKSON



JUNE23, 2020 | PAGE21

Functionalizationofpolymericscaffoldswithhumanchorionicvillusmesenchymalstemcellderivedexosomestoimprovevascularizationandregenerationpotential

DakeHao1,HilaSwindell1,RuiwuLiu2,KitLam2,DianaFarmer1,AijunWang1,3

1DepartmentofSurgery,2DepartmentofBiochemistryandMolecularBiology,3DepartmentofBiomedicalEngineering,UCDavis

Introduction:Polymericscaffoldshavebeenwidelyusedinregenerativemedicinetoprovidestructuralsupport to guide cell growth and tissue regeneration. Electrospun nanofibrous scaffold has a three-dimensional structure mimicking the native extracellular matrix (ECM) architecture, however, lackbiological motifs and surface cytocompatibility. Exosomes have immense potential to impact tissueengineering and regenerativemedicine applications due to themediation of intercellular informationtransferinnumerousbiologicalsystems.Vascularizationiscrucialtosupplycellsandtissuewithnutrientsand oxygen for tissue engineering and regeneration. Thus, in this study, we propose to improve thevascularizationandregenerationpotentialofthepolymericelectrospunscaffoldsbyloadingthescaffoldswithfunctionalexosomes.Methods:We isolated exosomes fromhuman chorionic villusmesenchymal stem cells (CV-MSCs) andcharacterizedthembynanoparticletrackinganalysis(NTA),transmissionelectronmicroscopy(TEM)andWestern-blot. We previously identified LLP2A, an integrin α4β1 ligand by One-Bead One-Compound(OBOC)technology.Weheredevelopedanapproachtoenable‘clickchemistry’toimmobilizeLLP2Aontothesurfaceofpolymericelectrospunscaffoldsasalinkertoimmobilizeexosome.Exosomeimmobilizationwasevaluatedbyscanningelectronmicroscope(SEM).Theendothelialcell(EC)functionsontheexosome-modifiedelectrospunscaffoldswereevaluatedbyMTS,RT-PCRandWestern-blot.Results: Exosomes derived from CV-MSCs significantly improved EC migration and endothelial geneexpression. LLP2A treated2Dculture surface significantly improvedexosomeattachment. SEMresultsshowed exosomes were successfully immobilized onto the surface of LLP2A modified electrospunnanofibrous scaffolds. Exosome modified electrospun scaffolds significantly improved EC attachment,survivalandphosphorylationofAKT,decreasedtheexpressionofapoptosis-relatedgenessuchascaspase9.Conclusion:Thisstudydemonstratesthatexosomesholdpromisingpotentialtofunctionalizebiomaterialconstructsandimprovethevascularizationandregenerationpotential.Theexosomemodifiedbiomaterialscaffoldscanbewidelyusedfordifferenttissueengineeringapplications

DAKEHAO


JUNE23, 2020 | PAGE22

Postnataltreatmentofcaninespinabifidausingplacenta-derivedmesenchymalstem/stromalcells:ClinicaltrialupdateKaitlinClark1,2,MelissaVanover1,NicoleKreutzberg1,ConnorLong1,LeeLankford1PriyadarsiniKumar1,NaomiWalker2,RogérioMartinsAmorim2,DoriBorjesson2,BeverlySturges2,DianaL.Farmer1,AijunWang1,21SurgicalBioengineeringLaboratory,2VeterinaryInstituteforRegenerativeCuresIntroduction:Thecanineisincreasinglyrecognizedasavaluablepre-clinicallargeanimalmodelformanyhuman diseases. Canine spina bifida (SB) clinically presents very similarly to human SB, and EnglishbulldogsinparticularhaveahighincidenceofnaturallyoccurringSB.Placentalmesenchymalstemcells(PMSCs)arebeinginvestigatedasanadjuncttoprenatalrepairofSB;however,similartreatmentshavenotbeenexploredforpostnatalrepair.EnglishbulldogscouldserveasthefirstpostnatalanimalmodelofSB.ThegoalofthisstudyistoevaluatecaninePMSCs(cPMSCs)totesttheirefficacyasapostnataltherapyinanaturallyoccurringlargeanimaldiseasemodel.Methods: To date, we have enrolled six 10-week-old English bulldogs with SB defects confirmed byneurological evaluation andmagnetic resonance imaging (MRI). Each dog underwent amulti-segmentlaminectomyand4/6dog’s treatmentwas coupledwith transplantof allogeneic cPMSCsembedded inhydrogelandextracellularmatrixscaffold.One-yearfollow-uphasbeencompletedonfourstudyanimalsandtheremainingtwoanimalsarecurrentlybeingevaluated.Results:The first two dogs enrolled were initially ambulatory with notable abnormal gaits andincontinence. MRI revealed L7-S1 defects of varying severity. One MRI also showed a largesyringohydromyelnia involving the lumbar spinal cord.Electrophysiologic testing revealed low-normalconduction velocity for bothmotor and sensory hindlimbnerves. Both dogs recovered fromposteriorlaminectomy and cPMSC implantation uneventfully. At 8 weeks post-treatment both dogs showedimprovedambulatorygaits.MRIsperformedat8weeks showedonly syrinx recurrence.Nosignificantadverseeventsoccurredinanydogby12months.Theremainingfouranimals’evaluationsarecurrentlybeingcollectedand/oranalyzed.Conclusions:PostnataltreatmentofanaturallyoccurringcaninemodelofSBwithallogeneiccPMSCsisclinicallyfeasibleandappearssafe.Furtherstudiesarecurrentlybeingperformedtoevaluateefficacy.Thefindings fromthisstudysuggest thatnaturallyoccurringcanineSB isavaluable translationalmodel toevaluatePMSCpostnataltherapyandwillprovidecriticalinsightsforhumanclinicalstudies.

KAITLINCLARK


JUNE23, 2020 | PAGE23

Highversuslowvolumefluidresuscitationstrategiesinaporcinemodel(Susscrofa)ofthermalandtraumaticbraininjury

TimGuenther,LindseyBach,MargueriteSpruce,CarlBeyer,ConorCaples,JohnKGrayson,TinaPalmieri,IanBrown

DivisionofBurnSurgery,UCD

DivisionofTraumaandAcuteCareSurgery,UCD

Background:Combinedburnandtraumaticbraininjury(TBI)treatmentprioritiesmaynotalignduetotheneedforhighvolumeburnresuscitationwhileattemptingtominimizecerebraledemaduetoTBI.WedevelopedaporcinemodelofcombinedthermalinjuryandTBIandcomparedan“aggressive”strategyusingtheParklandformulaanda“restrictive”strategyusingthemodifiedBrookeformula.Methods:28Yorkshirecrossswinewereanesthetizedandreceiveda40%totalbodysurfacearea fullthickness burn injury and TBI. Swine were then randomized to receive “restrictive” or “aggressive”resuscitation.Resuscitationcontinuedfor8hoursafterwhichtimeanimalswereeuthanizedandnecropsywasperformed.Thevolumeofbraininjurywasassessedafteranalyzingsegmentalslicesofbraintissue.Results:Swineintheaggressiveresuscitationgroupgainedsignificantlymoremassduringresuscitation(2.3±1.3kgvs1.1±1.1,pvalue0.01).Therewerenodifferencesbetweentherestrictiveandaggressiveresuscitation groups in MAP, heart rate, central venous pressure, or ICP. There were no significantelevationsinserumlactateforeithergroupcomparedtobaselinemeasurementsorbetweengroupsafter8 hours of resuscitation. UOPwas higher in the aggressive resuscitation group (7.3±1.8mL/kg/hr. vs5.3±1.8, p value <0.01). The restrictive group had a significantly higher serumBUN in comparison tobaselineandincomparison,totheaggressivegroup.Therewasnosignificantdifferenceinsizeofbraininjurybetweengroups.(1.4±0.5cm3vs1.6±0.8,pvalve0.51)Conclusions:Bywidelyusedclinicalassessmentsofresuscitation(MAP,serumlactate,andUOP),boththerestrictiveandaggressiveresuscitationgroupsappearedtodemonstrateadequateresuscitationat8hoursfrominjury.ElevationinserumBUNwereseenintherestrictivegroupandmaybeanindicatorofearlyacutekidneyinjury,eventhoughbothgroupshadUOPthatwasclinicallyadequate(>1mL/kg/hr.).ResuscitationstrategydidnotappeartoeffectICPlevelsorthesizeofbraininjury.

