Center Experience Research Articles

Efficiency and safety of cold snare polypectomy in patients with colon lesions ≤1.6 cm: two centers experience

Efficiency and safety of cold snare polypectomy in patients with colon lesions ≤1.6 cm: two centers experience

Restrictive effects of thalassemia on respiratory functions: One center experience.

Respiratory functions in thalassemia major (TM) patients concerning poor chelation are a frequently researched issue. Our study aims to evaluate the lung functions of our patients with TM in the chronic transfusion program and to correlate them with their age, ferritin levels, and pre-transfusion hemoglobin values. Height, weight, pulmonary function test (PFT) results, pre-transfusion hemoglobin levels, and ferritin levels of 97 patients (55 boys and 42 girls) without any underlying cardiac or chronic respiratory disease were recorded. PFT is consisted of forced vital capacity (FVC) and forced expiratory volume in one second (FEV1), the ratio of FEV1/FVC to peak expiratory flow (PEF), and forced mid-exhaled flow between 25% and 75% of mid-expiratory flow (MEF25-75). Data were analyzed with IBM SPSS V25. Low FVC was observed in 58 patients (60%), and low FEV1 was observed in 26 patients (27.6%). Low PEF was observed in 62 patients (64.5%), and low MEF25-75 was observed in 8 (8.3%). PFT was affected in 75 patients (78.1%). The pattern of involvement was restrictive. Age, height, and ferritin values significantly affected the MEF25-75 (p<0.05). Age and pre-transfusion hemoglobin values had a significant effect on the FVC test (p<0.05). There was a weak negative correlation between ferritin values and MEF25-75 (r=-0.221) and a weak positive correlation between pre-transfusion hemoglobin and FVC (r=0.222). Age and height are the main risk factors affecting FEV1, MEF25-75, and PEF. Serum ferritin has only an effect on MEF25-75 in our study. The respiratory functions of TM patients were affected in a restrictive pattern.

Surgical treatment of post-traumatic vertebral osteonecrosis including intravertebral expansive implants-clinical, functional and imaging outcomes and a center experience over 7 years.

The effective treatment of post-traumatic vertebral osteonecrosis continues to be an under discussion and controversial subject. Armed kyphoplasty with expansive intravertebral implants is an emerging procedure, which, in theory, allow for a more effective preservation of the restored vertebral height. The development of the indications for these recent devices has given rise to auspicious outcomes in vertebral non-union situations. The aim of this study is to evaluate the clinical, functional and imaging outcomes of the surgical treatment of situations of post-traumatic vertebral necrosis, following a therapeutic algorithm that includes armed kyphoplasty with intravertebral expansive implants and bridge pedicular stabilization, according to a predefined necrosis stage. We present a retrospective observational study, in which 35 patients took part, including a total of 35 cases of post-traumatic vertebral osteonecrosis submitted to surgical treatment over 7 years (between 2016 and 2023) at the same center according to a defined therapeutic algorithm. The cases were staged according to vertebral morphology (non-plana or plana) and mobility (mobile or immobile)-stages 1m (mobile necrotic vertebra non-plana), 1i (immobile necrotic vertebra non-plana), 2m (mobile necrotic vertebra plana), and 2i (immobile necrotic vertebra plana)-and the following surgeries were performed: armed kyphoplasty with intravertebral expansive implants filled with bone cement, associated or not to adjacent pedicle instrumentation; or bridge pedicle fixation of the adjacent levels. Clinical results [Patient Global Impression of Change (PGIC), Visual Analogue Scale (VAS) and Oswestry Disability Index (ODI)] as well as imaging outcomes (restoration and preservation of the heights of the vertebral body) were studied. The mean follow-up time corresponded to 3.17 years (range, 1-7.5 years). Most of the clinical-functional and imaging parameters showed important improvements after surgical treatment, with few complications. A statistically significant greater degree of functional improvement was found in plana vertebrae when compared to non-plana, which reflects that the first are quite symptomatic and disabling at the beginning and improve a lot with surgical treatment. Significant indirect correlations were found between the time from the initial fracture to surgical intervention after diagnosis of vertebral necrosis and the anterior sagittal height in the immediate postoperative time and at the ending of the follow-up. Also, a significant direct correlation was identified between this time and the VAS for pain at the end of the follow-up and the PGIC scale in the same period. It was also found that patients with surgical complications had a statistically significantly longer time between the initial fracture and surgery for post-traumatic necrosis. We present the results of a surgical therapeutic algorithm that includes the use of recent expansive intravertebral implants at post-traumatic vertebral osteonecrosis, resulting in satisfactory clinical, functional and imaging results. This work shows a pioneering statistical demonstration of the clinical, functional and imaging importance of early detection of this condition (ideally in vertebrae non-plana morphology stages), so that there is still sufficient bone tissue in the vertebral body to permit the stabilization and restoration of its anatomy through a minimally invasive interior reconstruction, with percutaneous access and quicker convalescence, that is to say, armed kyphoplasty, avoiding the unwanted disease progression that will require more aggressive surgical solutions that doesn't allow anatomical restauration.

