Weaver, Amy L.

AbstractObjectiveWhereas studies in adult epilepsy patients have shown higher rates of suicidal ideation and attempt, such studies in children are limited. Using the Rochester Epidemiology Project database, we compared the risk of self‐injurious behavior and suicidal ideation in a population‐based cohort of childhood epilepsy to controls.MethodsWe studied 339 cases with epilepsy and 678 age‐ and sex‐matched controls followed to a median age of 24.7 and 23.4 years, and identified 98 subjects with self‐injurious behavior or suicidal ideation (43 with epilepsy and 55 controls). All behaviors were categorized using the Columbia Suicide Severity Rating Scale.ResultsThose with epilepsy had a significantly higher rate of any self‐injurious behavior and suicidal ideation (hazard ratio [HR] = 1.56, 95% confidence interval [CI] = 1.04‐2.35) and tended to have an increased risk of suicidal ideation and attempt (HR = 1.48, 95% CI = 0.93‐2.37). The prevalence of preceding mood and substance abuse disorders was similarly high in both cases and controls with self‐injurious behavior or suicidal ideation; however, preceding attention‐deficit/hyperactivity disorder was more than twice as common in the epilepsy cases. Among cases with epilepsy, we did not identify any specific epilepsy‐related variable that was significantly correlated with risk of self‐injurious behavior or suicidal ideation.SignificanceChildren, teens, and young adults with a history of childhood epilepsy are at greater risk of self‐injurious behavior, highlighting the need for careful screening of mental health concerns as part of routine epilepsy care.

American Academy of Pediatrics (AAP) guidelines for children with Down syndrome (DS) include assessment for celiac disease (CD), although data to support this recommendation have been inconsistent. We determined the incidence of CD among children with DS in a population-based birth cohort of children born from 1976 to 2000 in Olmsted County, Minnesota. Individuals with karyotype-confirmed DS and CD (using diagnosis codes, positive serology, and duodenal biopsies) were identified. The incidence of CD in DS was compared with the published incidence of CD for Olmsted County residents (17.4 [95% confidence interval = 15.2-19.6] per 100 000 person-years). Among 45 individuals with DS from the birth cohort, 3 (6.7%) were identified with positive celiac serology and confirmatory biopsies at ages 9, 12, and 23 years, for an incidence of 325 per 100 000 person-years. Thus, individuals with DS have more than 18 times the incidence rate of CD compared with the general population, supporting the AAP guidelines.

INTRODUCTION: Adverse patient events inevitably occur in OB/GYN practice. Health care provider who are “second victims” experience psychological trauma and progress through defined stages of recovery as they process the event. This experience is believed to be an under-recognized, yet prevalent phenomenon. Study aims were to determine the prevalence of second victims and the risk factors for feeling like a second victim among staff caring for OB/GYN patients to guide the implementation of new resources for second victims. METHODS: We administered the validated Second Victim Experience and Support Tool (SVEST) supplemented with non-validated questions to multidisciplinary team members caring for OB/GYN patients at Mayo Clinic in Rochester, MN. Respondents to the self-administered, anonymous survey included physicians, nurse practitioners, physician assistants, certified nurse midwife, registered nurses, allied health professionals, and desk staff. RESULTS: The survey was completed by 205 staff (117 OB only, 73 GYN only, 15 both). During their career, 44.8% felt like a second victim while 18.8% had this experience in the last 12 months. Residents and fellows had the highest percentage of second victims (41.7%). Respondents who reported greater psychological distress were more likely to report that they felt like a second victim after an adverse patient safety event within the preceding 12 months (p-value<0.001). The same finding was observed for measures of physical distress. CONCLUSION: OB/GYN team members report significant differences in physiological and physical symptoms after adverse events. Understanding and screening for psychological and physical symptoms may be useful in identifying second victims and guiding support following adverse events.

9073 Background: An accumulating body of evidence suggests that the outcome of early-stage melanoma is influenced by endocrine and menopausal status. However, it remains controversial as to whether the superior female melanoma-specific survival (MSS) is restricted to early stage disease or if it also pertains to patients with metastatic melanoma (MM). Methods: We analyzed data from the 13 registries that participate in the National Cancer Institute Surveillance, Epidemiology, and End Results (SEER) program. We identified all cases of primary invasive melanoma diagnosed between 1992 and 2009; none of the patients had a prior history of another cancer. MSS was compared between males and females, stratified by stage of disease. Age groups were defined as 18-45y, 46-54y, 55-64y, 65+y as a proxy of female menopausal status. Results: The study population included 87,165primary invasive melanoma cases (unstaged n=2834). MSS was significantly poorer for males compared to females for localized (n=72,456) and regional (n=8,945) disease for all age groups (Hazard ratio (HR) ranging from 1.21 to 2.09, all p<0.001). MSS was not significantly different between males and females for patients with distant disease at diagnosis (n= 2930; HR 0.99, 0.92, 1.11, 1.07 for each age group) and remained non-significant after adjusting for Breslow thickness, histologic subtype, anatomic site, and age group (adjusted HR 1.04 males vs. females; 95% CI 0.95-1.14; p=0.41). Conclusions: While our results were consistent with earlier reports that women have higher MSS rates compared to men for early (stage I-III) melanoma, the intriguing finding of this study was that the female survival advantage does not vary with age or menopausal status as compared to men, which is contrary to previously published reports. Furthermore, we found that the difference in survival was no longer significant for patients with MM, suggesting that sex may influence local and regional, but not distant cancer progression.

