University of Tennessee Medical Center

Introduction: Early allograft dysfunction (EAD) is a life-threatening complication associated with liver transplantation, with a main risk factor being ischemia reperfusion injury (IRI). There is limited guidance available regarding pharmacologic prevention strategies for IRI, but there is a growing interest in using N-acetylcysteine (NAC). Recently, Methodist University Hospital (MUH) started utilizing NAC as pharmacologic prophylaxis for IRI in orthotopic liver transplant (OLT) patients. The purpose of this study was to compare rates of EAD in OLT recipients before and after the implementation of a NAC IRI protocol. Methods: This was a single-center, retrospective chart review at MUH from January 1st, 2023 to September 30th, 2023 and November 1st, 2023 to June 30th, 2024. Adult patients > 18 years old that received an OLT were eligible for inclusion. Patients were excluded if they expired within 7 days post-transplant, demonstrated NAC intolerance, received a multi-organ transplant, or previously received a liver transplant. Patients meeting inclusion criteria were divided into those who received the NAC protocol (exposure group) and those who did not (control group). The primary outcome was the incidence of EAD as measured by changes in bilirubin, AST, ALT, or INR through post-operative day (POD) 7. Secondary outcomes included graft nonfunction by POD 7, changes in renal function by POD 7, and intraoperative blood product requirements. Results: Of the 126 patients screened, 108 patients were included, with 47 in the exposure group and 61 in the control. On average, patients were 56.5 years old, 50% male, had a MELD 3.0 score of 21.9 with alcoholic cirrhosis being the most common indication for transplant. There was no difference between groups regarding the incidence of EAD (p=0.514). For secondary outcomes, NAC resulted in a statistically significant decrease in the incidence of primary graft nonfunction by POD 7 (p=0.035). All other secondary outcomes were not significantly different, including AKI (p=0.686), eGFR change (p=0.355), and intraoperative blood requirements (p=0.452). Conclusions: This retrospective study revealed no difference in EAD between the NAC and control groups, but did find a significant reduction in primary graft nonfunction at 7 days.

Abstract Background The rising incidence of Breast cancer (BC) in young women requires further genomic characterization, as only a fraction carry a germline mutation. Given the growing interest in therapies targeting the phosphoinositide 3-kinase/AKT (PI3K/AKT), mammalian target of rapamycin (mTOR), and phosphatase and tensin homolog (PTEN) pathways, central to BC pathogenesis, we evaluated whether PI3K/AKT/mTOR pathway alterations and gene expression differed by age at BC diagnosis. Methods: In this analysis of patients’ tumor/germline whole exome DNA and RNA sequencing data from the Ohio State University Total Cancer Care registry, 71 profiled patients were young adults (YA) aged < 40 years, and 675 were non-YA aged ≥40 years. Descriptive statistics characterized the frequency and co-occurrence of BC-specific alterations and mRNA expression profiles by age groups. Results The prevalence of these BC-relevant mutations are reported in Table 1 Table: Prevalence of BC-relevant mutations by age cohort Mutation Age Group % of Patients with Mutation Fisher's Exact Test p-value (<40 vs ≥ 40) PIK3CA <40 16.9% (12/71) 0.0002 ≥ 40 39% (263/675) AKT1 <40 5.6% (4/71) 0.220 ≥40 10.8% (73/675) mTOR <40 16.9% (12/71) 0.450 ≥40 21.5% (145/675) PTEN <40 12.7% (9/71) 0.550 ≥40 10.5% (71/675) . PIK3CA mutation occurred more frequently in non-YA patients (16.9% YA versus (vs) 39% non-YA; p<0.0002). The frequency of driver mutations were similar between cohorts (73% in YA vs 82% in non-YA). Most hotspot mutations were enriched in non-YA group, particularly H1047R (15.11% n=102 non-YA vs 4.23%, n=3 YA; p= 0.01). Others include: E545K (6.52%, n=44 vs 2.82%, n=2, p=0.302), E542K (4.59%, n=31 vs 1.41%, n=1; p=0.352); H1047L (1.93%, n=13 vs none, p=0.625) and N345K (1.78%, n=12 vs 1.41% n=1; p=1.00). There were no age-based differences in AKT1 mutation (5.6% YA vs 10.8% non-YA patients; p=0.220). Hotspot alterations E17K, E17G, and L52R were numerically enriched, albeit nonsignificant, in non-YA. There were no significant differences in the presence of mTOR by age (16.9% YA and 21.5% non-YA; p=0.450). Most alterations in both groups were variants of unknown significance (17/17 in YA, 157/159 in non-YA). YA and non-YA cohorts had similar frequency of PTEN mutations (12.7% YA vs 10.5% non-YA; p=0.550). The proportion of PTEN driver mutations also did not differ (82% YA and 93% non-YA). Conclusion PIK3CA mutations were more prevalent among non-YAs highlighting potential age-associated oncogenic drivers. Although AKT1, mTOR, and PTEN gene mutations did not differ between age groups, in general, oncogenic/hotspot mutations occurred more frequently in patients ≥40 years. As management of BC evolves to incorporate PI3K/AKT/mTOR inhibitors, age-specific somatic alterations may uncover therapeutic vulnerabilities and inform customized treatment. Citation Format: N. Lopetegui-Lia, A. Davenport, J. Gill, A. M. Roy, S. Myers, D. Agnese, E. Burke, T. Y. Andraos, D. M. Schimming, S. Hulett, H. LeFebvre, M. Gatti-Mays, D. Stover. Age-driven genomic differences in breast cancer: relevance for PI3K-pathway [abstract]. In: Proceedings of the San Antonio Breast Cancer Symposium 2025; 2025 Dec 9-12; San Antonio, TX. Philadelphia (PA): AACR; Clin Cancer Res 2026;32(4 Suppl):Abstract nr PS4-03-03.

