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2021 Abstracts

Marc Altimari, BS

Student

Neoadjuvant therapy and nodal downstaging in pancreatic adenocarcinoma

Introduction: Neoadjuvant chemotherapy and radiation have been shown to enhance resectability in patients with pancreatic adenocarcinoma. However, its role in downstaging remains poorly understood. This study aims to compare the effect of neoadjuvant chemotherapy and chemotherapy with radiation on lymph node downstaging in patients with pancreatic adenocarcinoma.

Methods: The National Cancer Database (NCDB) Pancreas Participant User File from 2004-2016 was used to identify patients who underwent surgery for a confirmed diagnosis of non-metastatic pancreatic adenocarcinoma. Patients who underwent neoadjuvant chemotherapy and chemotherapy with radiotherapy and surgical resection were included in the study.
Fisher’s exact test, ANOVA, and log-rank were used in analysis. Multivariate logistic regression was used to identify predictors of nodal downstaging.

Results: Of the 45,059 patients who underwent surgical resection for pancreatic adenocarcinoma, 3,311 received neoadjuvant chemotherapy alone and 3,602 received neoadjuvant chemotherapy and radiation. We identified 38,008 who did not undergo neoadjuvant therapy. In both the chemotherapy alone and chemotherapy plus radiotherapy groups, roughly 28% of patients were clinically staged as having node-positive disease. After surgery for clinically node-positive disease, 23.3% of patients who received neoadjuvant chemotherapy alone and 46.7% of patients who received chemotherapy and radiotherapy were downstaged to node-negative on pathology (p<0.001). Younger age and lower comorbidity index were found as independent predictors of nodal downstaging. Additionally, 68.8% of patients who received chemotherapy alone and 41.0% of patients who received chemotherapy and radiotherapy were not downstaged and still had node-positive disease on pathology (p<0.001). Despite this, median survival in patients who were downstaged was better in patients who received neoadjuvant chemotherapy only versus chemotherapy and radiotherapy (37.5 vs. 30.7 months, log-rank p=0.005). There was no difference in survival between these treatment groups in patients who were clinically node-positive and not downstaged.

Conclusion: Careful selection of patient factors, particularly patient age and comorbidity status is important when determining the optimal neoadjuvant therapy regimen for pancreatic adenocarcinoma. Although neoadjuvant chemotherapy plus radiation may help to decrease rates of nodal positivity, it may not confer a survival benefit, suggesting that disease survival is determined by systemic burden of disease.

Competition Category: Basic Science or Translational

Mentor: Akhil Chawla, MD

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Sarah Applebaum, MD

Junior Resident (Clinical PGY1-2)

Morphological changes of skin related to acellular dermal matrix incorporation in subacute tissue expansion

Introduction: Acellular dermal matrix (ADM) is used to create an inferolateral sling nearly three-quarters of the time in breast reconstruction and has proven a valuable alternative to total submuscular coverage of the implant. Previous work has demonstrated decreased inflammation and fibrosis of the pocket lining the ADM sling; however there has been minimal investigation into the role of ADM in skin growth and regeneration. The present study evaluates morphologic and molecular changes mediated by use of ADM in tissue expansion.

Methods: Two tissue expanders, one wrapped in ADM, were placed subcutaneously on the back of Yucatan minipigs. All expanders were inflated with two weekly fills of 60cc of normal saline and skin biopsies were harvested after two weeks of expansion from each condition: control, tissue expansion (TE), and tissue expansion with ADM (TE+ADM). Three biopsies per condition were embedded in paraffin or OCT medium and stained with Russell Movat Pentachrome and immunofluorescence (IF) of CD31, respectively. Collagen in the papillary dermis of pentachrome-stained images were analyzed using an ImageJ plug-in, Fibril Tool, that applies circular statistics to estimate average fibril orientation as the direction angle from -90 to 90 with respect to the x-axis. One-way ANOVA evaluated seventy-two measurements per condition and post-hoc analysis with Tukey’s HSD test identified significant comparisons between the groups. Number of fluorescent cells expressing CD31 (a marker of endothelial cells) were counted on 12 photographs per condition. P-values ≤ .05 were considered significant. Total deformation was calculated using a computational model and isogeometric analysis.

Results: The mean fibril orientation of TE and TE+ADM underwent -85% change (P < .001) and -15% change (P = .65), respectively, compared to control. Three times more CD31+ cells were observed in TE+ADM compared to control (P < .001), but no significant changes were detected in TE alone. Histogram of total deformation revealed more even distribution of forces in TE+ADM compared to TE and control.

Conclusions: The use of ADM in a porcine tissue expansion model appears to mitigate disarray of the collagen network in adjacent tissue, thereby creating a more extensive, yet even, distribution of stretched skin. This observation, combined with the finding of increased angiogenesis, suggests it is the incorporation of ADM that confers these protective benefits. Future studies will evaluate whether the protective effects of ADM can serve to improve TE in compromised tissue beds, as seen in patients undergoing TE concurrent with perioperative radiation therapy.

Competition Category: Basic Science or Translational

Mentor: Arun Gosain, MD

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Sofia Aronson, MD

Senior Resident (Clinical PGY3-5)

Predictors of resident success

Background: The plastic surgery match is one of the most competitive for applicants. On average, each program receives 100 applications per residency position. The COVID-19 pandemic has created a unique situation with limited in person evaluations of applicants, and difficulty in assessing personal qualities and fit. With this barrier in mind, the question remains, what applicant factors are most predictive of success as a resident?

Methods: Recent literature and the NMRP 2018 program directors survey were reviewed to determine the correlations between traditional applicant evaluation criteria and resident success, most often measured by subjective faculty evaluations. Emphasized selection criteria included: 1) USMLE scores, 2) clerkship performance/AOA, 3) research, 4) medical school background, 5) letters of recommendation, 6) visiting student rotations, and 7) interview performance.

Results: The most highly ranked factors in the decision to interview applicants were USMLE Step 1, AOA, and research. After interview completion, subjective components such as interpersonal skills and letters of recommendation became more important. No direct relationship between Step 1 and resident performance has been established, though it has been shown that Step 2CK and third year clerkship grades are predictors of surgical intern success. The number and quality of research publications appears less important as long as the applicant has published at least once, and this increases odds of publishing during residency. Medical students from the top 40 medical schools are more likely to match at highly ranked programs, though this does not correlate with better performance. Letters of recommendation are heavily weighed in the decision to interview and rank despite evidence they are vulnerable to inconsistent interpretation. Lastly, visiting rotations and interviews are the highest ranked selection criteria as these are the opportunities to assess the personal traits of an applicant, and thus differentiate amongst an otherwise academically homogenous population. The traits deemed most important included honestly, work ethic, empathy, humor, and ability to be a team player. Program directors who emphasized subjective criteria reported greater satisfaction with the selection process than those who emphasized academic qualifications, but only about 50% felt that interview performance predicted resident performance.

Conclusion: Resident success is not uniformly defined by every program. Thus selecting residents is unique for every program. Third-year clerkship grades are most predictive of resident performance among objective metrics, however objective metrics as a group are less important compared to interpersonal skills, work ethic, and personality.

Competition Category: Clinical or Quality

Mentor: Arun Gosain, MD

Mona Ascha, MD

Fellow (Clinical or Postdoctoral Researcher)

A pilot study of a mobile application to assess neurogenic pain

Introduction: Neurogenic pain can be debilitating and result in low quality of life. Targeted muscle reinnervation (TMR) is a technique developed by the senior author to prevent and treat neurogenic pain caused by painful neuroma. We developed and launched mobile application to monitor pre- and post-operative pain, medication use, and quality of life among patients with neurogenic pain.

Methods: Subjects were recruited from the clinics of the senior authors (JHK, SWJ, GAD). Patients were asked to complete weekly surveys and medication logs via the mobile application. Survey questions were selected based on the biopsychosocial approach to pain assessment. Data was collected from August 1, 2020 to May 1, 2021. Exploratory data analysis was performed on all patients to assess retention rate and fitness data. A subset of patients who met the following criteria was evaluated: at least one pre-operative survey, underwent surgical treatment of neuroma, and at least one post-operative survey. Demographic information on surgical patients was also collected and analyzed.

Results: A total of 95 patients were recruited. The retention rate at the end of the study period was 34.9%, demonstrating a steady decrease over time. The mean number of post-operative steps per month increased over time. Among surgical patients, 27 had a pre-operative survey, surgery, and a post-operative survey.  Among this subgroup, median (IQR) age was 48 (40.5, 55.6), 25 (%) participants were white, and 15 (55.6%) were never smokers. Mechanism of injury varied and include trauma, cancer, and iatrogenic. Most patients suffered from depression and anxiety. Surgical subgroups included amputation-related pain (n = 9), occipital nerve pain (n = 4), trunk pain (n = 4), groin pain (n = 3), and non-amputation limb pain (n = 7). Complications were minimal. The mean number of survey entries per patient was 10.7, with a mean response time of 19.6 days between surveys per patient. Pain appeared to increase in the immediate post-operative period, with a steady downtrend thereafter. A similar trend was demonstrated with post-operative medication use. Patients generally reported little depression and anxiety.

Discussion: This is the first study to utilize a mobile application to assess neurogenic pain. User retention can be improved with personalized alerts and gamification. Granular pain data can provide important information regarding patients’ post-operative courses, and guide appropriate post-operative counseling. Additional recruitment to increase sample sizes in subgroups is needed for future studies and additional analyses.

Competition Category: Clinical or Quality

Mentor: Sumanas Jordan, MD, PhD

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Jennifer Bai, MD

Senior Resident (Clinical PGY3-5)

Reducing postoperative opioids after reduction mammaplasty with the implementation of an electronic medical record discharge order set

Introduction: The opioid epidemic is a growing public health concern in the United States along with the increase in deaths from opioid overdoses. New persistent opioid use was found to be common after surgery, with breast procedures identified as having the greatest odds for persistent opioid use after plastic surgery. We aimed to reduce the amount of postoperative opioids prescribed after reduction mammaplasty by implementing standardized prescribing guidelines into our electronic medical record system (EMR).

Methods: This study is a retrospective chart review examining patterns of postoperative opioid prescriptions after reduction mammaplasty before and after implementation of standardized guidelines for postoperative opioid prescriptions into our EMR. All plastic surgery procedures were grouped into 4 different pain tiers. Literature and expert consensus were used to create recommended dosages, durations, and frequencies of opioid medication for each pain tier, and these guidelines were associated with Current Procedural Terminology (CPT) codes in the EMR. Using reduction mammaplasty as a pilot cohort of patients to study, all patients who underwent reduction mammaplasty were identified using the CPT code 19318, beginning 12 months before to 15 months after implementation of the order set. The primary outcome was Morphine Milligram Equivalents (MME) prescribed before and after implementation of the order set. A segmented regression analysis was performed using a linear mixed effects model, adjusting for potential confounders. 

Results: 278 patients who underwent reduction mammaplasty were identified: there were 92 patients before and 186 patients after implementation of the order set. The mean age at time of surgery was 39.3 ± 14.2 years and 89.2% of patients were female. 85.3% of patients did not have opioid use prior to surgery. After the implementation of guidelines for postoperative opioid prescribing into the EMR, there was a 30% decrease in amount of opioid prescribed for reduction mammaplasty (eβ: 0.70, 95% CI: (0.54,0.89), p-value=0.0060), and this decrease was stable over the course of the 15 months.

Conclusions: Standardizing the prescription of postoperative opioids using a discharge order set integrated into the EMR is an effective way to reduce the amount of opioids prescribed after surgery. In this pilot study, the amount of opioids prescribed after reduction mammaplasty was reduced by one third post-intervention, which demonstrates that this order set may be a promising tool to help reduce over-prescription and persistent opioid use after plastic surgery procedures.

Competition Category: Clinical or Quality

Mentor: Jason Ko, MD, MBA

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Nusaiba Baker, PhD

Student

Beyond the scalpel: Nurturing and molding surgeon-scientists in plastic surgery

Background: With plastic surgery (PS) at the forefront of innovation and discovery in multiple research disciplines, one would expect more MD/PhD (and research-focused MD) trainees to be intrigued by this field. However, recent reports have shown that the number of surgeon-scientists pursuing research is on the decline, with this being even more pronounced within PS. The purpose of this presentation is to discuss potential reasons deterring research-oriented trainees from pursuing a career as a plastic surgeon-scientist.

Methods: We performed a focused review of the available evidence investigating the demographics of MD/PhDs in PS and examined the literature for potential reasons deterring research-oriented trainees from pursuing a career in PS.

Results: Potential drawbacks to pursuing PS for the research-oriented applicant include the length of training as well as board “Score Creep”, a steady increase in board scores over the course of the MD/PhD student’s training. Moreover, since plastic surgeons tend to have less opportunity to engage in basic research during their training, they may be less likely to procure extra-mural grant funding once in practice, resulting in less grant funding to support the next generation of surgeon-scientists. Investigation of K awards by the NIH RePORTER in PS departments compared to other departments showed significantly fewer numbers of this career development award.

Conclusion: While the timing of PS residency is unlikely to change, and the newfound transition by the USMLE to pass/fail board scores alleviates the concern of “Score Creep”, perhaps one of the most promising ways to expand the ranks of PS research is to promote structured programs that would attract surgeon-scientists. Programs such as Physician-Scientist Training Programs (PSTPs) and NIH-supported research fellowships made available to PS residents are likely to have the greatest impact in attracting and retaining surgeon-scientists in the field.

Competition Category: Clinical or Quality

Mentor: Arun Gosain, MD

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Megan Bouchard, MD, MPH

Senior Resident (Clinical PGY3-5)

The association between timely access to pediatric appendicitis care and neighborhood factors

Introduction: Complicated appendicitis may indicate a delay in care, partially due to patient-level social determinants of health (SDoH) such as race, insurance and income. Neighborhood-level SDoH have been associated with disparities in other pediatric health conditions, though their effect on appendicitis outcomes remains unknown. We examined the association between the Child Opportunity Index (COI), a validated, comprehensive measure of 29 neighborhood indicators that impact children’s health, and the odds of presenting with complicated appendicitis.

Methods: We retrospectively identified patients ≤ 18 years old diagnosed with appendicitis between 2016-2018 from the Pediatric Health Information System (PHIS) database. Elective admissions were excluded to remove interval appendectomies.  We linked PHIS to the COI Database at the zip code level.  Nationally-normalized COI measurements were divided into quintiles (very low to very high opportunity) and its subdomains: education, socioeconomic and health/environment. Hierarchical logistic regression was used to assess the odds of presenting with complicated appendicitis and unplanned healthcare utilization as a function of COI.  Adjustments included age, sex, race/ethnicity, insurance, rurality and complex chronic conditions. 

Results: A total of 67,489 patients were identified, of whom 21,728 (38.2%) were complicated. The highest proportion of patients were non-Hispanic white (43.3%), male (60.1%), publicly-insured (47.8%) and aged 10-14 years (42.7%). Patients living in very low COI neighborhoods were 34% more likely to present with complicated appendicitis (OR 1.34, 95% CI 1.26, 1.42) compared to those in very high COI neighborhoods. This pattern was also observed for the education, socioeconomic and health/environment subdomains. There was no association observed between unplanned post-operative healthcare utilization and COI level.

Conclusions: Children from lower COI neighborhoods had an increased risk of presenting with complicated appendicitis, though no difference was observed in unplanned healthcare utilization post-operatively.  Reducing appendicitis disparities should involve addressing SDoH, including patient-level screening to mitigate risk factors and policy-level interventions such as neighborhood-focused investment, reallocation of community resources and improved healthcare access to geographically underserved regions.

Competition Category: Clinical or Quality

Mentor: Fizan Abdullah, MD, PhD

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Brian C. Brajcich, MD MS

Senior Resident (Clinical PGY3-5)

National evaluation of the association between resident labor union participation and surgical trainee well-being

Introduction: Labor unions are purported to improve working conditions; however, little evidence exists regarding the impact of resident physician unions on resident well-being and education. Therefore, our objective was to evaluate the association of resident unions with well-being, educational environment, salary, and benefits among general surgery residents nationally.

Methods: All general surgery residents in accredited U.S. programs were surveyed following the 2019 American Board of Surgery In-Training Exam. Program union status was confirmed by surveying program directors. The primary outcome was burnout, which was assessed using a modified version of the abbreviated Maslach Burnout Inventory. Secondary outcomes included measures of suicidality, job satisfaction, duty hour violations, mistreatment, educational environment, salary, and benefits. Multivariable logistic regression was used to evaluate the association of unions with outcomes, and instrumental variable (IV) analysis was performed to address unmeasured confounding factors and simultaneity.

Results: The survey response rate was 85.6%, with 5701 residents at 285 programs completing the pertinent questions, including 690 residents from 30 unionized programs (10.5% of programs). There was no difference in burnout for residents at unionized versus non-unionized programs (43.0% vs. 43.4%; OR, 0.92; 95% CI, 0.75-1.13; IV difference in probability, 0.15; 95% CI, -0.11 to 0.42). There were no significant differences in suicidality, job satisfaction, duty hour violations, mistreatment, educational environment, salary, or benefits, except that unionized programs more frequently offered 4 weeks instead of 2-3 weeks of vacation (93.1% vs. 30.6%; OR 19.18; 95% CI, 3.92-93.81; IV difference in probability, 0.77; 95% CI, 0.09-1.45) and housing stipends (38.5% vs. 16.1%; OR 2.15; 95% CI 0.58-7.95; IV difference in probability, 0.62; 95% CI 0.04-1.20).

