Ochsner's Sixth Annual Research Night May 12, 2009 Ochsner Clinic Foundation New Orleans, LA

R1 EXPRESSION OF AN ANGIOTENSIN AT₁ RECEPTOR CLEAVAGE FRAGMENT TRIGGERS APOPTOSIS: EVIDENCE FROM DNA LADDER ASSAYS

Turner B, BS^*; Alam J, PhD^*; Re RN, MD^†; Cook JL, PhD^*

^*Department of Molecular Genetics, Ochsner Clinic Foundation, New Orleans

^†Department of Cardiology, Ochsner Clinic Foundation, New Orleans

Background: We have previously reported that the AT₁ receptor is cleaved in a ligand-dependent manner with trafficking of the cytoplasmic carboxy-terminal fragment (CF) to the nucleus and shedding of the extracellular domain.

Objectives: To determine the effects of the CF in cultured cells by overexpressing a yellow fluorescent fusion protein of the CF and evaluating cells by DNA laddering.

Methods: CHO-K1 and HeLa cells and H9c2 cardiomyoblasts were transfected with AT₁R_CF/EYFP (or mock control) and DNA collected and evaluated by agarose gel electrophoresis at 24 and 48 h posttransfection.

Results: Expression of the cleavage fragment causes visible DNA laddering as early as 24 h and dramatic laddering by 48 h in all cell types examined. DNA laddering is the gold-standard assay for apoptosis but generally is useful only if large populations are simultaneously undergoing cell death. The CF is clearly an extremely powerful apoptotic reagent in all cells examined.

Conclusions: These results are consistent with an apoptotic role for the AT₁R cleavage fragment, and both corroborate and extend the findings presented on our sister abstract (Singh et al). The renin-angiotensin system has been associated with apoptosis in several disease processes, including heart failure, glioblastoma, atherosclerosis, and restenosis. Our data are consistent with the hypothesis that cleavage and nuclear trafficking of the receptor fragment may underlie apoptosis in one or more of these pathologies.

R2 AT₁ RECEPTOR TRAFFICKING IN A GABARAP-INDUCIBLE CHO-K1 CELL LINE

Redding KM, MS^*; Alam J, PhD^*; Re RN, MD^†; Cook JL, PhD^*

^*Department of Molecular Genetics, Ochsner Clinic Foundation, New Orleans

^†Department of Cardiology, Ochsner Clinic Foundation, New Orleans

Background: We have previously reported that the accessory protein GABARAP enhances cell surface trafficking of the AT₁ receptor (AT₁R) in several cell types.

Objectives: We sought to develop a cell line in which GABARAP expression could be turned on and off in a given population of cells. In this manner, within a given microscopic field of view, we would be able to evaluate the effects of GABARAP expression on AT₁R accumulation and trafficking.

Methods: The T-REx-CHO cell line (Invitrogen, Carlsbad, CA) represents CHO-K1 cells stably transfected with the tetracycline repressor protein. We designed an expression plasmid, which encodes a fluorescent fusion of the GABARAP protein regulated by the tet operator and generated stables in T-REx-CHO. This allowed for only low levels of GABARAP expression in the repressed state but for dramatic expression in the tetracycline-induced state. In this manner, we were able to express AT₁R and then follow accumulation and trafficking upon tet-induction of GABARAP.

Results: Within individual cells expressing the AT₁R fusion protein, we observed dramatic mobilization and movement from the secretory pathway to the plasma membrane within 3 h of transfection and significant enhancement of AT₁R accumulation and cell surface expression between 6 and 48 h of induction.

Conclusions: Inducible/repressible systems allowed us to monitor the effects of an inducer/repressor on a single given cell or cell population and, therefore, represented a more rigorous assay for “effect” than comparison of vehicle versus agent-treated cells.

R3 EXPRESSION OF A NATURALLY OCCURRING ANGIOTENSIN AT₁ RECEPTOR CLEAVAGE FRAGMENT IS CORRELATED WITH CASPASE-ACTIVATION AND CELL DEATH

Singh A, MD^*; Alam J, PhD^*; Re RN, MD^†; Cook JL, PhD^*

^*Department of Molecular Genetics, Ochsner Clinic Foundation, New Orleans

^†Department of Cardiology, Ochsner Clinic Foundation, New Orleans

Background: We have previously reported that the AT₁ receptor is cleaved in a ligand-dependent manner with trafficking of the cytoplasmic carboxy-terminal fragment (CF) to the nucleus and shedding of the extracellular domain.

Objectives: Our objective was to determine the effects of the CF in cultured cells by overexpressing a yellow fluorescent fusion protein of the CF and evaluating cells by imaging.

Methods: CHO-K1, HeLa, and MCF-7 cells were transfected with AT₁R_CF/EYFP and evaluated by 3D deconvolution imaging for expression and trafficking of the fusion protein. Cells were further evaluated for expression of markers of apoptosis by annexin V and polycaspase assays.

Results: Expression of the cleavage fragment caused rapid morphological changes (as early as 3 h posttransfection), the details of which varied depending on the cell type, but all were consistent with apoptosis. Nuclear fragmentation, membrane blebbing, nuclear disintegration, and expression of activated caspases and cell-surface phosphatidylserine were observed.

Conclusions: These results are consistent with an apoptotic role for the AT₁R cleavage fragment. The renin-angiotensin system has been associated with apoptosis in several disease processes, including heart failure, glioblastoma, atherosclerosis, and restenosis. Our data are consistent with the hypothesis that cleavage and nuclear trafficking of the receptor fragment may underlie apoptosis in one or more of these pathologies.

R4 EVALUATION OF THE 2008 SCIENCE-TECHNOLOGY-ACADEMICS-RESEARCH (STAR) SUMMER PROGRAM FOR HIGH SCHOOL STUDENTS

Alam J, PhD^*; Reed C, BS^†; Ohlmeyer R, BS^†; Madden E, MLIS^†; Barnett K, MPA^†; Fischtziur A, BS^†

^*Molecular Genetics Laboratory, Ochsner Clinic Foundation, New Orleans

^†Center for Knowledge Management, Ochsner Clinic Foundation, New Orleans

Background: STAR was created to stimulate the interest of local students—particularly underrepresented minorities—in biomedical science and health care, with the ultimate goal of expanding the pipeline to careers in these fields. In 2008, the program was modified by increasing eligibility to students from all Jefferson and Orleans parish schools and by incorporating six interactive experimental modules and two demonstrations to be carried out primarily within the newly renovated student learning laboratory, the iLab.

Objectives: The primary objectives of this study were to evaluate 1) the effect of open enrollment on the composition of the STAR 2008 class and 2) the overall effectiveness of the newly incorporated experiments and demonstrations.

Methods: Relevant data were obtained from the student application forms, and STAR students were queried through preprogram, postprogram, and postexperimental module surveys.

Results: Six different schools, including two private schools, were represented in the class of 2008 compared to only two public schools in 2007. The number of minority students decreased from 64% to 50% but the number of female students increased from 73% to 83%. Both the experimental modules and demonstrations were received favorably by the students. On a scale of 1 to 10, the students gave higher ratings to the experiments for enjoyment and educational value.

Conclusions: The overall diversity of the STAR class of 2008 increased from that of 2007 as judged by several indices. Along with this trend was the even greater number of female participants. Although both the iLab experiments and the demonstrations were judged to be of high educational value, there was a detectable preference for hands-on, multiday experiments compared to less interactive, single-afternoon demonstrations.

R5 AUTOPHAGYLIE, C-TERMINAL CLEAVAGE OF GABARAP IS NOT REQUIRED FOR INTERACTION WITH THE ANGIOTENSIN TYPE-1 RECEPTOR

Cook JL, PhD^*; DeHaro D, BS^*; Redding KM, MS^*; Re RN, MD^†; Alam J, PhD^*

^*Department of Molecular Genetics, Ochsner Clinic Foundation, New Orleans

^†Department of Cardiology, Ochsner Clinic Foundation, New Orleans

Background and Significance: Autophagy is the bulk degradation of proteins and organelles and is essential for cellular homeostasis and viability. Aberrant autophagy has been implicated in numerous pathologies, including neurodegenerative diseases, muscular disorders, and cancer. A molecular hallmark of autophagy is the cleavage of certain essential proteins at a glycine residue near their C-terminus and subsequent conjugation of phosphoethanolamine to this amino acid. One target of this processing machinery is GABAP, a protein we have recently shown to interact with, and modulate the activity of, the angiotensin type-1 receptor (AT₁R), a critical regulator of blood pressure.

Objectives: The objective of this study was to determine if C-terminal processing of GABARAP is necessary for interaction with, and modulation of, AT₁R activity.

Methods: Mutants of GABARAP were generated and tested for C-terminal cleavage, interaction with AT₁R, or effect on AT₁R- and angiotensin II (AII)-dependent cellular signaling activity.

Results: Expression of epitope-tagged GABARAP in PC12 pheochromocytoma cells revealed that GABARAP is constitutively and quantitatively cleaved at the C-terminus. No cleavage was detected after mutation of glycine residue 116 to alanine (G116A). Wild-type GABARAP and the G116A mutant bound to AT₁R with similar affinity. AII (100 nM) stimulated the cyclic AMP response pathway 27-fold in PC12 cells. Both GABARAP and the G116A mutant further enhanced this stimulation by similar levels, approximately 2.5-fold.

Conclusions: GABARAP is constitutively cleaved at the C-terminal side of glycine 116, but this processing is not necessary for interaction with AT₁R and modulation of its signaling activity.

R6 ECFP/ANG II TRANSGENIC MICE DEMONSTRATE ELEVATED BLOOD PRESSURE

Chen BL, MD^*; Redding KM, MS^*; Singh A, MD^*; Alam J, PhD^*; Cook JL, PhD^*; Re RN, MD^†

^*Department of Molecular Genetics, Ochsner Clinic Foundation, New Orleans

^†Department of Cardiology, Ochsner Clinic Foundation, New Orleans

Background: Angiotensin II (Ang II) is the primary biologically active component of the renin-angiotensin-aldosterone system (RAAS). Elevated circulating Ang II causes vasoconstriction and raises blood pressure. We have previously shown that fluorescent fusion constructs of Ang II retain biological activity, stimulating CREB phosphorylation activation and cell proliferation, and altering the AT₁ receptor distribution.

Objectives: To evaluate the effects of overexpression of intracellular Ang II regulated via the global metallothionein promoter, in a mouse whole animal system.

Methods: Southern blots were used to genotype ECFP/Ang II transgenic mice, as well as to test for relative copy number between the different lines of mice that were generated. RT-PCRs were performed to test for the presence of transgene mRNA in a variety of tissues and organs. Murine embryonic fibroblasts were isolated, cultured, and evaluated by imaging of the fluorescent protein. Finally, telemetric pressure sensors were implanted in the carotid artery of the transgenic and wild-type mice, and blood pressure was measured.

Results: Transgene mRNA was found to be present in all of the tissues tested, and fluorescent ECFP was found in whole animals and cultured cells. Systolic and diastolic pressures were elevated in those mice expressing the transgene.

Conclusions: Intracellular Ang II in this global overexpression model is correlated with high blood pressure. Transgenic mice will be further evaluated by Ang II radioimmunoassay of plasma and organs.

R7 CARDIOVASCULAR EFFECTS OF INHIBITION OF THE VARIOUS COMPONENTS OF THE RENIN-ANGIOTENSIN-ALDOSTERONE SYSTEM IN HYPERTENSIVE RATS GIVEN SALT EXCESS

Susic D, MD^*; Varagic J, MD PhD^†; Frohlich ED, MD^*

^*Hypertension Research Laboratory, Ochsner Clinic Foundation, New Orleans

^†Wake Forest University Baptist Medical Center, Winston-Salem, NC

Background: This study examined the role of the renin-angiotensin-aldosterone system (RAAS) in mediating cardiovascular and renal damage in spontaneously hypertensive rats (SHRs) given salt excess. Since the circulating RAAS is inhibited in this model, it permits examination of the role of local tissue RAASs in mediating injury.

Methods: Male 8-week SHRs were divided into 7 groups. The control group (C) received normal NaCl (0.6%) diet. All others were given 8% NaCl chow. In addition, Group P was given placebo; Group E mineralocorticoid receptor blocker eplerenone (100/mg/day); Group Q an AI, quinapril (3 mg/kg/day); Group C an angiotensin II receptor blocker, candesartan (10 mg/kg/day); and Groups E+Q and E+C the respective two agents. The treatments lasted 8 weeks.

Results: Compared to controls, mean arterial pressure (MAP), renal blood flow, minimal coronary vascular resistance, coronary flow reserve, diastolic time constant, and maximal rate of ventricular pressure decline were adversely affected by salt loading. Left ventricular mass and fibrosis as well as proteinuria were also increased in salt-overloaded SHRs. E induced only slight changes, whereas Q and C normalized all indices except MAP. Combination therapy also normalized all indices, including MAP.

Conclusions: These data suggested that: (1) cardiovascular and renal damage induced by salt excess was not pressure dependent, (2) mineralocorticoids were only marginally involved, and (3) local tissue generation of AII seemed to be responsible for the other adverse effects.

R8 DEFECTIVE INSULIN SIGNALING ALTERS THE MOLECULAR MECHANISMS REGULATING VASCULAR SMOOTH MUSCLE CELL PROLIFERATION AND MIGRATION

Lightell D Jr, BS^*; Moss SC, MS^†; Woods TC, PhD^*,†

^*Molecular Cardiology Laboratory, Ochsner Clinic Foundation, New Orleans

^†Department of Pharmacology & Experimental Therapeutics, LSU Health Sciences Center, New Orleans

R9 PROTEIN KINASE C-EPSILON: A POTENTIAL THERAPEUTIC TARGET IN THE TREATMENT OF B-CELL CHRONIC LYMPHOCYTIC LEUKEMIA (B-CLL)

Velcheti V, MD^†; Tamma S, MD^‡; Larned ZL, MD^‡; Fuloria J, MD^‡; Li L, MD PhD^§; Rodwig FR, MD^‖; Cole JT, MD^‡; Prakash O, PhD^†

^*Department of Medicine, Ochsner Clinic Foundation, New Orleans

^†Molecular Oncology Laboratory, Ochsner Clinic Foundation, New Orleans

^‡Department of Hematology/Oncology, Ochsner Clinic Foundation, New Orleans

^§Cellular Immunology Laboratory, Ochsner Clinic Foundation, New Orleans

^‖Department of Pathology, Ochsner Clinic Foundation, New Orleans

Background: Lyn, a Src family kinase, and protein kinase C (PKC)-epsilon are negative regulators of apoptosis and are linked to chemo-resistance.

Objectives: We examined the role of Lyn kinase in the regulation of PKC-epsilon in B-CLL cells and its link to the apoptotic defects.

Methods: B-CLL cells, or nonmalignant B cells, were isolated from peripheral blood mononuclear cells of B-CLL patients or normal blood donors. Cytoplasmic and nuclear fractions of B-CLL cells and nonmalignant cells were prepared and examined for PKC-epsilon localization by Western blot analysis.

Results: Unlike the cytoplasmic localization in nonmalignant cells, a large fraction of PKC-epsilon in B-CLL cells was located in the nuclear fraction. Nuclear localization of PKC-epsilon in B-CLL cells was linked to the transcriptional activation of the antiapoptotic genes such as Mcl-1, XP, and Bcl-2, as well as NF-kappaB activation and vascular endothelial growth factor (VEGF) production, both strongly implicated in the apoptotic resistance of B-CLL cells. Treatment of B-CLL cells for 16–20 hours with 10 micromolar Lyn-specific inhibitor peptide resulted in redistribution of PKC-epsilon from the nuclear to the cytoplasmic fraction, decreased expression of the antiapoptotic genes, and decreased the viability of the leukemic cells. In addition, the Lyn-specific inhibitor peptide induced more than 50% inhibition of NF-kappaB p65 nuclear translocation and VEGF production in B-CLL cells but not in nonmalignant B cells. Similar results were obtained when a selective inhibitor peptide of PKC-epsilon translocation but not the negative control peptide was used.

Conclusions: Our results suggest that PKC-epsilon is a downstream target of Lyn kinase and that inhibition of PKC-epsilon nuclear translocation may have therapeutic potential for the treatment of B-CLL.