TIMOTHYGUENTHER


JUNE23, 2020 | PAGE24

Therapeuticpotentialofplacenta-derivedmesenchymalstem/stromalcellsculturedinhumanplateletlysateforacquiredspinalcordinjury

MounikaL.Bhaskara,PriyadarsiniKumar,ChristopherD.Pivetti,KaitlinC.Clark,AijunWang,DianaL.Farmer

SurgicalBioengineeringLaboratory

Introduction:SpinalCordInjury(SCI)isalife-alteringeventthatcanresultinirreversibledisabilities.Wehavesuccessfullyusedplacenta-derivedmesenchymalstem/stromalcells(PMSCs)asatherapyinanovinemodelofmyelomeningocele,acongenitalformofSCI.PMSCsarecurrentlyculturedinagrowthmediumcontainingfetalbovineserum.But,tolimittheriskofanyzoonotictransmissions,weproposeserum-freebasedexpansionofPMSCsusingHumanPlateletLysate(HPL)forthetreatmentofacquiredSCIs.Methods:PMSCswereisolatedfromdiscarded2nd-trimesterhumanplacentaviaanestablishedexplantculture method in HPL supplemented medium. PMSCs were evaluated for growth kinetics, trilineagedifferentiationpotential,MSCphenotypeby flow cytometry, andbasal concentrationsof brain-derivedneurotrophic factor (BDNF), vascular endothelial growth factor (VEGF), and hepatocyte growth factor(HGF) by enzyme-linked immunosorbent assay (ELISA). The neuroprotective capability of PMSCswasstudied using a staurosporine-induced apoptotic human neuroblastoma cell line. PMSC angiogenicpotentialwasanalyzedusinganexvivoaorticringsproutingassayandtheimmunomodulatoryeffectwasobservedviaamixedleukocytereaction(MLR).Results:HPLcontaininggrowthmediumincreasedPMSCproliferationasevaluatedbytheirdoublingtime.PMSCs cultured inHPLcontainingmediumexpressed typicalMSCsurfacemarkersCD29,CD44,CD73,CD105andCD90anddidnotexpressendothelialmarkerCD31,orhematopoieticmarkersCD45andCD34.PMSCsmaintainedtheirdifferentiationpotentialintoadipogenic,chondrogenicandosteogeniclineages.The secretory profiles of the cells contained substantial amounts of BDNF, VEGF, and HGF. PMSCsdemonstrated robust neuroprotective capabilities based on increased neurite outgrowth. Improvedsprouting was seen in the aortic rings treated with PMSCs. The cells were also able to inhibit T-cellproliferationinanMLRassayasshownbyreducedBrdUincorporation.Conclusion:TheseresultsdemonstratedthatPMSCsculturedinHPLcontainingmediummaintaintheirtherapeuticpotential.OurnextaimistotestthecellsinvivoinaSCIratcontusionmodeltoestablishatherapyforAcquiredSpinalCordInjuries.

MOUNIKABHASKARA


JUNE23, 2020 | PAGE25

Comparingfrailtyscoresandpredictingfallsinacutelyinjuredelderlypatientsovertime:Aprospectivestudy

S.Tejiram,MD1,V.H.Hatcher,MHS2,C.Galet,PhD2,J.Cartwright,BA3,D.A.Skeete,MD4,K.S.

Romanowski,MD11BurnSurgery,UniversityofCalifornia,Davis;2UniversityofIowaCarverCollegeofMedicine;3UniversityofMichiganSchoolofMedicine;4DivisionofAcuteCareSurgery,UniversityofIowa

Introduction:Elderlyfall-relatedinjuriesareasignificantcauseofmorbidityandmortality.Thoughfrailtyisconsideredapredictorofpooroutcomesingeriatrictrauma,literaturecomparingfrailtyscoringsystemsremainslimited.Thisstudyseekstoexaminewhichfrailtyscoringsystembestpredictsfallsovertimeintheelderly.

MaterialsandMethods:Acutely injuredpatients65yearsandolderwereenrolledandprospectivelyobserved.DemographicsandfrailtymeasuresusingFRAILScale,TraumaSpecificFrailtyIndex(TSFI),andCanadianFrailtyScale(CSHA-CFS)weredeterminedfromsurveysatenrollmentand3monthsintervalsfollowingdischargeforoneyear.Surveysqueriedthetotalnumberandtimingoffalls.Changesinfrailtyovertimewereassessedbylogisticregressionandareaunderthecurve(AUC).Results:Fifty-eightpatientswereenrolled.FRAILScaleandCSHA-CFSdidnotchangeovertime,butTSFIdid(F4,152=4.52,p=0.002).WorseningfrailtywasobservedbyTSFIat6(p=0.006)and12months(p=0.0001)relativetobaseline.Mortalitydidnotdifferbetweenfrailtysystems.Increasingfrailtyscoresandtimepost-dischargewasassociatedwithincreasedoddsofafall.AUCestimateswith95%CIwere0.722[0.641, 0.803], 0.813 [0.744, 0.881], and 0.761 [0.682, 0.841] for Frail Scale, TSFI, and CSHA-CFS,respectively.Conclusions: Risk of falls post-dischargewas associatedwith increased age, time post-discharge, andfrailty in our population. No scale appeared to significantly outperform the other by AUC estimation.Furtherstudyonthelongitudinaleffectsoffrailtyiswarranted.

SHAWNTEJIRAM


JUNE23, 2020 | PAGE26

Post-operativeopioidprescribingtrendsinadolescentsandpain-relatedencounters

JordanEJackson,ChristinaMTheodorou,KaeliJYamashiro,SarahCStokes,ErinBrown,ShinjiroHirose,AlanaBeres,DianaFarmer,PayamSaadai

Purpose:TheUnitedStatesisamidstanopioidepidemicwithover-prescribinganddiversionofunusedprescriptionsasmajorcontributors.Thisstudyaimedtoevaluateopioidprescribingtrendsforadolescentsatatertiarychildren’shospitalasnationalawarenessofthisopioidcrisisincreased.Wehypothesizedthatopioidprescriptionswoulddecreaseandthatthisdecreasewouldnotbeassociatedwithanincreaseinclinicalencountersforpain.Methods:From7/2014to12/2017,patientsaged13-18yearswhounderwenteitheralaparoscopicappendectomy(LA)orlaparoscopiccholecystectomy(LC)wereincluded.Patientswerecategorizedbasedonyearandreceiptofopioidprescriptionsornon-opioidprescriptions(includingdischargeinstructionstotakeover-the-counterpainmedications)atdischarge.Encountersforpainwereevaluatedforeachpatient.DatawereanalyzedwithFischer’sexacttest.

Results:109totalpatients(77LAand32LC)withameanageof15.7±1.5yearswereincluded.Therewasadecreaseinproportionofpatientsreceivingopioidprescriptionsfrom95.2%in2014to52.0%in2017(p=0.002).Therewasalsoanincreaseinproportionofpatientsreceivingnon-opioidprescriptionsfrom14.3%in2014to96.0%in2017(p<0.0001)[Fig1].12patientshaddocumentedencountersforpain;11werepatientsprescribedanopioidatdischargeandonewasnotprescribedanopioid.Additionally,therewere3phonecallsforconstipation,allinpatientswhohadbeenprescribedopioids.

Conclusion:Mirroringthenationalemphasistodecreaseopioidprescriptions,therewasasignificantdecreaseintheproportionofadolescentpatientsprescribedopioidsandanincreaseinnon-opioidprescriptions.Thereweremorepost-dischargeencountersforpatientswhowereprescribedopioids,suggestingthatadecreaseinopioidprescriptionsisnotassociatedwithanincreaseinpost-dischargeencountersforpain.

2014 2015 2016 2017%Ptsreceiveopioid 95.24% 84.21% 72.00% 52.00%%Ptsreceivenonopioid 14.29% 47.37% 64.00% 96.00%

0%10%20%30%40%50%60%70%80%90%100%

% P

ts

PROPORTION OF PTS RECEIVING PRESCRIPTIONS*Ptsmay havereceived bothopioidandnonopioid.