Monoplane versus biplane fluoroscopy in patients undergoing fenestrated/branched endovascular aortic repair

ObjectiveEndovascular aortic repair (EVAR) with fenestrated (F-EVAR) or branched (B-EVAR) endografts represents an indispensable tool of modern patient care in vascular surgery. The purpose of this retrospective study was to evaluate the center's initial experience of F/B-EVAR procedures performed under biplane angiography guidance compared with a historical control group. MethodsFrom January 2020 to March 2022, 80 consecutive patients underwent F/B-EVAR under general anesthesia at a single institution. As from January 2021, the deployment of complex stent grafts was performed using an alternative intraoperative imaging modality—a biplane fluoroscopy and angiography. The cohort was divided into monoplane (MPA) and biplane (BPA) groups according to the imaging modality applied. The end points were operation time, fluoroscopy time, radiation exposure, dose of contrast agent, and technical success. ResultsThe MPA group included 59 patients (78% male; median age; 74 years; interquartile range [IQR], 66-78 years) and the BPA group 21 patients (85.7% males; median age, 75 years; IQR, 69-79 years). Operation time (median, 320 minutes; IQR, 266-376 minutes) versus (median, 275 minutes; IQR, 216-333 minutes) was significantly lower in the BPA group (P = .006). The median fluoroscopy time (median, 82 minutes; IQR, 57-110 minutes vs median, 68 minutes; IQR, 54-92 minutes), contrast agent volume applied (median, 220 mL; IQR, 179-250 mL vs median, 200 mL; IQR, 170-250 mL), and radiation dose (dose-area product, median, 413 Gy × cm2; IQR, 249-736 Gy × cm2; vs median, 542 Gy × cm2; IQR, 196-789 Gy × cm2) were similar in both groups. Technical success of 96.6% (57/59 cases) versus 100% (21/21 cases) could be achieved in MPA and BPA group, respectively. ConclusionsF/B-EVAR procedures performed under BPA guidance were associated with a significant decrease in operation time.

Intravenous infusion of methylene blue to visualize the ureter in laparoscopic colorectal surgery

Objective: Intraoperative localization of the ureter can contribute to accurate dissection and minimize ureteral injury in colorectal surgery. We aim to summarize a single center's experience of fluorescence ureteral visualization using methylene blue (MB) and explore its visualization efficiency. Methods: This is a descriptive case-series-study. Clinical data of patients who had undergone laparoscopic colorectal surgery and fluorescence visualization of the ureter in the Gastrointestinal Surgery Department of Guangdong Provincial People's Hospital from March 2022 to May 2022 were retrospectively collected. Patients with incomplete surgery videos, renal insufficiency, or allergic reactions were excluded. MB was infused with 0.9% NaCl at 1.0 mg/kg in 100 mL of normal saline for 5 to 15 minutes during laparoscopic exploration. Imaging was performed using a device developed in-house by OptoMedic (Guangdong, China) that operates at 660nm to achieve excitation of MB. Clinical information, MB dosage, rate of successful fluorescence, time to fluorescence, operation time, blood loss, intraoperative blood oxygen levels, pathological staging, changes in renal function, and post-operative complications were retrospectively analyzed. Results: The study cohort comprised 27 patients (24 men and 3 women) with an average age of (60.25±16.95) years and an average body mass index of (21.72±3.42) kg/m2. The dosage of MB was 0.3-1.0 mg/kg and the infusion time was 5-15 minutes. Fluorescence signals were detected in all patients. The median time to signal detection was 20 (range, 10 to 40) minutes after MB infusion. The range of intraoperative blood oxygen fluctuation averaged 2.5% (range, 0 to 7.0%). The median change in creatine concentration was -1.3 (range, -17.2 to 29.2) µmol/L. No patients had complications associated with use of MB. Fluorescence visualization of the ureter was very valuable clinically in two patients (thick mesentery, stage T4). Conclusion: MB is a safe and effective means of visualizing the ureter by fluorescence during laparoscopic colorectal surgery, especially when the procedure is difficult. MB in a dosage of less than 1 mg/kg can slowly infused for more than 5 minutes during laparoscopic exploration. During the infusion, attention must be paid to blood oxygen fluctuations.

Bipaddled Pectoralis Major Myocutaneous Flap in Complex Oral Cancer Defects- A Single Center Experience with Quality of Life Assessment.

Advanced stage malignancies of oral cavity commonly result in complex full thickness defects with subsequent functional and aesthetic loss. Through this article we describe our center's experience in reconstruction of such defects with bipaddled pectoralis myocutaneous (PMMC) flap through an immediate, single-staged procedure. The study included a total of 54 patients who underwent composite resection and neck dissection followed by reconstruction of the defect with bipaddled PMMC flap. All patients were followed up post-operatively for 1 year and were monitored for flap and donor site related complications. Using University of Washington Quality of life v4 questionnaire (UW-QOL4), we assessed the QOL of 54 patients. The mean scores were compared to other similar studies. Results: The overall complication rate was 66.6%, whereas, 33.3% patients had no complications. The most common complication was wound dehiscence seen in 31.5% of cases in the recipient site and 12.9% in the donor site. Other complications were seroma, hematoma, plate exposure, orocutaneous fistula etc. Around 73.7% patients reported a good, very good or outstanding overall quality of life in the post-operative period. The mean composite QOL score was 65.84. Our study showed comparable domains of pain, appearance, activity, recreation, swallowing, chewing, speech, shoulder function and taste with other similar studies. Conclusion: Bipaddled PMMC flap proves to be a considerable alternative for microvascular free flaps in reconstruction of full-thickness defects of oral cavity owing to its reliable blood supply, accessibility, easier harvesting technique, cost effectiveness, high success rate and acceptable quality of life. The online version contains supplementary material available at 10.1007/s12070-022-03324-6.

