Large Tertiary Care Center Research Articles

A retrospective analysis of the impact of the COVID-19 pandemic on staging at presentation of patients with invasive melanoma

A retrospective analysis of the impact of the COVID-19 pandemic on staging at presentation of patients with invasive melanoma

Long-Term Outcomes and Safety Trends of Autologous Stem-Cell Transplantation in Non-Hodgkin Lymphoma: A Report From A Tertiary Care Center in India.

PURPOSEPublished experience with autologous stem-cell transplantation (ASCT) in non-Hodgkin lymphoma (NHL) from the Indian subcontinent is extremely limited. Here, we describe the activity and outcomes of this treatment modality at a large tertiary care center in India.PATIENTS AND METHODSWe retrospectively analyzed adult patients with NHL who were eligible for ASCT and autografted between January 1, 2002, and December 15, 2020, at our transplant unit. Toxicities, complications, and long-term outcomes were compared between patients who underwent transplant during 2002-2012 (group A) and 2013-2020 (group B).RESULTSOverall, 80 patients (group A, n = 37; group B, n = 43) underwent ASCT using peripheral blood stem cells. At a median follow-up of 57.6 months, the 5-year event-free survival (EFS) and overall survival (OS) were 43.5% and 47.6%, respectively, for all patients. More recently (group B), patients had reduced 100-day transplant-related mortality (2.3% v 21.6%, P < .01), improved 3-year EFS (52.9% v 37.3%, P = .04), and superior OS (at 3-year; 63.4% v 43.2%, P = .02). Patients in group B also tolerated the procedure better, with improved resource utilization. In multivariate analysis, an International Prognostic Index (IPI) ≥ 3 at diagnosis adversely affected EFS (hazard ratio [HR] = 2.82, P = .009) and OS (HR = 2.84, P = .01) after ASCT. Low pretransplant serum albumin levels were associated with inferior EFS (HR = 2.68, P = .02) and transplant-related mortality (odds ratio = 10.80, P = .02) after ASCT.CONCLUSIONIt is feasible to achieve comparable short- and long-term outcomes in patients with NHL undergoing ASCT in a resource-poor country with improved supportive care and expertise of the transplant team and center.

Pathologist-performed ultrasound-guided fine-needle aspirations of the thyroid: A single institution observational study.

Ultrasound-guided fine-needle aspiration biopsies (USFNAs) are increasingly performed by pathologists. This study was designed to assess the diagnostic yield and characterization of thyroid nodules biopsied at a teaching hospital setting in which both attending physicians and trainees are involved in the performance of USFNAs. A retrospective study of pathologist-performed USFNAs of thyroid cases was performed over a period of 9 years at a tertiary medical center. Data collected included patient characteristics and The Bethesda System diagnostic categories. Over the study period, 1531 USFNAs of thyroid nodules were performed in the pathology-based clinic, with 1209 lesions in females and 322 in males. Ninety-three percent of samples were sufficient for diagnosis (n=1420). The majority of nodules biopsied were benign (65.4%, n=1002). Overall, 3.1% of nodules biopsied were diagnostic of malignancy (n=47). The number of USFNAs over the years showed a rapid increase initially, with a coronavirus disease 2019-related decrease in 2020. The authors report their experience with thyroid USFNA over nearly a decade. The most common diagnosis was benign and the second most common was Bethesda category III. Lesions that were diagnostic of malignancy were relatively uncommon. Over the study period, the results showed that at a large tertiary care center in which USFNAs were performed by trainees as well as attending physicians, the diagnostic yield was good with a majority of thyroid nodules biopsied associated with a definitive diagnosis.

Symptom burden, psychosocial distress and palliative care needs in heart failure – A cross-sectional explorative pilot study

BackgroundBeyond guideline-directed treatments aimed at improving cardiac function and prognosis in heart failure (HF), patient-reported outcomes have gained attention.PurposeUsing a cross-sectional approach, we assessed symptom burden, psychosocial distress, and potential palliative care (PC) needs in patients with advanced stages of HF.MethodsAt a large tertiary care center, we enrolled HF patients in an exploratory pilot study. Symptom burden and psychosocial distress were assessed using the MIDOS (Minimal Documentation System for Patients in PC) questionnaire and the Distress Thermometer (DT), respectively. The 4-item Patient Health Questionnaire (PHQ-4) was used to screen for anxiety and depression. To assess PC needs, physicians used the “Palliative Care Screening Tool for HF Patients”.ResultsWe included 259 patients, of whom 137 (53%) were enrolled at the Heart Failure Unit (HFU), and 122 (47%) at the outpatient clinic (OC). Mean age was 63 years, 72% were male. New York Heart Association class III or IV symptoms were present in 56%. With a mean 5-year survival 64% (HFU) vs. 69% (OC) calculated by the Seattle Heart Failure Model, estimated prognosis was comparatively good. Symptom burden (MIDOS score 8.0 vs. 5.4, max. 30 points, p < 0.001) and level of distress (DT score 6.0 vs. 4.8, max. 10 points, p < 0.001) were higher in hospitalised patients. Clinically relevant distress was detected in the majority of patients (HFU 76% vs. OC 57%, p = 0.001), and more than one third exhibited at least mild symptoms of depression or anxiety. Screening for PC needs revealed 82% of in- and 52% of outpatients fulfil criteria for specialized palliative support.ConclusionDespite a good prognosis, we found multiple undetected and unaddressed needs in an advanced HF cohort. This study’s tools and screening results may help to early explore these needs, to further improve integrated HF care.Graphical abstract

