Delay In Definitive Treatment Research Articles

067. Report in Delayed Peritonitis Due to Ileal Perforation Due to Abdominal Blunt Trauma in Sardjito Hospital

Background: Abdominal blunt trauma is a difficult situation, leading to considerable illness and death, particularly in developing nations. The later appearance of symptoms and indicators in these individuals significantly adds to the heightened illness and death rates experienced by the patients. Small bowel perforation following blunt abdominal trauma is an uncommon occurrence, and typically, such cases manifest right after the trauma. Case: We present one case of elderly patient with ileum perforation with Boey Score 2 who showed symptoms on the second day after the injury. We performed ileostomy on the perforation site. We found duodenal perforation 1.5 cm in diameter and 20 cm from ileocecal junction. We refreshed the perforation edge. Patient was in hospital for 5 days and before being discharged. Conclusion: Small bowel perforation is rare, leading to a delay in definitive treatment. Gathering a detailed injury mechanism, observing the patient, conducting thorough investigations using CT and/or FAST, and remaining aware of the potential for small bowel perforation are crucial for successful management of patients with blunt abdominal trauma.

A Percutaneous Triple K-Wire Fixation Technique for Nascent Malunion of Proximal Interphalangeal Joint Fracture-Dislocation: A Case Series With an Assessment of Functional Outcome

Fracture-dislocations of the proximal interphalangeal (PIP) joint are difficult to manage. In the case of a 2- to 4-week delay in definitive treatment, a nascent malunion may result. This study aimed to evaluate the effectiveness of the percutaneous triple K-wire technique for treatment of the PIP joint nascent malunion. We treated 13 patients with nascent malunion of PIP joint fracture-dislocations using the percutaneous triple K-wire fixation technique based on the principle of soft callus manipulation to achieve congruity and reduction in the joint. The study included cases where the percentage of articular involvement exceeded 40% and in whom there was a minimum follow-up of 12 months. At the final follow-up, we measured the range of motion at the PIP joint. The Ishida and Ikuta scores were determined. The mean period between injury and surgery was 17.2 days. The average follow-up time was 14.2 months. The mean active arc of motion before surgery in the PIP joint was 15 degrees and that at the final follow-up was 83 degrees. Seven patients achieved excellent outcomes according to the Ishida and Ikuta scores. The final postoperative range of motion at the PIP joint was comparable with that reported in the literature for patients who underwent different procedures. This procedure can be considered a viable alternative to open reduction and plating, hemihamate arthroplasty, and ligamentotaxis with distraction, particularly in the presence of nascent malunion. Therapeutic IV.

A phase 1/2 study of vusolimogene oderparepvec (RP1) in primary melanoma (mel) to reduce the risk of sentinel lymph node (SLN) metastasis.

TPS9614 Background: The majority of the 80,000 newly diagnosed mel patients in the US have localized early-stage disease and undergo wide local excision (WLE) with or without SLN biopsy. The SLN is a critical prognostic marker and pivotal to immune response initiation, and fosters tumor-mediated immune suppression and pre-metastatic niches. Thus, SLN is a key target for local immune intervention. Vusolimogene oderparepvec (RP1), a locally administered oncolytic immunotherapy, provides a unique opportunity for intervention following mel diagnosis, prior to definitive surgical management. Derived from the HSV1 strain RH018A, RP1 exhibits superior killing on human tumor cell lines, designed with deletions in neurovirulence factors (ICP34.5 and ICP47) and immune-stimulating elements (increased US11 expression, GM-CSF and GALV-GP R-) to maximize oncolytic potency and induce cell death. Preclinical and clinical data demonstrate RP1's robust antitumor efficacy in advanced mel. This trial addresses a crucial gap in understanding RP1's impact on SLN dynamics, holding promise for preventing disease recurrence in this high-risk population. We hypothesize that in mel patients with high risk, clinically node negative disease (pT3b-T4b), administration of RP1 will reduce rates of SLN positivity compared to a historic control by favorably reshaping the immune landscape of the primary tumor, SLN and peripheral blood. Methods: This investigator-initiated, single site, open label, non-randomized phase 1/2 pilot study (NCT06216938) will enroll 25 patients with high-risk, clinically node-negative mel (pT3b-T4b). Major eligibility criteria include diagnosis of pT3b, T4a, or T4b non-uveal mel with visible residual tumor or positive initial biopsy margins, ECOG 0 or 1 and adequate organ function on screening labs. Patients will receive 3 doses (1ml/dose) of RP1, locally injected at the primary tumor site before standard WLE and SLN biopsy (SLNB). The first dose on day 1 will be 10e6 pfu/ml, followed by 10e7 pfu/ml for the next two doses on days 15 and 21, administered over 4-5 weeks before WLE and SLNB. Surgery occurs within 35 days of the 1st RP1 injection to avoid delays in definitive treatment. Biopsies and blood samples are obtained pre- and post-treatment. Patients will be followed for up to 3 years. Safety assessments include physical exams, labs, and adverse events (AE) monitoring. The primary endpoint is the rate of SLN positivity in the overall cohort, calculated by comparing the observed rates to the expected number of positive SLNs for that cohort using the Melanoma Institute of Australia's Prediction Tool. Secondary endpoints include safety and tolerability of RP1, RFS and OS. Exploratory correlative assays will compare the immunophenotype in primary tumor and the SLN (IHC) and in peripheral blood (flow cytometry) between baseline and on treatment. Clinical trial information: NCT06216938 .

