2018 Kentucky Research Competition Abstracts
Scroll down to view all 2018 Abstracts
Differential Expression of RNA and the identification of enriched pathways in a
Presenting Author: Quattrone, McKell, University of Kentucky
Fibrinolysis shutdown is a coagulopathy that prevents clot breakdown following injury, which can be identified using thromboelastography (TEG). Shutdown occurs at high rates within the trauma population, and is associated with high mortality rates. However, shutdown has not been studied within the elderly trauma population, specifically those with a traumatic brain injury (TBI). This study aimed to determine the relationship between incidence of shutdown coagulopathy in elderly trauma patients with TBI and its association with mortality in these patients.
Retrospective medical record review, including TEG results, of elderly (>65yo) tier 1 trauma activations from 2013–2018 at a level 1 academic trauma center. Patients were assigned groups based injury location, and data recorded for injury characteristics, hospital course, transfusion therapy, disability and mortality. Patient TEG charts were analyzed and assigned a coagulation phenotype based on the LYS30 value as follows: physiologic fibrinolysis (LYS30=1.0-2.9%), hyperfibrinolysis (LYS30>3%), or fibrinolysis shutdown (LYS30 ≤ 0.9%).
349 cases with 10 undocumented TEG results excluded, leaving 339 for TEG analysis. Of the 339 patients, 242 (71%) presented with shutdown coagulopathy, compared to 37 and 60 patients with normal and hyperfibrinolysis phenotypes for all injury locations. Four hour volumes of PRBCs, platelets, cryoprecipitate, and fresh frozen plasma were all higher than normal TEG result patients in the hyperfibrinolysis group (all p < .05) and no different from normal in the shutdown group (all p > .69). Mortality varied significantly by TEG result group for all injury locations (p<.013), with the highest mortality occurring in the hyperfibrinolysis group (Figure 1). Risk of mortality increased across all TEG groups in patients with head injuries compared to those without (Figure 2). However, TEG coagulation phenotype results did not vary between TBI and non-TBI injuries (p=.827).
A high prevalence of fibrinolysis shutdown existed in the elderly trauma population studied and in the subgroup of TBI patients; however, the prevalence of shutdown was not significantly increased in TBI patients. The increase in mortality observed in patients with coagulopathies across the entire elderly population suggests that shutdown coagulopathy has a similar effect on elderly trauma patients as previously recorded in the adult trauma population. The increase in mortality risk across all TEG phenotypes in TBI injury patients, along with the shutdown group approaching the risk of the lysis group in TBI suggests clotting may be more detrimental in head injury patients.Risk of Recurrence in Differentiated Thyroid Cancer: A Population-Based
Comparison of the 7th and 8th Editions of the American Joint Committee on
Presenting Author: Gan, Tong, University of Kentucky
Thyroid cancer incidence has steadily increased in the past decade. Differentiated thyroid cancer (DTC) survival remains excellent but requires lifelong surveillance. Historically, the AJCC 7th edition staging system has been a poor predictor of recurrence requiring adjunctive prediction models. We hypothesize that the new American Joint Committee on Cancer 8th edition improves upon the utility of the 7th edition in stratifying the risk of recurrence in DTC.
A population-based retrospective review compared the risk of recurrence in DTC patients according to the AJCC 7th and 8th editions using the Kentucky Cancer Registry data from 2004-2012. We excluded patients with metastatic disease. Kaplan-Meier plots and Cox-regression analysis were performed.
The study cohort included 3248 patients with DTC considered disease free after treatment. In 20% of cases, patients were down-staged from the 7th to the 8th edition. Most patients had stage I disease (80% in the 7th edition and 94% in the 8th edition). A total of 110 (3%) patients recurred after a median of 27 months. Risk of recurrence was significantly associated with stage for both editions (p < 0.001). In the 7th edition, there was poor differentiation of lower stages and better differentiation of higher stages (HR 0.91, 95% CI 0.39-2.11 stage II; HR 3.72, 95% CI 2.29-6.07 stage III; HR 11.66, 95% CI 7.10-19.15 stage IV; all compared with stage I). The 8th edition better differentiated lower stages but not higher stages (HR 4.06, 95% CI 2.38-6.93 stage II; HR 13.07, 95% CI 5.30-32.22 stage III; 11.88, 95% CI 3.76-37.59 stage IV; all compared with stage I).
The 7th edition had an overall better fit to the data with better differentiation between stage III and IV disease. The 8th edition was better at differentiating lower stage disease while having no clear advantage in stage III and IV disease. Limitations remain, however, emphasizing the importance of adjunctive strategies to estimate risk of recurrence.INFLUENCE OF THE OPIOID EPIDEMIC ON FIREARM VIOLENCE
Presenting Author: Dittmer, Sarah, University of Kentucky
The opioid crisis is a major public health emergency, killing more Americans than motor vehicle collisions and firearms combined. However, current data likely underestimates the full impact on mortality due to limitations in reporting and toxicology screening that have been previously described. Given the established relationship between illicit drug use and gun-related behaviors, we aimed to explore the relationship between opioid overdose ED visits (ODED) and firearm-associated ED visits (FAED).
For the years 2010 to 2017 we analyzed county-level emergency department visits in Kentucky for ODED (per 1,000) and FAED (per 10,000) using Office of Health Policy and US Census Bureau data. Additional variables analyzed included: insurance status, ethnicity, median household earnings, unemployment rate, and education level.