In 2022, which is preferred: haploidentical or cord transplant?

Allogeneic hematopoietic stem cell transplantation is the treatment of choice for high-risk hematological malignancies such as acute myeloid and lymphocytic leukemia, myelodysplastic syndrome, and myeloproliferative disorders. Alternative donor transplantation from either haploidentical (haplo-SCT) or cord blood donor (CBT) is an established therapeutic alternative for patients who need transplants but lack a human leukocyte antigen-matched donor. Although haplo-SCT (mainly non-T-cell-depleted haplo-SCT with posttransplant cyclophosphamide) is increasing while CBT is decreasing worldwide (Figure 1), recent developments in CBT, especially cord blood expansion and other strategies to improve engraftment and immune reconstitution post-CBT, make CBT still a valuable option. This article discusses the 2 options based on the currently available data, focusing on adults, and tries to give some clues to help the transplant physician choose a haploidentical vs a cord blood donor. Given the limited numbers of published or ongoing well-designed randomized controlled trials comparing haplo-SCT to CBT and the overall similar clinical results in the available, mostly registry-based, and single-center studies, with substantial heterogeneity and variability, the decision to perform haplo-SCT or CBT in a given patient depends not only on the patient, disease, and donor characteristics and donor availability (although most if not all patients should have in principle an alternative donor) but also on the transplant physician's discretion and, most importantly, the center's experience and preference and ongoing protocols and strategies.

HPB P43 Stereotactic ablative radiotherapy is a safe and feasible option for non-surgical candidates with colorectal liver metastases

Abstract Background Stereotactic ablative radiotherapy (SABR) has been associated with an improvement in over-all survival in patients with oligometastatic colorectal cancer with a controlled primary tumour and one to five oligometastatic lesions. We report our centre's experience of SABR as an alternative local therapy for non-surgical candidates with colorectal liver metastases. Methods All patients were identified who received SABR irradiation for colorectal liver metastases in a tertiary HPB centre between June 2016 and February 2022. SABR criteria included patients with 1–3 liver metastasis with maximum tumour diameter &amp;lt; 6 cm, liver confined disease and a suitable performance status with pre-treatment Child-Pugh status A. A retrospective review of the patient's scans, letters and MDT outcomes was performed to analyse the pathology, indications and outcomes. Results 18 patients with oligometastatic colorectal cancer received SABR to metastases in the liver over the study period. Five were female and 13 were male. Median age was 71. Performance status was 1 in the majority of cases (10/18). Only 2 patients had synchronous disease. 4 patients had concomitant metastatic disease to the lung and all 4 had had a lung resection. Half of the patients had a previous liver resection with 2 of these having two previous liver resections and 1 having 3 liver resections. 4/18 patients underwent SABR because they were deemed unfit for surgery, 6/18 were for anatomical indications with risk of an R1 resection and one was down to patient choice. Metastases were of median size 30 mm (9–87 mm). 89% (16/18) patients had a single metastasis, 1 patient had 2 metastases and 1 patient had 3 metastases. Overall survival was 19 months (4–60 months). 3 patients achieved complete resolution of disease and 4 patients had partial resolution. 6 patients were deemed to have stable disease and 4 patients had disease progression. Outcome data was not available in 1 patient. Only 2/18 pa Conclusions We observed that SABR is feasible, well tolerated and effective in this cohort of patients. Longer-term follow up data is required to assess a survival benefit.

OGC P34 Endoscopy vacuum therapy for anastomotic leak after oesophagectomy – A single centre's experience

Abstract Background Anastomotic leak is one of the major complications following oesophagectomy and is associated with a prolonged ICU and hospital stay with high mortality. Over the years, endoscopic vacuum therapy (EVT) has an evolving role in managing anastomotic leak. The aim of this study was evaluate our experience in the use of EVT in managing anastomotic leak. Methods A retrospective analysis was conducted in patients who underwent elective oesophagectomy at our tertiary centre from May 2021 to April 2022. Patient demographics, complication profiles, length of stay (LOS) and survival outcomes were collected. The details of endoscopic procedure, therapy results, and adverse events were evaluated. Endo-SPONGE® by B Braun Medical Ltd was used at our centre. Results Over the last 12 months, 3 out of 11 patients (27.3%) who had anastomotic leak were treated with EVT. All 3 patients were males and diagnosed with anastomotic leak on Day 8, 9, 9. Two patients were treated with a stent at the time of the diagnosis and the management changed to Endo-Sponge on the subsequent endoscopy as the defect increased in size. They required 3 and 8 times of sponge exchange respectively. One patient was managed with Endo-Sponge at the time of diagnosis and required 7 times of sponge exchange. The successful anastomotic leak healing rate was 100% and none of them required further endoscopic or surgical interventions. The median changing time interval of sponges was 3 days (range 2–5 days). The average sponge exchange rate was 6 times. The median duration of EVT was 25 days (range 18–29 days). No other adverse events occurred during EVT. The average LOS was 49.3 days. Conclusions EVT is an effective and safe treatment option in patients with anastomotic leak post oesophagectomy for oesophageal cancer. With careful patient selection, EVT can be considered as the first-line treatment instead of surgery. Future studies involving a greater number of patients are essential to evaluate the efficacy of EVT.

