Fischer Exact Research Articles

551 Reduction of Fungus-Related Complications in a Burn Center

Abstract Introduction Fungal wound infections (FWI) cause morbidity and increase mortality in burn patients. Our burn center experienced 44 patients with fungal wound colonization (FWC) and/or FWI between JAN 2015 and JAN 2019. In response, we undertook a performance improvement project to prevent and treat FWC and FWI. Methods Members of the multidisciplinary team met to develop a clinical practice guideline (CPG) for the prevention and management of FWC and FWI based on current evidence. We focused on patients with elevated risk, that is, with burns ≥20% total body surface area (TBSA) and in the Burn ICU (BICU). Interventions included: utilizing alternating silver sulfadiazine and mafenide acetate creams upon admission; reducing the use of mafenide acetate solution; utilizing silver nitrate solution post-operatively; and applying topical nystatin cream or powder for suspected FWC or FWI. We educated all staff members and updated order sets and training materials. We collected data on all burn patients who had a wound biopsy out of concern for possible infection. Biopsy results were categorized as FWC or FWI. Retrospective data were collected for MAR 2020 - MAR 2021 (PRE). Post-implementation, prospective data collection began MAR 2022 (POST) and will continue for one year. Adherence to the CPG was assessed by chart review. Mann-Whitney and Fischer Exact tests were performed. Results The PRE (n=15) and POST (n=9) groups were similar in age (43±13 vs. 48±18 years) but differed in TBSA (49±19 vs 28±25%, p< .05). PRE group biopsies showed FWC in 0 patients and FWI in 11 of 15 patients (73%); 8 of these (53%), all with FWI, died. In the POST group, FWC was found in 1 patient (11%) and FWI was found in 2 of 9 patients (22%); one death occurred in the patient with FWC. Adherence to the CPG for admission topical wound care was 7% in the PRE group vs 89% in the POST group (p=0.0001); adherence to the CPG for day-of-biopsy topical wound care was 27% in the PRE group vs 89% in the POST group (p< 0.01). Conclusions Adherence to a CPG for the prevention and treatment of FWC and FWI was associated with a lower (but not statistically significant) prevalence of these complications. Limitations include a difference in the TBSA between the 2 groups and potential concurrent changes in practice. Ongoing data collection includes the evaluation of other potential contributing factors. Applicability of Research to Practice Fungi are common in the environment, and when combined with immunosuppression and extensive open wounds, may cause wound infection in burn patients. More research is needed to further evaluate effective treatments for the prevention and treatment of FWC and FWI in these patients.

Bilateral tonic seizures vs. bilateral tonic events in critically ill patients: differences in semiology

PurposeOur primary aim was to analyze bilateral epileptic tonic seizures (ETS) and bilateral non-epileptic tonic events (NTE) in critically ill patients. Our secondary aim was to analyze ETS per their epileptogenic zone. MethodsWe performed a retrospective analysis of clinical signs in patients with bilateral ETS and NTE. Two authors independently reviewed 34 videos of ETS in 34 patients and 15 videos of NTEs in 15 patients. Initial screening and review was performed in an unblinded manner. Subsequently, the semiology was characterized independently and blindly by a co-author. Statistical analysis was conducted using Bonferroni correction and two-tailed Fischer exact test. Positive predictive value (PPV) was calculated for all signs. Cluster analysis of signs with a PPV >80% was performed to evaluate co-occurring semiological features in the two groups. ResultsCompared to patients with ETS, those with NTEs more frequently had predominant involvement of proximal upper extremities (UE) (67% vs. 21%), internal rotation of UE (67% vs. 3%), adduction of UE (80% vs. 6%) and bilateral elbow extension (80% vs. 6%). In contrast, those with ETS more frequently had abduction of UE (82% vs 0%), elevation of UE (91% vs. 33%), open eyelids (74% vs. 20%), and involvement of both proximal and distal UE (79% vs. 27%). In addition, seizures that remained symmetrical throughout were more likely to have a generalized onset than focal (38% vs. 6%), p = 0.032, PPV 86%. ConclusionsA careful analysis of semiology can often help differentiate between ETS and NTE in the ICU. The combination of eyelids open, upper extremity abduction, and elevation reached a PPV of 100% for ETS. The combination of bilateral arms extension, internal rotation, and adduction reached a PPV of 90.9% for NTE.

