London Health Sciences Centre Research Articles

Abstract PO3-03-09: Clinical Significance of Grade in Triple Negative Breast Cancer

Abstract Triple negative breast cancer (TNBC) is a heterogeneous cancer type that lacks receptors for estrogen (ER), progesterone (PR), and human epidermal growth factor receptor-2 proteins (HER-2). An important prognostic factor for breast cancer patients is the tumour grade, which is the degree of cell proliferation or differentiation of the tumour cells from normal cells. In our initial study involving 305 TNBC patients from 2004-2017 at Windsor Regional Hospital Cancer Centre, we found a statistically significant difference between grade 2 and grade 3 patients, with grade 2 predicting significantly inferior progression-free and overall survival. In our initial study, the overall survival rates for grade 1, 2, and 3 tumours were 90.12%, 64.4%, and 77.2% respectively (p = 0.019) with relapse rates of 70%, 55.6%, and 75.6% respectively (p = 0.04). Our current study is an attempt to validate these initial findings by expanding our data set to include data from the London Health Sciences Centre. A literature review on TNBC and grade was conducted, followed by a retrospective chart review for 305 TNBC patients from the Windsor Regional Hospital and 515 TNBC patients from the London Health Sciences Centre. The parameters for data collection included patient demographics, tumour demographics, therapies, and patient outcomes. We calculated all patient stages using both American Joint Committee on Cancer 7th edition (AJCC7) and the updated AJCC8 staging systems. Initial review of the data supports our earlier findings with a relapse rate of 12.5% in patients with grade 3 tumours and 17% in patients with grade 1 and grade 2 tumours. The completed data set will be analyzed and presented at the conference. Validating our previous findings of significantly inferior patient outcomes for grade 2 compared to grade 3 patients may alter the staging system used for TNBC patients. Citation Format: Mah-noor Malik, Neya Ramanan, Sarang Upneja, Muriel Brackstone, Lisa Porter, Bre-Anne Fifield, Caroline Hamm. Clinical Significance of Grade in Triple Negative Breast Cancer [abstract]. In: Proceedings of the 2023 San Antonio Breast Cancer Symposium; 2023 Dec 5-9; San Antonio, TX. Philadelphia (PA): AACR; Cancer Res 2024;84(9 Suppl):Abstract nr PO3-03-09.

The Use of Ipratropium Bromide for the Treatment of Pediatric Sialorrhea: A Retrospective Clinical Case Series.

This retrospective review documents the experience of ipratropium bromide use among pediatric patients with sialorrhea at our multidisciplinary sialorrhea clinic at Children's Hospital at London Health Sciences Centre (LHSC). A retrospective chart review of patients diagnosed with sialorrhea at our multidisciplinary clinic between January 2015 and June 2021 was completed. Data on patient demographics, comorbidities, clinical presentation, previous interventions, quality of life, and medication adverse side effects was collected. Drooling Frequency and Severity Scale (DFSS) scores were reviewed to compare sialorrhea management pre- and post-treatment with topical 0.03% ipratropium bromide nasal solution. A descriptive analysis and Wilcoxon signed rank tests were conducted to compare pre- versus post-treatment DFSS scores. A total of 12 patients presented for follow-up and were included in the final analysis. At the pre-treatment visit, the median DFSS score was 4 for frequency and 5 for severity. Post-treatment, median DFSS score was 3 for frequency and 4.5 for severity, (P = .020 and .129, respectively). Minimal adverse effects were encountered. Ipratropium bromide provided a statistically significant benefit for drooling frequency in the patients studied and may present an additional topical medical option for pediatric sialorrhea with limited adverse effects.

Ischemic Stroke in the Cardiac Surgery Intensive Care Unit: A Quality Improvement Study