Treatment approach in ovarian pathologies in children: A single center's experience

Treatment approach in ovarian pathologies in children: A single center's experience

ACUTE BLOOD PURIFICATION METHODS IN INTENSIVE CARE OF COMPLICATIONS AFTER CARDIAC SURGERY.

<h3>Objective</h3> Complications after cardiac surgery have serious negative consequences, prolonging intensive care (ICU) stay days and significantly increasing costs. Prevention and treatment of complications after cardiac surgery is a serious problem. According to numerous authors, the incidence of complications after cardiac surgery varies from 10 to 60%. The most common and prognostically significant complications are bleeding, acute kidney injury and infection. Advances in cardiac surgery have led to a reduction in the overall mortality associated with open-heart surgery, however, still extremely high among patients with complications. Impaired renal function, or active infectious process, sepsis has significant prognostic consequences which are the cause of up to 40% of deaths. As a solution may serve various methods of blood purification. In recent decades, the blood purification method of choice in the therapy of numerous pathological conditions is resistant to traditional therapy. This study details one centre's experience of acute blood purification application in the ICU. <h3>Materials and Methods</h3> Structural analysis of acute extracorporeal blood purification methods application to patients in ICU. The period from 2015 to the 2021 year. <h3>Results and Discussion</h3> For the period from 2015 to 2021 more than a thousand patients underwent extracorporeal methods of blood purification due to complications after cardiac surgery or the severity of the condition. Throughout the period effectiveness and safety were assessed. Blood purification is an option of therapy for numerous complications in the postoperative period(acute kidney injury, Systemic inflammatory response reaction syndrome, sepsis cytokine storm, fluid overload). We have a positive experience with extracorporeal blood purification application to patients after different types of cardiac surgery (open valve surgery, surgery of myocardium revascularization, implantation of left ventricular assist device, heart and lungs transplantation, transcatheter manipulation) in the immediate postoperative period. The structure of procedures and patients' characteristics are shown in table 1. <h3>Conclusion</h3> Acute extracorporeal blood purification methods are a significant option in therapy of complications after cardiac surgery. Procedures are effective and safe. This direction requires further development and study.

Stent-armed kyphoplasty in osteoporotic thoracolumbar fractures-clinical and functional results and a center experience over 10 years.

The optimal treatment of osteoporotic vertebral fractures is still a controversial and under discussion topic. Armed kyphoplasty with expansive intravertebral implants is an emerging procedure, which, in theory, it not only makes it possible to achieve instant analgesia, and to get stabilization gains of benefits of kyphoplasty and vertebroplasty, but also, allows for a more effective maintenance of the restored vertebral height. A retrospective observational study is presented, in which 30 patients participated, including a total of 33 osteoporotic thoracolumbar compression burst vertebral fractures with involvement of one or both vertebral platforms and of more than one fifth of the posterior wall. These individuals underwent armed kyphoplasty with VBS® stents (or stentoplasty) filled with bone cement over 10 years (between 2012 and 2022) at the same center. Clinical (visual analogue scale, Oswestry Disability Index and Patient Global Impression of Change) and imaging results (restoration and maintenance of vertebral body heights) achieved were investigated. The mean follow-up time was 4.5 years (range, 1-10 years). There was a statistically significant improvement in all clinical and functional parameters evaluated, as well as a statistically significant difference in the various vertebral body heights between preoperative and end of follow-up time [increase of 10.7-15.2-5.0 mm (anterior-median-posterior) in the sagittal plane and 6.7-11.6-9.7 mm (right-median-left) in the coronal plane]. There was a statistically significant direct correlation between vertebral heights in the coronal plane, and between the Beck index assessed at the end of the follow-up period and the improvement in functional disability. The percutaneous transpedicular posterior approach, the ability to anatomically restore the fractured vertebra and to maintain it in the medium-long term, as well as the reduced risk of adverse effects, make stent-armed kyphoplasty a very attractive treatment option for osteoporotic compressive thoracolumbar fractures. A clinical-morphological correlation was demonstrated regarding the surgical treatment of these fractures, it was found that a more effective morphological restoration of vertebral heights in both the sagittal and coronal planes is associated with superior satisfactory clinical functional parameters.

Five-year outcomes after surgery for class 1 obesity: a retrospective analysis of a Canadian bariatric centre's experience.

There is a paucity of literature exploring the role of bariatric surgery in class 1 obesity. We evaluated the 5-year outcomes after bariatric surgery in patients with class 1 obesity, assessing weight loss, resolution/reduction of obesity-related comorbidities, morbidity and mortality. We performed a single-centre retrospective analysis of patients who underwent bariatric surgery (laparoscopic sleeve gastrectomy [LSG] or laparoscopic Roux-en-Y gastric bypass [LRYGB)]) for class 1 obesity (body mass index [BMI] 30.0-34.9) between January 2012 and February 2019. Thirty-seven patients (35 [95%] female, mean age 44.5 yr [standard error (SE) 11.3 yr], mean preoperative BMI 33.1) were included, of whom 32 underwent LSG and 5 underwent LRYGB. Thirty-five patients were followed for 5 years post-operatively, achieving a mean BMI of 25.6 (SE 1.2) and excess weight loss of 89.4% (SE 15.1%). Remission of hypertension was achieved in 5 of 12 patients (42%), and remission of dyslipidemia was achieved in 7 of 11 patients (64%). Of the 11 patients with diabetes, 7 underwent LSG and 4, LRYGB. At 5 years postoperatively, the mean glycosylated hemoglobin concentration was 6.3%. Four patients in the LSG group developed de novo reflux, 1 patient required conversion to LRYGB, and 1 patient with sleeve stenosis required endoscopic dilatation. There were no deaths in either patient group. At our centre, bariatric surgery for class 1 obesity was safe and had long-term efficacy, with remission or reduction of related comorbidities. Prospective controlled trials are required to confirm these results.

