Providence Park Hospital

INTRODUCTION: The Michigan CRC Screening Quality Improvement Project (CRC-QIP) is a multi-center, 4-phase project to improve adherence with recommending 10-year intervals after normal screening colonoscopies. Per guidelines, target is 90% adherence with recommended intervals. METHODS: Inclusion criteria: In order to minimize possible confounders, patients were limited to: (a) average-risk, 50–75 year olds; (b) colonoscopy performed in 2017; (c) sole indication-CRC screening; (d) no biopsy, polypectomy, or any abnormal findings on procedure report. Study Setting: In order to minimize confounders when stratifying for specialty and type of practice, only medical centers with (a) GI fellowship program; (b) Hospital-based “open” endoscopy unit (i.e., utilized by private practice gastroenterologists (GIs), colorectal surgeons, and general surgeons). Primary Outcome: Adherence to guideline-consistent intervals defined as repeat colonoscopy in 10 years or discontinue CRC screening due to patient's age when bowel preparation is adequate or <1 year if bowel preparation is inadequate. Primary analysis is frequency of adherence based on endoscopist specialty after adjusting for multiple confounders, including procedure-related factors (e.g., withdrawal time), and endoscopist-related factors (e.g., yrs in practice, solo vs group practice, colonoscopies performed per yr). Hierarchical logistic regression model was used with adherence as the dependent variable with random intercepts for endoscopist performing procedure to account for correlation between endoscopist and site as fixed effects. RESULTS: Among 1,694 eligible patients, mean age was 58.7 ± 6.5, 43% male, and 68% African-American. Adherence was better for academic gastroenterologists with or without GI fellows vs private practice GIs or academic general surgeons (P = 0.04). The latter two groups were adherent in <40% of patients (Table 1). Adherence was significantly better with good/excellent bowel preps compared to all other bowel prep categories (P < 0.05), and patients with poor, fair, or no documentation of prep were adherent <50% (Table 2). CONCLUSION: In this project, adherence did not meet guideline-specified target of 90% among private practice GIs and general surgeons. Phase 2 will include additional analysis to identify factors associated with non-adherence and a mixed methods qualitative study to identify appropriate interventions to improve performance.

The clinical role of catheter ablation using radiofrequency or cryothermal energy has become an important therapy in the management of patients with recurrent or persistent tachyarrhythmia that is refractory to medical therapy. It is regarded as a safe and reliable procedure and is performed routinely in health care facilities across the country. Like all procedures, there are associated risks and benefits. Development of an esophageal–atrial fistula is a rare but often-fatal complication of radiofrequency ablation. It is the second most frequent cause of death caused by the procedure, with mortality rates in excess of 70%. Death usually occurs as a result of cerebral or myocardial air embolism, endocarditis, massive gastrointestinal bleeding, and/or septic shock. Electrophysiologists have instituted a number of safeguard techniques to diminish the risk of developing esophageal–atrial fistula. Despite these measurements, instances of fistulous development still occur. Herein, we report a case of a 74-year-old male who presented with chest pain secondary to esophageal–pericardial fistula 19 days after pulmonary vein isolation using radiofrequency energy for atrial fibrillation in order to illustrate the clinical variability and diagnostic challenges associated with this dreaded gastrointestinal complication.

Introduction: Cirrhotic patients undergoing inpatient large volume paracentesis (LVP) are at increased risk of paracentesis induced circulatory dysfunction (PICD) and mortality. Current AASLD guidelines recommend an albumin infusion of 6-8 g per liter of fluid removed when undergoing LVP. Adherence to these recommendations in a community-based setting is unclear. We aimed to assess adherence to albumin infusion after LVP and associated factors in receiving appropriate albumin infusion. Methods: This was a retrospective study. We included all patients who received an inpatient LVP (defined as ≥ 5 liters removed) at 4 community-based hospitals between 01/01/2013 and 12/31/2017. We queried the billing database for paracentesis using CPT code 49082 and 49083 and ICD-9 code 54.91. We identified patients who met the following inclusion criteria: (1) age ≥ 18; (2) ≥ 5L ascites removed; (3) documented cirrhosis prior to LVP; (4) inpatient LVP. Exclusion criteria included: (1) ESRD; (2) GI bleeding requiring RBC transfusion; (3) on vasopressor support; (4) spontaneous bacterial peritonitis; and (5) allergy to albumin. We assessed the overall frequency of adherence, used Wilcoxon rank sum tests, repeated measure GEEs for comparisons, and a multivariable GEE analysis to identify factors associated with adherence. Results: There were 328 LVPs performed that met our criteria. Patients were predominately white (79%) and male (65%). Most cirrhosis was caused by alcohol (46%), followed by Hep C (16%), NASH (15%) and other (22%). The median MELD was 19 (IQR = 14-23). Only 91/328 LVPs (28%) received the appropriate albumin infusion. In addition, 166/328 (55%) patients received any dose of albumin after LVP. African-Americans were much less likely to receive appropriate albumin infusion compared to Caucasians (13% vs 34%; p = 0.008). Similarly, in a multivariable GEE repeated measures analysis, African-American race was the only factor that influenced appropriate albumin infusion after LVP (Z = -2.68; p = 0.007). Conclusion: Cirrhotic patients undergoing LVP are at increased risk of PICD and mortality. Appropriate albumin infusion after LVP is recommended to help minimize this. Without systematic interventions, hospitals are not only at risk for poor adherence to albumin infusion guidelines but are inadvertently widening racial gaps. Future studies are needed to assess interventions that increase adherence of albumin infusion after LVPs, for all patients in the community-setting.