R10 ROLE OF FOLLICULAR DENDRITIC CELLS (FDC) IN BREAST CANCER METASTASIS

Lee CG, PhD; Lavezzi T, BS; Lee IY, PhD; Li L, MD PhD

Cellular Immunology Laboratory, Ochsner Clinic Foundation, New Orleans

Background: Breast cancer is the second leading cause of cancer death in women in the United States. During the progression of breast cancer, invasive carcinoma cells migrate and populate to form secondary breast tumors in disparate organs such as lymph nodes (LNs). Frequently, breast carcinoma cells are found in regional LNs at diagnosis. Of patients with axillary LN metastases, 70% relapse within 10 years of diagnosis, suggesting the importance of controlling carcinoma cell growth in LN. It has been shown that stromal-cell-derived factor (SDF)-1 promoted proliferation of mammary carcinoma cells via its receptor, CXCR7. We have shown previously that FDC promote tumor growth by mammary carcinoma cells and that an FDC factor, SDF-1, is critical for tumor growth and angiogenesis.

Objectives: We sought to delineate how FDC-derived SDF-1 promotes tumor formation.

Methods: Human mammary carcinoma cells (MMCA) and FDC line HK cells were implanted subcutaneously into the nonobese diabetes/severe combined immunodeficiency (NOD/SCID) mice. The effect of SDF-1 signaling for tumor growth by MMCA was assessed with a small molecule inhibitor (CCX771) of the SDF-1 receptor, CXCR7. CCX771 was administered to the skin adjacent to the growing tumor every other day for the period of 3 weeks after implantation. Tumor growth was determined by whole body in vivo imaging analysis.

Results: FDC expressed SDF-1, and MMCA cells were positive for CXCR7 by immunohistochemistry staining. FDC-dependent MMCA cell tumor growth was specifically inhibited by CCX771 in a dose-dependent manner.

Conclusions: FDC/SDF-1 is likely to support tumor growth in part via the CXCR7 receptor on tumor cells.

R11 CD9 ON B LYMPHOMA CELLS MODULATES INTEGRIN MEDIATED BINDING TO FOLLICULAR DENDRITIC CELLS (FDC)

Zhang X, MD PhD; Berner P, BS; Lee IY, PhD; Yoon SO, PhD

Cellular Immunology Laboratory, Ochsner Clinic Foundation, New Orleans

Background: Previously, we discovered that indolent B cell lymphomas (i.e., FDC dependent) express CD9 but aggressive ones (i.e., FDC independent) do not. Hence, we investigated the functional roles of CD9 in the interaction between B lymphomas and FDC.

Methods: Using CD9 positive and CD9 negative B lymphoma cells, we determined whether CD9 is involved in the interactions with FDC or extracellular matrix (ECM) secreted by FDC. Because it is known that integrins and other tetraspanin molecules cooperate with CD9, we identified molecules associated with CD9 by immunoprecipitation and confirmed their colocalization by microscopy.

Results: Anti-CD9 mAb inhibited the binding of CD9 positive B lymphoma cells to ECM. CD9 was associated with integrin α4β1 and strengthened integrin α4β1-mediated ECM binding.

Conclusions: Our data suggest that CD9 is associated integrin α4β1 and modulates B lymphoma cell adhesion to ECM produced by FDC. Loss of CD9 might reduce B lymphoma cell binding to ECM and enhance migration and metastasis.

R12 ROLE OF FOLLICULAR DENDRITIC CELLS (FDC) IN THE RELAPSE OF B LYMPHOMAS

Yoon SO, PhD; Zhang X, MD PhD; Berner P, BS; Choi YS, PhD

Cellular Immunology Laboratory, Ochsner Clinic Foundation, New Orleans

Background: Most of B lymphoma patients treated with standard therapeutic regimens have partial responses and experienced relapse. Since lymph node microenvironment is recognized as an important factor for tumor progression and drug resistance, we investigated the role of FC, major stromal cells in lymph nodes, in the relapse of B lymphomas.

Methods: B lymphoma cell lines were treated with chemo drugs or rituximab in the absence and presence of FC, and apoptosis caused by these reagents was measured by Annexin-V/PI staining to examine whether FDC can protect B lymphoma cells from apoptosis. The signaling pathways were identified by adding specific inhibitors to the coculture of B lymphoma cells and FDC.

Results: Stromal cells rescued B lymphoma cells from apoptosis induced by chemo drugs or rituximab. The addition of PI3K pathway inhibitors in the culture diminished the protective effect of FDC against drug treatment.

Conclusions: Stromal cells contribute to relapse of B lymphomas by conferring drug resistance. Therefore, blocking signals from FDC in combination with the current therapy might be more effective to prevent relapse.

R13 COLON CANCER STEM CELLS AND THEIR MICROENVIRONMENT

Regn R; Lavezzi T, BS; Li L, MD PhD

Cellular Immunology Laboratory, Ochsner Clinic Foundation, New Orleans

Background: Colorectal cancer (CRC) is the third most common malignancy and the second most common cause of cancer-related death in the United States. Nearly two-thirds of newly diagnosed cases of CRC have lymph node involvement or metastatic disease, indicating the microenvironment in lymph nodes may be important for disease progress. It is believed that a small proportion of cancer cells are cancer stem cells (CSC), capable of self-renewal and multipotency. These cells may be identified using antibodies to CD133, an important CSC marker in a number of malignancies, including colon carcinoma.

Objectives: To establish an in vivo model for colon CSC study.

Methods: Magnetic cell separation was performed on HT29 cell line using monoclonal antibody CD133 then microbeads conjugated rat anti-mouse IgG₁. Different numbers of HT29 cells and purified CD133⁺ HT29 cells were mixed with or without HK cells and then injected subcutaneously into nude mice. Tumorigenesis was assessed by measuring solid tumors in three dimensions with a caliper twice a week. Immunohistochemical studies were performed using CD31-PE for blood vessel endothelial cells, CD133-PerCP for CC, and DAPI for nuclear staining.

Results: The FDC line, HK cells, and enhanced HT29 cells formed tumors in nude mice and increased tumor vascularization relative to the control tumor formed by HT29 cells alone. CD133⁺ HT29 cells are more tumorigenic than unseparated cells. Other host inflammation cells can also be quantified in xenoplants.

Conclusions: These data may aid the design of a xenoplant model for analyzing colon CSC and their microenvironment from patient biopsy samples to determine the percentage of CSC in order to better predict recurrence and invasiveness.

R14 FOLLICULAR DENDRITIC CELLS (FDC) SUPPORT LYMPHOMA STEM CELLS BY PRODUCING SDF-1

Lavezzi T, BS; Regn R; Lee CG, PhD; Li, MD PhD

Cellular Immunology Laboratory, Ochsner Clinic Foundation, New Orleans

Background: B cell lymphoma is the most common hematological malignancy in adults. Relapsed and drug-resistant diseases are still unsolved problems for follicular lymphoma. Microenvironmental factors are important for the survival of drug-resistant B cell lymphoma stem cells (BCL-SC) during therapy. The chemoattractant stromal-cell-derived factor 1 (SDF-1) and its receptor CXCR4 are the main chemokine system involved in the chemotactic interaction between B lymphoma cells and lymph node stromal cells.

Objectives: Identification of the B lymphoma stem cell microenvironment.

Methods: Real-time polymerase chain reaction methods were used to detect the expression levels of SDF-1 on an FDC line, HK cells, and CXCR4 on lymphoma cells. Immunohistochemistry was used to stain SDF-1 expression in FDC. An in vitro transwell experiment was used to investigate the migration of lymphoma cells toward HK cells and SDF-1, and a side population (SP) from lymphoma cells was analyzed to delineate the target cell populations of SDF-1.

Results: SDF-1α was expressed over nine-fold higher by HK cells than control fibroblasts (HFF-1), and CXCR4 was upregulated in SP versus parental lymphoma cells. In a human tonsil, SDF-1 molecules were expressed by FDC in germinal centers. A small population of FLK-1 cells migrated toward HK cells and SDF-1 in a dose-dependent manner. SDF-1 signaling was specifically blocked by AMD3100. Lymphoma cells adherent to HK cells and homing to HK cells and SDF-1 contained enriched SP, and ABCG2⁺ cells were in close contact to HK cells in the early stage of lymphomagenesis and in close contact to vasculature in tumors.

Conclusion: SDF-1 by FDC may play crucial roles in B cell lymphomagenesis. Identification of the microenvironmental factors specific to BCL-SC in lymphomagenesis will provide the basis for developing a rational BCL-SC-specific therapeutic strategy to eliminate follicular lymphoma.

R15 A NOVEL FUSION PROTEIN FOR THE TREATMENT OF CHEMOTHERAPY-INDUCED ALOPECIA IN MICE

Ponnapakkam T, PhD^*; Katikaneni R, MD^*; Miller E^†; Mollaee M, MD^*; Gensure R, MD PhD^*

^*Pediatric Endocrinology Research Laboratory, Ochsner Clinic Foundation, New Orleans

^†Millsaps College, Jackson, MS

Background: Hair loss is a side effect of many chemotherapy protocols and is one of the most psychologically devastating aspects of cancer therapy. So far, no satisfactory strategy for preventing chemotherapy-induced alopecia (CIA) is available and no treatment modality for preventing CIA has been clearly shown to be effective. Parathyroid hormone (PTH) induces a degree of hair growth in mice when applied directly to the skin; however, poor skin absorption of the peptide limits its efficacy. We have linked PTH (1–34) to a protein domain that binds collagen (PTH-CBD). The hybrid peptide activates the PTH/PTHrP receptor with similar potency and efficacy to that of PTH (1–34).

Objectives: To test the effect of PTH-CBD on the pattern of hair growth after CIA with cyclophosphamide.

Methods: Twenty 3–5 week female C7BL/6J mice were given cyclophosphoamide (150 mg/kg) at 0, 2 weeks, and 6 weeks. After the chemotherapy-induced hair loss was evident, the animals were divided into two groups. The control group received collagen-binding buffer, and the treated group received (320 mg/kg) PTH-CBD.

Results: The chemotherapeutic agent caused hair thinning and color change (black-to-white). The animals treated with PTH-CBD showed more rapid regrowth of the hair, and the chemotherapy-induced thinning/color change of the hair was reversed, as evidenced by gross and histological examination.

Conclusions: It appears that PTH-CBD can reverse CIA. Our primary goal is to utilize these pilot studies for the development of safe and effective therapies to treat hair loss and help patients undergoing chemotherapy treatments.

R16 TISSUE INHIBITOR OF METALLOPROTEINASE-3 (TIMP-3) PROTECTS LIVER HISTOLOGY AND BIOCHEMISTRY IN RATS UNDERGOING SUBLETHAL TOTAL HEPATIC ISCHEMIA

Swamy OR, PhD; Zetzmann C; Loss GE Jr, MD PhD; Cohen AJ, MD

Transplantation Research Laboratory, Ochsner Clinic Foundation, New Orleans

Background: Tumor necrosis factor-alpha (TNF-α) converting enzyme (TACE) is a metalloproteinase disintegrin that cleaves precursor TNF-α to its mature form. Limited information exists on the role of TIMP-3 in its ability to protect livers from injury. TIMP-3 has been administered to study its influence on the hepatic ischemia-reperfusion injury on a rat model.

Methods: Wistar rats (n = 8) were intraperitoneally injected with TIMP-3 at a dosage of 0 (control group), 1000 ng/Kg body weight. One hour after pretreatment, all animals were subjected to 30 minutes of full warm hepatic ischemia followed by 6 hours of reperfusion. Animals were euthanized at 24 hours, 48 hours, and 7 days.

Results: In the TIMP-3-treated animals, histological changes were minimized at 24 hours and markedly reduced at 7 days, while the control animals had typically ischemic changes at both time points. Control animals subjected to ischemia/reperfusion injury had high levels of serum TNF-αup to7 days after injury (range: 61.3 pg/mL to107.6 pg/mL). With TIMP-3 pretreatment, there was notable inhibition (81–89%) for the first 48 hours after injury (range: 11.6 to 11.7 pg/mL, P<0.05). On day 7, it was still 53% below the control animals (P<0.005). Pretreatment with TIMP-3 resulted in markedly suppressed levels of AT, and IL-6 level changed in a similar pattern to the serum TNF-α levels at all time points up to 7 days (P<0.05).

Conclusions: TNF-α remains elevated for up to 7 days following injury. Pretreatment with TIMP-3 resulted in significantly lower circulating levels of TNF-α, for at least 7 days following sublethal total ischemic hepatic injury. TIMP-3 reduced the biochemical and histological injury in this model. This study suggests that TIMP-3 may potentially play a clinically relevant role in protecting livers undergoing total hepatic ischemia.

R17 IN VITRO ANTIBACTERIAL ACTIVITY OF TIGECYCLINE BY TIME-KILL ASSAY AGAINST ENTEROCOCCUS FAECALIS AND LINEZOLID-SUSCEPTIBLE AND RESISTANT VANCOMYCIN-RESISTANT ENTEROCOCCUS FAECIUM

Pankey GA, MD; Ashcraft DS, BS MT

Infectious Diseases Research, Ochsner Clinic Foundation, New Orleans

Background: Tigecycline demonstrates in vitro bacteriostatic activity against Enterococcus faecalis and Enterococcus faecium (vancomycin-susceptible and -resistant). We were interested in whether the antibacterial activity persisted throughout 48 h in time-kill assay (TKA) using different concentrations of tigecycline and if similar activity occurs with vancomycin-resistant E. faecium also resistant to linezolid.

Methods: During 2002–07, 25 genetically-unique, U.S.A. clinical isolates, E. faecalis (5) and E. faecium [10 vancomycin-resistant (VRE), 10 vancomycin- and linezolid-resistant (LRVRE)], were collected. Identification was determined using the Vitek (bioMérieux, Marcy l'Etoile, France). TKA was performed following National Committee on Clinical Laboratory Standards (presently Clinical and Laboratory Standards Institute) 1999 guidelines and using tigecycline concentrations equal to 1, 2, and 4 times minimum inhibitory concentration (MIC). Colony counts were determined at 0, 4, 8, 12, 24, 36, and 48 h. Fresh Mueller-Hinton II broth (<12 h old) was used for all testing. Bacteriostatic activity was defined by a decrease (<3 log₁₀) in CFU/mL.

Results: Tigecycline MICs for E. faecalis, VRE and LRVRE were 0.03–0.12 µg/mL, 0.015–0.25 µg/mL, and 0.015–0.06 µg/mL, respectively. The Food and Drug Administration (FDA)-approved breakpoint for tigecycline and E. faecalis (vancomycin-susceptible only) is <0.25 µg/mL. There is no FDA-approved breakpoint for tigecycline and E. faecium. Bacteriostatic activity was demonstrated by all isolates with all tigecycline concentrations during the 48 h TKA. When compared to the original inoculum, antibacterial activity increased when the tigecycline concentration increased.

Conclusions: TKA showed that tigecycline demonstrated bacteriostatic activity against E. faecalis, VE, and LRVRE. Results suggest that susceptibility breakpoints for VRE are the same as for the FDA-approved breakpoints for E. faecalis. No data suggest that these in vitro results can be translated into in vivo applications. Clinical data for tigecycline against enterococci are needed.

R18 PHAEOHYPHOMYCOSIS INFECTIONS IN SOLID ORGAN TRANSPLANT RECIPIENTS: THE LARGEST SINGLE INSTITUTION EXPERIENCE

Beckman EN, MD^*; Garcia-Diaz JB, MD^†; ; Schieffelin JS, MD^†; Staffeld-Coit CG, MD^§; Garces JC, MD^§; Keller RA, MD^‖; Pankey GA, MD^†

^*Department of Anatomic Pathology, Ochsner Clinic Foundation, New Orleans

^†Infectious Diseases Research, Ochsner Clinic Foundation, New Orleans

^‡Multi-Organ Transplant Center, Ochsner Clinic Foundation, New Orleans

^§Department of Nephrology, Ochsner Clinic Foundation, New Orleans

^‖Department of Dermatology, Ochsner Clinic Foundation, New Orleans

Background: Phaeohyphomycotic infections are relatively common in solid organ transplant recipients. Awareness of the characteristic morphology is important in prompt treatment, especially if the lesion was not cultured.