JORDANJACKSON


JUNE23, 2020 | PAGE27

MEDICAL EDUCATION BUILDING SESS ION 1 LECTURE 1222

LUIS GODOY

YUNFENGXUE

P ING SONG

GANESHRAJASEKAR

ANGELAAGUIRRE

AVNI SURI

UGURBASMACI

SARAHMAHDAVI

ANDREWW ISHY


JUNE23, 2020 | PAGE28

Comparisonoffirst25roboticlobectomyatUCDavisforlungcancertocontemporaneousandhistoricalvideo-assistedthoracoscopicsurgerylobectomy

LuisGodoy,MD,TimothyHuynh,BA,JamesM.Clark,MD,LisaM.Brown,MD,MAS,DavidT.Cooke,MD

SectionofGeneralThoracicSurgery,DepartmentofSurgery,UniversityofCalifornia,DavisHealth

Introduction: Technical innovation, including improved image quality, wristed movements, andinstrumentstabilityhavepromotedthegrowinguseofroboticsurgeryasanalternativetoVideo-AssistedThoracoscopicSurgery(VATS)lobectomyinpatientswithstage1lungcancer.Wesoughttocomparethequalityandsafetyofourfirst25Robot-Assistedlobectomy,toVATSandtestedthehypothesisthatnewandcomplexsurgicaltechnologycanbeintroducedwithoutsacrificingpatientsafetyoroutcomes.

Methods: Using the UC Davis Section of General Thoracic Surgery Database, we compared roboticlobectomy and VATS lobectomy cases, from 2/2017 to 2/2018 (the year before introducing the newroboticsystem)and3/2018to2/2019(theyearofintroductionofthenewroboticsystem).Wemeasuredperioperativemorbidity, 30-daymortality, nodal upstaging andweperformed a univariate analysis toobservedifferencesbetweenthethreecohorts:Robotic(3/2018-2/2019),VATS(3/2018-2/2019),andVATS(2/2017-2/2018).Results: We identified 25 robotic lobectomy and 28 contemporaneous VATS lobectomy cases from3/2018to2/2019(yearofintroductionoftheroboticsystem),and35VATSlobectomycasesfrom2/2017to2/2018(yearbeforeintroducingtheroboticsystem).RoboticlobectomyoperatingroomtimeswerelongercomparedtoVATS(median383versus295minutes,respectively;p<0.0001);allotheroperativemeasurementsweresimilar.Allpostoperativeoutcomesweresimilar,including30-daymortality(roboticlobectomy,0%versusVATS,0%)andperioperativecomplications.Medianlengthofstaywas4daysforallthreecohorts.Therewasnodifferenceinnodalupstaging(28%incidenceinrobotic,versus14.4%and10.7%inVATS2/17-2/18and3/18-2/19, respectively;p=0.377).Therewasadecreaseover time inroboticORtime.Conclusion: Patients undergoing robotic lobectomy had longer operative times, but otherwise nodifferenceinhospitallengthofstay,perioperativeoutcomes,mortality,andhadsimilarincidenceofnodalupstagingwhen compared toVATS lobectomy. These results suggest equipoisewhen comparing earlyexperienceofroboticlobectomywithVATSanddemonstratesthatnewandcomplexsurgicaltechnologycanbeintroducedwithoutsacrificingpatientoutcomes.

LUISGODOY


JUNE23, 2020 | PAGE29

Panniculectomyinpreparationforrenaltransplant:Aten-yearexperienceYunfengXue,MD;PopeRodnoi,BS;PingSong,MD;JenniferH.Kuo,MD,ChristophTroppmann,MD;ChadBailey,MD;MichaelS.Wong,MD

DivisionofPlasticSurgery

DivisionofTransplantSurgeryIntroduction:Patientswithend-stagerenaldiseasearefrequentlydeniedaccesstotransplantsurgeryduetoobesityandpoorfunctionalstatus.Thosewitha largepanniculusmaybedeclinedsecondarytoconcern for potential wound healing complications. To decrease post-transplant wound and graftcomplications,weimplementedaprogramwherepatientsunderwentpanniculectomytoregaincandidacyforrenaltransplant.Methods: We performed a retrospective review of all patients deemed high-risk for post-kidneytransplantwoundcomplicationswhounderwentpanniculectomyinpreparation forrenal transplantatourinstitutionfrom2008to2018.Aminimumof3monthsfollow-upisneededforinclusioninthestudy.Patient characteristics (age, BMI, medical comorbidities, maximum BMI and weight lost prior topanniculectomy)andsurgicaloutcomes(specimenweight,operationlength,timetodrainremoval,woundcomplications, time to treat complication) were analyzed after panniculectomy as well as aftertransplantation.Results:Atotalof65panniculectomiesinrenaltransplantcandidateswereincludedinourstudy.Overallcomplicationsoccurred in33patients (50.8%).Minor complications (woundseparation, cellulitis, skinnecrosis)occurredin23patients(35.4%);majorcomplications(hematoma,seroma,abscess,unplannedreturntotheoperatingroom)andmedicalcomplicationsoccurredin12patients(17%).32patientshavesince undergone renal transplant. No patients have experienced post-transplant wound healingcomplications.Conclusions:Panniculectomyinpreparationforrenaltransplantationcanbeperformedinpatientswithend-stagerenaldiseasewithahighbutmanageablecomplicationrate, convertingpreviously ineligiblepatientsintoeligiblecandidatesforkidneytransplantation.Thesewoundcomplicationsaremoreeasilymanagedpriortoinstitutionofimmunosuppressionrequiredforrenaltransplant.

YUNFENGXUE


JUNE23, 2020 | PAGE30

Driversofincreasedhospitalresourceutilizationin15,510handinfectionpatientsPingSong,MD,1CoreyBascone,MD,1AustinD.Chen,MD,2SamuelJ.Lin,MD,MBA,2AndrewLi,MD1

1DivisionofPlasticandReconstructiveSurgery,UniversityofCalifornia,Davis,Sacramento,CA

2DivisionofPlasticandReconstructiveSurgery,BethIsraelDeaconessMedicalCenter,HarvardMedical

School,Boston,MA

Introduction:Handinfectionsarecommonlyencountered,withseverecasesoftennecessitatingsurgicalintervention and hospitalization. This study aims to characterize patient and hospital level factorsassociatedwithincreasedhospitalresourceutilization.Methods:Patientswithaprimarydiagnosisofhandinfectionandprimaryinterventionof incisionanddrainage were retrieved from the Healthcare Cost and Utilization Project National Inpatient SampleDatabase (2014-2015). A gamma regression with a log-link function was performed to adjust forconfoundersandtoidentifydriversofincreasedlengthofstay(LOS),hospitalcosts,aswellasproceduraldelay followingadmission.Referencegroups forregressionwere included,race,age<65years,privateinsurance,andElixhauserComorbidityIndex(ECI):0,Results:Therewere15,510identifiedpatients.SignificantdriversofincreasedLOSincludednon-Whiterace (Black: 0.190 days, Hispanic: 0.560 days), age >65 years, income in the 3rd quartile, non-privateinsurancestatus,andECI(1:0.219days,2:1.132days).Driversofincreasedhospitalcostsincludednon-White race, income quartile, non-private insurance, and ECI (1: $326.23; 2: $2049.26). Notably, suchdriverswereassociatedwithpatientswhoreceivedincisionanddrainageatasignificantlydelayedtimefollowingadmission.

Conclusions:Ourresultssuggestthatincreasedhospitalresourceutilizationforseverehandinfectionsrequiring incisionanddrainageandhospitalization is largelyassociated toracialminority,non-privateinsurancestatus,andincreasedcomorbiditystatus,ratherthanhospital-levelinfluences.

Figure1.Drowningincidenceandcasefatalityratesbetween2000and2016byage.

PINGSONG


JUNE23, 2020 | PAGE31

Trendsinpediatricdrowningfrom2000-2016:Challengesandopportunities

GaneshRajasekar1,MPH,MiriamNuño,PhD11UniversityofCalifornia,DavisMedicalCenter,Sacramento,USA

Introduction: Drowning is the leading cause of death in children under the age of 5 years. Despitepreventionefforts,drowningcontinuestodisproportionatelyaffectchildrenintheUS.Weexaminedthenationalincidenceofdrowningandnotedhigh-riskpopulations.Method: A retrospective analysis of a nationally representative sample of children ages 0-5 years,hospitalized for drowning between 2000 and 2016, was conducted using the Health Care Cost andUtilizationProjectKidInpatientDatabase.Results: The average annual incidence of drowning in the study period is 6.5 cases per 100,000hospitalizations. From 2000 to 2016, incidence decreased from 8.4 to 4.3 cases per 100,000hospitalizationsperyear(49%reduction).Casefatalitydecreasedfrom1.04to0.46per100,000casesperyear(56%reduction).Two-year-oldchildrenexperiencedthehighestincidence,witharateof15.3in2000and8.5in2016per100,000hospitalizationsperyear.Thecasefatalityratewasalsohighestin2-year-olds,13.1in2000and5.4in2016per100,000casesperyear(Figure1).Theaverageannualincidenceofdrowningper100,000hospitalizationswashigherinmales(7.9)versusfemales(4.9)andhospitalsintheWest(8.6)andSouth(7.9),comparedtoMidwest(3.8),andNorth(3.7).Conclusion:Preventionefforts toreducedrowning inchildrenhavebeeneffective,asevidencedbyanoverallreductionofcasesinthelastdecade.However,2-year-oldchildren,boysofallages,andchildreninhospitals intheWestandSouthcontinuetoexperienceratesthatexceednationalaverages.Preventioneffortstargetedtoreducedrowninginthesehigh-riskgroupsareneeded.

