Tertiary Referral Hospital Research Articles

Cost analysis of limb salvage: comparing limb revascularisation and amputation in patients with Chronic Limb-Threatening Ischaemia (CLTI) at University Hospital Limerick.

The prevalence of peripheral arterial disease (PAD) is increasing globally. An increase in PAD in an ageing population inevitably results in an increase in incidence of Chronic Limb Threatening Ischemia (CLTI). Loss of a limb is a life-changing event with immeasurable cost to the individual, while the potential financial benefit of saving a limb is not well documented. The focus of this study was to estimate the cost associated with surgical interventions used in the treatment of CLTI compared with amputation. The cost to treat a CLTI diagnosis in 124 patients was analysed in an acute tertiary referral hospital over a 13-month study period. The analysis included staffing, medical devices used, number of blood components used and the length of stay. Statistical methods included descriptive statistical data and the Mann-Whitney U test. The median cost, associated with length of stay, post-amputation and post-revascularisation (hybrid) was €61,313 [IQR = €44,417,€83,331] and €46,573 [IQR = €25,687, €58,554] respectively, p < 0.001. The total median cost for length of stay for amputees in an acute hospital, rehabilitation and a prosthetic limb was €88,820 [IQR = €74,486, €110,248]. The median surgical cost of an amputation was €2,064 [IQR = €1,342, €2,866], whilst the median surgical cost of a revascularisation procedure (hybrid) was €5,966 [IQR = €4,380, €7,723], p < 0.001, inclusive of total blood components transfused. Revascularisation surgical interventions are more expensive than amputation, however, the length of stay, rehabilitation and prosthetic limb costs, for a patient undergoing a major limb amputation, is significantly more costly.

Inter-reader agreement for diagnosing thymic cysts on chest MRI in two tertiary referral centers.

Despite the substantial role of chest MRI for the diagnosis and follow-up of thymic cysts, information about inter-reader agreement and optimal MR sequences is still limited. We aimed to investigate the inter-reader agreement for diagnosing thymic cysts using various combinations of MR sequences and to assess the effect of the addition of CT on inter-reader agreement. A total of 76 anterior mediastinal lesions (≤ 30mm) from two tertiary referral hospitals (55 from Institution A and 21 from Institution B) who underwent chest CT and contrast-enhanced chest MR were included. Internal and external reading sets consisted of different combinations of MR sequences (pre- and post-contrast T1-weighted, T2-weighted, subtracted images, and diffusion-weighted imaging [DWI]/apparent diffusion coefficient [ADC] map) and CT. Four and three radiologists independently reviewed internal and external reading sets. The overall inter-reader agreement was moderate (κ = 0.50-0.57) for diagnosing cysts without significant differences between MR sequence combinations (all p-values > 0.05). The mean pairwise inter-reader agreement was the highest (κ = 0.65) when both the subtracted image and DWI/ADC map were provided. The addition of CT had no positive effect on the inter-reader agreement in the internal reading set (κ, from 0.57 to 0.50) but increased inter-reader agreement in the external reading set from moderate (κ = 0.48) to substantial (κ = 0.74). In conclusion, the overall inter-reader agreement for diagnosing thymic cysts on MRI was moderate. MR sequences including both the subtracted image and DWI/ADC map may be optimal in terms of inter-reader agreement.

Unique North American isolates of severe metastatic hypervirulent Klebsiella pneumoniae strain infections with hepatic abscesses seen in young patients within Texas.

Hypervirulent Klebsiella pneumoniae (hvKp) infections have principally been identified in Asia. Within a two-month period, two patients between the ages of 30 to 50 years old presented to a tertiary referral hospital in Texas with septic shock, hepatic abscess, and septic thrombophlebitis. Blood cultures were positive for Klebsiella pneumoniae (isolates 2020CK-00441 and 2021CK-00720 respectively). The first patient survived after a prolonged hospital course while the second patient expired. Describe the clinical presentation of these two patients. Perform whole genome sequencing and bioinformatic analysis to evaluate potential outbreak of specific hvKp bacteria isolates. Whole genome sequencing was performed using both paired-end Illumina MiSeq and nanopore sequencing to obtain a Completed genome for both isolates. 2020CK-00441 belonged to ST23 type while 2021CK-00720 was a ST65 type isolate. Kleborate analyses predicted with high confidence both isolates were hvKp. Phylogenetic analyses showed the two strains are not closely related to each other nor to any known hvKp isolates reported. Both isolates had yersiniabactin, colibactin, aerobactin and salmochelin producing loci which likely confer these isolates hvKp phenotype. 2020CK-00441 and 2021CK-00720 had a unique pK2044 like plasmid. HvKp strains capable of causing devastating metastatic septic infections have emerged in Texas. These isolates are unique compared to other hvKp strains globally. Country-wide surveillance and whole genome sequencing of these strains is essential to prevent a major public health emergency in the USA.