IDF21-0636 Effects of COVID-19 lockdown on lifestyle changes and medical challenges in patients with type 1 diabetes in south India

Background: India has become a major epicentre of the Coronavirus (COVID-19) pandemic. The lockdown imposed by the Indian government during the pandemic of COVID-19 has inflicted changes in diet and lifestyle patterns in patients with diabetes. There are unique challenges in addressing management of type 1 diabetes (T1D) during the lockdown period. Aim: To evaluate the effects of nationwide lockdown due to COVID-19 on lifestyle changes and medical challenges in patients with T1D in south India. Method: Data was collected through telephonic interview (between April 30 and May 15, 2020), from a random list of 154 individuals with T1D, who had visited a large tertiary diabetes care centre during the past year. A structured questionnaire was used to collect information on changes in lifestyle, access and challenges to diabetes care, use of technologies such as telemedicine facilities, self-monitoring of blood glucose, and hypoglycemia. Results: The mean age of the participants was 27.3 ± 10.5 years, and 59.1% of the participants were males. Overall, 27.3% of the participants utilized online information like Youtube, Facebook, WhatsApp for control of diabetes of whom, 76.2% reported watching videos about diabetes. Table 1 presents data on access to diabetes care during the lockdown in T1D individuals. Majority (80%) of the participants monitored their blood glucose at home and 38.3% of them had documented episodes (weekly or monthly once) of hypoglycemia and but were able to treat themselves at home. Of the total participants, 49.3% of them reported that their physical activity pattern has changed (50.6% reported no change in their activity) of whom in 52.5% the activity increased, and in 47.5% it decreased. Over 60% of the participants consumed more vegetables, and 38.7% had consumed more fruits, during the lockdown.Table 1Access to diabetes care during the lockdown in T1D individuals.Access to diabetes careTotal (n=154) n(%)Tried to see a Doctor since lockdown (Yes)20(13.0)The main reason for wanting to see a Doctor Treatment or evaluation of diabetes, blood pressure, or heart disease Treatment or evaluation of other chronic diseases Other reason14(70.0) 1(5.0) 5(25.0)The outcome in trying to see the doctor Yes, in-person Yes, by Telemedicine No, tried but could not be seen16(80.0) 2(10.0) 2(10.0)Had any blood tests done since lockdown? Yes – tried and successful Yes – tried but could not be done No11(7.1) 2(1.3) 141(91.6)Have you run out of any of your medications during lockdown? (Yes)9(5.8)Ran out of insulin9 (100.0)What was the main reason for running out of insulin? Lockdown restrictions in going out to buy medications Unable to afford Pharmacy out of stock Others-Pharmacy closed2(22.2) 1(11.1) 5(55.6) 1(11.1)Have you had access to home delivery of medicines? (Yes)48(31.6)Interested in getting medicines home-delivered even after the current situation eases? (Yes)38(25.0) Open table in a new tab Discussion: Among T1D participants, both positive and negative behavioral changes occurred during lockdown due to COVID-19. More research is needed on the long-term effects of COVID-19 on the health and well-being of persons with T1D.

Clinical outcomes of patients treated on the Heidelberg interprofessional training ward vs. care on a conventional surgical ward: A retrospective cohort study

ABSTRACT Interprofessional training wards (IPTW) are a form of interprofessional education enabling trainees of different healthcare professions to work together in teams. Concerns about patient safety are a major barrier to the implementation of IPTWs. The objective of this retrospective study was to analyze patient relevant clinical outcomes on Germany’s first IPTW (Heidelberger Interprofessionelle Ausbildungsstation; HIPSTA) in the Department of Surgery at University Hospital Heidelberg in comparison to a conventional surgical ward (CSW). The setting is a large tertiary care center with a focus on major oncological surgery. The endpoints were postoperative complications according to the Dindo-Clavien Classification and a set of patient-safety outcomes. In total, 232 patients treated on HIPSTA were retrospectively compared with 465 patients on a CSW. Baseline characteristics were comparable between groups. No significant difference between rate or severity of overall postoperative complications was observed. In-hospital mortality did not significantly differ between groups. However, the mean length of hospital stay was significantly shorter on HIPSTA. Furthermore, HIPSTA patients had less frequent reoperations. Patient safety in surgical IPTW was not compromised in comparison to a CSW, and there were some areas where significantly better outcomes were identified.