Time to therapy and safety of testicular tissue cryopreservation in children undergoing gonadotoxic treatment or hematopoietic stem cell transplant

BackgroundWith the use of multimodal treatments and hematopoietic stem cell transplant, the majority of children diagnosed with malignancies and hematologic diseases are now surviving into adulthood. Due to the gonadotoxic effects and potential for future infertility associated with many of these treatments, fertility counseling with sperm cryopreservation prior to starting therapy is the standard of care for post-pubertal males. Unfortunately, the options are limited for pre-pubertal patients or those unable to provide a specimen. Testicular tissue cryopreservation (TTC) is an investigational method to surgically obtain germ cells from testicular tissue and potentially restore future spermatogenesis. While TTC has been shown to be safe, little is reported on the time to treatment following the procedure to ensure adequate wound healing and avoid delays in definitive therapy. ObjectivesThe primary outcome was the time to initiation of treatment following TTC. Secondary outcomes were complication rates, delays in treatment due to TTC, and presence of germ cells. MethodsWe conducted a single-institution retrospective cohort study of patients undergoing TTC between 2017-2023. Patients at significant risk for treatment related infertility based on established criteria were eligible for TTC. Patients were excluded if they received their oncology or hematology care elsewhere. All patients were enrolled in an IRB approved research protocol with 75% of the tissue submitted for cryopreservation and 25% for research purposes. Time to therapy was defined as the first receipt of gonadotoxic treatment following TTC. ResultsA total of 122 patients (53=malignant, 69=non-malignant) underwent TTC with a median age of 5.9 years (IQR 2.3-9.35). Germ cells were identified in 115 (94%) specimens. A total of 109 (89%) patients underwent concomitant procedures. The median time to initiation of therapy was 5 (IQR 1.0-7.0) and 7 days (IQR 6.0-13.0) for malignant and non-malignant disease, respectively. The 30-day surgical complication rate was 2.5% and was similar between malignant vs non-malignant diagnoses (p=0.58). All surgical complications were managed non-operatively. No patients had a delay in definitive treatment due to concern for wound healing or complications. DiscussionOur surgical complication rates are similar to previous studies and are not affected by the time to treatment following TTC. Limitations of the study are its retrospective design, single institution, and short-term follow up. ConclusionTTC can be performed safely, efficiently, and in conjunction with other necessary procedures without resulting in delays of definitive treatment . TTC affords the opportunity for fertility preservation in children who have no other options.

Potential causes of delays in paediatric perforated appendicitis: A prospective interview study.

Delays in care may be a driver of inequities in perforated appendicitis rates. The goal of this study was to explore potential causes of delay in care for children with perforated appendicitis. We conducted an interview study of caregivers of children admitted with perforated appendicitis to a children's hospital between December 2022 and March 2023. Semi-structured interviews based on an iteratively revised interview guide were conducted in-person during the child's admission. All interviews were transcribed, coded and underwent a process of thematic analysis. We reached thematic saturation after 12 interviews. The median age for children was 13.5 years, 50% were male, 83% of caregivers self-identified as White, and one interview required an interpreter. Through thematic analysis, four major themes for potential causes of delay emerged. The first theme of symptom recognition includes delays related to recognising the symptoms, their severity and the need for medical evaluation. The second theme - accessing care - describes delays that occur after a decision was made to seek care until the child was evaluated. The third theme includes delays that occur in making the diagnosis after evaluation. The last theme captures potential delays in definitive treatment after a diagnosis of appendicitis is made. We identify four major themes from the patient and family perspective, each with multiple sub-themes, for potential delays in definitive care for children with perforated appendicitis. Additional research is needed to further characterise these potential delays and quantify their role in contributing to inequities in perforation rates.

