Significant Comorbidities Research Articles

Endoscopic Repair of Anterior Skull Base Cerebrospinal Fluid Leaks is Successful in Frail Patients.

Surgical frailty estimates a patient's ability to withstand the physiologic stress of an intervention. There is limited data regarding the impact of frailty on endoscopic cerebrospinal fluid (CSF) leak repair. Patients undergoing CSF leak repair at two tertiary academic skull base programs were retrospectively reviewed. Demographic, treatment, and postoperative outcomes data were recorded. Frailty was calculated using validated indices, including the American Society of Anesthesiologists (ASA) classification, Charlson Comorbidity Index (CCI), and the Modified 5-Item Frailty Index (mFI-5). Outcomes included 30-day medical and surgical complications and readmission. A total of 185 patients were included with 128 (69.2%) female patients and average age of 54 ± 14 years. The average body mass index was 34.6 ± 8.5. The most common identified etiology was idiopathic intracranial hypertension (IIH) in 64 patients (34.6%). A total of 125 patients (68%) underwent perioperative lumbar drain placement (primarily to measure intracranial pressures and diagnose IIH). Most patients were ASA class 3 (48.6%) with mean CCI 2.14 ± 2.23 and mFI-5 0.97 ± 0.90. Three patients had postoperative CSF leaks, with an overall repair success rate of 98.4%. There was no association between increased frailty and 30-day medical outcomes, surgical outcomes, or readmission (all p > 0.05). Endoscopic CSF leak repair in a frail population, including lumbar drain placement and bed rest, was not associated with an increased rate of complications. Previous data suggests increased complications in open craniotomy procedures in patients with significant comorbidities. This study suggests that the endoscopic approach to CSF leak repair is well tolerated in the frail population. IV Laryngoscope, 134:2713-2717, 2024.

Upfront multi-bipolar radiofrequency ablation for HCC in transplant-eligible cirrhotic patients with salvage transplantation in case of recurrence.

We aim to assess the long-term outcomes of percutaneous multi-bipolar radiofrequency (mbpRFA) as the first treatment for hepatocellular carcinoma (HCC) in transplant-eligible cirrhotic patients, followed by salvage transplantation for intrahepatic distant tumour recurrence or liver failure. We included transplant-eligible patients with cirrhosis and a first diagnosis of HCC within Milan criteria treated by upfront mbp RFA. Transplantability was defined by age <70 years, social support, absence of significant comorbidities, no active alcohol use and no recent extrahepatic cancer. Baseline variables were correlated with outcomes using the Kaplan-Meier and Cox models. Among 435 patients with HCC, 172 were considered as transplantable with HCCs >2 cm (53%), uninodular (87%) and AFP >100 ng/mL (13%). Median overall survival was 87 months, with 75% of patients alive at 3 years, 61% at 5 years and 43% at 10 years. Age (p = .003) and MELD>10 (p = .01) were associated with the risk of death. Recurrence occurred in 118 patients within Milan criteria in 81% of cases. Local recurrence was observed in 24.5% of cases at 10 years and distant recurrence rates were observed in 69% at 10 years. After local recurrence, 69% of patients were still alive at 10 years. At the first tumour recurrence, 75 patients (65%) were considered transplantable. Forty-one patients underwent transplantation, mainly for distant intrahepatic tumour recurrence. The overall 5-year survival post-transplantation was 72%, with a tumour recurrence of 2.4%. Upfront multi-bipolar RFA for a first diagnosis of early HCC on cirrhosis coupled with salvage liver transplantation had a favourable intention-to-treat long-term prognosis, allowing for spare grafts.

Conversion of sleeve gastrectomy to Roux-en-Y gastric bypass: impact on reflux and weight loss