Late fracture-related infections in HIV-positive patients : a prospective cohort study.

HIV and musculoskeletal injuries both disproportionately affect individuals living in low- and middle-income countries (LMICs), leading to a significant number of fractures in HIV-positive patients. Despite this, little is known about the long-term outcomes for these patients. This prospective cohort study investigated whether HIV infection is associated with fracture-related infections (FRIs). All adult patients between September 2017 and December 2018 who received intramedullary nail fixation of lower limb fractures in two tertiary referral hospitals in Cape Town, South Africa, were deemed eligible. In total, 358 participants were recruited for this study, 33 of whom were lost to follow-up. Of the 325 participants, 37 (11.4%) developed a total of 39 FRIs over the study period; 25 were early FRIs (64.1%) and 14 were late FRIs (35.9%). Participants were followed up for a minimum of 24 months. Throughout follow-up, participants were monitored for FRIs. These were categorized as early FRIs (< 90 days) and late FRIs (> 90 days). Overall, 71 participants (21.8%) were HIV-positive and 254 participants were HIV-negative (78.2%). In the HIV-positive population, 15 participants (21.1%) suffered 16 FRIs: seven early FRIs (9.9%) and nine late FRIs (7.0%). In the HIV-negative population, 22 participants (8.7%) experienced 23 FRIs, 18 were early FRIs (7.1%), and five participants experienced late FRIs (2.0%). On univariate and multivariate regression, being HIV-positive increased a participant's likelihood of suffering late FRIs, and FRIs overall. HIV status made no significant difference to early FRI rates. Contrary to recent evidence, this study demonstrates an association between HIV and an increased risk of a patient developing late FRIs. However, there was no significant difference in early FRI rates.

Angiotensin-Receptor Blockers Prevent Vestibular Schwannoma-Associated Hearing Loss.

Vestibular schwannoma (VS) tumors typically present with sensorineural hearing loss (SNHL). Losartan has recently demonstrated prevention of tumor-associated SNHL in a mouse model of VS through suppression of inflammatory and pro-fibrotic factors, and the current study investigates this association in humans. This is a retrospective study of patients with unilateral VS and hypertension followed with sequential audiometry at a tertiary referral hospital from January 1994 to June 2023. Patients were stratified into subgroups by anti-hypertensive medication class. SNHL progression was assessed using Kaplan-Meier analysis to account for variable follow-up times. Two hundred thirty-six patients were identified with diagnosis of both VS and hypertension, and with sequential audiometry. Of these, 186 were taking anti-hypertensive therapy at the time of initial VS diagnosis, and 23 were taking losartan or another angiotensin receptor blocker (ARB). Patients taking an ARB were both more likely to have normal baseline hearing and no progressive hearing loss with 36.5 total patient-years of follow-up. Patients taking other anti-hypertensives all showed expected declines in hearing consistent with natural history of VS tumors. This study represents the first statistically significant association between ARB intake and hearing preservation in a real-world VS patient population. Significant confounding factors, such as concomitant hypertension in these patients, could still cloud the full effect of ARB medications' interaction with SNHL progression. Given that ARBs are well tolerated and safe, the results advocate for a prospective clinical trial to validate this effect.

Indications and Current Surgical Techniques for Keratoplasty: A 10-year Review from 2011 through 2020 at a Tertiary Referral Hospital in Thailand

Objective: To report the indications and current trends in surgical techniques for keratoplasty over 10 years at Siriraj Hospital. Materials and Methods: We retrospectively reviewed the medical records of hospitalized patients who underwent keratoplasty from 2011 to 2020. The collected data comprised demographics, indications for keratoplasty, and surgical techniques used. Results: A total of 754 eyes were included. Active infectious keratitis was the most common indication (26.1%), followed by bullous keratopathy (20.8%) and regraft (19.2%). There was no significant change in indications for keratoplasty between the first 5-year period and the second 5-year period. Fungal keratitis remained the most common etiology for keratoplasty. Penetrating keratoplasty (PKP) was the most common procedure overall (90.7%), followed by endothelial keratoplasty (EK; 5.7%) and deep anterior lamellar keratoplasty (DALK; 3.6%). However, surgical techniques used in the second 5-year period differed significantly from those in the first 5-year period (P &lt; 0.05). The use of PKP decreased from 96.0% to 86.7%; however, EK increased from 1.5% to 8.9%, while DALK rose slightly from 2.5% to 4.4%. Conclusion: Active infectious keratitis was the most common indication for keratoplasty, followed by bullous keratopathy and regraft. These indications may be reduced through collaborative efforts among government leaders, public health officers, and ophthalmologists. PKP remained the most common surgical technique due to the high incidence of infectious keratitis. However, the use of lamellar keratoplasty, including EK and DALK, significantly increased for other indications. Descemet membrane endothelial keratoplasty was performed mostly in eyes with Fuchs endothelial dystrophy.

