Mean Total Days Research Articles

Assessment of Surgical Complications Strengthen the Relationship Between Spine Surgery Procedure Intensity and Chronic Opioid Use After Surgery.

Prospective cohort using routinely collected health data. To compare opioid use based on surgery intensity (low or high). Many factors influence an individual's experience of pain. The extent to which postsurgical opioid use is influenced by the severity of spine surgery is unknown. The participants were individuals undergoing spine surgery in a large military hospital. Procedures were categorized as low intensity (eg, microdiscectomy and laminectomy) and high intensity (eg, fusion and arthroplasty). The Surgical Scheduling System and Military Health System Data Repository were queried for healthcare utilization the 1 year before and after surgery. We compared opioid use after surgery between groups, adjusting for prior opioid use and surgical complications. A total of 342 individuals met the inclusion criteria, with mean age 45.4 years (SD 10.9), and 33.0% were women. Of these, 221 (64.6%) underwent a low-intensity procedure and 121 (35.4%) underwent a high-intensity procedure. Mean postoperative opioid prescription fills were greater in the high- versus low-intensity group (9.0 vs. 5.7; P <0.001), as were the mean total days' supply (158.9 vs. 81.8; P <0.001). Median morphine milligram equivalents (MMEs) were not significantly different (40.2 vs. 42.7; P =0.287). Of the cohort, 26.3% were chronic opioid users after surgery. Adjusted rates of long-term opioid use were not different between groups when only accounting for prior opioid use but significantly higher for the high-intensity group when adjusting for surgical complications (OR=2.08; 95% CI 1.09-3.97). Of the entire cohort, 52.5% was still filling opioid prescriptions after 6 months. Higher-intensity procedures were associated with greater postoperative opioid use than lower-intensity procedures. Chronic opioid use was not significantly different between surgical intensity groups when considering only prior opioid use. Chronic opioid use was significantly higher among higher intensity procedures when accounting for surgical complications. The presence of surgical complications is a stronger predictor of postsurgical long-term opioid use in high-intensity surgeries than history of opioid use alone. Level III.

Changes in End-of-Life Symptom Management Prescribing among Long-Term Care Residents during COVID-19

ObjectiveTo examine changes in the prescribing of end-of-life symptom management medications in long-term care (LTC) homes during the COVID-19 pandemic. DesignRetrospective cohort study using routinely collected health administrative data in Ontario, Canada. Setting and ParticipantsWe included all individuals who died in LTC homes between January 1, 2017, and March 31, 2021. We separated the study into 2 periods: before COVID-19 (January 1, 2017, to March 17, 2020) and during COVID-19 (March 18, 2020, to March 31, 2021). MethodsFor each LTC home, we measured the percentage of residents who died before and during COVID-19 who had a subcutaneous symptom management medication prescription in their last 14 days of life. We grouped LTC homes into quintiles based on their mean prescribing rates before COVID-19, and examined changes in prescribing during COVID-19 and COVID-19 outcomes across quintiles. ResultsWe captured 75,438 LTC residents who died in Ontario's 626 LTC homes during the entire study period, with 19,522 (25.9%) dying during COVID-19. The mean prescribing rate during COVID-19 ranged from 46.9% to 79.4% between the lowest and highest prescribing quintiles. During COVID-19, the mean prescribing rate in the lowest prescribing quintile increased by 9.6% compared to before COVID-19. Compared to LTC homes in the highest prescribing quintile, homes in the lowest prescribing quintile experienced the highest proportion of COVID-19 outbreaks (73.4% vs 50.0%), the largest mean outbreak intensity (0.27 vs 0.09 cases/bed), the highest mean total days with a COVID-19 outbreak (72.7 vs 24.2 days), and the greatest proportion of decedents who were transferred and died outside of LTC (22.1% vs 8.6%). Conclusions and ImplicationsLTC homes in Ontario had wide variations in the prescribing rates of end-of-life symptom management medications before and during COVID-19. Homes in the lower prescribing quintiles had more COVID-19 cases per bed and days spent in an outbreak.

Safety and Effectiveness of Fibrin Sheath Stripping of Pediatric Chest Ports

PurposeTo report the safety and effectiveness of fibrin sheath stripping of pediatric chest ports. Materials and MethodsFibrin sheath stripping procedures for pediatric chest ports between 2018 and 2023 were retrospectively reviewed. The treatment indication was the inability to aspirate blood from the port. The technical success, adverse events, days of primary and secondary service intervals, fluoroscopy time, and fluoroscopy dose were recorded. ResultsFibrin sheath stripping procedures were performed in 15 patients for a total of 18 procedures. All patients treated with fibrin sheath stripping had failed fibrinolytic treatment and a preprocedural fluoroscopy examination suggestive of fibrin sheath before attempting stripping. All fibrin sheath stripping procedures were technically successful. The median and mean total days of primary service interval from the date of port placement to the date of suspected fibrin sheath were 666 and 617 days, respectively. The median and mean total number of days of secondary service interval were 385 and 561 days, respectively. The mean fluoroscopy time was 16.9 minutes. The mean fluoroscopy air kerma was 29.8 mGy. No adverse events were observed. ConclusionsFibrin sheath stripping is a safe and effective minimally invasive option to maintain the function of pediatric chest ports.