ObjectiveTo investigate the frequency of stroke and code stroke activation, and the factors influencing code stroke management in postoperative cardiac surgical patients. DesignA retrospective quality improvement study conducted between January 1st, 2016, and December 31st, 2021. SettingCardiac Surgery Recovery Unit (CSRU) at London Health Sciences Centre (LHSC) in London, Ontario, Canada. ParticipantsPost-cardiac surgery patients aged 18 years or older who developed ischemic stroke during their admission to the CSRU. InterventionsNo specific interventions were administered as part of this study. “Code Stroke" activation mobilizes a specialized team. The objectives include assessment by a physician within 10 minutes, obtaining neuroimaging and interpretation within 45 minutes, and commencement of treatment within 60 minutes. Measurements and Main ResultsThe incidence rate of stroke in the CSRU was 1.3%, and 34% of these cases had code stroke activated. The last known well time was 11 +/- 8 hours. The most common reasons for not activating code stroke were not meeting both timing and clinical criteria. The average time to Computed Tomography (CT) scan was 36 +/- 22 minutes. Among patients who had code stroke activated, 24% had large vessel occlusion (LVO), and 67% of those with LVO had an established stroke on their initial CT. ConclusionCode stroke was activated in only one-third of patients who experienced a stroke following cardiac surgery. Additionally, out of those who had code stroke activated, only one-fourth were diagnosed with LVO. Among those with LVO, two-thirds were found to have a well-established stroke on non-contrast CT scans and were deemed ineligible for intervention.

A236 THE EFFECTIVENESS AND SAFETY OF DUAL ADVANCED THERAPIES IN PATIENTS WITH INFLAMMATORY BOWEL DISEASE: A CASE-SERIES

Abstract Background Patients with inflammatory bowel disease (IBD) refractory to medical therapy and patients with IBD and concurrent extra-intestinal manifestations (EIMs) pose a challenge within gastroenterology. The small number of approved agents for IBD limits therapeutic options for this population. Utilizing a combination of newer biologic therapies with favourable safety profiles may provide a safe and efficacious option for treating patients with refractory disease or patients with well-controlled IBD but uncontrolled EIMs. Aims The aim of our study was to assess the safety and efficacy of dual advanced therapies for patients with IBD. Methods Patients at London Health Sciences Centre and St. Joseph’s Healthcare Centre on dual advanced therapies for inflammatory bowel disease were retrospectively assessed for a minimum period of 12 months. Major bacterial infection, adverse events, endoscopic, histologic, and clinical remission of IBD, and remission of EIMs of IBD were assessed. Results Five patients with Crohn’s disease receiving dual advanced therapies were identified. Stricturing Crohn’s disease was the predominant phenotype in 80% of the patients. One patient had perianal fistulizing disease. Dual therapy was initiated for concurrent management of EIMs in 80% of patients (enteropathic arthritis in 2 patients, spondyloarthritis in 2 patients, rheumatoid arthritis in 1 patient) and for refractory IBD in one patient. The majority of patients were on a combination of a tumour-necrosis-factor inhibitor and vedolizumab. Other advanced therapies included JAK inhibitors and ustekinumab. The patients were predominantly female (80%) and age at diagnosis was ampersand:003C50 years old in 80% of patients. No adverse events or major bacterial infections were observed during dual therapy. At the end of follow-up, all 5 patients were in clinical remission of their IBD and 4 patients demonstrated endoscopic remission. Only 60% of patients had remission of their EIMs within the follow-up period. Conclusions Our findings suggest that dual advanced therapies are safe and may represent a long-term treatment option for complicated patients with IBD. Funding Agencies None

A67 REDUCING INAPPROPRIATE GAMMA-GLUTAMYL TRANSFERASE TESTING FOR INPATIENTS: A QUALITY IMPROVEMENT INITIATIVE IN LAB WASTE REDUCTION APPLYING THE MODEL FOR CONTINUOUS IMPROVEMENT

Abstract Background Review of the literature identifies a rising trend in laboratory testing, with over 30% of tests estimated to be inappropriately repeated. Laboratory overutilization increases healthcare costs, and can lead to overdiagnosis, overtreatment and negative health outcomes. Indications for repeat Gamma Glutamyl Transferase (GGT) testing in adults are limited, particularly repeat testing within the same admission. Aims Our aim was to reduce the inappropriate ordering of repeat GGT testing by 25% for all inpatients at the London Health Sciences Centre (LHSC) over a one-year study period. Methods An interprofessional team was created to help engage relevant stakeholders, collect baseline data and reassess the indications for GGT testing. A combination of root cause analysis tools, specifically the Ishikawa diagram and Pareto chart, were employed to identify potential factors contributing to the overutilization of GGT testing. After prioritizing potential solutions, intervention bundles were developed, and Plan-Do-Study-Act (PDSA) cycles were created to target correctable factors. In PDSA cycle #1, the process started by eliminating GGT as a laboratory testing option in the three most commonly used admission order care sets. Considering the hierarchy of intervention effectiveness, PDSA cycle #2 involved implementing a computerized Clinical Decision Support (CDS) system to restrict the reordering of GGT tests within 72 hours of the same admission. Results Baseline data showed that in 2022, a total of 62,542 GGT tests were ordered, with an average of approximately 5,200 GGT tests ordered per month. Of these, 16.4% were ordered through the top 3 most prevalent admission order care sets, and around 25% of all GGT tests were repeats within 72 hours of admission. Referring to Figure 1, PDSA cycle #1 yielded no significant reduction in GGT testing. PDSA cycle #2 successfully reduced the proportion of repeat GGT tests ordered by 12% within two months of implementation, leading to an estimated annualized cost savings of approximately $37,440. Conclusions Our results establish the effectiveness of CDS systems in reducing laboratory testing overutilization, suggesting their superiority to individual care set targeting interventions, and emphasize the potential for cost-effective CDS development in contemporary healthcare. Funding Agencies None