Inability to Remove Locking Screws From the Femoral Neck System Due to Stripping of the Screwdriver Within the Locking Screw Head.

The purposes of this study were to investigate the frequency of screwdriver stripping in the head of the locking screw that attaches to the side plate to the femur shaft among the patients who underwent implant removal after femoral neck system (FNS) for femoral neck fracture, to determine the risk factors for locking head screw stripping in FNS treatment of femoral neck fracture, and to suggest a surgical tip that removes FNS, which is difficult to remove due to screw stripping. Retrospective cohort study. Eight Urban tertiary referral academic hospitals. Included were patients with Orthopedic Trauma Association/Arbeitsgemeinschaft für Osteosynthesefragen 31-B1, 31-B2, and 31-B3 femoral neck fractures who underwent surgical fixation with FNS from November 2019 to February 2023. The frequency of locking head screw stripping of FNS during the implant removal was evaluated. Among the 47 patients (18 (38%) men and 29 (62%) women) who met the inclusion criteria with an average age of 59.2 years (range, 28-94 years), 13 (27.7%) experienced screwdriver stripping in the head of the distal locking screw during FNS removal surgery. A higher body mass index showed a borderline significant association with the stripping in the adjusted model (odds ratio = 1.233; 95% confidence interval: 0.988-1.539; P = 0.064). No other variables showed significant association with the stripped locking head screw ( P > 0.05). Stripping of the screwdriver within the head of the distal locking screw occurred in over one-quarter of cases. While a higher body mass index demonstrated a borderline significant association, none of the other variables examined showed a statistically significant relationship with the stripped locking head screw. Prognostic Level III. See Instructions for Authors for a complete description of levels of evidence.

Perioperative and long-term outcomes of bilateral cardiac sympathetic denervation via video-assisted thoracoscopic surgery in patients with refractory ventricular arrhythmias.

Bilateral cardiac sympathetic denervation (CSD) performed via video-assisted thoracoscopic (VAT) surgery shows potential in managing ventricular tachycardia (VT), thereby reducing arrhythmic burden. In this setting, the scarcity of studies addressing both perioperative and long-term outcomes creates a substantial gap in the optimal management of patients with multiple comorbidities and limited treatment options. This observational study aimed to assess the medical comorbidities, as well as the short- and long-term outcomes of patients who underwent CSD for VT refractory to catheter ablation and medical therapy at a referral tertiary teaching hospital. We retrospectively analyzed data of all patients with VT who underwent bilateral CSD-VAT surgery at a single center. Unadjusted Kaplan-Meier survival curves were generated to analyze the survival rates at 1-year and 2-years following the procedure. Ten consecutive patients were unrolled between August 2014 and March 2024. Bilateral CSD-VAT surgery was successfully performed in all patients. Pre-operative ejection fraction was 33% (26-41). Two patients (22%) suffered cardiogenic shock and 1 vasoplegia. Half (50%) of the patients necessitated inotrope/vasopressor support and 1 an intra-aortic balloon pump. Median hospital stay was 12 (9-19) days. Three (33%) patients required postoperative ICU admission. All patients were alive upon hospital discharge. Neither major surgical complications nor complications typically associated with VAT-CSD (e.g., Horner's syndrome) were observed. The 1-year survival was 80% while the survival at 24months was 60%. CSD-VAT is a feasible rescue treatment in patients with refractory VT and is associated with limited intra- and postoperative complications alongside an acceptable long-term survival rate.

Percutaneous edge-to-edge mitral valve repair in patients with complex mitral valve anatomy: mid- to long-term results in a tertiary referral university hospital.