311 A Twist in the Tale - Study of the Management of Sigmoid Volvulus (SV)

Abstract Aim As SV has no current NICE guidance, nor large UK reviews, there is a requirement to outline best practice in the management. A review was undertaken of SV cases to determine how variation in management affects outcomes. Method Forty five patients (35:10 M:F) (median age 79 years, 29-93) with SV contributing 95 admissions 2017-2019 were studied using electronic notes and imaging. Estimated costs per patient were calculated using national tariff documents. Results Two groups were identified: conservative (non-operative management) (n = 39) and operative (n = 6), with a 90-day mortality of 41.02% and 16.67% respectively. Mean total days in hospital for each patient was 28.49 (range 1-215), 18.17 for operative and 30.08 for conservative. Nineteen patients had readmissions for SV 2017-2019, 30 in 2013-2021. No readmissions occurred post-surgery. Estimated cost of SV admissions 2017-2019 was £934,151, with no significant difference in cost for operative versus conservative. Rigid sigmoidoscopy was performed in 65.26% (n = 62) of admissions, 38.71% (n = 24) were successful. Flexible sigmoidoscopy was performed in 61.05% (n = 58) of admissions, 17 without rigid. Decompression was achieved in 72.41% (n = 42) with flexible more successful than rigid sigmoidoscopy (p = &amp;lt;0.0001). Conclusions SV patients are mostly male, older, co-morbid and managed conservatively. Mortality is high but reduced in patients managed surgically. Without surgery, patients had multiple admissions, decompressions, and long hospital stays, leading to increased costs. This project recommends the consideration of surgery in order to improve patient outcomes. A prospective large-scale study is required to improve data.

Real-World Treatment Patterns in Patients with Vitiligo in the United States.

Vitiligo is an autoimmune disorder resulting in skin depigmentation, with limited approved treatment options. This study evaluated medication utilization and treatment patterns among patients in the first year following vitiligo diagnosis. This retrospective analysis of claims data from the Merative® MarketScan Research Databases included patients aged ≥ 12years newly diagnosed with vitiligo. Patients were identified between October 1, 2016, and April 30, 2021, and had ≥ 12months of continuous enrollment pre- and post-vitiligo diagnosis. Medication use, treatment line of therapy, time to and number of medication claims, and length of therapy were reported in the 12months post-vitiligo diagnosis. Results are reported separately for treatment initiators post-vitiligo diagnosis, patients with moderate-to-severe vitiligo, and adolescents (aged 12-17years). A total of 19,335 patients were included in the analysis, with half (N = 9648, 49.9%) not receiving any treatment during the 12-month follow-up. Switching was minimal among treatment initiators (N = 5845) in the 12months post-vitiligo diagnosis, with the most frequent first-line treatments being high-potency topical corticosteroids (25.4%), oral corticosteroids (23.1%), and topical calcineurin inhibitors (TCI, 14.7%). Adolescents initiating treatment (N = 486) most frequently received TCI (30.9%) as first-line therapy. Patients with moderate-to-severe vitiligo (N = 3462) were very likely to receive treatment during follow-up, with only 1.5% not receiving treatment. Among patients with no vitiligo treatment prior to diagnosis, time to first medication claim ranged from 51.9days (standard deviation [SD], 84.0) for TCI to 178.6days (SD 116.0) for systemic immunosuppressants; mean total days supplied ranged from 14.4days (SD 27.1) for oral corticosteroids to 121.0 (SD 114.0) for immunosuppressants. In this real-world study, a high proportion of patients did not receive any treatment. Among those receiving treatment, most were unlikely to switch or use a combination of treatments within the first year of vitiligo diagnosis.

Comparative Study of Short-Term Outcome between Laser Hemorrhoidoplasty and Milligan-Morgan Hemorrhoidectomy

Background: Due to the fear of postoperative pain and complications associated with open Milligan-Morgan (MM) surgery, mildly symptomatic patients often hesitate and delay undergoing surgical treatment for internal haemorrhoids. Laser Hemorrhoidoplasty (LHP) has been gaining popularity recently in the management of hemorrhoid. This study aimed to evaluate the efficacy of the LHP compared with MM surgery in the management of internal haemorrhoids. Materials and methods: This multi-center, open label, randomized controlled trial included 60 patietns with secondand third-degree internal haemorrhoids. The patients were randomized in a 1:1 ratio to receive either LHP (Group I) or conventional MM hemorrhoidectomy (Group II). Primary outcome parameter was postoperative pain assessed by Visual Anlougue Scale (VAS) at 24 hours, 7 days and 30 postoperative days. Results: Both the groups were comparable in terms of the demographic characteristics. The mean operation time was significantly lower in group I than group II (19.13±3.42 vs. 28.67±4.54 minutes, p&lt;0.001). The mean VAS score of pain at 24 hours and 7 days postoperative were significantly lower in group I than in group II (p&lt;0.001 and p&lt;0.004, respectively). At postoperative, 30 days the mean VAS scores were similar in both groups (p=0.722). The mean total days of consumed analgesic were significantly shorter in group I than in group II (7.94±5.79 vs. 11.01±2.96 days, p&lt;0.001). The mean time to return to regular activity was significantly earlier in group I than in group II (8.76±3.58 vs. 13.6±3.47, p&lt;0.001). Postoperative bleeding was less in group I than in group II (6.6% vs. 26.7%). The mean length of hospital stay, rate of complete resolution and need for medical treatment for residual symptom and repeated surgery were similar between two groups. Conclusion: LHP was associated with reduction of postoperative pain, postoperative bleeding, and administered with analgesics. So, if available LHP is preferred to open hemorrhoidectomy. IAHS Medical Journal Vol 5(2), Dec 2022; 15-19

