Need For Additional Interventions Research Articles

Safety and Efficacy of Lumen-Apposing Metal Stents for Management of Late Refractory Gastro-jejunal Structures in Patients with Roux-en-Y Gastric Bypass (with Video).

Roux-en-Y gastric bypass (RYGB) related late gastro-jejunal (GJ) strictures are often resistant to endoscopic balloon dilations. Lumen-apposing metal stents (LAMSs) have been used to treat benign strictures with favorable results. However, the data remains limited to justify LAMS use for management of post-RYGB late GJ strictures. We aim to evaluate the safety and efficacy of LAMS placement for the management of late GJ strictures that are refractory to balloon dilations in post-RYGB patients. This was a single center retrospective study that included all post-RYGB patients who underwent LAMS placement for management of late GJ strictures that had previously failed balloon dilations. Primary outcomes were technical and clinical success, and secondary outcomes were LAMS-related adverse events. A total of 28 patients underwent LAMS placement for management of GJ strictures. Median age was 60.5 (IQR 50.5, 67.0) years and majority were females (27, 96.4%). Median interval between surgery and first diagnosis of GJ stricture was 13 years (IQR 7, 17.5). 20 × 10 mm LAMS was the most used stent (n = 24, 85.7%). The median procedure time was 23.5 (IQR 14.5, 32.0) minutes. Technical and short-term clinical success of LAMS placement was 100% (95% CI 87.9-100.0). Long-term success was achieved in 19 out of 25 patients (76.0%, 95% CI 56.6-88.5) that had over 3 months follow-up after LAMS removal. Stent migration was noted in 2 (7.1%) patients, and 1 (3.6%) patient each experienced pain and minor bleeding without the need for additional interventions. No patient in our cohort required surgical revision of GJ anastomosis. Placement of LAMS is safe, technically feasible, and associated with a high clinical success rate in patients with late GJ strictures after RYGB who have failed prior balloon dilations. Placement of LAMS can be considered early in patients requiring multiple balloon dilations.

Wide exposure VS. stab surgical incisions in necrotizing fasciitis of the head and neck: a retrospective analysis of 22 cases.

Necrotizing fasciitis of the head and neck is a rare, rapidly progressing bacterial infection with high mortality. Traditional surgical management involves wide exposure incisions, but minimally invasive stab incisions have emerged as a potential alternative. This study aimed to compare outcomes between wide exposure and stab surgical incisions in the management of head and neck necrotizing fasciitis. A retrospective analysis was conducted on 22 patients treated for necrotizing fasciitis of the head and neck between January 2006 and January 2023. Patients were divided into two groups based on the surgical approach: wide exposure incisions (N = 15) and stab surgical incisions (N = 7). Data on mortality, hospital stay, hypertrophic scarring, neck contractures, and tracheostomy tube dependence were collected. The overall mortality rate was 9.1%, with 6.7% in the wide exposure group and 14.3% in the stab surgical incision group (p > 0.05). Hypertrophic scarring occurred in 59.1% of patients, all of whom underwent wide exposure incisions. Neck contractures were observed in 9.1% of cases, also in the wide exposure group. Tracheostomy was performed in 63.6% of patients, with successful decannulation achieved in 91.7%. The median hospital stay was longer in the stab surgical incision group (p < 0.05), partly due to the need for revision surgeries. Wide exposure incisions remain the standard treatment for necrotizing fasciitis of the head and neck due to their effectiveness in managing extensive tissue necrosis. However, stab surgical incisions offer the advantage of reduced morbidity and functional impairment. These benefits are offset by a slightly higher mortality rate and the potential need for additional interventions. Stab incisions may be a viable option in carefully selected patients, particularly those without extensive comorbidities or advanced disease.

Suggestion for customized PROMIS measurements of sleep disturbance and fatigue for patients with ovarian cancer.