Conclusions: In this national evaluation of surgical residency programs, unions were not associated with improved resident well-being or educational environment perception; however, unionized programs offered improved vacation and housing stipend benefits. These findings should be noted as residency programs discuss resident well-being and contemplate unionization.

Competition Category: Clinical or Quality

Mentor: Karl Bilimoria, MD MS

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Taylor Brown, BS

Student

Development of a vascular calcification model in mouse femoral artery by sympathetic nerve denervation

Introduction: Vascular calcification is a common comorbidity of peripheral artery disease (PAD), chronic kidney disease (CKD), and diabetes mellitus. This condition complicates treatment, as the inelastic vessel walls are difficult to manipulate. Calcification is characterized by transdifferentiation of vascular smooth muscle cells (VSMCs) into osteo- or chondrogenic cells that deposit hydroxyapatite crystals into the artery wall. The current understanding of calcification pathogenesis is insufficient, as no effective treatment options have been identified to date. In a healthy state, VSMCs are innervated to receive signals to regulate blood flow and pressure. Maintenance of the healthy, contractile phenotype of VSMCs relies on proper cell communication, likely including nerve signals. However, this critical interaction has not been studied in previous animal models of calcification. The goal of this project is to elucidate the relationship between innervation and calcification pathogenesis by creating a novel mouse model. The hypothesis is that sympathetic denervation of the femoral artery will cause osteo-chondrogenic differentiation of arterial VSMCs, leading to the onset of vascular calcification.

Methods: The femoral arteries of male wild-type BALB/c mice were chosen as the target artery. This vessel is physiologically relevant since calcification and PAD commonly affect the lower limbs in human patients. In each limb, the femoral artery was separated from the nerve bundle after incision. To denervate the animal’s left artery, 0.1 mg/mL 6-hydroxydopamine (6-OHDA), a specific dopaminergic neurotoxin, was delivered into the incision site and soaked for five minutes before rinsing with buffer solution (0.1% ascorbic acid in PBS). The contralateral limb served as the control by soaking the artery in buffer solution instead of 6-OHDA. The animals were sacrificed at 1, 2 and 4 weeks after treatments and the femoral arteries harvested for histological and immunohistochemical analysis.

Results: At one week, the 6-OHDA treatment resulted in successful denervation compared to the control (n=2), as shown by the reduction of tyrosine hydroxylase staining (sympathetic nerve marker). Two- and four-week studies are currently in progress (n=3 each), and changes in extracellular matrix composition, wall thickness, and osteogenic markers will be investigated to track pathological progression.

Conclusions: If a causal relationship is defined between denervation and calcification, this may provide a viable target for therapeutic intervention. Nerve stimulation or regeneration techniques can be studied as a feasible way to improve not only calcification-specific patient outcomes, but also provide better care for those affected by PAD, CKD, and diabetes.

Competition Category: Basic Science or Translational

Mentor: Bin Jiang, PhD

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Mariana Bustamante Eduardo, PhD

Fellow (Clinical or Postdoctoral Researcher)

Elucidating the role of fatty acid metabolism in the genesis of estrogen receptor negative breast cancer

Introduction: The lack of targeted preventive and therapeutic agents for estrogen receptor (ER) negative breast cancer is a significant unmet clinical need. Progress is severely hampered by our lack understanding of the local breast biology that promotes the development of ER-negative rather than ER-positive disease. Understanding of the genesis of sporadic ER-negative breast cancer has been a persistent focus of our research group. Analysis of gene expression in the epithelial cells from the contralateral unaffected breasts (CUBs) of breast cancer patients identified a lipid metabolism (LiMe) gene signature, which was enriched in the CUBs of women with ER-negative breast cancer. To explain the biologic basis for this association, we have developed an in vitro model system to enable us to study the effects of lipids on non-transformed breast epithelial cells. Fatty acid exposure resulted in profound changes in gene expression, chromatin packing density, chromatin accessibility and histone posttranslational modifications. In addition, flux through thirty-eight metabolic reactions was significantly increased including through Complex III of the electron transport chain (ETC). However, the mechanisms by which lipids induce molecular changes that result in epigenomic reprogramming, which potentially promote malignant transformation remain to be elucidated

Methods: We took advantage of our in vitro model system to further study the effects of lipids on non-transformed breast epithelial cells. The cells were expose to octanoic acid or linoleic acid for 24 hours. In addition cells were exposed to these fatty acids in presence or absence of inhibitors of ETC Complex III (Antimycin A and Atovaquone) and Complex I (Metformin). We assayed post-translational histone protein modifications and measured the level of expression of genes coding for writers, readers and erasers of epigenetic information.

Results: Fatty acids treatment resulted in the modulation of writers, readers and erasers of histone posttranslational modifications, DNA and RNA methylation. In addition, methylation and acetylation marks relative abundance changed after fatty acids exposure. When Complex I and II were inhibited, many of the epigenetic editors were up or downregulated. Some of which were modulated in the opposite direction compared to fatty acid responsive genes.

Conclusions: Fatty acid exposure impacts epigenetics, which appears to be regulated in part through the ETC. These alterations likely play a role in malignant transformation.

Competition Category: Fellow

Mentor: Seema Khan, MD

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Alexandria Byskosh, BS

Student

Subtotal laparoscopic cholecystectomy: A safe and effective alternative
Introduction: Subtotal laparoscopic cholecystectomy (SUB) is a frequent alternative to total laparoscopic cholecystectomy (TOT) when the critical view of safety (CVS) cannot be achieved. Little is known about the clinical factors associated with SUB and associated outcomes. Our objective was to determine predictive factors and outcomes of SUB as compared to TOT.

Methods: We retrospectively reviewed the clinical factors and outcomes for patients who were admitted from our ED to the acute care service (ACS) and underwent SUB or TOT by an ACS surgeon for acute biliary disease (September 2017-December 2019). Wilcoxon rank sum and Fisher’s exact tests were used for continuous and categorical data, respectively.

Results: 428 patients underwent cholecystectomy; 28 were SUB (6.5%). Of the SUB cases, two were laparoscopic converted to open, and, of the TOT cases, three were open. SUB patients were more likely to be older (57 v. 43 years, p=0.015), male (60.7% v. 29.3%; p<0.001), and have a history of liver disease (14.3% v. 2.0%, p=0.005). SUB had greater leukocytosis (14.6 v. 10.9, p<0.001), more often received preoperative antibiotics (96.4% v. 79.3%; p=0.025), and had operative findings including gallbladder decompression (82.1% v. 19.3%; p < 0.001), perforated gallbladder (7.1% v. 0.8%, p=0.053), and inability to achieve the CVS (78.6% v. 3.0%; p< 0.001). SUB patients had an increased length of stay (4 v. 3 days; p < 0.001) and more one-year readmissions. No major vascular injuries occurred in either group with one biliary injury in the TOT group.

Conclusion: SUB patients present with more significant markers of biliary disease and have more complicated intraoperative and postoperative courses. However, the lack of biliary or vascular injuries suggests that SUB may represent a safe alternative when the CVS cannot be achieved.

Competition Category: Clinical or Quality

Mentor: Joseph Posluszny, MD

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Nina Byskosh, BS

Student

Identifying gaps in disease knowledge among patients with peripheral artery disease

Introduction: Poor patient understanding of disease risk factors and potential consequences impedes the acceptance and adoption of lifestyle, behavioral, and treatment recommendations. We hypothesized that despite the high global prevalence and morbidity and mortality associated with peripheral artery disease (PAD), patients with PAD have inadequate knowledge of PAD.

Methods: This was an observational study of patients with PAD recruited from vascular surgery outpatient clinic at a NMH and from 2 PAD clinical studies over an 8-month period. A 55-item paper survey assessed demographic and socioeconomic information, knowledge of personal medical history and of general risk factors and consequences of PAD, and PAD education preferences. Inclusion and exclusion criteria were a diagnosis of PAD and inability to complete the survey and/or provide informed consent, respectively. Disease “awareness” was defined as correct acknowledgement of the presence or absence of disease, including PAD, in the personal medical history. “PAD knowledge score” was the percentage of correct responses to questions on general PAD risk factors and consequences. Of 126 eligible patients, 109 agreed to participate. Bivariate analysis was used to study factors associated with awareness of PAD diagnosis. Factors associated with PAD knowledge score were studied using Pearson correlation coefficient, two-sample T-test, or one-way ANOVA. P value <.05 considered statistically significant.

Results: Mean participant age was 69.4±11.0 years and 39.4% (N=43) were female. Most participants (80%;N=86) had critical limb-threatening ischemia. Only 65.4% (N=70) of participants were aware of their PAD diagnosis, which was less than their awareness of related comorbidities. Factors positively associated with PAD diagnosis awareness were female sex (81.4% v.54.7%;p=.004) and history of percutaneous leg revascularization (78.6% v.47.9%;p=.001). Among 17 patients who had undergone major leg amputation, 35% (N=6) were unaware of a diagnosis of PAD. PAD knowledge scores correlated positively with an awareness of PAD diagnosis (59.1% vs.48.7%;p=.02) and negatively with a history of hypertension (53.4% vs.68.1%;p=.001). Most participants expressed a desire to be further educated on PAD. The most popular education topics were causes, dietary recommendations, and treatment for PAD.

Conclusion: Patients with PAD have major deficits in their awareness of this diagnosis and general knowledge about PAD. Future research should prioritize the development of effective educational strategies, which could improve early diagnosis and treatment, alter the natural history of the disease, and lead to better patient outcomes.

Competition Category: Clinical or Quality

Mentor: Karen Ho, MD

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Emily Cerier, MD

Senior Resident (Clinical PGY3-5)

Need for ergonomics curriculum in general surgery residency to address musculoskeletal symptoms
Introduction: Ergonomics is an applied science concerned with designing and arranging things people use so that the people and things interact most efficiently and safely. Therefore, given the hands-on nature inherent to practice of surgery, utilizing a wide variety of instruments and tools to perform anywhere from basic to complex operations combined with increasing time constraints placed on physicians , one would assume ergonomics was a key component of surgical training. However, ergonomics has not traditionally been included within surgical education, including didactics or operative teaching, despite evidence that poor operative ergonomics may lead to muscle fatigue, injury, and burnout. Since few studies have analyzed ergonomics as it applies to surgical residents, our research aims to investigate the prevalence of and risk factors for musculoskeletal symptoms among surgical residents and to assess ergonomics knowledge.

Methods: A 35-question voluntary survey was developed by a multidisciplinary team including physiatrists and surgeons and distributed via anonymous link to all general surgery residents of an academic surgical residency. It assessed demographics, musculoskeletal symptoms and ergonomics knowledge. Results were analyzed using Chi-squared and pairwise Z-tests.

Results: 33/35 (94%) of surgical residents responded (48.5% female, 51.5% male, 60.6% junior residents, 39.4% senior residents.) 100% indicated experiencing musculoskeletal pain, with neck (79%), back (76%), and shoulder (61%) being the most affected sites. Shorter residents (<5’4”) were 77.8% and 52.9%, respectively) and more likely to report muscle fatigue (100% vs 88.9% and 4.7%). Senior residents (those higher than third year of training) were more likely to report back pain compared to junior residents (100% vs 66%, p=0.04.) Females reported higher frequencies of musculoskeletal pain (p=0.01) and experienced more muscle fatigue (100% vs 73.3%, p=0.03) than males. Residents attributed symptoms to prolonged standing, poor posture, and table height.

100% indicated little to no ergonomics knowledge. 68% reported ergonomics was never to rarely discussed in the operating room, with 86% reporting that applying ergonomics principles would contribute to their well-being.

Conclusions: Musculoskeletal pain is common among surgical residents with gender, seniority, and height associated with different symptoms. Residents’ ergonomics knowledge is poor, showing a clear need for a personalized surgical ergonomics curriculum and integration of ergonomics into the operating room.

Competition Category: Clinical or Quality

Mentor: Swati Kulkarni, MD

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Zhangying Chen, BS

Student

Microglia modulate the age-effect on acute TBI outcomes

Introduction: The CDC estimates nearly 3 million people sustain a traumatic brain injury (TBI) each year. Elderly are particularly vulnerable and suffer worse outcomes. Recent work in our laboratory has demonstrated that aged mice have attenuated neuronal loss and preserved white matter connectivity after TBI compared to young mice. Contrarily, young mice demonstrate evidence of neurogenesis after TBI, while aged mice do not. Microglia, the brain's resident innate immune cell, are complicit in all processes.

Hypothesis: We hypothesized that microglia would adopt divergent, age-dependent, TBI-associated transcriptional profiles post-TBI.

Methods: Young-adult male mice (14-weeks) and aged male mice (80-weeks) underwent TBI via controlled cortical impact vs. sham injury. Eight hours post-TBI, brains were harvested and microglia isolated. Approximately 5,000 microglia were sorted via florescence-activated cell sorting from each group. cDNA libraries were prepared via the 10x Genomics Chromium Single Cell 3' Reagent Kit, followed by sequencing on a HiSeq 4000 instrument. Raw data were processed using the Cell Ranger pipeline mapped to the mm10 mouse genome. Seurat and Ingenuity Pathway Analysis were used for downstream analyses.

Results: We observed markedly disparate transcriptional signatures within the microglia of young-adult and aged mice at baseline, which then corresponded to divergent transcriptional responses post-TBI. These marked, age-dependent, differences in transcriptional profiles resulted from a unique population of microglia within the injured brains of aged mice (n=2076) and young-adult mice (n=3042). Aged mice had enriched neuroinflammatory and immune responses (e.g., cytokine responses, FDR q= 3.03e-13) while young-adult mice had enriched regulatory and maintenance pathways (e.g., unfolded protein response, FDR q= 6.2e-12). By comparison, anti-inflammatory pathways were more predominant in aged TBI mice than young-adult TBI mice (e.g., IL-10, 2.75-fold more enriched in aged microglia). In particular, aged TBI mice demonstrated conversion towards a disease-associated-microglia (DAM) phenotype, a microglial phenotype heavily implicated in Alzheimer’s Diseases (AD).

Conclusions: We hypothesized that there are age-dependent transcriptional responses within the microglia of aged mice versus young-adult mice after TBI.  We found that aged microglia adopt a unique phenotype with enriched inflammatory and immune responses, corresponding to a disease-associated microglial phenotype typically found during the onset and progression of AD. Meanwhile, young-adult mice upregulated transcripts consistent with a maintenance response to injury. These data suggest that the molecular mechanisms of injury are different between young and aged subjects and that age should be a priori considering in future trial design.

Competition Category: Basic Science or Translational

Mentor: Steven Schwulst, MD

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Matthew Chia, MD

Senior Resident (Clinical PGY3-5)

Prevalence and risk factors for burnout in U.S. vascular surgery trainees

Introduction: Burnout and suicidality are known risks for vascular surgeons above other surgical subspecialties, with surgical trainees at risk for exposure to factors that increase burnout.  This study aimed to inform initiatives to improve wellness by assessing the prevalence of hazards in vascular training (mistreatment, duty hour violations) and the rates of wellness outcomes (burnout, thoughts of attrition/specialty change/suicide).

Methods: We performed a cross-sectional study of residents and fellows enrolled in accredited U.S. vascular surgery training programs using a voluntary, confidential survey administered during the 2020 Vascular Surgery In-Training Examination.  The primary outcome assessed was burnout symptoms reported on a weekly basis or more frequently.  The rates of wellness outcomes were measured.  The association of mistreatment and duty hours with the primary outcome was modeled with multivariable logistic regression. 

Results: A total of 475 residents and fellows enrolled in 120 vascular surgery programs completed the survey (84.2% response rate).  Of 408 trainees completing burnout survey items, 182 (44.6%) reported symptoms of burnout.  Fewer trainees reported thoughts of attrition (n = 42 [10.0%], specialty change (n = 35 [8.4%]), or suicide (n = 22 [4.9%]).  Mistreatment was reported by 191 (47.3%) vascular trainees and was more common in female trainees (n = 63 [48.5%] reporting monthly or more frequently) compared to male trainees (n = 51 [18.6%], p < .001).  Duty-hour violations were also more commonly reported by female trainees (n = 31 [21.4%] reporting 3+ months in violation) compared to male trainees (n = 50 [16.2%], p = .002).  After controlling for race/ethnicity, post-graduate year, program type, and geography, female trainees were less likely to report burnout (odds ratio [OR] 0.49, 95% CI 0.28 – 0.86).  Trainees experiencing mistreatment monthly or more were three times more likely to report burnout (OR 3.09, 95% CI 1.78 – 5.39).  Frequency of duty hour violations also increased the odds of reporting burnout (1-2 months in violation OR 2.09, 95% CI 1.17 – 3.73; 3+ months in violation OR 3.95, 95% CI 2.24 – 6.97).

Conclusions: Nearly half of vascular surgery trainees reported symptoms of burnout, which was associated with frequency of mistreatment and duty hour violations.  Interventions to improve well-being in vascular surgery must be tailored to the local training environment to address trainee experiences that contribute to burnout.

Competition Category: Clinical or Quality

Mentor: Dawn Coleman, MD

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Emily Chwa, BA

Student

The use of telemedicine across surgical specialties in an academic medical center

Introduction: Telemedicine has played an increasingly important role in surgical care during the COVID-19 pandemic. The objective of this study was to quantify the number of telemedicine visits compared to in-person ones across surgical specialties.