Development and clinical application of a new sternal zenithal traction system in video-assisted percutaneous thoracoplasty

IntroductionVideo-assisted percutaneous thoracoplasty involves a complex surgical access with risk of damaging vital structures during the procedure. Historically, different traction and sternal elevation systems have been applied during the intervention to minimize the risk associated with the passage of the instruments between the sternum and the pericardium. Material and methodsA new sternal traction system is presented by means of an illustrated description. Clinical and sociodemographic data were extracted from the 36 patients operated in our center for Pectus Excavatum between July 2017 and August 2021. The Haller index was not applied as a criterion to determine the use or not of the sternal traction system. Patients were classified according to whether the sternal traction system (TE) or not (ST) had been employed. Statistical analysis of the data collected was performed with STATA, version 15.0 (StataCorp). ResultsBoth groups were comparable. Haller's Index was 4.19 ± 0.7 for the sternal traction (TE) group and 3.79 ± 0.3 for the no sternal traction (ST) group. In 25 of the patients the described traction system was used, and in 11 no traction system was used. All patients were operated on by the same surgeon. The mean operative time in minutes was 97.73 ± 46.2 for the ST group and 88.13 ± 18.1 for the TE group (p = 0.87). The mean total days of admission was 7.67 ± 0.82 (TE) and 7.73 ± 1.35 (ST). Mean days of intravenous PCA was 6.08 ± 0.72 (TE) and 5.89 ± 1.45 (ST). The mean number of epidural PCA days was 3.79 ± 0.5 (TE) and 3.36 ± 0.5 (ST) (p = 0.01). All patients presented a favorable postoperative evolution. None of the patients presented discomfort at the level of the sternal wounds during hospitalization. Cosmetic evolution was favorable in all patients. ConclusionsThe sternal traction system presented provides safety when performing retrosternal dissection and placement of the thoracoplasty bar, leading to a decrease in surgical time in cases with a Haller Index higher than 3.5. There have been no complications associated with its use, nor has there been an increase in the number of days of hospitalization or analgesic requirements. There are no aesthetic sequelae for the patients.

Personal protective equipment and adverse dermatological reactions among healthcare workers: Survey observations from the COVID-19 pandemic.

The pandemic of the 2019 novel coronavirus disease (COVID-19) has caused an unprecedented mobilization of the United States’ healthcare workforce. In addition to working extended hours under increased duress, healthcare professionals (HCP) of all stations have been making use of various types of personal protective equipment (PPE) with greatly increased frequency and duration. Current data regarding adverse skin reactions as a possible consequence of PPE use are, particularly in the United States, largely insufficient for policy-makers to make informed decisions regarding daily PPE use among HCP.The research vehicle employed by this study is a cross-sectional 25-item survey distributed via email to workers currently employed by a five-hospital system in southcentral Kentucky. This survey was used to collect information from hospital workers of all professional roles about their experiences during the COVID-19 pandemic, focusing on reports of adverse dermatological reactions and associated risk factors.Out of 879 respondents, 54.4% reported some type of skin irritation reaction. Skin irritation was significantly more prevalent among medical and medical support staff than non-medical hospital workers, with the highest prevalence among Certified Nurse Assistant (CNAs). Among clinical workers, those in dedicated COVID-19 units reported the highest prevalence of adverse skin reaction. The most common complaint was dryness/scaling of the skin (306 out of 439, 69.7%), and the most common location was the facial cheeks (305 out of 516, 59.1%). Among those who reported skin irritation, the average self-reported severity of skin reaction (on a scale of 1–5) was 2.00 ± 0.05, and the mean total days of skin reaction per month was 11.70 ± 0.39 days. Total days of irritation per month was found to be significantly related to “total days of PPE use per month,” “hours of PPE use per day,” “frequency of hand washing,” and “use of disinfecting UV irradiation.” Severity of skin reaction was found to be significantly related to “hours per day of PPE use,” “consecutive days of PPE use,” and “female sex.”Clinical workers that put in the most face-to-face time with patients, and those in dedicated COVID-19 units, had the highest risk of adverse skin reaction. Overall, skin reactions were found to be mild, even in those hospital workers with the heaviest PPE use. Because the widespread and consistent use of facial masks in public settings has become a key tool in our protracted struggle with SARS-CoV-2, these findings may help to ameliorate concerns that everyday facial mask and/or other PPE usage contributes to significant dermatologic morbidity among both medical professionals and public citizens.