Prevalence, Predictors and Morphological Patterns of Acanthosis Nigricans Between Obese Non-diabetic Patients on Second Generation Antipsychotics Versus Non-obese Insulin Dependent Diabetes mellitus: A Nested Case-Control Study

INTRODUCTION: There is no study in literature for analyzing acanthosis nigricans (AN) in psychotropic induced obesity or hypercholesterolemia.
 AIM: To assess the prevalence and explore the predictors and morphological patterns in AN in patients on antipsychotics induced hypercholesterolemia versus those with diabetes mellitus.
 MATERIALS AND METHODS: 491 schizophrenia patients on second generation antipsychotics were screened. 26 out of 491 patients have AN and cholesterol 200 mg/dl but non-diabetic. We used MannWhitney U-test, Pearsons 2 test, Fischer Exact and Spearmans correlation coefficient.
 RESULTS: In the group of antipsychotics induced hypercholesterolemia having developed AN in 5.29% (26 out of 491) of individuals, we observed significance of Burkes knuckle (p 0.001), knee (p = 0.002), elbow (p = 0.042) compared to patients without hypercholesterolemia. Interestingly Burkes neck severity (p 0.001), neck texture (p = 0.001) and axilla (p = 0.007) index also showed marked differences on MannWhitney U-test and Wilcoxson W-test. On Spearmans correlation coefficient antipsychotics induced hypercholesterolemia was found to affect most positively and significantly as the emergence of AN specifically for neck texture ( = 0.413, p = 0.003) compared to other bodily regions.
 CONCLUSION: About 5.29% prevalence of AN in the group having obesity secondary to psychotropic drugs which was significantly less than what even non-obese, insulin dependent diabetic patients who almost had 13.55% prevalence, close to three times. This suggests that diabetes is strongly linked with occurrence of AN lesions and might reflect the continuity in the paradigm of metabolic syndrome as its definitive predictor of severity while obesity is the initiation of phase shift in the process.

STUDY OF HUMAN PAPILLOMA VIRUS (HPV) & PAP SMEAR IN CLINICALLY SUSPECTED CASES OF HPV IN A TERTIARY CARE HOSPITAL IN MUMBAI

Background: Cervical cancer is the commonest cancer amongst Indian women and the second most common cancer in the women worldwide. Persistent infection with high-risk HPV (HR-HPV) is the most important risk factor for cervical cancer precursors and invasive cervical cancer. Present study was conducted to study prevalence of Human Papilloma Virus (HPV) & correlation of PAP smear in clinically suspected cases of HPV. Present study was prospective, observational study, conducted in female pa Material and Methods: tients clinically suspected of having HPV infections like bleeding per vagina, irregular menstruation, pain in lower abdomen or post-coital bleeding or had any abnormal ndings on per vaginal examination. In the present study, majority of patients were in age group Results: 31-40 years (39.38%), married (88.75%), were married at 18-20 years age (54.36%) & had parity of 2-4 (83.75%). The patients who used homemade napkins had a highest seroprevalence of HPV (68.18 %), followed by patients who are suffering from STD's (63.83%), family history of cervical cancer (50%), women who used to smoke (37.7%). It was observed that serological test and PAP smear was positive among 03 patients with 34 false positive tests. Comparison between ELISA and cytological study showed that ELISA test was better, and nding was statistically signicant; p value <0.001 (p= Fischer Exact test). Conclusion: Out of 160 PAP smears 2.20% were positive. The PAP smear positive patients were also seropositive of HPV by ELISA method

Evaluation of ctDNA in patients with CRPC with pathogenic germline mutations in BRCA2.

253 Background: Approximately 3-5% of advanced prostate cancer patients have pathogenic BRCA2 mutations in germline tests. In this study, we examine the relationship between pathogenic germline BRCA2 mutation and somatic changes in ctDNA. Methods: Germline screenings were performed by Invitae multi-cancer gene panel which includes 50-84 genes. ctDNA alterations were detected by Guardant 360 assays which report somatic changes in 70-83 genes. All ctDNA samples were collected in post-abiraterone and/or enzalutamide (in CRPC patients). Any pathogenic/likely pathogenic somatic alterations in the ctDNAs with more than 0.1% of allelic fraction were included in this cohort. The type of mutation detected in ctDNA was also assessed (truncating, point, etc.). Statistical significance for comparison is calculated with Fischer Exact Probablity Test and Chi-Square Test. Results: A total of 11 patients had germline BRCA2 pathogenic mutations and ctDNA assays; 267 patients had no germline DNA pathogenic alterations and ctDNA assays. Compared to germline normal patients, the germline BRCA2 mutations were less likely to have AR alterations on ctDNA (OR=0.2133, 95% C.I. [0.087, 0.525], p-value = 0.0003). BRCA2 germline positive patients were also more likely to have a mutated BRCA1, BRCA2, and TP53 ctDNA (OR=7.899, 95% C.I. [1.2745, 48.9548], p=0.055), (OR=7.899, 95% C.I. [1.7529, 16.059], p=0.008), and (OR=6.442, 95% C.I. [2.449, 16.946], p=0.00001), respectively. All other ctDNA assessed genes were mutated at a similar frequency between germline BRCA2 mutated and “normal” germline patients. BRCA2 germline mutations patients are less likely to have copy number alterations (CNVs) (OR=0.3992, 95% C.I. [0.2168, 0.7352], p=0.0031) and more likely to have frameshift mutations (OR=2.3182, 95% C.I. [1.169, 4.5972], p=0.0183). Conclusions: The ctDNA testing in this CRPC population (after abiraterone and/or enzalutamide) was less likely to find AR alterations and more likely to find pathogenic mutations for BRCA1, BRCA2, and TP53 in BRCA2 germline positive patients. In addition, BRCA2 germline positive CRPC patients were more likely to have frameshift mutations and less likely to have CNVs than those with an intact germline. Characterizing the mutational landscape in BRCA2 germline mutated patients may help to better define underlying disease biology. Those with BRCA mutated germline may be less likely to have AR driven tumors. More study is needed to better understand patients with underlying DNA repair defects.