Methods: In this single-center retrospective study, we reviewed the total number of both in-person and telemedicine visits for all available surgical specialties (cardiovascular and thoracic, neurosurgery, ophthalmology, orthopedics, otolaryngology, pediatric, plastic, transplant, and urology) between February and December 2020. The percent of total visits that were telemedicine was analyzed over time for each specialty.

Results: Of 80,874 surgical clinical visits identified, 4,764 encounters (5.89%) were telemedicine. The specialties with the highest total percentages of telemedicine visits were neurosurgery (32%) and urology (15%). Plastic surgery, orthopedics, and ophthalmology reported the lowest total percentage of telemedicine visits at 4% each. Every surgical specialty except cardiovascular and thoracic experienced its largest percentage of telehealth visits in April. These specialties also experienced the largest decline in percentage of telemedicine visits between April and May. Otolaryngology, transplant surgery, and urology had the steepest decline, with the proportion of telehealth appointments decreasing by at least 70% each. Neurosurgery had the mildest decline, with the proportion of telehealth appointments decreasing by only 36%. Telemedicine usage in most specialties did not fluctuate by more than 5% between June and December. By December 2020, the percentage of telehealth appointments for nearly every specialty was below 10%, while neurosurgery remained at 30%.

Conclusions: Our institutional trends reveal neurosurgery and urology had the highest percentages of telemedicine appointments while plastic surgery, orthopedics, and ophthalmology had the lowest. While nearly all specialties displayed a decrease in telemedicine use from April to December 2020, neurosurgery had the significantly lowest percent decrease. Telemedicine rates for all specialties relatively plateaued from June to December, suggesting that past trends may be indicative of future patterns in telemedicine use. Understanding trends in telemedicine volume instigated by and following the pandemic may better prepare institutions to navigate the accelerated adoption of telemedicine within surgical fields and gauge the utility of telemedicine for different surgical subspecialties.

Competition Category: Clinical or Quality

Mentor: Arun Gosain, MD

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Lauren Connor, MD

Senior Resident (Clinical PGY3-5)

Targeted muscle reinnervation: A tour de force

Introduction: Targeted muscle reinnervation (TMR) was originally developed out of Northwestern to provide improved prostheses control for amputees. It has since contributed to a paradigm shift in the treatment of phantom limb pain and residual limb pain in major limb amputees. Here, we review the most recent clinical studies out of Northwestern regarding the impact of TMR on phantom limb pain and neuroma related pain in amputees and expanding applications for the non-amputee patient population.

Methods: We conducted a literature review of Northwestern based studies on TMR published from 2016-2021. Primary endpoints of interested were patient reported outcomes regarding pain via numerical rating scale (NRS) and Patient Reported Outcomes Measurement Score (PROMIS) values. Technique based studies were also reviewed to highlight the expanding applications and uses of TMR.

Results: TMR leads to improvements in phantom limb pain, residual limb pain and functional status for chronic major limb amputees. It also leads to a significant reduction in phantom limb and residual limb pain values when done in the acute setting for major limb amputations. Moreover, TMR can be a treatment of choice for non-amputee patients suffering from pain related to neuromas in continuity or end-neuromas.

Competition Category: Clinical or Quality

Mentor: Gregory Dumanian, MD

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Booker Davis IV, PhD

Fellow (Clinical or Postdoctoral Researcher)

Fecal microbiome transfer reverses dysbiosis and functional deficits after traumatic brain injury in mice

Introduction: Traumatic brain injury (TBI) is an underrecognized public health threat.  Survivors of TBI often suffer long-term neurocognitive deficits leading to the progressive onset of chronic neurodegenerative disease.  Recent data suggests that the gut-brain axis is complicit in this process. However, no study has specifically addressed whether fecal microbiota transplantation (FMT) can attenuate neurologic deficits after TBI.

Hypothesis: We hypothesized that fecal microbiota transplant would attenuate neurocognitive deficits after TBI.

Methods: 14-week-old male C57Bl/6 mice were subjected to severe TBI (n=20) or sham-injury (n=20) via an open-head controlled cortical impact. Post-injury, mice underwent 4 weekly oral gavages with a slurry of healthy mouse stool or vehicle alone. Zero maze (ZM) and Open field testing (OF) were used to evaluate post-traumatic anxiety, exploratory behavior, and generalized activity at 45 day post-injury (DPI). 16S ribosomal RNA (rRNA) sequencing of fecal samples was performed to characterize the resultant gut microbiota at 60 days post-injury.

Results: Behavioral testing demonstrated a rescue of normal anxiety-like and exploratory behavior in TBI mice treated with FMT.  FMT-treated TBI mice spent a greater percentage of time (14.9 ± 1.1, p=0.004) in the center regions of the Open Field as compared to untreated TBI mice )  (12.93 ± 2.2%). Untreated TBI animals also spent less time (17.0 ± 2.741%) in the open areas of ZM than treated TBI mice (27.3 ± 5.8, p=0.004). Fecal microbiome analysis revealed a large variance between TBI and sham animals treated with vehicle, while FMT treated TBI mice had restoration of gut dysbiosis back to levels of control mice.

Conclusion: Fecal microbiota transplant attenuated post-traumatic anxiety in TBI mice as compared to TBI mice treated with vehicle alone. This functional improvement correlated with correction of TBI-induced gut dysbiosis after TBI.  These data suggest that restoring a pre-injury gut microbiota may be a promising therapeutic intervention after TBI.

Competition Category: Basic Science or Translational

Mentor: Steven Schwulst, MD

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Megan Fracol, MD

Senior Resident (Clinical PGY3-5)

Breast implants and breast cancer immunosurveillance

Background: Women with cosmetic breast implants have significantly lower rates of subsequent breast cancer than the general population.1  We hypothesized breast implant-induced local inflammation stimulates immunosurveillance recognition of breast tumor antigen.  We previously showed women with cosmetic breast implants have elevated antibody responses to mammaglobin-A and MUC-1 one month post-implant placement.  Here, we present an updated analysis with a larger sample size of antibody responses to breast cancer antigen post implant placement.

Methods: Women presenting for first time breast augmentation were recruited from the plastic surgery clinic.  Sera were collected prior to, and one month after, breast implant placement.  Sera were tested via ELISA assay for antibody responses to common breast tumor antigens: BRCA2, CEA, HER-2, mammaglobin-A and MUC-1, as well as tetanus.  Antibody responses pre- and post-implant placement were compared with paired t-test. Statistical analysis was performed with Graphpad Prism v8.0.2.

Results: Sera were collected from 19 patients pre- and one month post- breast implant placement. Average age was 31.7 years (SD 9.5 years) and average BMI was 23.4 (SD 4.7).  Sixteen (84.2%) had silicone implants versus three (15.8%) with saline.  All implants were smooth and 18 of the 19 (94.7%) were placed sub-muscular. Antibody responses post-implant placement were significantly increased to mammaglobin-A (mean difference 0.045, p=0.01), MUC-1 (mean difference 0.052, p=0.007) and BRCA2 (mean difference 0.051, p=0.04).  There was no difference in post-implant responses to HER-2, CEA or tetanus.

Conclusion: We previously reported women with breast implants have higher antibody recognition of the breast tumor-associated antigens mammaglobin-A and MUC-1.  Our updated analysis confirms this effect with the novel finding of elevated antibody recognition to BRCA2.

Competition Category: Basic Science or Translational

Mentor: John Kim, MD

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Courtney L. Furlough, MD MS

Senior Resident (Clinical PGY3-5)

Clinician evaluation of the ethical decision-making climate in the intensive care unit

Introduction: This study evaluated the ethical decision making climates (EDMC) of five subspecialty intensive care units (ICUs) at an academic medical center. Our aim was to compare clinician perception of the EDMC across these ICUs and assess the association between perception of EDMC and clinician burnout.

Methods: A questionnaire was distributed to all clinicians currently practicing in a subspecialty ICU using the Research Electronic Data Capture application. Invited clinicians included 1) physicians (attendings and fellows), 2) nurses, and 3) a composite category of: respiratory therapists, social workers, chaplains, physical, and occupational therapists. The questionnaire was composed of a validated 32-item scale known as the ethical decision-making climate questionnaire (EDMCQ) and two single-measure items to assess perceived burnout. On the EDMCQ a higher raw score reflects a more favorable EDMC with possible total score ranging from 32 – 160.

Results: A total of 187 clinicians completed the questionnaire out of 576 invited to participate (32.5% overall response rate, 52% physician rate,  27% nursing rate, and 31.6% other clinician rate). Overall EDMCQ raw scores ranged from 59-150.  Physicians’ overall EDMC raw scores were significantly higher than non-physician clinicians (116.4 vs 105.23, p<0.001). Physicians also reported lower levels of emotional exhaustion (2.82 vs 3.12, p = 0.07) and depersonalization (2.9 vs 3.4 , p<0.05) than non-physicians.

Conclusions: Compared to physicians, non-physician ICU clinicians report worse ethical decision making climates and higher levels of depersonalization related to their work. The contribution of the unit-level ethical climate to ICU clinician burnout warrants further investigation.

Competition Category: Clinical or Quality

Mentor: Jacqueline Kruser, MD MS

Ben Gastevich, BA

Student

Post-operative subtotal laparoscopic cholecystectomy treatment pathway

Introduction: Subtotal laparoscopic cholecystectomy (STLC) is a frequent alternative for the difficult gallbladder. Despite the increased use of STLC, there is no literature describing how to manage these patients post-operatively. The objective of this study was to describe our pathway and outcomes for the post-operative treatment of STLC patients.

Methods: This descriptive study incorporated a retrospective analysis of all patients who underwent STLC at NMH from 9/2017 through 12/2019. STLC patients were managed with a treatment pathway that minimizes additional procedures and LOS. This pathway included clinic assessment 2 weeks after discharge.  At that time, if the drain output was both < 50mL/day and non-bilious, the drain was removed. If the drain was not removed, it was placed on suction for 12 hours overnight and off for 12 hours during daytime for 4 days.  If tolerated, the drain was placed off suction for 24 hours.  If this was also tolerated, then it was removed in clinic.  If drain output remained >50 mL or bilious despite being off suction, then the drain stitch was cut and the drain pulled back until the JP flange abutted the skin.  If this was not successfully tolerated or decreased drain output, then ERCP was considered. We reviewed clinical factors and outcomes for patients who were admitted from our ED to the acute care service (ACS) and underwent STLC by an ACS surgeon for acute biliary disease. Data are presented as frequency (percent) and median [interquartile range].

Results: There were 26 patients that underwent STLC, all of which were managed with surgical drains placed intra-operatively. Twenty (patients had a drain present at discharge, and 10 of these patients had bile present in the drain at the time of discharge. Total LOS was 4 days [3-7.5], and post-operative LOS was 2 days [2-4.5]. Three patients had an ERCP performed post-operatively prior to discharge. Four patients underwent post-discharge ERCP for indications other than stent removal. The median number of post-discharge clinic visits was 1 [1-2]. Patients had their surgical drains removed on POD 22 [16-35]. There was one episode of bile leak after removal of the drain. Four patients were readmitted within 30 days, three were related to the antecedent episode of acute biliary disease.

Conclusion: We describe a STLC post-operative pathway that minimizes length of stay and number of additional procedures. This treatment pathway is simple to implement and focuses on patient centered outcomes.

Competition Category: Clinical or Quality

Mentor: Joseph Posluszny, MD

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Cody Goedderz, BS

Student

Trends in leadership within orthopaedic foot and ankle fellowships

Background: No study in the orthopaedic literature has analyzed the demographic characteristics or surgical training of foot and ankle fellowship directors (FDs). Objective determinations for leadership positions within orthopaedic surgery remain inconclusive. Our group sought to illustrate demographic trends among foot and ankle fellowship leaders. 

Methods: The American Orthopaedic Foot and Ankle Society (AOFAS) Fellowship Directory for the 2021 to 2022 program year was queried in order to identify all foot and ankle fellowship leaders at programs currently offering positions in the United States and Canada. For all fellowship leaders, data points gathered included age, sex, race/ethnicity, medical school/residency/fellowship location of training, time from training completion until FD appointment, length in FD role, and individual research H-index. A current or past president title in the AOFAS and current major editorial board positions were also recorded.

Results: We identified 68 fellowship leaders, which consisted of 48 FDs and 19 co-FDs. 65 individuals (95.6%) were male and three (4.4%) were female. 88.2% of the leadership was Caucasian (n = 60), 7.4% was Asian American (n = 5), 1.5% was Hispanic/Latino (n = 1), and 1.5% was African American (n = 1). The average age was 51.5 years, and the calculated mean Scopus H-index was 15.28. The mean duration from fellowship training graduation to acquisition of a fellowship leader position was 11.23 years. Among current FDs, the most attended residency program was Harvard (n=5) and the most attended fellowship program was Mercy Medical Center (n=6).

Conclusion: Leaders within foot and ankle orthopaedic surgery are characterized by research productivity and experience, but more demographic diversity is needed as women and minority groups are largely underrepresented among leadership positions in the field of orthopaedic foot and ankle surgery.

Competition Category: Clinical or Quality

Mentor: Anish Kadakia, MD

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Rayyan Gorashi, BS

Student

Modeling diabetic endothelial cell dysfunction with induced pluripotent stem cells

Introduction: Diabetes is one of the major risk factors for cardiovascular diseases (CVDs), which is mediated with vascular endothelial dysfunction. Currently, there is no in vitro disease model of endothelial cell (EC) dysfunction in diabetic patients, which hinders mechanistic understanding and therapeutic discovery. The diabetic blood microenvironment results in increased oxidative stress experienced by ECs, leading to compromised barrier function and increased endothelial permeability. Diabetic patients also have chronic inflammation, allowing for increased risk of development of thrombosis. The goal of this study is to develop a comprehensive model of diabetic EC dysfunction using patient-derived induced pluripotent stem cells (iPSCs) through recapitulation of the diabetic microenvironment.

Methods: Our model utilizes iPSC derived ECs from the following sources: healthy patients, non-diabetic patients with underlying CVDs, and diabetic patients with underlying CVDs (n=3). To simulate in situ conditions of diabetes, we used the following treatment for 4 days: hyperglycemia (25 mM glucose); high urea (9 mM); high cholesterol (2.5 mM); and chronic inflammatory stimulation with tumor necrosis factor alpha, TNFa (8 pg/ml). EC dysfunction was assessed for oxidative stress, inflammation, permeability, and thrombosis. Specifically, immunofluorescence was used to identify protein localization for surface adhesion molecules, including vascular cell adhesion molecule-1 (VCAM-1), intercellular adhesion molecule-1 (ICAM-1), endothelial selectin (E-selectin), and platelet selectin (P-selectin). Enzyme-linked immunosorbent assay (ELISA) was used to gain quantitative measurements of protein expression.

Results: Overall, the qualitative effect of the high glucose and high urea treatment group resulted in the most apparent effect on permeability, while the high urea group increased the expression of VCAM-1. Interestingly, after TNF-α treatment, significant increase in expression of P-selectin was observed in cells derived from healthy subjects, but not from the diabetic patients. This indicates the patient-derived cell lines have been pre-conditioned to tolerate the pro-inflammatory conditions.  Ongoing experimentation will provide results for both qualitative and quantitative expression of ICAM-1, E-selectin, and P-selectin after treatment with the complete diabetic microenvironment.

Conclusion: The development of a robust in vitro model of diabetic endothelial dysfunction, similar to the onset of type II diabetes, will allow for high-throughput testing of pharmacological agents to ultimately treat the disease’s effects within the vascular bed. The widespread implications of type II diabetes on the vascular bed further amplify the significance of this study in the development of pharmacological agents to treat the disease.

Competition Category: Basic Science or Translational

Mentor: Bin Jiang, PhD

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Kendra Grundman, DO

Senior Resident (Clinical PGY3-5)

The role of myofibroblasts in diabetic wound healing

Introduction: Diabetes is a systemic disease in which the body cannot regulate the amount of sugar, namely glucose, in the blood. The insufficient production (Type 1) or inadequate usage (Type 2) of insulin results in a lack of glucose regulation. High glucose toxicity has been implicated in the dysfunction of diabetic wound healing. Diabetic wound restoration deals with dysregulated fibroblast differentiation, dysfunctional extracellular matrix remodeling, and amplified oxidative damage. Diabetes alters the activities of myofibroblasts and significantly impairs the process of wound healing. Understanding the influence of diabetes on the myofibroblast biological activity can help scientists and clinicians understand and manage diabetic wound healing more efficiently. Our comprehensive review describes and evaluates the impact of diabetes on wound healing, myofibroblast biology, relevant signaling cascades, and potential therapeutic treatments.

Methods: A literature search for full text articles (case reports, case series, clinical trials, and reviews) written in the English language and published between 1979 and 2021 was performed using the PubMed online database. The search strategy included using the phrase “diabetes wound healing” with each of the following phrases: “myofibroblast,” “fibroblast,” “fibroblast differentiation,” “experimental model,” and “therapeutic treatments.” Relevant reference articles were also reviewed for appropriate inclusion. The last search was conducted in March of 2021.

