Lohse, Christine M.

ObjectiveTo examine the impact of treatment on disease‐specific health‐related quality of life (HRQOL) among patients with sporadic vestibular schwannoma (VS).Study DesignNational cross‐sectional study.SettingTertiary referral center and the Acoustic Neuroma Association.Subjects and MethodsAdult patients with VS who completed the Penn Acoustic Neuroma Quality of Life (PANQOL) survey. Patients were classified by treatment at the most recent survey as microsurgery, radiosurgery, observation, or recently diagnosed (RD). PANQOL scores were compared among VS treatment groups and with nontumor controls using analysis of covariance.ResultsA total of 1362 respondents with VS were analyzed. Total PANQOL scores differed significantly by treatment (P =. 024) with adjusted means of 60, 63, 65, and 62 for the microsurgery, radiosurgery, observation, and RD groups, respectively. Subdomain scores for facial function, balance, hearing loss, and pain differed significantly (P <. 05) by treatment. Comparisons that surpassed thresholds for clinical significance included microsurgery compared to radiosurgery and observation for facial function, microsurgery compared to observation and RD for hearing loss, and microsurgery compared to radiosurgery and observation for pain. Subdomain scores for anxiety, facial function, balance, hearing loss, energy, and pain and total PANQOL scores for nontumor controls were significantly higher (ie, more favorable) compared to the VS groups (P <. 05). General health scores did not differ significantly between the nontumor controls and the VS groups (P =. 19).ConclusionDifferences in HRQOL among treatment modalities are small and variably exceed the minimal clinically important difference. The impact of a VS diagnosis on HRQOL supersedes that of the treatment type.

EXECUTIVE SUMMARY We sought to determine emergency medicine physicians’ accuracy in designating patients’ disposition status as “inpatient” or “observation” at the time of hospital admission in the context of Medicare’s Two-Midnight rule and to identify characteristics that may improve the providers’ predictions. We conducted a 90-day observational study of emergency department (ED) admissions involving adults aged 65 years and older and assessed the accuracy of physicians’ disposition decisions. Logistic regression models were fit to explore associations and predictors of disposition. A total of 2,257 patients 65 and older were admitted through the ED. The overall error rate in physician designation of observation or inpatient was 36%. Diagnoses most strongly associated with stays lasting less than two midnights included diverticulitis, syncope, and nonspecific chest pain. Diagnoses most strongly associated with stays lasting two or more midnights included orthopedic fractures, biliary tract disease, and back pain. ED physicians inaccurately predicted patient length of stay in more than one third of all patients. Under the Two-Midnight rule, these inaccurate predictions place hospitals at risk of underpayment and patients at risk of significant financial liability. Further work is needed to increase providers’ awareness of the financial repercussions of their admission designations and to identify interventions that can improve prediction accuracy.

Objective: Definitive treatment of sporadic vestibular schwannoma (VS) following documented growth is common practice at most centers in the United States. However, as a natural extension of this paradigm, very little evidence exists surrounding the natural history of growing tumors. The primary objective of the current work was to describe the natural history of sporadic VS following documentation of initial tumor growth. Study Design: Retrospective cohort study. Setting: Tertiary referral center. Patients: Patients diagnosed with sporadic VS between January 1, 2001 and December 31, 2015 who elected continued observation despite having volumetric growth ≥20% of original tumor volume on interval magnetic resonance imaging (MRI). Main Outcome Measure: Survival free of subsequent volumetric growth. Results: Of 361 patients undergoing observation with serial imaging during the study period, 85 patients met inclusion criteria at a median age of 66 years (interquartile ranges [IQR] 55–71). Within this cohort, 40 patients demonstrated subsequent volumetric growth at a median of 1.7 years (IQR 1.0–2.6) from the date of initial MRI that documented growth. The median volumetric growth was 43% (IQR 28–57), and the median growth rate was 0.026 cm3 per year (IQR 0.009–0.107). Survival free of subsequent volumetric growth rates (95% CI; number still at risk) at 1, 2, 3, 4, and 5 years were 93% (87–99; 75), 67% (58–79; 45), 54% (43–67; 29), 44% (33–59; 19), and 41% (30–56; 12), respectively. Conclusions: In a cohort exclusively comprised of sporadic VS with documented growth, over 40% of tumors demonstrated no subsequent volumetric growth after 5 years of continued MRI surveillance. These data challenge the supposition that once growth occurs, all tumors will exhibit sustained growth. Continued observation after documented growth of sporadic VS is a reasonable consideration in appropriately selected cases.