Figure2.Drowningincidenceandcasefatalityratesbetween2000and2016byage.

GANESHRAJASEKAR


JUNE23, 2020 | PAGE32

Timetodiagnostictestingandriskofamputationforpatientswithlowerextremityulcers

AngelaAguirre,AmanAroro,MistyD.Humphries.DivisionofVascularSurgery

Objectives:Patientswith lowerextremitywounds fromdiabetesmellitusorperipheral arterydiseasehaveariskofamputationashighas25%.Inpatientswitharterialdisease,revascularizationdecreasestherisk of amputation. We aimed to determine if early assessment of arterial perfusion correlates withamputationrates.Methods:Weretrospectivelyreviewedpatientsreferredtothevascularclinicoveran18monthswithlower extremity wounds to determine when and who performed a complete pulse exam, and whendiagnosticstudiestoevaluateperfusionwereperformed.KaplanMeieranalysiswasusedtodetermineiftimingaffectedoutcomesfortreatmentanamputation.

Results:Sixty-onepatientswithlowerextremitywoundswereidentified.Ofthese,26patients(43%)didnothaveapulseexamperformedbytheirprimarycareproviderwhenthewoundwasidentified.Patientswereclassifiedbywhentheyunderwentanklebrachialindextestingtoassessarterialperfusion.FourteenpatientshadearlyABI(<30days)testing,withtheremaining47patientshavinglateABItesting.PatientsintheearlyABIgroupweremorelikelytohaveapulseexamdonebytheirPCPthanthoseinthelategroup,11(78%)vs23(49%),p=0.13.EarlyABIpatientshadaquickertimetovascularreferral.(Table)Earlypatientsalsohadquickertimestorevascularizationandwoundhealingthanthoseinthelategroup.Finally,patientsthatunderwentearlyABIwerelesslikelytorequiremajoramputation(Figure),althoughthisdidnotreachstatisticalsignificance(p=0.2).

Discussion:EarlyABItestingexpeditesspecialtyreferralandtimetorevascularization.Itcandecreasetimetowoundhealing.LargercohortstudiesareneededtodeterminetheoveralleffectofearlyABItestingtodecreaseamputationrates.

PatientCharacteristic

EarlyABIn=14

LateABIn=47

p-value

Age (Mean andSD)

69years

70years

0.93

MaleGender 11 27 0.26Diabetes 10 33 0.87Coronary ArteryDisease

6 16 0.82

COPD 3 8 0.97Mean Time toVascularReferral

17days

165days

0.0001

Mean Time toRevascularization

48days

101days

0.02

Mean Time toWoundHealing

141days

349days

0.005

ANGELAAGUIRRE


JUNE23, 2020 | PAGE33

PredictorsofunplannedreadmissionandmortalityafterbelowkneeamputationAvniSuri,LeoM.V.Andrada,AndrewM.Wishy,MatthewVuoncino,MatthewW.Mell,MimmieKwong.Division:VascularIntroduction:Perioperativemortalityandunplannedreadmissionsareconsideredqualityindicatorsforpatientcare.Publisheddatasuggests thatmajor lowerextremityamputationsareassociatedwithhighperioperativecomplicationratesandlowlong-termsurvival.Methods:Weconductedaretrospectivereviewofallpatientswhounderwentbelow-kneeamputation(BKA)betweenJuly2014andJune2019atourmedicalcenter.Patientdemographicsandpreoperativeconditions were collected and statistical analysis was performed to determine predictors of 30-daymortalityandunplanned30-dayreadmission.Results:128patientsunderwentbelowkneeamputationsduringthestudyperiod(52%right;48%left).69%ofpatientsweremale,31%werefemale,withameanageof62.7years.Therewerehighratesofmedicalcomorbidities,including48%ofpatientswithcoronaryarterydisease,48%withchronickidneydisease,and71%withdiabetes.Theoverall30-daymortalityratewas4.8%.27.3%ofpatientsexperienceda complication during the admission. The overall unplanned 30-day readmission rate was 29.8%.Independentpredictorsof30-daymortality includedcoronaryarterydisease (p=.01), congestiveheartfailure(p=.008),preoperativeclopidogreluse(p=.01),andcomplicationsduringtheindexadmission(p=0.046). The most significant predictor of unplanned 30-day readmission was wound complications(p=.002).Conclusion:PatientsundergoingBKAatourinstitutionhadhighratesofcomorbidconditions.Whiletheoverallperioperativemortalityratewaslow,nearly30%ofpatientswerereadmittedwithin30dayswithwoundbreakdownbeingtheprimarycontributingfactor forunplannedreadmissions.Futureeffortstoreducereadmissionsafterlowerextremityamputationshouldbeaimedtowardpreventionandoutpatienttreatmentofwoundbreakdown.

AVNISURI


JUNE23, 2020 | PAGE34

Surgicalandoncologicoutcomesinvascularresectionandreconstructionforadvancedcancer:Acaseseries

UgurN.Basmaci,BS1;MistyD.Humphries,MD2;RobertJ.Canter,MD2

1SchoolofMedicine;2DepartmentofSurgery,UCDavisHealthSystem

Introduction: Arterial involvement/encasement is a rare complication of advanced tumors, and theoptimalmanagementofthesepatientsisunclear.Limiteddatacurrentlyexistdescribingshort-andlong-term outcomes, including peri-operative morbidity/mortality and oncologic outcomes. We sought toevaluate surgical outcomes including vascular graft patency and long-termoncologic outcomes amongpatientsundergoingmajortumorresectionwithenblocarterialresectionandreconstruction.

Methods: From a prospective database, we identified and retrospectively analyzed 7 patients whounderwentoncologicsurgerywithvascularresectionandreconstructionforvariousneoplasmsinvolvingmajorbloodvesselsatUCDMedicalCentersince2010.Datawereabstractedonpatientandtreatmentfactorsaswellassurgicalandoncologicoutcomes.Descriptivestatisticswereevaluated.

Results:Inthiscohort,themeanagewas58.3±21.7yrsand86%werefemale.Medianlengthofstaywas14days [7,30].Diagnoseswereprimary sarcomas (4), recurrent carcinomas (2)andan inflammatorypseudotumorencasingtheaorta.Allpatientsunderwentarterialreconstructionofamajorvessel(2aortic,4iliac,and1femoral)usingcryopreservedallografts.Twopatientshadnopost-Opcomplicationsand3had complications unrelated to oncologic/vascular surgery. One patient developed fascial dehiscencerequiringre-operationand1wasreadmittedduetoacuteDVTs.Onepatientdevelopedcancerrecurrenceanddiedafter29mo.,and1isunderactivesurveillanceforpotentialrecurrence.Allgraftsarepatentatamedianfollow-upof1.2yrswith0%re-interventionrateforstenosis/occlusion.Conclusion: In this small series, vascular resection and reconstruction as part of the multi-modalitytreatmentofregionallyadvancedcancers isassociatedwithacceptableshort-andlong-termoutcomes,including excellent graft patency with cryopreserved allografts. In appropriately selected patients,involvementofmajorarterialstructuresshouldnotbeacontraindicationtoattemptedcurativesurgery.