Methods: From years 1988–2005, specimens were reviewed from 24 patients with solid organ transplants and phaeohyphomycosis infection.

Results: Biopsy material from the skin and subcutaneous tissue was most common (38 separate specimen). The typical histologic appearance was one of purulent granulomas with central acute inflammation, surrounding granulomatous change with varying number of giant cells, and peripheral inflammation and fibrosis. In older lesions, the granulomatous quality was less well defined, and there was more fibrosis and chronic inflammation. Varying numbers of brown fungal forms were evident with hematoxylin and eosin stains. Of the 38, 25 had visible brown fungus, although in a minority of cases the organisms were only faintly brown. The most intensely brown structures were yeast. In 13 specimens, the organisms were only seen with a special stain. Fungi were consistently positive with the GS, PS, and Fontana-Masson stains, although the GMS stain was the one commonly used. Fungal forms varied and included forms that were simple mycelial, mycelial with bulbous distention, mycelial and yeast, and only yeast. Fungal forms, especially mycelial, tended to be within giant cells. Of the 38 skin and subcutaneous specimens, 8 consisted of only deeper tissue. Of the 30 specimens that were not exclusively deep, pseudoepitheliomatous hyperplasia of the epidermis was present in 20. That hyperplasia was mild in 8, moderate in 4, and pronounced in 8. In one specimen, this proliferation was very difficult to distinguish from well-differentiated squamous carcinoma. A brain specimen had purulent granulomas with brown fungi. One lung and one subcutaneous cytology specimen each contained brown fungi. Fungi of all specimens were compatible with forms of phaeohyphomycosis (culture confirmed in 20 patients).

Conclusions: In cases of possible phaeohyphomycosis infection, a culture of the specimen is highly desirable. Still, definitive diagnosis can usually be made based on the morphology.

R19 LEFT ATRIAL VOLUME INDEX AND LEFT VENTRICULAR GEOMETRY INDEPENDENTLY PREDICT MORTALITY IN 47,865 PATIENTS WITH PRESERVED EJECTION FRACTION

Patel DA, MD MPH; Lavie CJ, MD; Milani RV, MD; Ventura HO, MD

Department of Cardiology, Ochsner Clinic Foundation, New Orleans

R20 LEFT ATRIAL VOLUME INDEX AND LEFT VENTRICULAR GEOMETRY INDEPENDENTLY PREDICT MORTALITY IN 16,904 ELDERLY PATIENTS WITH PRESERVED EJECTION FRACTION

Patel DA, MD MPH; Lavie CJ, MD; Milani RV, MD; Ventura HO, MD

Department of Cardiology, Ochsner Clinic Foundation, New Orleans

R21 LEFT VENTRICULAR GEOMETRY PREDICTS MORTALITY IN 26,216 WOMEN WITH PRESERVED SYSTOLIC FUNCTION

Patel DA, MD MPH; Lavie CJ, MD; Milani RV, MD; Ventura HO, MD

Department of Cardiology, Ochsner Clinic Foundation, New Orleans

R22 IMPACT OF LEFT ATRIAL VOLUME INDEX AND LEFT VENTRICULAR GEOMETRY ON MORTALITY IN OBESE VERSUS NONOBESE PATIENTS WITH PRESERVED EJECTION FRACTION

Patel DA, MD MPH; Lavie CJ, MD; Artham SM, MD MPH; Milani RV, MD; Ventura HO, MD

Department of Cardiology, Ochsner Clinic Foundation, New Orleans

R23 DOES RELATIVE WALL THICKNESS OR LEFT VENTRICULAR MASS INDEX BEST PREDICT MORTALITY RISK IN PATIENTS WITH PRESERVED SYSTOLIC FUNCTION?

Patel DA, MD MPH; Lavie CJ, MD; Shah S, MD; Gilliland Y, MD; Milani RV, MD

Department of Cardiology, Ochsner Clinic Foundation, New Orleans

R24 THE OBESITY PARADOX: HIGHER BODY FAT PREDICTS BETTER PROGNOSIS IN HEART FAILURE AND CORONARY PATIENTS—A REVIEW OF OCHSNER STUDIES

Artham SM, MD MPH; Lavie CJ, MD; Ventura HO, MD

Department of Cardiology, Ochsner Clinic Foundation, New Orleans

R25 IMPACT OF CARDIAC REHABILITATION PROGRAMS ON PSYCHOLOGICAL RISK FACTORS IN CORONARY HEART DISEASE PATIENTS

Artham SM, MD MPH; Lavie CJ, MD; Milani RV, MD

Department of Cardiology, Ochsner Clinic Foundation, New Orleans

R26 IMPACT OF LEFT VENTRICULAR GEOMETRY ON ALL-CAUSE MORTALITY: A REVIEW OF OCHSNER STUDIES

Artham SM, MD MPH; Lavie CJ, MD; Milani RV, MD; Patel DA, MD MPH; Ventura HO, MD

Department of Cardiology, Ochsner Clinic Foundation, New Orleans

R27 DISPARATE EFFECTS OF LEFT VENTRICULAR GEOMETRY AND OBESITY ON MORTALITY IN WOMEN WITH PRESERVED SYSTOLIC FUNCTION: THE OBESITY PARADOX IN WOMEN

Patel DA, MD MPH; Lavie CJ, MD; Milani RV, MD; Artham SM, MD MPH; Ventura HO, MD

Department of Cardiology, Ochsner Clinic Foundation, New Orleans

R28 THE OBESITY PARADOX IN CORONARY HEART DISEASE: DOES BODY FAT COMPLETE THE PUZZLE?

Lavie CJ, MD; Milani RV, MD; Artham SM, MD MPH; Patel DA, MD MPH; Ventura HO, MD

Department of Cardiology, Ochsner Clinic Foundation, New Orleans

R29 RELATIONSHIP BETWEEN EXTRACELLULAR MATRIX TURNOVER AND CARDIAC STRUCTURAL AND FUNCTIONAL ABNORMALITIES IN PATIENTS WITH CHRONIC HEART FAILURE

Verma A, MD^*; Latini R, MD^†; McMurray JJV, MD^†; Maggioni AP, MD^†; Pitt B, MD^†; Prescott MF, PhD^†; Keefe DL, MD^†; Solomon SD, MD^†

^*Ochsner Heart and Vascular Institute, Ochsner Clinic Foundation, New Orleans

^†Brigham and Women's Hospital/Harvard Medical School, Boston, MA

Background: Increased procollagen type III amino-terminal peptide (PIIINP), a marker of extracellular matrix (ECM) turnover and cardiac remodeling, portends adverse outcomes. However, the relationship between PIIINP and cardiac structure and function in patients with chronic heart failure (CHF) has not been well defined.

Methods: A total of 299 patients from the Aliskiren Observation of Heart Failure Treatment study underwent echocardiographic assessment of cardiac structure, function, and measurements of PIIP, B-type natriuretic peptide (BNP), and NT-proBNP. We related plasma PIIINP to neurohormonal measures and echocardiography.

Results: In multivariable model including age, gender, body mass index, diabetes, systolic blood pressure (BP), and aldosterone blocker use, baseline PIIINP was related to mitral regurgitation (MR), jet/left atrial (LA) area, NT-proBNP (both P<0.01), and BNP (p = 0.034). There was no association between PIIINP and baseline left ventricular (LV) ejection fraction, LV volumes, LV wall thickness, LA volume, or right ventricular fractional shortening (all p>0.10). Moreover, after 3 months of follow-up, aliskiren had no effect on PIIP, but reduced PIIINP was associated with reductions in MR, E/E′, and NT-proBNP (all p<0.01), even after adjusting for baseline values and treatment group in addition to the above variables.

Conclusions: Improvement in PIIP, a marker of cardiac ECM turnover, paralleled reduction in MR and improvement in Doppler measures of filling pressure in stable CHF patients.

R30 ADVERSE PATIENT OUTCOMES AFTER NEGATIVE LOWER EXTREMITY VENOUS ULTRASOUND: DOES EVALUATING THE CALF VEINS MAKE A DIFFERENCE?

Smith T, MD; Smetherman D, MD; Bluth EI, MD FACR

Department of Radiology, Ochsner Clinic Foundation, New Orleans

Objectives: The purpose of our study was to determine if adverse outcomes increase if the calf veins were not examined with ultrasound (US) for suspected deep venous thrombosis (DVT).

Methods: We conducted a retrospective review of normal limited and complete lower extremity venous US examinations. In limited studies, only thigh veins of the symptomatic side and contralateral common femoral vein were interrogated. In complete studies, both thigh and calf veins were evaluated. Adverse outcomes were defined as DVT or pulmonary embolism (PE) within 6 months after US.

Results: There were 105 limited studies on 96 patients and 101 complete studies on 101 patients. Two patients (2.08%) in the limited study group and three patients (2.97%) in the complete study group developed PE (positive computed tomography angiogram or high probability ventilation/perfusion scan). One patient in each group developed calf vein thrombosis. There were no deaths from PE. No patients developed thigh DVT. No statistically significant difference in the age and gender of the patients in the two groups existed. Using the chi-square method, there was no statistically significant difference in adverse outcomes (p = 1).

Conclusions: Based on our data, there was no statistically significant difference in adverse outcomes (PE and thigh DVT) between patients who had limited and complete examinations. Our study suggests that evaluation of the calf veins could be deferred to the nonemergency setting.

R31 THERAPEUTIC HYPOTHERMIA

McMullan P, MD; Winterbottom F, RN MSN ACNS-BC CCRN

Critical Care, Ochsner Clinic Foundation, New Orleans

Background: Coronary heart disease is the leading cause of death in America, with 1.2 million Americans experiencing myocardial infarction every year. Sudden arrest accounts for more than 400,000 deaths annually in the United States, with more than 90% of deaths occurring before reaching the hospital. Patients undergoing successful resuscitation frequently receive supportive care, with only 5–30% surviving to discharge. Patients often sustain ischemic brain injury, resulting in severe disabilities. Studies suggest systemic hypothermia can improve neurological outcomes in these patients.

Objectives: To optimize cardiopulmonary function and systemic perfusion, transport the victim of out-of-hospital cardiac arrest to an emergency department or critical care unit, identify precipitating causes of arrest, institute measures to prevent recurrence, and improve long-term, neurologically intact survival.

Methods: Patients with return of spontaneous circulation after cardiac arrest are cooled to 34.5°C in a cooling device. They are removed from that device and are maintained at 32–34°C for a total of 24 h, then rewarmed at 0.3–0.5°C per hour until normothermic. Data associated with cooling episodes, including temperature, neurological status, other morbidities, and mortality, were collected and examined for trends.

Results: Eleven patients received therapy since March 2008. Five patients had ventricular fibrillation (VF) or ventricular tachycardia (VT) as a presenting rhythm with lengthy “down times.” All were discharged home neurologically intact. Six patients presented with pulseless electrical activity: Two received palliative care and died; one coded and died; one went to long-term acute care; one went home; one recovered neurologically from cardiac arrest but died within a month from heart failure complications.

Conclusions: Ochsner's experience supports evidence from randomized trials that therapeutic hypothermia improves neurological outcomes after sudden cardiac death, particularly in patients presenting with VF or VT.

R32 ULTRASOUND VELOCITY DIFFERENCES IN CAROTID IN-STENT RESTENOSIS ACCORDING TO STENT TYPES AND DESIGNS

Chi YW, MD; Yelamanchili P, MD; Ali L, MD; Reilly JP, MD; Woods TC, PhD

Department of Cardiology, Ochsner Clinic Foundation, New Orleans

Background: Carotid stent placement is an alternative to surgery for the treatment of carotid stenosis in the high risk surgical patients. Duplex ultrasound (US) using velocity information is the primary method used to follow carotid stent patency.

Objectives: This study investigates the US velocity differences in carotid in-stent restenosis (ISR) according to stent types and designs.

Methods: From 1994 to 2006, 1,500 consecutive patients with carotid stent placement were followed with serial US. ISR was determined by using the standard US velocity criteria using peak systolic velocity (PSV), end diastolic velocity (EDV), and internal carotid to common carotid velocity ratio (ICA/CCA ratio). Patients suspected of having ISR ≥50% underwent confirmatory angiography. US velocity information and the degree of ISR were compared between the nitinol versus non-nitinol stents and open versus closed cell design using general linear model (Minitab Inc., State College, PA). A p value <0.05 was considered significant.

Results: Seventy-five patients with carotid ISR were evaluated. We found that the use of non-nitinol stents was associated with a significant increase in mean PSV (p = 0.003) and mean EDV (p =  .001) but not ICA/CCA ratio (p = ns). Mean % ISR was not statistically different between the 2 stent types (p = ns). Stent design did not significantly impact PV, EV, or ICA/CCA ratio.

Conclusions: In patients with IR, non-nitinol stents were associated with a significantly higher mean PSV (p = 0.003) and mean EDV (p = 0.001) than nitinol stents. Therefore, US laboratories should consider taking into account the differences in velocity according to stent types when interpreting % ISR based on velocity criteria.

R33 VISUALIZATION OF THE LEFT ATRIAL APPENDAGE TO PLAN PERCUTANEOUS APPENDAGE CLOSURE

Reilly JP, MD; Anand R, MD; Patel S, MD; Gilliland Y, MD; White CJ, MD

Ochsner Heart and Vascular Institute, New Orleans

Background: Imaging prior to percutaneous closure of the left atrial appendage (LAA) is an important determinant of eligibility for the procedure. Transesophageal echocardiography (TEE) has been the standard imaging modality prior to closure, but this modality is invasive and limited. This report compares the characterization of the LAA by multidetector computed tomography (MDCT) with prior published data.

Methods: Patients who underwent cardiac MDCT July 2007–April 2008 were evaluated for inclusion. Patients with a history of hypertension, heart failure, or cardiomyopathy were excluded. Measurements of the LAA included the orifice diameter, linear, and curvilinear measurement. The number of lobes of the LAA was also recorded. These measurements were compared to published anatomic measurements made in 500 autopsy specimens.

Results: Ninety-seven patients underwent MDCT during the inclusion period; 65 were eligible for enrollment in this analysis. The orifice width measured 18±3.4 mm, the linear length measured 34.7±7.5 mm, and the curvilinear length measured 48.3±10.1 mm. The mean lobes per LAA was 2.8±0.9. The published mean orifice width was 17 mm; linear length was 26 mm in women and 24–29 mm in men, with a mean of 2.1 lobes per LAA.

Conclusions: MDCT provided excellent correlation with published anatomic data for orifice width and length. The noninvasive, three-dimensional imaging of MDCT makes it a potentially more attractive imaging modality prior to percutaneous repair of structural heart disease.

R34 LIVER TRANSPLANTATION IN THE SUPER MORBIDLY OBESE: A SINGLE CENTER EXPERIENCE

Seals S, MD; Girgrah N, MD PhD; Cohen AJ, MD; Carmody IC, MD; Davidson M; Bohorquez HE, MD; Bruce D, MD; Joshi S, MD; Loss GE Jr, MD PhD

Section of Abdominal Transplantation, Ochsner Clinic Foundation, New Orleans, LA

Background: Morbid obesity is considered a relative contraindication to liver transplantation at many transplant centers.

Objectives: To evaluate the experience in initial liver transplants of the super obese as compared to other adult liver or liver/kidney transplant recipients.

Methods: A chart review of initial primary liver or combined liver/kidney transplant at Ochsner between September 1, 2005, and December 31, 2008 was conducted. Comparison of the super obese vs. control patients was calculated for body mass index (BMI), 30-day and 1-year survival data, age, model end-state liver disease (MELD), length of stay, and 30-day reoperation rates.

