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Background We previously presented that women with chronic rhinosinusitis (CRS) who elected endoscopic sinus surgery (ESS) have a higher symptom burden than men. Causes of these gender-based differences warranted further study. Objectives To study gender differences in another cohort of adult patients with CRS who underwent ESS and to compare key histopathologic and serologic features Methods Patients with CRS who underwent ESS (from 2011 to 2014) with structured histopathology reports on surgical samples were studied. The 13-item structured histopathology report detailed key metrics of inflammation and the presence of fungal elements. Clinical, 22-item Sino-Nasal Outcome Test (SNOT-22) score, Lund-Mackay computed tomography (CT) score, serologic (immunoglobulin E [IgE] level, absolute eosinophil count) and histopathologic data were compared between male and female patients by using statistical software. Results We studied 130 eligible subjects (mean age, 54.7 years; 49.2% women). Compared with the men, the women had significantly higher preoperative SNOT-22 scores (women, 48.7; men 38.0 [p = 0.004]) but similar CT scores. Serum IgE levels were significantly higher among women versus men (peak, 433.3 versus 190.8 kU/L [p = 0.03]; closest to surgery, 435.0 versus 190.8 kU/L [p = 0.03]). Tissue fungal elements were significantly more prevalent in women versus men (19.0 versus 5.2%; p = 0.02). Up to this point, the analysis was agnostic of clinical details of the subjects. Further analysis was conducted regarding clinical features. Allergic fungal sinusitis (AFS) was found significantly more commonly in the female versus male patients (21.9 versus 9.1%; p = 0.04). Women versus men had a higher prevalence of migraine (19.4 versus 4.6%; p = 0.01) or any primary headache disorders (23.0 versus 6.2%; p = 0.007). Conclusion Women who underwent ESS for CRS had higher SNOT-22 symptom burden. Worsened symptomatology may be secondary to a higher prevalence of primary headache disorders in women. However, surgeons should also be aware that female patients with CRS who seek ESS may have a higher prevalence of severe disease endotypes (more tissue fungal elements, elevated serum IgE levels) and phenotypes.

131 Background: Research demonstrating a volume-outcome relationship has resulted in regionalization of complex cancer surgery to high volume hospitals. A simultaneous national trend towards improved surgical outcomes brings into question whether the potential benefits of regionalization are still relevant. We hypothesize that the difference in adjusted post-operative mortality between low and high volume hospitals has decreased over time. Methods: The National Cancer Database (NCDB) was used to identify patients with colon, esophageal, and pancreatic cancer undergoing curative intent surgery from 2003-2011. Hospitals were divided into low ( < 25th percentile), medium (25th-75th) and high ( > 75thpercentile) volume groups depending on annual volume of cancer-specific surgery. Year-specific hospital averaged observed/expected (O/E) ratios were calculated for 90-day mortality. Poisson regression was used to model hospital averaged O/E ratios over time. Results: Our study population included 343,929 patients with colon (88%), esophageal (5%) and pancreatic (7%) cancer. There were significant (p < 0.05) improvements in adjusted 90-day mortality from 2003 and 2011 for all volume categories and cancer types, except in high volume hospitals for esophageal cancer. In 2003, high volume hospitals had significantly better outcomes compared to low volume hospitals for all cancer types, as suggested by lower O/E ratios for 90 day mortality (p < 0.05). However, by 2011 the difference in O/E ratios for 90 day mortality was no longer significantly lower for high compared to low volume hospitals (p > 0.05); this was true for all three cancer types (Figure1). Conclusions: During the period of our study, 90-day mortality following gastrointestinal cancer surgery improved in low, medium and high volume hospitals. However, by 2011 the difference in adjusted post-operative mortality between low and high volume hospitals was not significantly different, likely due to global improvements in operative and peri-operative care. This attenuation of the volume-outcome curve has important implications for policy pertaining to regionalization of cancer care in the US.