Desarrollo y aplicación clínica de nuevo sistema de tracción cenital esternal en la toracoplastia percutánea videoasistida

IntroductionVideo-assisted percutaneous thoracoplasty involves a complex surgical access with risk of damaging vital structures during the procedure. Historically, different traction and sternal elevation systems have been applied during the intervention to minimize the risk associated with the passage of the instruments between the sternum and the pericardium. MethodsA new sternal traction system is presented by means of an illustrated description. Clinical and sociodemographic data were extracted from the 36 patients operated in our center for Pectus Excavatum between July 2017 and August 2021. The Haller index was not applied as a criterion to determine the use or not of the sternal traction system. Patients were classified according to whether the sternal traction system (TE) or not (ST) had been employed. Statistical analysis of the data collected was performed with STATA, version 15.0 (StataCorp). ResultsBoth groups were comparable. In 25 of the patients the described traction system was used, and in 11 no traction system was used. Haller's index was 4.19±0.7 for the TE group and 3.79±0.3 for the ST group. All patients were operated on by the same surgeon. The mean operative time in minutes was 97.73±46.2 for the ST group and 88.13±18.1 for the TE group (P=.87). The mean total days of admission was 7.67±0.82 (TE) and 7.73±1.35 (ST). Mean days of intravenous PCA was 6.08±0.72 (TE) and 5.89±1.45 (ST). The mean number of epidural PCA days was 3.79±0.5 (TE) and 3.36±0.5 (ST) (P=.01). All patients presented a favorable postoperative evolution. None of the patients presented discomfort at the level of the sternal wounds during hospitalization. Cosmetic evolution was favorable in all patients. ConclusionsThe sternal traction system presented provides safety when performing retrosternal dissection and placement of the thoracoplasty bar, leading to a decrease in surgical time in cases with a Haller index higher than 3.5. There have been no complications associated with its use, nor has there been an increase in the number of days of hospitalization or analgesic requirements. There are no aesthetic sequelae for the patients.

A249 RETROSPECTIVE CHART REVIEW OF PATIENTS WITH MALNUTRITION REQUIRING ADVANCED NUTRITIONAL SUPPORT POST BARIATRIC SURGERY

BackgroundObesity is a global pandemic with a steady increase in global BMI since 1975. Bariatric surgery is an effective treatment for patients with severe obesity in order to sustain long-term weight loss and reduce comorbidity burden and mortality associated with obesity. However, post-bariatric surgery patients face nutritional complications ranging from micronutrient deficiencies to intestinal failure requiring total parenteral nutrition (TPN). From our institution of home TPN patients, 6.4% of patients had bariatric surgery. Intestinal failure is a burdensome diagnosis for patients, and there is a paucity of literature characterizing patients post-bariatric surgery who develop intestinal failure.AimsWe aim to identify the patient characteristics, surgical details, and nutritional traits that predisposed patients to developing intestinal failure requiring advanced nutritional support.MethodsThis is a retrospective chart review of 48 patient admitted to the Royal Alexandra Hospital post-bariatric surgery for nutritional support and followed by the TPN program dieticians and nurses.ResultsOur results show the mean BMI was 49.94 kg/m2 pre-bariatric surgery. Interestingly, the mean BMI at time of hospitalization for bariatric-surgery related complications was 33.210 kg/m2 which is classified as overweight but most of patients were severely malnourished with SGA C (43.8%), SGA B (29.17%), and 8.3% were SGA A. Patients requiring parenteral nutrition post-bariatric surgery are mostly female, developed barriers to oral intake, 15% engaged in medical tourism, 58.3% had an underlying mental health diagnosis, and only 18.8% were on a multivitamin even though it is standard of post-bariatric surgery care. The time between initial bariatric surgery to hospital admission was 11.2 years, and most required ≥1 revisional surgery. The mean age at bariatric surgery was 33.2-years old and the average age at initial hospitalization was 48.9-years old. Patients requiring ≥2 admissions had vertical band gastroplasty or sleeve gastrectomy (both 36.8%) while 21.1% had Roux-en-Y gastric bypass. Of these patients, 39.6% of patients required ≥2 hospital admissions and the mean total days spent in hospital was 57.15 days. While these complications are uncommon, these patients result in multiple prolonged hospitalizations and can be difficult to manage.ConclusionsOverall, the results of our study will allow the multidisciplinary teams that care for post-bariatric surgery patients to identify patients at risk of intestinal failure and potentially intervene with early enrollment into home nutrition program. With increasing awareness, patients at higher risk can be closely monitored in order to prevent micronutrient deficiencies before they progress to intestinal failure and require lifetime parenteral nutrition.Funding AgenciesNone

Association of State-Imposed Restrictions on Gabapentin with Changes in Prescribing in Medicare.