Abstract Background: Awareness of burnout has led residency programs to seek interventions to promote well-being, resiliency, camaraderie and social network development. Limited evidence exists on the efficacy of specific interventions. This study evaluated the efficacy of an emergency medicine residency program’s semi-annual retreat using serial administration of the Maslach burnout index and resident well-being survey.Methods: Surveys were administered to all emergency medicine residents (n=25) in July 2018 and before and after fall 2018 and winter 2019 retreats. Retreats included a meal, team building, and social networking opportunities (bowling, softball, snow tubing, and sledding). Comparisons of responses between baseline, pre-retreat, and post-retreat were evaluated using two-sample t, Wilcoxon rank sum, and Fisher exact tests. Results: Sixteen emergency medicine residents (64%) responded at baseline. Response rates on subsequent surveys ranged from 14 (56%) to 21 (84%). Nineteen percent of residents exhibited burnout at baseline. This peaked at 36% pre-winter retreat. Burnout decreased after each retreat (fall: 29% to 6%, winter: 36% to 13%). Mean Maslach burnout index subscores for emotional exhaustion (13 to 9) and depersonalization (7 to 5) decreased from baseline to post-fall retreat, but neither changed significantly over the entire study period (emotional exhaustion: 13 to 12, depersonalization: 7 to 6). Resident well-being survey pre- and post-retreat responses were similar on all items.Conclusion: Meaningful, but not statistically significant differences were detected on the Maslach burnout index and resident well-being survey in association with a retreat. Mean emotional exhaustion, depersonalization and burnout decreased after retreats. Larger studies would provide further insight into the significance of these trends.

AbstractBackgroundMany clinicians believe that a patient's body mass index (BMI) affects the likelihood of obtaining high quality ultrasound images.ObjectivesTo assess the hypothesis that increased BMI is associated with worsening focused assessment with sonography in trauma (FAST) image quality.MethodsWe conducted a retrospective single‐center study of FAST examinations performed in a large academic emergency department (ED) with fellowship‐trained emergency ultrasonography faculty performing quality assurance review.ResultsMean (SD) BMI was 28.0 (6.6) among the 302 included studies. The overall quality rating tended to decrease as BMI increased but did not achieve statistical significance in a univariable setting (P = .06) or after adjustment for age and sex (P = .06). Operators perception of image adequacy was largely unaffected by BMI, with the exception of the pericardial view.ConclusionThis study did not identify a statistically significant difference in FAST quality with increased BMI. This result may help assuage clinician concerns about ultrasonography for patients in the ED.

Objective: Recurrent laryngeal nerve injury is a potential complication of cardiothoracic surgery and cause of unilateral vocal fold paralysis (UVFP). Injection laryngoplasty (IL) is an intervention offered to patients with UVFP to alleviate symptoms including dysphagia, dysphonia and weak cough. There is no definitive evidence that IL prevents pneumonia. In this study, we compare rates of pneumonia in patients with UVFP secondary to cardiothoracic surgery who did or did not undergo IL. Methods: A retrospective chart review identified patients diagnosed with UVFP by an otolaryngologist using flexible laryngoscopy following cardiothoracic surgery from January 1, 2008 to December 31, 2017. Each subject was grouped by IL status and assessed for subsequent pneumonia within 6 months of their diagnosis of UVFP. The association of IL with pneumonia was evaluated using Cox proportional hazards regression. Results: Of 92 patients who met inclusion criteria, 35 (38%) underwent IL and 57 (62%) did not. Twenty patients developed pneumonia, four who had undergone IL and 16 who had not; 12 patients developed aspiration pneumonia including two having undergone IL and 10 who had not. Those who had IL were less likely to develop total pneumonia compared to those who had not (HR = 0.33, P = .045). The protective effect of IL was not as clearly sustained when measuring for aspiration pneumonia, specifically (HR = 0.34; P = .10). Discussion: Injection laryngoplasty may reduce the risk of pneumonia in patients with UVFP secondary to cardiothoracic surgery; however, further research is needed to quantify the potential protective nature of IL in this patient population. Level of evidence: 3 (A retrospective cohort study).

Abstract Background Awareness of burnout has led residency programs to seek interventions to promote well-being, resiliency, camaraderie and social network development. Limited evidence exists on the efficacy of specific interventions. This study evaluated the efficacy of an emergency medicine residency program’s semi-annual retreat using serial administration of the Maslach burnout index and resident well-being survey. Methods Surveys were administered to all emergency medicine residents (n = 25) in July 2018 and before and after fall 2018 and winter 2019 retreats. Retreats included a meal, team building, and social networking opportunities (bowling, softball, snow tubing, and sledding). Comparisons of responses between baseline, pre-retreat, and post-retreat were evaluated using two-sample t, Wilcoxon rank sum, and Fisher exact tests. Results Sixteen emergency medicine residents (64%) responded at baseline. Response rates on subsequent surveys ranged from 14 (56%) to 21 (84%). Nineteen percent of residents exhibited burnout at baseline. This peaked at 36% pre-winter retreat. Burnout decreased after each retreat (fall: 29–6%, winter: 36–13%). Mean Maslach burnout index subscores for emotional exhaustion (13 to 9) and depersonalization (7 to 5) decreased from baseline to post-fall retreat, but neither changed significantly over the entire study period (emotional exhaustion: 13 to 12, depersonalization: 7 to 6). Resident well-being survey pre- and post-retreat responses were similar on all items. Conclusion Meaningful, but not statistically significant differences were detected on the Maslach burnout index and resident well-being survey in association with a retreat. Mean emotional exhaustion, depersonalization and burnout decreased after retreats. Larger studies would provide further insight into the significance of these trends.