BackgroundSleeve gastrectomy (SG) is the most commonly performed weight loss operation, and its 2 most common complications are postoperative reflux and weight recurrence. There is limited evidence to guide decision-making in treating these conditions. ObjectivesTo determine the efficacy of conversion of SG to Roux-en-Y gastric bypass (RYGB) for GERD management and weight loss. SettingForty-one hospitals in Michigan. MethodsWe conducted a retrospective cohort study examining patients who underwent conversion of SG to RYGB from 2014 to 2022. The primary outcomes were changes in GERD-HRQL scores, anti-reflux medication use, and weight from baseline to 1 year after conversion. Secondary outcomes included 30-day postoperative complications and resource utilization. ResultsAmong 2133 patients undergoing conversion, 279 (13%) patients had baseline and 1-year GERD-HRQL survey data and anti-reflux medication data. GERD-HRQL scores decreased significantly from 24.6 to 6.6 (P < .01). Among these, 207 patients (74%) required anti-reflux medication at baseline, with only 76 patients (27%) requiring anti-reflux medication at 1 year postoperatively (P < .01). Of the 380 patients (18%) with weight loss data, mean weight decreased by 68.4lbs, with a 24.3% decline in total body weight and 51.5% decline in excess body weight. In terms of 30-day complications, 308 (14%) patients experienced any complication and 89 (4%) experienced a serious complication, but there were no leaks, perforations, or deaths. Three-hundred and fifty-five (17%) patients presented to the emergency department and 64 (3%) patients underwent reoperation. ConclusionsThis study represents the largest reported experience with conversion from SG to RYGB. We found that conversion to RYGB is associated with significant improvement in GERD symptoms, reduction in anti-reflux medication use, and significant weight loss and is therefore an effective treatment for GERD and weight regain after SG. However, the risks and benefits of conversion surgery should be carefully considered, especially in patients with significant comorbidity burden.

Abstract CT150: Trial in progress: A phase 1b single-arm, open-label, study of emavusertib (CA-4948) in combination with azacitidine and venetoclax in acute myeloid leukemia patients in complete response with measurable residual disease

Abstract Background: Emavusertib is a novel potent oral inhibitor of interleukin-1 receptor-associated kinase 4 (IRAK4) with additional inhibitory activity against FMS-like tyrosine kinase 3 (FLT3) and CDC-like kinases (CLK1/2/4). Inhibition of these onco-proteins may induce remission thereby addressing a critical unmet need for novel therapies in acute myeloid leukemia (AML). Clinical studies with emavusertib monotherapy have demonstrated a significant reduction in AML blasts with clinical and molecular responses, including patients with relapsed or refractory AML, previously treated with an HMA and/or FLT3 inhibitors (Metzeler 2022). Azacitidine + venetoclax (aza+ven) has been approved in newly diagnosed, unfit patients with AML. In the VIALE-A study, composite complete response (CRc) (CR, CRh, or CRi) in the absence of measurable residual disease (MRD) of &amp;lt;1 residual blast/1000 leukocytes (MRD negative [MRD−]) resulted in longer duration of response (DOR), event-free survival, and overall survival (OS), and better HSCT outcome compared with patients who achieved CRc but were MRD+ (Pratz, 2022). In pre-clinical studies, emavusertib in combination with aza+ven demonstrated synergistic antileukemic effects in AML cell lines, including azacitidine- or venetoclax-resistant cell lines. Adding emavusertib to aza+ven in MRD+ patients at the time of CR may convert MRD status without adding significant toxicity and confirm that emavusertib can be safely added to aza+ven as a potential new regimen in front-line therapy. Study Design: This is a single-arm, open-label Phase 1b trial evaluating safety and tolerability, PK, and conversion of MRD status with emavusertib as an add-on agent to aza+ven in AML patients who achieved CR or CRh with MRD+ based on local testing (EU CT Number 2023-505828-58-00). The primary objective of the study is to determine a safe and tolerable dosing schedule for the triple combination. Secondary objectives include MRD conversion rate, DOR, OS, and pharmacokinetics. The study will enroll approximately 24 patients at 5 to 10 sites globally. Patients will have received azacitidine and venetoclax as first line therapy and achieved CR or CRh after 1-6 cycles of aza/ven. If MRD status remains positive, emavusertib will be added to the existing well tolerated aza+ven regimen. The starting emavusertib dose is 200 mg BID for 7 days per cycle of 28 days. If well tolerated, duration of emavusertib treatment will be extended to 14 and 21, respectively; no intra-patient change of emavusertib dosing duration is planned. The patients will continue triple treatment (emavusertib+aza+ven) until consent withdrawal, disease progression, intolerable toxicity, or not achieving MRD- within 6 cycles of triple treatment. In this Phase 1b trial, MRD can be evaluated by local testing of bone marrow. Key exclusion criteria include residual toxicities and significant comorbidities. Citation Format: Reinhard von Roemeling, Adolfo De La Fuente, Claudio Cerchione, Sebastian Scholl, Jan Moritz Middeke, Gaurav S. Choudhary, Maria Lamar, Steven Angelides, Uwe Platzbecker. Trial in progress: A phase 1b single-arm, open-label, study of emavusertib (CA-4948) in combination with azacitidine and venetoclax in acute myeloid leukemia patients in complete response with measurable residual disease [abstract]. In: Proceedings of the American Association for Cancer Research Annual Meeting 2024; Part 2 (Late-Breaking, Clinical Trial, and Invited Abstracts); 2024 Apr 5-10; San Diego, CA. Philadelphia (PA): AACR; Cancer Res 2024;84(7_Suppl):Abstract nr CT150.