239 Background: Ovarian cancer (OC) patients experience a high incidence of sleep disturbance and fatigue, which impacts their health-related quality of life (HRQoL). PROMIS short forms are important tools to assess sleep disturbance and fatigue in OC patients and identify the need for additional intervention. However, these frequently used short forms (SFs) may not capture the diversity and range of issues OC patients experience. Methods: In this mixed-methods study, data were collected from stage III/IV OC patients diagnosed within 3 years with diverse treatment trajectories, race/ethnicity, and locations, including semi-structured interviews with 20 patients and surveys of 200 patients. In addition to their medical history, participants were asked to complete PROMIS Sleep Disturbance SF 8b, and Fatigue SF 8a to evaluate their current symptom burden. Participants were also asked to retrospectively assess their fatigue and sleep during each type of treatment they received with a set of custom sleep and fatigue items from the PROMIS bank. Qualitative data were used to determine the best custom survey items in the PROMIS bank to match the issues raised by patients. Construct validity was evaluated with code prevalence from interview data. Cronbach’s Alpha coefficient was used to assess the scale reliability based on survey testing. Results: Sleep disturbance SF 8b does not capture 3 prominent issues OC patients reported as disrupting their sleep: pain, anxiety, and rumination at bedtime. Related PROMIS items were tested in the survey: trouble getting in a comfortable sleeping position (Sleep 71), stress disturbing sleep (Sleep 78), and trouble stopping thoughts during bedtime (Sleep 69). Significant fatigue issues included forcing oneself to get up and do things (FATIMP47), being frustrated by being too tired to do things they want to do (AN15), feeling like fatigue made them slowed down in their thinking (FATIMP2), feeling less effective at work (FATIMP37), and having to limit social activities because of fatigue (FATIMP18 ) . For custom items, Cronbach’s α ranged from 0.898 to 0.946 for sleep and from 0.939 to 0.985 for fatigue when asked for experience during each treatment type, suggesting a possible increase in robustness of the measures over the SFs. Conclusions: Interviews with OC patients identified significant issues not captured in common PROMIS sleep and fatigue short forms. Testing use of custom PROMIS items better matching the OC patients’ profile with a survey of 200 OC patients showed excellent reliability (α ≥ 0.9). Customizing the menu of PROMIS measures used to assess symptom burden among OC patients may improve identification of sleep disturbance and fatigue issues for this patient population. Further research could help identify the best fitting set of questions for a clinical setting when screening advanced OC patients, as well as other patient groups with long term sleep and fatigue issues.

Effectiveness of pharmacological treatments for severe agitation in real-world emergency settings: protocol of individual-participant-data network meta-analysis

BackgroundSevere psychomotor agitation and aggression often require immediate pharmacological intervention, but clear evidence-based recommendations for choosing among the multiple options are lacking. To address this gap, we plan a systematic review and individual-participant-data network meta-analysis to investigate their comparative effectiveness in real-world emergency settings with increased precision.MethodsWe will include randomized controlled trials investigating intramuscular or intravenous pharmacological interventions, as monotherapy or in combination, in adults with severe psychomotor agitation irrespective of the underlying diagnosis and requiring rapid tranquilization in general or psychiatric emergency settings. We will exclude studies before 2002, those focusing on specific reasons for agitation and placebo-controlled trials to avoid concerns related to the transitivity assumption and potential selection biases. We will search for eligible studies in BIOSIS, CENTRAL, CINAHL Plus, Embase, LILACS, MEDLINE via Ovid, PubMed, ProQuest, PsycINFO, ClinicalTrials.gov, and WHO-ICTRP. Individual-participant data will be requested from the study authors and harmonized into a uniform format, and aggregated data will also be extracted from the studies. At least two independent reviewers will conduct the study selection, data extraction, risk-of-bias assessment using RoB 2, and applicability evaluation using the RITES tool. The primary outcome will be the number of patients achieving adequate sedation within 30 min after treatment, with secondary outcomes including the need for additional interventions and adverse events, using odds ratios as the effect size. If enough individual-participant data will be collected, we will synthesize them in a network meta-regression model within a Bayesian framework, incorporating study- and participant-level characteristics to explore potential sources of heterogeneity. In cases where individual-participant data are unavailable, potential data availability bias will be explored, and models allowing for the inclusion of studies reporting only aggregated data will be considered. We will assess the confidence in the evidence using the Confidence in Network Meta-Analysis (CINeMA) approach.DiscussionThis individual-participant-data network meta-analysis aims to provide a fine-tuned synthesis of the evidence on the comparative effectiveness of pharmacological interventions for severe psychomotor agitation in real-world emergency settings. The findings from this study can greatly be provided clearer evidence-based guidance on the most effective treatments.Systematic review registrationPROSPERO CRD42023402365.