A284 EVALUATING THE INCIDENCE OF MAJOR GASTROINTESTINAL BLEEDING IN PATIENTS WITH CIRRHOSIS ON ANTICOAGULATION THERAPY: A TERTIARY SINGLE CENTRE EXPERIENCE

Abstract Background Patients with chronic liver disease, especially those with cirrhosis, face an increased risk of bleeding and thrombosis due to hemostasis dysregulation. In such cases, prescribing anticoagulation therapy requires a cautious approach, given the inherent risk-reduction in thrombosis alongside a suspected elevated bleeding risk. Aims Perform a retrospective study to evaluate anticoagulation safety and gastrointestinal bleeding incidence in cirrhotic patients. Methods A retrospective study was conducted at the University Hospital of London Health Sciences Centre, involving patients who attended outpatient hepatology clinics between 2010 and 2022. To be eligible, patients had to be 18 years or older and have confirmed cirrhosis through imaging, radiology, or pathology. They were monitored for up to 5 years for the primary outcome, which was major gastrointestinal bleeding requiring hospitalization. Exclusions included patients with underlying hematologic or thrombotic conditions contributing to abnormal hemostasis beyond cirrhosis and those who underwent liver transplantation. Descriptive statistics were provided, such as means and standard deviations for continuous variables, and proportions/percentages for categorical ones. Group comparisons utilized the Student's t-test for continuous variables and chi-squared tests for categorical variables. Univariate and multivariate logistic regression were employed to calculate odds ratios and their associated 95% confidence intervals for the primary outcome Results We retrospectively enrolled 300 patients, with 34.0% having cirrhosis and anticoagulation history. The average age was 63.1 years [95% CI 61.7 – 64.6], and 43.7% were female. Atrial fibrillation was the primary reason for anticoagulation (53.9%). Cirrhotic patients on anticoagulation had a 13.1% bleeding rate, while those without had 18.6% (p-value = 0.207, not significant). Univariate analysis suggested a possible link between anticoagulation and bleeding risk (OR 1.51 [95% CI 0.79 – 2.89]). No covariates predicted bleeding in univariate logistic regression. In multivariate analysis adjusting for age and sex, the odds ratio remained at 1.50 [95% CI 0.78 – 2.88]. The study hints at a higher bleeding risk in cirrhotic patients on anticoagulation, but more statistical power is needed, either through a larger sample or a multicenter approach. Conclusions To further investigate the association between anticoagulation and bleeding risk in cirrhotic patients, a larger multicentre study with increased enrollment is required. Nonetheless, interim findings do suggest the potential existence of an associated bleeding risk in cirrhotic patients undergoing anticoagulation therapy, albeit with a small observed effect size and uncertain clinical significance. Funding Agencies None

Evaluating yield and utilization of ganglioside antibody testing in clinical practice