Correct administration aid for oral liquid medicines: Is a household spoon the right choice?

Correct medicine dosing is an important component in the safe and effective delivery of medicines, particularly for the pediatric population. However, there is a scarcity of public campaigns on the correct administration and choice of dosing aids for oral liquid dosage form in many countries, leading to medicine safety issues and therapeutic failures. The study targeted the assessment of the knowledge and practice of university students. It utilizes pre- and post-intervention surveys administered through google forms as a survey tool during online zoom and in-person sessions. The intervention included a short video presentation detailing the selection and use of medicine spoons and other aids for the administration of oral liquid dosage. The Fischer Exact test was used to assess the pre- and post-test shift of responses. Nine-degree programs were engaged in the activity, and 108 students attended this health awareness activity after obtaining formal consent. A significant decline (CI = 95%, **** p-value < 0.05) in the choice of selecting tablespoon and a shift to a low-volume spoon, as well as rejection of an entire variety of household spoons, were observed. A significant improvement in the correct naming of spoons, the meaning of the abbreviation "tsp," and the correct volume of a standard teaspoon were also observed with a p-value of <0.001. A deficit in the knowledge of the proper use of measuring devices for oral liquid medicines in the educated population was observed, which can be enhanced through simple tools like short video presentations and awareness seminars.

Analysis of Manheim Peritonitis Index Scoring in Predicting Outcome in Patients with Perforation Peritonitis

Scoring systems are essential to calibrate the severity of abdominal sepsis for adequate management. Disease specific scoring system based on easy to handle clinical parameters can help the cause. Objective: To study the role of Manheim peritonitis index scoring in predicting outcome and prognosis in patients with perforation peritonitis. Methods: This prospective study was carried out in Surgical Unit 1, Nishtar Hospital, Multan from 20th of August 2019 to 31st of December, 2019. It includes both sexes aged 20 years and above diagnosed at laparotomy after confirmation of peritonitis due to perforated viscus regardless of the etiology. Data were analyzed using SPSS version 19.0 Software. The outcome (death vs discharge) was compared separately to different predictors using Chi-square test. Fischer Exact test was used where assumptions of Chi-square were not met. Results: Advance age, female gender, colonic perforation, organ failure and fecal contamination were associated with high mortality. The mean MPI Score was 25.06 ± 4.96. The lowest score was 16 and the highest was 37. Overall, the in-hospital mortality rate was 14.3% in patients with MPI ≥26 compared to 6.4% in patients with MPI &lt;26, implying over a twofold higher risk in the former group. For a score of 26 or greater as a predictor of mortality, the sensitivity was 75.0%, specificity was 38.2% at an accuracy of 94%. Conclusion: MPI enables us to categorize patients into different groups so as to tailor management according to individual needs

Decannulation in Trisomy 21 patients undergoing laryngotracheal reconstruction.