Between August 2016 and July 2018, three states classified gabapentin as a Schedule V drug and nine states implemented prescription drug monitoring program (PDMP) regulation for gabapentin. It is highly unusual for states to take drug regulation into their own hands. The impact of these changes on gabapentin prescribing is unclear. To determine the effect of state-imposed regulation on gabapentin prescribing for Medicare Part D enrollees from 2013 to 2018. Population-based difference-in-difference(DID) analysis study utilizing the Medicare Part D Prescriber Public Use File. All eligible Medicare Part D prescribers excluding those outside of the fifty states and the District of Columbia were included in our analysis. Prescriber data and key sociodemographic variables were organized by state and year. States with a gabapentin schedule change or PDMP regulation enacted before 2019 were included in the intervention group. For the Schedule V DID analysis, a control group of the ten highest opioid-prescribing states was used. States with gabapentin schedule changes or PDMP regulation before January 1, 2019, were included and compared to control states that did not implement these policies. Total days' supply of gabapentin per enrollee per year was the primary outcome variable. The mean total days' supply of gabapentin per enrollee increased 41% from 19.71 to 27.81 total days' supply per enrollee per year between 2013 and 2018. After adjustment, Schedule V gabapentin regulation resulted in a reduction of 8.37 total days of gabapentin prescribed per enrollee (95% confidence interval of - 10.34 to - 6.39). In contrast, PDMP regulation resulted in a reduction of 1.01 total days of gabapentin prescribed per enrollee (95% confidence interval of - 1.74 to - 0.29). Classifying gabapentin as a Schedule V drug results in substantial reduction in total days prescribed whereas PDMP regulation results in modest reduction.

Does Engaging Patients with Relevant Education About Long-Term Opioid Use Before Spine Surgery Affect Long-term Opioid Use? A Randomized Controlled Trial.

Parallel-arm randomized controlled trial. To assess the effectiveness of an enhanced video education session highlighting risks of opioid utilization on longterm opioid utilization after spine surgery. Long-term opioid use occurs in more than half of patients undergoing spine surgery and strategies to reduce this use are needed. Patients undergoing spine surgery at Brooke Army Medical Center between July 2015 and February 2017 were recruited at their preoperative appointment, receiving the singlesession interactive video education or control at that same appointment. Opioid utilization was tracked for the full year after surgery from the Pharmacy Data Transaction Service of the Military Health System Data Repository. Self-reported pain also collected weekly for 1 and at 6months. A total of 120 participants (40 women, 33.3%) with a mean age of 45.9 ± 10.6 years were randomized 1:1 to the enhanced education and usual care control (60 per group). In the year following surgery the cohort had a mean 5.1 (standard deviation [SD] 5.9) unique prescription fills, mean total days' supply was 88.3 (SD 134.9), and mean cumulative morphine milligrams equivalents per participant was 4193.0 (SD 12,187.9) within the year after surgery, with no significant differences in any opioid use measures between groups. Twelve individuals in the standard care group and 13 in the enhanced education group were classified with having long-term opioid utilization. The video education session did not influence opioid use after spine surgery compared to the usual care control. There was no significant difference in individuals classified as long-term opioid users after surgery based on the intervention group. Prior opioid use was a strong predictor of future opioid use in this cohort. Strategies to improve education engagement, understanding, and decision- making continue to be of high importance for mitigating risk of long-term opioid use after spine surgery.Level of Evidence: 1.

PRO141 Treatment Patterns PRIOR to the Use of Thrombopoietin Receptor Agonists in Patients with Immune Thrombocytopenia in Germany

To describe real-world treatment patterns and steroid usage as well as the steroid prescription alignment to clinical guidelines, prior to the use of thrombopoietin receptor agonists (TPO-RAs) in patients with immune thrombocytopenia (ITP) in Germany. The IMS® LRx prescription database was used to identify patients with at least one TPO-RA (romiplostim or eltrombopag) prescription between 7/2016 and 6/2019 in Germany. ITP treatments received prior to TPO-RA therapy were assessed. In total 3,553 patients were included in the analysis (2,752 eltrombopag, 801 romiplostim). Overall, 48% of patients were male and 57% of patients were >60 years when initiating TPO-RA. Oral steroids were the most commonly used therapy before TPO-RAs, in 2,289 of patients (64%; 69% eltrombopag, 48% romiplostim), followed by intravenous immunoglobulins (IVIg) in 249 of patients (7%; 6% eltrombopag, 10% romiplostim). Rituximab or other ITP treatments (e.g. azathioprine, mycophenolate mofetil, cyclophosphamide, dapsone) were rarely used before TPO-RAs. Rituximab was used in 2% of patients (1% eltrombopag, 4% romiplostim), other prior treatments in 5% of patients (5% eltrombopag, 6% romiplostim). Mean total days of steroid use prior to TPO-RAs was 169 days (median 105 days, maximum 540 days) and mean cumulative steroid (prednisolone equivalent) dose before TPO-RA therapy was 3,328 mg (median 2,522 mg, maximum 39,702 mg). Oral steroids were the most commonly used medication before TPO-RA therapy, reflecting their continued importance in the management of newly diagnosed ITP. However, treatment duration and cumulative steroid dose exceeded current guideline recommendations (ie from the American Society of Hematology 2019) and international consensus on ITP treatment. This over-use of steroids has the potential to lead to serious side effects and negatively impact on mental health, mood, sleep or weight gain for patients.