UGURBASMACI


JUNE23, 2020 | PAGE35

Optimizedlong-termresultofnipple-areolacomplexreconstructioninimplant-basedbreastreconstructionSarahMahdavi,BS1,PingSong,MD2,LeeL.Q.Pu,MD,PhD21UniversityofCalifornia,Davis,SchoolofMedicine

2DivisionofPlasticandReconstructiveSurgery,UniversityofCalifornia,Davis,Sacramento,CABackground: Nipple-areola complex reconstruction (NACR) is a crucial step providing the visualappearanceofproceduralcompletionafterbreastreconstruction.However,thelong-termoutcomesafterNACRremainlessthansatisfactory.Weperformedthesereconstructionswithamodifiedskateflapandderma-fatgraftsandassessedpatientsatisfactionandsurgicaloutcomes.Surgicaltechnique:Aflapisdesignedbetween1-1.5cmandthediameterofthenewareolais3.8or4.2cmdependingontheexpectedfinalsizeandprojectionof thereconstructednipple.Toreconstruct theareola, a skin graft is harvested from common donor sites. Derma-fat graft is inserted into thereconstructednipplebeforefinalclosureforadditionalprojection.Completehealingisachievedbythreeweeks. If excess skin develops around the reconstructed nipple, de-epilthelization and skin-edge re-approximationareperformedtoimproveshapewithoutcompromisingvascularity.

Methods:30patientsunderwentunilateral(n=9)orbilateral(n=21)NACRspost implant-basedbreastreconstruction. Patient satisfaction (with respect to size, shape, and, projection of nipple) and post-operativecomplicationswerereviewedinpatientchartsandpost-operativephotography.Results:Reconstructednipplesshowedmaintenanceofadequateshape,sizeandprojection,withthefinalprojectionofeachnippleappearingtobemorethan5mm.24(80%)patientsreportedfullsatisfaction.6(20%)weresatisfiedwithsizeandprojection,butnotshapeduetoexcessskinaroundthereconstructednipple.Withrevision,allpatientsreportedfullsatisfaction.Therewerenosurgicalcomplicationsrequiringreoperation.

Conclusion: A modified skate flap with derma-fat grafts after implant-based breast reconstructionimproveslong-termpatientsatisfactionandmaymaintaingoodlong-termprojectionwithouttheneedforadditionalpatientdonorsites.

SARAHMAHDAVI


JUNE23, 2020 | PAGE36

MAGnesia:MagnesiuminfusionforanalgesiainthecriticallyilltraumapatientLaurenColemanMD,AdoniaEskondariPharmD,JeremiahDubyPharmD,DiegoAnayaBS,JinLeePharmD,GregoryJurkovichMD,ChristineCocanourMDDivisionofTrauma,AcuteCareSurgery,andSurgicalCriticalCare

Introduction: Inperioperativepatients,magnesiumhasbeenshowntoreducepostoperativepainandanalgesicrequirements.However,magnesiumhasyettobeappliedsystematicallyoutsideoftheoperatingroom. Critically ill trauma patients often require opiate-based pain regimens and may benefit frommagnesiumasanadjuncttodecreaseopiaterequirementsandprovideadequatepaincontrol.

Methods: This double-blinded randomized, placebo-controlled trial will enroll 156 patients whencomplete.Patientsarerandomizedtoreceivea40mg/kgbolusfollowedbya24-hourinfusionofnormalsaline (placebo)ormagnesiumsulfate.Oralmorphineequivalents (OMEs)andpainscoresare trackedbefore, during, and after study drug infusion. Instances of bradycardia, dysrhythmia, over-sedation,agitation,andrespiratorydepressionarerecorded.Forthisinterimreport,thegroupsremainblindedandwerelabeled“GroupA”and“GroupB”bythepharmacyteamperformingrandomization.Results:Currently,22patients(32%female,meanage=48)havereceivedstudydruginfusion.MechanismofinjuryhasbeenMVC(50%),fall(27%),assault(9%),gunshotwound(9%),andmotorcyclecrash(5%).Commoninjurypatternsincludefractureofatleastonerib(64%),spine(55%),andatleastoneextremity(55%).Sevenpatientshavehadanintra-abdominalinjury(32%).ThemeanISSscoreofGroupAis21;GroupBis16.Bothgroupshavereceivedanaverageof23hoursof infusion;3patientsrequiredearlyterminationofinfusionduetoasurgery.OnepatientinGroupBexperiencedmildrespiratorydepression,notrequiringcessationofinfusion.Therehavebeennootherinstancesofsideeffectsineithergroup.ThereisnodifferenceinOMErequirementbetweengroupsduring(57vs.88p=0.28)orafterinfusion(50vs.69,p=0.45).TheinstancesofseverepainscoresduringinfusionhavebeenlowerinGroupA(p=0.01).Conclusion:Thusfar,infusionofmagnesiumsulfateforpaincontrolhasbeensafe;itsefficacyremainsunknown. Group A has had significantly fewer instances of severe pain during infusion, though OMErequirementsarenotdifferentbetweengroups.Patientaccrualcontinues,withagoalof156patients.

LAURENCOLEMAN


JUNE23, 2020 | PAGE37

Objective:Belowkneeamputations(BKA)havehighratesofwoundcomplicationsandsurgicalrevisions.Publishedstudiessuggestacorrelationbetweenclosuretechniqueandwoundhealing,however,thereisapaucityofliteraturediscussingwoundclosuretypesandamputationoutcomes.

Methods: This single institution study included all BKA patients over a 5-year period. Patients withsubdermalclosureandtourniquetuse(TREATMENT)werecomparedwiththoseclosedwithstaples,skinsutures, or without tourniquet use (CONTROL). Demographics, preoperative conditions, andintraoperativefactorswererecorded.Theprimaryoutcomewas30-daywoundbreakdown.Results: 128 patients received BKA with complete data (101 [78.9%] TREATMENT and 27 [21.1%]CONTROL).Groupsweresimilarwithexceptionofrace,sex,andindicationforoperation.Medianlengthofstaywas 5 days (IQR 3-8 days).Wound breakdown occurred in 29 (24%) of patients. Of these, 83%happenedafterdischarge.TREATMENTpatientshadlesswoundbreakdown(18.6%vs.40.7%,p=.016).Onunivariateanalysis,surgicaltechnique,post-operativeantiplatelet(19.8%vs.44.4%,p=.022),andsex(male15.1%vs.female42.1%p=.001)wereassociatedwithlesswoundbreakdownwhilepost-operativeanticoagulationwasassociatedwithmorewoundbreakdown(40%vs.15.5%,p=.003).Afterstratifyingforsex,multivariatelogisticregressionshowedapersistentbenefitfortheTREATMENTinmen(OR.09,CI.016–.55,p=.009)butnobenefitinwomen(OR4.1,CI.36–46,p=.26).Surgicalrevisionwasrequiredin51.7%ofpatientswithwoundbreakdownvs.0%patientswithoutbreakdown(p<.0001).Discussion:SubdermalskinclosurewiththeuseoftourniquetsignificantlydecreasedwoundbreakdownandsubsequentsurgicalrevisionafterBKA.Thisbenefitwasseen formenbutnot forwomen.Factorsexplainingtheinteractionbetweensexandsurgicaltechniqueareunknownandmaybeatangibleareaforfurtherinvestigation.

ANDREWWISHYREWWISHY


JUNE23, 2020 | PAGE38

MEDICAL EDUCATION BUILDING SESS ION2 LECTURE 2222

AMANDAPHARES STEPHANIE KWAN

LEORAGOLDBLOONM-HELZNER MOLLIE MUSTOE N IKIA MCFADDEN

S IQI HE

KARAKLEBER

SAMM IOTKE

CHARLESTONCHUA

SARAHSTOKES


JUNE23, 2020 | PAGE39

DivisionofTrauma,AcuteCare,andGeneralSurgery,DepartmentofSurgery,UCDavisHealthMSpruce,APhares,KRichards,ESalcedoIntroduction:Trauma-informedcare(TIC)isanorganizationalstructureandtreatmentframeworkthatunderstandsthecomplexinteractionsandconsequencesofalltypesoftraumawithanemphasisonrespondingtotraumavictimsinawaythatprotectsboththevictimandtheproviderfromadditionalharm.Methods:GeneralsurgeryresidentsatalargeacademicmedicalandLevelItraumacenterwereinvitedtoparticipateinatwo-hourworkshoponTIC.A12-itemsurveywascreatedtoassessawareness,understanding,andattitudessurroundingTICandsecondarytraumatizationandwasadministeredbeforeandaftertheworkshop.