Down Syndrome (DS) patients are more susceptible to either congenital or acquired subglottic stenosis (SGS). This often creates a multilevel airway obstruction and can lead to tracheostomy dependence early in life. As a result, they may require Laryngotracheal Reconstruction (LTR) to achieve decannulation. The primary objective of this study was to assess decannulation rates, time to decannulation and potential barriers to decannulation in DS patients undergoing LTR. We performed a retrospective chart review from 2008 to 2021 of 193 children who underwent LTR for treatment for laryngotracheal stenosis at a stand-alone tertiary children's hospital. The relationship between clinical data and decannulation status was evaluated using multivariable logistic regression and Fisher exact tests. Time to decannulation analysis was performed using Kaplan Meier analysis and evaluated with log-rank and Cox proportional hazards regression. We determined that DS patients carry an inherit risk for decannulation failure compared to the general population (OR: 6.112, P=. 044, CI 1.046-35.730). Of the 8 patients with DS only three were decannulated. Overall, patients with Trisomy 21 had a significantly increased time to decannulation when compared to all LTR patients (P=.008, Log-rank). We found that these patients are more likely to have both suprastomal collapse (P=.0004, Fischer's Exact) and Tracheomalacia (P=.034, Fischer's Exact) compared to all other LTR patients. While post-operative tracheomalacia did not significantly affect decannulation failure (P=.056, Fischer's Exact) it did significantly prolong decannulation in all LTR patients (P=.018, Log-rank). Trisomy 21 patients are at an increased risk for decannulation failure. Our study illustrates that these poor outcomes are likely a result of conditions more commonly found in this cohort including: narrow tracheal caliber, tracheomalacia and hypotonia.

Radiographic patterns of periosteal bone reactions associated with endodontic lesions.

The formation of new bone by periosteum due to an insult is called periosteal bone reaction (PBR). This study assessed the cone beam computed tomography (CBCT) patterns of periosteal bone reactions associated with periapical inflammatory lesion (apical periodontitis/periapical rarefying osteitis). Twenty-two small field of view CBCT images of patients with PBR were selected from a database of a private practice limited to endodontics. The volume of the periapical inflammatory lesion, the presence of cortical fenestration, the distance of the root apices to the affected cortex, and the location, pattern, and longest diameter of the periosteal reaction were recorded. Statistical analysis was performed using Wilcoxon Ranksum, Fischer's exact, Spearman Correlation Coefficient, and paired t-test. In all cases, periosteal bone reaction manifested as either parallel (90.9%) or irregular (9.1%). No correlation was found between periapical inflammatory lesion volume and the periosteal reaction's longest diameter (p > 0.05). Cortical fenestration was noted in 72.7% of the cases. In addition, the findings showed that periosteal reactions were located mostly on the buccal and were present 53.8% and 100% of the time in the mandible and maxilla, respectively. The periosteal reactions of endodontic origin had a nonaggressive form (i.e., parallel or irregular), and none of the lesions resulted in a periosteal reaction with an ominous Codman's triangle or spicule pattern.

Determinants of sexual dysfunction in pregnancy in a large tertiary hospital in Ghana.

To determine the factors associated with sexual dysfunction in pregnancy. A cross-sectional facility-based study using quantitative methods was carried out among pregnant women attending antenatal clinic of the Greater Accra Regional Hospital from 14th May to 25th June 2018. Four hundred and twenty-seven married or cohabiting women who were at least eight weeks pregnant and have been living together with their partners for at least four weeks prior to the survey were consecutively recruited. The Female Sexual Function Index (FSFI) tool was used to assess their sexual function. Pearson's Chi Square, Fischer's exact, Mann Whitney and Student's t-tests were used for bivariate analysis where appropriate between sexual dysfunction (dependent variable) and demographic, obstetrics and gynecologic factors (independent variables). Multiple logistic regression was done. Statistical significance was set at p-value of less than 0.05 at bivariate and multivariable analyses. The mean age of the respondents was 30.8 ± 4.8 years. Their mean gestational age was 32.3 ± 7.1 weeks. Marital status and duration of stay in marriage or cohabitation were significantly associated with sexual dysfunction with adjusted odds ratios of 1.88 (p-value < 0.05) and 1.08 (p-value < 0.05) respectively. Cohabiting and increasing length of stay with spouse are significantly associated with sexual dysfunction in pregnancy.