Results: Based on the published experimental and clinical studies, 1) With a generally increased TGF-β expression under hyperglycemic condition, the wound healing cells in the diabetic wounds and at the wound margins have reduced levels of TGF-β and reduced number of M2 macrophages, thus attenuated TGF-β/Smad signaling. 2) Diabetes also causes reduced IGF-1 and HIF-1 levels, which promote fibroblast differentiation. 3) Appropriate and regulated adipocyte lipolysis is important in generating wound bed myofibroblasts after trauma. Impaired lipolysis reduces myofibroblasts derived from adipocytes, resulting in reduced extracellular matrix and contraction of the wounds. 4) In clinical settings, the synergistic association between diabetic and ischemic tissues is frequently observed. Nondiabetic patients tend to have a more favorable recovery from an ischemic wound than diabetic patients. Damage to hypoxic myofibroblasts is amplified by hyperglycemia. 5) TNF-α expression is increased in diabetic wounds, leading to inappropriate myofibroblast apoptosis. 

Conclusions: Based on studies utilizing experimental animal models, hyperglycemic conditions can interfere with cytokine expression, dysregulate dermal lipolysis and enhance hypoxia damage. Given the data on myofibroblast activity in human diabetic wound healing is limited, additional research on the impact of diabetes on human myofibroblasts should be conducted.

Competition Category: Basic Science or Translational

Mentor: Robert Galiano, MD

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Andres Guerra, MD

Fellow (Clinical or Postdoctoral Researcher)

Characterizing post-discharge venous thromboembolism chemoprophylaxis after colorectal cancer surgery following the implementation of a surgical quality improvement collaborative process measure

Introduction: Venous thromboembolism (VTE) remains the number one preventable cause of post-operative mortality after abdominopelvic cancer surgery. Nevertheless, low national adherence rates to VTE chemoprophylaxis persist. We therefore implemented a post-discharge VTE chemoprophylaxis process measure in a statewide quality improvement collaborative and aim to (1) characterize adherence to the process measure after implementation, and (2) determine factors associated with low VTE chemoprophylaxis adherence.

Methods: A retrospective review of patients who underwent colorectal cancer surgery between September 1, 2016 and June 30, 2020 was performed utilizing data from the American College of Surgeons National Surgical Quality Improvement Program (ACS NSQIP) and the Illinois Surgical Quality Improvement Collaborative (ISQIC). Adherence to the ISQIC VTE post-discharge chemoprophylaxis process measure was defined as discharge with low molecular weight heparin for 28 days post-operatively. Multivariable logistic regression evaluated the association of perioperative and operative factors with VTE chemoprophylaxis use.

Results: A total of 4,118 patients from 34 hospitals were identified in our cohort. The majority of patients were male (51.4%), non-Hispanic white (75.2%), with mean age of 64.5 years. Most procedures were colectomies (92.6%) with the most common operative approach being laparoscopic (65.9%). There were 2,246 patients (54.5%) discharged with chemoprophylaxis during the study period. During the first three months of process measure implementation, 51.6% of patients received post-discharge chemoprophylaxis, which increased to as high as 72.8% in the last three months of the study period. Patients with ASA class IV-V had higher odds of being discharged on chemoprophylaxis (OR 1.98, 95% CI 1.20–3.26) compared to ASA class I-II. There was no association with operative approach or case urgency however, those who underwent proctectomy had higher odds of receiving chemoprophylaxis (OR 2.26, 95% CI 1.2–4.26) compared to colectomy. Operative times less than 2 hours had lower odds of post-discharge chemoprophylaxis (OR 0.48, 95% CI 0.38 – 0.60) compared to those between 2 and 5 hours. Additionally, patients with post-operative sepsis had decreased odds of receiving chemoprophylaxis (0.42, 95% CI 0.26 – 0.68). 

Conclusion: Adherence with post-discharge VTE chemoprophylaxis in patients undergoing colorectal cancer surgery has steadily improved after implementation of a surgical quality improvement collaborative process measure. Several factors were associated with decreased process measure adherence including higher ASA class, procedure type, and operative times.  Continued improvement will require hospital-specific, tailored, quality improvement efforts.

Competition Category: Clinical or Quality

Mentor: Ryan Merkow, MD

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Atieh Hajirahimkhan, PhD

Fellow (Clinical or Postdoctoral Researcher)

The potential role of licorice and its bioactive compounds in promoting a tumor preventive environment in the postmenopausal breast

Introduction: our purpose was to define if licorice and its main bioactive compounds can suppress aromatase expression/activity and Nrf2 dependent detoxification pathways in the postmenopausal breast. This chemopreventive potential has not previously been reported in preclinical models of high-risk postmenopausal breast.

Methods: Inhibition of aromatase activity by three licorice extracts (Glycyrrhiza species), and their bioactive compounds, (liquiritigenin; LigF, isoliquiritigenin; LigC, 8-prenylapigenin; 8-PA, and licochalcone A; LicA) were evaluated fluorometrically, using aromatase supersomes. Computational docking was performed to assess the binding of the bioactive compounds to the binding pocket of aromatase crystal structure compared to the known aromatase inhibitors, letrozole (non-steroidal) and exemestane (steroidal). Using qPCR, the effects of treatments on the expression of aromatase (CYP19A1) mRNA and Nrf2 dependent detoxification enzyme NADPH:quinone oxidoreductase 1 (NQO1) in breast microstructures obtained from high risk postmenopausal women were evaluated.

Results: Among the three medicinally used licorice species, Glycyrrhiza inflata (GI) showed the highest aromatase inhibitory potency (IC50 ≈ 1 µg/mL). Licorice phytoestrogens, LigF (400 nM or 0.1 µg/mL), and 8-PA (IC50 ≈ 590 nM or 0.2 µg/mL) exhibited the highest potency compared to the other tested licorice compounds. Computational docking suggested that these phytoestrogens bind to the aromatase binding pocket like the aromatase inhibitor, letrozole. This effect was not observed with non-estrogenic bioactive compounds of licorice, LigC and LicA (specific to GI). In breast microstructures obtained from high risk postmenopausal women, expression of aromatase mRNA was suppressed by GI (30%, P < 0.05), LigF (20%, P < 0.05), and LicA (45%, P< 0.05), while the expression of NQO1 mRNA was enhanced by LicA (200%, P < 0.0001).

Conclusions: Licorice species, and their bioactive compounds inhibited aromatase activity in vitro. In the breast microstructures, GI, its compounds LigF and LicA suppressed aromatase expression, and LicA enhanced NQO1 induction, significantly. Future studies will further elucidate the potential of these natural products for promoting a breast tumor preventive environment in postmenopausal women.

Competition Category: Basic Science or Translational

Mentor: Seema Khan, MD

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Monika Halas, MD

Fellow (Clinical or Postdoctoral Researcher)

Transcatheter mitral valve replacement (TMVR) - why so few?

Introduction: Mitral regurgitation (MR), the most prevalent form of valvular heart disease, remains a formidable public health care problem. Non-surgical interventional treatment is based on important arguments, such as the poor prognosis if left untreated, as well as the reluctance for open surgical replacements in elderly patients. Transcatheter mitral valve replacement (TMVR) has emerged as a compelling possibility after successful implementation of transcatheter aortic valve replacement interventions. Yet, despite the advancement in technology, progress of TMVR therapy remains slow and feasible only for selected patients.  We sought to determine the relative frequency of interventional MR treatment options, with a focus on the use of TMVR.

Methods: From 9/18/2015 (when TMVR first became available in our institution) until 12/31/2019, 721 patients underwent a mitral intervention or evaluation for TMVR. Inclusion criteria used for analysis was TMVR, MitraClip, and surgical MV repair or replacement procedures. Data was collected from our prospective STS database and TVT Registry. Patients with prior mitral replacement surgery, bacterial endocarditis, concomitant aortic valve replacement, aneurysm > 5.0 were excluded. Patients that failed to enroll in TMVR intervention were carefully reviewed in terms of their MR etiology and reason for screen fail, and followed on their alternative management choice. 

Results: Of these 721 mitral interventions, 410 patients underwent mitral valve repair (57%); 102 had surgical MVR (14%); 178 had MitraClip (25%); 9 MViV (1%); 5 TMVR (1%). TMVR screening identified 81 patients. Only 5 (6%) qualified for TMVR, whereas 76 (94%) failed the screening process due to: inadequate medical condition (32%; n=24/76); valvular technical implant difficulties such as size of the annulus (30%, n=23/76); anticipated ventricular problems such as neo-LVOT risk (25%; n=19/76); and withdrawal from TMVR therapy 13% (n=10/76). For alternative treatment choice medical management was the most prevalent (50%, n=38/76), followed by surgical MV replacement (16%, n=12/76); MitraClip (13%, n=10/76); and in 11% unknown (n=8/76). In medically managed patients 30-day and 1-year mortality were 2% (n=2/38) and 13%(n=5/38), respectively. 

Conclusions: TMVR theoretically is a valuable option for patients requiring mitral intervention. However, its application is limited by current technology, primarily due to anatomical limitations in patients. Survival for medically managed screen failures remains lower than desirable. Hence, there is still an unmet need for technical improvements in TMVR devices.

Competition Category: Clinical or Quality

Mentor: Patrick McCarthy, MD

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Katherine Hekman, MD, PhD

Senior Resident (Clinical PGY3-5)

Direct oral anticoagulants decrease treatment failure for acute lower extremity DVT

Objective: Optimal medical therapy for acute lower extremity deep venous thrombosis (DVT) remains an enigma. While clinical trials demonstrate non-inferiority with an oral anti-Xa inhibitor, or direct oral anticoagulant (DOAC), versus combined low molecular weight heparin (LMWH) and oral vitamin K agonist (VKA), the most effective regimen remains to be determined.

Methods: This study is a single-center retrospective cohort study from October 2014-December 2015 of patients with a diagnosis of acute DVT and subsequent serial lower extremity venous duplex. Demographics, medical history, medications, serial ultrasound findings as well as the primary anticoagulant used for treatment were collected and analyzed by two independent data extractors. Treatment failure was defined as any new DVT or progression of an existing DVT within 3 months of diagnosis of the index clot. Risk factors for treatment failure were assessed using standard odds ratios and Fischer’s exact test.

Results: Among 496 patients with an acute lower extremity DVT, 54% (n=266) were men, mean age was 61 years, 35% (n=174) involved the popliteal or more proximal segments, and 442 had documentation of the primary treatment for DVT: 20% (n=90) received nothing; 20% (n=92) received an oral VKA; 34% (n=149) received a DOAC; 20% (n=90) received LMWH; and 5% (n=21) received another class of anticoagulant.  Within 3 months, 21% (n=89 out of 427) had treatment failure defined as any new DVT or progression of prior DVT. Patients treated with a DOAC were less likely to experience treatment failure when compared with any other treatment (odds ratio 0.43; 95% confidence intervals [0.23, 0.79]; p=0.0069), and when compared with traditional oral VKA (OR 0.44; 95% CI [0.21, 0.92]; p=0.029). None of prior history of DVT, pulmonary embolism, thrombophilia, renal insufficiency, hepatic insufficiency, cancer, or antiplatelet therapy correlated with treatment failure. Treatment outcome did not correlate with being on any anticoagulation versus none (p=0.74), nor did it correlate with the duration of treatment (<3 months versus >3 months) (p=0.42). Proximal and distal DVTs showed no difference in treatment failure (19% versus 22%, respectively; p=0.43).

Conclusion: In summary, the use of a DOAC for acute lower extremity DVT yielded better overall outcomes and fewer treatment failures at 3 months as compared to traditional oral VKA therapy based on serial duplex imaging.

Competition Category: Clinical or Quality

Mentor: Mark Eskandari, MD

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Jessie Ho, MD

Senior Resident (Clinical PGY3-5)

Results of a modified lower extremity venous duplex ultrasound protocol for patients with COVID-19

Objectives: COVID-19 is associated with increased risk of venous thromboembolism, for which timely and accurate diagnosis are crucial. Sonographers performing lower extremity venous duplex ultrasound (LEVDUS) in this setting are placed at an increased risk for exposure to COVID-19 due to close contact with these patents for an extended period of time. In March 2020, our division instituted a modified LEVDUS protocol for patients with suspected or confirmed COVID-19: If an acute DVT was detected, the test could be terminated early. Here we evaluate our preliminary results with this modified protocol.

Methods: This was a single center retrospective review. Patients who underwent a COVID-19 protocol LEVDES between March 1, 2020, and June 30, 2020, with a confirmed COVID-19 diagnosis either by testing or clinical exam were included. The number of segments recorded by the sonographer was utilized as a surrogate measure for time spent with the patient.

Results: One hundred sixty subjects who underwent 208 studies using the COVID-19 LEVDES protocol met inclusion criteria, with 57.5% (N=92/160) male subjects. Studies on average included 21.7 images (range 3-112) and visualized 10.6 of 14 possible segments (range 1-14). 35.6% of index studies were abbreviated, visualizing fewer than 12 segments. On initial duplex, 27.5% of subjects (N=44/160) had an acute DVT, while 5.0% (N=8/160) had a chronic DVT. Women were less likely to have an acute DVT (odds ratio 0.47, 95% confidence interval [0.22, 0.98]; p=0.045). On subsequent imaging, most (56.4%, N=22/38) had no DVT, while 17.9% (N=7) demonstrated a new acute DVT and 23.1% (N=9) were either chronic, stable or resolved. Only 1 new acute DVT occurred in a patient who index study was abbreviated due to the presence of a DVT in a different segment. Index duplexes that were positive for acute DVT had fewer visualized segments (8.4 vs 11.5, p<0.0001). 34 of the 160 patients had a CT to evaluate for pulmonary embolism (PE) at the time of or after their index venous duplex, with a total of 14 studies positive for PE.

Discussion: The modified COVID-19 LEVDUS protocol reduces time sonographers spend with patients with COVID-19. Few subsequent duplexes demonstrated new acute DVT, and nearly all (6/7) occurred in segments that had been visualized in the index study, confirming that they were not “missed” in the index study.

Competition Category: Clinical or Quality

Mentor: Tadaki Tomita, MD

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Andrew Hu, MD

Fellow (Clinical or Postdoctoral Researcher)

Association of surgery delay related to SARS-CoV-2 with complications among pediatric patients with inguinal hernia

Background: During the peak of the SARS-CoV-2 pandemic, several elective surgical procedures were strategically delayed.  The purpose of this study was to determine if delays in elective pediatric inguinal hernia repair were associated with complications.  

Methods: We performed a multi-center retrospective cohort study at 14 children’s hospitals in the US comparing patients ≤ 18 years of age undergoing inguinal hernia repair during a 6 month period before and after the SARS-CoV-2 pandemic elective surgical procedure restriction.  Patient demographics, interval healthcare utilization, incarceration rates, and operative characteristics were collected. Fisher’s exact, Wilcoxon rank-sum, and Chi-squared statistical tests were used for comparison.

Results: Of 1598 patients included in the study, 772 (48.3%) received their operation following elective surgical restrictions, 1248 (78.1%) were male, and 716 (44.8%) were diagnosed at <1 year of age. After initiation of restrictions, patients had significantly more days between diagnosis and surgery (Figure 1) but no significant difference in the rate of incarceration (pre 7.64% vs post 5.81%, p=0.14). There was no significant difference in the median number of days from diagnosis to incarceration (pre 17.5 (IQR 9 – 64) vs post 24 (IQR 5 – 71), p = 0.83). After restrictions, diagnosis was more frequently performed via telehealth (pre 0.12% vs post 6.09%) and in the emergency department (pre 9.7% vs post 13.9%, overall p<0.01).

Conclusions: Delays in elective surgery due to the SARS-CoV-2 pandemic were not associated with inguinal hernia complications but were associated with an increase in diagnosis through telemedicine and emergency department encounters.

Competition Category: Clinical or Quality

Mentor: Mehul Raval, MD, MS

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Mecca B.A.R. Islam, MS

Fellow (Clinical or Postdoctoral Researcher)

Short chain fatty acid supplementation improves neurocognitive outcomes after traumatic brain injury in mice

Introduction: Over 3 million Americans sustain a traumatic brain injury (TBI) annually with significant long-term morbidity resulting in motor, cognitive and behavioral deficits. Evolving evidence suggests that post-TBI disruption in the gut microbiome may play a role in these long-term neurocognitive outcomes. In particular, post-TBI depletion of commensal bacteria responsible for fermenting dietary fiber into short-chain fatty acids (SCFA) is an increasing area of interest.

Hypothesis: We hypothesized that dietary supplementation with short-chain fatty acids would attenuate neurocognitive impairment after traumatic brain injury.

Methods: Severe TBI or sham-injury was induced in 15-week-old (n=32) male C57BL/6 mice via controlled cortical impact. The short-chain fatty acids acetate, butyrate, and propionate vs. vehicle were added to the drinking water post-injury. 45-days post-TBI or sham-injury, mice underwent neurocognitive testing with open-field testing and cued fear conditioning to assess learning, memory, and anxiety. Data analyzed using one-way ANOVA and Tukey’s multiple comparison test.

Results:  TBI mice supplemented with SCFA post-injury displayed markedly less anxiety-like behavior than vehicle-treated TBI mice as measured by time spent in the center region of the open field (19.75 ± 6.1% time vs. 29.9 ± 4.9% time, p=0.004).  In addition, we observed significant preservation of associative learning and memory in  SCFA treated TBI mice as compared to the vehicle-treated TBI mice as measured by cued fear conditioning (68.44s ± 12.99% time freezing vs. 47.03 ± 24.5 % time freezing,  p=0.03).

Conclusions: Dietary supplementation with short-chain fatty acids markedly improved neurocognitive outcomes after TBI. These data suggest preservation of the connectivity between the hippocampus and prefrontal cortex in SCFA treated TBI mice. Additionally, vehicle-treated TBI mice showed marked disinhibition of normal anxiety-like behavior suggesting a greater loss of connectivity between the amygdala and hippocampus as compared to SCFA treated TBI mice. Taken together, these data suggest a therapeutic benefit of SCFA supplementation after TBI.