Characterizing sleep disorders in an autism-specific collection of electronic health records

Objective/backgroundSleep problems are common in people on the autism spectrum. This study reviews one detailed approach to querying the electronic health record (EHR) in a large tertiary care center. Patients/methodsWe developed methods for identifying people on the autism spectrum and defined their sleep problems using the key words, “sleep” or “melatonin”, or International Classification of Diseases (ICD) codes. We examined treatment responses of these individuals to melatonin supplementation. ResultsSleep problems were documented in 86% of patients with ages ranging from 6 to 30 years old. Our specific keyword search yielded more patients with sleep diagnoses than ICD codes alone. About two-thirds of patients who received melatonin supplementation reported benefit from its use. ConclusionsOur study provides a framework for using deidentified medical records to characterize sleep, a common co-occurring condition, in people on the autism spectrum. Using specific keywords could be helpful in future work that queries the EHR.

A CLINICO-ETIOLOGICAL STUDY OF ADVERSE CUTANEOUS DRUG REACTIONS AT TERTIARY CARE CENTER IN SOUTH INDIA

Objective: The objective of the study was to study the most common aetiology, different clinical manifestations of adverse cutaneous drug reactions (ACDR), and to assess the association of morphological cutaneous pattern of ACDR and etiological group of drugs. Methods: A cross-sectional, observational study was carried out at dermatological department of a large tertiary care center in Southern India. All clinically suspected ACDRs due to allopathic drugs, presented during two year period of all age groups and both sex were included in the study. A written informed consent was taken from patients and data were collected by means of pre-tested Performa including detailed clinical history, examination and relevant laboratory investigations. SPSS (Version 23.0) was used to obtain the results. Results: About 46% were between age group of 19–40 years. Majority were female (54%). 59% had generalized lesions, 98% had cutaneous manifestations, and 30% had mucous involvement. Itching was the most common presenting feature (48%). However, only 6% patients were asymptomatic. Most common etiological group of drugs responsible for ACDRs are antibiotics (27%) and NSAIDs (19%) pointing toward its rampant use with and without prescription. Among the Antibiotics, Ciprofloxacin was noted to be the most common responsible for ACDR. Diclofenac was found be the most common NSAID followed by Ibuprofen and Ketorolac. Majority of ACDRs, that is, 72% comprised of probable ACDRsas per “Naranjo’s algorithm.” The most common type of lesions observed was plaques (29%), macules (19%), papules (6%), and edema (6%). A predominant pattern of correlation was noted between antibiotics and erythematous drug eruption, SJS, vasculitis, erythroderma, and AGEP. The most common clinical pattern of ACDR observed was Urticaria (19%), Fixed Drug Eruption (13%), Erythema Multiforme (9%), and Lichenoid drug eruption (8%). Conclusion: The significance of this study was to study the profile of ACDR and to emphasize the awareness to the health-care providers on vigilant monitoring of ADRs and promptly reporting the same to prevent the occurrence of reactions in the vulnerable population. A systemic comprehensive monitoring and documentation of ADRs can curtail many untoward reactions in patient care and will lead to an effective drug administration. More studies are essential to create awareness of possible ACDR and to assist in the early recognition which, in turn, aids in the implementation of effective drug safety measures.

The Safety and Efficacy of Low-Molecular-Weight Heparin in Pregnant Women With Rheumatic Heart Disease and Valves Replacement.

Background: In patients with rheumatic heart disease (RHD) and prosthetic valve replacement, the risk of thromboembolic complications is the highest during and immediately after pregnancy. Therapeutic anticoagulation during this period is crucial to minimize the risk of thromboembolic complications. The use of low-molecular-weight heparin (LMWH) remains an off-label indication. The type of anticoagulants used, dosing regimens, target anti-Xa levels, and frequency of anti-Xa monitoring are highly variable in the pregnant population and have been derived from pilots, observational studies, and empirical evidence. Herein, in a real-world setting, we sought to examine the efficacy and safety of variable anticoagulation options with a focus on LMWH in the management of RHD-related valvular disease in pregnant women.Methods: This study is a retrospective study conducted at a large university-affiliated tertiary care center (King Saud University Medical City) between January 2011 and February 2020. All pregnant women with RHD who had heart valve replacements were reviewed. Patient data were extracted for demographic information, baseline characteristics, anticoagulation type, and primary outcomes. Primary endpoints were thromboembolic events, hemorrhagic complications, and fetal outcomes.Results: A total of 744 pregnancies in 149 women were identified. The mean age ± SD of the women was 43.8 ± 12 years. A total of 86 women (58%) were on the LMWH regimen, 35 women (23%) were on LMWH and warfarin regimen, and 28 women (19%) were on unfractionated heparin (UFH) and warfarin regimen. Overall, thromboembolic events developed in five (0.7%) pregnancies. Of those, two were in the LMWH group, two were in the LMWH and warfarin group, and one was in the UFH and warfarin group. In addition, significant hemorrhagic complications occurred in five pregnancies. Of these, two occurred in the LMWH group, two in the LMWH and warfarin group, and one in the UFH and warfarin group. No adverse maternal and fetal outcomes were noted.Conclusion: This study presents the largest retrospective study of variable anticoagulation options in pregnant women with RHD and prosthetic valve replacement. LMWH is both safe and effective in preventing major thromboembolic complications compared to other forms of anticoagulation used during pregnancy.