Results: During the study period, 255 adult patients underwent an initial primary liver or combined liver/kidney transplant. Of those, 34 had a BMI ≥40 kg/m² (range 40–56 kg/m², mean 45.6 kg/m²) and 221 had a BMI <40 kg/m² (range 14–39 kg/m², mean 28.1 kg/m²). Absolute survival rates of the super obese vs. control were 100% vs. 98.6% at 30 days and 94.1% vs. 95.3% at 1 year. As of December 31, 2008, 22 of 34 super obese patients and 150 of 221 control patients have follow-up data 1-year posttransplant. Median recipient age (super obese vs. control) was 53±8.3 years vs. 54±9.7 years, respectively. MELD scores for the super obese vs. control ranged from 15–40 (mean 23±5.1) vs. 6–40 (mean 23±7.3). Length of stay in the super obese group had a mean of 19 days and a median 13 days, while the control group had a mean of 16.8 days and median of 9 days. Thirty-day reoperation occurred in 12% of super obese patients and 23% of control patients.

Conclusions: Liver transplantation of the super obese, while technically challenging, yields very good short-term results. Longer follow-up is needed.

R35 PREVALENCE AND IMPACT OF PREOPERATIVE COR PULMONALE ASCERTAINED BY 2-D ECHOCARDIOGRAPHY IN ADULT LUNG TRANSPLANT RECIPIENTS

Seoane L, MD^*; Cheema M, MD^†; Taylor DE, MD^*; Valentine V, MD^‡; Arcement L, MD^†

^*Ochsner Clinic Foundation, New Orleans

^†Leonard Chabert Medical Center, Houma

^‡University of Texas Medical Branch, Galveston, TX

Background: Cor pulmonale (CP) is not uncommon in patients referred for lung transplantation. The prevalence and impact of CP on outcomes following lung transplantation are not well defined.

Objectives: To ascertain the prevalence and impact of preoperative CP on hospital length of stay and mortality following lung transplantation.

Methods: A retrospective review of 206 patients transplanted at the Ochsner Medical Center between 1991 and 2005 was conducted. Right ventricular enlargement (RVE) was measured in the parasternal long axis, and patients were divided into 2 groups (no RVE vs. RVE). Right ventricular dysfunction (RVD) was obtained from multiple views and graded by visual estimation as none, mild, moderate, or severe. Clinical outcomes included all-cause mortality and postoperative hospital length of stay.

Results: No significant difference existed between groups regarding gender, race, body mass index, coronary artery disease, hypertension, smoking, diabetes, cystic fibrosis, or left ventricular ejection fraction. CP was associated with age (OR [odds ratio] 1.04, p = 0.039), chronic obstructive pulmonary disease (COPD) (OR 1.13, p = 0.041), and idiopathic pulmonary fibrosis (IPF) (OR 1.21, p = 0.025). Prevalence of RVE was 22% and RVD 15% (severe 2%). Hospital length of stay was the same in both groups: 9.7±2.6 days in the non-CP group vs. 10.4±3.5 in the CP group. There was no difference in 1- and 5-year survival between the groups.

Conclusions: CP prior to lung transplantation is associated with age, CD, and IPF. Preoperative CP was not associated with increased length of hospital stay or mortality post-lung transplant.

R36 COMBINED LIVER AND KIDNEY TRANSPLANT ACHIEVED SIMILAR RESULTS AS LIVER TRANSPLANT ALONE DESPITE POOR NATIVE KIDNEY FUNCTION RECOVERY

Bohorquez HE, MD; Cohen AJ, MD; Carmody IC, MD; Bruce D, MD; Girgrah N, MD PhD; Joshi S, MD; Garces JC, MD; Staffeld-Coit CG, MD; Loss GE Jr, MD PhD

Multi-Organ Transplant Institute, Ochsner Clinic Foundation, New Orleans

Background: Renal failure is a negative predicted factor in liver transplantation. In the MELD era, there is an increasing use of combined liver and kidney transplantation (LKT).

Objective: The purpose of this study was to evaluate at 1-year post-combined-LKT survival rates and contribution of native vs. allograft kidneys to the total renal function.

Methods: The Ochsner Clinic retrospective liver transplant database was reviewed for cases between January 2003 and May 2007. LKT was considered in patients with glomerular filtration rate (GFR) ≤40 mL/min for ≥6 weeks.

Results: Of the 359 adult primary liver transplants performed, 40 (11.1%) of the patients received a combined LKT. One-year patient survival rate in the LKT group was 89.7%, and 1-year graft survival rate was 89.7%, similar to the liver transplant alone group. Prior to transplantation, 30.7% of the patients were on dialysis and the mean creatinine was 3.08±0.85 mg/dL and GFR 19.8±6.57 mL/min. One year after LT, all patients were off of dialysis, and their GFR at 1 year was 64.6±17.3 mL/min. Split renal function (native vs. allograft kidney) was evaluated by TC-99 MAG-3 nuclear scan in 23 patients. Percentage of renal function provided by the native kidneys ranged from 0–45% (12.7±14.3%). The GFR contribution of the native kidneys was 8.0±9.4 mL/min.

Conclusions: 1. Combined liver-kidney transplantation achieved a survival rate similar to that for liver transplant alone. 2. Function recovery of native kidneys after LKT was incomplete, and their contribution did not assure normal renal function.

R37 BILIARY TRANSPOSITION: USING THE CYSTIC DUCT FOR BILIARY RECONSTRUCTION

Carmody IC, MD; Bohorquez HE, MD; Bruce D, MD; Cohen AJ, MD; Loss GE Jr, MD PhD

Multi-Organ Transplant Institute, Ochsner Clinic Foundation, New Orleans

Background: Biliary complications remain a significant problem following liver transplantation. We report a novel use of the recipient cystic duct for biliary reconstruction in 5 cadaveric liver transplant recipients.

Methods: Three reconstructions were performed using an internal stent (8 Fr pediatric feeding tube), and two were performed without. Follow-up ranged from 2 months to 6 months.

Results: All patients were managed with standard immunosuppression and ursodiol. There were no anastomotic leaks, one patient had an internal stent removed for recurrent unexplained leukocytosis, and another patient required endoscopic retrograde cholangiography and stent change for internal stent blockage. All patients had improvement in biochemical markers of biliary flow posttransplant. There were no biopsy-proven episodes of acute cellular rejection or recurrent hepatitis C.

Conclusions: Our results indicate biliary reconstruction using the cystic duct is feasible and safe for cadaveric liver transplantation. This technique is particularly useful when a significant mismatch in size exists between the donor and recipient bile duct.

R38 BREAST-FEEDING DOES NOT PROTECT AGAINST URINARY TRACT INFECTION IN THE FIRST 3 MONTHSOFLIFE, BUT VITAMIN D SUPPLEMENTATION OF FORMULA-FED INFANTS DOUBLES THE RISK

Katikaneni R, MD^*; Ponnapakkam T, PhD^*; Ponnapakkam A^†; Gensure R, MD PhD^*

^*Pediatric Endocrinology Research Laboratory, Ochsner Clinic Foundation, New Orleans

^†Benjamin Franklin High School, New Orleans

Background: Urinary tract infections (UTI) are the most common serious bacterial infection in infants. Breast-feeding may reduce infection risk, including UTIs. There are concerns that exposing children to higher levels of vitamin D supplementation may increase their risk for developing UTIs.

Objectives: To determine if breast-feeding provides any protection against UTI and if vitamin D supplementation imposes any additional risks for UTI in infants <3 months.

Methods: We performed a chart review of infants who had urine cultures obtained within the first 3 months of life at Ochsner Clinic Foundation (2001–2006).

Results: Of the children who had urine cultures, 40% were breast fed and 18.7% were exclusively breast fed. The cultures tested positive for 20%. There was no significant difference between the rates of positive urine cultures in exclusively breast-fed vs. formula-fed infants. The relative risk of UTI with breast-feeding vs. formula-feeding was 1.03 (0.58–1.82) and for any breast-feeding versus no breast-feeding was 0.92 (0.58–1.45). Vitamin D supplementation increased the UTI risk with a relative risk of 1.76 (1.07–2.91, p<0.05). However, in subgroup analysis only, formula-fed infants showed a significantly increased risk of UTI after vitamin D supplementation.

Conclusions: Breast-feeding does not protect against UI, but supplementing infants with vitamin D increases their risk of UTI by 76%, which is further increased to 125% in formula-fed infants. We recommend that parents whose children are formula-fed be advised against providing vitamin D supplements to their children.

R39 COMPARISON OF A LARGE ENTEROCOLITIS CLUSTER TO NECTOTIZING ENTEROCOLITIS (NEC) CASES FROM OUR LEVEL III REGIONAL NICU DATABASE REVEALS THAT NEC COMMONLY PRESENTS WITH LYMPHOCYTOSIS AND THROMBOCYTOSIS

Gordon PV, MD; Thibeau S, MSN RNC; Pennier C, RN; Ginsberg H, MD; Lunyong V, MD; Cortez M, MD; Adolph V, MD

Section of Neonatology, Department of Pediatrics, Ochsner Children's Health Center, New Orleans

Background: We considered an enterocolitis cluster of 10 neonates with ≥ Bell's stage I NEC occurring within a single 3-week time period. Ninety percent of these patients were tolerating full feeds upon presentation, most were on breast milk, and most demonstrated lactose intolerance upon refeeding. Lymphocytosis and thrombocytosis were common features at presentation, and two infants developed skin findings consistent with enterovirus-16. Three infants progressed to stage II NEC; one progressed to stage III NEC and then died. We hypothesized that NEC presenting with lymphocytosis would have different outcomes in comparison to other forms of NEC.

Methods: We performed a retrospective cohort review of all cases of NEC ≥ Bell's stage II within our regional level III C database over the past 6 years, not including the recent time period of the enterocolitis outbreak. We captured birth weight, gestational age, day of onset, feeding history (when available), complete blood count data, surgical management, and outcomes. NEC with lymphocytosis was defined as >40% lymphocytes in the 48 h surrounding the time of diagnosis.

Results: A total of 42 cases of NEC were identified out of 2,094 admits (2.1%). Upon review of electronic postoperative notes, 10 of these were subsequently identified as intestinal perforations (IP). Of the remaining 32 infants with NC, 53% were found to have presented with lymphocytosis and thrombocytosis. Infants with NEC were found to have a temporal window of vulnerability to NEC associated with gestational age, not found in cases of IP. Finally, NEC with lymphocytosis was found to trend toward longer postsurgical bowel lengths compared to patients with lymphocyte counts <40%.

Conclusions: We demonstrated that NEC commonly presents with lymphocytosis and thrombocytosis, a putative signature for viral enterocolitis triggering of NEC. Such cases were associated with longer bowel lengths following laparotomy when compared to patients with lower lymphocyte counts. One explanation for this might be that infants with “normal” lymphocyte counts may acquire NEC through hypoxic-ischemic mechanisms, which may make the patient more vulnerable to partial or total small bowel necrosis (versus viral enterocolitis, where progression promotes translocation of flora out of the bowel and induces early detection due to sepsis).

R40 IMPROVING EFFICIENCY IN AIRWAY MANAGEMENT OUTSIDE OF THE OPERATING ROOM

Graham K, MD; Nossaman B, MD; Ramadhyani U, MD; Subaiya C, MD

Department of Anesthesiology, Ochsner Clinic Foundation, New Orleans

Background: Anesthesiologists are trained to be experts in airway management. These skills are primarily taught in the operating room (OR), where multiple airway tools are readily available should conventional direct laryngoscopy (cDL) prove to be difficult. Furthermore, the patient's airway is carefully evaluated so difficulties can be anticipated. However, outside the OR, the urgency for immediate airway management often precludes this evaluation, making these intubations more difficult with a potential for increased morbidity and mortality.

Objectives: Our study sought to document the incidence of difficult intubations (defined as requiring more than one attempt at cDL, or requiring the use of advanced airway tools), and to determine how these intubations can be made safer and more efficient.

Methods: We evaluated 68 endotracheal intubations performed outside the OR from November 2008 to January 2009. After each intubation, a survey was completed describing the intubation in detail.

Results: We found that of 68 intubations performed, 19 (27.9%) were deemed difficult. On 11 occasions (16.2%), advanced airway tools were necessary for successful intubation. In 4 of these intubations (5.9%), non-functioning tools had to be replaced prior to intubation. And, 8 intubations (11.8%) were delayed waiting for advanced airway tools to arrive.

Conclusions: Based on this initial survey, we conclude that difficult endotracheal intubations are encountered outside the OR. In addition, a number of intubations were delayed until the procurement of advanced airway tools. We propose that advanced airways tools such as video laryngoscopy and Intubating Wands be immediately available in non-OR patient care settings. Secondly, all airway equipment must be maintained in working condition at all times.

R41 REPORTING OF MEDICATION ERRORS IMPROVES IN ANESTHESIA PRACTICE WHEN REPORTING IS FACILITATED

Cooper L, MD^*; DiGiovanni N, MD^†; Schultz L, RN^†; Taylor A, PharmD^†; Nossaman B, MD^†

^*Anesthesiology, University of Miami Miller School of Medicine, Miami, FL

^†Department of Anesthesiology, Ochsner Clinic Foundation, New Orleans

Background: Medical errors (largely due to medication errors) are now the seventh leading cause of death in the United States. Moreover, upward of 20% of administered medications in hospitals are by anesthesia providers; however, current reporting systems may underreport these medication errors due to a number of factors.

Objectives: To attempt to improve medication error reporting rates through use of a facilitated reporting tool, over historical experience at a large, tertiary care, academic hospital.

Methods: A new paper-based medication error reporting form was designed and attached to every anesthetic record during a 6-month period (08/20/07–02/20/08). Providers were asked to voluntarily and anonymously return the reporting form for every anesthetic case, whether or not a medication error or pre-error occurred. Collected data were compared to medication errors reported in S.T.O.R.M. (Standardized Tracking & Occurrence Report Management), a computerized risk management software program, for a similar time period (08/20/06–02/20/07).

Results: A total of 8,777 forms out of a possible 10,574 anesthetics were returned, which corresponds to an 83% reporting rate. The frequency of both medication errors and pre-errors was 0.0049, or an estimated occurrence rate of 1 out of every 203 anesthetics. This finding was compared to data from the previous medication error reporting system (S.T.O.R.M.), in which only 1 medication error was reported out of 10,145 anesthetics, corresponding to a frequency of 0.0001. This difference in reported error rates was highly statistically significant (p<0.0001).

Conclusions: We achieved similar reporting (83% vs. 80%) and error rates (0.49% vs. 0.75%) compared to previously reported rates, thus validating our data. We have demonstrated that a facilitated reporting system can improve compliance in reporting among anesthesia providers.

R42 RAPID CYCLE CHANGE APPROACH TO MANAGEMENT OF SEVERE SEPSIS

Winterbottom F, RN MSN ACNS-BC CCRN; Rodriguez S, RN MSN; Nash T, PharmD; Jennings B, RN BSN; Sundell E, MD; Seoane L, MD

Critical Care, Ochsner Medical Center, New Orleans

Background: Sepsis is a severe illness caused by overwhelming infection. Sepsis strikes approximately 750,000 people in the United States and is responsible for more than 215,000 deaths annually. Mortality remains high at 28–50% at a cost of $17 billion each year.

Objectives: To evaluate standardized order sets as part of a performance improvement project for the management of patients with severe sepsis and septic shock.

Methods: An interdisciplinary team was created to improve early recognition, process of care, and mortality in septic patients. A plan, study, do, and act methodology was used with rapid cycle changes to improve the management of severe sepsis and septic shock. Physician and nursing education was rolled out over 6 months, and sepsis “bundle” order sets were developed for the emergency department and intensive care unit. All patients with a diagnosis of severe sepsis or septic shock were included in the protocol. Data were collected prospectively with regards to process of care. Mortality data were collected retrospectively.

Results: Early trends show improvement in outcomes for patients with severe sepsis and septic shock. Results from third quarter of 2008 are: a 38% reduction in risk-adjusted mortality for sepsis in 2008 over 2007. There was a reduction in raw mortality of 57% despite a 24% increase in appropriately recognizing principal (admitting) diagnosis of sepsis. This equates to 31 LIVES SAVED in 2008. Patients with specified “goals met” at 6 hours increased to 81% (up from 33% in June).

Conclusions: Six- and 24-hour bundled sepsis orders improve process of care and in-hospital mortality in patients with severe sepsis and septic shock.

R43 DOES CHRONIC IMMUNOSUPPRESSION INCREASE THE RISK OF DEVELOPING ADENOMATOUS COLON POLYPS?