MRD Status and ELN 2022 Predicts for Outcomes of Venetoclax + Hypomethylating Therapy in AML: Single-Center Real-World Analysis

Background Patients (pts) with Acute Myeloid Leukemia (AML) have a bleak prognosis, particularly those who are elderly and/or have significant comorbidities. The treatment paradigm for such patients has shifted to less-intensive regimens, primarily venetoclax (Ven) plus either azacitidine (Aza) or decitabine (Dec). However, to date, it is unclear which regimen is optimal and which new molecular classifications are relevant. We performed a real-world analysis of our center's experience with Ven-based regimens to address the role of measurable residual disease (MRD) and the new ELN2022 in predicting clinical outcomes. Methods We conducted a retrospective review of consecutive adult pts (aged ≥ 18 yo) at Roswell Park Comprehensive Cancer Center with a confirmed diagnosis of AML who received a Ven-based regimen between July 2017 and December 2021. Newly diagnosed (ND) and relapsed/refractory (R/R) AML pts were included. Demographics, disease-specific variables [including cytogenetics and mutations], and outcomes [responses, MRD status by multiparameter flow cytometry, and transplant status] were collected. Responses were defined according to the 2003 International Working Group criteria. For overall survival (OS), Kaplan-Meier method estimated the survival functions and log-rank test was used for between-group comparisons. Cox proportional hazards model was used for multivariable analysis. Univariate associations between categorical variables were assessed using Fisher's exact tests. Logistic regressions were used to evaluate the multivariable association between independent variables and treatment responses. Results 83 pts (63 ND, 20 R/R) were analyzed. Median age was 73 years (range: 32-89); 62.7% were male. 50 pts (60%) received Aza/Ven, 27 Dec/Ven, and 6 (7%) LDAC/Ven. By ELN 2017 criteria, 42 (51.9%) pts had intermediate-risk cytogenetics while 37 (45.7%) had adverse-risk cytogenetics. Per ELN 2022 criteria, 11 (14.9%) had intermediate-risk disease while 58 (78.4%) had adverse-risk disease. Of note, 18 pts with favorable or intermediate-risk disease based on ELN 2017 criteria were re-classified as adverse-risk by ELN 2022 risk stratification, likely due to the addition of 7 mutations in the ELN 2022 risk stratification. 20 pts (24.1%) underwent allogeneic stem cell transplant (alloSCT) after receiving ven-based regimen. Median OS (mOS) for all pts was 11 months (mos) (95% CI: 8-19.5 mos). No significant differences in mOS were observed with gender, age (<75 vs. ≥ 75 yo), or ELN 2017. ND AML pts had significantly improved mOS, vs R/R disease (13 vs. 5.5 mos; p=0.015). ELN 2022 adverse risk (p=0.01) and TP53 mutation (p=0.006) were associated with significantly poorer OS. Pts who underwent alloSCT after receiving ven-based therapy had improved mOS (19.5 vs. 8 mos; p=0.01). Although there was no statistically significant difference in OS due to regimen, there was a trend towards better mOS with Aza/Ven over Dec/Ven (11.3 vs 8 mos, p=0.17) in ND-AML, likely reflecting higher numbers of TP53 mutant pts in the latter group (11.4% vs 37.5%, p=0.025). There was no difference in OS based on ven-based regimens in secondary AML pts. In the entire cohort, the CR/CRi rate was 43%: Aza/Ven 49% vs Dec/Ven 34.6% (p=0.33). In 67 pts with CR/CRi and MRD results, 36 (53.7%) achieved MRD negativity at any time point following therapy. MRD negativity was associated with improved mOS for all pts in univariate analysis (20.25 vs. 7.25 mos; p=0.0013) (Figure 1). MRD status also predicted for outcomes of either regimen (Figure 2). Pts treated with Aza/Ven demonstrated significantly higher rates of MRD neg CR/CRi than Dec/Ven (72.2% vs 22.2%; p=0.037). Multivariate Cox regression analysis demonstrated MRD status, ND vs R/R AML, alloSCT, and secondary AML (but not regimen) as independent factors for OS. Conclusions In this real-world analysis, MRD-positive CR/CRi, TP53 mutation, and ELN 2022 adverse risk were associated with worse OS following Ven-based therapy. AML pts treated with Aza/Ven had higher rates of MRD-negative CR/CRi and a trend to improved OS vs Dec/Ven, possibly due to higher numbers of TP53 mutant pts receiving the latter therapy. Our results, while limited by small pt numbers, support wider adoption of MRD endpoints and improved molecular classification as predictors of outcomes of ven-based therapy. Further comparison of different hypomethylating agents with ven is also warranted. Figure 1View largeDownload PPTFigure 1View largeDownload PPT Close modal