Competition Category: Basic Science or Translational

Mentor: Steven Schwulst, MD

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Lindsay Janes, MD

Senior Resident (Clinical PGY3-5)

An in-vivo comparison: Novel mesh suture versus traditional suture-based repair in a rabbit tendon model

Background: Despite advancements in surgical technique, suture pull-though and rupture continue to limit early range of motion and functional rehabilitation after flexor tendon repairs. A novel mesh suture has been described for use in abdominal wall repairs with resultant improvements in suture pull-through and repair strength; however, the utility of mesh suture in flexor tendon repairs remains relatively unknown. The aim of this study was to evaluate a mesh suture compared to a commonly used braided suture in an in-vivo rabbit intrasynovial tendon model.

Methods: Twenty-four 3.0-4.0 kg New Zealand Female Rabbits were injected with 2u/kg botulinum toxin evenly distributed into 4 sites in the left calf.  After 1 week, animals underwent surgical tenotomy of the flexor digitorum tendon and were randomized into repair with either 2-0 DurameshTM suturable mesh or 2-0 Fiberwire® utilizing a 2-strand modified Kessler and 6-0 polypropylene running epitendinous suture. Rabbits were sacrificed at 2, 4, and 9 weeks postoperatively.  The tendon repairs were evaluated, and biomechanical testing was performed.

Results: Grouping time points, 58.33% (7 of 12) of DurameshTM repairs were noted to be intact at explant compared to 16.67% (2 of 12) Fiberwire® repairs (p = 0.0894). At 2 weeks, the mean DurameshTM repairs were significantly stronger than the Fiberwire® repairs with a mean failure load of 50.69N ± 12.72N compared to 14.84N ± 18.26N (p = 0.0212). The load supported by the DurameshTM repairs at 2 weeks (mean 50.69 ± 12.72) was similar to the load supported by both Fiberwire® (52.19 ± 13.62) and DurameshTM (57.59 ± 22.30) at 4 weeks.  The strength of repair between Fiberwire®  and DurameshTM at 4 weeks and 9 weeks was not significantly different.

Conclusions: Tendon repair with mesh suture presents an exciting new technique that may allow earlier active motion and stronger tendon repairs.  Future studies should evaluate strength of repair prior to two weeks to determine a strength curve for this novel suture material.

Competition Category: Basic Science or Translational

Mentor: Jason Ko, MD, MBA

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Rachel Joung, MD

Senior Resident (Clinical PGY3-5)

Genetic testing in colon cancer: How are we doing?

Introduction: Microsatellite instability (MSI), caused by DNA mismatch repair (MMR) deficiency, is observed in up to 15% of colorectal cancers, and it has important implications in treatment and prognosis. Despite NCCN-guideline recommendations to broaden testing in 2014 (all patients age <70 and/or stage II), the impact of these recommendations on MSI/MMR testing in the US is unclear. Our objectives were to (1) evaluate MSI/MMR testing trends over time, (2) identify factors associated with appropriate MSI/MMR testing, and (3) assess hospital-level variation in MSI/MMR testing.

Methods: Patients diagnosed with invasive colon adenocarcinoma between 2010 and 2017 who were less than 70 years old or had stage II disease were identified in the National Cancer Database. The primary outcome was receipt of MSI/MMR testing. Trends were evaluated by comparing pre-guideline (2010-2014) and post-guideline (2015-2017) periods. Patient, tumor, treatment, and hospital factors associated with MSI/MMR testing were assessed by hierarchical multivariable logistic regression.

Results: A total of 280,099 patients at 1,348 hospitals were included. Overall, 30.3% received MSI/MMR testing. There was a significant increase in testing after guideline recommendations (pre: 25.2% vs post: 38.2%; OR 2.15, 95% CI 2.11-2.20). Patients were more likely to receive testing post-guideline release if younger (<50 vs 50-69 years: OR 1.27, 95% CI 1.21-1.34), later year of diagnosis (2017 vs 2015: OR 1.72, 95% CI 1.66-1.78), treated at an academic facility (OR 1.26, 95% CI 1.09-1.44), underwent surgery (OR 4.17, 95% CI 3.88-4.48), or received chemotherapy (OR 1.20, 95% CI 1.15-1.26). Among hospitals, the rates of MSI/MMR testing ranged from 0% to 100% (median 35.4%; IQR 13.0-60.5%). The greatest amount of variation in MSI/MMR testing occurred at the hospital level (47.1%).

Conclusion: Rates of MSI/MMR testing has increased over time but adherence to guideline recommendations remains low. Predictors of low MSI/MMR testing included patient, tumor, and treatment factors; however, the majority of the variation occurred at the hospital-level. MSI/MMR testing is an ideal target for national quality improvement efforts to improve colorectal cancer care.

Competition Category: Clinical or Quality

Mentor: Ryan Merkow, MD, MS

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Aaron Kearney, MD

Senior Resident (Clinical PGY3-5)

A multi-hospital system electronic medical record order set reduces prescription opioids in hand surgery

Introduction: Postoperative opioid prescriptions have played a role in the epidemic of opioid addiction, leading to persistent opioid use in some patients as well as the potential for opioid misuse and diversion. We hypothesize that an electronic medical record order set will reduce the amounts of opioids prescribed for hand surgical procedures.

Methods: An order set for postoperative pain medication prescribing for orthopedic, spine and plastic surgeons was implemented into a 10-hospital electronic health record system. In this order set, each Current Procedural Terminology (CPT) code is linked to 1 of 4 pain Tiers associated with recommended opioid pill numbers.

We identified all hand surgery patients by CPT codes beginning 12 months before to 15 months after implementation of the order set. Patient demographics were tabulated, including age, sex, ethnicity, comorbidities, and insurance status. 

The primary outcome was Morphine Milligram Equivalents (MME) prescribed before and after implementation of the order set. Secondary outcomes included opioid refills, lengths of stay, readmissions, emergency room visits, and death within 30 days of discharge before and after order set implementation. A segmented regression analysis was performed utilizing a linear mixed effects model controlling for potential confounders.

Results: 1,844 patients were identified: 883 patients before and 961 patients after implementation of the order set. The mean age at the time of surgery was 54.7 ±17.3 years. Approximately 50% of patients were female, 1,030 (55.9%) patients had private insurance, 692 (37.5%) had public insurance, and 83 (4.5%) patients were covered by workers’ compensation.

Before implementation of the order set, prescribed MME for postoperative pain decreased 14% each quarter (eβ: 0.86, 95% CI: (0.82, 0.91), p-value<0.0001). After implementation, MME prescribed decreased 23% (eβ: 0.77, 95% CI: (0.67, 0.90), p-value=0.0010); this decrease persisted over the ensuing 15 months (Figures 1 and 2) (Median MME per surgery: 600 before vs. 400 after). There was no increase in opioid prescription refills. In both time periods, median length of stay was 0 days, no deaths within 30 days were observed, and both 30-day readmissions and ER visits were rare (<1%).

Conclusions: The electronic medical record order set led to a rapid and sustained reduction in opioid prescription MME for hand surgery patients.

Lowering prescription opioid pill numbers with use of the electronic medical record order set did not lead to an increase in opioid prescription refills postoperatively.

Competition Category: Clinical or Quality

Mentor: David Kalainov, MD, MBA

Bona Ko, MD

Senior Resident (Clinical PGY3-5)

Is grade A post-hepatectomy liver failure clinically relevant?

Introduction: The clinical relevance of mild elevations in serum bilirubin after resection (grade A post-hepatectomy liver failure) remains unclear. Our objective was to evaluate differences in postoperative outcomes among patients with grade A PHLF against those without PHLF and those with grade B/C PHLF.

Methods: Patients who underwent elective major hepatectomy from 2014 to 2018 were identified in the ACS NSQIP hepatectomy-targeted dataset. The outcomes assessed included 30-day mortality, morbidities, re-intervention, and length of stay (LOS). Multivariable logistic regression was used to evaluate the association between of PHLF grade and 30-day outcomes.

Results: A total of 6274 patients were identified. The incidence of grade A PHLF was 4.3% and grade B/C was 5.3%, making the overall incidence of PHLF 9.6%. The rate of 30-day mortality was 1.2% in patients without PHLF, 1.1 % in patients with grade A PHLF, and 25.4% in patients with grade B/C PHLF (P< 0.001). PHLF was associated with increased LOS, overall morbidity, serious morbidity, postoperative interventions, and mortality. Patients with grade A had similar odds of mortality compared to patients without PHLF but had significantly worst odds of morbidity and LOS.

Conclusion: Our analysis shows a high incidence of PHLF following major hepatectomy. Although mortality was similar between patients without PHLF and with grade A PHLF, other postoperative outcomes were notably worse for grade A patients. Grade A PHLF is a clinically significant entity with relevant associated postoperative morbidity.

Competition Category: Clinical or Quality

Mentor: David Bentrem, MD

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Annemarie Leonard, BS

Student

Use-mediated thermogenic properties of cast saw blades

Introduction: Cast saw burns are a costly, avoidable iatrogenic injury with a multitude of modifiable risk factors including the use of old saw blades in cast removal. The blade characteristics that are responsible for contributing to that increased risk is not well described in the literature. Thus, this study aims to characterize the use-mediated thermogenic properties of cast saw blades to determine when a blade becomes unsafe for use.

Methods: Stryker saw blades with a variable amount of wear were used with a Stryker vacuum cast saw [insert model number] by an experienced orthopedic surgeon to remove fiberglass casts. Blade temperature were recorded before, after five passes, and after ten passes with a K-type Proster thermocouple.

Results & Conclusion: Preliminary data demonstrates a linear correlation between quantity of blade debris and blade dullness is correlated with an increased in blade temperature after ten passes.

Competition Category: Clinical or Quality

Mentor: Jill Larson, MD

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Ruojia Li, MD, MS

Junior Resident (Clinical PGY1-2)

Percutaneous vascular surgery procedures shorten hospital sty with the risk for more post-discharge complications

Objectives: Percutaneous endovascular treatment for arterial vascular diseases have revolutionized vascular care. While these procedures offer improved morbidity, mortality, and length of stay (LOS), their effect on post-discharge complications is unknown. The objectives of the study were to (1) evaluate trends in LOS and post-discharge complications over time, and (2) assess factors associated with post-discharge complications.

Methods: Patients who underwent surgery for common vascular pathologies (AAA, aortoiliac disease, lower extremity disease, and carotid stenosis) were identified from the ACS NSQIP Procedure-Targeted database (2014-2019).  Outcomes included LOS, 30-day complications, and proportions of post-discharge complications. Predictors of post-discharge complications were assessed using multivariable logistic regression.

Results: Of 80,311 patients evaluated, median LOS did not change from 2014 to 2019 (2, IQR 1-5). Overall, 15.7% of patients experienced any 30-day complication, with 31.3% occurring after discharge. The proportion of post-discharge complications increased from 29.1% (2014) to 35.9% (2019), p<0.001. With exception of carotid procedures, endovascular procedures had lower complication rates than open procedures (Figure 1), however, there was increased proportion of post-discharge complications for endovascular procedures (Figure 2), (all p<0.001). Factors associated with an increased odds of post-discharge complications included female, Black or other race, dependent functional status, underweight or obesity, increased LOS, and operation time, all p<0.05. 

Conclusion: Across four representative vascular pathologies, endovascular treatments had a higher proportion of post-discharge complications compared to open procedures. Early identification and evaluation of post-discharge complications for endovascular patients may be warranted to avoid unplanned readmission.

Competition Category: Clinical or Quality

Mentor: Mark Eskandari, MD

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Charles Logan, MD

Senior Resident (Clinical PGY3-5)

Danger in America’s small towns: rural-urban survival disparities for patients with surgically treated lung cancer

Introduction: Non-small cell lung cancer (NSCLC) is a common cancer diagnosis among patients living in rural areas and small-towns who face unique challenges accessing care. We examined regional differences in survival for rural patients compared to those from urban and metropolitan areas. 

Methods: The National Cancer Database (NCDB) was used to identify surgically treated NSCLC patients from 2004-2016. Patients from rural and small-town counties were compared to urban and metropolitan counties. Differences in patient sociodemographic, clinical, hospital, and travel distance characteristics were described using Chi square tests. Kaplan-Meier methods with log-rank tests and Cox proportional hazards analysis was used to examine differences in mortality. 

Results: The study included 366,373 surgically treated NSCLC patients with 12.4% (n=45,304) categorized as rural/small-town. Rural/small-town patients traveled farther for treatment and were from areas characterized by lower income and educational attainment (all p < 0.001). Survival probabilities for rural/small-town patients were worse at one year (85% vs 87%), five years (48% vs 54%), ten years (26% vs 31%), and fifteen years (11% vs 15%) (all p < 0.001). Living in a rural/small-town location remained an independent risk for death [HR=1.04, 95% CI 1.01-1.07] after controlling for cancer stage, patient and hospital characteristics, and travel distance. Risk of death increased as distance from the treating facility increased, with distance of 25-50 miles [HR 1.03, 95% CI 1.01-1.05], distance greater than 50 and less than 100 miles [HR 1.05, 95% CI 1.01-1.09] and distance greater than 100 miles [HR 1.11, 95% CI 1.06-1.15].

Conclusion: Rural and small-town patients with surgically treated NSCLC had worse survival outcomes compared to urban and metropolitan patients.

Competition Category: Clinical or Quality

Mentor: David Odell, MD

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Natalie Luehmann, MD

Fellow (Clinical or Postdoctoral Researcher)

Adherence to screening mammogram guidelines in the transgender/non-binary population

Introduction: Data is limited regarding rates of breast cancer and mammography screening within the transgender/non-binary (TGNB) population. Screening recommendations vary and there is no global consensus. TGNB patients face unique challenges that may preclude screening and risk assessment, such as barriers to accessing healthcare, lack of education among providers, and lack of clarity regarding hormonal impacts on risk. This study aims to address adherence to current screening mammogram recommendations within the TGNB population.

Methods: A retrospective chart review was performed using ICD codes, sexual orientation and gender identity data, and key words to identify TGNB patients that had contact with the Northwestern Hospital system between March 2019 and February 2021.  Patients assigned female at birth (AFAB) and age ≥ 40 with breasts were included as well as patients assigned male at birth (AMAB) and age ≥ 50 with ≥ 5 years of hormone use. Rates of screening mammogram were evaluated along with analysis of demographic factors that may predict for or against adherence to recommendations. ASBrS and USPSTF guidelines, screening mammograms starting at age 40 and 50, respectively, were applied to patients AFAB. UCSF Center for Transgender Health and Fenway Health guidelines (screening mammogram at age 50 and ≥ 5 years of hormone therapy) were applied to patients AMAB.

Results: Of the 32 patients that were AFAB and ≥ 40 years old, only one (3.1%) underwent screening mammogram by age 42. One of fifteen patients (6.7%) AFAB and ≥ 50 years old completed screening mammogram by age 52. In total there were 42 patients AMAB ≥ 50 years old with a ≥ 5 year history of hormone use; one (2.3%) completed screening mammogram by age 52. Univariate analysis and multivariate analysis evaluating for insurance status, employment status, level of education, and hormone use (i.e. testosterone in AFAB patients) did not identify any factors associated with likelihood of adhering to screening guidelines in either the transgender female or male population.

Conclusions: Adherence to screening mammogram recommendations among these TGNB population at Northwestern Hospital system is low across all sub-groups. In contrast, the ACO rate of adherence to screening mammogram at our institution for all-comers (age ≥ 50-74) in 2019 was 77.33%. Demographic data failed to elucidate any association with likeliness to undergo appropriate breast cancer screening. This disparity demands the development of initiatives aimed at increasing breast cancer screening rates for the Northwestern TGNB population.

Competition Category: Fellow

Mentor: Sumanas Jordan, MD, PhD

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Maxwell McMahon, BS

Student

Urgent versus emergent surgical workflow for acute appendicitis in children

Introduction: There is no evidence-based consensus regarding timing for appendectomy following initial presentation with acute appendicitis. Our institution underwent a temporary initiative to emergently expedite all appendectomies in order to decrease length of stay; here, we evaluate the association of urgent surgical intervention on outcomes relative to historic controls.

Methods: Patient records at a freestanding children’s hospital were reviewed from a six-month period where appendectomies for acute appendicitis were performed within two hours of diagnosis (expedited workflow). Outcomes were compared to the same calendar dates of the previous year (standard workflow). Descriptive statistics between the two groups were performed, using rate of complicated disease as the primary outcome, and including other clinical secondary outcomes.

Results: 164 patients underwent an appendectomy for acute appendicitis with 93 (56.7%) presenting in the expedited workflow cohort. The expedited workflow cohort hospital length of stay (LOS) was shorter, without differences in perforation rates, 30-day readmissions, or reintervention rates between the two groups (Table). In multivariate regression, complicated disease was associated with prehospital duration of symptoms, without significant effect from in-hospital time to OR.

Conclusion: We found that compared to standard practice, increasing the degree of urgency to appendectomy had no effect on clinical outcomes. Overall hospital length of stay was shorter in the expedited cohort, though this must be interpreted in the context of other ongoing quality improvement initiatives.  We conclude that appendectomy outcomes are best predicted by prehospital factors such as duration of symptoms, rather than in-hospital delays in surgical management.

