Percentage Of Cases Research Articles

Migrant Deaths in California’s Borderlands, 2018–2023

Executive Summary We examine the deaths of undocumented migrants in southern California (i.e., San Diego and Imperial counties) for fiscal years (FYs) 2018–2023 using data obtained from the San Diego County Medical Examiner’s Office (SDCMEO) and Imperial County Coroner’s Office (ICCO). We recorded 314 deaths of undocumented migrants, with 157 in San Diego County (SDC) and 157 in Imperial County (IC). We describe trend fluctuations in migrant deaths and both the overall and county-specific proportions as they relate to causes of death and demographic characteristics (biological sex and age at death). Additionally, to capture the potential effects of the 2019 border wall expansion and COVID-19 pandemic on migrant deaths, we examined differences in these factors between two periods: FY 2018–2019 and FY 2020–2023. We conclude by comparing migrant deaths reported by the medicolegal authorities to estimates published by US Customs and Border Protection’s (CBP) Border Patrol for southern California. From 2018 to 2020, there were approximately 30 known migrant fatalities annually in California. This increased to about 88 deaths per year in 2021 and 2022 before dropping to 50 in 2023. Across the study period, the leading causes of death were drowning (35.4 percent), environmental exposure (23.6 percent), and blunt force trauma (16.9 percent), with the latter cause being largely associated with falls from the border wall. However, we found significant differences between SDC and IC. For instance, 51.6 percent of migrant deaths in IC were due to drowning, compared to 19.1 percent in SDC. Conversely, 21.7 percent of deaths in SDC were due to blunt force trauma, while just 12.1 percent of deaths in IC occurred in this manner. Overall, we found that 75.2 percent of decedents were male, 20.4 percent were female, and 4.5 percent were of unknown sex. Among cases in which a precise age at death was listed, the average age was 34.6 years. Nevertheless, sex and age differed by county in that SDC had a higher proportion of female decedents (28 percent in SDC vs. 12.7 percent in IC) and a higher average age at death (SDC x¯ = 36.8 vs. IC x¯ = 32.0). We also found significant differences between the two periods examined. Perhaps most striking, deaths due to blunt force trauma increased from 3.4 percent of cases in FY 2018–2019 to 19.9 percent of cases in FY 2020–2023. Decedent characteristics also appear to have changed across time. The share of male decedents decreased from 84.5 percent to 73.0 percent, while the share of females increased from 5.2 percent to 23.8 percent between the two periods, while the proportion of decedents ages 50 to 64 years increased significantly (from 4.7 percent to 12.7 percent). Finally, for FYs 2018–2022, CBP reported 25.6 percent fewer migrant deaths than medicolegal authorities in southern California. High numbers of migrant deaths in 2021 and 2022 can be attributed to circumstances during and following the COVID-19 pandemic, including a Trump Administration policy aimed at blocking access to the US asylum system. The expansion of the border wall during the Trump era may also explain increased migrant mortality in 2021 and 2022. Decreases in deaths in California in 2023 may be because of a novel entry location in the San Judas Break or result from a shift in migration trends toward other border states (i.e., Arizona, New Mexico, and Texas). County differences in drowning and blunt force trauma deaths were likely due to the presence of the All-American Canal in IC (drowning), and greater coverage of the pedestrian border wall in SDC (blunt force trauma), respectively. Although speculatory, the higher percentage of female decedents and older age of decedents in SDC may be because these vulnerable individuals perceive San Diego to be a safer route. Changes between FYs 2018–2019 and FYs 2020–2023 in blunt force trauma deaths (3.4 percent to 19.9 percent) are a result of falls from the newly expanded and constructed border wall. We suggest that after more than 30 years of implementation, the United States should eliminate the use of “deterrence” strategies to prevent further and unnecessary loss of life. Additionally, the following actions could reduce migrant mortality in California: installing buoys or other anti-drowning devices in the All-American Canal, making potentially life-saving resources (e.g., blankets and water) available on known migrant routes, and reducing the height of or removing the border barrier. We call for both CBP and medicolegal authorities to provide disaggregated data on migrant fatalities, which would facilitate an accurate accounting these deaths, increase understanding of where and why deaths occur, and therefore be used to support policy changes.