"Big Boom" (4 Gy x 1) Radiation Treatment (RT) Versus "Big Boom" (2 Gy x 2) for Non-Hodgkin Lymphoma (NHL)

Purpose/Objectives Indolent lymphomas are exquisitely sensitive to radiation. Recently, programs of only 4 Gy in 2 daily fractions (Boom-Boom) were shown to be highly effective in controlling irradiated site(s). During the COVID-19 pandemic, the International Lymphoma Radiation Oncology Group (ILROG) proposed guidelines that allowed substitution of the Boom Boom (2 Gy x 2) regimen with Big Boom single fraction regimen of only 4 Gy. This report compares our center's experience with Big Boom to Boom-Boom. Materials/Methods All consecutive indolent lymphomas were included. After April 2020 both options of very low dose as well as choice of a standard full dose of 24 Gy were discussed with the patient and choice was made with consideration of access logistics, patient preference as well as disease site(s). Patients were treated with a definitive or palliative intent depending on disease stage and prior therapy exposure. Patients treated with 24 Gy are not included in this report. Overall response rate was assessed with Lugano PET criteria at the initial post-RT imaging. Differences between the two groups were examined using the Fisher's exact test and Mann-Whitney test. Results We evaluated a total of 440 lesions in 363 patients, including 142 lesions (32%) treated with 4 Gy x 1 ("Big Boom") and 298 lesions (67%) treated with 2 Gy x 2 ("Boom Boom"). Table 1 summarizes the patient and treatment characteristics. Patient age at the time of RT, sex, and the proportion of treated lesions with maximum axial diameter of greater than 5 cm were not significantly different between the two groups. Marginal zone lymphoma comprised 27% of each cohort. The Big Boom cohort was more likely to have follicular lymphomas (66% vs 52%, p = 0 .003), though the proportion of higher-grade follicular lymphomas was similar between cohorts. The overall response rate was 87% for both groups at the first post-RT evaluation (median of 2 months from RT for both cohorts). Furthermore, there was no significance difference in the rate of complete response, partial response, stable disease, or progressive disease between the cohorts at initial post-RT imaging. For both regimens, no directly related short-term side effects were observed. Conclusions Both the Big Boom and Boom Boom regimens demonstrated excellent overall response rates at the initial post-RT imaging assessment among patients with indolent lymphomas. While longer term follow-up is required to confirm durability of these findings, our initial experience suggests that the single dose, single visit Big Boom regimen (4 Gy x 1) recommended by ILROG during the Covid-19 pandemic is an effective treatment approach. Figure 1View largeDownload PPTFigure 1View largeDownload PPT Close modal

Brain MRI Screening and Abnormal Findings in Sickle Cell Patients, a Single Center Experience

Background Neuropsychiatric effects of Sickle Cell Disease (SCD) are not very well understood. Sickle cells cause vaso-occlusion and ischemic manifestations that can affect various organ systems. The cumulative effect of insults to the brain can be detrimental resulting in potential cognitive delays. Regular blood transfusions and hydroxyurea are established as preventative and therapeutic measures to decrease the risk of cerebrovascular accidents. Strong evidence for timing of screening for brain damage in SCD patients is not available (S C Thust et al). A conditional recommendation from the ASH guideline panel 2020 suggests at least a one-time screening MRI to detect silent cerebral infarcts in adults with SCD (DeBaun MR et al) Objectives 1. To determine rates of obtaining screening MRI for adult SCD patients enrolled in the Sickle Cell Clinic at Henry Ford Hospital 2. To investigate brain parenchymal changes manifested by Brain MRIs and Head CTs and study associated factors Methods: We performed a retrospective chart review on 105 patients enrolled in the sickle cell clinic at Henry Ford Hospital who have been followed from June 2013 - June 2022. Baseline characteristics, laboratory findings and presence of comorbidities along with provided therapies are compared among patients with abnormal MRI findings. Results Out of the 105 patients, 20 (19%) had a Brain MRI done at least once during their lifetime for various reasons. A total of 14/20 MRI reports picked up abnormal findings (70%). Conversely, 44 patients had a CT head done (42%), 17 of which described abnormal findings (39%). Of note, only 4 patients had a transcranial doppler ultrasound, all of which were normal. Dissecting those 14 brain MRI reports, 7 cases had ischemic changes/chronic infarcts, 2 cases had white matter changes and 6 cases had other findings including tonsillar ectopia, cerebral and cerebellar volume loss, aneurysms, and degenerative changes. The baseline characteristics as well as clinical parameters of those patients are described in tables 1 and 2. Looking at the 17 total abnormal head CT reports: 9 cases were described as chronic ischemic changes, 3 hemorrhage cases (one subarachnoid hemorrhage, one subdural and one intracranial hematoma), 2 cases had brain atrophy and 4 cases had other findings including encephalomalacia, punctate hyper-density and trabeculation or lacy appearance of the skull base. Discussion At least 25% of individuals with SCD will have a neurological complication over their lifetime (Lonergan G et al). Despite paucity of literature looking into prevalence of neuroradiological findings, they have been reported in 44-60% of patients with SCD (Silva et al). Looking at our center's experience approximately half of the screened patients had chronic ischemic changes reported, which intuitively corelates with silent infarcts known to happen in SCD patients. Patients with neurological deficits and developmental delays are more likely to be screened. Despite the lack of statistical power to extrapolate further, it seemed that patients with abnormal brain MRI reports were more likely to have Congestive Heart Failure and Deep Vein Thrombosis. They also possibly consumed more alcohol and illicit drugs. Those patients were slightly more likely to be on hydroxyurea and had more frequent blood transfusions, emergency department visits and hospitalizations. Worth mentioning, out of the 14 patients with positive MRI findings, 13 had head CT scans performed concomitantly. 6 of those CT scans reported abnormal findings (46%) and 7 were normal (54%). This infers that there is a high proportion of patients who have normally read head CT scans but have brain parenchymal changes if screened by an MRI. Conclusions Our center presently screened SCD patients by brain MRI in only 19% of cases. The results of this study help to encourage incorporating and reinforcing the implementation of ASH 2020 guidelines. It is likely that patients with more comorbidities have been screened earlier than others. Detection of neurological complications in SCD may potentially reduce ED visits and hospitalizations if picked up and managed early. Our results propose to re-study patient characteristics on a larger scale once more screening is performed and to compare it with our current data, aiming to have more informative conclusions on SCD patients with neuroradiological findings. Figure 1View largeDownload PPTFigure 1View largeDownload PPT Close modal