61 Background: Patients with cancer often have complex symptoms and morbidity that prompt frequent Emergency Department visits. The length of stay in the ED for cancer patients exceeds that of patients without cancer. Patients with cancer are also more likely to be admitted, but are often discharged within 72h. Protracted ED visits, extensive investigations, and the burdens of even a short admission may be distressing and may not be aligned with patients’ care goals and preferences. Furthermore, the healthcare resources dedicated to these patients is considerable and has economic implications. We recently established a Supportive Care Infusion Center (SCIC), an on-campus outpatient unit where patients can receive treatments for symptom relief and comfort; they are assured integrated palliative care with routine oncologic care. We believe there is a subset of cancer patients who can be safely transferred from the ED to the SCIC for appropriate care. Methods: We are retrospectively evaluating cancer patients admitted through the ED to validate clinical parameters likely to lead to admission, and also identify any differences between patients admitted for <72h vs >72h. Patients are analyzed based on symptoms, cancer type, prior cancer therapies, performance status, comorbidities, and presence/absence of advance care planning as well as previous contact with Palliative Care. Data are also being gathered on patient outcomes, including mortality within 60d of admission. Results: Previously established indicators predictive of admission included shortness of breath and SIRS criteria, which our current review validates. We also observe that patients admitted for >72h have greater symptom burden and comorbidities and have received multiple lines of therapy. They also less frequently have advance care planning in place. Data analysis is ongoing. Conclusions: There exists a difference between cancer patients admitted >72h and those discharged within 72h. Awareness of these characteristics may lead to improved workflow in the ED. Identifying patients who may be suitable for transfer to an outpatient supportive care unit rather than short-term admission will also facilitate cost-effectiveness. Future direction includes evaluation of outcomes such as mortality, quality of life, and patient-caregiver satisfaction.

Background Cardiovascular disease (CVD) is an important driver of mortality after kidney transplantation. Its broader impact on posttransplant health care utilization in US hospitals is unknown. Methods We used administrative claims data from the Nationwide Inpatient Sample and the American Hospital Association Annual Survey to identify hospitalizations for kidney transplant patients with a cardiovascular diagnosis from 2005 to 2011. CVD hospitalizations were stratified by transplant hospital status to characterize patterns in inpatient health care utilization and outcomes. Based on these analyses, the domestic burden of treatment for posttransplant CVD (myocardial infarction, stroke, congestive heart failure, dysrhythmia, cardiac arrest, malignant hypertension) was estimated. Results The total domestic burden of post-kidney transplant hospitalization between 2005 and 2011 is estimated at 389 138 of which 26.5% of episodes were related to CVD (n = 103 118). CVD was responsible for a growing proportion of post-transplant hospitalizations over time (24.4%-30.4%, P < 0.001). Compared with nontransplant hospitals, transplant hospitals had similar length of stay (median length of stay, 3.7 days), higher median costs per hospitalization (US $10 364 vs US $8606, overall US $9324), and lower adjusted mortality (3.2% vs 3.9%, overall 3.6%; P = 0.003). Conclusions Inpatient CVD care is increasing over time for kidney transplant patients, accounting for 30% of all post-transplant hospitalizations. Variation exists in the inpatient care, outcomes, and costs between by hospital type. Further studies are needed to better understand the mechanisms behind these phenomena.

AbstractBackgroundDiagnosis of suspected basal cell carcinoma (BCC) is typically confirmed with incisional biopsy before referral to final surgery.ObjectiveTo investigate the clinical confidence and accuracy of physicians making a diagnosis of BCC based on dermoscopic and reflectance confocal microscopy (RCM) features.MethodsThis study was designed as a simulation to determine the certainty and willingness to refer to surgery without previous biopsy confirmation of BCC. Study subjects were identified with suspected BCC. Dermoscopic and RCM lesion images were obtained before biopsy. Eight clinicians with various expertise levels blindly interpreted these images and chose among four hypothetical treatment options: definite BCC, refer directly to surgery without biopsy; other malignancy, perform biopsy for diagnosis; uncertain diagnosis, perform biopsy; benign, do not biopsy. Decisions for treatment were based on dermoscopic images alone and, subsequently, on dermoscopic and RCM images combined.ResultsThe sensitivity for referral to surgery without biopsy was 67.6% with the use of dermoscopy; the positive predictive value (PPV) was 97.0%. Adding RCM increased the sensitivity to 76.5% and the PPV to 98.6%.ConclusionsDermoscopy provides a high PPV for BCC. The addition of RCM to dermoscopy increases diagnostic sensitivity, particularly in less experienced dermoscopists. Physician behavior might be different if actual referrals were made for surgery without biopsy.