Association of Operating Room Costs With Head and Neck Surgical Instrumentation Optimization

In an era of increasing health care expenditure, reduction of redundant head and neck surgical instrumentation may minimize waste. To (1) optimize head and neck surgical instrument trays at a single large academic tertiary care center and (2) identify associated direct cost savings. This prospective quality improvement initiative was conducted at an academic tertiary care medical center from July 2017 through July 2021. Participants were a multidisciplinary surgical quality team consisting of head and neck surgeons, operating room nurses, surgical technicians, and supply chain analysts. The 4 primary surgical instrument trays (major otolaryngology [Oto], Oto plastics, direct laryngoscopy, and microdirect laryngoscopy) used in all head and neck procedures were reviewed by 10 head and neck surgical faculty with detailed case observation of instrument utilization performed by trained operating room nurses and surgical technologists. Instruments used in less than 40% of cases were excluded from surgical trays, and novel instrument trays were established based on faculty feedback and utilization. Data on instrument processing, utilization, and associated institutional direct costs were prospectively collected over a 3-year period. The primary outcome measure was change in operating room direct costs. Surgeon satisfaction with the quality improvement intervention was the secondary outcome. Direct cost savings were identified as a function of surgical volume, labor and supply costs, and instrument depreciation. More than 1500 eligible surgical cases were reviewed during the preintervention period. Of the 149 instruments in the major Oto tray, only 118 (79%) instruments were used in more than 40% of cases. There were 58 (49%) and 32 (21%) instruments in this tray that were used in more than 40% of neck dissections and sentinel lymph node biopsies, respectively. Resulting intervention included development of a streamlined major Oto tray with 118 instruments and novel neck dissection and sentinel lymph node biopsy trays. Similar processes were applied to the remaining head and neck trays, with a total of 257 instruments removed. Over a 3-year postintervention period, streamlined surgical trays were used 9284 times with direct cost savings of $228 338 (95% CI, $227 817-$228 854). Overall surgeon satisfaction with the optimized head and neck surgical trays was 100%. In this quality improvement study, surgeon-led elimination of redundant or rarely used instruments from surgical instrument trays was associated with reduced operating room direct costs while maintaining stakeholder satisfaction.

Compression Stocking Compliance Does Not Impact Reintervention or Symptom Change after Iliac Vein Stenting in Patients with Moderate to Severe Lower Extremity Edema

Medical compression stocking (MCS) therapy remains a core treatment for chronic venous disease, particularly in patients with lower extremity edema. This study investigated the impact of postoperative MCS adherence on patients with moderate to severe edema who underwent iliac vein stenting (IVS). Patients at a large tertiary care center who underwent IVS from August 2011 to June 2021 were analyzed. Symptoms were quantified using the venous clinical severity score (VCSS) and clinical assessment score (CAS). The criterion for inclusion was moderate or severe lower extremity edema at the time of IVS. Patients were stratified into two cohorts: complete postoperative compression therapy compliance (MCS+) and no postoperative compression therapy use (MCS-). Among 376 patients fitting our study criteria, we identified 168 MCS+ and 208 MCS- patients. The VCSS edema score did not significantly differ between groups (P=0.179). Postoperatively, the mean changes in VCSS edema at the first postoperative visit, the one-year follow-up, and the two-year follow-up were not significantly different between the MCS+ and MCS- cohorts (P=0.123, 0.296, and 0.534, respectively). An analysis of CAS for edema revealed that the MCS+cohort had a modestly better improvement in edema at the 90-day follow-up visit versus the MCS- cohort (P=0.018), but this difference was not observed in the 30-day (P=0.834) or six-month follow-up visit (P=0.755). A multivariate analysis revealed no difference in the need for major intervention (OR 0.93, 95% CI 0.44 to 1.50, P=0.504). A Kaplan-Meier analysis via log-rank test revealed no difference in reintervention-free survival between groups (P=0.77). Many patients with moderate to severe lower extremity edema experience a reduction in their edema after IVS. In our study, compression stocking compliance after surgery had a little impact on edema relief in this population.

Real-World Experience With a Large Bore Vascular Closure Device During TAVI Procedure: Features and Predictors of Access-Site Vascular Complications.