Abstract Introduction Transcatheter edge-to-edge repair (TEER) has proven to be an effective therapeutic alternative for certain cases of mitral regurgitation (MR) in patients who are not surgical candidates. Accumulated experience and technological advances allow TEER in selected patients with complex mitral valve anatomy who might initially be considered non-candidates for percutaneous treatment. Our main objective was to analyse the mid-to long-term characteristics and prognosis in patients with complex mitral valve anatomy treated with this technique compared to those with non-complex mitral anatomy. Methods An observational study was conducted on a prospective cohort of patients from a tertiary referral hospital, which included all cases of severe MR treated using TEER from November 2011 to January 2024. Two groups of patients were compared: those with complex valve anatomy (CVA) versus those who did not present it (NCVA). Mitral valve complexity was defined as the presence of mitral cleft, calcification in the grasping zone, mitral valve area (MVA) ≤3cm2 , mobile posterior leaflet length &amp;lt;7mm, rheumatic leaflet thickening or presence of Barlow syndrome. Clinical, analytical and echocardiographic variables were analysed at baseline and during follow-up. Baseline characteristics and event-free survival, defined as death or hospitalisation for heart failure (HF) during follow-up, were compared between the CVA and NCVA groups using Kaplan-Meier curves. Results A total of 191 patients were analysed (67% male, median age 74 (64-80) years), of whom 53 cases had complex valve anatomy. Among these, 7 cases presented with a mitral cleft, 2 cases had calcification in grasping zone, 3 cases had MVA≤3cm2, 35 cases with a mobile posterior leaflet length &amp;lt;7mm, 3 cases with rheumatic leaflet thickening and 8 cases had Barlow syndrome. Baseline clinical characteristics of both groups showed no significant differences, though there was a higher prevalence of hypertension in the CVA group, as shown in table 1. Most patients were in NYHA III-IV (62.3% CVA vs 72.4% NCVA, p=0.40) with a high percentage of prior hospitalization for HF in both groups without significant differences. The most common etiology of MR was functional with no differences between groups (CVA 77.4% vs NCVA 78.2%, p=0.43). With a median follow-up of 24 [9-50] months, event-free survival for readmission due to HF or all-cause mortality was 67% in CVA group, versus 64% in NCVA group, with no significant differences in median survival between them (p=0.41) (Figure 1). Conclusions In patients with MR and complex mitral valve anatomy who were initially not candidates for surgical or percutaneous treatment, a high event-free survival from death or readmission due to HF was achieved in the medium to long term. In centres with accumulated experience, TEER represents an effective therapeutic tool even in cases with complex anatomy, with no differences compared to those with more favourable anatomy. Baseline clinical characteristics. Kaplan-Meier curves

P-867. Carbapenem-resistant gram-negative bacterial infections in South India: A four-year retrospective study

Abstract Background Carbapenem-resistant Gram-negative bacteria (CRGNB) posed a global healthcare threat due to antibiotic resistance. In India, carbapenem resistance surged, and Ceftazidime–avibactam (CAZ-AVI) and Aztreonam (AZT) saw increased use without efficacy data. Previous international studies comparing polymyxins with CAZ-AVI plus AZT highlighted the need for region-specific evaluation. Here, we report the epidemiological, clinical, and treatment outcomes of patients admitted with CRGNB infections in a South Indian tertiary care referral hospital. Common CRO'S reported during the study period Methods This retrospective study was conducted at a 250-bed tertiary care referral hospital in South India. Over the last four years (2019 to 2023), we identified all blood culture results indicating the growth of carbapenem-resistant Gram-negative bacteria (CRGNB). Subsequently, we systematically reviewed the medical records of these patients, focusing on demographical, clinical, microbiological, and outcome data. Blood cultures utilized the BacT/ALERT (Biomerieux) culture system, and species identification was accomplished with the VITEK GNI card (Biomerieux). Antibiotic susceptibility testing followed the revised Clinical and Laboratory Standards Institute performance standards. Data were entered into an Excel spreadsheet, and descriptive statistics were employed for data interpretation. Results The study comprised 122 patients with positive blood cultures for carbapenem-resistant Gram-negative bacteria (CRGNB), with 70.50% males and 29.50% females, averaging 58.3 years. Common CRGNBs were identified, as shown in Figure 1. Minimum Inhibitory Concentrations (MICs) for colistin were available on 34.4% occasions. CRGNBs exhibited a 41% mortality rate. Combinational therapy (n=79) for CR showed lower mortality than monotherapy (n=43), especially Colistin monotherapy (72% mortality) and Polymyxin B (20%) compared to ceftazidime avibactam + aztreonam (14%) mortality. Conclusion A 41% mortality rate was noted in patients with CRGNB infections in South India, with significantly higher mortality (72%) associated with colistin monotherapy. Future strategies should focus on the role of combination therapies to enhance patient outcomes in the context of CRGNB infections. Disclosures All Authors: No reported disclosures

P-751. A 10-year retrospective review of Necrotizing Fasciitis at a Tertiary Referral Hospital in a Low/Middle Income Country