5076 Background: Advanced OVCA should be managed aggressively, and extensive surgery has been the most accepted initial treatment. Medically unfit patients or those with extensive disease, in which complete cytoreduction is unlikely, may not benefit from upfront radical surgery, and neoadjuvant chemotherapy might be an appropriate alternative. Thus, reliable preoperative indicators of surgical outcome are necessary for considering primary surgery vs. neoadjuvant chemotherapy. Our aim is to determine if C-reactive protein (CRP), IL-6, albumin and Glasgow Prognostic Score (GPS – score based on CRP and albumin) correlate with overall survival (OS), length of hospital stay (LOS), surgical morbidity, and suboptimal cytoreduction. Methods: We randomly selected 50 stages III/IV OVCA who underwent surgery as a primary treatment between July 2002 and June 2009 at Mayo Clinic with serum albumin levels and frozen serum available. CRP and IL-6 were measured in stored serum. Univariate and multivariate regression models were fit to evaluate associations with each of the outcomes. Results: Among the 50 patients, the mean age was 67.7 years. 34% had pretreatment albumin <3.5 g/ml, 22.4% had CRP level ≥10 mg/l, 26.5% had IL-6 ≥24 pg/ml and 45% had abnormal GPS score. At 1, 3 and 5 years following surgery, the OS was 75.6%, 49.8% and 36.9%, respectively. RD (0, <1, ≥1cm; p<0.001) was the only independent predictor of OS. Also, IL-6 (p=0.028) and stage (p=0.046) were independently associated with LOS, but no inflammatory or nutritional markers were significant associated with post surgical complications. Stage IV (p=0.019) and elevated CRP (p=0.044) were independent predictors of suboptimal surgery (RD ≥ 1cm). Conclusions: One-third of the patients in our series had low serum albumin at the time of the OVCA diagnosis, and at least one-fourth had elevated inflammatory markers. Advanced stage and elevated inflammatory markers (CRP and IL-6) were independent predictors of longer hospital stay and suboptimal debulking. These pilot data, if confirmed in a larger population, may help in the selection of candidates for neoadjuvant chemotherapy.

5577 Background: Perioperative red blood cell transfusion (PRBCT) may be a negative prognostic marker in surgical oncology. We assessed PRBCT as an independent risk factor for recurrence and death from epithelial ovarian cancer (EOC) in the largest cohort to date. Methods: Patient characteristics and process-of-care variables (NSQIP-defined, >130 variables) were retrospectively abstracted from 587 women who underwent primary staging and cytoreduction for EOC (1/1/03-12/29/08). Evaluated using propensity scoring with univariate logistic regression and odds ratios (OR) and Cox proportional hazards regression and hazard ratios (HR). Factors with p<0.1 used in multivariate models. Results: Rate of PRBCT was 77.0% (452/587). In univariable analysis, PRBCT was associated with older age (OR 1.25[95% CI 1.06, 1.48]/10yr increase), stage≥IIIa (4.66[3.04, 7.13]), splenectomy (26.63[3.67, 193.17]), higher surgical complexity (1.86[1.17, 2.95] score 2; 21.48 [7.37, 62.59] 3; referent 1), serous histology (2.36[1.57, 3.55]vs non-serous), longer operating time (1.58[1.36, 1.83]/hr increase), and residual disease (3.26[1.97, 5.41]≤1cm; 1.97[1.09, 3.56]>1cm), and lower preop hemoglobin (Hb) (1.89[1.59, 2.27]per 1g/dL decrease). In univariable analysis, PRBCT was associated with a higher risk of recurrence (HR 1.96[95% CI 1.43, 2.68]) and death (1.71[1.28, 2.28]). However, in multivariable analysis, stage≥IIIa (4.03[2.05, 6.49]), splenectomy (1.41[1.02, 1.95]), residual disease (1.86[1.41, 2.46]≤1cm; 2.91[2.02, 4.18]>1cm), and lower preop Hb (1.09[1.01, 1.19]) were associated with higher risk of recurrence. Older age (1.24[1.12, 1.37]), stage≥IIIa (3.07[1.93, 4.90]), albumin ≤3 g/dL (2.06[1.28, 3.31]), residual disease (1.63[1.22, 2.19]≤1cm; 3.03[2.19, 4.18]>1cm), and low Hb (1.08[1.00, 1.19]) were associated with higher risk of death. Serous histology (0.70[0.52, 0.95]) associated with lower risk of death. Conclusions: PRBCT does not appear to be directly associated with disease-free and overall survival in EOC. Lower preoperative Hb was associated with a higher risk of both recurrence and death. The need for PRBCT appears to be a stronger prognostic indicator than the receipt of PRBCT.