BackgroundsAmong vascular closure devices (VCDs), the novel collagen plug-based MANTA VCD is the first designed for large bore percutaneous access. We aimed to assess the features and predictors of access-site vascular complications in an unselected trans-femoral transcatheter aortic valve replacement (TF-TAVR) population.MethodsPatients undergoing large bore arteriotomy closure with 18F MANTA VCD following TF-TAVR at a large tertiary care center from September 2019 to January 2021 were prospectively analyzed. Primary Outcome was the MANTA VCD access-site-related complications according to Valve Academic Research Consortium-3 (VARC) definitions. Its incidence and predictors were evaluated.ResultsEighty-eight patients (median age 82 years, 48% male, 3.3 median Society of Thoracic Surgeons score) undergoing TF-TAVR were included, mostly (63%) treated with a self-expandable device and with outer diameter sizes varied from 18F to 24-F. MANTA VCD technical success rate was 98%, while 10 patients (11%) experienced MANTA VCD access-site vascular complications which included 8% of minor complications and only to 2% of major events resulting in VARC type ≥2 bleeding. Vessel occlusion/stenosis (60%), perforation (20%), and pseudoaneurysm/dissection/hematoma (20%) occurred, but all were managed without surgical treatment. Independent predictors of failure were age (p = 0.04), minimum common femoral artery diameter (CFA) (p < 0.01), sheath-to-femoral-artery ratio (SFAR) (p < 0.01), and a lower puncture height (p = 0.03). A CFA diameter <7.1 mm with a SFAR threshold of 1.01 were associated with VCD failure.ConclusionsIn a more comers TF-TAVR population, MANTA VCD was associated with reassuring rates of technical success and major access-site vascular complications. Avoiding lower vessel size and less puncture site distance to CFA bifurcation might further improve outcomes.

The Association of Twin Chorionicity with Maternal Outcomes.

Our objective was to investigate the association between maternal outcomes and twin chorionicity in a large, contemporary obstetric population. Retrospective cohort study was conducted at a single, large tertiary care center. Prenatal and inpatient records for all individuals with twin gestations were reviewed from 2000 to 2016. Patients with monoamniotic twins, higher-order multiples reduced to twins, multiple sets of twins in the study period, or undetermined chorionicity were excluded. Patients with monochorionic twins were compared with those with dichorionic twins. The co-primary outcomes were gestational diabetes mellitus and hypertensive disorders of pregnancy. Secondary outcomes included cesarean delivery, preterm delivery, postpartum hemorrhage, and other maternal outcomes. Bivariate and multivariate analyses were performed to assess associations of chorionicity with maternal outcomes. Of the 2,979 patients eligible for inclusion, 2,627 (88.2%) had dichorionic twin gestations and 352 (11.8%) had monochorionic twin gestations. Patients with monochorionic twins were less likely to self-identify as non-Hispanic White and to have conceived via assisted reproductive technology but were more likely to be publicly insured, multiparous and have prenatal care with a maternal-fetal medicine provider. Neither gestational diabetes mellitus (6.8% monochorionic vs. 6.2% dichorionic, p = 0.74; adjusted odds ratio [OR] 1.06, 95% confidence interval (CI) 0.60-1.86) nor hypertensive disorders of pregnancy (21.9% monochorionic vs. 26.3% dichorionic, p = 0.09; adjusted OR 0.99, 95% CI, 0.71-1.38) differed by chorionicity. Of the secondary maternal outcomes, patients with monochorionic twins experienced a lower frequency of cesarean delivery (46.0 vs. 61.8%, p < 0.001), which persisted after multivariate analyses (adjusted OR 0.60, 95% CI 0.46-0.80). There were no differences in preterm delivery, preterm premature rupture of membranes, hemorrhage, hysterectomy, or intrahepatic cholestasis of pregnancy. The odds of gestational diabetes mellitus and hypertensive disorders of pregnancy do not appear to differ by twin chorionicity. · Hypertensive disorders of pregnancy do not differ by twin chorionicity.. · Gestational diabetes mellitus does not differ by twin chorionicity.. · Maternal outcomes are similar for individuals with monochorionic and dichorionic twin gestations..

Comparison of quality of life (QoL) in survivors of testicular nonseminomatous germ cell tumor (NSGCT) with age-matched controls using EORTC QLQ-C30 questionnaire.

413 Background: Testicular NSGCT is typically diagnosed in young males, and is a highly curable cancer. Data pertaining to the quality of life of testicular NSGCT survivors are limited. Methods: Patients aged 18 or more years with a diagnosis of testicular NSGCT treated in a large tertiary care centre in New Delhi, India between January 2015 and July 2019 were eligible to participate. Patients had to be disease free for at least two years for QoL assessment using EORTC QLQ-C30 questionnaire. Raw scores were transformed as per the EORTC scoring manual. Controls were healthy age-matched adults recruited from the patient accompanying population. Results: We identified 55 survivors and 100 controls. Median age was 32 (range, 18-65) years and 58.2% of patients stage III disease, while the rest were equally divided in stage I and II. Chemotherapy was administered in 94% patients, while 25% had retroperitoneal lymph node resection for residual disease and relapse occurred in 11%, who were treated with salvage chemotherapy and resection of the residual disease. Emotional, social and global scores were significantly lower in survivors as compared to controls. Among symptom scales, fatigue, pain, dyspnoea, insomnia, appetite loss, and financial difficulty were significantly increased in patients as compare to survivors (Table). On a multivariate analysis, neither stage of disease nor treatment were found to be associated significantly with QOL scores. Conclusions: Survivors of testicular NSGCT have lower emotional, social and global functioning and a higher symptom burden. Since NSGCT affects young males, aggressive measures may be needed to improve the QoL in such patients.[Table: see text]