Abstract Background Necrotizing fasciitis (NF) is a rare, yet potentially fatal skin and soft tissue infection, with a global annual incidence of 0.3 to 15 per 100,000 cases. Early surgical debridement is crucial as mortality rates can reach up to 76%. there is a notable scarcity of data on the epidemiology of NF in the Eastern Mediterranean region. Our aim is to investigate clinical characteristics and outcomes among patients diagnosed with necrotizing fasciitis in a tertiary referral center in Beirut, Lebanon. Demographic and Clinical Characteristics in the Study Population Methods A retrospective chart review of hospitalized cases between 2011 and 2021. The study population included adult patients diagnosed with NF during this period. Data included demographic and clinical characteristics. Physical Findings Results We identified and included a total of 41 cases of NF in this cohort. The average age of the patients was 54.6 years, with males comprising the majority at 73%. The most prevalent co-morbidity was Diabetes Mellitus (48.78%), followed by hypertension (41.46%), cardiovascular diseases (41.46%), and renal failure (36.59%). Pain (87.80%), erythema (78.80%), and swelling (75.61%) were the most common symptoms. Skin discoloration was present in twenty-four of the forty-one patients (59%). Regarding outcomes, the patients identified were divided in two groups: survivors and deceased. overall mortality rate was 37%, and amputation rate was 10% (Table 3). Patients in both groups underwent a median of 3 surgical debridement’s. Time to diagnosis did not significantly differ between survivors (median 1.75 hours) and non-survivors (median 6 hours), whereas antibiotics were administered with a median time of 30 minutes from diagnosis in the survival group, compared to one hour in the deceased group. Time to surgery showed a 7-hour delay in the deceased group compared to survivors (p=0.096). Timelines and Clinical Outcomes Conclusion To our knowledge, this study represents the first comprehensive review of necrotizing fasciitis (NF) in Lebanon, providing valuable insights into demographics and comorbidities. Our findings reveal a mortality rate of 37%, which is consistent with the ranges reported in existing literature, highlighting the need for continued efforts to improve outcomes for patients with NF in our region. Disclosures All Authors: No reported disclosures

P-738. A Microbiological Profile of Necrotizing Fasciitis at a Tertiary Referral Hospital in a Low/Middle Income Country

Abstract Background : Necrotizing fasciitis (NF), an uncommon, fatal infection of the skin and soft tissues, carries a significant mortality risk, with rates reaching as high as 76% despite prompt surgical interventions. While polymicrobial infections were more likely to be encountered, few studies reported a monomicrobial predominance. Despite its relevance, there is a notable lack of data in the Eastern Mediterranean region. We aimed to investigate the microbiological profile among patients diagnosed with necrotizing fasciitis in a tertiary referral center in Lebanon, with a particular focus on Multidrug-resistant organisms (MDROs) and Antimicrobial Resistance (AMR), given their increasing prevalence and the challenges they pose in clinical management.Table 1:Distribution of Organisms Methods A retrospective chart review of hospitalized cases between 2011 and 2021. The study population included adult patients diagnosed with NF during this period. Data included microbiological characteristics, with focus on Multidrug-resistant organisms (MDROs).Figure 1:Yearly Trend of MDROs Among Isolated Organisms Results 41 cases of NF were identified showing a mortality rate of 37%. 46 % of cases had polymicrobial infections versus 42% monomicrobial. The predominant gram negative pathogen was E.coli in both types of infections followed by the gram positive pathogen, Enterococcus species. No difference in the type of infection was noticed in the survival group compared to a predominance of polymicrobial infection in the non-survival group. Fungi were recovered represented in 5.4% of cases and were part of a polymicrobial infection. Out of all the isolated organisms, 21.2% showed patterns of resistance (Extended Spectrum Beta Lactamase, Multidrug resistant, Vancomycin Resistant Enterococcus, and Carbapenem Resistant Enterobacteriaceae) with a yearly incremental rise. Conclusion This 10-year study emphasizes the urgency of prompt surgical intervention and tailored antibiotic treatment for NF, particularly in the context of increasing AMR and the presence of MDROs, contributing crucial regional data on NF demographics, comorbidities, and microbiology Disclosures All Authors: No reported disclosures

P-1749. Implementation of an Automatic 36-hour Stop Order on Empiric Meropenem Usage

Abstract Background Implementation of automatic stop orders (ASOs) for empiric antimicrobials have reduced antimicrobial use without negatively impacting patient outcomes. Given a recent increase in empiric meropenem use at our tertiary referral pediatric hospital, a 36-hour meropenem ASO option was implemented in the EMR for patients with sepsis requiring empiric antibiotics active against ESBL-producing organisms. We sought to evaluate the impact this initiative had on meropenem use and safety outcomes. Methods A 36-hour ASO for meropenem was implemented on October 12th, 2022. We conducted a single-center, retrospective pre/post evaluation of order set implementation of all patients admitted to Riley Hospital for Children and treated with meropenem between 9/01/2019–9/01/2021 (pre-intervention) and 10/13/2022–10/13/2023 (post-intervention). The primary outcome was meropenem utilization, as measured by the number of meropenem days and doses per admission. Secondary outcomes included total hospital and ICU mean length of stay (LOS), mortality within 30 days of meropenem exposure, and 30-day readmission rate. Results 309 admissions during which meropenem was administered were included. Demographics between pre-ASO (147 patients; n = 193 admissions) and post-ASO (88 patients; n = 116 admissions) groups were similar. There was no difference in the number of meropenem days (pre and post-ASO: median = 4; p = 0.88) or the number of meropenem doses (pre-ASO: 11 vs. post-ASO: 10; p = 0.63). Secondary safety outcomes including death within 30 days of meropenem administration (8.7% vs. 8.7%; p = 0.99), hospital LOS (18 vs 15.5 days; p = 0.42), ICU admission, and 30-day readmission rate were not significantly different. The new ASO was utilized in 23.3% of admissions in the post-implementation period. Conclusion Use of the new ASO was not widely adopted, making evaluation of impact difficult. No significant difference in meropenem use nor clinical outcomes were identified after implementation, which has informed the next Plan-Do-Study-Act (PDSA) cycle for quality improvement at our center, likely with a focus on EMR modifications and education. Disclosures Jack G. Schneider, MD, MiraVista Diagnostics: Advisor/Consultant