Impact of ambulance paramedics missing STEMI diagnosis on subsequent management

Abstract Background/introduction Acute ST elevation myocardial infarction (STEMI) is defined by acute changes in the electrocardiograph (ECG) reflecting acute occlusion of a coronary artery. Rapid and complete reperfusion of the culprit lesion improves immediate mortality and long-term outcomes. Systems of care have been developed to optimise recognition and management of acute STEMI to facilitate the best possible patient outcomes. Pre-hospital diagnosis by ambulance paramedics and activation of Code STEMI teams has been shown to significantly impact treatment times and patient outcomes. But what is the outcome if the diagnosis is missed? Methods We studied 559 consecutive STEMI cases presenting to our health network with two 24/7 interventional sites over a three-year period (2020-2022 inclusive), comparing the impact of arrival by ambulance or self-presentation. Ambulance arrival cases were further stratified by whether Code STEMI was activated prior to hospital arrival or afterwards. Patients who developed STEMI after presentation to hospital or who were transferred from another institution were excluded from this analysis. Only patients proceeding to percutaneous intervention of the culprit lesion were included. First medical contact (FMC) is either hospital door time or time of ambulance paramedic arrival at patient. ECG time reflects first recorded ECG, either by ambulance paramedic or hospital emergency department. Results Results are depicted in the table below. Patients with STEMI had similar FMC to treatment times if diagnosed pre-hospital by the ambulance paramedic or after self-presentation to the emergency department. Interestingly, patients self-presenting to the emergency department had a longer symptom duration, perhaps reflecting uncertainty regarding the cause for symptoms and the rationale for not utilising ambulance services. Patients presenting via ambulance, where the diagnosis and activation of Code STEMI did not occur prior to hospital arrival, had less ST elevation and a significant delay in definitive treatment. Conclusion(s) Ambulance paramedics successfully diagnosed 69% of STEMI cases they transported, activating a Code STEMI prior to hospital arrival. Cases that were not pre-notified had less marked ST elevation, potentially creating uncertainty as to the diagnosis. Strategies to enable direct discussion of equivocal ECG changes and symptoms between ambulance paramedics and interventional cardiologists my assist in more complete recognition of all STEMI cases without creating excessive false activations.Table 1:Results

Intraocular Foreign Body: Striving the Optimal Visual Outcome

Introduction: Intraocular foreign bodies (IOFBs) are defined as intraocularly retained, unintentional projectiles that require urgent diagnosis and treatment to prevent blindness or globe loss. Case Presentation: We report a case of IOFB due to occupational accidents. In this case, there were delays in extraction considering the health facilities and conditions related to COVID-19 infection. Initially, the patient underwent closure of the entrance wound, which was performed within the first 24 hours post-trauma. However, although there was no endophthalmitis, visual acuity at the end of the observation still showed an unexpected outcome. The patient was followed up for three months after IOFBs extraction. The timing of IOFBs removal depends on several factors, including the patient’s overall health status, the nature of the injury, and the composition of the IOFBs. The postoperative examinations focus on complications such as endophthalmitis, postoperative retinal detachment, proliferative vitreoretinopathy (PVR), and sympathetic ophthalmia. The numerical values can then be used to predict the expected visual acuity using the ocular trauma score system. Conclusions: Many factors could affect the outcome quality of visual acuity. Primary wound closure, foreign body extraction, and anatomic reconstruction of the holistic ocular should be performed as soon as possible. Delay in definitive treatment was thought to affect worsening prognosis due to tissue proliferation and the tendency for severe complications, including endophthalmitis.