A modified trabeculectomy technique with direct filtration into the Tenon's capsule

ObjectiveTo report the surgical outcomes of a modified trabeculectomy technique involving implanting the Tenon's layer under the scleral flap. DesignProspective, interventional case series. Participants51 eyes with medically uncontrolled glaucoma were enrolled for this study. A new trabeculectomy technique, the Tenon's filtration technique for trabeculectomy (TFT-LEC) was used in 26 eyes, while a conventional procedure, normal trabeculectomy (N-LEC), was used for 25 eyes. MethodsIntraocular pressure (IOP) control, the number of glaucoma medications, the need for additional interventions, and postoperative complications were assessed. ResultsTwelve months postoperatively, the mean IOP was 13.5 ± 0.5 mmHg in the TFT-LEC group and 15.4 ± 0.5 mmHg in the N-LEC group (p = 0.13). The TFT-LEC group required an average of 1.3 ± 1.0 additional glaucoma medications (21 cases required only ripasudil) postoperatively, with no cases of bleb needling revision or reoperation. The N-LEC group required an average of 1.7 ± 1.5 glaucoma medications (p = 0.43) compared to TFT-LEC group, eight cases (32%) required bleb needling revision (p = 0.002), and one case (4%) of reoperation (p = 0.49). The complications in the TFT-LEC group included shallow anterior chamber in six (23 %) cases (p = 1.00) compared to N-LEC group, choroidal detachment in two (8%) cases (p = 0.42), and anterior chamber hemorrhage in seven (27%) cases (p = 0.29). None of these complications affected visual function. ConclusionsThis new technique involving implanting the Tenon's layer under the scleral flap may improve the postoperative outcomes of trabeculectomy.

Prophylactic embolization versus observation for high-grade blunt trauma splenic injury: a systematic review with meta-analysis.

The objective of this systematic review was to compare the effectiveness of prophylactic angioembolization with observation as primary management strategies for patients with high-grade (grades 3-5) blunt trauma splenic injury. The spleen is frequently injured in abdominal trauma. Historical management practices involved splenectomy, but more recent evidence suggests an increased risk of severe infections and sepsis associated with this approach. Accordingly, non-operative management strategies, including prophylactic splenic artery embolization and clinical observation, have gained prominence. This systematic review with meta-analysis directly compares angioembolization with clinical observation for high-grade splenic injuries only, aiming to provide clarity on this matter amid ongoing debates and variations in clinical practice. This review included adult patients aged 15 years or older with high-grade splenic injuries (grade 3-5) due to blunt trauma. Outcomes of interest include the need for further intervention (failure of management), mortality, complications, red blood cell transfusion requirements, hospital length of stay, and intensive care unit length of stay. A comprehensive search of PubMed, Embase, and CINAHL (EBSCOhost), was performed with no restrictions on language or publication date. Gray literature was searched, including trial registries and relevant conference proceedings. After deduplication, 2 reviewers independently assessed titles and abstracts, and, subsequently, full-text articles for eligibility. Methodological quality of the included studies was assessed using standardized instruments from JBI. Data was extracted using predefined templates, and statistical meta-analysis was performed, where possible, using a random effects model. Heterogeneity was assessed using statistical methods, and potential publication bias was tested with a funnel plot. The Grading of Recommendations, Assessment, Development, and Evaluation (GRADE) approach was used to evaluate the certainty of evidence. Sixteen studies were included in this review. Methodological quality assessment indicated some risk of bias in most studies, with concerns primarily related to differences in injury severity and potential confounding factors. Meta-analysis revealed that prophylactic angioembolization significantly reduced risk of management failure by 57% (OR 0.43, 95% CI 0.28-0.68, I2=53%, 15 studies) and decreased patient mortality by 37% (OR 0.63, 95% CI 0.43-0.93, I2=0%, 9 studies) compared with clinical observation alone. There was a 47% reduction in risk of complications associated with prophylactic embolization compared with clinical observation (OR 0.53, 95% CI 0.29-0.95, I2=0%, 4 studies). Some statistical heterogeneity was observed, with I2 ranging from 0% to 53%. No significant differences were observed between the 2 management strategies for red blood cell transfusion requirements and hospital length of stay. The results of this study support the use of prophylactic embolization for high-grade blunt trauma splenic injuries, indicated by lower failure of management rates, reduced need for additional interventions, lower mortality, and fewer complications. PROSPERO CRD42023420220.