BackgroundAn appropriately sized tracheostomy is essential to minimizing risk for complications in critically ill patients requiring prolonged ventilator support; however, there are a few recognized guidelines to assist surgeons in selecting appropriate tracheostomy tube length. Advanced imaging studies can be beneficial in evaluating patients with challenging airway anatomy. We aim to determine anthropomorphic factors that can assist in identifying patients who are at increased risk for tracheostomy complications in the adult trauma population.MethodsWe performed a retrospective review of trauma patients who received an open tracheostomy at a level-1 trauma center from August 2021 through March 2023. Criteria for inclusion were a preoperative computed tomography scan of the chest and postoperative chest x-ray. Eighty-seven patients met these criteria.ResultsThere were 17 (19.5%) supraclavicular placements, 22 (25.3%) infraclavicular placements (of which 5 (5.7%) were right mainstem intubations requiring immediate surgical revision, and 11 inadvertent dislodgements (12.6%). The overall average skin-to-trachea (STT) distance was 4.0cm. Patients with STT >4cm had 0.280 [0.115-0.680] times lower odds of ETT termination between the clavicles (P = 0.004). Patients with supraclavicular termination depth were 3.667 times more likely to have STT >4cm (P = 0.024). Infraclavicular placement did not achieve statistical significance for STT >4cm (P = 0.061).DiscussionPatients with pre-tracheal soft tissue >4cm have greater odds of suboptimal tracheostomy placement and inadequate tracheostomy tube termination depth. Measuring STT on preoperative neck/chest computed tomography (CT) may be useful in identifying adult trauma patients who will present additional challenges in determining the appropriate tracheostomy tube length.