EPCO-17. CARM1 METHYLATES GLIOBLASTOMA TUMOR SUPPRESSOR QUAKING TO REGULATE ITS TRANSCRIPTIONAL COACTIVATOR FUNCTION

Abstract Glioblastoma (GBM) represents the most prevalent and deadly primary brain tumor in adults, and it remains highly refractory to current therapeutic interventions. Significant intratumor heterogeneity drives rapid invasion, immune escape, and therapeutic resistance. Therapeutic paradigms based on deconvoluting key molecular mechanisms driving gliomagenesis are urgently needed. Quaking (Qki, encoded by Qk) is frequently altered in GBM patients; Qk mutations or deletions occur in 35% percent of cases, and the Qki protein is absent in 50-60% of cases. Our lab has characterized Qki as important tumor suppressor in GBM, where deletion of Qk enables pre-malignant neural stem cells to expand outside their niche and develop into tumors that recapitulate human GBM. We discovered that Qki functions as a transcriptional coactivator of lipid metabolism genes, whereby Qki loss disrupts lipid homeostasis and compromises the integrity of various membrane structures. Several downstream processes governed by Qki have been delineated; however, upstream regulators of Qki have yet to be identified. Recurrent cancer mutations to specific Qki arginine sites implicate the dysregulation of arginine methylation, a common post-translational modification catalyzed by protein arginine methyltransferases (PRMTs). Leveraging in vitro methylation assays, we demonstrate that Qki is selectively methylated by the PRMT coactivator-associated arginine methyltransferase 1 (CARM1), specifically in the Quaking regulatory domain where cancer mutations are reported. We observe that Qki interacts with known CARM1 substrates, functioning in the transcriptional complex assembled by CARM1. Through mutagenesis studies, we identified arginine 242 (R242) and arginine 256 (R256) as specific CARM1-mediated methylation sites on Qki. Importantly, mutations to these sites compromise Qki’s activity as a transcriptional coactivator. Moreover, brain-specific deletion of CARM1 in vivo results in neurological phenotypes reminiscent of Qki deletion. Altogether, we provide evidence that CARM1 represents a novel tumor suppressor in GBM that functions through the arginine methylation of Qki.

Reducing Patient Care Delays in Radiation Oncology Via Optimization of Insurance Preauthorization

Purpose/ObjectivesDifficulties and delays in insurance pre-authorization (pre-auth) can negatively impact patient care, resulting in postponing, modifying, or even cancelling radiation therapy for patients. We aimed to perform a root cause analysis for pre-auth delays in our department and implement solutions to optimize our workflow. Our primary objectives were to decrease mean time for clinical treatment plan (CTP) completion, and for number of cases delayed/denied, by 50% each. Materials/MethodsWe performed a root cause analysis for pre-auth delays, and used the PDSA & A3 quality improvement methods. We sampled ∼2 cases per disease site (19 cases from July – Aug 2022) to determine the baseline. Countermeasures included: 1) optimizing our CTP templates per disease site to contain the specific clinical information required for pre-auth, 2) formalizing earlier completion of CTPs in our Care Path®, and 3) formalizing the pre auth workflow in our Care Path®. We tracked various metrics, including mean time for CTP completion, % usage of our Care Path®, % usage of revised CTP templates, mean time until pre-auth initiated & completed, and % of cases delayed/denied. Two-tailed T-tests and Chi-squared tests were used to generate p-values comparing mean values and percentages, respectively. Results495 patients completed CT simulation in our department between October 2022 and February 2023. Mean time for CTP completion (Day 0 = day of CT simulation scheduling) improved from 16 days at baseline to 4 days (p<0.001). Care Path® usage improved from 16% to 97% (p<0.001), as did usage of our revised CTP templates, from 0% to 97% (p<0.001). The mean time from insurance pre-auth initiation to completion improved from 5 days to 1 day. The percent of cases that were delayed/denied was reduced significantly from 32% to 8% (p<0.001). ConclusionsImproving timeliness and details of CTP documentation and pre-auth by using our Care Path® and optimizing CTP templates improved efficiency of insurance pre-auth completion and reduced the number of cases delayed/denied.

Stage of lactation, parity, breed, milk composition and minerals affect the non-enzymatic antioxidant activity of sheep milk

The aims of this study were to i) characterize sheep milk for non-enzymatic antioxidant activity via 2 different assays, namely the ferric reducing antioxidant power (FRAP) and the 2-diphenyl-1-picryl-hydrazyl-hydrate (DPPH), and ii) investigate the effect of milk composition and animal-related parameters on these 2 assays by using Generalized Additive Mixed Model (GAMM) approach. A total of 740 ewes belonging to Massese and Comisana breeds were sampled once during the morning milking across 11 sampling sessions. All milk samples were analyzed for fat, protein, casein, and lactose, somatic cell score (SCS) and minerals (Ca, Mg, Na and Cl). The FRAP and DPPH assays were tested to measure the non-enzymatic antioxidant activity of milk, expressed as μM eq. ascorbic acid/mL of milk and % of inhibition, respectively. The GAMM model included the effect of parity and breed as parametric terms, and the effect of days in milk (DIM), milk yield and the interactions protein × fat, casein × SCS, Ca × Mg and Na × Cl as smooth terms. The sampling day was included in the model as random effect. Results revealed that the non-enzymatic antioxidant capacity of sheep milk, expressed as FRAP, was affected by DIM, potentially because of changes in milk composition over time. Conversely, parity and breed of ewes affected DPPH, suggesting that age- and breed-specific factors are related to specific components in milk acting as hydrogen donors. Milk fat and high casein percentages were found to significantly affect FRAP, while protein content was crucial for high DPPH levels. Additionally, Ca and Mg emerged as important non-enzymatic antioxidants for both FRAP and DPPH, highlighting their important role in antioxidant activity of sheep milk. On the other side, combinations of Na and Cl were particularly influential for FRAP, revealing the complex relationship between these minerals and non-enzymatic antioxidant activity of milk. These findings offer valuable insights into the factors affecting the antioxidative properties of sheep milk, highlighting the need for further exploration of other non-enzymatic antioxidants and their contribution to the total antioxidant activity.