Background and objectivesGanglioside antibodies can help diagnose distinct acute and chronic inflammatory neuropathies including axonal variants of Guillain-Barre syndrome, Miller-Fisher syndrome (MFS), multifocal motor neuropathy, and chronic sensory ataxic neuropathies. Because ganglioside antibody testing may be routinely ordered in patients with suspected inflammatory neuropathy, we sought to evaluate its yield and utilization in clinical practice. MethodsWe performed a retrospective chart review of all patients at London Health Sciences Centre who underwent ganglioside antibody testing between April 2019 and August 2023. The disease phenotype was determined for each patient, and the proportion of all tests that yielded a true-positive result was calculated. Ganglioside antibody positivity was classified as a true-positive result if the disease phenotype was robustly associated with the detected ganglioside antibody and there was no other more likely diagnosis. ResultsWe identified 92 patients who underwent ganglioside antibody testing. One patient (1%) was classified as having a true-positive result; this patient had GQ1b-IgG positivity with MFS. Among 92 patients tested, 20 patients (22%) had a disease phenotype that was considered to be robustly associated with ganglioside antibody positivity. ConclusionsThe yield of ganglioside antibody testing in clinical practice is low. We found that this testing is frequently ordered in patients with disease phenotypes that are not robustly associated with ganglioside antibody positivity, indicating that suboptimal test utilization is a primary contributor to its low yield. Restricting ganglioside antibody testing to patients with characteristic disease phenotypes would be valuable to improving yield and utilization of this testing.

Deep learning system for true- and pseudo-invasion in colorectal polyps

Over 15 million colonoscopies were performed yearly in North America, during which biopsies were taken for pathological examination to identify abnormalities. Distinguishing between true- and pseudo-invasion in colon polyps is critical in treatment planning. Surgical resection of the colon is often the treatment option for true invasion, whereas observation is recommended for pseudo-invasion. The task of identifying true- vs pseudo-invasion, however, could be highly challenging. There is no specialized software tool for this task, and no well-annotated dataset is available. In our work, we obtained (only) 150 whole-slide images (WSIs) from the London Health Science Centre. We built three deep neural networks representing different magnifications in WSIs, mimicking the workflow of pathologists. We also built an online tool for pathologists to annotate WSIs to train our deep neural networks. Results showed that our novel system classifies tissue types with 95.3% accuracy and differentiates true- and pseudo-invasions with 83.9% accuracy. The system’s efficiency is comparable to an expert pathologist. Our system can also be easily adjusted to serve as a confirmatory or screening tool. Our system (available at http://ai4path.ca) will lead to better, faster patient care and reduced healthcare costs.

SH2B3 Mutations in Patients with JAK2-Negative Erythrocytosis

Introduction: Erythrocytosis is a common reason for referral to Hematology clinics. Molecular testing for JAK2 mutations, often by next-generation sequencing (NGS), has become part of the diagnostic workup of patients with erythrocytosis, increasing the molecular characterization of this previously undifferentiated patient population. A recent study (Bhai et al. 2022) found that 4% of patients referred for JAK2-negative erythrocytosis harboured variants in the SH2B3 gene, which encodes the LNK protein, a known negative regulator of JAK2/STAT5 signaling. The objective of this study was to characterize a cohort of patients with JAK2-negative erythrocytosis with SH2B3 mutations, evaluating clinical presentation, hematologic parameters, as well as cardiovascular and thrombotic outcomes. Methods: All adult patients referred to the London Health Sciences Centre, a tertiary care centre in Southwestern Ontario, for assessment of erythrocytosis (hemoglobin >160g/L in women; >165g/L in men) between January 1, 2018 and December 31, 2022 and who underwent NGS testing were reviewed. NGS testing was performed using the Oncomine Myeloid Research Assay (Thermofisher Scientific, MA, USA). Patients with JAK2, CALR, MPL, or BCR::ABL1 mutations were excluded. Patients without JAK2 mutations ( JAK2-negative) with variants in SH2B3 were further characterized. Clinical variables included risk factors for secondary erythrocytosis and occurrence of arterial/venous thrombotic events. Laboratory variables included complete blood count and white cell differential. Results: Sixteen patients with JAK2-negative erythrocytosis met inclusion criteria with mutations in SH2B3. All mutations in SH2B3 were characterized as Tier III variants (Variants of Uncertain Significance). Laboratory and clinical parameters in this patient population are presented in Table 1. Mean hemoglobin was 181 g/L, hematocrit 0.54 L/L, leukocyte count 7.2 x10 9 cells/L, and platelets 229 x10 9 cells/L. Secondary causes of erythrocytosis were identified in 13 (81%) patients: 10 (63%) reported active smoking or had a smoking history, 4 (25%) had obstructive sleep apnea, 2 (13%) had chronic obstructive pulmonary disease, 1 (6%) had a right-to-left cardiac shunt, 4 (25%) were on an SGLT2 inhibitor, and 1 (6%) reported testosterone use. Of note, one patient had a history of stroke and another had a myocardial infarction both of which predated the development of erythrocytosis and NGS testing. One patient had a recurrent deep vein thrombosis (DVT) at the time of NGS testing. Full molecular data and comparative analysis with other cases of JAK2-negative erythrocytosis will be presented at ASH. Discussion: SH2B3 mutations have been identified in rare cases of congenital erythrocytosis and implicated in the pathogenesis of erythropoiesis. To our knowledge, this is the largest cohort of patients with JAK2-negative erythrocytosis with variants in SH2B3 reported to date. This cohort showed similar laboratory parameters and prevalence of secondary risk factors for erythrocytosis as previously reported in the general population of patients with JAK2-negative erythrocytosis at our centre (Chin-Yee et al. 2022). Thrombotic outcomes were also similar, and lower than patients with polycythemia vera. Given the high prevalence of potential secondary causes of erythrocytosis in our cohort we cannot confirm that SH2B3 mutations are causally implicated in elevated hemoglobin in these cases. Nonetheless, we cannot exclude that SH2B3 variants may confer an additional risk factor for erythrocytosis in this patient population. Further research is required to elucidate the potential impact of SH2B3 variants in patients with JAK2-negative erythrocytosis.