Competition Category:

Mentor: Seth Goldstein, MD, MPhil

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Emily Merrick, BS

Student

National trends in gender affirming surgical procedures: a Google Trends analysis

Introduction: According to the American Society of Plastic Surgeon’s annual reports, there has been a 300% increase in gender-affirming surgery (GAS) procedures from 2015 to 2019. We evaluated if this increased interest translated into Google search trends related to GAS. Analyzing trends in searches will allow providers to determine where there may be an increased need for gender-affirming care.

Methods: Google Trends (GT) search terms were analyzed for national queries regarding GAS from January 2004 to February 2021. The 14 selected keywords covered GAS topics including but not limited to: “transgender surgery,” “gender-affirming surgery,” “top surgery,” and “bottom surgery.” The number of plastic surgery providers and academic surgery centers was collected from the World Professional Association for Transgender Health and Trans-health.com. Relative search volumes (RSVs) were analyzed by metro area to determine the relationship between search demand and personal income as defined by the Bureau of Economic Analysis. State Medicaid policies for transgender health services were also determined. Descriptive statistics were used to evaluate trends over time, RSVs, and geographical distribution in searches and available care. To account for population size, all data was collected as RSVs.

Results: Using GT, "bottom surgery” showed the greatest increase in interest. Geographic search volume was greatest in the Mountain/Pacific and New England/Middle Atlantic regions. It was the least in the South Atlantic region. The Mountain/Pacific region had the most providers offering GAS while the East/West South Central region had the least. The New England/Middle Atlantic and Mountain/Pacific regions had the most states with Medicaid policies covering gender-affirming care. Metro areas in the top 10 for RSV but bottom quartile for per capita personal income included: Florence, South Carolina, Beckley, West Virginia, and Bowling Green, Kentucky.

Conclusions: Since 2004, there has been an increase in general interest related to GAS with interest in “bottom surgery” most rapidly trending upwards. Regional RSVs were higher in states with explicit Medicaid policies related to transgender health and lower in states without these policies. Finances are therefore likely a barrier to seeking care. 67% of the low-income metro areas that demonstrated high search demand fell into the two regions with the fewest providers offering GAS. Using GT can help target care efforts to low-income areas with limited providers but high interest. Monitoring regional and metro trends in search terms will help ensure that interest in GAS is being matched with access to providers offering it.

Competition Category: Clinical or Quality

Mentor: Sumanas Jordan, MD, PhD

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Simon Moradian, MD

Senior Resident (Clinical PGY3-5)

Novel 3-D printed digit Osseo-integration prosthetic designs based on Fox Hound metacarpal and proximal phalanx measurements

Introduction: Digital amputation is the most common upper extremity amputation in the world. This can cause significant impairment in hand function, as well as psychosocial stigma. Currently, the gold standard for the reconstruction of digit amputations involves revision amputations, autologous reconstruction, or socket based prosthetics. However, if autologous options are not feasible, we believe that an osseo-integrated prosthetic reconstruction could provide a functionally and aesthetically superior alternative. Osseo-integration (OI) is the method by which a titanium implant is directly embedded into the bone shaft and allowed to heal.  A titanium abutment is positioned at the distal end and a skin aperture is fashioned around the abutment for external attachment. Since there are limited to no practical (OI) finger prosthetics in wide scale use, the goal of this project was to create a novel digit OI implant using measurements of a fox hound’s metacarpal/proximal phalanges. We hypothesize that the fox hound would be a suitable animal model given the metacarpal and proximal phalanx lengths which are similar to humans. 

Methods: 3 amputated cadaveric fox hound paws were obtained for dissection. The metatarsals/proximal phalanges were dissected.  Each bone was then sectioned. 16 measurements were taken for each cross-section to determine mean length of the bone piece, cortical bone thickness, and intramedullary space.  These measurements were then used to design/3-D print various implant protoypes.

Results: 3 metatarsal bones were sectioned into 14 separate 3 mm pieces. The mean bone length, cortical thickness, and intramedullary width for the 3 metatarsals was 74.1 mm +/- SD 0.67 mm, 1.80 mm +/- SD 0.47 mm, and 3.34 mm +/- SD 0.77 mm respectively. 3 proximal phalanges were sectioned into 6 separate 3 mm pieces. The mean bone length, cortical thickness, and intramedullary width for the 3 proximal phalanges was 35.2 mm +/- SD 0.42 mm, 2.01 mm +/- SD 0.38 mm, and 2.60 mm +/- SD 0.91 mm respectively. Based on these measurements, a 3-D, 6 implant protoypes designed and 3-D printed. 

Conclusion: The OI method is gaining traction as a feasible technique to treat large extremity amputees, although there are limited examples of digit OI.  Given that there is a large population that could benefit from such a simple yet elegant potential design, we believe that these novel designs ideas may be the stepping stone to create a functional experimental implant.

Competition Category: Basic Science or Translational

Mentor: Todd Kuiken, MD, PhD

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Katherine Ott, MD

Senior Resident (Clinical PGY3-5)

Maternal-to-fetal leukocyte trafficking in fetal maldevelopment

Introduction: The evolutionary advantage for the natural trafficking of maternal leukocytes to the fetal circulation remains unexplained. A role in the surveillance of early embryogenesis has recently been proposed. No previous study has examined the influence of abnormal development on maternal cell trafficking. To address this knowledge gap, we hypothesized that maternal cell trafficking to the fetal circulation is increased in response to abnormal development.

Methods: We challenged this hypothesis using a murine model of neural tube teratogenesis in which pregnant dams received intraperitoneal valproic acid (VPA) on E8.  Quantitative changes in maternal leukocyte trafficking were compared between VPA groups and controls.  Studies were performed in both immunologically matched (B6.Ly5.1 female x B6.Ly5.2 male) and immunologically mis-matched (B6.Ly5.1 female x Balb/c male) maternal-fetal hybrid matings. All litters were harvested on E14 and maternal chimerism measured in the circulating blood of individual fetuses.

Results: Maternal cell chimerism was higher in the blood of immunologically-matched fetuses that were exposed to VPA when compared to saline-injected controls (18.2% vs 7.7%, p<0.05).  Similarly, maternal cell chimerism was higher in immunologically mismatched fetuses exposed to VPA when compared to controls (8.1% vs 5.1%, p<0.05). A higher overall rate of fetal absorption was also seen in the VPA-treated litters when compared to controls (8.2% vs 1.3%, p<0.05).

Conclusion: Collectively, these results support that maternal cell chimerism to the fetus is significantly affected by abnormal fetal development.  Furthermore, the higher rates of fetal resorption in abnormal litters support a link between maternal leukocyte trafficking and the surveillance of fetal fitness.  Future experiments will clarify the specific cell phenotypes and mechanisms regulating this process.

Competition Category: Basic Science or Translational

Mentor: Aimen Shaaban, MD

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Vivek Pamulapati, MD

Senior Resident (Clinical PGY3-5)

Fecal transplantation-mediated modulation of neointimal hyperplasia after arterial injury in antibiotic-treated mice

Introduction: Neointimal hyperplasia after arterial injury is an inflammatory process resulting in restenosis and failure of bypass surgery, angioplasty, and stenting. We previously showed that germ-free (GF) mice have diminished susceptibility to neointimal hyperplasia after arterial injury, which is reversed by fecal transplantation (FT), suggesting that arterial remodeling is influenced by microbiota. However, GF mice have broadly impaired immune development, which could impact causative pathways. We hypothesized that gut microbiota transfer to adult antibiotic-treated conventional mice would confer the injury-induced arterial remodeling phenotype of the fecal donor.

Methods: Adult C57BL/6 mice were treated with cefoperazone (cefo) for 3 weeks followed by FT using donors from rat strains which are known to be susceptible (Sprague-Dawley;SD) or resistant (Lewis;LE) to neointimal hyperplasia. Control cohorts either received cefo alone or had neither cefo nor FT. All mice underwent left femoral artery wire injury (WI) 2 weeks after FT. Neointimal hyperplasia was assessed by morphometric analysis of arterial sections 2 weeks after injury. The gut microbiome of the recipients was assessed using 16S rRNA qPCR and shotgun metagenomics analysis of stool samples.

Results: Two weeks after WI, neointimal hyperplasia was similar between control and cefo-treated cohorts. Contrary to our hypothesis, LE recipients had significantly more neointimal hyperplasia compared to both controls and SD recipients (p=0.03). Microbial community profiling based on 16S rRNA and shotgun metagenomics of stool samples from the FT recipients revealed a strong negative correlation between relative abundance of Akkermansia muciniphilia  and neointimal hyperplasia (r=-0.7, p<0.0001). There was also differential expression of microbial genes related to complex sugar and metal metabolism. Interestingly, relative abundance of Akkermansia was significantly higher in the SD recipients than in the donor SD fecal slurry, indicating that cefo-treatment and FT resulted in complex alterations to recipient microbiota rather than direct microbial transfer.

Conclusion: We demonstrate that FT subsequent to antibiotic treatment in adult conventionally-raised mice is associated with neointimal hyperplasia susceptibility after arterial injury through complex alterations to the recipient gut microbial community structure. Relative abundance of Akkermansia muciniphilia was associated with decreased neointimal hyperplasia. Ongoing transcriptomic analysis will be used to identify key microbial metabolic pathways and their impact on arterial remodeling in the host.

Competition Category: Basic Science or Translational

Mentor: Karen Ho, MD

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Matias Pollevick, BS

Student

Outcomes and reintervention after repair of Type I aortic dissection

Introduction: After emergency surgery for ascending aortic dissection, patients frequently have residual dissection of the thoracic or thoracoabdominal aorta that mandates lifelong surveillance and management.  This study examines outcomes for these patients based on the extent of aortic reconstruction at index repair.

Methods: This is a single-center, retrospective analysis of acute Debakey Type 1 dissections treated between October 2009-July 2020.  Patient characteristics, procedural details, and reintervention data were obtained from the EHR.  The extent of index repair was defined as a total arch if any aortic arch vessels were reconstructed, and hemiarch if not.  Reintervention was defined as any aortic procedure after index repair.  Procedure characteristics were compared with Fisher's exact test; Kaplan-Meier and log-rank tests were used for intervention and overall survival.

Results: 157 patients underwent operative repair for acute Type I aortic dissection during the study period, with median followup of 26.3 months (interquartile range [IQR] 7.0 – 60.7).  Patients were predominantly male (n = 109, 69.9%), with mean age of 58.7 years at time of index repair.  More patients underwent a hemiarch (n = 106, 67.5%), compared to total arch reconstruction with (n = 23, 14.7%) or without (n = 28, 17.8%) an elephant trunk procedure.  Rates of valve replacements were similar between index repair type (42.5% hemiarch vs 47.1% total arch, p = 0.610).  Operative reinterventions were required in 26 patients (16.2%), of which 14 (53.9%) were open reconstructions, 4 (15.4%) were hybrid procedures, and 8 (30.8%) were endovascular only.  Most reinterventions occurred within two years of index repair (n = 19, 73.1%), with median time to reintervention of 7.7 months (IQR 2.9 – 42.0).  Asymptomatic arch or descending thoracic aortic aneurysm were the most common indications for reintervention (n = 12, 46.2%).  Symptomatic indications for reintervention were present in 9 patients (34.6%), and included symptomatic aneurysm (n = 4), recurrent TIA (n = 2), and chronic mesenteric ischemia (n = 1).  Freedom from reintervention (86.8% hemiarch vs 78.5% total arch, p = 0.097) and overall survival at 3 years (75.7% hemiarch vs 80.5% total arch, p = 0.780) were not different by extent of index repair.

Conclusion: Aortic reintervention is common after surgical repair of Type I dissection.  Longitudinal, multidisciplinary management of these patients is warranted.

Competition Category: Clinical or Quality

Mentor: Andrew Hoel, MD

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Narainsai Reddy, BA

Fellow (Clinical or Postdoctoral Researcher)

A global health database of international rotations by plastic surgery programs

Introduction: Global health exposure is a crucial aspect of residency training which affords trainees the ability to gain cultural humility and a deeper understanding of different health systems. For host countries and sites, these rotations enable longitudinal capacity building. Within plastic surgery programs, international rotations must be approved by the American Council of Graduate Medical Education (ACGME) for cases done during these rotations to count toward the case logs for participating residents. A rotation site requires approval from an institution’s designated institutional officer (DIO), a signed Program Letter of Agreement (PLA) between the institution and rotation site, and on-site faculty who meet the home institution’s educational criteria. Approval must then be obtained from the ACGME Plastic Surgery Residency Review Committee (RRC) and American Board of Plastic Surgery (ABPS). This multi-step approval process creates significant variability among international rotation opportunities offered by residency programs.

Methods: We surveyed program directors from all 102 integrated and independent plastic surgery programs about their international rotations. We compiled a dynamic list of the 57 programs which responded and identified the 30 programs with approved global health rotations. We utilized this data to create a database containing the 30 plastic surgery programs which offer international rotations with prior DIO and RRC/ABPS approval. This dynamic database will be part of the American College of Academic Plastic Surgeons (ACAPS) website.

Results: The database includes basic program structure, DIO/RRC approval status of rotations, postgraduate year of participating residents, minimum and maximum durations of rotations, rotation sites, approval status for using vacation time to participate, the status of recent resident participation, approval for resident participation from outside institutions, and types of coverage offered.

Conclusions: A centralized list will help applicants make an informed decision when ranking programs with global health offerings. Additionally, it will begin to stimulate programs to seek approval for their rotations, create multi-institutional partnerships, and arm program directors with the necessary data to advocate their respective DIO to obtain institution approval. This database will incentivize programs to sustainably explore global health involvement within their institutions. Global health opportunities add meaningful value to trainees, programs, and host countries, and should play a larger role in residency.

Competition Category: Fellow

Mentor: Arun Gosain, MD

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Daniel Sasson, BA

Student

The impact of top surgery on chest dysphoria in transgender and non-binary adolescents and young adults

Introduction: Top surgery has been shown to improve gender dysphoria and quality of life in adult transmasculine patients. However, as an increasing number of adolescents and young adults present for gender-affirming surgery, the impact of top surgery on this population is not well described. Minors require parental consent and often face more stringent insurance restrictions. This study aims to increase the body of evidence for gender-affirming top surgery in adolescents and young adults.

Methods: Transmasculine and non-binary patients between the ages of 13-25 years presenting for top surgery consultation were recruited from Northwestern Memorial Hospital, The University of Illinois at Chicago, or Ann & Robert H. Lurie Children’s Hospital. Patients completed four patient-reported outcomes measures at three time points: pre-operative baseline, three-months postoperative, and one-year postoperative. The questionnaires employed included the Transgender Congruence Scale (TCS), Utrecht Gender Dysphoria Scale (UGDS), Chest Dysphoria Measure (CDM), and Body Image Scale (BIS). Preliminary analysis of mean change scores between pre- and three-month post-operative surveys was performed using paired, two-sided t-tests.

Results: Eighty-five patients have been enrolled to date. At the interim analysis, 27 patients, mean age 18.6±3.2, range 14-24 years, had completed the 3-month follow-up. Twenty-four identified as transmasculine, two non-binary/genderqueer, and one ‘other.’ Mean change from baseline to three-months of the TCS appearance congruence sub-scale was 8.1 points (p < 0.01), internal congruence sub-scale was 0.3 points (p = 0.21), and total score scale was 8.4 points (p < 0.01). The UGDS demonstrated a mean change of −1.5 points at three-months (p = 0.025). The CDM showed a mean change of −29.0 points at three-months (p < 0.01). The BIS total score mean change was −13.0 points at three-months (p < 0.01). Among the BIS subscales, the primary sexual characteristics score had a mean change of −6.2 points (p < 0.01), secondary sexual characteristics had a mean change of −3.4 points (p < 0.01), and neutral characteristics had a mean change of −2.4 points (p < 0.01) at three months.

Conclusion: Our preliminary findings demonstrate that gender-affirming chest surgery improves chest dysphoria, appearance congruence, and overall gender congruence in transmasculine and non-binary adolescents and young adults. We anticipate that the final data will inform clinical practice guidelines for transgender and non-binary patients seeking mastectomy and chest masculinization.

Competition Category: Clinical or Quality

Mentor: Sumanas Jordan, MD, PhD

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Carlos Serna III, PhD

Fellow (Clinical or Postdoctoral Researcher)

Incorporation of decellularized extracellular matrix in 3D-printed graphene-based scaffolds for treatment of volumetric muscle loss

Introduction: Large scale injuries from high-energy impact events are characterized by volumetric muscle loss (VML) and are irreparable by the innate skeletal muscle repair system. This loss of muscle mass exacerbates a reduction in peripheral nerve functionality as a severe consequence of VML. The application of 3D additive manufacturing processes in tissue engineering provides an opportunity to develop patient-specific implants for VML with personalized physical and biochemical properties. Graphene as a biomaterial has gained popularity in the field of rehabilitation due to its highly conductive nature and suitable biocompatibility, properties ideal for the regeneration of excitable tissues. Graphene has also demonstrated an ability to be incorporated into 3D manufacturing solutions, an attribute stemming from its superior mechanical flexibility. A significant drawback of these products, however, is low bioactivity. Extracellular matrix (ECM) derived from decellularized tissue offers an approach to mitigate this shortcoming. For VML specifically, decellularized muscle ECM (dECM) contains muscle-specific proteins and growth factors beneficial to tissue regeneration.

Methods: Here, we present a 3D composite with mouse-pup dECM fabricated using bioink made consisting primarily of graphene and the biocompatible elastomer, poly(lactide-co-glycolide) (PLGA). Using an extrusion-based system, graphene structures with and without dECM were printed under ambient conditions in four-layered stacks with strut sizes ranging between 125 – 250 µm in width.