PSAT043 Liraglutide Ameliorates Symptoms of Cushing Syndrome in a Pediatric Patient

Abstract Background Cushing Syndrome (CS) is a rare disease characterized by hypercortisolism. Pituitary adenomas resulting in ACTH-dependent disease may be difficult to visualize radiologically, resulting in a prolonged diagnostic course and delay in definitive treatment. Adjuvant medical treatment with pharmacologic agents, including steroidogenesis inhibitors and adrenolytics, can be utilized for symptom management. However, hypercortisolemia may be refractory to medical therapy making it necessary to consider symptomatic treatments. We present a case of a pediatric patient with Cushing syndrome in whom treatment with liraglutide, a GLP-1 agonist approved for the treatment of hyperglycemia and obesity, resulted in improvement of symptoms of hypercortisolemia. Case A 13 year old Caucasian female presented with a 2 year history of linear growth arrest, accelerated weight gain and delayed puberty. Her physical examination was remarkable for overt signs of hypercortisolemia. Initial laboratory evaluation showed normal thyroid function, hyperglycemia with HbA1c 7.2% (normal < 5.7%), dyslipidemia and elevated midnight salivary cortisol 0.898 (normal < 0.112 mcg/mL). Hypercortisolemia was confirmed when morning serum cortisol was 25.6 mcg/dL after 1 mg overnight dexamethasone suppression test (DST). This along with an elevated morning ACTH level, 72.8 (7.2- 63.3 pg/mL), confirmed a diagnosis of ACTH-dependent Cushing syndrome. Magnetic Resonance Imaging of the pituitary gland with contrast showed a 4 mm non- enhancing lesion consistent with a Rathke's cleft cyst which was unlikely to be the source of excess ACTH. Results from high dose (8 mg overnight) DST, Corticotropin Releasing Hormone (CRH) stimulation test, and Inferior Petrosal Sinus Sampling for ACTH post CRH stimulation were partially inconsistent with pituitary disease. Further workup for ectopic source(s) of ACTH showed normal imaging of the neck, chest, abdomen and pelvis. A DOTATATE PET scan failed to identify an ACTH source. Adrenolytic adjuvant treatment with mitotane was started but was discontinued due to intolerable gastrointestinal effects. Treatment was changed to ketoconazole, however, hypercortisolemia remained refractory to treatment as evidenced by continued elevation of 24- hour urine free cortisol levels. Metformin was initiated for hyperglycemia treatment but was not tolerated due to persistent nausea and vomiting. The patient was switched to liraglutide and within 3 months she had 10% weight loss, normalization of fasting blood glucose levels and reduction of HbA1c to 5.7%. Additionally, the patient's energy level and baseline hidradenitis suppurativa improved. Conclusion In some pediatric patients with CS, definitive treatment of hypercortisolemia may be delayed or not feasible due to a lack of biochemical or radiological evidence showing the specific etiology for CS. Medical treatment with pharmacologic agents can be utilized for symptom management, however, hypercortisolemia may persist and even be recalcitrant to therapy. In this setting, clinicians should consider using liraglutide to ameliorate some of the cardinal symptoms of CS in pediatric patients. Presentation: Saturday, June 11, 2022 1:00 p.m. - 3:00 p.m.

Primary Lymphoepithelial Carcinoma of Parotid Gland: Inadequate Preoperative Assessment Resulting in Extensive Surgery

Parotid lymphoepithelial carcinoma is extremely rare, and makes up only 0.4% of cases among the anaplastic variant of salivary gland carcinoma. We present a 63-year-old man who had progressive enlarging right neck swelling for one year. He sought treatment in another centre and underwent superficial parotidectomy, following an ultrasound assessment of the mass that was suggestive of a benign parotid tumour. There was no fine needle aspiration cytology or other radiological imaging performed prior to the surgery. However, the surgeon encountered difficulty intraoperatively and abandoned the surgery. The incisional biopsy of the tumour was reported as lymphoepithelial carcinoma. He then presented to us with the progression of the residual parotid malignant tumour. CT and MRI showed a locally aggressive parotid tumour that had infiltrated the subcutaneous tissue, external auditory canal, facial nerve, and multiple ipsilateral metastatic cervical lymph nodes. Subsequently, the patient underwent total parotidectomy with facial nerve resection, lateral temporal bone resection and ipsilateral modified radical neck dissection. The surgical site defect was reconstructed with anterolateral thigh myocutaneous free flap. Concurrent static facial reanimation with fascia lata sling was performed. The patient received adjuvant chemoradiation following the surgery. The extent of the local infiltration by the tumour and the resulting surgery could have been reduced if the tumour had been properly assessed and excised at the initial stage. A complete preoperative assessment of a parotid mass is essential to avoid misdiagnosis, unexpected intraoperative finding and delay in definitive treatment.