P-914. Clinical Outcomes and Predictors of Mortality among Hospitalized HIV/ AIDS Adult Patients Diagnosed with Central Nervous System Infections in a National Tertiary Referral Hospital in the Philippines: A 5-year Retrospective Study

Abstract Background HIV infection remains a significant global health concern despite the major advances in its understanding and treatment. Central nervous system (CNS) infections are common complications among HIV-infected patients. In the Philippines, limited local data on the clinical profile and outcome among HIV-infected patients with CNS infections is available. Case Distribution of CNS Infections among HIV-infected patients in the Philippines Methods This is a 5-year retrospective study of confirmed HIV-infected patients hospitalized and managed as CNS Infections at San Lazaro Hospital, Manila Philippines between 2018 and 2022. Demographics and clinical data were extracted from medical records and the association with clinical outcome and length of hospital stay were analyzed. Incidence and Case Fatality Rate of CNS Infections among HIV-infected patients in the Philippines Results One hundred twenty-eight (128) HIV-infected patients, mostly male (95%), were included, with a mean age of 31 years, and a mean CD4 lymphocyte count of 56.8 (0-282) cells/mm3. Forty-one patients (32%) were newly diagnosed with HIV, and 51% (n=65) were not on antiretroviral therapy (ART). The mean duration of HIV diagnosis among those known to have HIV before admission was 1.4 years. The most common CNS infection was Tuberculous Meningitis (TBM) (35%), followed by Cryptococcal Meningitis (CM) (29%), and Toxoplasma Encephalitis (TE) (17%). The presence of dual CNS Infection was diagnosed among 20 patients (15.6%), of which a total of 16 (12.5%) had co-infection of TBM and TE, while 4 (3.1%) had co-infection of TBM and CM. The most common clinical manifestations were headache (87.5%), fever (61%), and sensorial changes (60%). The overall in-hospital mortality rate was 30.4% (n=39), with the highest case-fatality rate among those infected with Cryptococcal Meningitis at 53% (n=19). Among those diagnosed with CM, 23 patients (62%) had concomitant Cryptococcal Fungaemia. Those with CM and dual CNS infection had a longer hospital stay of &amp;gt;31 days ( &amp;gt;1 month). Conclusion In the Philippines, the most common CNS infection among HIV-infected patients was Tuberculous Meningitis, followed by Cryptococcal Meningitis, and Toxoplasma Encephalitis. Early diagnosis of HIV infection with timely initiation of ART, together with an effective diagnostic and management approach to these conditions is needed to decrease the risk of further complications and death. Disclosures All Authors: No reported disclosures

P-257. Effectiveness of Pulsed-Xenon Ultraviolet Disinfection during Terminal Cleaning of Patient Rooms in the Intensive Care Unit on the Sustained Containment of Drug-resistant Acinetobacter baumannii

Abstract Background Environmental disinfection by ultraviolet (UV) has been shown to be effective in controlling transmission of multidrug-resistant organisms, and introduced into daily practices in addition to manual terminal cleaning in some hospitals in the US. However, its effectiveness outside the US healthcare setting is not well investigated. Moreover, its effectiveness to control gram-negative bacteria has not been well described. Methods This study was conducted in the intensive care unit (ICU) of Yamagata University Hospital, a 637-bed tertiary referral hospital. Sporadic transmission of two drug-resistant Acinetobacter baumannii (2DRA) began in late 2013. Despite intensified hand hygiene promotion and manual terminal cleaning, transmission of 2DRA continued. In January 2018, we added pulsed-xenon ultraviolet (PX-UV) disinfection for the terminal cleaning after every patient discharge. The study periods were defined as follows: the baseline period (August 2016 to January 2018, manual cleaning only) and the intervention period (February 2018 to December 2023, addition of PX-UV). All patients admitted in the ICU were regularly screened for 2DRA for the detection of possible acquisition of 2DRA throughout the study periods. Results The incidence of acquisition of 2DRA in the ICU significantly declined (4.45 per 1,000 patient days in the baseline period to 1.09 in the intervention period, relative risk (RR): 0.26, 95% confidence interval: 0.12-0.51). Cases in the intervention period were sporadic, and no cluster was found. In contrast, in non-ICU wards, where PX-UV disinfection was performed only after the discharge of patients known to be colonized or infected with 2DRA or other multidrug-resistant pathogens, possible transmission of 2DRA was observed several times. Conclusion Adding PX-UV after manual terminal cleaning was effective in controlling acquisition of 2DRA in the ICU patients. The effectiveness of PX-UV in controlling gram-negative MDROs in the non-US healthcare settings is suggested. In contrast, there was room for improvement in controlling of 2DRA in non-intervention wards. Disclosures All Authors: No reported disclosures