Results: A reduction in electrical conductivity from 286.4 S/m to 74.4 S/m was observed in graphene scaffolds containing 2.5% dECM (gECM). Conversely, zeta potential values were measured to be -17.9 ± 5.14 mV in graphene scaffolds and -22.7 ± 5.76 mV in gECM scaffolds. These electrokinetic potentials help describe potential interactions between scaffold and cell surface. Scanning electron microscopy images showed no distinct differences in surface topography between the two scaffold types. In vitro experiments indicated that graphene and gECM scaffolds are both suitable in supporting glial cells and motor neurons. Both scaffold variants were also shown to be effective in supporting C2C12 muscle myoblast adhesion, alignment, viability, proliferation, and differentiation. Confocal imaging showed improved neural network interconnectivity in motor neurons seeded onto graphene scaffolds containing dECM. Increased fusion in C2C12 muscle myoblasts were also observed as they differentiated into myotubes on the surface of gECM scaffolds.

Conclusions: These findings suggest that graphene scaffolds containing dECM are capable of enhancing functional recovery following VML by promoting a neurogenic environment conducive to myoblast differentiation and myofiber maturation.

Competition Category: Basic Science or Translational

Mentor: Sumanas Jordan, MD, PhD

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Nikhil Shah, BS

Student

Craniofacial practice patterns in secondary cleft rhinoplasty procedures

Introduction: Patients with cleft lip often undergo a primary rhinoplasty at the time of cleft lip repair. Further surgical correction with secondary cleft rhinoplasty (SCR) can sometimes improve both form and function. While there is a general consensus regarding the technical details of primary rhinoplasty, the timing and technique of SCR remains variable. The purpose of this study was to better elucidate practice patterns for SCR performed in the United States.

Methods: We administered a survey to 193 American Cleft Palate Craniofacial Association (ACPA) approved cleft lip and palate care teams. Surveys were sent out to cleft team coordinators to be disseminated to their respective craniofacial surgeons.

Results: We received responses from 40 ACPA-approved teams for a response rate of 20.7%, with 55 craniofacial surgeons completing the survey. Data were divided between intermediate cleft rhinoplasty (3-14 years) and definitive cleft rhinoplasty (>15 years).
Intermediate cleft rhinoplasty: 76.4% of respondents perform intermediate cleft rhinoplasties. Among those who perform intermediate cleft rhinoplasty, many surgeons would first consider performing it at 5 years of age (41.2%). 65.3% of surgeons reported using an open (external) approach for unilateral cleft cases, and 73.5% of surgeons reported using an open approach for bilateral cleft cases. 61.2% of surgeons performing intermediate procedures utilize autologous cartilage grafts in up to a quarter of their cases. Additionally, surgeons reported utilizing cadaveric cartilages in 38.1% of their cases and absorbable plates in 37.5% of cases.
Definitive cleft rhinoplasty: 98.1% of respondents perform definitive cleft rhinoplasties. Most surgeons reported that they would first consider performing a definitive case at 16 years of age (55.8%). 98.1% of surgeons reported using an open (external) approach for unilateral cleft cases, and 96.3% of surgeons reported using an open approach for bilateral cleft cases. A majority of surgeons (64.8%) utilize autologous cartilage grafts in more than 75% of their cases. 55.6% of surgeons reported using cadaveric cartilage and 27.5% of surgeons utilized absorbable plates.

Conclusions: The present study highlights major trends among craniofacial surgeons from ACPA-approved teams. Differences in technique for intermediate and definitive cleft rhinoplasty among cleft surgeons have not previously been evaluated across cleft teams. The inconsistencies in secondary cleft rhinoplasty represents the need for more robust outcomes data for specific timing, techniques, and materials utilized to help better inform best practices among surgeons.

Competition Category: Clinical or Quality

Mentor: Arun Gosain, MD

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Sripadh Sharma, PhD

Student

Drawbacks to current medical school curricula regarding specialty selection and potential solutions

Introduction: “What specialty should I go in to?” This question is laden with stress/anxiety and the intensity of which only increases until the student finishes applications for residency (sometimes even beyond this). The conventional idea has been that the student will learn a base of general medicine and experience enough specialties in the first three years of medical school so that he/she can apply at the end of the third year. However, obtaining a wide enough breadth of specialty experience is rarely (if at all) emphasized to the student. There are currently 24 specialties in which medical students can apply, and it is impossible for students to make an informed decision without luck and vast amounts of extracurricular time/effort. Even after the decision has been made, to be competitive in a specific specialty is another intimidating effort for students. We analyze the salient reasons why current medical student curricula should be reformatted to emphasize a diverse specialty experience for medical students (especially the first and second-year students), potential solutions for these difficulties, and hopeful next steps that medical schools should take.

Methods: We identified the two major factors in causing this issue: time needed to consider specialties and the sheer number of available specialties in which to match (24). We, then, identified where in conventional American medical school curricula these could be reconciled.

Results: Three potential solutions exist among many others: (1) With potentially more time in the future medical school curricula (from less emphasis on Step 1 studying), true diverse clinical experiences can start as early as the first year of medical school. (2) Additionally, required active participation in interest groups and shadowing sessions of lesser-known specialties to the first-year medical student could also be used because, for example, radiology, anesthesiology, PM&R, etc. are very rarely considered by first-year medical students. (3) During M3 year, adjacent fields could be incorporated into core rotations (e.g., doing a week of anesthesiology during surgery, a week of ophthalmology during neurology, etc.).

Conclusion: As the medical field progresses, there are further specialized fields which necessitates medical students to make a specialty decision earlier in their careers. Current curricula do not meet students’ standards to adequately make an informed decision of a plethora of specialties. Perhaps incorporating some measures during the preclinical phase of medical school could subvert some of this anxiety/stress and rush to “pick a specialty.”

Competition Category: Clinical or Quality

Mentor: Arun Gosain, MD

Tracy Smith, PhD

Fellow (Clinical or Postdoctoral Researcher)

Mechanism and targeting of the host-microbial trimethylamine pathway to reduce neointimal hyperplasia after injury

Introduction: Cardiovascular disease is a leading cause of death globally. Despite advancements in surgical approaches for cardiovascular disease, up to 50% of vascular procedures such as balloon angioplasty, stenting, and surgical bypass fail due to neointimal hyperplasia, a pathologic response of the blood vessel to vascular procedures. The pathologic neointima is composed of cells from multiple possible sources, including resident smooth muscle cells, adventitial fibroblasts, and endothelial cells that transform into myofibroblasts via endothelial-to-mesenchymal transition (endoMT). Gut microbiota exposed to a Western diet rich in compounds such as choline generate trimethylamine (TMA) via the enzyme TMA lyase, which is converted to trimethylamine N-oxide (TMAO). Elevated TMAO is associated with atherogenesis, endothelial injury, and the promotion of fibrotic cellular phenotypes. However, the pathogenic role has never been studied. We aim to further elucidate the link between gut microbiota, TMAO produced by gut microbiota from dietary nutrients, and neointimal hyperplasia after vascular surgery.

Methods: To determine if a choline-rich diet, via TMA generation by the gut microbiome, will increase the severity of neointimal hyperplasia after arterial surgery mice will be fed a chemically-defined diet with either control drinking water or water medicated with 1% choline to stimulate microbial production of TMA in the gut to yield chronically elevated levels of TMAO. All mice will undergo left carotid ligation, a well-accepted model of neointimal hyperplasia. The effect of diet on inflammation, in vivo endoMT, and endothelial injury will be evaluated. We will use iodomethylcholine (IMC), a potent inhibitor of microbial TMA lyase to determine if selectively blocking TMA production by gut microbiota will mitigate the inflammatory and restenosis effects of a choline diet. In all mice, the right carotid will be the unoperated control. To unravel the role of endoMT as the mechanistic link between elevated TMAO, arterial injury, and neointimal hyperplasia endothelial cells (HUVEC) will be treated with a physiologic range of TMAO. We will measure markers for angiogenesis and endoMT.

Results: Preliminary studies suggest that mice on a choline-rich diet have enhanced neointimal hyperplasia after arterial injury and that selectively blocking microbial TMA lyase using IMC reduces TMA and TMAO levels. Additionally, our results suggest that treating HUVEC with TMAO induced a reduction in EC-specific and an increase in mesenchymal-specific cell marker expression suggesting that TMAO does indeed drive endoMT.

Conclusions: The proposed studies will allow us to elucidate the mechanism by which TMAO exacerbates neointimal hyperplasia after arterial injury.

Competition Category: Basic Science or Translational

Mentor: Karen Ho, MD

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Matthew Snyder, MD, MS

Senior Resident (Clinical PGY3-5)

A socially distanced approach to surgical education: a hybrid web and simulator-based course for laparoscopic common bile duct exploration

Introduction: The COVID-19 pandemic has had a profound impact on surgical education. Social distancing and travel limitations have made many large-scale in-person courses untenable. In light of these constraints, we adapted a laparoscopic common bile duct exploration (LCBDE) course into a “hub-and-spoke” model in which a central site led satellite centers using a hybrid web and hands-on simulator-based mastery learning curriculum.

Methods: Prior to the courses, faculty underwent a “train-the-trainers” curriculum focused on principles of simulator-based education and use of the rating scale. Day-long courses were then led by faculty in Chicago with content streamed via a web-based platform to satellite centers with local faculty and learners. A mastery learning model was employed, in which learners completed a simulator-based pre-test at the onset of the course. The subsequent course curriculum consisted of streamed lectures followed by hands-on deliberate practice using an LCBDE-specific simulator. The simulators were equipped with a flexible choledochoscope to facilitate a transcystic LCBDE approach. Faculty at each site provided learners with immediate performance feedback with a 2:1 learner to faculty ratio. Learners then completed an identical post-test on the simulator. The pre- and post-tests were assessed using a previously validated LCBDE procedural rating scale with a “mastery standard” that had been developed using a modified Angoff method.

Results: Forty attending and fellow-level surgeon learners participated in the two courses held in Chicago and at 9 satellite locations. All learners were within driving distance of their course site. The learners had a mean of 9 years of post-training experience with 48% having ≤5 years in practice. Most participants reported some exposure to the procedure during training but only 62% had previously performed LCBDE as an attending. On pre-testing, 88% of learners failed to meet the mastery standard (a score of ≥ 31 out of 45). All 40 learners (100%) met or exceeded the mastery standard on post-testing and mean scores were significantly improved (pre-test 24 ±8 vs post-test 43 ±2; scale 0-45, p<0.001). When analyzed separately, even the five participants who passed the pre-test had a significant increase in their post-test scores (36 ±3 vs 43 ±2, p<0.01).

Conclusion: Using a multisite course design to overcome COVID-19 travel restrictions, we were able to train surgeons uniformly to a mastery standard in LCBDE. This hybrid web and hands-on simulator-based approach may serve as a model for other procedural curricula during the COVID-19 era and beyond.

Competition Category: Clinical or Quality

Mentor: Eric Hungness, MD

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Benjamin Stocker, BS

Student

Challenges in predicting discharge disposition for trauma and emergency general surgery patients

Introduction: Changes in discharge disposition and delays in discharge negatively impact the patient and hospital system. Our objectives were (1) to determine the accuracy with which trauma and emergency general surgery (TEGS) providers could predict the discharge disposition for patients and (2) determine the factors associated with incorrect predictions.

Methods: Discharge dispositions and perceived barriers to discharge for 200 TEGS patients were predicted individually by members of the multidisciplinary TEGS team within 24 hours of patient admission. Univariate analyses and multivariable LASSO logistic regressions determined the associations between patient characteristics and correct predictions.

Results: 1,498 predictions of discharge disposition were made by the multidisciplinary TEGS team for 200 TEGS patients. Providers correctly predicted 74% of discharge dispositions. It was more difficult to predict the discharge disposition for patients that had a change is disposition as compared to those who returned home (35% v. 83%; p < 0.001). Prediction accuracy was not associated with clinical experience or job title. Incorrect predictions were independently associated with older age (OR 0.98; p < 0.001), trauma admission as compared to emergency general surgery (OR 0.33; p < 0.001), higher Injury Severity Scores (OR 0.96; p < 0.001), longer lengths of stay (OR 0.90; p < 0.001), frailty (OR 0.43; p = 0.001), ICU admission (OR 0.54; p < 0.001), and higher APACHE II scores (OR 0.94; p = 0.006). Perceived barriers to patient discharge associated with incorrect disposition predictions were age, comorbidities, wound care, social support, and physical impairment from injuries.

Conclusion: The TEGS team can accurately predict the majority of discharge dispositions. Patients with risk factors for unpredictable dispositions should be flagged to better allocate appropriate resources and more intensively plan their discharges.

Competition Category: Clinical or Quality

Mentor: Joseph Posluszny, MD

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Jenna Rose Stoehr, BA

Student

Attrition in academia: Why does interest in craniofacial surgery, microsurgery, and academic practice decrease during plastic surgery residency training?

Background: Plastic surgery residency applicants often express interest in academic subspecialties, but only a small percentage of graduating residents pursue academic careers. Identifying reasons for academic attrition may help training programs address this discrepancy.

Methods: A survey was sent to plastic surgery residents via the American Society of Plastic Surgeons Resident Council to assess interest in six plastic surgery subspecialties during junior and senior years of training. If a resident changed their subspecialty interest, the reasons for change were recorded. The perceived reasons for subspecialty interest over time were analyzed with paired t-tests, and reasons for change, when applicable, were analyzed with two-sample t-tests.

Results: 276 plastic surgery residents out of 593 potential respondents (46.5 percent response rate) completed the survey. Out of 150 senior residents, 60 residents reported changing interests from their junior to senior years. Craniofacial and microsurgery were identified as the specialties with the highest attrition of interest, while interest in aesthetic, gender-affirmation, and hand surgery increased. For residents who left craniofacial and microsurgery, the desire for higher compensation, to work in private practice, and the desire for improved job opportunities significantly increased. The desire for improved work/life balance was a significant reason for subspecialty change among senior residents who changed to aesthetic surgery.

Conclusions: Plastic surgery subspecialties associated with academia suffer from resident attrition due to a variety of factors. Increased retention of trainees in academia, microsurgery, and craniofacial surgery could be improved through dedicated mentorship, improved job opportunities, and advocacy for fair reimbursement.

Competition Category: Clinical or Quality

Mentor: Arun Gosain, MD

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Arielle Thomas, MD, MPH

Junior Resident (Clinical PGY1-2)

The impact of stay-at-home orders on volume and mechanism of injury: A retrospective analysis of TQIP hospitals across the US

Introduction: The COVID-19 pandemic has had numerous negative effects on the US healthcare system.  During the beginning of the pandemic, to avoid the possibility of an overwhelmed hospital system, many states responded with stay-at-home (SAH) orders. These orders varied in duration and intensity but fundamentally encouraged people to cease non-essential travel, business, and interpersonal interactions to decrease virus transmission. We hypothesized that these orders with their negative impact on social support networks might alter the rate and type of injuries treated at American trauma centers. We sought to measure the impact of the stay-at-home orders on trauma center volume and injury mechanism.

Methods: Utilizing the ACS Trauma Quality Improvement Program, we analyzed years 2018-2020 using start and end dates for each SAH order for each state. Patient demographics and injury characteristics were compared across the corresponding yearly SAH time periods using chi-square tests of association for categorical and one-way ANOVA for continuous variables.  Patient volume was modeled using harmonic regression and a random hospital effect.  

Results: A total of 878,802 patients were cared for from 2018 through the first 9 months of 2020 at 506 TQIP centers; 177,660 patients were admitted in 2020 after a SAH order was in place. An average of 171,864 patients were admitted over the corresponding time periods in 2018 and 2019 for comparison. The time intervals following a SAH order were characterized by 3.6% fewer patients admitted to the hospital from motor vehicle crashes, 34% higher rates of firearm injury, and a 17% increase in assaults. There was also a 19% increase in Black patients and a 26% increase in those with a pre-existing diagnosis of alcoholism. This translated to 4,518 more Black patients, 2,696 more assaulted patients, and 3,729 more firearm injured patients than would be expected given 2018-19 rates. In the weeks before the SAH orders were issued, trauma center admission volume declined which roughly coincided with the onset of the pandemic.  Conversely, a week subsequent to implementation, there was a linear increase in the rate of admissions per trauma center (p<0.0001) until it plateaued about 10 weeks later.

Conclusion: Volume decreased in the weeks leading up to the implementation of the SAH order and increased steadily in the weeks following. After the SAH orders were issued in 2020, there was an increase in assaults from penetrating injury compared to the same period in the two previous years.

Competition Category: Clinical or Quality

Mentor: Avery Nathens, MD, PhD

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Madeline Timken, BS

Student

Sex matters in traumatic brain injury

Introduction: Approximately 3 million Americans sustain a traumatic brain injury (TBI) each year with a high rate of subsequent neuropsychiatric morbidity. TBI outcomes differ markedly between males and females in both clinical and preclinical studies. Nonetheless, there are limited studies examining sex as an independent variable in neuropsychiatric outcomes after TBI. We hypothesized that female mice would have attenuated post-traumatic anxiety after TBI as compared to male mice. 