ODED and FAED visits were correlated (Rho = .178, p < .001) and both increased over the study period, remarkably so after 2013 (p < .001 for increase, Figure 1). FAED visits were higher in rural compared to urban counties (p < .001), while ODED visits were not (Figure 2). In multivariable analysis, FAED visits were associated with ODED visits (B= 0.17, p=.001), rural status (B = 0.33, p = .012), white race rate (B = -2.4, p = .012), and high school diploma rate (-6.45, p < .001) after adjustment for year. Unemployment and earnings were univariate correlates with FAED visits (rho = .19, p < .001 and -.15, p < .001 resp.) but were not significant in the multivariable model.
In addition to existing nonfatal consequences of the opioid crisis (e.g,. neonatal abstinence, burden on the criminal justice & foster care systems, incidence of opioid use disorder, etc.), firearm violence appears to be a corollary impact, particularly in rural counties. Future analyses should examine opioid use characteristics (e.g., prescription vs. illicit) as well as the impact of interventional models to reduce associated harm.
Figure 1. Firearm ED Visits and Overdose Per Year
Figure 2. Overdose ED Visits and Firearm Visits by County Rurality
EMERGENT TRANSFER PATIENTS
Presenting Author: Keeven, David, University of Kentucky
To identify the mortality, morbidity and resource utilization burden of non-trauma
transfers to emergency general surgery services.
Background: Emergency General Surgery (EGS) Patients require greater resources and have
increased rates of morbidity and mortality. Previous work isolating colectomy procedures has
shown increased mortality with respect to transferring institution; Emergency Department (ED),
Inpatient (IPT), Nursing Home (NH) and Direct Admissions (DA). With length of stay, time in
need of critical care measures and duration of operation being major factors in cost we
hypothesize that “Patient transfer status negatively effects morbidity, mortality and resource
Data was obtained for patients undergoing emergency general surgery, for the top ten
procedures by volume, using public files from the American College of Surgeons National
Surgery Quality Improvement Program for years 2012 and 2016 (Table 1). We analyzed risk
factors and 30-day outcomes by transfer status using chi-square analysis and multivariable
logistic regression. Significance was set at p < .001.
Results: A total of 101,244 procedures were identified. Transferred patients had increased
clinical risk, operative complexity, and poorer outcomes. Fewer transfers were initiated for less
technically sophisticated cases such as laparoscopic appendectomy and cholecystectomy while
more complex acute open cases were transferred. Transfer patients required longer operations,
more transfusions, incurred greater critical care complications identified as; prolonged and
unplanned intubations, renal failure, treated pulmonary embolisms, sepsis, cardiac arrest, infarct,
and stroke. Transfer patients returned to the operating room more often, had higher rates of
readmission and greater 30-day mortality (Table 2). These effects remained after adjusting for
procedure group, secondary procedures, age and ASA class.
Our study demonstrates significant differences in mortality, morbidity and
resource burden of EGS transfer patients dependent upon the transferring facility that were not
attributable to case mix, age and comorbid status alone. These data point to potential financial
and quality assessment challenges of tertiary referral centers.
Table1. The distribution of the top ten procedures (by volume) performed emergently on general surgery services varied with transfer status (chi-square p < .001)
Management of enteroatmospheric fistulae using patient-matched 3D-printed
Presenting Author: Warwick, James, University of Kentucky
An enteroatmosperic fistula (EAF) is a dreaded complication of open abdomen (OA) that can develop following OA surgery. An EAF is an abnormal connection between the intestinal lumen and the outside environment. The development of an EAF greatly complicates wound management and is associated with a higher mortality rate. EAF leakage of intestinal contents into the surrounding wound bed make fistula isolation the top wound care priority in these patients. However, the high variability and volatility of EAF/OA presentation make effective wound care difficult, and no optimal approach has been standardized. Many current management plans involve the use of negative pressure wound therapy (NPWT), which has been indicated to accelerate general wound healing. However, in EAF/OA patients, utilizing NPWT efficiently can be challenging. The special dressings and air tight seals NPWT requires frequently fail because of device leakage and necessitate frequent dressing changes, which are tedious and time consuming. NPWT also restricts mobility and is expensive, which limits the ability of patients to manage their wound in the outpatient setting. Thus, the need exists for an EAF/OA management system that effectively isolates EAF contents, is cost-efficient, accessible for patient use, and can be customized to meet individual patient characteristics.
This study investigates the efficacy of a 3D-printed device to isolate fistula effluent independent of negative pressure. The device would act as a shunt, diverting fistula contents away from the OA wound bed and into an anteriorly placed ostomy bag. The 3D-printing manufacturing process allows detailed customization to account for individual EAF variants such as output, location, size, and depth; this customizability is anticipated to result in more effective isolation and minimal device dislodgement. Due to the relative rarity of EAF/OA patients, this clinical investigation will be a compilation of individual case studies.
Data will be collected while patients remain admitted to the University of Kentucky Hospital (with potential for outpatient continuation), regarding dressing change frequency/time, leakage rates, patient mobility, complication rates, technology acceptance (TAM model), and patient quality of life. We will assess the efficacy of device usage as a viable EAF management technique based on its overall effectiveness, its ease of use, and its cost relative to other techniques.
This device is not approved by the FDA for commercial use. It is being studied under an abbreviated investigational device exemption (IDE) protocol. Upon IRB approval, this clinical study would be conducted and monitored solely within the University of Kentucky. Further study of this device involving other institutions or commercialized use would require more extensive FDA regulation, which may hinder the investigative process.
Incidence of and Risk Factors for Multiple Readmissions following Kidney
Unplanned Re-operation following Deceased Donor Renal Transplantation