Adams JB, MD; Beck DE, MD; Hicks TC, MD; Timmcke AE, MD; Whitlow CB, MD; Margolin DA, MD

Department of Colon and Rectal Surgery, Ochsner Clinic Foundation, New Orleans

R44 THERE IS NO CAUSAL RELATION BETWEEN THE RISK OF DELAYED FECAL INCONTINENCE AND CHILDBIRTH

Adams JB, MD^*; Lawhorn NA, MPP^†; Beck DE, MD^*; Hicks TC, MD^*; Timmcke AE, MD^*; Whitlow CB, MD^*; Margolin DA, MD^*

^*Department of Colon and Rectal Surgery, Ochsner Clinic Foundation, New Orleans

^†Louisiana Public Health Institute, New Orleans

Background: Studies examining vaginal childbirth as a risk factor for fecal incontinence have demonstrated conflicting conclusions and have been performed at short intervals following childbirth.

Objectives: We conducted this study to examine if events surrounding childbirth could predict long-term problems with fecal continence.

Methods: Ochsner Clinic Foundation (OCF) birth records from 1962–1964 were reviewed after Institutional Review Board approval. Data concerning technique of anesthesia, mode of delivery, use of episiotomy, length of labor, position of the fetal presentation, and infant weight were recorded. Due to Hurricane Katrina, patients who had not been seen at OCF since 2006 were excluded. Deceased patients were excluded using the Social Security Death Index. A total of 508 patients were mailed questionnaires regarding fecal incontinence, obstetrical history, and medical history; 164 (32.3%) of the questionnaires were returned and are included in this study.

Results: A total of 134 patients (81.7%) reported perfect to good fecal continence. Thirty patients (18.3%) reported moderate to severe fecal incontinence. Of the variables examined, only a history of neurological disease was a significant predictor of moderate to severe fecal incontinence in our population (p = 0.0184).

Conclusions: Vaginal childbirth is not a risk factor for fecal incontinence in the long term.

R45 MESENTERIC EMBOLIZATION: A SAFE AND EFFICACIOUS TREATMENT MODALITY OF LOWER GASTROINTESTINAL HEMORRHAGE

Rider PF, MD; Beck DE, MD; Hicks TC, MD; Whitlow CB, MD; Timmcke AE, MD; Margolin DA, MD

Department of Colon and Rectal Surgery, Ochsner Clinic Foundation, New Orleans

R46 THE USE OF FULL-FIELD DIGITAL IMAGING FOR REMOTE DIAGNOSTIC MAMMOGRAPHY

Smetherman D, MD; Galandak J, MD

Department of Radiology, Ochsner Clinic Foundation, New Orleans

Background: Conventional film-screen mammography (FSM) is increasingly being replaced by full-field digital mammography (FFDM). Among other benefits, digital imaging facilitates remote interpretation. Although off-site screening mammography is easily implemented, remote interpretation of diagnostic mammography poses multiple challenges. A literature review revealed no data on the use of FFDM for remote diagnostic mammography.

Objectives: Our aim was to determine the prevalence of remote interpretation of diagnostic mammography in the United States and to identify potential barriers to performing off-site diagnostic mammography.

Methods: A questionnaire was sent to breast imaging professionals who were members of the Society of Breast Imaging using a web-based survey manager.

Results: Of the 352 members who completed the survey, 94.9% utilized FM, either exclusively or in combination with FSM. Although 65.1% provided off-site screening mammography, only 12.6% performed off-site diagnostic mammography. When those not currently performing off-site diagnostic mammography were asked if they would consider offering this service, 24.9% responded “yes,” 54.8% responded “no” and 20.2% responded “maybe.” The two most common reasons for a negative response were inability to perform ultrasounds and lack of opportunity to discuss results with patients.

Conclusions: Our survey demonstrates that the majority of respondents are not performing off-site diagnostic mammography. In addition, 54.8% of respondents who are not providing off-site diagnostic mammography would not even consider incorporating this service.

R47 ABNORMAL BAFF EXPRESSION ON CIRCULATING T CELLS IN SYSTEMIC LUPUS ERYTHEMATOSUS

Zhang X, MD PhD^*; Dupre B, MD^†; Clementine R, MD MPH^†; Zakem J, MD^†; Davis W, MD^†; Serebro L, MD^†; Quinet R, MD^†

^*Cellular Immunology Laboratory, Ochsner Clinic Foundation, New Orleans

^†Department of Rheumatology, Ochsner Clinic Foundation, New Orleans

Background: B cell-activating factor (BAFF) of the tumor necrosis factor family is a fundamental B cell survival factor produced by monocytes, neutrophils, and dendritic cells. It plays a critical role in normal B cell survival by binding to its receptors consisting of BAFR, TI, and BCMA. BAFF has been implicated in many autoimmune diseases. Systemic lupus erythematosus (SLE) is a chronic autoimmune disease characterized by the presence of abnormally activated B cells, which play a major role in the pathogenesis of SLE by producing autoantibodies and generating an immune complex that deposits in tissue, causing endogenous damage. Our precious study showed BAFF-R expression on B cells was occupied by endogenous BAFF in SLE patients.

Objectives: Here we investigated the potential cell source of this endogenous BAFF.

Methods: BAFF level in the serum and intracellular BAFF expression on different cell populations from SLE patients and healthy donors were examined. The amount of BAFF in serum was assessed by sandwich enzyme-linked immunosorbent assay. Intracelluar BAFF expression was determined by anti-BAFF mAb staining followed by allophycocyanin-conjugated goat antimouse Ig and measured by four-color FACS.

Results: The serum BAFF level was elevated in 50% of the serum of SLE patients vs. normal healthy controls. CD14+ cell expressed highest amount of BAFF (median fluorescence intensity: 36.2) among different cell population, but there was no significant difference between SLE patients and normal healthy controls. However, certain CD3+ T cells from SLE patients expressed intracellular BF, whereas T cells from healthy controls did not (10.1% vs. 1.7%, P<0.05).

Conclusions: Our data suggest that T cell-originated BAFF in SLE patients may bind to B cells with highly expressed BAFF-R and contribute to the survival of autoreactive B cells.

R48 BAFF LEVELS AND BAFF RECEPTOR OCCUPANCY IN ACTIVE SYSTEMIC LUPUS ERYTHEMATOSUS B LYMPHOCYTES

Dupre B, MD^*; Zhang X, MD PhD^†; Harris P, MD^*; Mallepalli J, MD^*; Quinet R, MD^*; Zakem J, MD^*; Davis W, MD^*; Webb-Detiege T, MD^*; Scopelitis E, MD^*; Serebro L, MD^*

^*Department of Rheumatology, Ochsner Clinic Foundation, New Orleans

^†Cellular Immunology Laboratory, Ochsner Clinic Foundation, New Orleans

Purpose: To understand the role of B cell-activating factor (BAFF) of the tumor necrosis factor family and its receptor (BAFF-R) in systemic lupus erythematosus (SLE).

Methods: Twenty patients with active SE, by SLE Disease Activity Index (SLEDAI) of 2 or greater, and 10 healthy controls were included in the study. B cell populations were first investigated using FACS to evaluate cell surface markers indicative of several B-cell subsets. Then, serum BAFF levels were assessed by enzyme-linked immunosorbent assay, and flow cytometry staining of peripheral blood lymphocytes (PBB) was used to examine BAFF-R levels. In addition, the PBBs of 5 active SLE patients and 5 healthy controls were examined after the addition of exogenous myc labeled BAFF by indirect immunofluorescence staining to demonstrate the binding capacity of BAFF-R.

Results: B cell populations were found to be altered in SLE patients with a larger number of pre-plasma cells (CD38+IgD+) compared to controls (13.764% vs. 0.925%, p<0.001) and with the emergence of activated B cells (CD40L+CD3−) (2.646%) that was not found in controls. Increased serum BAFF and BAFF-R levels were demonstrated (50% of SLE patients vs. 33% of controls) and (372.7±51.28 vs. 124.2±24.76; p<0.005), respectively. Binding capacity of myc-BAFF was higher in the control group compared to SLE patients (20.9±2.8 vs. 7.8±1.8, p<0.01).

Conclusions: SLE patients demonstrate increased numbers of active B cells with increased levels of both serum BAFF and occupied BAFF-R suggesting that BAFF plays a role in the survival and activation of autoreactive B cells in SLE and possibly the induction and maintenance of autoimmunity.

R49 ASSESSMENT OF CONTRACEPTIVE COUNSELING IN PATIENTS TAKING POTENTIALLY TERATOGENIC MEDICATIONS

Clementine R, MD MPH; Dupre B, MD; Lyman J, MD; Davis W, MD; Scopelitis E, MD; Serebro L, MD; Webb-Detiege T, MD; Zakem J, MD; Quinet R, MD

Ochsner Department of Rheumatology Performance Improvement Project, New Orleans

Background: Many rheumatic diseases occur in women of childbearing age. Most of these diseases require therapy with potentially teratogenic drugs.

Objectives: To assess the frequency of contraceptive counseling rates among 6 rheumatology staff physicians during routine clinic visits at Ochsner Department of Rheumatology.

Methods: Retrospective review of 90 charts in women aged 16–40 years at Ochsner Health System, Department of Internal Medicine, Section of Rheumatology, was conducted. Diagnoses included systemic lupus erythematosus, rheumatoid arthritis, mixed connective tissue disease, Sjogren's syndrome, scleroderma, antiphospholipid antibody syndrome, fibromyalgia, and steroid-induced osteoporosis. Routine clinic visits were reviewed from October 2006 through January 2009, measuring rates of contraceptive counseling, medications prescribed, the Food and Drug Administration (FDA) pregnancy categories, and number of patients prescribed for each medication.

Results: Approximately 40 different medications were prescribed to the 90 patients. Four of these medications are classified as FDA pregnancy category X, which has been shown to cause fetal abnormalities in either animal or human studies. Six of these medications are classified as FDA pregnancy category D, in which there is positive evidence of human fetal risk. The contraceptive counseling rates in our department ranged from 17–78% among staff physicians. Of the 90 charts reviewed, 6 of these patients got pregnant while taking potentially teratogenic medications during this time frame. Of these 6 patients, 2 were not counseled on contraception prior to conceiving.

Conclusions: Previous studies have reported that women of childbearing age are frequently not counseled on potentially teratogenic medications. In our department, prescriptions for potentially teratogenic medications were frequently given to women of childbearing age without documentation of contraceptive counseling. It is important to discuss the teratogenic risks of these medications with patients. Each of the six staff physicians reviewed their respective contraceptive counseling rate. Ochsner Department of Rheumatology, in conjunction with Ochsner Quality Assurance Department, is currently in the process of implementing an alert mechanism into the electronic medical record for women of childbearing age in an attempt to prompt physicians to address contraceptive counseling.

R50 TREATMENT OF PERIOCULAR MALIGNANCY BY INTERDISCIPLINARY APPROACH

Hesse RJ, MD^*; Walia S, MD^†; Bodman M, MD^*

^*Department of Ophthalmology, Ochsner Clinic Foundation, New Orleans

^†Department of Dermatology, Ochsner Clinic Foundation, New Orleans

In 1941, Frederich Mohs described a unique technique for removing cutaneous cancer involving microscopically guided histographic surgery. This has since been modified to eliminate the chemical fixation and to perform intraoperative microscopic assessment of peripheral and deep surgical margins with a fresh tissue technique. Original healing occurred by granulation, but unacceptable functional and cosmetic results, especially in the periorbital region, has necessitated a cooperative approach involving an oculoplastic surgeon for the reconstruction. For the past 10 years, this has been the evolving algorithm for patient care at Ochsner Medical Center. Mohs micrographic surgery is performed by the Mohs surgeon in the dermatology department after which the defect is bandaged and the patient is sent to ophthalmology (or to the outpatient surgery center if a large reconstruction is anticipated).

R51 GLAUCOMA SURGERY OUTCOMES IN A GRADUATE MEDICAL EDUCATION COMMUNITY HOSPITAL SETTING

Balagani A, DO^*; Nussdorf JD, MD^†

^*Deen-Gross Eye Centers, Merrillville, IN

^†Department of Ophthalmology, Ochsner Medical Foundation, New Orleans, and Leonard Chabert Medical Center, Houma

Background: Glaucoma is a leading cause of blindness worldwide. When less invasive therapeutic methods fail to adequately lower intraocular pressure (IOP), incisional surgery becomes a viable option for the glaucoma patient.

Objectives: To evaluate glaucoma surgical outcomes performed by ophthalmology residents and glaucoma fellows under the supervision of a single staff physician at the Leonard Chabert Medical Center between January 1, 2006, and June 31, 2007.

Methods: Outcomes were obtained using retrospective chart reviews of adult glaucoma surgeries performed for the treatment of inadequately controlled IOP ≥18 mmHg while the patient was on maximally tolerated medical therapy. Surgical procedures were either 1) fornix-based trabeculectomy with mitomycin C or 2) Baerveldt 350 mm² implant with watertight 7-0 Vicryl ligature of the stent.

Results: A total of 35 eyes were analyzed, with 17 eyes undergoing trabeculectomy and 18 eyes undergoing Baerveldt implantation. Surgical success was defined as IOP <21 mmHg or IOP reduced by >20% from preoperative levels, IOP not <6 mmHg for >3 months, no loss of light perception vision, and no need for reoperation. Success was similar for trabeculectomies (82%) and Baerveldt implants (83%). All complications resolved by 1 year.

Conclusions: Glaucoma surgical outcomes in this graduate medical education setting achieved success rates similar to that of larger studies in the literature. It is encouraging to know that these surgical interventions performed in this patient population and setting are reasonable options in controlling IOP and treating glaucoma.

R52 COSMO: LOW MEDICATION ADHERENCE AND USE OF LIFESTYLE MODIFICATIONS AND ALTERNATIVE THERAPIES AMONG HYPERTENSIVE OLDER ADULTS

Krousel-Wood MA, MD^†; Stanley E, MPH^*; Morisky DE, ScD^‡; Muntner P, PhD^§; Webber LS, PhD^†

^*Center for Health Research, Ochsner Clinic Foundation, New Orleans

^†Tulane University, New Orleans

^‡University of California at Los Angeles, Los Angeles, CA

^§Mount Sinai Medical Center, New York, NY

R53 EVALUATING INAPPROPRIATE PRESCRIBING IN THE ELDERLY

Boutan C, PharmD; Billeter M, PharmD BCPS

Pharmacy, Ochsner Clinical Foundation, New Orleans

Background: Studies have shown that 20–25% of older patients receive drugs identified as inappropriate by the 1997 Beers criteria. The estimated annual rate of adverse drug reactions for elderly patients is more than twice the rate in younger adults. This project will specifically assess the incidence of adverse drug reactions related to use of potentially inappropriate medications (as defined by Beers Criteria) on admission and during hospitalization.

Objectives: The purpose of this research project is to determine if elderly patients' home medications are potentially responsible for admission based on Beers Criteria and to evaluate factors that may interfere with safe and effective drug therapy.

Methods: This retrospective chart review randomly reviewed elderly patients receiving drugs found on Beers Criteria and assessed if patients' home medications were responsible for adverse events on admission. Patients older than 65 years of age admitted from November 1, 2008, to February 12, 2009, were included. Patients with a length of stay shorter than 3 days were excluded. Information was obtained from Ochsner Clinic Workstation (OCW), Hospital Information System (HIS), Siemens Pharmacy, and patient medical records.

Results: Results to date are as follows: Of the 75 patients evaluated, each patient averaged at least one inappropriate medication as defined by Beers Criteria. The most commonly prescribed agent on Beers criteria was opiate analgesics, accounting for 15% of inappropriate prescribing. Other agents commonly seen include antipsychotics, benzodiazepines, fluoxetine, and stimulant laxatives. Drug-related adverse events were uncommon; however, the most frequently reported were central nervous system effects including but not limited to sedation, confusion, and falls. Lastly, most inappropriate medications administered during hospitalization were discontinued on discharge.