HAS THE COVID-19 PANDEMIC AFFECTED THE PREVALENCE OF MAXILLOFACIAL FRACTURES? A SINGLE CENTRE STUDY

Objectives The aim of the present study was to assess whether the current COVID-19 pandemic affect the prevalence of patients with maxillofacial fractures in a major tertiary hospital in Greece. Materials and Methods A retrospective comparative study was performed, assessing the hospitalization of patients with maxillofacial fractures in a university-affiliated Department of Oral and Maxillofacial Surgery. Patients were recorded from March 2020 and for 18 months (COVID period). For comparative reasons, a similar period was set, starting from September 2018 to February 2020 (pre-COVID period). All patients admitted with any form of maxillofacial fracture during these periods were included in the study. Results 301 patients were included in the study, 158 in the pre-COVID period and 143 in the COVID period. The mean age was 37.8 years in total. A male predominance was observed (81.7% males). Most fractures concerned the mandible in both periods (61.4% and 53.1% respectively). Panfacial fractures were recorded in 8.2% in patients pre-COVID and 6.9% in patients post-COVID. Concomitant injuries were observed in 20.6% of patients pre-COVID and 8.3% post-COVID, and ICU hospitalization was recorded in 8.9% and 4.2% respectively. Delay in definitive treatment was recorded in 1.2% and 14% of patients respectively. Conclusions Despite the relative stability of the prevalence of patients with maxillofacial fractures, the severity of those seems lower in the pandemic period. Higher delays until definitive treatment were recorded, as expected by the reduction of available human and technical resources during the pandemic.

Impact of emergency physician-staffed ambulances on preoperative time course and survival among injured patients requiring emergency surgery or transarterial embolization: A retrospective cohort study at a community emergency department in Japan.

Injured patients requiring definitive intervention, such as surgery or transarterial embolization (TAE), are an extremely time-sensitive population. The effect of an emergency physician (EP) patient care delivery system in this important trauma subset remains unclear. We aimed to clarify whether the preoperative time course and mortality among injured patients differ between ambulances staffed by EPs and those staffed by emergency life-saving technicians (ELST). This was a retrospective cohort study at a community emergency department (ED) in Japan. We included all injured patients requiring emergency surgery or TAE who were transported directly from the ED to the operating room from January 2002 to December 2019. The primary exposure was dispatch of an EP-staffed ambulance to the prehospital scene. The primary outcome measures were preoperative time course including prehospital length of stay (LOS), ED LOS, and total time to definitive intervention. The other outcome of interest was in-hospital mortality. One-to-one propensity score matching was performed to compare these outcomes between the groups. Of the 1,020 eligible patients, 353 (34.6%) were transported to the ED by an EP-staffed ambulance. In the propensity score-matched analysis with 295 pairs, the EP group showed a significant increase in median prehospital LOS (71.0 min vs. 41.0 min, P < 0.001) and total time to definitive intervention (189.0 min vs. 177.0 min, P = 0.002) in comparison with the ELST group. Conversely, ED LOS was significantly shorter in the EP group than in the ELST group (120.0 min vs. 131.0 min, P = 0.043). There was no significant difference in mortality between the two groups (8.8% vs.9.8%, P = 0.671). At a community hospital in Japan, EP-staffed ambulances were found to be associated with prolonged prehospital time, delay in definitive treatment, and did not improve survival among injured patients needing definitive hemostatic procedures compared with ELST-staffed ambulances.

Piriformis Syndrome Masquerading as an Ischiofemoral Impingement

Hip pain can have a number of different etiologies. Ischiofemoral impingement (IFI), an etiology causing extra-articular hip pain, shares many of the same symptoms as other causes of gluteal or inguinal pain, making its diagnosis difficult. We present a case of a young female with persistent deep gluteal pain who was diagnosed with IFI based on radiographic findings; however, a diagnostic injection into the quadratus femoris did not confirm IFI as the primary pain generator. The patient subsequently failed several trials of physical therapy designed to address this diagnosis. The diagnosis was expanded to include piriformis syndrome and the modified treatment approach resulted in complete resolution of her pain. The similarities of these pathologies resulted in a delay of definitive treatment and would have potentially required unnecessary surgery. This case study highlights the diagnostic conundrum clinicians face in the evaluation of gluteal hip pain and provides an algorithm for considering alternate diagnoses when conservative management fails to achieve expected results.

Necrotizing Soft Tissue Infections, the Challenge Remains.