8590 Background: Merkel Cell Carcinoma (MCC) is an aggressive cutaneous malignancy of neuroendocrine origin associated with immunosuppression presumably through infection with Merkel Cell Polyomavirus present in >80% of patients (pts). The impact of immune status on clinical outcomes in pts with MCC is unknown. The primary objective of this study was to compare clinical characteristics and outcomes of pts with MCC who are immunosuppressed (ISP) versus non-immunosuppressed (non-ISP). Methods: We performed a retrospective chart review on pts with MCC diagnosed at the Mayo Clinic between 1981 and 2009. A dermatopathologist confirmed all cases. ISP was defined as pts diagnosed with chronic lymphocytic leukemia, HIV, solid organ transplant recipients, or chronic immunosuppressive medication. The association between ISP status and overall survival was summarized using the hazard ratio (HR) and 95% confidence interval (CI) estimated from a Cox regression model. Results: Of the 268 pts identified and included in the study, 38 (14%) were ISP. We found no differences in age, tumor size, tumor location, stage of disease, or recurrence rate in ISP vs Non-ISP. Among pts who had Stage 3-4 disease, there was no difference in the size of the primary between groups. Among pts with Stage 1-2 disease, ISP status was not significantly associated with poorer survival (HR 1.5, 95% CI 0.7-3.3). However, among pts with Stage 3-4 disease, ISP pts had significantly poorer survival compared to non-ISP pts (HR 2.7, 95% CI 1.2 - 6.2). Conclusions: Baseline clinical characteristics of pts with MCC do not differ based on immunosuppression, and outcomes do not differ in pts in regards to immunosuppression in early stage MCC (Stage 1-2). However, in pts with Stage III-IV MCC, ISP pts have a worse clinical outcome suggesting that metastatic MCC either behaves more aggressively in ISP pts either through intrinsic differences in the biology of the tumor or improved immune evasion in ISP pts. These results should be cautiously interpreted given the small number (n=12) of immunosuppressed pts with advanced stage MCC. The authors will update their data with an additional 58 patients by the date of presentation.

5004 Background: Since 1999, patients with low-risk endometrial cancer (EC) as defined by the Mayo criteria have preferably not undergone lymphadenectomy (LND) at our institution. We assess survival, sites of recurrence, morbidity, and cost per up-staged case in this low-risk cohort. Methods: Consecutive patients with Mayo-defined low-risk EC managed without (non-LND) and with LND were compared. Cause-specific survival (CSS) was estimated using the Kaplan-Meier method and compared using the log-rank test. 30-day cost analyses were equated to 2010 Medicare dollars. Results: Among 1,393 consecutive surgically managed EC cases, 385 (27.6%) met the Mayo low-risk criteria, accounting for 34.1% of type I EC. The 5-year CSS of the low-risk cases was 98.6 %. There were 80 LND cases (median # nodes, 29) and 305 non-LND cases. Complications within 30 days occurred in 37.5% and 19.3% of LND and non-LND cases, respectively (P<0.001). Nodal metastasis was identified in a single LND case (1.3%). There were 11 recurrences, 6 of which were vaginal. Not a single recurrence was detected in the pelvic or paraaortic nodal areas in these 385 patients, with a median follow-up of 5.4 years. The estimated prevalence (combining surgery and surveillance) of lymph node metastasis was 0.3%. The 5-year CSS in LND and non-LND cases was 97.3% and 99.0%, respectively (P=0.32). Patients were more than seven times as likely to die of co-morbidities than from EC. The 30-day median cost of care was $15,678 for LND cases compared to $11,028 for non-LND cases (P<0.001). The estimated cost per up-staged low-risk case was $439,990 if performed via endoscopy and $327,866 via laparotomy. If the 305 non-LND cases had been subjected to LND, an estimated additional $1,418,189 would have been expended. Conclusions: For patients with low-risk EC as defined by the Mayo criteria, lymphadenectomy dramatically increases morbidity and 30-day cost of care without discernible short- or long-term benefits: CSS was 99% with a 0.3% rate of nodal metastasis. In these low-risk patients, hysterectomy with salpingo-oophorectomy alone is appropriate surgical management and should be standard of care.