Pediatric Thoracic Empyema-Outcomes of Intrapleural Thrombolytics: Ten Years of Experience.

Introduction. Pediatric thoracic empyema is a special entity with increasing frequency. Consensus regarding the best management strategy is still evolving. We describe our single-center 10-year experience adopting intrapleural thrombolytics using tissue plasminogen activator as first-line treatment following failure of simple thoracostomy drainage techniques. Methods. Observational prospective study included all children from 1 day to 18 years admitted for parapneumonic effusion and treated with intrapleural thrombolytics. Results. From January 2008 to December 2018, 95 patients were treated by intrapleural thrombolytics for different stages of empyema thoracis. Number of thrombolytic doses required is 2.1 (range = 1-3), and mean amount of drainage is 1050 mL (range = 400-2500 mL). Mean total days of hospitalization is 7.3 days. Complete re-expansion was the primary outcome in 94 patients (98.9%). Conclusion. Intrapleural thrombolytics in complicated pediatric thoracic empyema results in excellent outcome and should be encouraged particularly in limited resource countries.

The Safety and Efficacy Intra-Aortic Balloon Pump as a Bridge to Transplant Strategy under the New UNOS Allocation

Introduction We report the safety and efficacy of the IABP as a bridge to orthotopic heart transplantation (OHT) since the United Network of Organ Sharing (UNOS) instituted its updated organ allocation system on October 18th, 2018. Methods This is single-center retrospective analysis reporting the feasibility, safety, and efficacy of the use of IABP as a bridge to OHT. All patients in this study were admitted with cardiogenic shock to the heart failure ICU with an average cardiac index of 1.73±0.22 L/min/m2 and met criteria for hemodynamic support with IABP placement. Results The cohort consisted of 20 consecutive patients with IABP as a bridge to transplant (BTT). Mean age was 50 years old, 65% male, 60% non-ischemic, 20% ischemic, 10% congenital (CC-TGA), and 10% restrictive cardiomyopathy. The rate of successful axillary IABP insertion was 100%, with the majority from a percutaneous approach (15/16) and one via surgical graft. Of the original cohort, 17 patients were successfully bridged to OHT (axillary IABP n=14, femoral IABP n=3), 1 patient who did not have a contraindication to durable MCS received a BTT LVAD after 30 days of IABP support, and 2 patients required upgrade to higher levels of MCS support (Fig 1). All patients with axillary IABP placement ambulated with a physical therapist while awaiting OHT. There were no neurologic events, major bleeding, infections, or death. Balloon rupture necessitating urgent balloon replacement occurred in 15% of patients, and one patient with a femoral IABP required surgical thrombectomy of the common femoral artery. The mean total days with IABP before transplantation or LVAD was 12, with range of 2-30 days (Fig 2). Conclusion Since the recent change in the heart transplant allocation system, we report the largest series, to our knowledge, of patients being bridged to OHT with IABP, the majority of which are axillary. We demonstrate that IABP is a safe and effective platform of support for patients awaiting OHT, and furthermore, we demonstrate the feasibility of the axillary IABP approach.

Abstract WP270: Can Left Atrial Volume Index Be Used to Identify Patients With Asymptomatic Atrial Fibrillation After Acute Ischemic Stroke or Transient Ischemic Attack?

Introduction: Detecting atrial fibrillation (AF) after an ischemic stroke may be challenging. We aimed to determine whether using the left atrial volume index (LAVi) can help screen patients at risk of having AF after an ischemic stroke or transient ischemic attack (TIA). Methods: All adult patients who were admitted to our comprehensive stroke center with ischemic strokes or TIA from January 2017 to January 2018 were retrospectively analyzed. Demographics, risk factors, stroke etiology and transthoracic echocardiography (TTE) data were collected. AF detection was based on either in-hospital cardiac telemetry and/or a 14-day or 30-day ambulatory ECG monitoring. Reference values for LAVi were derived from 2015 Guidelines from the American Society of Echocardiography. TTE and ECG parameters were analyzed using Fisher’s exact test for categorical variables and non-parametric tests for continuous variables. Results: We identified 334 patients with ischemic strokes and TIA without documented AF (66 ± 11 years, 49% females, 70% White, 23% African American, 6% Other). The mean total days of cardiac monitoring was 9.8 ± 7.2 days and it was lower in patients with AF vs without AF (3.8 ± 5.0 days vs. 10.6 ± 7.1 days, p &lt; 0.0001). Newly diagnosed AF was detected in 37 of 334 patients (11%). Of the 241 patients with normal left atrium (LA), 15 (6%) were diagnosed with AF; 10 of 49 (20%) with mildly dilated LA; 5 of 23 (22%) with moderately dilated LA; 7 of 21 (33%) with severely dilated LA. The proportions of AF detection differed significantly between the LA categories ( p &lt; 0.0001). The mean LAVi was higher in patients with AF vs without AF (40.0 ± 13.8 mL/m 2 vs. 28 ± 10.5 mL/m 2 , p &lt; 0.001), and in those with cardioembolic strokes (34.7 ± 13.3 mL/m 2 , p &lt; 0.0001). The mean LAVi for non-cardioembolic strokes including cryptogenic, small vessel and large vessel were 29.3 ± 10.2 mL/m 2 , 28.6 ± 8.5 mL/m 2 , 26.2 ± 12.8 mL/m 2 , respectively. Conclusion: Our data demonstrates a significant association between higher LAVi on routine TTE and detecting AF using non-invasive ECG monitoring in patients with ischemic strokes or TIA. Use of LAVi measured during the stroke hospitalization may help identify patients who would benefit from additional non-invasive cardiac monitoring post-discharge.