CLINICAL AND BLOOD PARAMETERS IN RELATION TO THE OUTCOMES OF COMMUNITY ACQUIRED PNEUMONIA

Background: Risk stratification of Community acquired pneumonia (CAP) is challenging for physicians. Though various biomarkers are available, they are costly or not readily available in all health care settings. This study aimed to analyze the prognostic value of routinely available clinical and blood parameters in relation to the outcome of patients admitted with community acquired pneumonia. Methods: This was a hospital-based observational study of the patients admitted to Chitwan Medical College (CMC), Nepal between August 2021 and December 2021. We enrolled patients 18 years old and above with the diagnosis of CAP in the study and excluded patients with COVID and active pulmonary tuberculosis. The outcomes of the patients were recorded as improved, not-improved, or dead. Fischer exact, Kruskal-Wallis or Mann-Whitney tests were used for analysis wherever appropriate. Results: Total 92 patients with mean age 58.2 years were enrolled in the study. Patients who were not improved or were dead had higher age (p=0.029), respiratory rate (p&lt;0.001), shock index (p=0.013), total leukocyte count (TLC) (p=0.019), urea (p=0.046), creatinine (p&lt;0.01), potassium (p&lt;0.001), bilirubin (p=0.029), and lactate (P&lt;0.05) and lower SpO2 (p&lt;0.01), SpO2/FiO2 (p=0.018), pH (p=0.0497), and PaCO2 (p&lt;0.001). Patients with nervous (p&lt;0.001), cardiovascular (p=0.032) and renal system (p=0.019) involvement were also found to be associated with poor outcome. Conclusions: CAP patients with higher TLC, urea, creatinine, bilirubin and lactate, with lower SpO2, SpO2/FiO2, pH and PaCO2 and with involvement of more than one organ systems were found to have unfavorable prognosis. Higher potassium level was also found to be a potential marker of CAP severity.

845: TRANSITION FROM DIRECT TO VIDEO LARYNGOSCOPY IN A PEDIATRIC ICU

Introduction: As an infection control measure for COVID-19, our PICU transitioned to near universal video laryngoscopy (VL). In 2019, 24% of intubations used VL; this increased to 96% in 2021. Comparing these two cohorts elucidates the effect of transitioning from direct laryngoscopy (DL) to VL on first time success rate (FTSR), Cormack-Lehane (C-L) grade view and successful trainee intubation. First time intubation success is associated with fewer complications and is therefore an important marker of intubation safety. Methods: Single Center retrospective case control. Data for 2019 were identified via chart review. Data from 2021 were obtained through a dedicated form introduced in the Fall of 2020. Each comparison group was limited to a full calendar year (Jan-Dec) to account for progression in trainee skill. A comparison was made between all patients in cohort groups with additional stratification of patients above and below the age of one. Included intubations were those in the PICU as well as those in the pediatric floor or ED performed by PICU staff. Statistics via Fischer Exact test. Results: 75 patients met criteria for 2019 and 73 in 2021. The age range in both groups was 2 days to 23 years. C-L view was documented in 72 of 75 patients in 2019 and all patients in 2021. 2019 had a 69.4% grade 1 C-L view rate, while 2021 had a 79.5% grade 1 C-L view rate (p=0.19). The overall FTSR in 2019 was 57.3% vs 65.7% in 2021 (p=0.31). 26 children under the age of one were intubated in both years, with a FTSR of 53.8% and 50% respectively. The FTSR in children above one year was 59.2% and 74.5% respectively (p=0.13). Additionally, an airway provider was documented in all but two cases in 2019. Of these, 75.3% were managed successfully by pediatric subspecialty fellows (PICU or rotating PEM). In 2021 this number increased to 84.9% (p=0.21). Conclusions: FTSR did not improve with transition to VL. In the 2021 cohort, children above age one had a 15.3% increased FTSR and trainees had a 9.6% increase in completed intubations. While not significant, these findings would benefit from reanalysis with a larger sample. First time success is an important marker for safe intubation practice, however there may be other benefits to either approach such as set up time and assistance from a second viewer.

603: BILIARY ATRESIA AND ACUTE-ON-CHRONIC LIVER FAILURE IN CHILDREN: OUTCOMES POST-LIVER TRANSPLANTATION

Introduction: Long term outcomes in patients with biliary atresia (BA) undergoing liver transplantation (LT) have improved but there remains significant perioperative morbidity. Acute-on-chronic liver failure (ACLF) is characterized by decompensated liver disease, multi-organ failure, and high mortality. Though well described in adults, pediatric ACLF and its impact on postoperative outcomes in children with BA undergoing LT is relatively understudied. Methods: A single-institutional retrospective analysis was performed. Patients aged < 18 years with BA who underwent LT between 1/2011 – 12/2021 were included. Patients who died awaiting LT, and those who received LT with incomplete documentation were excluded. ACLF was defined using the North American Consortium for the Study of End-Stage Liver Disease (NACSELD)-ACLF criteria: presence of 2 or more extrahepatic organ failures, and was characterized during the index admission for LT. Mann Whitney U test for continuous variables and Fischer Exact for categorical variables was used. Results are expressed as medians with interquartile ranges. Results: Of 132 patients, 10 (7.5%) who died awaiting LT and 15 (11.4%) who had incomplete pre-LT documentation were excluded. 107 (65% female; median age 14 [9-31] months) were included in this study. Based on the NACSELD-ACLF criteria, 11 (10.3%) patients had ACLF during index admission. Five of 11 (46%) patients were listed status 1B prior to LT. Patient with ACLF were younger at time of LT (9 [7-11] vs. 15 [10-37] months, p < 0.001), had a higher PELD score (34 [24-35] vs. 28 [24-33]; p < 0.001), higher total length of stay (178 [119-224] vs. 21 [9-48] days, p < 0.001), and had a higher rate of return to the operating room (36% vs. 18%; p < 0.01) compared to the non-ACLF group (n=96). The 1-year readmission (64 % vs. 38 %; p = 0.09) and overall 1-year survival (100% vs. 91%; p=0.28) rates were comparable between ACLF and non ACLF groups. Conclusions: In children with BA undergoing LT, survival outcomes post-LT between ACLF and non ACLF patients are comparable despite increased perioperative morbidity seen in those with ACLF. This reiterates the need for further studies to understand the impact of ACLF and prioritization of these critically ill patients for LT.