R54 DESTINATION: ME, ME, FASR, FASTER. HOW RISK MONITORPRO GOT US THERE

Saxton D, FACHE MHA MPH^*; Janeau CH, RN LNC BSN^*; Tate S, BS^†

^*Performance Improvement, Ochsner Clinic Foundation, New Orleans

^†Information Services, Ochsner Clinic Foundation, New Orleans

Background: Ochsner Health System is a multihospital clinic system composed of a large academic medical center, 4 community hospitals, and more than 40 clinic locations in Southeast Louisiana. The 4 community hospitals were acquired after Hurricane Katrina, and the past 2 years have been focused on integration. The community hospitals relied on traditional paper-based occurrence reporting and manual data aggregation until the implementation of rL Solutions (Toronto, Ontario, Canada).

Objectives: The purpose of this case study was to demonstrate how a rapid cycle implementation of an electronic occurrence reporting solution integrates patient safety indicator reporting on organization system-wide dashboards and garners leadership support in organization-wide patient safety initiatives.

Description: Leadership created a standard operating dashboard for the hospital system that included limited quality and patient safety metrics. Each hospital had individual dashboards that were used to populate the system operating dashboard. In addition, a quality dashboard was then created by leadership, and standardized definitions for the quality dashboard metrics were determined for use across the system.

The data that feed the quality dashboard are harvested from the Risk MonitorPro product from each hospital facility. The electronic solution supports a consistent reporting process by standardizing the way the data are submitted. Department heads use the report to drive improvement on the department level, and customized Risk MonitorPro reports have been built to provide local facility leadership leading indicators on patient safety metrics.

Conclusions: Risk MonitorPro supports a standardized method of data collection and analysis within a complex health system to garner leadership support in patient safety monitoring and patient safety initiatives.

R55 THE ROLE OF A RAPID ADOPTION NETWORK TO IMPROVE CENTERS FOR MEDICARE AND MEDICAID SERVICES (CMS) CORE MEASURE OUTCOMES

Volpi D, RN MSN; Chapman J, RN CIC BSN; Sumrall D, MD; Margolin DA, MD; Alliston A, RN CNOR; Moll A, RN BS CNOR; Landry J, RN; Stieffel M, RN CPAN

Perioperative Services, Ochsner Clinic Foundation, New Orleans

Background: In May 2008, VA, Inc. organized and implemented a coalition of regional hospitals whose primary focus was to assist with increasing CMS Core Measure outcomes through implementation of action items with rapid cycle change. The group was called Rapid Adoption Network (RAN). RAN focused on two CMS Core Measures: congestive heart failure and Surgical Care Improvement Project (SCIP) outcomes.

Objectives: The group sought to examine whether focused rapid cycle change would increase SCIP outcomes.

Methods: A task force consisting of performance improvement, infection control, perioperative staff, and 2 physician champions representing surgery and anesthesia was formed. The SCIP Task Force met to review concurrent data and implement action items based on the findings. Information was reported to the perioperative staff, and action items were initiated in a timely manner. Results of SCIP-RAN were reported monthly to the Performance Improvement Committee.

Results: Data collection began in July 2008. The data revealed a lack of appropriate documentation regarding preoperative antibiotic timing and route. By August 1, 2008, scores related to documentation compliance had increased steadily by 10–40%. The increase in compliance resulted in an increase to the overall SCIP core measures in 3rd quarter 2008 and the beginning of 4th quarter 2008.

Conclusions: The implementation of rapid cycle change did improve overall CMS compliance outcomes for SCIP. Collaboration is essential among the perioperative team for continued success and improvement toward a compliance goal of 90% or better.

R56 DOES CASE COMPLEXITY AND AMERICAN SOCIETY OF ANESTHESIOLOGISTS (ASA) CLASSIFICATION RESULT IN A HIGHER FREQUENCY OF MEDICATION ERRORS?

Cooper L, MD^*; DiGiovanni N, MD^†; Schultz L, RN^†; Taylor A, PharmD^†; Nossaman B, MD^†

^*Anesthesiology, University of Miami Miller School of Medicine, Miami, FL

^†Department of Anesthesiology, Ochsner Clinic Foundation, New Orleans

Background: Medication administration errors are a common occurrence in anesthesia (proposed frequency of 1 out of every 130–200 anesthetics). It has been suggested that higher complexity cases lead to more frequent medication errors.

Objectives: The objective of this study was to assess if complex anesthesia cases (stratified via ASA classification) lead to a greater frequency of medication errors.

Methods: Medication error reporting forms were designed and attached to every anesthetic record during a 6-month period (08/20/07–02/20/08) at a large, tertiary care, academic hospital. Providers were asked to voluntarily and anonymously return the reporting form for every anesthetic case whether or not a medication error or pre-error occurred. After cases were assigned to one of two groups—medication error or non-medication error—comparisons were made between ASA classifications.

Results: A total of 52 forms out of a possible 10,574 indicated that either a medication error or pre-error had occurred. The relative risk of a medication error occurring in ASA III patients compared to ASA I or ASA II patients was 2.9∶1 and 1.9∶1, respectively. Using chi-square tests and Pearson's Statistic, the difference was statistically significant (p = 0.0231)

Conclusions: Higher complexity anesthetic cases routinely require frequent interventions for hemodynamic instability. We found a trend to more frequent errors in ASA class III patients, although there were not similar findings in ASA IV or V patients. A likely reason for the lack of significant findings in these complex patients may be the small number of cases in these classes in the overall distribution. A larger study looking at these complex cases is warranted.

R57 THE FREQUENCY OF MEDICATION ERROR INCREASES BASED ON SURGICAL CASE TYPE

Cooper L, MD^*; DiGiovanni N, MD^†; Schultz L, RN^†; Taylor A, PharmD^†; Nossaman B, MD^†

^*Anesthesiology, University of Miami Miller School of Medicine, Miami, FL

^†Department of Anesthesiology, Ochsner Clinic Foundation, New Orleans

Background: Medication errors are a common occurrence in anesthesia (proposed frequency of 1 out of every 130–200 anesthetics). Several factors may contribute to medication errors in anesthesia, but does the type of surgical case contribute to medication errors?

Objectives: The aim of this study was to assess if certain types of surgical cases at a tertiary training hospital have higher frequency of medication errors than others.

Methods: Medication error reporting forms were designed and attached to every anesthetic record during a 6-month period (08/20/07–02/20/08). Providers were asked to voluntarily and anonymously return the reporting form for every anesthetic case whether or not a medication error occurred.

Results: A total of 52 forms out of 10,574 anesthetics were returned with a positive response indicating that a medication error/pre-error occurred. As no errors were reported in ophthalmology cases, all other case types were compared to this standard. Neurosurgery cases showed no significant increase from ophthalmology. There were 5 errors reported in OBGN, resulting in an incidence of 0.31%. Although this may be clinically significant, there was no statistical significance. All other case types, including general, orthopedic, otolaryngology, cerebral venous thrombosis (CVT), colorectal, transplant, and peripheral vascular, showed a statistically significant increase in error rate over the standard.

Conclusions: CT, colorectal, vascular, and transplant cases all were found to have an incidence of >1%, resulting in a frequency of 1 in 66–100 anesthetics. These types of cases tended to include American Society of Anesthesiologists III or higher, require multiple infusions, and typically required medications not frequently used in anesthesia. Our findings showed that a specific type of case has a higher incidence of medication error than previously reported.

R58 MEDICATION ERRORS ARE COMMITTED MORE FREQUENTLY BY TRAINEES IN ANESTHESIA THAN BY EXPERIENCED PRACTITIONERS

Cooper L, MD^*; DiGiovanni N, MD^†; Schultz L, RN^†; Taylor A, PharmD^†; Nossaman B, MD^†

^*Anesthesiology, University of Miami Miller School of Medicine, Miami, FL

^†Department of Anesthesiology, Ochsner Clinic Foundation, New Orleans

Background: Medication errors are a common occurrence in anesthesia (proposed frequency of 1 out of every 130–203 anesthetics). It has been suggested that the inexperience of anesthesia providers-in-training may lead to a higher frequency of medication errors in teaching programs.

Objectives: The aim of this study was to assess if medication errors occur at a higher frequency in trainees versus those who have completed their training in a tertiary care, academic hospital.

Methods: Medication error reporting forms were designed and attached to every anesthetic record during a 6-month period (08/20/07–02/20/08). Trainees in anesthesia include anesthesiology residents (CA1–CA3) and student nurse anesthetists. Experienced providers who have completed training included anesthesiologist attending physicians and Certified Registered Nurse Anesthetists. Providers were asked to voluntarily and anonymously return the reporting form for every anesthetic case whether or not a medication error or pre-error occurred.

Results: A total of 52 forms out of a possible 10,574 anesthetics were returned with a positive response, indicating either a medication error/pre-error occurred. The distribution of cases included 7,049 by those who completed their training as compared to 3,473 who were still in training, 62.1% vs. 37.9%, respectively. The distribution for type of provider who committed the error/pre-error was: trainee 24/3,473 and nontrainee 23/7,049. Comparison of the two groups, using chi-square tests and Pearson's statistic, resulted in a statistically significant difference (p = 0.0087) with a relative risk ratio of 2.11.

Conclusions: Although it is intuitive that any type of trainee in a medical specialty might be responsible for a higher medication error rate than those who have completed their training and have had more practice experience, this has not been shown before. This study is the first of its kind known to demonstrate a two-fold increase in medication error rate among trainees versus nontrainees.

R59 BEREAVEMENT SURVEY AS A MEASURE OF FAMILY SATISFACTION WITH END-OF-LIFE CARE

Taylor DE, MD; Bourgeois D, RN BSN CHPN

Palliative Care, Ochsner Clinic Foundation, New Orleans

R60 A CASE-BASED APPROACH FOR TEACHING RESIDENTS PALLIATIVE CARE MANAGEMENT IN THE MEDICAL INTENSIVE CARE UNIT

Gonzalez ME, MD; Bourgeois D, RN BSN CHPN; Taylor DE, MD; Seoane L, MD

Palliative Care, Ochsner Clinic Foundation, New Orleans

R61 REVIEW OF OB/GYN RESIDENT PERFORMANCE ON A PROFICIENCY-BASED KNOT-TYING AND SUTURING CURRICULUM

Gala RB, MD; Lapeyre E, MD; Gillispie V, MD; Longo S, MD; Morris J, MD; Robichaux A, MD

Department of Obstetrics and Gynecology, Ochsner Clinic Foundation, New Orleans

Objectives: The primary objective was to evaluate the educational benefit and feasibility of implementing a proficiency-based open knot-tying curriculum within an OB/GYN residency program.

Methods: Residents from two different institutions [University of Texas South West (Dallas) and Ochsner (New Orleans), n = 70] were enrolled in this Institutional Review Board-approved prospective study between April 2007 and February 2009. Residents watched a video tutorial during orientation and performed 1 repetition of each of the 9 stations at baseline and post-testing. The residents were expected to self-practice until proficient and document the amount of time spent in the simulation laboratory.

Results: To date, the performance of 36 residents has been analyzed. The pre-test performance between the two groups of residents was not significantly different at the initiation of the study. There was significant improvement from baseline between both groups after training.

Conclusions: The findings suggest that proficiency-based simulated surgical training of basic skills offers significant benefit over traditional surgical education among all levels of residents. This curriculum validates the importance of moving from “quantity of performance” to “quality of performance” and could help improve standardization of documenting basic surgical competency.

R62 EVALUATION OF A STANDARDIZED ORDER SET FOR PLANNED WITHDRAWAL OF LIFE SUPPORT IN CRITICAL CARE

Bourgeois D, RN BSN CHPN; Winterbottom F, RN MSN ACNS-BC CCRN; Taylor DE, MD

Critical Care, Ochsner Clinic Foundation, New Orleans

R63 REDESIGNING DISCHARGE INSTRUCTIONS PROCESS FOR HEART FAILURE PATIENTS TO PREVENT READMISSION AND IMPROVE CENTERS FOR MEDICARE AND MEDICAID SERVICES CORE MEASURE OUTCOMES

Lavigne J, RN BSN; DiGiovanni R, BS BSN RN-BC CCTN; Goodlett D, RN BSN; MacMahon J, RN BSN; McDonald PF, MD; Saxton D, FACHE MHA MPH

Cardiology Services, Ochsner Clinic Foundation, New Orleans

Background: Heart failure readmits were escalating and compliance with heart failure discharge documentation declining. Therefore, in May 2008 the facility partnered with VA, Inc., to participate in a Rapid Adoption Network (RAN) project to rapid cycle change in these areas.

Objectives: To increase compliance with discharge documentation utilizing a team approach to engage nurses and physicians in patient education on heart failure and to redesign the discharge instruction process to prevent heart failure readmits.

Methods: A multidisciplinary team of physicians and nurses collaborated to identify barriers to documentation compliance. Processes and available tools were evaluated and redesigned. The redesigned tool was piloted on our Transplant Step-Down Unit. The nursing and medical staffs were educated prior to inception of the pilot. A system to monitor outcomes was devised. Follow-up telephone calls were placed to randomized patients to determine their retention of the information provided on the redesigned educational tool.

Results: The program was initiated on June 23, 2008. The project has resulted in a downward trend in the number of readmits with a primary diagnosis of heart failure from 18.49% in Q2 2008 to 9.68% in Q3 2008. Additionally, the facility's performance rate for the 6 elements of discharge instructions for core measures is trending upward, from 58% in Q2 2008 to 79.4% in Q3 2008.

Conclusions: Utilizing an all-inclusive tool and continuing education of end users will ensure compliance with the process. The project's future success will also continue to be realized by providing updates on the facility's progress to senior leadership.

R64 EVALUATING THE EFFECTIVENESS OF A COMPREHENSIVE PRESSURE ULCER PREVENTION PLAN IN AN ADULT INTENSIVE CARE UNIT

Fuselier J, RN BSN MBA; Sanford K, BSN RN

Ochsner Medical Center–West Bank, Gretna

Background: After a high number of pressure ulcers were noted in the intensive care unit, a comprehensive education plan regarding the assessment and prevention of pressure ulcers was instituted.

Objectives: To compare the prevalence of pressure ulcers in an adult intensive care unit before and after the implementation of a comprehensive nursing education plan.

Methods: The prevalence of pressure ulcers was recorded prior to and after the education plan was implemented. Random audits measuring compliance with interventions and assessments were concurrently conducted to evaluate compliance with the plan.

Results: Nine hospital-acquired pressure ulcers were identified in the month prior to the implementation of the educational program. Beginning in February 2008, nurses in the intensive care unit were educated on the assessment of patients at high risk for developing pressure ulcers and implementing appropriate interventions for those patients. Since the educational program began, a total of 13 hospital-acquired pressure ulcers have been identified. In no month have more than 3 hospital-acquired pressure ulcers been identified. On average, nurses were 85% compliant in implementing all appropriate interventions.

Conclusions: Findings support that nursing education on the assessment of patients at high risk for developing pressure ulcers and implementing the appropriate preventive interventions have decreased the prevalence of pressure ulcers in an adult intensive care unit.

R65 EVALUATION OF THE USE OF ANTIFUNGAL AGENTS

Kaufmann C, PharmD; Billeter M, PharmD BCPS

Pharmacy, Ochsner Clinic Foundation, New Orleans

Background: Due to the increasing prevalence of fungal infections and the availability of several new antifungal agents, it is important to investigate the use of these agents at Ochsner Medical Center. Voriconazole, posaconazole, and anidulafungin are new and expensive alternatives to fluconazole. Their increased pricing and utilization in our facility are leading to extensive costs to both the institution and to patients.

Objectives: To assess the clinical and pharmacoeconomical outcomes as well as the use of anidulafungin, fluconazole, voriconazole, and posaconazole in patients at Ochsner Medical Center.

Methods: A retrospective chart review was conducted to evaluate the use of anidulafungin, fluconazole, posaconazole, and voriconazole in patients at Ochsner Medical Center to assess the clinical and pharmacoeconomic outcomes associated with their use. Data were collected over a 5-month period. Patients included were over the age of 18 and non-pregnant, who were admitted to the main campus facility and prescribed anidulafungin, fluconazole, posaconazole, or voriconazole. Hospital and pharmacy databases were used to collect patient demographics, antifungal therapy and duration, microbiology, risk factors, and cost data on all patients.