Role of Chemoablation Using UGN-101 in Upper Tract Urothelial Carcinoma: A Systematic Review and MetaAnalysis of Available Evidence.

To examine the safety and efficacy of chemoablation using UGN-101 in patients with upper tract urothelial cancer (UTUC). We conducted a systematic search through 7 databases/registries to identify key observational and experimental studies reporting either the efficacy or safety of UGN-101 in UTUC patients regardless of the risk or grade of the disease. The outcomes included efficacy (complete/partial/no response, survival, death, recurrence, or progression) and safety endpoints. All meta-analyses were conducted through STATA. The prevalence rate and its 95% CI were pooled across studies. A subgroup meta-analysis was conducted on follow-up. The quality was assessed using the Newcastle Ottawa Scale. Twenty studies (1051 patients) were analyzed. Complete response was reported in 49% (39%-60%) of cases, and 5% (0%- 15%) had disease progression. Treatment cessation was reported in 13% (3%-27%) of patients. Four percent of cases needed radical nephroureterectomy. Recurrence and death occurred in 14% (7%-23%) and 6% (2%-10%) of patients. Complications occurred in 63% (39%-85%), the majority of which were of grades I, II, and III. Ureteral stenosis was the most common complication accounting for 35% of cases. Chemoablationrelated complications occurred more than procedure-related ones. Based on available evidence, the intracavitary instillation of UGN-101 gel provides an alternative therapeutic option for upper tract urothelial cancer. Chemoablation provides good clinical outcomes in terms of complete response, disease progression and recurrence, and the need to undergo nephroureterectomy. Complications were encountered in more than half the population; however, most of them were of low grades.

Comparison of postoperative outcomes between tissue glue and suture for mesh fixation in open tension-free inguinal hernia repair: a prospective analytical study.

A hernia is an abnormal protrusion of the viscus through the normal or abnormal opening of its containing cavity. Lichtenstein tension-free mesh repair is a commonly performed surgery for hernia. Various studies have revealed atraumatic fixation of the mesh produces less pain without compromising the outcomes. This is a prospective analytical study conducted in a tertiary hospital over a year. Eighty patients with primary inguinal hernia undergoing open mesh repair were enrolled and divided into two groups with 40 patients in each group. Mesh fixation was done with N-butyl 2 cyano-acrylate glue in one group, while polypropylene 2-0 suture in the other group. Postoperative pain, the number of dosages of analgesia required, the incidence of hematoma/seroma formation, surgical site infection, and length of hospital stay were compared between the two groups. Data were analyzed using SPSS 25. Visual analog scores were significantly reduced in the glue group at 12 h and 24 h (P<0.05) with a reduction of the mean number of analgesic doses from 6.42±0.984 in the suture group to 5.95±0.597 in the glue group (P<0.05). The operating time was significantly reduced from 70.03±4.376 minutes in the suture group to 58.43±4.540 min in the glue group (P<0.05), while there was no significant difference in the length of hospital stay. Five percent of cases in the suture group developed seroma while no SSI was reported in this study. This study demonstrates mesh fixation with cyanoacrylate glue in open hernioplasty for primary groin hernias is associated with reduced immediate postoperative pain, dose of analgesia required, and operating time in comparison to fixation with suture.

Using Deep Learning Neural Networks to Predict Violent vs. Nonviolent Extremist Behaviors

ABSTRACT Recent analyses of radicalization processes have shown that extremist attitudes and violent behavior may be related in some cases, but are rarely collinear. It therefore benefits analysts of political violence to leverage tools that assist in the distinction of characteristics that might move an individual towards violence (vs. nonviolence) in support of their beliefs. To this end, the current study explores the efficacy of deep learning neural networks for classifying extremists as potentially violent or nonviolent based on dozens of common predictors derived from various perspectives on radicalization. Specifically, this study uses 337 predictors from the Profiles of Individual Radicalization in the U.S. dataset to populate a neural network with two hidden layers composed of four processing nodes. The model correctly predicted whether an individual engaged in violence (or not) in 94.2 percent of cases, on average. Analyses further identified several predictors that were most important in classifying violent and nonviolent cases. These analyses demonstrate neural networks may be effective tools in the study of radicalization and extremism, particularly regarding the disaggregation of salient outcomes.