Predictor Factor for Severity Degree of Pediatric Hydronephrosis in Tertiary Hospital

Pediatric hydronephrosis is often hideous, and its severity highly correlates with a significantly increased incidence of pathological condition and outcome. The management of this disease is based on the severity level by identifying the clinical manifestation, so performing an early detection is crucial to prevent the disease progression. This research aimed to determine the predictor factors for the severity degree of pediatric hydronephrosis to give better treatments for patients. This study retrospectively reported 51 data of hydronephrosis cases that were collected from January 2012 to August 2019. Severity degree was evaluated using SFU (Society of Fetal Urology) scoring system and divided into two groups, mild-moderate (first and second degree) and moderate-severe (third and fourth degree). Data including age, gender, number of kidneys affected, etiology, and antenatal care were collected and statistically analyzed using Pearson's Chi-square and Fischer Exact test. The research result from 51 pediatric patients, 72.55% were categorized as moderate-severe hydronephrosis while the remaining 27.45% were categorized ad mild-moderate hydronephrosis. Ureteropelvic junction (UPJ) stenosis (37.25%) is the most common cause of pediatric hydronephrosis. Significant correlations are noted among severity degree and gender, the number of kidneys affected, etiology, and chosen antenatal care between obstetrician-gynecologist and midwife (p&lt;0.05). In short, gender, number of kidneys affected, etiology, patient's choice on antenatal care can be the predictor factors for pediatric hydronephrosis. Thus, these findings are essential for urologists in pediatric hydronephrosis management.

COVID-19 Pandemic Effects on the Epidemiology and Mortality of Pediatric Firearm Injuries; A Single Center Study

BackgroundThe COVID-19 pandemic has been associated with increased firearm injuries amongst adults, though the pandemic's effect on children is less clearly understood. MethodsThis cross-sectional study was performed at a Level 1 Pediatric Trauma Center and included youths 0–19 years. The trauma registry was retrospectively queried for firearm injuries occurring pre-COVID-19 pandemic (March 2015-February 2020). Baseline data was compared to prospectively collected data occurring during the COVID-19 pandemic (March 2020-March 2022). Fischer's exact, Pearson's Chi-square and/or correlation analysis was used to compare pre and post-COVID-19 firearm injury rates and intent, victim demographics and disposition. Temporal relationships between firearm injury rates and local COVID-19 death rates were also described. Results413 pre-COVID-19 firearm injuries were compared to 259 pandemic firearm injuries. Victims were mostly Black males with a mean age of 13.4 years. Compared to the 5 years pre-pandemic, monthly firearm injury rates increased 51.5% (6.8 vs 10.3 shootings/month), including a significant increase (p = 0.04) in firearm assaults/homicides and a relative decrease in unintentional shootings. Deaths increased 29%, and there were significantly fewer ED discharges and more admissions to OR and/or PICU (p = 0.005). There was a significant increase in Black victims (p = 0.01) and those having Medicaid or self-pay (p<0.001). Firearm injury spikes were noted during or within the 3 months following surges in local COVID-19 death rates. ConclusionsThe COVID-19 pandemic was associated with an increase in the frequency and mortality of pediatric firearm injuries, particularly assaults amongst Black children following surges in COVID death rates. Increased violence-intervention services are needed, particularly amongst marginalized communities. Level of evidenceThis is a prognostic study, evaluating the effects of the COVID-19 pandemic on pediatric firearm injuries, including victim demographics, injury intent and mortality. This study is retrospective and observational, making it Oxford Level III evidence.

HIGH RISK PREGNANCY WITH POOR FETAL OUTCOME- IS PLACENTA THE REAL CULPRIT ?.