Assessment of Epidemiology and Clinical Profile of Psoriatic Arthritis Patients in India.

Psoriasis is an inflammatory skin disease associated with significant comorbidity. However, the characteristics of patients with psoriasis are not well documented in India, and a more detailed understanding is needed to delineate the epidemiologic profile at the regional level for better management of psoriasis. Herein, we reported the clinical profile and demographic pattern of psoriasis to further understand its burden in the Indian setting. We conducted a retrospective observational study of patients diagnosed with psoriasis who fulfilled the classification criteria for psoriatic arthritis (CASPAR) criteria. Patients were included from the rheumatology outpatient department of Kokilaben Dhirubhai Ambani Hospital and Medical Research Institute in Mumbai, India. The outcomes included demographic and clinical profiles, patterns of joint involvement, and comorbidities associated with psoriasis. A p-value of <0.05 was considered significant. We enrolled 60 patients, with a mean age of 50.87 years and a higher proportion of females (62%). The majority of patients with less than five joints had associated comorbidities (40 out of 60). Psoriatic arthritis (PsA) occurred in 41 patients [mean ± standard deviation (SD) age of onset-38.88 ± 13.24 years], with the highest occurrence in the 30-50 years (53.3%). The majority of patients with PsA developed it within 2 to ≥5 years of psoriasis occurrence. We did not find any significant correlation between the occurrence of PsA and comorbidities, as well as the duration of PsA and the number of joints (p = 0.152). Pitting and enthesitis were the most common morphological changes noted in almost half of the patients. Our study provides an overview of the epidemiologic and clinical characteristics of psoriasis patients in India. These findings could be useful for early diagnosis of PsA and help clinicians in assessing the progression of psoriasis into PsA.

First episode psychosis in a young person with a diagnosis of Autistic Spectrum Disorder: A Case report

IntroductionPsychotic disorders are significant comorbidities in young people with Autistic Spectrum Disorder (ASD). Evidence suggests that ASD &amp; psychosis present with overlapping clinical features &amp; cognitive symptoms leading to misdiagnosis (Trevisan et al. Front.Psych 2020;11:548). Clinicians encounter diagnostic dilemma during assessment of psychosis in adolescents with ASD.ObjectivesTo discuss the clinical challenges in the assessment &amp; treatment of young people with ASD &amp; comorbid psychosis.MethodsA case report of a young girl with ASD &amp; comorbid psychotic illness.ResultsA young girl with ASD was admitted to CAMHS inpatient Unit with unusual beliefs &amp; perceptual disturbances. She reported hearing the voice of ‘Hydrogis’ who was talking to her about his girlfriend. She made a voodoo doll &amp; tried to set it on fire, as she believed that this would kill the girlfriend. She also heard voices of characters from a TV show, discussing her in third person. She absconded from home due to the distress associated. She attempted suicide by tying a ligature. She was seen responding to external stimuli, laughing incongruously &amp; was thought disordered. Despite never being to USA, she spoke in American accent. She lacked insight &amp; struggled to differentiate reality from fantasy. The aim of admission was to determine if the symptoms were part of ASD or a psychotic disorder. She had medication free assessment but continued to be very distressed. We commenced Aripiprazole which was optimised. She responded well to the treatment &amp; was discharged to the care of Early Intervention in Psychosis team with partial remission of symptoms.ConclusionsHistorically psychotic illnesses &amp; ASD were thought to be closely linked. Research suggest that they are two separate disorders with specific onset, progress, signs &amp; symptoms. ASD might be misdiagnosed as psychosis as difficulties in communication may resemble thought disorder, ‘melt down’ may mimic catatonia &amp; difficulties in recognising others’ intentions may mimic paranoia. Our patient was experiencing first episode psychosis in late adolescence. This age of onset is consistent with research findings. A study to differentiate between ASD &amp; psychosis found that positive symptoms like hallucinations &amp; delusions were suggestive of psychosis while odd emotional gestures, stereotyped speech &amp; restricted interests indicated ASD. Our patient predominantly had positive symptoms of delusions, hallucinations &amp; thought disorder, hence our diagnosis of psychotic episode. In some cases, it is difficult to differentiate childhood fantasies from delusional beliefs (Ribolsi et al. Front.Psych 2022;13:768586). Bleuler explains that children with ASD replace imperfect realities with imaginations &amp; hallucinations but Michael Rutter claims that autistic children lack fantasy. There are varying views on this subject &amp; this is the challenge we faced when treating this young person.Disclosure of InterestNone Declared