Cutaneous Metastasis of Ovarian Tumor after Hysterectomy and Bilateral Salpingo-oophorectomy: A Case Report

OBJECTIVES Cutaneous metastases are a very rare presentation of ovarian tumors (OV). They occur in about 3.5 percent of cases. The prognosis of cutaneous metastases is not good despite recent treatment modalities. Researchers are looking for much more personalized treatments. The patient had a history of ovarian tumor, for which she had a hysterectomy and bilateral salpingo-oophorectomy. She presented with multiple cutaneous eruptions. The histopathology shows high-grade serous carcinoma of the ovaries. Immunochemistry is positive for cytokeratin 7, WT1, and CAX. She had developed left leg swelling, generalized edema, and complaints of dysuria and difficulty defecating. Many targeted therapies have been developed, such as inhibiting growth factor receptors and immunological treatments that induce cell death, opening the door to precision medicine.

Echo-Anatomy of the Uterus of Pubescent Girls in Lomé (Togo) and its Correlation with the Occurrence of Dysmenorrhea

Introduction: This study aimed to examine the echo morphometry of the uterus in pubescent girls in Lomé and its potential relationship with essential dysmenorrhoea. Essential dysmenorrhoea, characterized by menstrual pain without identifiable causes, affects a significant portion of young women. Methodology: This was a preliminary, prospective, cross-sectional, descriptive, and analytical study performed over six months in the anatomy laboratory of the University of Lomé (Togo), at a teaching hospital Campus and in a school in Lomé. The study was based on a convenience sample of 100 pubescent, nulligravid pupils aged between 13 and 18 years with no pelvic surgery history. Results: Dysmenorrhea was noted in 60% of cases. No abnormality of uterine shape or structure was observed. In seven percent of cases, uterine malposition’s such as retroflection and retroversion were noted. There was a statistically significant correlation between uterine retroflection and the occurrence of dysmenorrhoea. The values of the biometric parameters tended to increase in girls with dysmenorrhoea. Conclusion: To corroborate the results of the aforementioned preliminary work, a subsequent study on the same sample using a more objective means of exploration than ultrasound is necessary. KEYWORDS: Echo-Anatomy, Uterus, Dysmenorrhoea, Lomé (Togo).

Molecular and clinical characteristics of patients with non-small-cell lung cancer (NSCLC) harboring KRAS G12V mutations.

8618 Background: KRAS G12V is one of the most common drivers of non-small cell lung cancer (NSCLC), accounting for around 3 percent of cases. Recently, there have been promising approaches in early clinical research to therapeutically target this mutation. However, this subset of patients is poorly characterized both molecularly and clinically, and data on therapy-dependent outcome are lacking. We performed this real world analysis to gain insight into the genomic and clinical characteristics of a large cohort of NSCLC patients with KRAS G12V mutations. Methods: Molecular data of 662 UICC stage I-IV lung cancer patients diagnosed between 2018 and 2023 and harbouring a KRAS G12V mutation in their tumor tissue were linked to the medical record data in the Network Genomic Medicine (NGM) database. The mutational status was determined by next-generation sequencing (NGS) and further immunohistochemistry (IHC) for PD-L1 status was performed. Results: 662 patients with a KRAS G12V mutation were diagnosed between 01/2018 and 03/2023 (stage I: 33 (6.0%), II: 29 (5.3%), III: 89 (16.3%), IV: 396 (72.4%)), which is a proportion of 15.3% among all registered KRAS-mutated lung cancer patients in this period (n=4332). Among the KRASG12V positive primary lung carcinomas, 605 (94.3%) showed an adenocarcinoma and 17 (2.6%) a squamous cell carcinoma. The median age at diagnosis was 67 years (range: 33-91), of which 338 were men (52.6%) and 304 women (47.4%). The majority of the cohort were active or former smokers (active: 289 (54.9%); former: 208 (39.2%)). In the group of never smokers (n=33, 6.2%), there were 5 men (15.2% of never smokers) and 28 women (84.8% of never smokers). The most common mutation site at initial diagnosis in patients with metastatic disease was brain and bone metastases with 41.5% and 37.4%, respectively. The most common co-mutations with a frequency of ≥ 5% were TP53 (40.2%), STK11 (28.3%), KEAP1 (22.6%) and NTRK1-3 (8.7%). Preliminary median overall survival at UICC stage IV was 525 (95% CI: 427 – 579) days. The first PD-L1-independent analysis showed a response rate of 40.9% (18/44) to initial chemotherapy (CTX)/immune-checkpoint blockade (ICB) combination, 66.7% (8/13) to ICB alone and 18.8% (6/32) to CTX alone. Conclusions: The cohort is characterized by heavy tobacco consumption. Among the never-smokers, the high proportion of women is noteworthy and will be analyzed further. Metastases at first diagnosis and concurrent mutations show clear differences to other KRAS subtypes, which highlights the heterogeneity of KRAS subtypes. We will continue to analyze the overall prognosis as well as the first indications of a PD-L1-independent benefit of immunotherapy compared to chemotherapy alone.