Abstract P3-19-11: Long-term outcomes of primary and secondary angiosarcomas of the breast: A 20-year single-center experience

Abstract Introduction: Sarcomas of the breast comprise less than 1% of breast malignancies. Angiosarcomas are aggressive tumors that arise in the breast more than other sites, radiation-associated angiosarcomas (RAA) account for 0.05 - 0.2% of breast malignancies. Primary angiosarcomas are mostly diagnosed in women between 30-50 years of age while RAA occur after a prolonged latency following radiation therapy. This study aims to evaluate the management and subsequent outcomes of breast angiosarcomas (BAS) at the McGill University Health Centre (MUHC), a large tertiary care center, from 2000-2020. Methods: Using our institutional cancer registry database, we identified patients with histologically confirmed BAS diagnosed between 2000- 2020. Data was collected retrospectively including demographics, operative and oncologic interventions, and outcomes. Descriptive statistics were used to summarize the characteristics of the study population. Kaplan Meier curves were used to describe progression-free survival probability, overall survival, and corresponding 95% confidence intervals. Results: A total of 14 patients were identified including 3 (21.4%) with primary BAS and 11 (78.6%) with radiation-associated angiosarcoma (RAA). The mean age of RAA patients at presentation was 71.4 years (range 59-82), and 44 years for the primary BAS (range: 28-53). The mean latency period in developing RAA was 8.0 years (range 4.4-13.3). Treatment of primary angiosarcomas included surgery in all 3 patients, radiotherapy (RT) in 2 and chemotherapy in one who received neoadjuvant chemotherapy and radiotherapy followed by total mastectomy. Treatment of RAA (n=11) included surgery (100%), radiotherapy (18%), chemotherapy (9%). Total mastectomy was performed in ten (91%) patients, one of whom received neoadjuvant chemotherapy and two adjuvant RT. Partial mastectomy (PM) was performed in one patient. After a median follow-up time of 32.5 months (range 0-172), following initial treatment, five patients (35.7%) experienced local recurrence, two of whom had had positive margins after initial surgery. Salvage treatments included wide excision (100%), adjuvant RT in two patients (66.6%) and chemotherapy at time of development of distant metastasis in one. In the primary angiosarcoma population, after accounting for one patient that was lost to follow-up, none experienced recurrence or death. Overall survival probability in the whole study population and in the secondary RAA group was 100% at 36 months. The PFS at 24 months was 51.3% (95% CI: 29.6-88.8%) for the whole population and 41.6% (95% CI: 19.9-86.8%) in the RAA group. In the RAA group, out of the five patients that recurred locally, one patient developed a third malignancy (endometrial) and three patients are currently alive. Conclusion: Overall, our 20-year single center experience confirms the rare nature of BAS. Despite a favorable overall survival rate, local recurrence remains a significant challenge. Our results underscore the importance of optimal salvage therapies such as wide surgical excisions, RT, and chemotherapy that in our series lead to better-than-expected overall survival. Given the rarity of BAS, patients should be managed in large tertiary care centers where multidisciplinary management and clinical expertise can guide salvage approaches. Citation Format: Marwan Tolba, Vanessa Di Lalla, Farzin Khosrow-Khavar, Ayesha Baig, Carolyn Freeman, Valerie Panet-Raymond. Long-term outcomes of primary and secondary angiosarcomas of the breast: A 20-year single-center experience [abstract]. In: Proceedings of the 2021 San Antonio Breast Cancer Symposium; 2021 Dec 7-10; San Antonio, TX. Philadelphia (PA): AACR; Cancer Res 2022;82(4 Suppl):Abstract nr P3-19-11.