Improving wound swab collection in paediatric patients: a quality improvement project

Microbiology sample swabs may be unsuccessful or rejected for a variety of reasons. Typically, errors occur in the preanalytical phase of sample collection. Errors with collection, handling and transport can...

Evaluation of hospital management of paediatric out-of-hospital cardiac arrest

IntroductionPediatric out of hospital cardiac arrest (POHCA) is rare, with high mortality and neurological morbidity. Adherence to Pediatric Advanced Life Support guidelines standardizes in-hospital care and improves outcomes. We hypothesized that in-hospital care of POHCA patients was variable and deviations from guidelines were associated with higher mortality. MethodsPOHCA patients in the London-Middlesex region between January 2012 and June 2020 were included. The care of children with ongoing arrest (intra-arrest) and post-arrest outcomes were reviewed using the Children’s Hospital, London Health Sciences Centre (LHSC) patient database and the Adverse Event Management System. Results50 POHCA patients arrived to hospital, with 15 (30%) patients admitted and 2 (4.0%) surviving to discharge, both with poor neurological outcomes and no improvement at 90 days. Deviations occurred at every event with intra-arrest care deviations occurring mostly in medication delivery and defibrillation (98%). Post-arrest deviations occurred mostly in temperature monitoring (60%). Data missingness was 15.9% in the intra-arrest and 1.7% in the post-arrest group. DiscussionDeviations commonly occurred in both in-hospital arrest and post-arrest care. The study was under-powered to identify associations between DEVs and outcomes. Future work includes addressing specific deviations in intra-arrest and post-arrest care of POHCA patients and standardizing electronic documentation.

Prospective Evaluation of Pregnancy Outcomes after Gestational Exposure to Prazosin.

Prazosin is an antihypertensive medication which can be used to help with post-traumatic stress disorder (PTSD) symptoms. Little data is currently available on its safety in pregnancy. To assess the fetal and pregnancy safety associated with prazosin exposures in early pregnancy. Subjects were 11 patients who took prazosin during pregnancy and were counselled at the FRAME clinic in London Health Sciences Centre (Ontario, Canada) between January 1, 2000 to December 31, 2021. Data on their other exposures and pregnancy outcomes were collected from medical records and through telephone questionnaires. It was found that 6/11 (54.5%) subjects did not report any adverse outcomes and were uneventful pregnancies. There were 2 miscarriages. Birthweights were within the normal range for the remaining 9 pregnancies. Adverse events reported were consistent with background population expectation, including: 1 postpartum hemorrhage, 1 case of preeclampsia, 1 preterm birth, 2 NICU admissions, and 2 caesarean sections. For these 11 subjects, pregnancy outcomes after exposure to prazosin were consistent with typical outcomes from unexposed pregnancies. More data are needed to conclude that prazosin is safe for use in pregnant subjects. However, the lack of adverse effects above baseline is reassuring to future patients who may be unintentionally exposed to prazosin while pregnant. Therefore, this study contributes valuable data toward monitoring safety of prazosin in Pregnancy.