Facteurs influençant le délai de prise en charge aux urgences chirurgicales du CHU Sourô Sanou

Assessing patient turnaround times is essential for improving the quality of care in emergency service departments. This study looked at waiting and treatment times, and their associated factors, in the surgical emergency service department at the Souro Sanou National Teaching Hospital (SSNTH) in Bobo-Dioulasso, Burkina Faso. This study was carried out on 380 patients with a median age of thirty-eight. The sex ratio was 0.54. In 63.7 percent of cases, the participants lived in urban areas. Most of the patients surveyed were farmers (34.7 percent). The median waiting time for patients was eleven minutes. The nature of the trauma sustained was associated with the waiting time. The median time taken to administer first aid was sixty-three minutes, with the unavailability of medication at the hospital pharmacy cited as a factor contributing to this delay. The median time taken to obtain paraclinical results was 134 minutes and 102 minutes for laboratory tests and scans, respectively. The factor associated with delays in obtaining scan results was the need for surgical intervention. The median waiting time for surgery was 24.3 hours. The turnaround times in the SSNTH surgical emergency department are long. For the improvement of patient turnaround times to be possible, an overhaul of the department is in order. In particular, a rapid consultation team needs to be established, and essential drugs for emergency care need to be made readily available.

Comparison of deep learning approaches to estimate injury severity from the International Classification of Diseases codes

Objective The injury severity classification based on the Abbreviated Injury Scale (AIS) provides information that allows for standardized comparisons for injury research. However, the majority of injury data is captured using the International Classification of Diseases (ICD), which lacks injury severity information. It has been shown that the encoder-decoder-based neural machine translation (NMT) model is more accurate than other methods for determining injury severity from ICD codes. The objectives of this project were to determine if feed-forward neural networks (FFNN) perform as well as NMT and to determine if direct estimation of injury severity is more accurate than using AIS codes as an intermediary (indirect method). Methods Patient data from the National Trauma Data Bank were used to develop and test the four models (NMT/Indirect, NMT/Direct, FFNN/Indirect, FFNN/Direct). There were 2,031,793 cases from 2017–2018 used to train and 1,091,792 cases from 2019 were used for testing. The primary outcome of interest was the percent of cases with the correct binary classification of Injury Severity Score (ISS) ≥16, using ISS values recorded in NTDB for benchmarking. The secondary outcome was the percent of predicted ISS exactly matching the recorded ISS. Results The results show that indirect estimation through first converting to AIS using an NMT was the most accurate in predicting ISS ≥ 16 (94.0%), followed by direct estimation with FFNN (93.4%), direct estimation with NMT (93.1%), and then indirect estimation with FFNN (93.1%), with statistically significant differences in pairwise comparison. The rankings were the same when evaluating models based on exactly matches of ISS. Training times were similar for all models (range 11–14 h), but testing was much faster for FFNN models (GPU: 1–2 min) compared to the NMT models (GPU: 69–82 min). Conclusions The most accurate method for obtaining injury severity from ICD was NMT using AIS codes as an intermediary (indirect method), although all methods performed well. The indirect NMT model was the most resource intensive in terms of processing time. The optimal approach for researchers will be based on their needs and the computing resources available.

Combined Therapy of Paravertebral Nerve Pulsed Radiofrequency and Subcutaneous Block for Acute/Subacute Herpetic Neuralgia: A Retrospective Study.

This retrospective study aimed to investigate the effectiveness and safety of early combined therapy with CT-guided paravertebral nerve (PVN), pulsed radiofrequency (PRF), and subcutaneous block on acute/subacute herpes zoster (HZ). A total of 98 medical records were analyzed. All patients underwent CT-guided PRF on PVN immediately followed by a single subcutaneous block with lidocaine and dexamethasone in acute/subacute phase. The therapy efficacy was evaluated by pain numeric rating scale (NRS) and effective rate, which was defined as a percent of cases with a reduction in pain NRS>50% at day 1, week 2, 4, 12, and 24 after the procedure. The incidences of medication reduction and postherpetic neuralgia (PHN) were also retrieved. Further comparison was conducted between acute group (disease duration<30 days from HZ onset) and subacute group (30 day<duration<90 days from HZ onset). Early combined therapy indicated an immediate and sustained improvement in pain NRS as compared with before treatment ( P <0.0001), with effective rates of 74%, 79%, 80%, 76%, and 79% at day 1, week 2, 4, 12, and 24 after procedure, respectively. At the end of follow-up, the proportion of patients with a reduction of >50% in prior medications amounted to 83% and the incidence of clinically meaningful PHN decreased to 23%. The clinical efficacy was more profound in acute group than in subacute group at every time points ( P <0.05). No severe complications occurred. Our data revealed surprising levels of pain relief by combination therapies of PRF and subcutaneous block targeting different sites of pain pathway, thus suggesting a valuable treatment option for acute/subacute herpetic neuralgia.