Abstract P3-19-23: Radiation-induced sarcomas of the breast: A 20-year single-centre experience

Abstract Background: Radiation-induced sarcomas (RIS) are rare malignancies comprising only 2.5-5.5% of all sarcomas. As per the Cahan criteria, diagnosis requires histologically proven sarcoma within or around a previously irradiated site. Breast cancer patients are known to have a higher incidence of RIS compared to other primary solid cancers. Following breast irradiation, RIS typically occur after a prolonged latency up to 20 years, although this is often shorter for angiosarcomas. A clear mechanism for RIS development has not yet been elucidated, and prognosis remains poor given limited treatment options. This study aimed to review incidence, risk factors, management, and subsequent oncologic outcomes of breast RIS using 20-year experience at the McGill University Health Centre (MUHC), a large tertiary care centre. Methods: Using our institutional cancer registry database, we identified patients with histologically proven sarcomas of the breast diagnosed between the years 2000 to 2020. We then identified and included patients meeting the Cahan criteria as described above. Patient data including demographics, oncologic treatment of primary breast cancer as well as subsequent sarcoma, and oncologic outcomes were collected from our electronic medical record systems. Descriptive statistics were used to describe patient demographic data. Oncologic outcomes were assessed using the Kaplan Meier method. Results: From 2000 to 2020, we identified 19 patients with breast RIS: 11 angiosarcomas (57.9%), 3 osteosarcomas (15.8%), 2 carcinosarcomas (10.5%), 2 undifferentiated pleomorphic sarcomas (10.5%) and 1 high-grade leiomyosarcoma (5.3%). The median age at RIS diagnosis was 72 years (range 39-82, mean 67) and median latency period for development of RIS was 112 months (range 53-300, mean 120). In terms of secondary treatment, all patients underwent surgery, either total or partial mastectomy (n=14 and n=5, respectively), 3 patients received systemic therapy, and 6 patients received re-irradiation. The median follow-up time was 31 months (range 6-172, mean 48) from diagnosis of RIS. Overall, 5 patients had recurrence at the site of sarcoma and 1 patient developed distant metastases through the study follow-up. The median time to progression was 7 months (range 4-14). The progression-free survival (95% CI) at two years was 56.1 % (37.4-84.4%). At two years follow-up after sarcoma diagnosis, 2 patients were deceased, resulting in an overall survival (95% CI) of 88.9% (75.5-100%). Conclusion: Our 20-year institutional experience confirms that while RIS of the breast remains rare, when managed in a high patient-volume centre, overall survival outcomes appear favorable when salvage is possible. However, a significant proportion of patients still recur locally after maximal treatment, confirming the aggressive nature of this disease and suggesting further follow-up is needed for survival data maturation. Given the rarity of this disease in the context of limited treatment options, patients with RIS should be ideally managed in high-volume centres where multidisciplinary management is available. Citation Format: Vanessa Di Lalla, Marwan Tolba, Farzin Khosrow-Khavar, Ayesha Baig, Carolyn Freeman, Valerie Panet-Raymond. Radiation-induced sarcomas of the breast: A 20-year single-centre experience [abstract]. In: Proceedings of the 2021 San Antonio Breast Cancer Symposium; 2021 Dec 7-10; San Antonio, TX. Philadelphia (PA): AACR; Cancer Res 2022;82(4 Suppl):Abstract nr P3-19-23.

Residents and staff perceptions of a pediatric clinical teaching unit in a large tertiary care center in Saudi Arabia

BackgroundThe clinical teaching unit (CTU) is a commonly used model of patient care and teaching. Despite being a common model of care, very few studies have looked at its impact on the education of trainees. In addition, it is a relatively new structure for pediatric inpatient care in Saudi Arabia. The purpose of this study was to compare postgraduate trainees (residents) and staff perceptions of the old and the new (the CTU) inpatient team structures, and to evaluate the impact of the CTU on residents’ education.MethodsAn online survey was sent to nurses, pediatric residents, and attending physicians who worked under both structures. Questions for residents were adopted from the National training survey of the General Medical Council, United Kingdom.ResultsA total of 147 pediatric healthcare workers completed the survey (97 nurses, 39 residents, and 11 attending physicians), most of whom worked in both the old and new inpatient team structures. More than 97% of residents reported being supervised by their attending on a daily basis in the CTU structure as compared with 15% in the old structure. A higher proportion of residents favored the old structure in terms of the opportunity it provided to develop their leadership skills. Eighty-seven percent of nurses believed the CTU had improved patient safety of pediatric inpatients. Overall, 82% of residents, 91% of nurses, and 100% of attending physicians favoured the CTU structure over the old inpatient model.ConclusionsOur study shows that pediatric residents and staff perceived the CTU structure as superior to the old inpatient team structure, especially in terms of patient safety. Although the CTU seemed to have a positive impact on residents’ education, this must be further examined especially with respect to its impact on residents’ leadership skills.