Methods: Age-matched C57Bl/6 male mice (N=21) and female mice (N=20) were grouped into TBI and sham-injury groups. An open-head controlled cortical impact was used to induce a severe TBI vs. sham-injury. At 45 days post-TBI, neuropsychiatric outcomes were assessed with the zero maze for anxiety-like behavior and the open field test for generalized activity levels, anxiety, and willingness to explore. Data was analyzed using one-way ANOVA and Tukey’s multiple comparison test.

Results: Contrary to our hypothesis, female mice demonstrated markedly increased levels of post-traumatic anxiety after TBI as compared to male mice. Female TBI mice spent significantly less time in the open space of the zero maze as compared to male TBI mice indicating increased levels of anxiety (22.86 ± 4.98% vs. 31.62 ± 9.7%, p=0.0171). Similarly, female TBI mice spent less time in the center of the open field demonstrating increased anxiety and less exploratory behavior than male TBI mice (12 ± 4% vs. 24.3 ± 5.4%, p<0.0001). This corresponded to more distance traveled over the course of open field testing in female TBI mice as compared to male TBI mice indicating a marked increase in generalized activity (7515.3 ± 1335.3cm vs. 6742.2 ± 1229.2cm, p=0.0047).

Conclusions: Female mice had increased levels of post-traumatic anxiety-like behavior, less exploratory behavior, and increased generalized activity as compared to male mice after TBI. These data suggest marked sex-linked differences in neuropsychiatric outcome after TBI. Future clinical trials should make sex an a priori consideration in future trial design.

Competition Category: Basic Science or Translational

Mentor: Steven Schwulst, MD

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Sergey Y Turin, MD

Senior Resident (Clinical PGY3-5)

Gluteal vein anatomy: Location, caliber, impact of patient positioning, and implications for fat grafting

Introduction: Safety concerns in gluteal lipo-augmentation are largely attributed to gluteal vein injury. However, there is a lack of data on the exact location and caliber of these veins. We used MRI to precisely determine the anatomy of gluteal veins to guide safety improvements to gluteal fat grafting.

Methods: Twelve females between the ages of 20 and 48 underwent MRI of the abdomen and pelvis.
Caliber and location of the inferior and superior gluteal veins (IGV/SGV) at their exit out of the pelvis and course under the gluteus major muscle (GMm) were mapped relative to the coccyx (Cx), posterior superior iliac spine (PSIS), and greater trochanter of the femur (GT). Measurements were then converted to percentages of the distances between the bony landmarks (Cx-GT, Cx-PSIS, PSIS-GT).

Results: The IGV exits the pelvis deep to the GMm at 31% of the Cx-GT distance laterally and 14% of the Cx-PSIS distance superiorly to the coccyx, then runs immediately deep to the muscle at an angle of 43.71° from vertical. IGV intramuscular caliber ranges from 3.47 to 5.05mm, with an average of 3.84 intramuscular branches.
The SGV exits the pelvis deep to the GMm at 43% of the Cx-GT distance laterally and 35% of the Cx-PSIS distance superiorly to the coccyx, then taking a tortuous course deep to the GMm, ranging in caliber from 3.19 to 4.10 mm and receiving on average 2.63 branches from the GMm 2.66 to 3.36mm in size.
Prone positioning with a bump under the hips decreased the vessel caliber by 2-3% relative to prone or lateral decubitus positioning.

Conclusions: The diverging courses of the SGV and IGV suggest a more complex pattern than a “triangle” or “quadrant” of danger. Prone positioning with a bump under the hips may decrease vessel caliber.

Competition Category: Clinical or Quality

Mentor: John Kim, MD

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Peter Ullrich, BS

Student

Prospective trial evaluating the long-term outcomes associated with the use of MTF allograft cartilage in cosmetic and reconstructive rhinoplasty procedures

Introduction: Augmentation of the nasal cartilages with cartilage grafts for cosmetic and reconstructive procedures is performed usually by grafting autologous cartilage. Although, it has complications. For this reason, costal cartilage allograft by the Musculoskeletal Transplant Foundation (MTF) provides an alternative in rhinoplasties. Our goal is to compare MTF’s allograft costal cartilage with autograft costal cartilage with respect to clinical utility, complications, and patient satisfaction in reconstructive and cosmetic rhinoplasty.

Methods: This is a single-center, non-blinded, clinical trial, conducted in healthy adult subjects undergoing a reconstructive or cosmetic rhinoplasty involving the use of cartilaginous graft. This study will evaluate the outcomes and utility of MTF allograft compared to autologous harvest of costal cartilage. 30 subjects will be recruited. Eligible, consenting patients will be grouped into their respective cohort. They will choose to receive either the autologous or cadaveric graft. Prior to surgery, the patients fill out the pre-operative sections of a Face-Q checklist and will have pictures taken for documentation purposes. Subjects will have 1 week, 6 weeks, 12 weeks, 6 months, and 1-year clinical follow-up, which will include, patients completing the corresponding sections of the Face-Q, standardized 2D and 3D photographs. Data on adverse effects and discomfort will also be collected throughout the study period. Observers involved in outcome assessments will be blinded to study treatments throughout the duration of each patient’s evaluation period.

Results/Complications: 30 patients have been recruited so far and are involved in different stages of follow up, divide into two groups (MTF and Autologous), both groups show no difference in the pre-operative Face-Q checklist (p-value >0.05). On 1 week, 6 weeks and 12 weeks follow up both groups show no significant difference. On 6 month and 1 year follow up there is still not enough data to project any results yet. Patients' 2D and 3D photos reveal that there is no warping or resorption in our cadaveric cartilage group so far compared with the rib cartilage group. Longer follow up will be collected.

Conclusion: It is expected to prove not a significant difference between MTF and autologous cartilage when it comes to 1-year outcomes in satisfaction, recovery, and complications, leaving the door open for further studies to explore additional benefits of MTF use.

Competition Category: Clinical or Quality

Mentor: Robert Galiano, MD

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Rou Wan, MD

Fellow (Clinical or Postdoctoral Researcher)

Nasal alar and tip reconstruction following mohs surgery using fresh frozen cadaveric cartilage: A novel approach

Introduction: Traditionally, autologous cartilage is the primary graft source used for reconstructive rhinoplasties after skin cancer resection. Nasal septum, auricular cartilage and costal cartilage are common options. However, these grafts often present with donor site complications, increased operative time, and expensive costs. Implantation of cadaveric rib cartilage can provide adequate supply and avoid donor site morbidities but reports higher rates of infection, resorption, and necrosis. This case series is to demonstrate the safety and feasibility of this novel material in reconstructive rhinoplasty after skin cancer removal.

Methods: We retrospectively reviewed the medical history and operative data of seven patients who underwent reconstructive rhinoplasties after basal cell carcinoma skin cancer resection using fresh frozen costal cartilage. The fresh frozen cartilage had a process of sterilization without irradiation. The cadaveric cartilages were stored in frozen conditions (-40℃ to -80℃), and temperature was maintained using dry ice during shipment. Before use for the implantation, cartilage tissue was thawed in normal saline. Pre and postoperative photographs were obtained. Anthropometric measurements were taken on 2D photos to evaluate nose tip projection on patients who underwent nasal tip reconstruction. Adverse events including infection, tissue necrosis, resorption, and difficulty of breathing were evaluated.

Results: Of the seven patients that met the inclusion criteria, the average age was 75 years (range, 63 to 90) with six males and one female. Average duration of follow-up was 7.4 months (range, 3 to 12 months). Types of grafts used included: Alar batten graft (n=5, 71.4%), nasal tip graft (n=1, 14.3%), and alar batten graft with nasal tip graft (n=1, 14.3%). One postoperative complication was reported (minor difficulty breathing), which did not require revision surgery. Measurements on the 2D photos of the patient who had alar batten graft with nasal tip grafts showed no significant resorption or deviation 7 months after the surgery.

Conclusions: Our case series highlights the low complication rate and cosmetically positive outcomes from using fresh frozen, non-irradiated, cadaveric cartilage allografts for reconstructive rhinoplasties. Decreased donor site complications, operative time, cost, rates of infection, and resorption were observed. In addition, cadaveric cartilage provides younger and higher quality cartilage for the elder population, as well as eliminating the problem of difficulties of wearing hearing aids after a cartilage removal from the conchal bowl. Further investigation involving a larger sample size would add to the existing data supporting the efficacy of fresh frozen cartilage.

Competition Category: Fellow

Mentor: Robert Galiano, MD

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Danyi Wang

Student

Biochemically induced biophysical forces on vascular smooth muscle cell (VSMC) nucleus can modify cell fate and the onset of vascular calcification

Introduction: Cardiovascular diseases are the leading causes of death globally. One common complication of cardiovascular diseases is vascular calcification, which has no known treatment. Here, we identify pathological vascular smooth muscle cells (VSMCs) as drivers of calcification. VSMCs are capable of transdifferentiating from a myogenic to an osteogenic phenotype. This switch can be accompanied by chromatin reorganization, i.e., from loosely folded euchromatin conductive to transcription to the condensed and less accessible heterochromatin. Previous research demonstrated that biophysical forces on cell nucleus alter chromatin structure and regulate cell fate for several cell lines. Here, we investigate how biophysical forces applied on VSMC nucleus can influence phenotype and the onset of calcification. We hypothesize that biophysical forces that cause nuclear contraction will decrease the presence of euchromatin and increase heterochromatin in the genome, promoting histone methylation while reducing transcriptional activity and the likelihood of osteogenic trans-differentiation.

Methods: Human aortic smooth muscle cells (HAoSMCs, Cell Applications, Inc) are cultured and treated with SMC differentiation media to induce the contractile phenotype prior to drug treatment. Biochemically induced biophysical forces are applied to VSMCs via the vasodilator Sodium Nitroprusside (SNP, 1.0µM, 10µM, and 100µM) and the vasoconstrictor Phenylephrine (PE, 0.1µM, 1.0µM, 10µM, and 50µM). No-treatment control groups are included. DAPI staining was used to confirm that the biochemical treatments generated the nuclear morphological changes expected from the corresponding biophysical forces. Changes in epigenetics and transcriptional activity will be evaluated via Acetyl H3 Staining and immunofluorescence imaging of acetylated histones. VSMC cell fate will be determined quantitatively via ELISA and qualitatively via immunofluorescence imaging for a-actin versus osteocalcin protein markers.

Results: Qualitative analysis of a-actin protein markers using immunofluorescence imaging confirm that the differentiation protocol resulted in VSMCs with the contractile phenotype. Compared to pre-treatment VSMCs with the synthetic phenotype, the post-treatment/contractile VSMCs exhibit organized actin fibers that strongly indicate contractility and the physiologically healthy, myogenic phenotype. Preliminary data collected confirm that after treating these differentiated VSMCs with SNP, the cells display the elongated morphological changes expected with cellular dilation. PE validation assays are currently in progress, with histone acetylation immunofluorescence imaging and VSMC protein expression analysis due to follow.

Conclusions: This project will not only increase fundamental knowledge concerning the mechanism of calcification and the role of mechanical forces on VSMC cell fate, but also introduce new therapeutic targets to combat vascular calcification.

Competition Category: Basic Science or Translational

Mentor: Bin Jiang, PhD

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Joshua Weissman, BBA

Student

Clinical practice patterns and evidence-based medicine in abdominoplasty: 16-year review of continuous certification tracer data from the American Board of Plastic Surgery

Introduction: The American Board of Plastic Surgery (ABPS) has collected data on cosmetic surgery tracers as part of the Continuous Certification (CC) process since 2003. The present study was performed to analyze evolving trends in abdominoplasty in the ABPS cosmetic module and to compare change in practice patterns to publications in Evidence-Based Medicine (EBM) over this timeframe.

Methods: Cumulative tracer data for abdominoplasty was reviewed as of January 2015 and March 2021 and compared with EBM articles published in Plastic and Reconstructive Surgery. Data were compared using Fisher’s exact tests and two-sample t-tests when appropriate. Topics were placed into categories based on their presence in EBM articles.

Results: Cumulative data included 4740 cases from 2005 to 2014 and 4250 cases from 2015 to 2021. Overall, significantly more abdominoplasties in the later cohort were being done with no complications (78% vs 81%, p<.001) and without the need for revisionary surgery (90% vs 92%, p<.001). The most common complication amongst both cohorts was seroma (7%). Comparing patient selection practices, the latter group had significantly fewer pregnancies (77% vs 73%, p<.001), previous intra-abdominal surgeries (37% vs 30%, p<.001), body scars (64% vs 60%, p=.001), and excess skin over the umbilicus (74% vs 71%, p=.009). The later cohort also had a significantly higher BMI (p<.001) and presence of striae (53% vs 56%, p=.008). Comparing surgical practices, more abdominoplasties are being done in the outpatient setting (77% vs 81%, p<.001) and more surgeons are prescribing LMWH heparin (13% vs 21%, p<.001) instead of postoperative sequential compression devices (28% vs 23%, p<.001). Liposuctioning the abdominal flap, hips, and flank is becoming more common while liposuctioning the thighs less common (p<.001). There has also been a decline in the use of wide undermining (81% vs 75%, p<.001), vertical plication of the abdomen (89% vs 86%, p<.001), and surgical drains (93% vs 89%, p<.001).

Conclusions: A review of the national ABPS abdominoplasty tracer data allows surgeons to compare their practice with national trends and EBM. Analysis of this CC tracer data highlights important trends in clinical practice over the last 16 years. Overall, we find that despite surgeons operating on higher BMIs and more aggressively liposuctioning the abdominoplasty flap, more abdominoplasties are being done with no complications and without the need for revisionary surgery.

Competition Category: Clinical or Quality

Mentor: Arun Gosain, MD

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Bridget Whitehead, MD

Fellow (Clinical or Postdoctoral Researcher)

Clinically significant portal hypertension (CEPH) is associated with low IGF-1 and fatigue in children with chronic liver disease

Background: Children with chronic liver disease exhibit growth hormone resistance with low levels of IGF-1, which has been associated with multiple negative effects in other pro-inflammatory conditions.  While the specific triggers are not entirely known, patients with liver disease have increased pro-inflammatory cytokines.  Low IGF-1 has been associated with increased fatigue in children in inflammatory bowel disease and PELD score in children with cirrhosis awaiting liver transplant. However, the impact of chronic inflammation and IGF-1 in children with and without clinically evident portal hypertension (CEPH) has not yet been studied.

Methods: Children 3 months-18 years with chronic liver disease were enrolled from 05/2015-03/2021 in the hepatology clinic at Lurie Children’s Hospital.  Patients with comorbidities affecting intestinal inflammation or the growth hormone axis were excluded. Patients were categorized by the presence or absence of CEPH using published criteria.  Clinical data, nutritional assessment, and serum samples were obtained for measurement of IGF-1 and cytokines.  IGF-1 Z scores were analyzed as both a continuous and categorical variable with low IGF-1 defined as Z score < -2.  Children and guardians completed the PedsQL Multidimensional Fatigue Scale (PedsQL MF) and were compared with a published cohort of 157 healthy children.  Continuous variables between groups were analyzed using Mann-Whitney U test.

Results: 48 patients with median age 12.4 years were enrolled and 40% (n=19) had CEPH.  Median IGF-1 level was -1.15. Children with CEPH had lower IGF-1 compared to patients without CEPH (p <.001). Median weight, length and MUAC Z scores in our cohort were close to 0 and had no association with IGF-1.  Median PedsQL MF scores from child and parent proxy were significantly lower compared to healthy children. Low IGF-1 was significantly associated with child (p 0.047) and parent (p 0.036) reported fatigue.  After correcting for multiple comparisons, there were no individual cytokine differences between patients with and without CEPH.

Conclusions: Children with CEPH have low IGF-1 even in this population of stable patients with preserved linear growth.  Children with chronic liver disease have a greater burden of fatigue compared to healthy children and increased fatigue is associated with low IGF-1 levels.  There are no individual differences in cytokines between groups, but next steps include principal component analysis of to identify patterns of pro versus anti-inflammatory networks.

Competition Category: Clinical or Quality

Mentor: Estella Alonso, MD

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Tarik Yuce, MD

Senior Resident (Clinical PGY3-5)

Impact of effective use of clinical support staff on resident education and wellness in U.S. surgical residency programs

Introduction: The use of clinical support staff (e.g. advance practice providers, social workers) has become increasingly common within surgical departments. Little evidence exists regarding the impact these staff have on surgical trainee education and wellness.

Methods: Residents in Accreditation Council for Graduate Medical Education-accredited general surgery programs were surveyed following the 2019 American Board of Surgery In-Training Examination (ABSITE). Residents were asked about support staff, perceptions of the learning experience, burnout, thoughts of attrition, and career satisfaction. Multivariable logistic regression models adjusting for program/resident characteristics were developed to evaluate associations between effective support staff use and resident education and wellness.

Results: Of the 6,956 clinically-active residents (85.6% response rate) from 301 programs who completed the survey, 6,415 responded to relevant questions. Effective use of clinical support staff was reported by 4,053 (63.2%). Female residents less frequently reported effective use of support staff by their program (59% vs 66%, p<0.001). Residents who reported effective use of support staff were significantly more likely to report having appropriate clinical autonomy, time for direct patient care, appropriate time in the OR, protected educational time, and satisfaction with their career choice. These residents were less likely to report duty hour violations, burnout, and thoughts of attrition. They also achieved significantly higher ABSITE scores.

Conclusions: Effective use of support staff in surgical residency programs is associated with improved resident education and wellness. However, this resource may be differentially distributed. Efforts to further increase effectiveness of support staff in surgical training programs may prove beneficial.

Competition Category: Clinical or Quality

Mentor: Yue-Yung Hu, MD

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