Results:Forty-sixgeneralsurgeryresidentsparticipatedintheworkshop.Pre-workshopresidentfamiliaritywithTICwaslowbutsignificantlyimprovedaftertheworkshop(1.85vs4.44,p<0.001).Residentperceivedabilitytorecognizesymptomsofsecondarytraumainthemselvesandothersimproved(3.28vs4.00,p<0.001;3.13vs3.86,p<0.001)asdidresidentawarenessoftreatmentstrategies(2.46vs3.95,p<0.001).Residentsoverwhelminglyagreedwithboth(4.49and4.58)theworkshop’svalueanditsbenefittoothertraumaproviders.

Conclusion:Researchhasdemonstratedthattrainingproviderstobetrauma-informedimprovespatient-centeredinteractions.ImprovedTICawarenessandpracticeisachievablethrougheducationalsessionssuchastheactivitydescribedabove.

AMANDAPHARES


JUNE23, 2020 | PAGE40

ReducingopioiduseinendocrinesurgerythroughpatienteducationandproviderprescribingpatternsStephanieY.Kwan,MD,MTM;ElizabethLancaster,MD;AnjaliDixit,MD,MPH;ChristinaInglis-Arkell,MD;SolmazManuel,MD;InsooSuh,MD;WenT.Shen,MD,MA;CarolynD.Seib,MD,MASUniversityofCalifornia-SanFrancisco,GeneralSurgery,SectionofEndocrineSurgeryUniversityofCalifornia-SanFrancisco,AnesthesiaandPerioperativeCareIntroductionPostoperativeopioidusecanleadtodependence,contributingtotheopioidepidemicintheU.S. New persistent opioid use after minor surgeries occurs in 5.9% of patients. With increaseddocumentationofpersistentopioidusepostoperatively, surgeonsmustpursue interventions toreduceopioiduseperi-operatively.MethodWeperformedaprospectivecohortstudytoassessthefeasibilityofapre-operativeinterventionviapatienteducation/counselingandchangesinproviderprescribingpatternstoreducepost-operativeopioid use. We included adult patients undergoing thyroidectomy and parathyroidectomy from1/22/2019-2/28/2019 at a tertiary referral, academic endocrine surgery practice. Surveys wereadministered to assess pain and patient satisfaction post-operatively. Prescription, demographic, andcomorbiditydatawerecollectedfromtheelectronichealthrecord.

Results66patients(74.2%women,meanage58.6[SD14.9]years)underwentthyroidectomy(n=35),parathyroidectomy(n=24),andothercervicalendocrineoperations(n=7).Allpatientsreceivedapre-operativeeducationalinterventionintheformofapaperhandout.91%ofpatientsweredischargedwithprescriptions fornon-opioidpainmedicationsand8%weregivenanopioidprescriptionondischarge.Amongthosewhomreceivedanopioidprescription,themedianquantityofopioidsprescribedwas135(IQR 120-150) oral morphine equivalents. On survey, four patients (6%) reported any postoperativeopioid use and 94% of patients expressed satisfaction with their pre-operative education and post-operativepainmanagement.

ConclusionClearandstandardizededucationregardingpost-operativepainmanagementisfeasibleandassociatedwithhighpatient satisfaction. Initiationof sucheducationmaysupportefforts tominimizeunnecessaryopioidprescriptionsintheendocrinesurgerypopulation.

STEPHANIEKWAN


JUNE23, 2020 | PAGE41

Optimizingtheyieldofplacentalmesenchymalstromalcell-derivedextracellularvesiclesin3Dculturesystems

LeoraGoldbloom-Helzner,TatuRojalin,HilaShimshiSwindell,KaitlinClark,AijunWang

SurgicalBioengineeringLab

Introduction:Extracellularvesicles(EVs)derivedfromplacentalmesenchymalstemcells(PMSCs)havebeenshowntoprovideneuroprotectionatsitesofinjury.However,aratelimitingstepinEVresearchislowyield,hightechnicaltime,andhighcostofcurrentisolationprocedures.Toaddressthisinefficiency,weculturedPMSCsonthePETmatrixofaunique3DbioreactorsystemtoincreasetheabsoluteyieldofEVspermLofmediaandpercell.Methods: PMSCs were cultured in this bioreactor system for 10 weeks. EV-conditioned media wascollectedweeklyandEVswereisolatedthroughdifferentialcentrifugation.Nanoparticletrackinganalysis(NTA)measuredEVsizeandconcentration.WesternblotswereperformedtoquantifynormalexpressionofEVmarkers (CD9, CD63, andCD81andCalnexin(-)). Enzyme-linked immunosorbent assays (ELISA)measured levels of characteristic growth factors including vascular endothelial growth factor (VEGF),brain-derivedneurotrophicfactor(BDNF),andhepatocytegrowthfactor(HGF).Results:EVmorphologicalfeaturesremainedunchangeduntilweek8,afterwhichadecreaseinbothEVsizeandconcentrationwasseen.WesternblotsrevealedtypicalexpressionoftheEVmarkersCD9,CD63,andCD81andnegativeexpressionofCalnexin.ConcentrationsofVEGF,BNDF,andHGF inconditionedmedia were comparable after 10 weeks. Cost analysis revealed an overall increase in EV yield whileshorteninglabortimeandmaterialcosts.FutureexperimentswillassessthepreservedneuroprotectivecapabilitiesofthePMSCEVs.

Conclusions:This initial study uses a new3D bioreactor system for a unique source of cells and hasbroughtusclosertooptimizingPMSCEVisolationprotocolsforincreasedyieldandmaintainedsamplepurity, while simultaneously lowering costs and time commitment. Future studies will assess theoptimization parameters using additional 3D culture systems including hollow fiber bioreactors,microspheres,andspheroidculture.

LEORAGOLDBLOOM-HELZNER


JUNE23, 2020 | PAGE42

Aprospectivetrialofintraoperativeliposomalbupivacaine(Exparel)versusbupivacaine/lidocaineforthoracoscopicsurgeryMollieMustoe,JamesM.Clark,MD,LuisA.Godoy,MD,AnnaXue,MD,SarahHolmesPA-C,JohnAnconaPA-C,LisaM.Brown,MD,MAS,DavidT.Cooke,MDSection of General Thoracic Surgery, Department of Surgery, University of California, Davis Health,Sacramento,CA

Introduction:Given theworsening opioid crisis, enhanced recovery protocols utilizing intraoperativeliposomal bupivacaine (LipoB) have been implemented in a variety of surgical specialties to improvepatientrecovery.NostudytodatehasexaminedtheeffectofLipoBonpatientreportedoutcomes(PROMs),andthereisapaucityofdataontheeffectoflong-termopioidusageupto2monthspostoperatively.Method: Through a prospective cohort trial we enrolled 20 patients to receive 1:1 0.25%bupivacaine:1.0%lidocaine(control)followedby20patientstoreceiveLipoBviaintraoperativeposteriorintercostalnerveblock.Eligiblepatientswerethoseundergoingplannedvideo-assistedorrobot-assistedthoracoscopic lung resection, lung biopsy, or pleural biopsy. Patient postoperative opioid usage inmorphineequivalentdoses(MEDs)wascalculated,andPROMswererecordedviaavalidatedsurveyinthepreoperativearea,ondayofdischarge,atpostoperativemonth1,andatpostoperativemonth2.Results:Therewerenodemographicdifferencesbetweentreatmentgroups.Controlpatientshada2.3xhigher opioid need postoperatively while inpatient compared to LipoB patients (MEDs 296±227 vs130±123mg,p=0.006),andweremorelikelytostillrequireopioidsattimeofdischarge(65.0vs30.0%,p=0.03).Onmultivariable analysis, use of LipoB compared to Control decreased inpatient opioidMEDrequirementsby125mg(β-125,95%CI-222to-29,p=0.013).Eachadditional10mgofinpatientMEDsrequiredpostoperatively increased theoddsof continuedopioidusageatdischargeby6.6%(OR1.07,95%CI1.01to1.13,p=0.03)andat1monthby10.4%(OR1.10,95%CI1.02to1.20,p=0.02).PROMsdidnotdifferatdischarge,1month,or2monthspostoperatively.Conclusion: LipoB significantly reduces the need for postoperative inpatient opioids after thoracicsurgery,andmayreducetheneedforopioidprescriptionsatthetimeofdischarge.TherewasnodifferenceinlongtermpostoperativePROMs,suggestingthatLipoBisnotmaskingshorttermsymptomsbutprovidesdurablelong-termpainreliefandpatientrecovery.Accordingly,theUCDavisPharmacyandTherapeuticsCommitteehasapprovedLipoBforuseinthoracicsurgeryproceduresinclinicalsettings.

MOLLIEMUSTOE

Table1.DemographicsandnarcoticusageofcontrolandLipoBpatients.