Experimental soil matrix, vortex and oil skimming technology as a tertiary treatment of wastewater effluent

Abstract Water is a necessary resource that must be carefully managed. Hazardous chemicals are produced with increased industrial activities and contamination has been detrimental to both people and the environment. An experimental investigation was performed to evaluate the efficiency of vortex technology, soil matrices, and oil skimmer separately for combination as a tertiary wastewater treatment in the design of a phytoremediation system. The objective of the study is to evaluate the performance of each component in removing oil and grease, reducing the concentration of ammonia, nitrate, and phosphate; quality control measures for dissolved oxygen, total dissolved solids, and chemical oxygen demand. One-way ANOVA, kinetics analysis, and adoption isotherm analysis were applied to determine the significance of the parameters. Analysis of results for the oil skimmer exhibited an efficiency of 96% in removing oil and grease after 5 hours of treatment. The vortex technology results were fluctuating with percentage removal of nitrates at 11% while ammonia with an initial concentration of 5.24 mg/L was reduced to 4.12 mg/L. Phosphate decreased after treatment from an initial of 0.87 mg/L to 0.809 mg/L. The analysis of pollutant concentration in the soil matrix after a 5-day period indicated a greater efficiency compared to the vortex technology in the removal of ammonia and phosphate. The ammonia concentration decreased from 18.7 mg/L and 21.4 mg/L to &lt;0.1 mg/L. Similarly, phosphate concentration decreased from 15.5 mg/L to 1.13 mg/L and from 32.5 mg/L to 0.948 mg/L. The research finding underscores the efficiency of the soil matrix in removing ammonia and phosphate but recommends the need for additional intervention to lower nitrate. Overall, the three technologies showed potential and greater efficiencies in mitigating wastewater streams resulting in a notable reduction in oil and pollutant concentrations.

Efficacy of 10 IU Syntocinon versus 800 µg Misoprostol Sublingual in Active Management of 3rd Stage of Labour

Background: The active management of the third stage of labor is crucial for preventing postpartum hemorrhage (PPH), a leading cause of maternal mortality. Syntocinon (oxytocin) and Misoprostol are prominent pharmacological agents used to manage this stage by inducing uterine contractions and minimizing blood loss. Objective: This study aimed to compare the efficacy of 10 IU intravenous Syntocinon and 800 µg sublingual Misoprostol in the active management of the third stage of labor, focusing on maternal outcomes, blood loss, side effects, and the need for additional interventions. Methods: A randomized controlled trial was conducted in the Department of Obstetrics and Gynaecology at Hayatabad Medical Complex from August 1, 2021, to February 1, 2022. A total of 284 women aged 18-40 years with singleton pregnancies were enrolled and randomized into two groups of 142 each. Group A received 800 µg of sublingual Misoprostol, while Group B received 10 IU intravenous Syntocinon at the delivery of the anterior shoulder of the baby. The third stage of labor was managed with early cord clamping and controlled cord traction. Blood loss was meticulously recorded, and patients were monitored for 24 hours postpartum. Data were analyzed using IBM SPSS Statistics version 25, with continuous variables expressed as mean ± standard deviation and categorical variables as frequencies and percentages. Post-stratification analysis utilized an independent sample t-test, with a p-value of ≤ 0.05 considered statistically significant. Results: The mean age of participants was 29.507±3.24 years in the Misoprostol group and 28.352±3.77 years in the Syntocinon group. Blood loss was slightly lower in the Misoprostol group (242.4 ± 3.72 ml) compared to the Syntocinon group (249.176 ± 4.07 ml). The majority of participants were aged 18-30 years (69.7% in Group A and 71.1% in Group B). No statistically significant differences were observed in blood loss based on age, gestational age, or parity. Conclusion: Misoprostol offers practical advantages in terms of ease of administration and stability at room temperature, making it a viable alternative, especially in low-resource settings. Both Misoprostol and Syntocinon are effective in managing the third stage of labor, with comparable efficacy in reducing blood loss.

Perception of Perioperative Risk for Arthroplasty Patients: A Poll of Chinese Orthopaedic Surgeons

BackgroundInformed by the precedent of an American Association of Hip and Knee Surgeons (AAHKS) survey, where 95% of participants reported instigating modifications to preoperative risk factors, this study appraised the approach of Chinese arthroplasty surgeons toward patients who had modifiable risks. MethodsAn adaptation of the AAHKS survey tool for a Chinese cohort was undertaken. The survey queried 600 Chinese Society of Hip and Knee Surgeons members on whether the perception of unoptimized medical comorbidities and socioeconomic elements affects the propensity to offer surgical procedures. ResultsOut of the distributed surveys, 150 responses were received, culminating in a response rate of 25%. The data illustrate that 98.7% of Chinese surgeons practice restrictions on arthroplasty access for patients who have modifiable risk factors, with notable frequencies for malnutrition (93.3%), anemia (91.3%), recent hyaluronic acid injections (within one month, 88.7%), and corticosteroid injections (within 3 months, 74.7%). Assessment criteria ahead of surgery included limitations such as a body mass index under 40 (47.3%), requirements for smoking cessation (57.3%), an acceptable hemoglobin A1c level (95.3%), and a dependent fasting blood glucose level (88%). Moreover, 87.3% of respondents endorsed the need for additional interventions for certain socioeconomically disadvantaged patients to achieve successful outcomes. A majority of respondents (94.7%) believed that more equitable access to care, facilitated by better-adjusted payment methodologies, could enhance patient outcomes. Current payment schemes were also perceived by a majority to potentially compromise outcomes for patients who have inadequate social support (80.7%), low socioeconomic status (67.3%), and those lacking insurance (72.7%). ConclusionsThe consistency of the almost 99% response rate in addressing modifiable risk factors prior to arthroplasty aligns closely with the reported practices in the AAHKS survey. These findings underscore the shared valuation of preoperative risk factor optimization by Chinese and American arthroplasty surgeons, notwithstanding divergent healthcare system structures.