Traumatic Native Hip Dislocations: An Audit at a Major Trauma Centre and Assessment of Clinical Practice at Centres Across the United Kingdom.

Native hip dislocations are defined as traumatic dislocations of the hip, typically high-energy and associated with polytrauma. The majority of these injuries occur following motor vehicle accidents (MVAs). Due to the inherent stability of the hip joint, a significant force is required to cause dislocation. It is critical that such injuries are managed and reduced in a timely manner. We evaluated the current practice in a major trauma centre (MTC) in Cardiff and gathered information from emergency departments (EDs) in Wales and MTCs around the United Kingdom (UK). We did an evaluation of the current practice with a retrospective audit of all traumatic native hip dislocations presenting to the MTC at Cardiff from August 2018 to February 2021. Data was obtained from Trauma Audit and Research Network (TARN), medical records, radiology and theatre management systems. An online survey was developed and disseminated to EDs in Wales and MTCs across the UK. There were 15 traumatic hip dislocation cases over the period evaluated. Sixty percentof cases were due to MVA. Eighty-six percent of patients had an associated fracture, with one Pipkin type IV fracture dislocation. The mean time to reduction from injury was 532 minutes (240-804 minutes), with 28.6% reduced within 6 hours and 71.4% reduced within 12 hours. Two patients had reduction performed in the ED (mean time to reduction, 275 minutes). There was one occurrence of avascular necrosis (AVN) and one of chondrolysis at the follow-up. The response rate to the survey was 80% and 83% in Wales and MTCs nationally, respectively. The majority (82%) of departments did not have an established pathway in place for managing traumatic native hip dislocations with a preference for reduction in the operating theatre. Native hip dislocations are rare, high-energy injuries associated with significant morbidity. The available evidence suggests time to reduction is imperative in reducing the risk of future complications. The establishment of a pathway to guide management and having a mechanism to perform reductions in the ED may produce significant reductions in this time, impacting outcomes.

Metronidazole and cefazolin vs cefazolin alone for surgical site infection prophylaxis in gynecologic surgery at a comprehensive cancer center

BackgroundSurgical site infection (SSI) is one of the most common complications of gynecologic cancer surgery. Current guidelines recommend the administration of cefazolin pre-operatively to reduce SSI rates for patients undergoing clean-contaminated surgeries such as hysterectomy. ObjectiveTo evaluate the impact of a quality improvement project adding metronidazole to cefazolin for antibiotic prophylaxis on SSI rate for women undergoing gynecologic surgery at a comprehensive cancer center. Study DesignThis retrospective, single-center, cohort study included patients who underwent surgery in the Gynecologic Oncology department from 5/2017 to 6/2023. Patients with penicillin allergies and those undergoing concomitant bowel resection(s) and/or joint cases were excluded. The pre-intervention group patients had surgery from 5/2017 to 4/2022, and the post-intervention group patients had surgery from 4/2022 to 6/2023. The primary outcome was 30-day SSI rate. Sensitivity analyses were performed to compare SSI rates based on actual antibiotic(s) received and for those who had a hysterectomy. Factors independently associated with SSI were identified using a multivariable logistic regression model adjusting for confounding variables. ResultsOf 3343 patients, 2572 (76.9%) and 771 (23.1%) were in the pre- and post-intervention groups, respectively. Most patients (74.7%) had a hysterectomy performed. Thirty four percent of cases were for non-oncologic (benign) indications. Pre-intervention patients were more likely to receive appropriate pre-operative antibiotics (95.6% vs 90.7%; p<0.001). The overall SSI rate prior to the intervention was 4.7% compared to 2.6% after the intervention (p=0.010). The SSI rate for all patients who underwent hysterectomy was 4.9% (pre-intervention) vs. 2.8% (post-intervention) (p=0.036); a similar trend was seen for benign cases (4.4% vs 2.4%; p=0.159). On multivariable analysis, the odds ratio for SSI was 0.49 (95% CI 0.38-0.63) for the post- compared to pre-intervention group (p<0.001). In a sensitivity analysis (n=3087), SSI rate was 4.5% for those who received cefazolin alone compared to 2.3% for those who received cefazolin plus metronidazole, with significant decreased odds of SSI for the cefazolin plus metronidazole group (adjusted OR 0.40, 95% CI 0.30-0.53; p<0.001). Among only those who had a hysterectomy performed, the odds of SSI was significantly reduced for those in the post-intervention group (adjusted OR 0.63, 95% CI 0.47-0.86; p=0.003). ConclusionThe addition of metronidazole to cefazolin before gynecologic surgery decreased the SSI rate by half, even after accounting for other known predictors of SSI and differences in practice patterns over time. Providers should consider this combination regimen in women undergoing gynecologic surgery, especially for cases involving hysterectomy.