JUNE23, 2020 | PAGE43

Injuredbehindbars:Adescriptivestudyofprisonerspresentingtoalevel1trauma

NikiaR.McFadden,MDandGarthH.Utter,MD

UniversityofCalifornia,Davis,DepartmentofSurgery

Introduction:Overthepast40years,theU.S.prisonpopulationhasincreasedbymorethan600%,butlittle has been previously described about this subpopulation of injured patients. Prisoners currentlyaccount for approximately 2-3% of hospitalized trauma patients at UCDMC. By improving ourunderstandingoftraumaticpatternsinprisonerswecanoptimizethecareofthismarginalizedpopulation.Methods:Themedical recordsof injuredadultprisonerswhopresented toUCDMCbetweenFebruary2011andApril2017werereviewed.Datafromthemedicalrecordwasthenlinkedtoour institution’straumaregistry.Weconducteddescriptiveanalysestosummarizecharacteristicsoftheinjuredprisonersandthecaretheyreceived.Results:Duringtheaforementionedperiod,14,461injuredadultswerehospitalizedatUCDMCandthehospitalizationsof299injuredprisonerswerereviewed.285(96%)patientsweremale,meanagewas40.5(SD=13)yearsandmedianlengthofhospitalstaywas3(IQ=5)days.67%sustainedbluntand42%sustainedpenetratingtrauma.43%wenttotheoperatingroomduringtheirhospitalization.70patients(23%) were victims of interpersonal violence between prisoners. 10% of those who were able tocommunicatewerenotedtonotbeforthcomingaboutcircumstancessurroundingtheirinjury.36cases(12%)involvedself-inflictedharmand33%ofpatientshadadocumentedhistoryofapsychiatricillness.However,psychiatrywasonlyconsultedin15%ofadmissions.Conclusion:A largenumberof injuredprisonerswhopresent toUCDMChaveahistoryofpsychiatricillness, are victims of interpersonal violence, and/or admit to self-harm. Clinicians who care for thispopulation should consider liberal psychiatric evaluation. Sincemany do not feel comfortable sharingdetailsabouttheirinjury,traumacenterswhocareforprisonersshouldconsidermechanismstobetterassureconfidentiality.

NIKIAMCFADDEN


JUNE23, 2020 | PAGE44

TheMotherInfantLactationQuestionnaire(MILQ):AssessingbreastfeedingperformanceJosephM.Firriolo,MD,LauraC.Nuzzi,BA,CatherineT.McNamara,BS,BrianI.Labow,MDIntroduction: Despiteagrowingfocusonbreastfeedingpromotionandresearch,therecurrentlyisnovalidatedmeasuretoassesslactationandbreastfeedingperformance.Methods:TheMotherInfantLactationQuestionnaire(MILQ)wasdevelopedbyourteaminconjunctionwithbiostatistics,nursing,andlactationsupportstafftoassesslactationandbreastfeedingperformanceacrossmultiplemotherandinfantdomains.TheMILQwaspilotedinasampleofmothersbetweentheagesof18-45yearswhowerebetween6months-5yearspostpartum.Results:FifteensubjectscompletedtheMILQ(meanage:31.8years).Allsubjectsproducedmilkwithinthefirstpostpartumweekand86.7%attemptedtobreastfeed. Twopatientsdidnotbreastfeedduetopreference or infection. Roughly one-third of breastfeedingmothers indicated having insufficientmilkproduction;ofwhich50%ofthesepatientsunderwentpriorsurgeryforfibroadenomaormacromastia.Ofmotherswhobreastfed,two-thirdsusedbreastmilktofeedtheirchildrenalmostexclusively.Thirty-eightpercentofbreastfeedingmothersnoted lackofemployersupportandspacetobreastfeedatworkasaconsiderablebarrier.Conclusion:TheMILQhasthepotentialtobecomeawidelyrecognizedtoolforcliniciansandresearcherstoquantifyandcomparebreastfeedingandlactationperformance.Ourfindingsindicatethatthemajorityofmothersinoursampleattempttobreastfeed,withmostexclusivelyusingbreastmilk.Allpatientsinoursamplewhounderwentpreviousbreastsurgerywereableto lactateandbreastfeed,althoughwithlimitedmilksupply.

JOSEPHF IRRIOLO


JUNE23, 2020 | PAGE45

Effectsof7,8-dihydroxyflavoneliposomesondiabeticwoundhealingSiqiHe1,2, Hengyue Song1,2, KewaGao1,2, HongyuanChen1, Xinke Zhang1, YifanWei1, Diana L. Farmer1,JiandaZhou2,AijunWang11SurgicalBioengineeringLaboratory,DepartmentofSurgery,UCDavis

2BurnsandPlasticSurgeryDepartment,TheThirdXiangyaHospitalofCentralSouthUniversityIntroduction:Diabetesisanimportantriskfactorofchronicwounds.Skininnervationandneuropeptidesmayplayan importantrole inwoundhealing.7,8-dihydroxyflavone(7,8-DHF),aselectiveagonist fortyrosinekinasereceptorB(TrkB)receptors,hasbeenwellstudiedforitsneurotrophicfunctions.However,itsroleinangiogenesisstillunknown.Since7,8-DHFisveryhydrophobicanditsbioavailabilityislow,wedesignedaliposomenanoformulationforeffectivedelivery.WefurtherengineeredtheliposomesurfacewithLXW7,aligandspecificallybindstointegrinαvβ3onendothelialcells(ECs).Wehypothesizethat7,8-DHF liposomes could possess adequate bioavailability and promote both skin innervation andangiogenesis and modification with LXW7 will further increase EC targeting and uptake efficiency,ultimatelyacceleratediabeticwoundhealing.Methods:Wedevelopedaprotocoltoproduce7,8-DHFliposomesandmodified7,8-DHFliposomesurfacewith LXW7 using Click chemistry.We characterized 7,8-DHF liposomes and tested their effects on ECfunctionandconfirmedtheactivationoftheTrkBpathwayinECs.Invivo,weusedb/dbdiabeticmouseexcisionalsplintwoundmodeltotesttheeffectof7,8-DHFonwoundhealing.WoundsweretreatedbyPBS, 7,8-DHF solution, 7,8-DHF liposomes or LXW7modified 7,8-DHF liposomes. The wound healingprocesswasdeterminedbyhistologicalanalysesandimmunohistochemistryoftheexcisionalwounds.Results:Wesuccessfullydevelopedaprotocoltoproduce7,8-DHFliposomeswithhighstability.Invitrofunctionofthe7,8-DHFliposomesonECsandneuronsandinvivofunctionfordiabeticwoundhealingarebeingevaluatedanddatawillbecollectedinthecomingweeks.Conclusion: The 7,8-DHF liposomes possess outstanding stability and bioavailability and represent apromisingnoveltreatmentfordiabeticwoundhealing.Futureworkwillfocusonthemechanismsofactionof7,8-DHFliposomesonbothtissueinnervationandneovascularization.

S IQI HE


JUNE23, 2020 | PAGE46

Economic&quantitativeassessmentofunanticipatedemergencydepartmentvisitsforrecentlydischargedviolentlyinjuredpatientsKaraKleber1,ChristyAdams1,NicoleKravitz-Wirtz1,JeffreyHoch*,AngelaSardo2,MichaelPrentice2,ScottBabb2,DaisyCruz2,IanBrown1.1DepartmentofTraumaandAcuteCareSurgery,2UCDavisSchoolofMedicine

Introduction: Evidence regarding emergency department (ED) recidivism specific to violent injury issparse,butdatasuggestthispopulationhasahigherrateofre-visitation.Determiningtheeconomicimpactand identifying predictive factors for unnecessary utilization can be used to tailor population specificinterventions. We hypothesized that our violently injured population at UC Davis would have a highvolume,lowacuityEDutilization.Methods:Thestudywasdesignedasaretrospectivecohortreviewofviolentlyinjuredpatients(VIP)overthreeyearsfollowedfor90-dayspostdischarge.Demographicdata,followupinstructions,EDvisits,andtraumaclinicvisitswererecorded.AfinancialanalysiswascompletedonallEDvisitstodeterminehospitalandprofessionalchargesforeachencounter.

Results:VIPpresentedtotheEDafterdischargeatarateof32%with16%havinggreaterthan1visit.Approximatelyhalfoftheseencountershadprofessionalchargeslessthan$500and90%hadprofessionalchargesunder$5000.Overall,themedianprofessionalcostwas$561.Mostofthe450patientsfollowed(76%)hasscheduledorinstructedoutpatientfollowup,howeveralmosthalfneverpresentedtotraumaclinic.