Randomized Comparison of Melphalan 200 Mg/m2 v. 280 Mg/m2 As a Preparative Regimen for Patients with Multiple Myeloma Undergoing Autologous Stem Cell Transplantation

Abstract 2009 IntroductionMelphalan 200 mg/m2 has remained the standard of care as a preparative regimen for patients with multiple myeloma (MM) undergoing autologous stem cell transplantation (ASCT). Higher doses of melphalan are associated with unacceptable gastrointestinal toxicity. Preliminary studies suggested that administration of the cytoprotective agent amifostine could protect patients with MM undergoing ASCT from excessive toxicity from doses of melphalan as high as 280 mg/m2. We conducted a prospective, multicenter, randomized trial comparing melphalan 200 mg/m2 (mel200) v. 280 mg/m2 (mel280) using amifostine pretreatment in patients with MM undergoing ASCT. MethodsThe primary endpoints of the trial were grades 3–4 toxicity and near complete response (nCR) or better 60–120 days after ASCT. Eligibility included age ≤70, no prior ASCT, acceptable organ function, measurable monoclonal protein in serum or urine by protein electrophoresis and adequate stem cells for ASCT. Patients were stratified by ß2 microglobulin >5 at study entry, del 13 by FISH and response (<≥PR) to the last cytoreductive regimen prior to ASCT. Amifostine 710 mg/m2, with appropriate hydration and pre-medications, was given by intravenous push the day prior to and again 15 minutes prior to mel200 or mel280 given as a single infusion over 30 minutes. ResultsOf 134 patients consented, consent was withdrawn for 4 patients, 1 patient who had abnormal renal function, one after a hypotensive episode following the first amifostine infusion, and 2 for other reasons. Manageable toxicities associated with amifostine infusion were hypotension (18), hypertension (3), dizziness (4), and nausea (33). Of 130 patients, 64 randomized to 200 mg/m2 and 66 280 mg/m2; 26 had del 13, and 55 had <PR to their last therapy; no patient had a ß2 microglobulin >5. Their median age was 60 years (range 42–70), they had received a median of 2 regimens (range 1–8) prior to stem cell collection, and 28 (22%) had received local radiation prior to ASCT. A total of 21 patients had grade 3–4 toxicity, 11% who received mel200 and 21% who received mel280 (p=0.11). Four of the seven in the mel200 group had a single grade 3–4 toxicity, while 3 had 2 grade 3–4 toxicities. Eight of the 14 in the mel280 group had a single toxicity, and 6 patients had two toxicities. By organ systems respectively, for mel200 v. mel 280, they were cardiac 1 v. 0, gastrointestinal 6 v. 11, mucositis 3 v. 7, CNS 0 v. 1 and pulmonary 0 v. 1. Hospitalization occurred in 94 patients 106 times; among the group receiving mel200 40 (62%) patients were hospitalized compared to 54 (82%) in the mel280 group, p=0.01. The mean total days of hospitalization were 7.3 and 10.2 days for mel200 and mel280, respectively (p=0.06); 3 patients in the mel200 group required 2 hospitalizations, 2 were admitted 3 times, while 5 patients in the mel280 group were admitted twice. The primary reasons for hospitalization for patients in receiving mel200 v mel280, respectively were, conditioning and transplant 9 v. 12, mucositis 2 v. 12, nausea and vomiting 8 v. 12, fever and infection 21 v. 18 and other 6 v. 6. No treatment related deaths occurred in this study. Responses following ASCT by EBMT criteria were for mel200 v. mel 280, respectively, ≥nCR 22% v. 39%, p=0.04, ≥PR 56% v. 70%, p= 0.09. The estimated progression-free survival at 1 and 3 years was 86% and 48%, respectively, for mel200 and 77% and 53%, respectively, for mel280. The risk of failure (death or progression) was similar (hazard ratio (mel280 vs. mel200) 1.12; 95% CI 0.64–1.95, p=0.69). The median follow-up among patients alive without progression was 524 and 555 days for mel200 and mel280, respectively. The estimated overall survival at 1 and 3 years was 96% and 83%, respectively, for mel200 and 89% and 73% for mel280, respectively. The risk of death was similar in the mel280 group relative to mel200 (HR=0.86; 95% CI 0.40–1.84; p=0.70). ConclusionsIn summary the combination of amifostine and mel280 was generally well tolerated although there were more grade 3–4 regimen-related toxicities, primarily mucositis and gastrointestinal. This resulted in slightly more frequent and longer hospitalizations (by 3 days) compared to amifostine + mel200. Mel280 resulted in a higher major response rate (CR + nCR) and warrants further study. Disclosures:Off Label Use: amifostine.