Background: Necrotizing Soft Tissue Infections (NSTIs) are uncommon rapidly spreading infection of the soft tissues for which prompt surgical treatment is vital for survival. Currently, even with sufficient awareness and facilities available, ambiguous symptoms frequently result in treatment delay.Objectives: To illustrate the heterogeneity in presentation of NSTIs and the pitfalls entailing from this heterogeneity.Discussion: NSTI symptoms appear on a spectrum with on one side the typical critically ill patient with fast onset and progression of symptoms combined with severe systemic toxicity resulting in severe physical derangement and sepsis. In these cases, the suspicion of a NSTI rises quickly. On the other far side of the spectrum is the less evident type of presentation of the patient with gradual but slow progression of non-specific symptoms over the past couple of days without clear signs of sepsis initially. This side of the spectrum is under represented in current literature and some physicians involved in the care for NSTI patients are still unaware of this heterogeneity in presentation.Conclusion: The presentation of a critically ill patient with evident pain out of proportion, erythema, necrotic skin and bullae is the classical presentation of NSTIs. On the other hand, non-specific symptoms without systemic toxicity at presentation frequently result in a battery of diagnostics tests and imaging before the treatment strategy is determined. This may result in a delay in presentation, delay in diagnosis and delay in definitive treatment. This failure to perform an adequate exploration expeditiously can result in a preventable mortality.

Gaps in the Care of Open Fractures: An Indian Scenario.

There is a distinct lack of published studies evaluating the reasons for delay in definitive treatment of open fractures. This study aimed to determine the specific factors causing delay in the timely treatment of open fractures from the time of injury and to analyse the quality of treatment performed at the pre-hospital level. In total, 250 consecutive patients with open fractures were assessed for time to surgery from injury and admission. The referred patients were analysed for distance of travel, level of referring hospital and appropriateness of care. The reasons for delay in terms of infrastructural- and patient-related factors were analysed individually and in combination. There were 37 direct patients (Group A) and 213 referred patients (Group B). Inappropriate care was present in 172 out of 213 (80.8%) referred patients. In total, 84% patients travelled more than 50 kms. The definitive surgery in referred patients was likely to be significantly delayed with regard to time from injury (29.84 vs 44.84h, p ≤ 0.02). After admission, the time to surgery was greater than 24h in 102 patients. Multivariate regression analysis determined that associated injuries and lack of fitness for surgery caused greater delay than non-availability of operation theatre or intensive care unit bed. Delayed referral, inadequate pre-hospital care and delay in surgery due to patient- and infrastructural-related issues at tertiary centre were identified as critical gaps in open fracture care in India. The importance of appropriate basic knowledge about management of open fractures should be emphasized at all structural level of care.

P–016 Using artificial intelligence to predict semen upgrading after microsurgical varicocele repair

Abstract Study question Can we use artificial intelligence models to predict semen upgrading after microsurgical varicocele repair? Summary answer A machine learning model performed well in predicting clinically meaningful post-varicocelectomy semen upgrade using pre-operative hormonal, clinical, and semen analysis data. What is known already Varicocele repair is recommended in the presence of a clinical varicocele together with at least one abnormal semen parameter, and male infertility. Unfortunately, up to 50% of men who meet criteria for repair will not see meaningful benefit in outcomes despite successful surgery. Nomograms exist to help predict success, but these are based out of single-center databases, do not incorporate hormonal data, and are rarely designed to predict pre-defined, clinically meaningful improvements in semen parameters. Study design, size, duration Data were collected from an international, multi-center retrospective cohort. A total of 240 men were identified. Data from 160 men from Miami, USA and 80 men from Toronto, Canada were included. Data was collected from 2006 to 2020. Participants/materials, setting, methods We collected pre and postoperative clinical data following varicocele surgery. Clinical upgrading was defined as an increase in sperm concentration that would allow a couple to access new reproductive technologies/techniques. The tiers used for upgrading were 0–1million/cc (Intracytoplasmic Sperm Injection), 1–5 million (In Vitro Fertilization), 5–15 million (Intrauterine Insemination), and &amp;gt;15 million (Natural conception). Artificial intelligence models were trained and tested using R to predict which patients upgraded after surgery. Main results and the role of chance 51% of men underwent bilateral varicocele repair. The majority of men had grade 2 varicocele on the left, and (when present) a grade 1 varicocele on the right. Overall, 47% of men experienced an upgrade following varicocele surgery, 47% did not change, and 6% downgraded. The data from Miami were used to create a random forest model for predicting clinically significant upgrade in sperm concentration. The most informative model parameters were preoperative FSH, sperm concentration, and surgical laterality. The model identified three clinical categories: men with unfavorable, intermediate, and favorable features to predict varicocele upgrade. On external validation using data from Toronto, the model accurately predicted upgrade in 87% of men with favorable features, and in 49% and 36% of men with intermediate and unfavorable features, respectively. Overall, the model performed well on external validation with an AUC of 0.72 and good calibration. Calibration plots, using cross-validation, define how well the predicted probabilities match the actual probability of sperm concentration upgrade. The random forest model was run twelve times. All model characteristics are the mean of ten model runs with the highest and lowest performing runs removed. The model was translated to an online calculator that can be used by clinicians. Limitations, reasons for caution One limitation to our study is that we were not able to predict total motile sperm count (TMSC), which has been shown to perform slightly better than concentration at predicting assisted reproduction outcomes. By focusing on clinically significant upgrading, this difference should be minimized. Wider implications of the findings: Predicting the chances of clinically significant semen upgrading after varicocele repair is essential for patients and clinicians to understand. Several men undergo surgery with no subsequent benefit, which may lead to a delay in definitive treatment with IVF/IUI. Understanding their chances will help couples make better informed decisions moving forward. Trial registration number Not applicable