Conclusion: Preliminary data demonstrates violently injured patients have a high rate of low acuityemergencydepartmentvisitsafterdischarge.Thislevelofacuitysuggeststhemajorityofconcernswerenon-emergent and could be addressed in an outpatient setting. Future analysis will further classifypredictivefactorsincludingreasonsforEDvisitsandamoredetailedeconomiccomponent.

KARAKLEBER


JUNE23, 2020 | PAGE47

CausesandinjurypatternsofelderlyburnpatientsSamMiotkeMD,KathleenRomanowskiMD,TinaPalmieriMD,DavidGreenhalghMD,SomanSenMDIntroduction:Olderpatientsareavulnerablepopulationwithrespecttoburninjuries.TheAmericanBurnAssociation has invested resources in improving burn care and preventionwithin this age group. TheNational Electronic Injury Surveillance System (NEISS) ismaintained by the Consumer Product SafetyCommission to surveil for injury trends and is populated with data from a representative group ofapproximately100emergencydepartmentsintheUnitedStates.Thisdatabasecouldbeusefultoevaluateburninjurypatternsinelderlypatientswithaneyetowardtargetedpreventionmeasures.Methods:TheNEISSwasqueriedforpatientsaged55yearsandolderwithadiagnosisofscald,thermal,chemical,electrical,orunspecifiedburninjuriesfortheyears2008-2017.Eachinjurywasclassifiedbybodypart(s)burned,causativeproduct,gender,andagegroupofpatient (55-64,65-74,75-84,85andolder). The ten most commonly burned sites and the ten most common causative products weredeterminedforeachgenderandagegroupandinaggregate.Weightedestimateswereutilizedtocalculateinjurynumbersacrossthepopulation.

Results: The most common etiology of burn injuries for all patients was hot water. Men were mostcommonlyinjuredbygasoline,aproductwhichdidnotrankinthetoptenforwomeninanyagegroup.Cookwarewasthesecondmostcommoncauseamongwomenandthesixthmostcommoncauseamongmen. Forwomen, the combination of cookware and ranges/ovenswas among the top two causativeproductswithineachagegroup.Themostcommonlyinjuredbodypartforallpatientswastheface,holdingacrossmostageandgendergroupings.Menweremorelikelytoinjuretheirhandsthanwomen.Conclusions:Themostcommoncauseofburninjuriesinolderadultsishotwater,andthemostcommonbodypartaffectedistheface.Womenaremorelikelytobeinjuredbycookwareandranges/ovens.Menaremorelikelytobeinjuredsecondarytogasolineandaremorelikelytoinjuretheirhands.ApplicabilityofResearchtoPractice:NEISSdatacouldbeusefulinthedevelopmentoftargetedpreventioncampaigns,suchasfocusededucationaboutthedangersofhotliquids,cooking,andaccelerants.

SAMM IOTKE


JUNE23, 2020 | PAGE48

Quantityofextirpatedtissuedoesnotpredictpost-operativeseromaratesCharlestonChua,MD,CoreyBascone,MD,PingSong,MD,CliffordPereira,MDPlasticSurgery

Introduction: Post-operative closed suction drainage is a common practice in surgery to address thepotentialspacecreatedduringaprocedure.Asurgicaldrainiscomposedofanevacuatorwhichgeneratesthenegativepressure,tubingwhichpropagatesthisnegativepressuretothesurgicalsite,andanopenendinthesurgicalsitewhichpromotestissueappositionbyevacuatingairorfluid.Theliteraturecurrentlydemonstrates that drains generally reduce seroma formation however the decision to place a drain islargelyanecdotalandtherearenoguidelines for thenecessityofadrain.Ourstudyaimstodeterminewhetherthepotentialspacecreatedduringsurgery,usingexcisedtissueweightasasurrogate,toguidedrainplacementisavalidstrategy.Methods:Aretrospectivechartreviewofadultpatientsbetween2014to2018whohadanextirpativesurgery followed by reconstruction by a plastic surgeon at the University of California, DavisMedicalCenterwereincludedinthestudy.Weightoftissueremoved,placementofclosedsuctiondrain,and90-daypost-operativefollowupforclinicallysignificantseroma(seromarequiringdrainage)wererecorded.Criteriafordrainremovalwasoutputoflessthan30mLinthe24hoursprecedingremovalwherebynomorethan1drainwasremovedatatimeina24hourperiodifmorethan1drainwasplacedinthesamepotentialspace.Results: Of 276 patientswhichmet initial criteria, 142 patients had intra-operative specimenweightrecorded.6patientswerediagnosedwithaclinicallysignificantseromarequiringdrainagewithameantissueexcisionmassof800.3grams.Theremaining136patientswithoutseromarelatedcomplicationshadameantissueexcisionmassof1020.7grams(p=0.602).100%ofpatientsintheseromagrouphadatleast1drainplacedintra-operatively.Thenon-seromagrouphad69.9%drainplacementrate.Conclusions:Theamountofexcisedtissuedoesnotpredicttheriskofclinicallysignificantpost-operativeseromadespitedrainplacement.

CHARLESTONCHUA


JUNE23, 2020 | PAGE49

Determiningtheneedforpre-operativeprophylacticantibioticsinpediatricpatientsreceivingantibioticsforacuteintra-abdominalinfection

SCStokes,CMTheodorou,JEJackson,KJYamashiro,DFarmer,SHirose,PSaadai,ABeres,EBrown

PediatricSurgery

Introduction:Administrationofantibioticswithinanhourofincisionisacommonqualitymetricforreductionofsurgicalsiteinfections(SSI).Manypediatricpatientswhoundergosurgeryforanacuteintraabdominalinfectionarestartedonsystemicantibiotictreatmentupondiagnosis.Forthesepatients,wehypothesizedthatadditionalprophylacticantibioticcoveragewithinanhourofincisionwouldnotdecreaseratesofSSI.Methods:Asingleinstitutionretrospectivereviewofpatients<18yearsundergoingappendectomyorcholecystectomyfromJuly2014toJuly2019wasperformed.Onlypatientsreceivingsystemicantibioticsinthe24hoursbeforesurgerywereincluded.Patientswerecategorizedbasedonreceiptofanantibiotictocovergrampositivebacteriawithinanhourofincision(noprophylaxisvs.prophylaxis).TheprimaryoutcomewasSSIwithin30days.SecondaryoutcomeswereClostridiumdifficilecolitis,anaphylacticreactionintheoperatingroomandreadmissionwithin30daysduetoinfection.Outcomeswerecomparedwithchi-squaretestandFisher’sexacttest.

Results:Atotalof363patientswereevaluated,with271(75%)receivingantibioticstocovergrampositivebacteriawithinanhourofincision.Therewasnosignificantdifferenceinrateofperforatedappendicitisbetweengroups(28.2%noprophylaxisvs.28.4%prophylaxis,p>0.999).TherewasnosignificantdifferenceinratesoforganspaceSSI(4.3%noprophylaxisvs.4.4%prophylaxis,p=0.97),superficialSSI(1.1%noprophylaxisvs.0.7%prophylaxis,p>0.999),anaphylaxisrateintheOR(2.2%noprophylaxisvs.0.7%prophylaxis)orreadmission(0%noprophylaxisvs.1.8%prophylaxis,p=0.19).Onepatientwhoreceivedprophylacticantibioticsanhourbeforeincisionwasreadmittedonpost-operativeday29withClostridiumdifficilecolitis.

Conclusion:Forpediatricpatientsreceivingsystemicantibioticsforacuteintraabdominalinfection,additionalprophylacticantibioticswithinanhourofincisionmaynotbenecessarytopreventsurgicalsiteinfections.

SARAHSTOKES


JUNE23, 2020 | PAGE50

ONBEHALFOFTHEDEPARTMENTOFSURGERY , WEWOULDL IKETOTHANKOURSTAFFFOR

ORGANIZINGTHISEVENT

SONIAKUMAR

THOANTRAN

MANNYD IAL

ELIZABETHSTEELE

KYLIEBLAISDELL

@SHRINERSHOSPITALS

@SHRINERSHOSPITALSFORCHILDREN

@SHRINERSHOSP

@UCDAVISSURGERY

EVENT AGENDA JUNE RD 2020 - UC Davis Health

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