Higher testosterone level is associated with improved cognitive functions in Klinefelter syndrome

AbstractKlinefelter syndrome (KS) is a common sex chromosome aneuploidy affecting one to two per 1000 live male births. Testosterone therapy and neuropsychological support can enhance the quality of life in affected individuals. While cognitive deficits have been documented in Klinefelter syndrome, the influence of hormonal variability on cognitive profiles remains underexplored. This study aimed to determine whether testosterone levels correlate with neurocognitive functions in Klinefelter syndrome individuals. This cross‐sectional study involved a heterogeneous clinical sample from a single tertiary referral hospital. Participants: Thirty Klinefelter syndrome individuals were enrolled, being 21 with 47, XXY without neurological comorbidities, aged 17–65 years. Participants underwent blood tests for total testosterone, free testosterone, estradiol, sex‐hormone‐binding globulin, follicle‐stimulating hormone, luteinizing hormone, and anti‐Müllerian hormone. A comprehensive neuropsychological assessment was also conducted, covering intellectual quotient (Wechsler Scale) and higher‐order cognitive functions (attention, executive functions, language, memory, and visuoconstructional abilities). Neuropsychological performance was notably better in Klinefelter syndrome individuals with higher levels of testosterone. Spearman's test revealed significant correlations between total testosterone, free testosterone, and gonadal status measured by free testosterone/luteinizing hormone and free testosterone/estradiol ratios and cognitive flexibility tasks. The mean age of participants was 33.1 years (SD = 14.0), and free testosterone/luteinizing hormone and free testosterone/estradiol measures were correlated with set‐shifting, verbal memory, visual functions, and adaptive behavior domains, including communication, daily living, and motor skills. The free testosterone:estradiol ratio was also consistently associated with total intellectual quotient, verbal comprehension, perceptual organization, and processing speed indexes. The study highlights the positive correlation between testosterone levels and cognitive functions in Klinefelter syndrome males. These insights reinforce the role of testosterone in neurocognitive development, suggesting the potential benefits of testosterone therapy in managing cognitive deficits in Klinefelter syndrome. More extensive confirmatory studies are necessary to substantiate these findings and to explore the mechanisms involved.

Emergency primary anastomosis with or without intraoperative colonic lavage following sigmoidectomy in sigmoid volvulus: 175-patient experience in a tertiary referral hospital

Objectives: Emergency primary anastomosis following sigmoidectomy is one of the main treatment options in sigmoid volvulus (SV). However, during this procedure, the role of intraoperative colonic lavage (ICL) is controversial. Our aim was to evaluate the role of ICL in 175-patient SV series. Methods: In Ataturk University Faculty of Medicine Department of General Surgery, ICL was applied in 76 cases (43.4%), while it was not used in the remained 99 patients (56.6%) in 58.5-year period. In a partial retrospective (first 20 years, from June 1966 to June 1986) and prospective (later 38.5 years, from June 1986 to December 2024) evaluation, some preoperative, operative, and postoperative findings were utilized. Results: As preoperative data, mean age (56.4 years vs. 57.1 years, P&gt;0.05), male/female ratio (4.8 vs. 4.2, P&gt;0.05), and rate of shock (5.3% vs. 6.1%, P&gt;0.05) were statistically similar in both groups, while mean ASA score (3.1 vs. 2.9, P&lt;0.05) was significantly lower in ICL group. Among operative findings, rates of bowel gangrene (67.1% vs. 63.6%, P&gt;0.05) and perforation (1.3% vs. 1.0%, P&gt;0.05) were statistically similar in both groups, while mean operation time (205.4 minutes vs. 176.8 minutes, P&lt;0.005) was significantly longer in ICL group. As surgical outcomes, rates of mortality (13.2% vs 12.1%, P&gt;0.05) and morbidity (39.5% vs. 28.3%, P&gt;0.05) were statistically similar in both groups, while mean hospitalization time (14.7 days vs. 9.4 days, P&lt;0.001) was significantly longer and mean cost (3,455.4 USD vs. 2,752.1 USD, P&lt;0.001) was significantly higher in ICL group. Conclusion: When compared with that of primary anastomosis with ICL, primary anastomosis without ICL provided shorter operation and hospitalization times, and less cost in addition to similar mortality and morbidity rates in the emergency treatment of SV. doi: https://doi.org/10.12669/pjms.41.2.11399 How to cite this: Altundas N, Peksoz R, Disci E, Atamanalp SS. Emergency primary anastomosis with or without intraoperative colonic lavage following sigmoidectomy in sigmoid volvulus: 175-patient experience in a tertiary referral hospital. Pak J Med Sci. 2025;41(2):603-607. doi: https://doi.org/10.12669/pjms.41.2.11399 This is an Open Access article distributed under the terms of the Creative Commons Attribution License (http://creativecommons.org/licenses/by/3.0), which permits unrestricted use, distribution, and reproduction in any medium, provided the original work is properly cited.