Expeditious formation of London Health Sciences Centre (LHSC) adult ground critical care transport team in aid of 3rd wave coronavirus disease 2019 (COVID-19) pandemic in Ontario, Canada

Expeditious formation of London Health Sciences Centre (LHSC) adult ground critical care transport team in aid of 3rd wave coronavirus disease 2019 (COVID-19) pandemic in Ontario, Canada

The effect of late-onset CMV infection on the outcome of renal allograft considering initial graft function.

Delayed graft function (DGF) increases the renal allograft failure risk. Late-onset Cytomegalovirus (CMV) infection's effect on the association between DGF and allograft failure has not been determined. In this retrospective cohort, we included all renal allograft recipients at London Health Sciences Centre from January 1, 2014 to December 30, 2017, and continued clinical follow-up until February 28, 2020. We determined whether late-onset CMV infection affects the association between DGF and allograft failure in stratified and Cox proportional hazard analyses. Of 384 patients (median age [interquartile range]: 55 [43.3-63]; 38.7% female), 57 recipients (14.8%) were diagnosed with DGF. Patients with DGF were at a greater risk of CMV infection than patients without DGF (22.8% vs. 11.3%, p = .017). Late-onset CMV infection (odds ratio [OR]: 4.7, 95% CI: 2.07-10.68) and rejection (OR: 9.59, 95% CI: 4.15-22.16) significantly increased the risk of allograft failure in recipients with DGF. Patients with DGF had a significantly greater risk of graft failure than those without DGF (17.5% vs. 6.1%, p = .007). In the adjusted Cox hazard model, CMV infection significantly increased the risk of allograft failure (aHR: 3.19, 95% CI: 1.49-6.84). Late-onset CMV infection considerably increased the risk of graft failure in patients with DGF. A hybrid preventive model including prophylaxis followed by CMV-specific cell-mediated immunity monitoring may decrease the risk of allograft failure in recipients with DGF.

Genetic testing in monogenic early-onset atrial fibrillation.

A substantial proportion of atrial fibrillation (AF) cases cannot be explained by acquired AF risk factors. Limited guidelines exist that support routine genetic testing. We aim to determine the prevalence of likely pathogenic and pathogenic variants from AF genes with robust evidence in a well phenotyped early-onset AF population. We performed whole exome sequencing on 200 early-onset AF patients. Variants from exome sequencing in affected individuals were filtered in a multi-step process, prior to undergoing clinical classification using current ACMG/AMP guidelines. 200 AF individuals were recruited from St. Paul's Hospital and London Health Sciences Centre who were ≤ 60 years of age and without any acquired AF risk factors at the time of AF diagnosis. 94 of these AF individuals had very early-onset AF ( ≤ 45). Mean age of AF onset was 43.6 ± 9.4 years, 167 (83.5%) were male and 58 (29.0%) had a confirmed family history. There was a 3.0% diagnostic yield for identifying a likely pathogenic or pathogenic variant across AF genes with robust gene-to-disease association evidence. This study demonstrates the current diagnostic yield for identifying a monogenic cause for AF in a well-phenotyped early-onset AF cohort. Our findings suggest a potential clinical utility for offering different screening and treatment regimens in AF patients with an underlying monogenic defect. However, further work is needed to dissect the additional monogenic and polygenic determinants for patients without a genetic explanation for their AF despite the presence of specific genetic indicators such as young age of onset and/or positive family history.

Impact of COVID-19-related health care disruptions on pathologic cancer staging during the first pandemic year: a retrospective cohort study from March 2018 to March 2021.