ObjectivesTo evaluate the timing and distribution of first renal cell carcinoma metastasis after nephrectomy stratified by nodal status.MethodsWe evaluated patients treated with nephrectomy for sporadic, unilateral renal cell carcinoma between 1970 and 2011 who subsequently developed distant metastasis to three or fewer sites. Site‐specific metastases‐free 2‐year survival rates were estimated using the Kaplan–Meier method. Associations of nodal status with time to metastasis were evaluated using multivariable Cox regression models.ResultsA total of 1049 patients met the inclusion criteria (135 pN1, 914 pN0/x patients). The median time to identification of first distant metastasis for pN1 patients was 0.4 years (interquartile range 0.2–1.1 years) versus 2.2 years (interquartile range 0.6–6.0 years) in pN0/x patients. The most common site of metastasis was to the lung, but this occurred earlier in pN1 patients (median 0.3 years vs 2.0 years). pN1 was associated with significantly lower site‐specific 2‐year metastases‐free survival when compared with pN0/x for lung (37% vs 70%, P < 0.001), bone (63% vs 87%, P < 0.001), non‐regional lymph nodes (60% vs 96%, P < 0.001) and liver metastases (79% vs 91%, P < 0.001). On multivariable analysis, pN1 status remained significantly associated with lung, bone, and non‐regional lymph node (all P < 0.001) metastases, but it was no longer associated with liver metastases (P = 0.3).ConclusionspN1 nodal status in M0 patients treated with nephrectomy for renal cell carcinoma is associated with more frequent early metastasis to sites conferring poor prognosis when compared with pN0/x. Our findings highlight the importance of rigorous, early surveillance though the multimodal use of a comprehensive history, physical, laboratory and radiological studies, as outlined in societal guidelines.

Ambiguity exists regarding the definition of a level III inferior vena cava tumor thrombus (IVC-TT), limiting comparisons between open and minimally-invasive series. We assessed 253 patients who underwent radical nephrectomy with IVC-TT from 2000-2015 and proposed a modified classification based on associations between intraoperative IVC clamp position and need for cardiopulmonary bypass with complications, length of stay, and blood transfusions. Predictive ability of the modified system was not meaningfully improved (AUCs 0.59–0.58; 0.61–0.61; 0.72–0.72). Nevertheless, we advocate for standardization of the border of a level III thrombus at or above the major hepatic veins to facilitate meaningful comparisons between techniques.

4567 Background: Trials combining anti-PDL1 and anti-VEGF therapies for clear cell renal cell carcinoma (ccRCC) are underway; however the relationship between the expression of PDL1 and genes in the VEGF pathway is poorly understood. Using the Affymetrix platform, we observed an inverse association between the expression of PDL1 and key genes in the VEGF pathway. Herein, we validate this inverse association using an independent set of 100 primary ccRCC tumors. Methods: From our registry database we sampled 100 ccRCC tumors with varying PDL1 protein expression (0%-100%) determined by immunohistochemistry (IHC). We extracted RNA from FFPE slides and performed RT-PCR to quantify gene expression of PDL1, VEGF, VEGFR1, and VEGFR2. All genes were normalized to the POLR2a gene. We evaluated the association of PDL1 protein expression and VEGF gene expression using Spearman rank correlation. In addition, we employed a linear mixed effects model to compare the fold-change in expression of VEGF genes between PDL1 low (0-5%, n=68) and PDL1 high (>5%, n=32) tumors. Results: As expected, PDL1 protein expression positively correlates with PDL1 geneexpression (corr=0.42, p<0.001). Validating our array data, PDL1 protein expression inversely correlates with expression of key VEGF genes: VEGF (corr=-0.23, p=0.01), VEGFR1 (corr=-0.34, p<0.001), and VEGFR2 (corr=-0.23, p=0.01). In our dichotomized analysis, we noted significantly higher expression of VEGF genes in the PDL1 low compared to the PDL1 high group: VEGF (fold change=1.82, p<0.001), VEGFR1 (FC=2.63, p<0.001), and VEGFR2 (FC=2.13, p=0.001). Conclusions: We independently validate an inverse association between the expression of PDL1 and key genes in the VEGF pathway in primary ccRCC. If validated further in larger studies, the existence of an immune evasive and an angiogenic phenotype within ccRCC could inform current clinical trials targeting these two pathways. Ultimately, whether VEGF signaling affects PDL1 expression, or whether angiogenic or immune evasive phenotypes predict response to anti-PDL1, anti-VEGF, or a combination of the two therapies remains unclear.