Post-Transcatheter Aortic Valve Replacement (TAVR) Vascular Complications: Femoral Artery Minimal Surgical Access Versus Percutaneous Approach.

Percutaneous transfemoral access approach for the transcatheter aortic valve implantation (TAVI) is still associated with significant vascular complications. Hence, evaluation of best techniques for the reduction of vascular injury via the femoral access remains a key subject of research. We report on a single centre's experience with TAVI performed via the Femoral Artery Minimal Surgical Access (MSA) and percutaneous approach (PC). The primary endpoints were to evaluate the incidents of vascular complications by comparing the MSA versus the PC approach according to the VARC-2 criteria. The secondary endpoint included the impact of vascular complications on the in-hospital 30-day mortality and morbidity. Between June 2010 and September 2020, two hundred and thirty-seven consecutive patients who underwent TAVI for severe symptomatic aortic stenosis in our department were divided into two groups: patients treated using the femoral artery minimal surgical access (n = 173), and patients treated using the percutaneous approach (n = 64). Overall rate of access site complications according the VARC-2 were significantly more frequent in the percutaneous cohort (n = 12/64, 18.8% vs n = 2/173, 1.1%, p = 0.0012). The minor access complications including haematoma, bleeding, aneurysm, dissection, stenosis, seroma and infection were more frequent in the PC group (n = 8/64, 12.5% vs n = 2/173, 1.1%, p < 0.001). There were no major access site complications and hospital deaths in the MSA group, which was statistically significant (p < 0.001). Major access complications (n = 4, 6.3%, p < 0.001) and hospital death (n = 2, 3.1%, p < 0.001) were found in the PC cohort. The minimal surgical access approach provided direct and controlled access and significantly reduced the incidence of access site vascular complications in our TAVI patients. It also significantly reduced the in-hospital vascular-related mortality and morbidity. Though both approaches are complementary to each other, minimal surgical access approach would be a better choice for a calcified or tortuous femoral artery, and for a relatively small femoral artery diameter.

Abstract 11588: Multicenter Development and Validation of a Machine Learning Model to Predict Myocardial Recovery During LVAD Support: The UCAR Score

Introduction: Although significant cardiac reverse remodeling is a prerequisite for a left ventricular (LV) assist device (LVAD) patient to be considered for device weaning, multiple factors including patient goals, physician comfort, and center experience, weigh in on this complex decision. Existing predictive models defining recovery as device removal may under detect patients that could benefit from a targeted bridge to recovery strategy. We sought to derive and validate a predictive tool to identify patients prone to reverse remodel, independent of the complex decision of device explant. Methods: Heart failure patients (N=782) requiring LVAD were enrolled at the Utah Transplant Affiliated Hospitals (n=537) and 5 US programs (n=245). Baseline characteristics were recorded. The primary outcome was ‘responder’ incidence, defined as follow-up LV ejection fraction (LVEF) ≥40% and LV end-diastolic diameter (LVEDD) ≤6 cm within one year on LVAD support. Bootstrap imputation and lasso variable selection techniques were used to derive a predictive model which was then validated. A predictive calculator was developed and patients were classified into groups with varying potential for reverse remodeling. Results: Patients were predominantly white (84%), males (82%), aged 56±1 years. Overall, 14.8% patients were identified as responders. A subset of 10 pre-operative variables associated with reverse remodeling were included in the multivariate model achieving an optimism-corrected C-statistic of 0.75 (95% CI: 0.73-0.84) (Figure) . Conclusions: The UCAR calculator is a machine learning-based multicenter and validated risk tool, implementing routine pre-operative clinical data, effectively stratifying patients into groups with varying potential for reverse remodeling. This tool can be useful in selecting patients to implement diagnostic and therapeutic protocols to promote reverse remodeling and myocardial recovery.