Esketamine in resistant depression: a case report

IntroductionMajor depressive disorder is a common psychiatric condition affecting around 264 million people worldwide (WHO: Depression Fact Sheet. [Apr;2021]). Despite pharmacological advances, many patients still do not respond to antidepressant treatment or do so partially. It is estimated that only 50-70% of patients respond to the initial antidepressant treatment according to the STAR-D study. 15% percent of cases do not respond significantly to various pharmacological and psychotherapeutic attempts (Rush AJ et. STAR*D report. al Am J Psychiatry). The current consensus places resistant depression for a practical approach in one that has been treated with two different antidepressant strategies in adequate doses and time and has not been remitted (Souery D et el, Treatment-resistant depression. J Clin Psychiatry 2006). We present a clinical case of a patient with Major Depressive Disorder, resistant to several therapeutic lines, in which intranasal esketamine was initiated.ObjectivesThe main objective is to report the result of treatment with esketamine in a clinical case.MethodsThis work analyze the clinical evolution and reponse of a 62-year-old patient after initiating intranasal esketamine.This is a patient with a single depressive episode, with no personal psychiatric history of interest that, after exhausting several options of pharmacological and non-pharmacological treatment.Regulated psychotherapy based on cognitive behavioral therapy was carried out along with different pharmacological strategies according to the recommendations of the main clinical guidelines: antidepressant dose increase, antidepressant change, combination of several antidepressants and potentiation with another drug. We measured clinical changes with MADRS Scale (Montgomery-Asberg Depression Rating Scale) at diferent times.ResultsFrom the fifth administration of esketamine the patient presented a clear improvement. At three months, the score on the MADRS scale improved markedly and at 6 months, the patient reported euthymia.Score MADRS:-Basal 46-3 Months 14-6 Months 1As for the adverse effects, the patient presented in all administrations very mild dizziness.ConclusionsThe use of esketamine is a new therapeutic approach, being fast, safe and well tolerated in patients with depression who do not respond to other treatments (Sapkota A et al. Efficacy and Safety of Intranasal Esketamine in Treatment-Resistant Depression in Adults: A Systematic Review. Cureus.2021 Aug 21;13(8)). In our patient has proven to be effective and fast.Disclosure of InterestNone Declared

Seizures in Multiple Sclerosis are, above all, a Matter of Brain Viability

Objectives: Most patients with Multiple Sclerosis (MS) never have a seizure, although they are at risk for seizures since the onset of MS. This paradox leads us to suppose that MS plays a minor role in seizure generation and epileptogenesis. Methods: Qualitative study using data triangulation and inductive content analysis. A comprehensive literature search was carried out in four electronic databases (MEDLINE, Embase, Web of Science, and Google Scholar). Results: In MS patients, unprovoked seizures occur rarely (in about 3 percent of cases). Pediatric MS involves seizures more common than adult or late-onset MS. In general, children with seizures do not have poorer MS prognoses than children without seizures. Contrary to the general population, seizures do not peak in older MS patients. Since the use of disease-modifying therapies in the treatment of MS (i.e., since 1993), the frequency of seizures in MS patients has not changed considerably. Epilepsy syndrome cannot be recognized in MS patients with seizures. As a rule, seizures in MS are not difficult to treat. A sudden unexpected death in MS patients with seizures has not been observed more commonly than in the general epilepsy population. A disruption of the blood–brain barrier is the most obvious proconvulsive factor of MS. However, neither MS relapses nor a high rate of MS relapses is normally accompanied by seizures. Structural brain abnormalities usually accumulate over the course of MS. However, a high brain magnetic resonance imaging lesion load does not have a substantial impact on seizure occurrence in MS. Conclusion: MS does not have a major role in seizure generation and epileptogenesis. In most cases, the seizure-promoting effects of MS can be successfully counteracted by the brain´s protective mechanisms.

The Impact of Clinical Factors and SARS-CoV-2 Variants on Antibody Production in Vaccinated German Healthcare Professionals Infected Either with the Delta or the Omicron Variant.