Public Attitudes, Inequities, and Polarization in the Launch of the 988 Lifeline

Context: To address the considerable burden of mental health need in the United States, Congress passed the National Suicide Hotline Designation Act in 2020. The act rebranded the national suicide prevention lifeline as 988, a three-digit number akin to 911 for individuals to call in the case of a mental health emergency. Surprisingly little is known about American attitudes toward this new lifeline. Methods: The authors use a demographically representative survey of 5,482 US adults conducted June 24–28, 2022, to examine the influence of mental health status, partisan identification, and demographic characteristics on public awareness of the new 988 lifeline, public support for the lifeline, and intention to use it. Findings: The authors find that while only a quarter of Americans are aware of the lifeline, support for the 988 lifeline is widespread, with more than 75% of Americans indicating they would be likely to use the new number if needed. The authors identify key disparities in awareness, support, and intended use, with Republicans, individuals with low socioeconomic status, and Blacks less supportive of the 988 lifeline and in some cases less likely to use it. Conclusions: The results point to the need for additional interventions that increase public awareness of 988 and reduce disparities in program knowledge, support, and intention to use.

Tranexamic Acid to Prevent Obstetrical Hemorrhage After Cesarean Delivery

(N Engl J Med 2023;388(15):1365–1375) Postpartum hemorrhage is the second leading cause of pregnancy-related death in the United States, and accounts for up to 27.1% of global maternal deaths. Tranexamic acid has been previously associated with a reduction in overall mortality in several different settings, but majorly in obstetrical contexts. Research has not discovered, however, if the use of tranexamic acid is beneficial when it comes to its prophylactic use to prevent significant blood loss after birth or related other outcomes such as incidence of blood transfusion products or need for additional intervention to control bleeding. This study was a randomized trial to assess the effectiveness of tranexamic acid administered immediately after umbilical cord clamping in reducing the risk of maternal death or blood transfusion compared to placebo.

Ultrasound-guided venipuncture of femoral veins vs standard palpation approach in patients undergoing pulmonary veins isolation

Abstract Introduction Complications related to vascular access frequently arise during transcatheter atrial fibrillation (AF) ablation. Vascular access related complications remain the main cause of procedure related adverse events. In the literature, there is no clear evidence supporting the benefit of ultrasound-guided (USG) vascular access. Purpose We hypothesized that USG venipuncture could reduce vascular complication rates and reduce the need for additional interventions due to complications related to vascular access. Methods We conducted a single-center retrospective study. The primary endpoint was the rate of major complications, defined as arteriovenous fistula, pseudoaneurysm, and groin hematoma with Bleeding Academic Research Consortium (BARC) classification ≥ 2 requiring interventions such as transfusions or surgical/percutaneous repair and/or resulting in hospital prolongation or readmission). The secondary endpoints were the rate of minor complications, defined as groin hematoma with BARC classification = 1 or bleeding without sequelae, and the composite rate of additional non-scheduled exams and procedures due to vascular complications. The study included all patients who underwent atrial fibrillation ablation with radiofrequency (RF) between January 2020 and December 2022 in our center, performed by two expert operators: one utilizing a classic palpation (BLIND) approach and the second one employing the USG approach. Identical materials were used for access in both groups, and the choice of protamine administration or closure method was decided by the operator on a case by case basis. In total, there were 946 patients, 352 in USG group and 594 in BLIND group. For patients in both groups who were on vitamin K antagonists (VKAs), uninterrupted administration with an international normalized ratio (INR) ratio between 2.0 and 3.0 was required. Results Major complications were significantly reduced in the USG group compared to the BLIND group (0 (0%) in USG vs. 9 (1.5%) in BLIND, P = 0.02). No significant difference was observed in minor complications between the two groups (3 (0.8%) in USG vs. 6 (1.0%) in BLIND, P = 0.809). During hospitalization or readmission, 3 additional non-scheduled exams/procedures were required (3 vascular echos) in the USG group, while 33 were needed in the BLIND group (23 vascular echos, 6 thrombin injections, 2 surgical procedures and 2 CT-Angio) with a significative reduction (P 0.034). Conclusions USG venipuncture was associated with a reduction in major complication rates and a decrease in additional exams required during hospitalization or readmission. However, it did not lead to a reduction in minor complications. These findings support the use of ultrasound in AF ablation procedures to avoid access related complications requiring intervention.Baseline CharacteristicsSummary