Navigating the complexities of managing placenta accreta spectrum: A case series and literature review.

Placenta accreta spectrum (PAS) poses a significant risk for maternal morbidity and mortality. There is a global rise in incidence of PAS in tandem with an increase in rates of cesarian section. Previous cesarian section and presence of placenta previa are two independent risk factors for development of PAS. Other risk factors are dilatation and curettage, endometrial ablation, and hysteroscopy. Ultrasound and magnetic resonance imaging are useful in prenatal diagnosis, antenatal follow-up, and pre-operative planning. Patient care is individualized to optimize outcomes with appropriate preoperative counseling. However, a significant number of cases remain undiagnosed and are incidentally discovered during cesarian section or management for retained placenta. Patients may suffer significant morbidity such as postpartum hemorrhage, massive blood transfusion, injury to pelvic viscera, hysterectomy, acute kidney infection, and even death. Cesarean hysterectomy is the mainstay of treatment. In selected cases, conservative management may be offered. This includes leaving the placenta insitu with interval resolution, manual removal, application of compression sutures and balloon tamponade, myometrial resection with repair, and the triple P procedure. In this series, we present seven patients with PAS managed at a tertiary teaching and referral hospital in Kenya. We highlight and discuss their antenatal presentation, intraoperative findings, management and the postoperative course. Early diagnosis, involvement of multidisciplinary team, and good preoperative planning are key to achieving a good outcome. Patients with PAS should be managed in facilities with sufficient resources, skilled personnel to manage complications arising from treatment such as need for massive transfusion, and intensive care.

P0359 Characteristics and long-term outcomes of biopsy proven serrated epithelial change in patients with inflammatory bowel disease: a retrospective analysis

Abstract Background Serrated epithelial change (SEC) is an increasingly recognised histologic finding in patients with inflammatory bowel disease (IBD) and may be associated with an increased risk of synchronous or metachronous colorectal dysplasia.1,2 The aims of this study were to characterise the clinical and histologic features of IBD patients with SEC and determine the incidence of dysplasia. Methods We performed a retrospective, observational, single-centre study at a tertiary referral hospital. IBD patients with SEC were identified by searching the pathology database for ‘serrated’, ‘epithelial’ and ‘change’ in pathology reports. The first colonic biopsy showing SEC between 2015 to 2023, was designated as the index SEC. SEC was defined as colonic mucosa with goblet cell-rich epithelium, disorganised crypt architecture and irregular serrations without distortion of basal aspects of crypts or features of dysplasia. Patients without follow-up colonoscopy or flexible sigmoidoscopy were excluded (see Figure 1). Clinical and histological data were extracted from electronic medical records and endoscopy reports. Results The cohort included 26 IBD patients (16 with Crohn’s Disease and 10 with ulcerative colitis), consisting of 14 males (53.8%) with a median age of 58 years at the time of the index SEC diagnosis. See Table 1 for patient characteristics. A total of 30 specimens with SEC were identified among the 26 patients, and all patients had at least one follow-up colonoscopy or flexible sigmoidoscopy. The mean disease duration was 15 years, and the median follow-up time was 24.5 months. SEC was detected on high-definition white light endoscopy in 61.5% of cases. SEC was primarily located in the cecum (30%), rectum (23.3%) and transverse colon (16.7%), detected on nodular or polypoid mucosa (60%), and exhibited multifocal distribution (19.2%). In patients with SEC, endoscopic and histologic inflammation was demonstrated in 50% and 46.2% of cases, respectively. One case (3.8%) of low-grade dysplasia in the caecum was observed in a patient with Crohn’s disease. Conclusion SEC was predominantly found as polypoid or nodular lesions proximal to the splenic flexure and associated with endoscopic and histologic inflammation. Larger, prospective, multi-centre studies are necessary to clarify the clinical implications of SEC in IBD, its potential role in carcinogenesis and dysplasia surveillance strategies.

Effect of ethnicity and other sociodemographic factors on attendance at ophthalmology appointments following referral from a Diabetic Eye Screening Programme: a retrospective cohort study

Background/aimsTo examine the association between sociodemographic characteristics and attendance at Hospital Eye Service (HES) referrals from the Diabetic Eye Screening Programme (DESP), in a large, ethnically diverse urban population.MethodsRetrospective cohort...