The COVID-19 pandemic has created major disruptions in cancer care, with reductions in diagnostic tests and treatments. We evaluated the impact of these health care-related changes on cancer staging by comparing cancers staged before and during the pandemic. We performed a retrospective cohort study at London Health Sciences Centre and St. Joseph's Health Care London, London, Ontario, Canada. We evaluated all pathologically staged breast, colorectal, prostate, endometrial and lung cancers (the 5 most common cancers by site, excluding nonmelanoma skin cancer) over a 3-year period (Mar. 15, 2018-Mar. 14, 2021). The pre-COVID-19 group included procedures performed between Mar. 15, 2018, and Mar. 14, 2020, and the COVID-19 group included procedures performed between Mar. 15, 2020, and Mar. 14, 2021. The primary outcome was cancer stage group, based on the pathologic tumour, lymph node, metastasis system. We performed univariate analyses to compare demographic characteristics, pathologic features and cancer stage between the 2 groups. We performed multivariable ordinal regression analyses using the proportional odds model to evaluate the association between stage and timing of staging (before v. during the pandemic). There were 4055 cases across the 5 cancer sites. The average number of breast cancer staging procedures per 30 days increased during the pandemic compared to the yearly average in the pre-COVID-19 period (41.3 v. 39.6), whereas decreases were observed for endometrial cancer (15.9 v. 16.4), colorectal cancer (21.8 v. 24.3), prostate cancer (13.6 v. 18.5) and lung cancer (11.5 v. 15.9). For all cancer sites, there were no statistically significant differences in demographic characteristics, pathologic features or cancer stage between the 2 groups (p > 0.05). In multivariable regression analysis, for all cancer sites, cases staged during the pandemic were not associated with higher stage (breast: odds ratio [OR] 1.071, 95% confidence interval [CI] 0.826-1.388; colorectal: OR 1.201, 95% CI 0.869-1.661; endometrium: OR 0.792, 95% CI 0.495-1.252; prostate: OR 1.171, 95% CI 0.765-1.794; and lung: OR 0.826, 95% CI 0.535-1.262). Cancer cases staged during the first year of the COVID-19 pandemic were not associated with higher stage; this likely reflects the prioritization of cancer procedures during times of reduced capacity. The impact of the pandemic period on staging procedures varied between cancer sites, which may reflect differences in clinical presentation, detection and treatment.

Prolonged Corticosteroids Without Maintenance Immunotherapy for Treatment of Anti-LGI1 Encephalitis: Analysis of Outcomes and Relapse Rate.

To analyze outcomes and relapse rate of patients with anti-LGI1 encephalitis referred to the London Health Sciences Centre Autoimmune Neurology Clinic, where prolonged (≥3 months) corticosteroids without steroid-sparing maintenance immunotherapy are the typical treatment approach. Retrospective chart review. Eighteen patients with anti-LGI1 encephalitis were identified. The median age at symptom onset was 65 years (interquartile range [IQR]: 62-70 years), and 13 (72%) were men. All patients received corticosteroids, with a median treatment duration of 6.3 months (IQR: 3.8-9.6 months). Other first-line immunotherapies used included IV immunoglobulin (n = 11, 61%) and plasma exchange (n = 2, 11%). Three patients referred for refractory disease received rituximab as second-line immunotherapy. No other steroid-sparing maintenance immunotherapies for anti-LGI1 encephalitis were prescribed. At last follow-up, 16/18 (89%) achieved seizure freedom, and 16/18 (89%) had a favorable modified Rankin Scale score. Among 9 patients who had ≥2 years of follow-up from symptom onset, there was disease relapse in 3 (33%), 2 of whom had been referred for refractory disease. Among our patients with anti-LGI1 encephalitis who typically received prolonged corticosteroids without steroid-sparing maintenance immunotherapy, outcomes were generally favorable, and relapses were uncommon outside of refractory disease. Further investigation is needed to clarify the optimal corticosteroid regimen and role of steroid-sparing maintenance immunotherapy in anti-LGI1 encephalitis.

Same-Day Discharge for Thyroidectomy: Why the Holdup?

Clinical ThyroidologyVol. 35, No. 4 Thyroid SurgerySame-Day Discharge for Thyroidectomy: Why the Holdup?Eric Walser and Jesse D. PasternakEric Walser Division of General Surgery, Division of Critical Care, Western University Schulich School of Medicine, London Health Sciences Center, London, Ontario, Canada. Section of Endocrine Surgery, Department of Surgery, University of Toronto, University Health Network, Toronto, Ontario, Canada.Search for more papers by this author and Jesse D. Pasternak Division of General Surgery, Division of Critical Care, Western University Schulich School of Medicine, London Health Sciences Center, London, Ontario, Canada. Section of Endocrine Surgery, Department of Surgery, University of Toronto, University Health Network, Toronto, Ontario, Canada.Search for more papers by this authorPublished Online:11 Apr 2023https://doi.org/10.1089/ct.2023;35.167-169AboutSectionsView articleView Full TextPDF/EPUB Permissions & CitationsPermissionsDownload CitationsTrack CitationsAdd to favorites Back To Publication ShareShare onFacebookTwitterLinked InRedditEmail View articleFiguresReferencesRelatedDetails Volume 35Issue 4Apr 2023 Information© Copyright 2023, Mary Ann Liebert, Inc.To cite this article:Eric Walser and Jesse D. Pasternak.Same-Day Discharge for Thyroidectomy: Why the Holdup?.Clinical Thyroidology.Apr 2023.167-169.http://doi.org/10.1089/ct.2023;35.167-169Published in Volume: 35 Issue 4: April 11, 2023PDF download

Comparison of the Liverpool Causality Assessment Tool vs. the Naranjo Scale for predicting the likelihood of an adverse drug reaction: A retrospective cohort study.