Background: In high risk pregnancies with poor fetal outcome careful examination of placenta along with microscopic study may frequently point to the cause of perinatal death. So we have planned a prospective observational study was to illustrate the gross and microscopic changes in placenta in certain normal and abnormal pregnancies and to analyses the relationship of placental pathology with fetal outcome. A p Methods: rospective study of 100 deliveries at a tertiary teaching hospital in India. Each placenta was studied macroscopically in labour room and sent for microscopic examination. The study included placentas of normal pregnancies and those with high-risk pregnancies. Microscopically placentas were studied for vessel wall thickening, infarction, villitis, chorioangiosis, calcication and intervillous hemorrhage. The outcome variables were studied in each histological group and compared with the normal group using Ψ2 test for homogeneity. For cell frequencies less than 5, Fischer Exact Test was used. Vess Results: el wall thickening was demonstrated in 51% patients. Infarcts were demonstrated in 14%. Placental abnormalities Conclusions: like vessel wall thickening, and infarction is associated with abnormal fetal and neonatal outcome.

THE INFLUENCE OF PATIENT EDUCATION LEVEL, PREGNANCY/BREASTFEEDING, AND INFERTILITY TREATMENT ON PERCEPTIONS OF THE COVID-19 VACCINE: A MIXED METHODS STUDY

To elucidate infertile patient perceptions of the novel COVID-19 vaccine as it pertained to fertility treatments and future pregnancies. This was an IRB approved, single center mixed methods survey study. A 60-question survey was administered assessing patient perceptions regarding the novel COVID-19 vaccine as it pertained to their fertility care and future fertility treatment. The survey was offered to a total of 760 patients undergoing fertility evaluation and treatment, 192 responded (25% response rate). Fischer exact or McNemar exact tests were performed depending on quantitative data distribution. Responses to the open-ended questions were analyzed using inductive content analysis to generate qualitative themes. Quantitative: Of the 192 respondents most were white females, holding private insurance, with a college degree. Participant willingness to accept the COVID-19 vaccine was analyzed in conjunction with various demographic variables to determine trends between these variables and vaccine acceptance. Respondents’ age, marital status, income level and insurance status did not correlate with perceived willingness to accept the COVID-19 vaccine. However, respondents who reported having a college education were more likely to consider the COVID-19 vaccine when it became available to them (No Degree= 5/16 (31.3%), College Degree= 76/104 (73.1%), Post-graduate Degree= 57/67 (85.1%), N=187, P<0.001). When asked if pregnancy or breastfeeding impacted respondents' willingness to consider the COVID-19 vaccine 79 (43.9%) responded yes, while 101 (56.1%) responded no or unsure. When participants’ responses were stratified by the number of previous completed fertility treatments (either embryo transfers or intrauterine inseminations), there was a statistically significant trend of increasing willingness to receive the COVID-19 vaccine during a pregnancy or while breastfeeding (1 Treatment= 53/135 (39.2%), 2 treatments= 19/37 (51.3%), 3 treatments= 6/6(100%), N=180). Qualitative themes included participants’: fear of the unknown due to existing perceptions, beliefs, and mistrust; interpretations of medical knowledge and self-generated benefit-risk assessments, and desire for provider guidance and mindful communication. This study suggests that despite identified hesitancy of the COVID-19 vaccine, patients with higher levels of education and those who completed >2 infertility treatments were more willing to consider the COVID-19 vaccine, even with pregnancy or breastfeeding in mind. Patients unwilling to receive the vaccine reported mistrust in healthcare, lack of communication with providers, and medical misunderstanding while formulating benefit-risk assessments.

P404 Biofilm formation by Cryptococcus species isolated from Cerebrospinal fluid (CSF)