The aim of the rapid introduction of vaccines during the COVID-19 pandemic was a reduction in SARS-CoV-2 transmission and a less frequent occurrence of severe COVID-19 courses. Thus, we evaluated COVID-19 severity in vaccinated individuals to examine variant-specific symptom characteristics and their clinical impact on the serological immune response. A total of 185 individuals previously vaccinated against and infected with the SARS-CoV-2 Delta (B.1.617.2) or Omicron (BA.4 and BA.5) variant, were enrolled for anti-SARS-CoV-2 anti-N- and anti-RBD/S1-Ig level detection. A structured survey regarding medical history was conducted. In 99.5 percent of cases, outpatient treatment was satisfactory. Specific symptoms associated with variants included ageusia and anosmia in patients with Delta infections and throat pain in Omicron infections. Among Delta-infected individuals with specific symptoms, significantly higher levels of anti-N antibodies were observed. Our study identified variant-specific differences in the amount of SARS-CoV-2 antibody production and COVID-19 symptoms. Despite this, vaccinated individuals with Omicron or Delta infections generally experienced mild disease courses. Additionally, asymptomatic individuals exhibit lower anti-SARS-CoV-2 antibody levels, indicating a clinical correlation between disease-specific antibodies and distinct symptoms, particularly in the case of the Delta variant. In follow-up studies, exploring post-COVID syndrome and focusing on cognitive symptoms in the acute phase of Omicron infections is crucial as it has the potential to longitudinally impact the lives of those affected.

Abstract TP117: Improving Thrombolysis Door-to-Needle Time With a Multi-Pronged Approach

Introduction: Reducing door-to-needle (DTN) times lead to improved patient outcomes in acute ischemic stroke. We sought to use innovative methods to continuously reduce the DTN time, with the specific goal of consistently achieving a median DTN time &lt; 30 minutes. Methods: At an academic Comprehensive Stroke Center, we implemented these strategies to reduce the DTN time: 1) Addition of a virtual DTN timer in the Electronic Medical Record (EMR) to display elapsed time since arrival.2) Creation of a multidisciplinary Thrombolysis Focus Group to analyze data and improve processes. Additional monthly quality improvement meetings were held to discuss all thrombolysis cases with times over our median. 3) Reduction of EMR barriers to recognize metric exclusion criteria and document accordingly. 4) Review of each thrombolysis case with direct provider feedback and an opportunity to appropriately document and clarify delays. 5) Addition of Specialized Neurovascular APPs responding to every Code Stroke with Neurology resident physicians.6) Creation of a “Golden Needle” award to recognize providers who achieved the fastest DTN time in the year. Results: The median DTN time steadily decreased over 3 academic years. The median DTN time was 40 minutes in 2020, 39 in 2021, 38 in 2022 and 36 in year-to-date 2023. Additionally, the percentage of thrombolysis cases meeting the institutional goal of &lt; 30 minutes improved from 21.5% in 2020, to 31.9% in 2021, to 59.6% in 2022, to 88.6% in year-to-date 2023 (figure). Conclusion: Novel multifaceted measures surrounding acute stroke thrombolysis can positively impact both the door-to-needle time and percent of cases within the institutional DTN time goal. Figure: Percentage of Thrombolysis Cases with DTN &lt; 30 Minutes

Abstract WMP36: Quality Improvement for Improved Ischemic Stroke Large Vessel Occlusion Door-In-Door-Out Times at an Urban Primary Stroke Center Integrated Health System

Background: Stroke patients who present to an Emergency Department (ED) with an acute ischemic stroke (AIS) due to a large vessel occlusion (LVO) and are eligible for endovascular stroke therapy (EST) require rapid transfer to a facility capable of EST. Nationwide data for 2022 suggest that 19% of LVO patients are transferred for EST within 90 minutes. Our practice center is a large urban community-based Primary Stroke Center, part of a spoke and hub integrated system. In 2022, we had a median door-in-door-out (DIDO) time of 98 min with 33% percent of cases under 90 min (n = 12). Purpose: Knowing the importance of early reperfusion, we implemented a quality improvement project using a pre-post design to improve our DIDO times for patients with AIS due to LVO, with a goal of achieving a median DIDO time of 75 min or less. Methods: Our approach was multidisciplinary. We completed comprehensive chart reviews focusing on critical time points and reviewed recent literature (2022 - 2023) for best practices. We created an ED interdisciplinary DIDO workgroup which developed and implemented a DIDO checklist after education and socialization. In March 2023, we created a dedicated regional neuro transfer hub to address changes with EMS notification and response to expedite LVO transfers. Other DIDO literature recommendations were already in place, including the use of a regionalized telestroke program. Best practices identified but not implemented focused on Emergency Medical Services (EMS), such as holding a rig while completing imaging, providing enroute reports, and conducting joint drills post-COVID. Results: After the implementation of the DIDO checklist, DIDO times decreased to 82 minutes from August 2022 to July 2023 (a decrease of 16 min), with 44% of cases under 75 mins (n = 9). Our median time for 2023 (January - July) is 68 min (n = 2). Conclusion: Transfer of LVO patients is a low-volume, high-risk event, but one where every minute matters for optimal patient outcomes. The DIDO checklist was a helpful aid for staff to ensure key steps were completed timely, leading to a decrease in DIDO times.