ODP232 Postoperative Glycemic Management of Children Undergoing Pancreatectomy with Islet Autotransplantation

Abstract Background Children with severe pancreatitis may require pancreatectomy, resulting in insulin-dependent diabetes. Our center has provided pediatric pancreatectomy with islet autotransplantation (PIAT) since 2003 to preserve pancreatic endocrine function and potentially prevent diabetes. We describe our experience with postoperative glycemic management after pediatric PIAT to provide guidance for future management. Method: We reviewed inpatient records for children who underwent PIAT. Data collected included age, indication for pancreatectomy, islet mass infused and details on insulin and nutritional support requirements. Descriptive analysis was performed. Results Twelve pediatric patients have undergone PIAT at our centre, with mean age 12.4 years (range 2.5-18.9) and mean duration of post-operative hospitalization 25 days (range 9-60). Indications for pancreatectomy included ten patients with chronic pancreatitis due to mutations in PRSS1, SPINK1, or CFTR, 1 patient due to trauma, and 1 patient due to tumor. Ten patients underwent total pancreatectomy, and 2 had partial pancreatectomies. Mean islet mass infused per body weight was 5867 IEQ/kg (range 1630-10276). Two patients did not receive insulin during hospitalization. The remaining ten required insulin, with mean maximum total daily dose of 0.9 u/kg/day (range 0.14-1.88). Total daily doses were higher while on parenteral nutrition (mean 0.75 versus 0.27 u/kg/day on days without parenteral nutrition). Duration of insulin therapy was also longer in patients who received parenteral nutrition (mean 25 versus 4 days). Six of the insulin-treated patients were able to discontinue insulin prior to discharge, with mean duration of insulin therapy 13 days (range 1-40). Four remained on insulin at discharge, with a mean total daily dose of 0.46 u/kg/day (range 0.12-0.82). Patients who were on insulin at discharge all had total pancreatectomies, were older (mean 17 versus 9 years), and had smaller islet mass per kilogram infused (mean 2718 versus 8116 IEQ/kg) compared to those not on insulin. Discussion We report our center's experience with PIAT. Seven of twelve patients were insulin-independent at discharge, and the remainder needed modest doses. Previous publications on islet autotransplantation have also demonstrated favourable outcomes in children, with insulin independence rates up to 82%1. Younger age and larger islet mass infused per kilogram predicted insulin independence in our cohort, similar to the findings of Chinnakotla et al2. In addition, our study suggests that feeding difficulties requiring parenteral nutrition increase daily insulin requirements and prolong the need for insulin therapy.

PSAT330 Excess Iodine Intake From a Cystic Fibrosis Supplement Induces Symptomatic Hypothyroidism

Abstract A 45-year-old woman with cystic fibrosis (delF508/delF508), pancreatic exocrine insufficiency, and diet-controlled cystic fibrosis-related diabetes presented with new complaints of dry skin, hair loss, and cold intolerance. She had no personal or family history of thyroid disease. Physical exam was notable for a mildly enlarged, non-tender thyroid gland without nodules, and 2+ bicep reflexes with delayed relaxation phase. Labs revealed a TSH of 17 mcIU/mL (n 0.3-4.20 mcIU/mL), free T4 of 0.6 ng/dL (n 0.9-1.7 ng/dL), and a thyroid peroxidase antibody of 15 units/mL (n 0-34 units/mL), consistent with new onset, overt hypothyroidism. Thyroid ultrasound revealed a hypervascular, heterogeneous gland, suggestive of underlying autoimmune thyroid disease. Given such an abrupt and significant change in previously normal thyroid studies, further history was obtained. The patient disclosed taking TauriNac, a supplement discovered online that is believed to help clear heavy metals, which she believed she was exposed to via IV antibiotics, and for treatment of her cystic fibrosis. The patient was taking 3-4 packets of TauriNac per day, totaling 16,000 mcg of potassium iodide, far exceeding the Recommended Dietary Allowance of 150 mcg per day. She discontinued TauriNac and one month later, thyroid function tests normalized. The patient then resumed TauriNac, 2-3 packets per day, and within five months TSH rose to 9.66 mcIU/mL with free T4 0.9 ng/dL. She again stopped taking TauriNac and two months after discontinuation thyroid levels normalized. Later, after yet again resuming TauriNac, 5 packets per week, her TSH increased to 4.71 mcIU/mL. She subsequently discontinued TauriNac with normalization of her TSH after three months. Over one year later, she remains off TauriNac and is clinically and biochemically euthyroid. In the 1970s, development of a goiter and hypothyroidism was reported in CF patients, especially those treated with iodine-based expectorants, raising concern for underlying thyroid dysfunction in CF; however the true prevalence of underlying thyroid dysfunction in CF patients is controversial. A 2016 United States-based study of CF patients revealed abnormal thyroid function tests in 27%, however the abnormalities were mild, and overt thyroid dysfunction was rare. In our center's experience, transient subclinical hypothyroidism associated with CF exacerbations is common and may correlate with poor dietary intake leading to iodine deficiency. In this case, excessive iodide intake via TauriNAC clearly correlated with the development of symptomatic hypothyroidism, presumably due to failure to escape the Wolff-Chaikoff effect. In a 2002 survey of adult CF patients, 70% reported having taken complementary and alternative medicine (CAM) in the past. The high prevalence of CAM use in the CF population as well as prior studies demonstrating iodine induced hypothyroidism in CF patients should inform providers of the potential harmful effects of iodine supplementation in an iodine-replete population. Presentation: Saturday, June 11, 2022 1:00 p.m. - 3:00 p.m.