Predictive Factors of Morbidity in Childhood Parapneumonic Effusion-associated Pneumonia

To find the clinical and laboratory criteria that best predict a prolonged fever in children with parapneumonic effusion-associated pneumonia treated conservatively. Retrospective, cohort study. Children admitted to the Shaare Zedek Medical Center between January 1, 1997, and December 31, 2006, and who had been discharged with a diagnosis of empyema and pleurisy. One hundred-twenty children were included, all of whom were treated with antibiotics; in 80 patients, a thoracic drain was introduced; in 23, pleural tap was performed; and in 17 patients, no special procedure was performed. In no case was video-assisted thoracic surgery performed. The mean total days of fever was 12.8 +/- 5.9 (2-29 days), and the mean length of stay at the hospital was 11.5 +/- 4.9 (3-25) days. In 44 patients (37%), a bacterial culture was positive either in blood or in pleural fluid or both. A positive blood or a positive pleural fluid culture was significantly associated with a prolonged fever as was a history of an underlying disease. Platelet counts, serum Na, serum protein, pleural lactate dehydrogenase (LDH), pleural glucose, pleural/serum LDH ratio, pleural/serum glucose ratio, and pleural fluid pH were the only factors significantly but weakly correlated with the total duration of fever or duration of fever after admission. A "fever duration" score using platelet count, pleural fluid pH, pleural/serum LDH ratio, and pleural/serum glucose ratio predicted a prolonged course of fever (>7 days) with a sensitivity of 91% (95% confidence interval: 60%-100%) and a specificity of 47% (95% confidence interval: 25%-71%). In children with parapneumonic effusion-associated pneumonia, a positive bacterial culture and an underlying disease are associated with prolonged fever. A low score based on platelet count, pH pleural fluid and glucose, and LDH pleural/serum ratio is associated with a prolonged fever. We speculate that children with the risk factors mentioned earlier may be the best candidates for an early aggressive approach.

059 Economic evaluation of the French subset of the SYNTAX trial at 1 year: drug-eluting stents compared with bypass surgery for patients with 3-vessel and/or left main coronary artery disease

SYNTAX is a randomized controlled trial comparing percutaneous coronary intervention (PCI) using drug-eluting stents with coronary artery bypass graft surgery (CABG) in patients (pts) with 3 vessel and/or left main disease. We will analyze health economic data associated with CABG and PCI in the subset of France compared with select countries in the EU (Germany, Italy and UK). Costs will be estimated using 1-year resource utilization data including procedural resource use (stents, guidewires etc.), hospitalizations major procedures and work days lost. Estimates are based on French patterns of resource utilization, number of hospital days and break down of those in intensive care, or ward days. Where data did not allow reliable French estimate, a Bayesian statistical model was applied combining the observed resource utilization with priors based on data on less rare events. Effects are measured in terms of MACCE-free survival. In France, 105 pts were randomized to CABG and 103 to PCI in the SYNTAX trial. There were 156 hospitalizations in the first year in CABG pts compared with 139 in PCI pts. Overall, CABG pts in France spent 23.3 days (d) in hospital (see Table). PCI pts spent 9.2 d in hospital. After the index procedure, pts in the CABG arm spent 9.1 d in hospital whereas PCI pts spent 5.7 d. Economic data comparing short- and long-term medical care costs for pts with left main and/or 3-vessel CAD treated with either DES or CABG will be available at time of presentation. Additional analyses of the procedural resources utilized and costs associated with the procedures will be presented as a comparison between the French subset and countries in the EU. Mean Total Days in Hospital Per Patient * Mean Days in Hospital During Follow-up CABG PCI CABG PCI Intensive Care Unit (ICU) 8.8 4.3 1.8 1.3 General Ward 10.7 3.7 6.7 4.2 Other Wards 2.5 0.9 0.6 0.2 Total Days 23.3 9.2 9.1 5.7 * Total days in hospital includes days spent during index procedure

Are Australian Men With Psychosis Spending More Time Homeless?

The objective of this study was to determine if homeless men with psychosis using emergency accommodation services are spending more time homeless. A 12-month accommodation history was collected from all men with psychosis referred to mental health services using two emergency accommodation services in inner Melbourne over a 5-year period. Of the 241 men referred with psychosis, 200 (81%) were able to provide a full accommodation history. In 2001 the mean total days spent in crisis accommodation was 27.0 days and in 2005 the mean number of days was 60.9. Over the 5 years, increasing time was spent homeless in the 12 months prior to assessment, most commonly in emergency accommodations. Australian men with psychosis using emergency accommodation are spending an increasing amount of time homeless.