Poster session 3, September 23, 2022, 12:30 PM - 1:30 PM IntroductionCases of Cryptococcal meningitis have increased exponentially in the last 30 years due to the advent of AIDS, the use of immunosuppressive drugs, and chemotherapeutic agents. Among HIV-infected patients’ relapse is seen often. The ability of Cryptococcus to form biofilm may influence the clinical outcome of patients though poor adherence to ART and/or anti-fungal therapy is a known factor for relapse.MethodsDuring a period of 2 years and 8 months (August 2019 to March 2022), 11 Cryptococcus sps. were isolated from 59 cerebrospinal fluids (CSF) collected from patients clinically suspected of meningitis. Samples were examined and processed by direct microscopy and fungal culture. Identification of cryptococcal isolates was carried out by conventional method and by using an automated VITEK-2 (Biomerieux) identification system. Biofilm production was estimated by XTT reduction assay. Statistical analysis was done in SPSS version 21 (IBM) and Fischer's exact was used to find an association between biofilm formation and relapse.ResultsOut of 11 Cryptococcus isolated 10 were identified as C. neoformans and one was C. gattii. Three HIV-infected patients had recurrent cryptococcal meningitis. A total of 6 (42.8%) cases reported non-adherence to ART and/or anti-fungal therapy. Biofilm was detected in 3 isolates one of which was from a patient with re-current cryptococcal meningitis but the association is not statistically significant.DiscussionNon-adherence to HAART among HIV patients is known to increase the rate of hospitalization and mortality. Recurrence of cryptococcal meningitis has been thought to be due to drug resistance. But Illnait-zaragozí MT et al. based on STR typing technique, concluded that recurrence was due to co-infection with different strains or strains genetically modified during the long maintenance therapy. Biofilms produced by bacteria as well as fungus have been associated with more stubborn, recurrent, and persistent infections, especially among the immunocompromised population. Although biofilm production was detected in only one out of 3 isolates from recurrent cryptococcal meningitis, it may be a contributing factor along with non-adherence to treatment.ConclusionNon-adherence to ART and/or antifungal therapy is an important cause of relapse of cryptococcal meningitis. Biofilm production may be responsible for recurrence, especially among non-adherent patients. Further studies with a larger sample size may shed more light on the association between biofilm formation and recurrence.

Frequency of Fab Subtype and Linicohaematological Manifestation in Elderly Acute Myeloid Leukemia Patients in Tertiary Care Hospitals Peshawar

Aim And Objectives: AML is the most common acute leukemia affecting adults, its incidence increases with increasing age; the study aims to find out the clinical and haematological parameters of adult AML patients and the frequency of AML FAB subtype among these patients. Methods: This descriptive, cross sectional study was conducted in IRNUM; KTH and HMC tertiary care hospitals of Peshawar, 30 diagnosed AML patients of age ≥ 50 years were included in the study. The demographic details were recorded in a questionnaire, previous clinical record was obtained and the hematological findings at the diagnosis were recorded. Data was recorded in Microsoft Excel® (version 2013) data sheet, for further analysis the data was imported into Statistical Package for Social Sciences® (SPSS) version 22. Results: Overall 30 diagnosed denovo AML patients of age ≥50 years of age, included 19 male (63.3%) and 11 females (36.7%) patients were included in the study. The mean age of our study patients was 57.83 ± 5.26 years whereas the median was 59.5 years. The most common AML-FAB subtype found among study patients was AML-M2 found in 12 (40%) of patients followed by AML M4 9(30%), AML M1 6(20%) and AML M5 3(10%) in respective order. The mean hemoglobin level among the study patients was 72.10 g/L. Anaemia severity was significantly higher in AML-M2 subtype (z-score 2.0). The AML-subtypes have statistically similar pattern of WBC count (Fischer Exact P-value 0.681). Among the presenting clinical features in the study group fever, anaemia, bone pain and weakness is the most frequent presenting features in all the AML FAB subtypes. However gingivitis and hepatomegaly is the most common presenting feature in AML-M5 in the study group. Conclusion: AML M2 was the most frequent AML FAB subtype found in study patients with the male predominance M: F is (1.7:1). Anaemia, fever, weakness and bone pain was the most frequent presenting feature among the study group. Weight loss is most common ......

429 Clinical Audit Ankle Fractures

Abstract Aim Ankle fractures are common among adult age group with an incidence of 174 per 100000 per year and they pose serious problems in management of geriatric age group because of osteoporotic bone. Our aim of current clinical audit was to introduce changes in current clinical practice by recommendations according to Standard BOAST guidelines of management of Ankle Fractures. Method Clinical Audit was carried out in Department of Orthopedics Benazir Bhutto Hospital in Outdoor and Emergency in March 2021 in patients of age group 20–70 years taking 50 patients for pre- and post-audit assessment. Emergency, Outdoor Slips were evaluated according to Standards of Practice formulated. Then a presentation was given to medical staff on Guidelines of Ankle fractures management, and they were informed about the deficiencies in their documentation and management. Panaflexes of Guidelines were displayed in ER, ward and then re-evaluation was done after 4 weeks in April 2021 using proformas in which clinical notes, discharge certificates and emergency slips were used for data analysis and observing improvement. Results The results of asymmetric data were calculated by Fischer Exact Test and with a p-value of &amp;lt;0.05 considered as significant. Results were very pleasing as they showed great improvements in documentation as well as management of patients in accordance with the set guidelines and protocols. Conclusion Clinical Audits should be carried out on regular basis in hospital settings as they help to improve the standards of care as well as proper documentation which has medico-legal importance.