Diagnostic Ureteroscopy in CT Urography-Diagnosed Upper Tract Urothelial Carcinoma: Delay in Definitive Treatment and Increased Intravesical Recurrence.

PurposeTo investigate the effect of diagnostic ureteroscopy (URS) on the delay to surgical treatment of upper tract urothelial carcinoma (UTUC) detected by imaging and the risk of intravesical recurrence.Materials and methodsWe undertook a retrospective case-note analysis of all patients who underwent radical nephroureterectomy (NUU) from November 2012 to July 2019. We identified those who underwent diagnostic ureteroscopy prior to NUU as Group 1 and those who did not undergo diagnostic URS as Group 2. Perioperative and pathological parameters were compared between both groups. Kaplan-Meier and Log-Rank analyses were used to compare delay to NUU and the intravesical recurrence (IVR) free survival. Cox regression models were employed to analyze the risk factors of intravesical recurrence.ResultsOut of 69 patients with a mean age of 71.3 years and a mean follow-up of 48.5 months, 49 (71%) underwent URS while 20 (29%) did not. The mean time between the computerized tomography urography (CTU) and surgery was 86 days with URS and 59 days in the control groups(p=0.007). Intravesical recurrence in year one postoperatively was 28.2 % in the URS group vs 5.9% in the control group (p=0.04). The Kaplan-Meier curve showed improved, yet insignificant, IVR-free survival for the control group (Log-Rank p-value=0.21). In multivariate Cox regression analysis, concomitant bladder carcinoma was an independent risk factor for IVR (HR, 15.01; 95%CI, 3.311 - 68.07; p=0.0004). Intravesical mitomycin-c was a protective factor (HR 0.154; 95%CI 0.025 - 0.922; p=0.040).ConclusionIn our retrospective single-unit study, diagnostic ureteroscopy for CTU-detected upper tract urothelial carcinoma delayed definitive surgical treatment. Furthermore, it was associated with a significantly increased risk of early intravesical recurrence. URS can provide useful information and reassurance prior to major surgery but must be used with caution in light of these findings.

Pediatric Trigger Digit Presenting in the Setting of Trauma.

Pediatric trigger digit is a relatively rare condition with incompletely understood etiology. In our practice, we noted a series of children presenting with pediatric trigger digit after an associated local trauma to the hand, which has not been previously described. The aim of this study was to analyze the nature of presentation of trigger digits, the accuracy of initial diagnosis, and the impact on treatment strategies used. An institutional review board-approved retrospective review of our institution's experience with pediatric trigger finger from 2001 to 2015 was performed. Twenty-two patients with 26 affected digits were identified. Eighty-eight percent of patients were diagnosed with trigger thumb, whereas 3 patients (12%) had small finger triggering. Thirteen patients (59%) presented as outpatients, whereas 9 (41%) presented through the emergency department. All patients presenting to the emergency department were in the setting of recent minor trauma. Of this subset of patients, 67% had an incorrect initial diagnosis, leading to an average delay in treatment of 60 days. Ten patients (45% of total) were initially treated with immobilization versus surgical release of the A1 pulley. However, all but 2 of these patients required eventual A1 pulley release for persistent or recurrent triggering (88%). The cause of trigger digit in children remains incompletely understood and may be multifactorial. In this series, a traumatic component to presentation was found in a significant number of patients. This association with minor trauma may contribute to misdiagnosis and delay in definitive treatment. Although initial treatment with immobilization does not seem to impact surgical outcome, we found a high rate of failure with initial immobilization. Most patients required eventual surgical management, regardless of whether or not the initial presentation was associated with trauma. When performed, we found that A1 pulley release alone has safe, reliable results.