Postponed endoscopic necrosectomy results in a lower rate of additional intervention for infected walled-off necrosis

Although endoscopic necrosectomy (EN) is more frequently used to manage walled-off necrosis (WON), there is still debate over how much time should pass between the initial stent placement and the first necrosectomy. This study aims to determine the effect of performing EN within different timings after placing the initial stent on clinical outcomes for WON. A retrospective study on infected WON patients compared an early necrosectomy within one week after the initial stent placement with a necrosectomy that was postponed after a week. The primary outcomes compared the rate of clinical success and the need for additional intervention after EN to achieve WON resolution. 77 patients were divided into early and postponed necrosectomy groups. The complete resolution of WON within six months of follow-up was attained in 73.7% and 74.3% of patients in both the early and postponed groups. The early group tended to a greater need for additional intervention after EN (26.8% early necrosectomy vs. 8.3% postponed necrosectomy, P = 0.036). Our study does not demonstrate that early necrosectomy is superior to postponed necrosectomy in terms of clinical success rate, total count of necrosectomy procedures, procedure-related complications, length of hospitalization and prognosis. Conversely, patients in the postponed group received fewer additional interventions.

Utilisation of intravenous iron and erythropoietin in dialysis patients: A prospective observational study

In this prospective observational study, the utilization of intravenous iron and erythropoietin in dialysis patients was thoroughly investigated. The study aimed to assess the effectiveness of these treatments in managing anaemia, a common complication in individuals undergoing dialysis. Anaemia is a significant concern in this population due to impaired erythropoiesis and iron deficiency resulting from renal dysfunction. The study followed a cohort of dialysis patients, tracking their response to intravenous iron supplementation and erythropoietin therapy over a specified period. Through regular monitoring and evaluation, the study sought to determine the impact of these interventions on haemoglobin levels, transfusion requirements, and overall patient outcomes. Additionally, the study likely analysed factors such as dosing regimens, adverse effects, and the need for additional interventions to achieve optimal haemoglobin levels. By conducting a prospective observational study, researchers aimed to provide valuable insights into the real-world effectiveness and safety of intravenous iron and erythropoietin in managing anaemia in dialysis patients, which could inform clinical practice and improve patient care strategies.

The role of diabetes on the development of abdominal aortic aneurysms (AAA)

An abdominal aortic aneurysm (AAA) is a pathological local dilatation of the abdominal aorta that may develop from a variety of causes. With a 80% mortality rate, it is mainly linked to male gender, age above 65 years, smoking, and a family history of AAA. Ultrasonography is an effective method for screening males who are 65 or older for AAA. Endovascular aneurysm repair (EVAR) procedure reduces 30-day operative mortality and hospital stay, becoming a global standard. Both open and endovascular surgery aim to cut off the aneurysm's circulation, preventing it from rupturing. Diabetes mellitus (DM) may provide protection against regrowth and the need for additional intervention after endovascular AAA repair, thereby limiting the enlargement and rupture of AAAs. Hyperglycemia thickens the aortic walls and reduces wall stress in diabetic patients' abdominal aortas. It stabilizes collagen structure and promotes the synthesis of collagen type IV. Anti-diabetic drugs like metformin, thiazolidinedione, and dipeptidyl peptidase 4 inhibitors (DPP-4i) have been shown in both animal and human studies to protect against aortic aneurysms. In a dose-response pattern, these antidiabetic drugs may lower the prevalence, incidence, and enlargement rate of AAA.

Outcomes of Video-assisted Thoracic Surgery-guided Early Evacuation of Traumatic Hemothorax: A Randomized Pilot Study at Level I Trauma Center.