Purpose According to the lung cancer staging project, T1a (≤ 2 cm) non–small-cell lung cancer (NSCLC) should be additionally classified into ≤ 1 cm and > 1 to 2 cm groups. This study aimed to investigate the surgical procedure for NSCLC ≤ 1 cm and > 1 to 2 cm. Methods We identified 15,760 patients with T1aN0M0 NSCLC after surgery from the Surveillance, Epidemiology, and End Results database. Overall survival (OS) and lung cancer–specific survival (LCSS) were compared among patients after lobectomy, segmentectomy, or wedge resection. The proportional hazards model was applied to evaluate multiple prognostic factors. Results OS and LCSS favored lobectomy compared with segmentectomy or wedge resection in patients with NSCLC ≤ 1 cm and > 1 to 2 cm. Multivariable analysis showed that segmentectomy and wedge resection were independently associated with poorer OS and LCSS than lobectomy for NSCLC ≤ 1 cm and > 1 to 2 cm. With sublobar resection, lower OS and LCSS emerged for NSCLC > 1 to 2 cm after wedge resection, whereas similar survivals were observed for NSCLC ≤ 1 cm. Multivariable analyses showed that wedge resection is an independent risk factor of survival for NSCLC > 1 to 2 cm but not for NSCLC ≤ 1 cm. Conclusion Lobectomy showed better survival than sublobar resection for patients with NSCLC ≤ 1 cm and > 1 to 2 cm. For patients in whom lobectomy is unsuitable, segmentectomy should be recommended for NSCLC > 1 to 2 cm, whereas surgeons could rely on surgical skills and the patient profile to decide between segmentectomy and wedge resection for NSCLC ≤ 1 cm.

Background Women electing endoscopic sinus surgery (ESS) for chronic rhinosinusitis (CRS) report higher symptom burden but have lower computed tomography (CT) scores. Gender‐specific analysis of outcomes from ESS therefore merits further study. The objective of this work was to study gender‐specific differences in outcomes from ESS for CRS by analyzing preoperative and postoperative 22‐item Sino‐Nasal Outcome Test (SNOT‐22) scores. Methods Data from adult CRS patients electing ESS (2011‐2013) were retrospectively collected. SNOT‐22 total, rhinologic/nonrhinologic subdomain, and individual item scores were analyzed for gender‐specific differences. Results Two hundred and forty‐eight patients met study criteria (mean age 55.4 years; 49.6% female). Preoperatively, mean Lund‐Mackay CT score was 11.1; average total SNOT‐22 score was 41.9. Compared to men, women had lower CT score (10.2 vs 12.0; p = 0.004) but higher total SNOT‐22 score (44.7 vs 39.1; p = 0.02). Both genders showed significant improvement in total SNOT‐22 scores at 3, 6, 12, and 24 months following ESS ( p < 0.001), with largely similar slopes of improvement. The greatest improvement occurred at 3 months (SNOT‐22 decreased by 25.4 points), with stable improvement after 12 months (SNOT‐22 decreased by 21.3 points). Higher total SNOT‐22 scores in females were noted preoperatively and until 6 months post‐ESS; these were driven by rhinologic and nonrhinologic‐otolaryngic subdomain items. No gender differences in anxiety/depression prevalence or psychological subdomain scores were noted preoperatively or postoperatively. Conclusion Both male and female CRS patients showed significant and durable symptom relief following ESS. Women reported higher symptom burden prior to surgery, and in the early postoperative period. However, after 1‐year post‐ESS, both genders showed similar symptom scores. The trend and magnitude of improvement were similar in both genders.