594 Optimising Hand Trauma Care at a Major Trauma Centre (MTC) During the COVID-19 Pandemic

IntroductionThis study evaluates the management of hand injuries during COVID-19 following the prompt implementation of the BOA guidelines; reconfiguration of hand services and implementation of the ‘one-stop’ model.Method285 cases OVER A 1-MONTH PERIOD were RETROSPECTIVELY reviewed to evaluate the effectiveness of managing patients using the ‘one-stop’ model and the new Urgent Treatment Centre (UTC).Results277 patients were included in the study. During Covid-19, operative cases fell by 62%. 86.3% (239/277) of cases were managed in the UTC; 54.4% (130/239) required conservative management and 45.6% (109/239) required minor procedures (in UTC). REMOVABLE SPLINT USE was optimized through design of ‘softcasts’ for non-operative management of distal radius fractures. A patient education video: ‘softcast removal at home’ was created and in cases requiring sutures, 95.1% (39/41) were absorbable, thereby avoiding COVID-19 exposure for follow-up. Only 50.5% (140/277) of patients had formal follow-up arranged and patient information follow-up cards were developed.ConclusionsThe one-stop model prevents delay in definitive treatment, allows effective initial treatment, and minimizes the need for face-to-face follow up. In light of a possible second wave of COVID-19 cases, this new model should be considered for implementation by all hand’s units for the foreseeable future.

P84 Optimising hand trauma care at a Major Trauma Centre (MTC) during the COVID-19 pandemic

IntroductionThis study evaluates the management of hand injuries during COVID-19 following the prompt implementation of the BOA guidelines; reconfiguration of hand services and implementation of the ‘one-stop’ model.Methods285 cases OVER A 1-MONTH PERIOD were RETROSPECTIVELY reviewed to evaluate the effectiveness of managing patients using the ‘one-stop’ model and the new Urgent Treatment Centre (UTC).Results277 patients were included in the study. During Covid-19, operative cases fell by 62%. 86.3% (239/277) of cases were managed in the UTC; 54.4% (130/239) required conservative management and 45.6% (109/239) required minor procedures (in UTC). REMOVABLE SPLINT USE was optimized through design of ‘softcasts’ for non-operative management of distal radius fractures. A patient education video: ‘softcast removal at home’ was created and in cases requiring sutures, 95.1% (39/41) were absorbable, thereby avoiding COVID-19 exposure for follow-up. Only 50.5% (140/277) of patients had formal follow-up arranged and patient information follow-up cards were developed.ConclusionThe one-stop model prevents delay in definitive treatment, allows effective initial treatment, and minimizes the need for face-to-face follow up. In light of a possible second wave of COVID-19 cases, this new model should be considered for implementation by all hand’s units for the foreseeable future.

Giant Bleeding Pseudo-aneurysm of left Sub-clavian Artery Complicating Neurologic Impairment: Management Challenges (Case Report)

Subclavian artery pseudoaneurysms are rare and occur mostly as a consequence of an inadvertent arterial puncture during central venous catheterization, endovascular therapeutic procedures or after penetrating or blunt trauma. They usually have a late clinical presentation, with pain, swelling or other compressive symptoms. We present a 40-year old man farmer who presented to our service with prior 14 days and 12 days history of left chest upper chest swelling and inability to use the left upper limb respectively, all on account of injury. He went on a night alcohol binge, got drunk and while getting to his sitting room slipped and fell on a nearby glass center table. He had a deep cut on the left upper anterior chest wall. There was immediate profuse spurting bleeding with estimated blood loss of 800 ml. After delay in definitive treatment due to financial constraint the aneurysm increased in size, ruptured and rebled profusely leading to syncope. He was managed by Doppler ultrasound, median sternotomy and subclavian artery exploration to achieve proximal and distal vascular control. Sac was entered into via an infraclavicular transverse incision, heamatoma manually evacuated, bleeding site isolated and secured. He received 5 units of blood. Postoperative course was uneventful as he was managed with analgesics, antibiotics, haematinics and physiotherapy. Power in the upper limb has improved to 3 around the shoulder, 2 around the elbow and 1 around the wrist.