Traumatic hemothorax is accounted for about 20% of traumatic chest injuries. Although majority can be managed with the timely placement of intercostal tube (ICT) drainage, the remaining pose a challenge owing to high complication rates associated with retained hemothorax. Although various treatment modalities including intrapleural instillation of fibrinolytics, radioimage guided drainage, VATS guided evacuation and thoractomy do exist to address the retained hemothorax, but indications along with timing to employ a specific treatment option is still unclear and ambiguous. Patient with residual hemothorax (>200 mL) on ultrasonography after 48 h of indwelling ICT was randomized into either early video-assisted thoracic surgery (VATS) or conventional approach cohort. Early VATS cohort was subjected to video-assisted thoracoscopic evacuation of undrained blood along with normal saline irrigation and ICT placement. The conventional cohort underwent intrapleural thrombolytic instillation for 3 consecutive days. The outcome measures were the duration of indwelling ICT, removal rate of tube thoracostomy, length of hospital stay, duration of intensive care unit (ICU) monitoring, need for mechanical ventilation, incidence of pulmonary and pleural complications, and requirement of additional intervention to address undrained hemothorax and mortality rate. The early VATS cohort had shorter length of hospital stay (7.50 ± 0.85 vs. 9.50 ± 3.03, P = 0.060), reduced duration of indwelling ICT (6.70 ± 1.25 vs. 8.30 ± 2.91, P = 0.127) with higher rate of tube thoracostomy removal (70% vs. 30%, P = 0.003) and lesser need of additional interventions (0% vs. 30%, P = 0.105). Thoracotomy (3 patients) and image-guided drainage (4 patients) were additional interventions to address retained hemothorax in the conventional cohort. However, similar length of ventilator assistance (0.7 ± 0.48 vs. 0.60 ± 1.08, P = 0.791) and prolonged ICU monitoring (1.30 ± 1.06 vs. 0.90 ± 1.45, P = 0.490) was observed in early VATS cohort. Both the cohorts had no mortality. VATS-guided early evacuation of traumatic hemothorax is associated with shorter length of hospital stay along with abbreviated indwelling ICT duration, reduced incidence of complications, lesser readmissions, and improved rate of tube thoracostomy removal. However, the duration of ventilator requirement, ICU stay, and mortality remain unchanged.

Current Utility of Transgastric Percutaneous Drainage for the Management of Pancreatitis-Related Retrogastric Walled-Off Necrotic Collections: A Prospective Observational Study.

Introduction Pancreatic fluid collection (PFC) is one of the most frequent complications associated with acute pancreatitis. The route of drainage is guided by the size and site of collection. The present study aims to assess the clinical and technical success of transgastric percutaneous drainage (PCD) for managing retrogastric walled-off pancreatic necrosis (WOPN). Materials and methods A total of 44 patients with acute pancreatitis diagnosed with WOPN who underwent transgastric PCD with ultrasound or CT guidance as part of standard clinical management were included in the study. Patients were observed for improvement in clinical parameters, and treatment outcomes were noted in terms of technical success, clinical success, adverse events, need for additional procedures, hospital stay, and duration of placement of all drains. Data for the internalization of transgastric PCD was also observed in the study. Results Technical success during the drain placement was observed in 93% (n=41) of patients.Internalization of the transgastric drain was attempted in 12 patients and successful in 11 (91%). The median duration of hospital stay from the time of placement of the first PCD until discharge and the median duration of all PCDs placed were higher in patients where the transgastric drain was not internalized as compared to patients where the transgastric drain was internalized. Conclusion In WOPN, transgastric drain placement and successful internalization in any form help in the early resolution of peripancreatic and abdominal collections. It also reduces the time to percutaneous catheter removal, which in turn reduces the morbidity and decreases the need for additional interventions or surgery.

Multiplex PCR and Antibiotic Use in Children with Community-Acquired Pneumonia.