BackgroundUnplanned ICU admissions (UA-ICU) is a TQIP metric associated with increased morbidity, mortality, and resource utilization. Despite identification of certain predictive factors in prior publications, gaps remain in identifying patients at-risk, particularly once in-hospital and outside the emergency room setting. Our study investigates novel predictors and emphasizes outcomes in UA-ICU for trauma.MethodsRetrospective cohort study. Single ACS-verified Level 1 Trauma Center (2019-2023). N = 140 UA-ICU after initial non-ICU hospital ward admission and 140 controls never admitted to ICU propensity-matched for age, gender, mechanism of injury (MOI), ISS, and top two highest abbreviated injury values (AIS). We compared variables including demographic, injuries, comorbidities, laboratory, and pharmacology. Statistical analysis was performed utilizing SPSS-28 (Armok, NY) software.ResultsUA-ICU patients demonstrated higher mortality (22.1% vs 1.4%, P < 0.001), longer length of stay (LOS) (10 vs 3 days, P < 0.001), and fewer discharges home (33.6%, P < 0.001). Comorbidity predictors included cirrhosis, active cancer diagnosis, CHF, and home medication for seizure and loop diuretics. Between 48-72h post-admission, UA-ICU had higher heart rates (107 vs 96 P < 0.001), lower hemoglobin (11 vs 13, P < 0.001), lower platelets (193 vs 229, P = 0.002) and supplemental oxygen requirements (2L vs 0, P < 0.001).DiscussionOur study affirms established predictors and introduces novel indicators for UA-ICU. Length of stay, discharge other than home, and mortality outcomes are consistent with research linking UA-ICU to prolonged hospitalization and adverse outcomes. Early detection, dynamic monitoring, and interdisciplinary interventions should coalesce to mitigate preventable UA-ICU and conserve resources. We proposed integration of additional predictors into clinical practice/scoring systems to optimize patient outcomes.

The American Association of Endocrine Surgeons (AAES) drafted Entrustable Professional Activities (EPAs) for Endocrine Surgery (ES) to assess general surgery residents and ES fellows in core topics. Here, we examine learner and teacher concordance of entrustability ratings. Fourteen EPAs were defined (10 "core"-6 with pre-, intra-, and post-operative phases, four single-phase-and four elective EPAs). Ten institutions collected three-item micro-assessments (MAs) of learner EPA performance using a web-based platform, where entrustment was assessed on observable behaviors using a five-point scale. Learner provided self-assessment ratings, while teachers separately assigned ratings for the same activities. Spearman rank correlation tests were applied to compare learner-teacher ratings for EPAs. MAs (n=698) were submitted between 7/2022-9/2023. Programs submitted between 3 and 468MAs. Among 3-phase core EPAs, the intraoperative phase was most assessed (n=496), followed by pre- and post-operative phases (n=108 and 55, respectively). Thirty-nine single-phase EPAs were submitted. Learner self-assessment and teacher ratings were equivalent for 32% of pre-operative EPAs, 53% of intra-operative EPAs, 29% of post-operative EPAs, and 64% of single phase of care EPAs. Spearman rank correlation between teacher and learner ratings for all phases of care combined was 0.66. Correlation was highest for the intra-operative phase (0.73), followed by single-phase (0.65), pre-operative phase (0.27), and post-operative phase (0.20). Rating concordance did not differ when high and low scores were examined independently. Learners were more prone to underestimate performance than to overestimate it when ratings were discordant. Learners' self-assessment and teacher ratings of endocrine surgery EPAs are strongly concordant with operative technical skills. However, learners often underestimate their performance of pre- and post-operative care compared to faculty ratings when using EPAs.

Surgical site infections (SSIs) and intra-abdominal abscesses (IAAs) are common and costly complications following elective colon surgery, requiring prompt diagnosis and treatment. Hemostatic cellulose, a widely used intraoperative hemostatic agent, can mimic pathological lesions such as abscesses on imaging, leading to potential misdiagnoses. We present the case of a 68-year-old man who underwent elective colostomy reversal complicated by a postoperative computed tomography (CT) scan suggestive of an IAA. Upon review of the operative note and repeat imaging, the suspected abscess was determined to be a hemostatic cellulose. This case highlights the importance of meticulous intraoperative documentation and interdepartmental communication to prevent unnecessary interventions and improve patient outcomes. Additionally, it underscores the need for awareness among clinicians regarding this masquerading ability of hemostatic cellulose to avoid misinterpretation and its potential impact on both patients and hospital quality metrics.