Real world utilization of Dalbavancin at a rural community emergency department

IntroductionAcute bacterial skin and skin structure infections (ABSSI) are frequently encountered in the emergency department and compromise more than 700,000 hospital admissions annually. Dalbavancin is a single dose long acting semi-synthetic lipogylcopepitde antibiotic with coverage against gram-positive organisms including methicillin resistant Staphylococcus aureus. Recent data from large tertiary care centers have shown a decrease in hospital admissions and repeat emergency department visits for ABSSI's but little data is available for those who practice in a rural community setting. The primary objective of this study was to describe the use of dalbavancin at a single rural emergency department. MethodsA retrospective cohort study of all adult patients who received dalbavancin between 2019 and 2021 while in the emergency department was completed. Abstracted data included patient demographics, infection location by body region, emergency department return visits, hospital admissions, and length of stay. Analysis was conducted using descriptive statistics, the Mann-Whitney test for continuous data, and the chi-squared analysis for nominal data. ResultsA total of 125 patients were included in the final analysis with 35.2% being female. The median age of those treated with dalbavancin was 54 years (42.0–64.0) and the most common infection site was the lower extremities. A total of 35 patients re-presented to the emergency department following treatment with dalbavancin within 30 days and 16 were admitted to the hospital. Of those who re-presented to the emergency department, the median age was 56 (40.0–66.0) and the median re-presentation was 9 days (3–17) after dalbavancin administration. A total of 16 patients (12.8%) were subsequently admitted to the hospital with a median length of stay of 5.5 days (3.0–8.0). 30-day readmission rates were 23.9% in those who had an abnormal WBC count at initial presentation, 26.1% for those with congestive heart failure, 20.3% for those with hypertension, and 26.0% in those who had diabetes mellitus. ConclusionFollowing the administration of dalbavancin for ABSSI at a rural emergency department, few patients are subsequently admitted within the following 30 days. To further decrease this number and alleviate the burden on emergency departments and hospitals, local treatment algorithms should be developed to minimize the risk of representation and hospitalization following administration.

POS-959 CLINICAL PROFILE AND OUTCOME OF SARS-CoV2 INFECTION IN RENAL TRANSPLANT RECIPIENTS - A SINGLE CENTRE EXPERIENCE

Kidney transplant recipients (KTR) form a vulnerable population group as they are on chronic immunosuppression and have comorbidities like diabetes. Previous studies have shown increased mortality of renal transplant patients infected with SARS-CoV2 infection compared to the general population. We compared the clinical presentations of renal transplant patients infected with SARS-CoV2 in the first and second wave from a large tertiary care centre of South India. Our study aims to analyze the clinical profile, impact on graft function and outcome of KTR infected with SARS-CoV2 and to find the long term effect of SARS-CoV2 infection in this subset of population.

P175 Low relapse rates after biologic therapy discontinuation in a large real life cohort of IBD patients with initial severe disease: do biologics alter the natural history of disease?

Abstract Background Discontinuation of biologic therapy has been associated with high risk of relapse. However indefinite biologic therapy is often not feasible in low resource settings of the developing countries where tuberculosis (TB) is endemic and cost is prohibitive. There is very limited data on the course of disease after stopping biologics from this region. We analysed the predictors of relapse including the rate and severity post withdrawal of biologics in a large real-world cohort of patients from India. Methods Prospectively collected data of consecutive patients treated with biologics from the IBD registry of a large tertiary care centre from India was analyzed. Demographic and disease characteristics, reasons for biologic discontinuation and relapse rate and severity post withdrawal including its management were analyzed. Cox proportional hazard analysis was done to identify predictors of relapse. Results 403 patients (Median age-35 yrs, range 6–75, 62.5% male, 58% Crohn’s disease:CD, 42% Ulcerative colitis:UC) received biologics for moderate-severe disease (steroid dependent or with complications) with a median follow up of 23 months (IQR-7–48 m, range- 3–228 m). 274 patients (68%) discontinued biologics. 77(28 %) were primary or secondary non-responders. 65 (24%) stopped due to financial constraints. 98 (36%) stopped after clinical and/or endoscopic remission. The other reasons included TB reactivation 8 (2.6%), non-TB infection-5 (2%); infusion reactions: 4 (1.5%); non compliance 14 (5%), aggravated psoriasis 2(1%) and death(1). 87/274 (32%) relapsed after stopping biologics. 187/274 (68%) were in remission over a median follow up of 24 months (IQR: 10–51 months). 52/87(60%) relapsed in first year and 67/87(77%) in 2 years. Most relapses were mild and responded to steroids 43 (49.4%) or re-treatment with biologics 34 (39%). 10 patients (11%) needed surgery. On Cox proportional hazard analysis, perianal/fistulizing disease (HR-2.03, 95% CI-1.1–3.8, p=0.027) and steroid dependent/resistant disease (HR-1.79, 95% CI-1.1–2.9, p=0.019) were associated with a higher risk of relapse after withdrawal of therapy. Patients who stopped after clinical and endoscopic remission had lower likelihood of relapse after biologics discontinuation(HR-0.48, 95% CI-0.29–0.80, p=0.005). Conclusion The relapse rates on discontinuation of biologic therapy was low in patients with clinical and endoscopic remission particularly in non-fistulizing, disease. Most relapses were mild. Majority of the patients with an initial severe disease had a milder course post withdrawal of biologic therapy suggesting that biologics could alter the natural course of the disease. Further multi-centre and long term studies are warranted.