To compare the perioperative outcomes of initial, consecutive robotic-assisted transabdominal preperitoneal (R-TAPP) inguinal hernia repair (IHR) cases with consecutive open cases completed by the same surgeons. Multicenter, retrospective, comparative study of perioperative results from open and robotic IHR using standard univariate and multivariate regression analyses for propensity score matched (1:1) cohorts. Seven general surgeons at six institutions contributed 602 consecutive open IHR and 652 consecutive R-TAPP IHR cases. Baseline patient characteristics in the unmatched groups were similar with the exception of previous abdominal surgery and all baseline characteristics were comparable in the matched cohorts. In matched analyses, postoperative complications prior to discharge were comparable. However, from post discharge through 30days, fewer patients experienced complications in the R-TAPP group than in the open group [4.3% vs 7.7% (p = 0.047)]. The R-TAPP group had no reoperations postdischarge through 30days of follow-up compared with five patients (1.1%) in the open group (p = 0.062), respectively. Multivariate logistic regression analysis which demonstrated patient age > 65years and the open approach were risk factors for complications within 30days postdischarge in the matched group [age > 65years: odds ratio (OR) = 3.33 (95% CI 1.89, 5.87; p < 0.0001); open approach: OR = 1.89 (95% CI 1.05, 3.38; p = 0.031)]. In this matched analysis, R-TAPP provides similar postoperative complications prior to discharge and a lower rate of postoperative complications through 30days compared to open repair. R-TAPP is a promising and reproducible approach, and may facilitate adoption of minimally invasive repairs of inguinal hernias.

The human umbilical cord (UC) and placenta are non-invasive, primitive and abundant sources of mesenchymal stromal cells (MSCs) that have increasingly gained attention because they do not pose any ethical or moral concerns. Current methods to isolate MSCs from UC yield low amounts of cells with variable proliferation potentials. Since UC is an anatomically-complex organ, differences in MSC properties may be due to the differences in the anatomical regions of their isolation. In this study, we first dissected the cord/placenta samples into three discrete anatomical regions: UC, cord-placenta junction (CPJ), and fetal placenta (FP). Second, two distinct zones, cord lining (CL) and Wharton's jelly (WJ), were separated. The explant culture technique was then used to isolate cells from the four sources. The time required for the primary culture of cells from the explants varied depending on the source of the tissue. Outgrowth of the cells occurred within 3 - 4 days of the CPJ explants, whereas growth was observed after 7 - 10 days and 11 - 14 days from CL/WJ and FP explants, respectively. The isolated cells were adherent to plastic and displayed fibroblastoid morphology and surface markers, such as CD29, CD44, CD73, CD90, and CD105, similarly to bone marrow (BM)-derived MSCs. However, the colony-forming efficiency of the cells varied, with CPJ-MSCs and WJ-MSCs showing higher efficiency than BM-MSCs. MSCs from all four sources differentiated into adipogenic, chondrogenic, and osteogenic lineages, indicating that they were multipotent. CPJ-MSCs differentiated more efficiently in comparison to other MSC sources. These results suggest that the CPJ is the most potent anatomical region and yields a higher number of cells, with greater proliferation and self-renewal capacities in vitro. In conclusion, the comparative analysis of the MSCs from the four sources indicated that CPJ is a more promising source of MSCs for cell therapy, regenerative medicine, and tissue engineering.