Results: During preliminary data collection, 88% of the patients evaluated in this study were administered fluconazole, 30% were administered anidulafungin, 6% were administered voriconazole, and 2% were administered posaconazole. Twenty-six percent of these patients were on more than one agent during their hospitalization. Of those, 76% were initially given fluconazole, which was later switched to anidulafungin.

Conclusions: Based on preliminary data, it is evident that fluconazole is the more widely prescribed antifungal at Ochsner Medical Center. The pharmacoeconomic data for this study are still pending.

R66 EVALUATING TREATMENT FOR CLOSTRIDIUM DIFFICILE ALONG WITH RISK FACTORS

Tesfazion S, PharmD; Billeter M, PharmD BCPS

Pharmacy, Ochsner Clinic Foundation, New Orleans

Background: Clostridium difficile is increasing in prevalence and severity in the adult population. C. difficile associated disease (CDAD) is steadily “increasing in incidence from 31/100,000 in 1996 to 61/100,000 in 2003,” and severity with the identification of “a new strain of Clostridium difficile NAP 1 (North American pulsed-field gel electrophoresis type 1).” The steady rise of CDAD has heightened hospital awareness, causing a closer assessment of this disease state.

Objectives: The purpose of this study was to identify common patient risk factors and assess treatment and effectiveness of CDAD therapy through relapse and length of hospital stay.

Methods: This is a retrospective chart review evaluating risk factors and treatment of C. difficile. Data were collected between the months of December 2008 and April 2009 at Ochsner Medical Center–Main Campus (OMC). All patients over the age of 18 years were included in this study if on admit or throughout the hospital course they were diagnosed by a positive enzyme-linked immunosorbent assay (ELISA) test for C. difficile; toxins were not differentiated. Patients who did not test positive for C. difficile but were receiving standard treatment doses of metronidazole were excluded from the study. Information was derived from Ochsner Clinic Workstation, daily bed isolation review, and daily Pyxis medical station print outs.

Results: To date, a total of 25 patients have been diagnosed by a positive C. difficile ELISA test at OMC. More than 40% are >65 yo, 8% are relapse patients, and 100% of the patients were started on metronidazole treatment drug therapy.

Conclusions: It is too early in the data collection to make a definitive conclusion; however, all patients who have presented with C. difficile have been started on recommended therapy.

R67 EVALUATION OF THE USE OF GRAM-POSITIVE ANTIMICROBIAL AGENTS

Puchot J, PharmD; Billeter M, PharmD BCPS

Pharmacy, Ochsner Clinic Foundation, New Orleans

Background: Increasing virulence and resistance have made treatment options for gram-positive infections a point of interest. Linezolid and daptomycin are costly alternatives to vancomycin that are frequently used at Ochsner Medical Center; thus, characterization of their use and assessment of clinical outcomes are important. Economic endpoints related to patient outcomes are also of concern because decreased healthcare costs benefit patients and healthcare organizations.

Objectives: To characterize the use of vancomycin, linezolid, and daptomycin along with clinical outcomes and pharmacoeconomic endpoints associated with their use.

Methods: A retrospective chart review of patients admitted to Ochsner Medical Center-New Orleans and treated with vancomycin, linezolid, and/or daptomycin was performed. The following data were collected: patient demographics, antimicrobial agent(s), length of antimicrobial therapy, source of infection, microbiological culture data, length of stay, plan upon discharge, estimated cost of antimicrobial therapy, total pharmacy cost, and total direct cost. Data will be compared to assess advantages or disadvantages related to treatment with vancomycin, linezolid, and/or daptomycin.

Results: Preliminary results suggest the majority of patients were treated with vancomycin, whether used alone or before linezolid or daptomycin. Slightly more than one-third of patients gathered thus far were treated with two or more of the agents of interest and had an average length of stay nearly 18 days. Comparing patients treated with only one of the three antimicrobials, length of treatment with vancomycin and linezolid was very similar.

Conclusions: Data collection is still in progress, but it seems as though vancomycin and linezolid are associated with similar clinical outcomes. Pharmacoeconomic data are still pending.

R68 MEETING RESCUE TEAM SUCCESS DETERMININGNONPREVENTABLE, NON-ICU CODES

Davis A, BSN RN CPHQ; Martin D, MBA RN; Brown L, RN; Digregorio V, RRT; Fuselier J, BSN RN MBA; Judd R, RN; Gafeney G, BSN RN; Phillips J, MD; Colletti L, MN RN

Quality Improvement, Ochsner Medical Center–West Bank, Gretna

Background: In a study published by Bellomo et al, the implementation of a critical care-based medical emergency team demonstrated a 65% relative risk reduction of cardiac arrest and a relative risk reduction of 56% in deaths attributed to cardiac arrest. Another study published by Bellomo et al revealed a reduction in the incidence of postoperative adverse outcomes, postoperative mortality rate, and mean duration of hospital stay. Given the evidence, a critical care-based medical emergency team was implemented at Ochsner Medical Center–West Bank in spring 2007 to improve survival to discharge by reducing the codes occurring outside of the intensive care unit (ICU).

Objectives: To reduce inpatient codes occurring outside of the critical care areas.

Methods: Retrospective data were collected over a period of 2 years (2007–2008), including the 4 months prior to implementation of the medical emergency team (RESCUE Team) in 2007. Data collection included all calls by staff to the RESCUE Team and all hospital codes within and outside of the ICU.

Results: After staff education and implementation in April 2007, there was an inverse correlation of calls to the medical emergency team and the number of codes called outside of the ICU. As the number of codes increased and the calls to the medical emergency team decreased, staff was reeducated on utilizing this resource. The calls to the medical emergency team, then, increased and the number of codes decreased. During these periods there were Pearson product moment correlation coefficients (r) of −0.61 to −0.076. However, in the final 4 months (September to December 2008), there was no longer an inverse correlation but an r of 0.87. Further investigation revealed a need to determine preventable versus nonpreventable codes where patient assessments would trigger calls to the medical emergency teams.

Conclusions: According to predefined criteria, there was only one preventable code outside of the ICU in the final 4 months of data collection.

R69 EVALUATING THE USE OF ESOMEPRAZOLE AT OCHSNER MEDICAL CENTER

Crawford B, PharmD; Billeter M, PharmD BCPS

Pharmacy, Ochsner Clinic Foundation, New Orleans

Background: In recent trials, proton pump inhibitor (PPI) use has been linked to adverse events such as community-acquired Clostridium difficile infection, community-acquired pneumonia, and osteoporosis-related fractures.

Objectives: The goal of this study was to evaluate the pattern of esomeprazole use in patients at Ochsner Medical Center to determine if patients are inappropriately started on PPI therapy, placing them at unnecessary risk for adverse events.

Methods: This is a retrospective chart review. A daily report will be generated of all patients on oral esomeprazole. Each patient's past medical history and/or current medical status will be reviewed to determine if an indication for PPI therapy exists. Patients not found to have an acceptable indication will be followed at discharge to determine if a PPI is inappropriately prescribed. Patients not given a discharge prescription will be followed to determine if a PPI is restarted at first follow-up clinic visit within 90 days.

Results: Thus far, data on 80 patients have been collected. Of these, 26% had a history of gastroesophageal reflux disease, 4% had a history of erosive esophagitis, 18% had a history of gastrointestinal bleed, 9% had indications for stress ulcer prophylaxis, 6% had a new indication, 15% had other indications, and 28% had no documented indication. Some patients had multiple indications. Seventy patients have been discharged, with 57% receiving a discharge PPI prescription; 18% of these prescriptions were unnecessary. Of patients not receiving a discharge prescription, 14 (47%) have followed-up in clinic; 4 patients have been restarted on a PI, with 1 case being unnecessary. Three patients in the study have died, thus providing insufficient data.

Conclusions: Based on preliminary results, 28% of inpatients treated with a PPI had no documented indication for use. With regards to outpatient use, 18% of patients were unnecessarily treated with a PPI.

R70 EVALUATING SAFETY OF HANDOFFS BETWEEN ANESTHESIA CARE PROVIDERS

Leopold R, MD; Hart S, MD

Department of Anesthesiology, Ochsner Clinic Foundation, New Orleans

Background: Anesthesia care providers frequently exchange care of patients among one another. This daily process of information exchange could be a potential source for adverse events.

Objectives: Our objectives were to determine if the current handoff system was ineffective and if more standardized methods for the exchange of patient information could improve the effectiveness of handoffs.

Methods: A survey was distributed to all anesthesia staff, residents, and certified registered nurse anesthetists. The survey queried the following: handoff adequacy, location for best handoff, method for best handoff, and need for inclusion in the electronic medical record.

Results: We received 70 completed surveys, of which 34% found the current handoff process to be inadequate. Most did report both giving and receiving a poor/incomplete handoff in the past year, and 28.5% related an adverse outcome to a poor handoff. The majority did feel that standardization of this process could improve patient care. Most people reported that ideal handoffs would occur both in the operating room and in person. Most also agreed that handoffs should be incorporated in the electronic medical record.

Conclusions: These data will be used to improve the method by which patient care handoffs occur and have assisted in devising techniques that can be incorporated in our daily practice to improve the safety of handoffs and to decrease complications. A handoff menu will be included on the electronic anesthesia record currently being implemented by our department.

R71 ASSESSING NURSES' READINESS FOR EVIDENCE-BASED PRACTICE

Parry G, MSN APRN-CNS CWON; Thibeau S, MSN RNC

Ochsner Medical Center–West Bank, Gretna

R72 ASSESSING REGISTERED NURSE (RN) SATISFACTION ON THE PATH TO MAGNET RECOGNITION IN A COMMUNITY HOSPITAL

Davis A, BSN RN CPHQ; Martin D, MBA RN; Cusanza S, BSN RN CPHQ; Colletti L, MN RN

Nursing Research, Ochsner Medical Center–West Bank, Gretna

Background: Ochsner Medical Center–West Bank has embarked on the journey to Magnet recognition by the American Nurses Credentialing Center. The Magnet Recognition Program designates hospitals based on their ability to attract and retain professional nurses. These elements are measured by nursing-sensitive quality indicators as well as standards of nursing practice defined by the American Nursing Association's Scope and Standards for Nurse Administrators. In addition, a measure of RN satisfaction is required. Therefore, RN satisfaction at Ochsner Medical Center–West Bank was assessed in August 2008.

Objective: To conduct a survey of RN satisfaction in a community hospital of Ochsner Health System.

Methods: A survey of RN satisfaction was conducted utilizing the electronic National Database of Nursing Quality Indicators, RN Survey with Job Satisfaction Scales. All facility nursing units were enrolled. Eligible RNs were full or part time, regardless of job title, spent at least 50% of their time in direct patient care, and had been employed a minimum of 3 months on the nursing unit. This included unit-based staff RNs and Advance Practice RNs as part of the unit.

Results: The response rate was 67.4% (145/215). The scores were reported as modified T-scores in which scores below 40 represent low satisfaction, scores of 40–60 represent moderate satisfaction, and scores above 60 represent high levels of satisfaction. The RNs reported high levels of satisfaction with RN-RN Interaction (70.21), Professional Status (67.11), Professional Development (64.73), Nursing Management (61.77), and Nursing Administration (63.55). Moderate levels of satisfaction were revealed in Job Enjoyment (59.16), Task (53.12), RN-MD Interaction (55.24), Decision-Making (54.79), Autonomy (58.29), and Pay (41.44). There were no scores of low satisfaction.

Conclusions: Although moderate levels of satisfaction were reported in RN-MD Interaction and Pay, these were among the categories of lowest satisfaction at this facility. In an effort to retain and recruit professional nurses, further feedback has been sought to implement changes that will increase the levels of RN satisfaction in these categories.

R73 THE PROGRESSIVE MARGINAL TAPING TECHNIQUE UTILIZED IN CLOSURE OF LARGE VOLUME WOUNDS RESULTING FROM DEHISCENT OR SURGICALLY OPENED CESAREAN SECTION INCISIONS

Schuler L, PT MHA CWS

Rehabilitation Services, Ochsner Clinic Foundation, New Orleans

Background: Wounds resulting from dehiscent or surgically opened Cesarean section incisions are often cavernous with large volumes, undermining, and tracts that prolong healing time and produce poor cosmetic results. The Progressive Marginal Taping Technique (PMTT) is a nontraditional approach to secondary intention wound closure developed by this clinician to address these issues. PMTT combines moist wound healing, debridement, and progressive withdrawal of cavity packing with progressive wound wall approximation. PMTT has shown promise in decreasing wound closure time while providing positive cosmetic results.

Methods: In this retrospective review of 16 patients treated with the PT, 8 met all of the below inclusion criteria:

• 1. C-section incision dehisced or surgically opened within 28 days post-partum.

• 2. Rehabilitation Services Outpatient Wound Care (RSOWC) provided care between 06/01/07 and 03/16/09.

• 3. RSOWC initiated care within 28 days post-partum.

• 4. RSOWC continued services until the wound displayed a minimum of 95% decrease in volume.

Results: Wounds of the 8 patients reviewed had an average volume of 111.07 cm³ (SD of 68.81 cm³) and required an average of 49.38 days (SD of 25.77 days) to achieve closure. This is an average healing rate of 2.78 cm³/d (SD of 2.69 cm³/d).

Discussion: In the small sample of patients reviewed, PMTT demonstrated wound closure at an average rate of 2.78 cm³/d. Additionally, all 8 patients reviewed expressed pleasure with the cosmetic appearance of the scar at time of discharge. Studies have compared traditional methods of healing by secondary intention to negative pressure wound therapy. Further research is warranted comparing outcomes of PMTT with outcomes utilizing negative pressure wound therapy.

R74 A STUDY OF BACTERIAL PATHOGENSONREUSABLE, CLEAN ECG LEAD WIRES: ARE PATIENTS AT RISK FOR HOSPITAL-ACQUIRED BACTERIAL INFECTIONS?

Rice KL, DNS APRN^*; Thibeau S, MSN RNC^†; Reed D, PhD^‡

^*Center for Nursing Research, Ochsner Clinic Foundation, New Orleans

^†Neonatal Intensive Care Unit, Ochsner Clinic Foundation, New Orleans

^‡Center for Quality Excellence, Ochsner Clinic Foundation, New Orleans

R75 A COMPARATIVE ANALYSIS OF COMPLEXITY COMPRESSION AND THE STAFF NURSE WORK ENVIRONMENT IN MAGNET AND NON-MAGNET HOSPITALS

Rice KL, DNS APRN^*; Cusanza S, RN CPHQ BSN^*; Pinkerton S, PhD RN^†; Jankowsky K^‡

^*Center for Nursing Research, Ochsner Clinic Foundation, New Orleans

^†Computer Sciences Corp., Atlanta, GA

^‡Computer Sciences Corp., Falls Church, VA

R76 EVALUATING NURSE AND EXPERT DIAGNOSTICIAN RATINGS FOR DELIRIUM IN HOSPITALIZED OLDER ADULTS

Rice KL, DNS APRN^*; Bennett M, DNS APRN^†; Gomez M, BSN RN^‡; Knight M, MD^§; Theall K, PhD^‖

^*Center for Nursing Research, Ochsner Clinic Foundation, New Orleans

^†School of Nursing, Louisiana State University Health Sciences Center, New Orleans

^‡Department of Nursing, Ochsner Clinic Foundation, New Orleans

^§Department of Psychiatry, Ochsner Clinic Foundation, New Orleans

^‖School of Public Health, Louisiana State University Health Sciences Center, New Orleans

C1 IMATINIB FAILURE AND ACCELERATED PHASE PROGRESSION TO BLAST CRISIS IN CHRONIC MYELOGENOUS LEUKEMIA

Matrana MR, MD MS; Ulfers G, MD; Velcheti V, MD

Department of Internal Medicine, Ochsner Clinic Foundation, New Orleans

Introduction: Chronic myelogenous leukemia (CML), a clonal myeloproliferative disease, is divided into a chronic and an accelerated phase. Blast crisis is the terminal event of CML.

Case Report: A 28-year-old male with history of CML presented with confusion. Imatinib had been started 2 years prior. Original cytogenetics revealed an E3554 mutation, correlating with imatinib resistance. He had a blast crisis 2 months prior to presentation despite imatinib and was treated with cytarabine and idarubicin. Imatinib was discontinued, and dasatinib was added. Currently, he had vomited for 1 week and developed confusion. On examination, the patient was emaciated, confused, and mildly somnolent. White blood cell (WBC) count was 481.7 K/µL, >80% blasts.