The aim of this study is to compare the Liverpool Causality Assessment Tool vs. Naranjo Scale for screening suspected adverse drug reaction (ADR) cases. We retrospectively reviewed patient charts with a history of suspected ADR, scored using both tools, and determined how each correlates with laboratory and other investigations. A total of 924 charts from the Clinical Pharmacology Clinic at the London Health Sciences Centre were reviewed, and 529 charts contained objective findings to support or against the diagnosis of ADR. The participant age ranged from 1 month to 93 years. We determined that the sensitivity (SN) and specificity (SP) of Liverpool and Naranjo tools for predicting ADRs with scores ranging from Possible to Definite were considered positive and Unlikely/Doubtful as negative for ADR. These results were confirmed by laboratory or clinical (re-challenge) testing in 529 cases. Liverpool causality tool had SN of 97.2 ± 2.4% and SP of 2.3 ± 1.57%. The positive (PPV) and negative predictive values (NPV) were 34.1 and 61.5%, respectively. The Naranjo Scale had SN of 81.2 ± 5.69% and SP of 13.2 ± 3.56%. PPV and NPV were 32.7 and 57.5%, respectively. The Liverpool Causality Assessment Tool is a more sensitive tool than the Naranjo Scale in the assessment of possible ADRs, but both tools have poor SP. The Liverpool Tool can be a useful screening tool in settings where other tests may not be readily available. However, the low PPV and NPV of both tools suggest that to pursue further testing is needed to confirm or deny an ADR.

Abstract WP187: Takotsubo Cardiomyopathy And Subsequent Risk Of Major Adverse Cardiovascular Events: A Cluster Analysis

Introduction: Takotsubo Cardiomyopathy (TCM) is a form of transient regional left ventricular dysfunction. The risk of MACE after TCM is poorly understood but appears to be higher. Predictors of cardiovascular (CV) events remain unclear. Methods: Retrospective study of patients admitted to London Health Sciences Centre hospitals with TCM between 2014 and 2021. Clinical data were collected. MACE during follow-up (FU) included stroke, acute coronary syndrome, admission for heart failure or CV death. Outcomes were assessed until the end of FU. A two-step cluster analysis was used to stratify patients' phenotypes. Variables for clustering included: TCM aetiology, age, sex, hypertension, dyslipidemia, smoking, previous stroke, diabetes, chronic kidney disease, ejection fraction, atrial fibrillation (AF), and antithrombotics. A Cox proportional-hazards model was used to determine the association between clusters and MACE. Results: We included 152 patients (88.8% females). Median age was 72.5 [65.5-80.0] years and aetiologies were emotional stress (31.6%), neurogenic (6.6%), acute medical conditions (23.7%), and unknown (38.2%). Overall, 80% received antithrombotic drugs post-TCM. At a median FU of 22.0 [8.2-44.5] months, 11.8% of the patients experienced a MACE. Cluster 1 (n=41) included more male patients (31.7%), and the highest rate of hypertension (100%), dyslipidemia (92.7%), smoking (31.7%), previous stroke (14.6%), and antiplatelet use (82.9%). Cluster 2 (n=21) included older patients (78 [73.5-84.5] years) with the highest prevalence of diabetes (23.8%), AF (95.2%) and anticoagulation (71.4%). Cluster 3 (n=90) included younger patients (69 [62.7-84.0] years) with the lowest burden of CV risk factors (CHA 2 DS 2 VASc 2.0 [1.0-2.2]) and antithrombotic therapy (68.9%). Cluster 1 was associated with increased risk of MACE (OR 2.9; 95%CI 1.1-7.3; p=0.02) and stroke (OR 4.9; 95%CI 1.1-20.6; p=0.02). Conclusion: CV events are relatively frequent after a diagnosis of TCM, affecting over one-tenth of patients. We identified a high-risk phenotype, predominantly characterized by male sex, a higher burden of CV comorbidities, and low anticoagulation rates, which was associated with an increased risk of MACE and stroke after TCM.