Antibiotics are frequently prescribed to children with pneumonia, although viruses are responsible for most cases. We aimed to evaluate the impact of multiplex polymerase chain reaction (mPCR) on antibiotic use. We conducted a prospective study of children under 14 years of age admitted for suspected viral pneumonia, from October 2019 to June 2022 (except March-November 2020). A mPCR respiratory panel (FilmArray® 2plus, bioMérieux, Marcy-l'Étoile, France) was performed within 72 h of admission. Patients with positive reverse transcription PCR for respiratory syncytial virus, influenza, or SARS-CoV-2 were excluded. We compared the patients with historical controls (2017-2018) who had suspected viral pneumonia but did not undergo an aetiological study. We included 64 patients and 50 controls, with a median age of 26 months. The respiratory panel detected viral pathogens in 55 patients (88%), including 17 (31%) with co-infections. Rhinovirus/enterovirus (n = 26) and human metapneumovirus (n = 22) were the most common pathogens, followed by adenovirus and parainfluenza (n = 10). There were no statistically significant differences in the total antibiotic consumption (83% of cases and 86% of controls) or antibiotics given for ≥72 h (58% vs. 66%). Antibiotics were prescribed in 41% of the cases and 72% of the controls at discharge (p = 0.001). Ampicillin was the most commonly prescribed antibiotic among the patients (44% vs. 18% for controls, p = 0.004), while azithromycin was the most commonly prescribed among the controls (19% vs. 48% for patients and controls, respectively; p = 0.001). Our findings underscore the need for additional interventions alongside molecular diagnosis to reduce antibiotic usage in paediatric community-acquired pneumonia.

5. DIAGNOSTIC ACCURACY OF EX-VIVO FUSION CONFOCAL MICROSCOPY IN BREAST CANCER

Abstract Introduction Ex-Vivo fusion confocal microscopy (EVFCM) provides a fast examination of breast tissues with the potential to reduce the rate of positive surgical margins and the need for additional interventions. This is an observational study aimed at verifying the diagnostic accuracy of EVFCM in diagnosing neoplasia and histologic subtypes. Methods Thirty-six breast tissue samples, including non-neoplastic (n=20) and neoplastic (n=16), underwent scanning using EVFCM. These samples were also processed through routine histopathological examination with hematoxylin and eosin, and the two techniques were subsequently compared. The assessment was performed by a Mohs surgeon dermatologist familiar with EVFCM (evaluator A) and two breast pathology experts (evaluators B and C) without experience in EVFCM, in a blinded diagnosis analysis. Results The ability to recognize neoplasia in the EVFCM images obtained a high level of concordance, as indicated by all kappa values (κ) presenting a p-value &amp;lt;0.001. Investigator A demonstrated a sensitivity and specificity of 100% in diagnosing neoplasia. Evaluators B and C exhibited a sensitivity &amp;gt;87% and a specificity &amp;gt;94% in diagnosing neoplasia, with positive predictive values (PPV)&amp;gt;95% and the negative predictive values (NPV) of 81% and 94%, respectively. The accuracy in recognizing the histological subtype was &amp;gt;86,1%, with a sensitivity &amp;gt;82%, specificity &amp;gt;88%, PPV&amp;gt;75% and NPV&amp;gt;92%. Conclusion EVFCM demonstrates excellent diagnostic accuracy for breast cancer, with high levels of concordance, sensitivity and specificity. Based on our data, we suggest and propose that EVFCM will be an excellent tool for intra-operative and definitive margin assessment, guiding breast conserving surgeries.

Abstract TP124: Evaluating Secondary Stroke Prevention Following Discharge From a Community Hospital

Background: Having major effects on both morbidity and mortality, stroke has become a large health burden worldwide. This disease state not only is the second leading cause of death; but also leaves about half of survivors chronically disabled. The 2021 AHA guidelines state that the risk of a recurrent stroke can be mitigated with appropriate secondary stroke prevention. The success of these interventions following discharge from the hospital largely lies in the hands of both the primary care physician and the patient. The goal of this investigation is to determine patient and provider compliance with risk factor modification and drug therapy within 3 months of hospitalization for acute ischemic stroke or transient ischemic attack. Methods: This quality improvement project is a single-center, retrospective chart review of the current secondary stroke prevention procedures exercised at a community hospital within a large healthcare system. This project has received Institutional Review Board approval. To be included, subject were required to have established primary care within the health system, discharged home following admission, and a final principle diagnosis of acute ischemic or transient ischemic event. The primary outcome assessed the percentage of patients that received a follow-up visit with a primary care provider within 30 days of hospital discharge. Additionally, this investigation also assessed modifiable risk factor management for secondary ischemic stroke prophylaxis. Results: Of the 97 patients that met inclusion criteria, 49 of them received a follow-up visit with a primary care provider within 30 days of hospital discharge (50.5%). In regards to secondary outcomes, all outcomes assessed showed to achieve appropriate clinical follow-up except for management of hypertension. It was reported that of the 49 patients, twenty-seven were reported to have controlled blood pressure at follow-up (55%). Conclusions: Results from the primary outcome of this quality improvement project highlighted the need for additional intervention to establish primary care prior to hospital discharge. Additionally this evaluation also highlighted further need for management of hypertension as a modifiable secondary risk factor.