The patient was given hydroxyurea and allopurinol. Leukapheresis was begun. A total of 2.3 liters of WBCs were collected. WBC decreased to 385.9 K/µL. Lactate dehydrogenase (LDH) increased from 366 to 19,850 U/L and uric acid from 1.8 mg/dL to 10.1 mg/dL, indicating tumor lysis syndrome. Rasburicase was administered. One hour later, the patient had a seizure and respiratory failure. He was intubated. His neurological status declined rapidly, progressing to brain death.

Discussion: Imatinib and other tyrosine kinase inhibitors (TKIs) prevent progression to the accelerated phase in CL, but imatinib failure does occur. Second-line TKIs such as dasatinib are indicated in cases of imatinib failure. Long-term imatinib response can be predicted based on karyotype or early cytogenetics. Blast crisis is an oncologic emergency that should be aggressively treated with leukoreductive strategies including chemotherapy and leukapheresis. Prognosis is poor.

C2 ACUTE BLINDNESS IN A YOUNG MAN WITH ANTIPHOSPHOLIPID SYNDROME

Matrana MR, MD MS; Moody A, MD

Department of Internal Medicine, Ochsner Clinic Foundation, New Orleans

Case Report: An 18-year-old male with a history of antiphospholipid syndrome (APS) and deep venous thrombosis of the lower extremity presented with eye pain and decreased vision, left greater than right. He had recently been discharged from the hospital after having tissue necrosis of the right hand secondary to warfarin failure. He had been placed on subcutaneous unfractionated heparin. On examination, his eyes were grossly swollen with proptosis bilaterally. He had no vision in the left eye and decreased vision in the right eye.

The ophthalmologist performed urgent lateral canthotomy and cantholysis bilaterally. Heparin drip was started. Computed tomography of the head showed acute thrombus in the left superior ophthalmic vein. Magnetic resonance imaging of the brain revealed left superior ophthalmic vein engorgement and possible cavernous sinus thrombosis. A magnetic resonance venogram performed several days later could not conclusively confirm this.

After a drop in platelets and a positive heparin-induced thrombocytopenia panel, the patient was started on fondaparinux but switched back to warfarin, with international normalized ratio goal of 3.0–3.5 (higher than previously). He developed a severe headache. Repeat imaging revealed a hemorrhage in the left temporoparietal region. Anticoagulation was held for 5 days and then restarted, but the hemorrhage evolved mildly, although no new focal neurological deficits were appreciated on examination. His vision in his left eye was stably absent, but vision in the right eye returned to 20/20.

Discussion: Ophthalmic manifestations are rare but significant complications of APS. Blindness infrequently results from central retinal artery occlusion, ophthalmic vein thrombosis, or optic nerve ischemia. Given the bilateral nature of our patient's presentation, it was suspected that the cavernous sinus may also have been involved, but imaging revealed no definitive answer. Rates of cavernous sinus thrombosis are increased in patients with APS.

C3 SEVERE HYPOKALEMIA AND HEMATURIA: AN INTERESTING CASE OF MUNCHAUSEN SYNDROME

Matrana MR, MD MS^*; McDonald PF, MD^*; Rostlund E, BS^†

^*Department of Internal Medicine, Ochsner Clinic Foundation, New Orleans

^†Tulane University School of Medicine, New Orleans

Introduction: Munchausen syndrome is a rare form of factitious disorder in which patients actively assume the sick role with no clear motives.

Case Report: A 47-year-old female was admitted for hypokalemia. Her history included fibromyalgia, nondiabetic gastroparesis, irritable bowel syndrome, migraines, multiple infections, depression, and anxiety. She complained of weakness, tingling and cramping of the extremities, and fatigue. Medications were methadone (for pain), hydrocodone, pregabalin, duloxetine, alprazolam, trazodone, and ondansetron. Potassium was 1.9 mmol/L. Electrocardiogram showed u-waves.

Over a week, her potassium dropped despite administration of >2,000 mEq of potassium. Laboratory test results were inconsistent with organic syndromes. The patient complained of bloody urine. Urinalysis was normal. Later, pure blood was noted in her Foley collection bag. Hemoglobin dropped from 12.3 gm/dL to 7.8 gm/dL. The urologist noted that aspirating the Foley balloon lumen produced blood. The balloon could not be deflated. The balloon was removed in cystoscopy; subsequent dissection revealed a large clot.

The patient's room was searched. Empty packaging for hundreds of laxative pills and two bloody syringes that the patient used to aspirate blood from her IVs and inject into her catheter were found. The patient was transferred to psychiatry. Her hematuria and hypokalemia resolved.

Discussion: Both self-induced hypokalemia and factitious hematuria have been reported but never in the same patient. Surreptitious laxative abuse should be considered when other organic causes of electrolyte abnormalities have been ruled out. Self-infusion of one's own blood into the bladder to simulate hematuria has been reported in two other known cases.

C4 EASY ACCESS: THE CASE AGAINST PORTS AND PICCS

Vuppala S, MD; Moody A, MD; Dhillon R, MD

Department of Internal Medicine, Ochsner Clinic Foundation, New Orleans

Case Report: A 38-year-old female with multiple hospitalizations for intractable migraines presented with nausea, vomiting, and fever. A peripherally inserted central catheter (PICC) line had been placed 1 month earlier for antibiotic administration for a port infection. The patient exhibited 3 of 4 systematic inflammatory response syndrome criteria, and her PICC line was removed as the suspected source of infection. Catheter tip cultures revealed Staphylococcus aureus as well as Enterococcus. Her previous blood cultures from her port infection showed diphtheroids.

During a previous hospitalization 1 month prior, she underwent a work-up with a chest computed tomography (CT) scan and bronchoscopy for an interstitial pattern on chest x-ray consistent with interstitial pneumonitis. CT revealed a micronodular pattern throughout both lungs. Transbronchial biopsies from the right lower lobe showed scattered noncaseating granulomata, with foreign body giant cells surrounding central foreign material.

Upon further questioning, she revealed that she frequently crushed her opioid pills and used her port or PICC to inject them. The patient was successfully treated with linezolid for her line sepsis, and on discharge she requested that she not be sent home with any narcotics. She was referred to the Jefferson Parish Mental Health Center for follow-up.

Discussion: Talc, the most widely used insoluble binding agent in the production of opioids, can cause significant pulmonary damage when injected. Talc embolization causes an initial arteritis followed by the development of foreign body granulomas, as talc particles migrate through the vessel wall. Unfortunately, the disorder has no proven treatments, including corticosteroids, and most individuals experience a progressive decline in pulmonary function.

C5 NRXN1 GENE DELETION IN A FAMILY WITH VARIABLEDEVELOPMENTALDELAY, AUTM, AND PREVIOUSLY UNREPORTED CARDIAC CONDUCTION ANOMALIES

Niyazov DM, MD^*; D'Angelo A, BS^*; Alliman S, MS^†; Snyder CS, MD^*; Shaffer LG, PhD^†

^*Department of Pediatrics, Ochsner Clinic Foundation, New Orleans

^†Signature Genomic Laboratories, Spokane, WA

Introduction: Chromosomal microdeletions and microduplications can have variable manifestations, including normal phenotype in a parent and severe impairment in a child. It is becoming more challenging to predict whether a particular copy number variant is pathogenic solely on the basis of whether it is de novo or inherited.

Case Report: We present a family with an unaffected parent and three siblings with varying phenotypes due to a 559.2 Kb deletion in 2p16.3 ascertained by oligonucleotide array comparative genomic hybridization and confirmed by fluorescence in situ hybridization. The microdeletion overlapped the NRXN1α gene, which encodes the neurexin1α protein, leaving neurexin1β intact. The mother is asymptomatic, while her daughter has learning disabilities and required special education. Two of the sons have autism, mental retardation (MR), and mild dysmorphism. Both of them also have atrioventricular node dysfunction requiring cardiac pacemaker placement.

Discussion: To our knowledge, there have been two reports in the literature of normal parents transmitting the NRXN1 deletion to their offspring affected with autism and MR. However, cardiac conduction defects have not been previously described. Another member of neurexin family, NRXN3, is widely expressed in heart tissue. Cardiac isoforms of NRXN3 can participate in a complex involving dystroglycan, a ubiquitously expressed transmembrane protein linking cytoskeletal actin to extracellular matrix. Dystroglycan extracted from brain, heart, and skeletal muscle is known to interact with neurexin 1, with which it forms a stoichiometric complex in the brain. Possible mechanisms and implications of incomplete penetrance, variable expressivity, and pleiotropy of the NRXN1 deletion are discussed.

C6 TNF-ALPHA ANTAGONIST-INDUCED SARCOIDOSIS

Clementine R, MD MPH^*; Lyman J, MD^*; Mallepalli J, MD^†; Lindsey S, MD^‡; Zakem J, MD^*; Quinet R, MD^*

^*Department of Rheumatology, Ochsner Clinic Foundation, New Orleans

^†Private practitioner, Monroe

^‡Department of Rheumatology, Ochsner Clinic Foundation, Baton Rouge

Introduction: Sarcoidosis is a multisystem granulomatous disease of unknown etiology. Tumor necrosis factor-alpha (TNF-α) is an important player in granuloma formation, and recent clinical trials have investigated the efficacy of TNF-α inhibitors in sarcoidosis. Paradoxically, several case reports in the medical literature describe the development of sarcoidosis in patients treated with TNF-α inhibitors.

Case Report: We describe three cases of TNF-α antagonist-induced sarcoidosis: one case of pulmonary, ocular, and cutaneous sarcoidosis developing in a patient receiving infliximab for erosive rheumatoid arthritis, one case of etanercept-induced sarcoidosis in a patient with seronegative rheumatoid arthritis, and one case of sarcoidosis developing in a patient receiving etanercept for erosive rheumatoid arthritis. We also provide a discussion on the role of TNF-α in granuloma formation and implications in the use of TNF-α antagonists in autoimmune disease.

Discussion: TNF-α is important in T-cell mediated granuloma formation, and TNF-α signaling is vital for the regulatory T cell function in sarcoidosis. The role of TNF-α changes as the granuloma progresses to fibrosis. It appears that TNF-α serves as a mediator of cell signaling in various immune responses, rather than for a specific immune response. Thus, the actions of TNF-α likely depend upon its interaction with surrounding cells and cytokines. In conclusion, it seems logical that TNF-α blockade might work at inhibiting progression to fibrosis and help suppress persistent disease if given in conjunction with other immunomodulators; however, the emergence of several cases of TNF-α inhibitor-induced autoimmune disease provides evidence that its effects are unpredictable. Our three cases presented, along with previously reported cases of TNF-α antagonist-induced sarcoidosis, support the need for further studies examining the role of TNF-α antagonist therapy in the development of sarcoidosis.

C7 EXTRACARDIAC SHUNTING SECONDARY TO SUPERIOR VENA CAVA THROMBOSIS

Artham SM, MD MPH; Shah S, MD; Lecce MD, MD; Dinshaw HK, MD; Grant A III, MD

Department of Cardiology, Ochsner Clinic Foundation, New Orleans

Case Report: A 49-year-old female was transferred to our institution with complaints of swelling and plethora of the head, neck, upper chest, and upper extremities for 2 weeks. She had additional complaints of headache and dizziness. She had been receiving high dose corticosteroids through a right chest port for 3 years for recurrent flare-ups of multiple sclerosis. On examination, she was hypoxic, cyanotic, and plethoric with swelling in the upper body, sitting upright all the time. The two-dimensional echocardiogram with bubble contrast showed significant filling of the left heart more than 6 cardiac cycles after injection, suggesting a noncardiac source of shunting. Cardiovascular magnetic resonance imaging (MRI) showed a filling defect in the superior vena cava (SVC) and the left and right innominate veins. A computed tomography scan showed SVC thrombus with good collateral formation in the chest and neck, and robust contrast filling of the azygos and hemiazygos in to the lumbar plexus and in to the inferior vena cava (IVC). The clinical, 2D echocardiography, and MRI findings all indicated SVC syndrome secondary to SVC thrombosis around the chronic in-dwelling catheter. The in-dwelling catheter was taken out promptly, and heparin infusion was initiated. The patient was taken to the catheterization laboratory for local urokinase infusion; 1 day later, the SVC showed improvement in the patency of the obstruction, and the residual block was treated with balloon dilatation resulting in good flow into the right atrium. The patient responded very well over the next few days, her symptoms completely resolved, and she was discharged home on warfarin for 6 months.

Discussion: SVC thrombosis is predominantly associated with malignancies, including lung cancer and non-Hodgkin's lymphoma, and also with other benign causes such as catheter thrombosis. In our patient, the in-dwelling catheter in the SVC was the nidus for the thrombus formation, which over the years led to the formation of commonly expected collaterals in the thorax, such as the internal thoracic vein, lateral thoracic vein, azygos-hemiazygos veins, and vertebral venous plexus (lumbar venous plexus in this patient). This case documents the interesting phenomenon of systemic-pulmonary venous collateral formation/shunting seen with SVC thrombosis.

C8 RUPTURED MIDDLE MENINGEAL ARTERY ANEURYSM PRESENTING AS A TEMPORAL LOBE INTRACEREBRAL HEMATOMA: A CASE REPORT

Yeremeyeva E, MD^*; Cherqui A, MD^*; Milburn JM, MD^†; Singh MK, MD^*; Dydynski PB, MD^†

^*Department of Neurosurgery, Ochsner Clinic Foundation, New Orleans

^†Department of Radiology, Ochsner Clinic Foundation, New Orleans

Case Report: A 55-year-old African-American female presented with sudden onset of global aphasia and confusion. Computed tomography of the head demonstrated a left temporal lobe intracerebral hemorrhage, which extended to involve the cortex and exerted moderate mass effect. Cerebral angiography revealed a bilobed aneurysmal deformity of the left middle meningeal artery in the left posterolateral middle cranial fossa. Embolization of the left middle meningeal artery with microcoils was performed. Postangiogram images demonstrated faint residual filling of the aneurysm. Surgical excision of the aneurysm and evacuation of the hematoma were subsequently performed. Postoperatively, the patient's speech improved markedly; she began to follow commands and eventually was discharged home. At 10 months follow-up, she was neurologically intact, but she developed a medically controlled seizure disorder as the sequela of the temporal lobe hemorrhage.

C9 PRIMARY CEREBRAL FIBROSARCOMA

Yeremeyeva E, MD^*; Singh MK, MD^*; Dydynski PB, MD^†; Milburn JM, MD^†

^*Department of Neurosurgery, Ochsner Clinic Foundation, New Orleans

^†Department of Radiology, Ochsner Clinic Foundation, New Orleans

Case Report: A 49-year-old male presented with a 3-day history of left-sided body paresthesias, mainly in the left upper extremity, and severe headaches. He was neurologically intact per physical examination. Nonenhanced computed tomography (NECT) of the head demonstrated a large area of vasogenic edema involving the right temporal lobe, which extended into the right frontoparietal region. Magnetic resonance imaging (MRI) of the brain further revealed a large mass in the right temporal lobe with a thick irregular rim of enhancement, a large degree of surrounding vasogenic edema, and a mass effect with uncal and subfalcine herniation. A small amount of an acute peritumoral hemorrhage was also demonstrated. Preoperative findings were compatible with a primary brain high grade neoplasm such as glioblastoma multiforme. The patient underwent a right frontal temporal craniotomy with gross total excision of the right temporal lobe mass and a placement of BCNU-carmustine wafers. Final histopathology was compatible with fibrosarcoma. Metastatic work-up—including imaging of the chest, abdomen, pelvis, and cervical spine—did not reveal a neoplastic process elsewhere. The patient was asymptomatic postoperatively and underwent a course of radiation therapy. At the 3-year follow-up, he remained neurologically intact. At the 4-year follow-up, MRI of the brain demonstrated a new enhancing lesion at the resection site suspicious for a recurrence, which is currently being evaluated. Primary cerebral fibrosarcoma is a rare entity, with fewer than 50 cases reported overall.