Pelvic Lymph Node Dissection in Bladder Cancer: Have We Agreed on the Extent?

Summary Radical cystectomy (RC) combined with pelvic lymph node dissection (PLND) is the gold standard for treating muscle invasive bladder cancer; however, the optimal extent of PLND, whether limited (lPLND), standard (sPLND), extended (ePLND), or super-extended (sePLND), remains controversial. This review assesses the existing literature, including randomized controlled trials, retrospective studies, and meta-analyses, to evaluate the impact of different PLND extents on oncological and survival outcomes in patients undergoing RC. For patients with advanced disease (cT3 or higher), ePLND provides significant diagnostic and therapeutic benefits by improving staging accuracy and potentially eradicating micrometastatic disease, which may translate into better survival outcomes. The advantages of ePLND often outweigh the associated surgical risks in such cases. Conversely, for patients with less advanced disease (≤pT2) or those with significant comorbidities, the incremental benefits of extensive dissection are limited, and a more conservative approach, such as lPLND or sPLND, is recommended to minimize surgical morbidity when still achieving effective oncologic control. Current evidence suggests that a well-performed sPLND is generally sufficient for accurate staging and prognostication, whereas sePLND does not offer additional survival benefits and increases the risk of complications.

1069 Assessing the Safety and Efficacy of Spinal Anesthesia in Patients With Higher Risk Comorbidities

INTRODUCTION: Spinal anesthesia (SA) is a safe and effective alternative to general anesthesia (GA) for lumbar surgery. Widespread adoption of SA has not occurred presumably due to surgeons’ concerns for difficulties in management of patients with comorbidities. Obesity (BMI =30 kg/m2), anxiety, obstructive sleep apnea, re-operation at the same level, and multilevel operations have recently been identified as risk factors for perioperative complications. METHODS: A retrospective analysis of 422 patients who underwent thoracolumbar surgery under spinal anesthesia by a single surgeon at a single academic center (2017-2021) was carried out. Patient demographics, comorbidities, as well as intraoperative and postoperative complications were abstracted from the medical record. In the overlapping groups, 149 patients had a BMI =30, 95 had diagnosed anxiety, 79 underwent multilevel surgery, 98 had obstructive sleep apnea, and 65 had a prior operation at the same level. The control group included 132 patients without these risk factors. Differences in perioperative outcomes were assessed with the Kruskal-Wallis rank sum test, Pearson's Chi-squared test, or Fisher's exact test using R (The R Foundation, v 4.1.1, Vienna, Austria). RESULTS: Postoperative pneumonia was observed in two patients in the anxiety group and in one patient in the reoperative group (p-value &lt; 0.05). There were no other statistically significant differences in intraoperative and postoperative complications within the entire cohort including when stratified by number of comorbidities. Rate of spinal fusion was comparable among groups, though mean length of stay and operative time were different (p-value &lt; 0.001). CONCLUSIONS: Spinal anesthesia is a feasible and safe anesthetic modality for most patients, including those with significant comorbidities. An updated algorithm for SA candidate selection is thus recommended.

Specialty Neurosurgery Hospitalists: Neurosurgeons’ Perspectives

Neurosurgery is increasingly performed on patients with significant medical co-morbidities. These could both delay surgery and can lead to postoperative complications. This situation highlights the role played by internal medicine-trained physicians, which include both outpatient providers and hospitalists. In our experience, the best care is provided in close collaboration between neurosurgeons and internal medicine physicians. In this article, we provide the view from the standpoint of a neurosurgeon. Management of co-morbidities by internal-medicine physicians enables neurosurgeons to focus on surgical care, improves patient’s experience and leads to improved resident training.

Ethics Consult: Using Hospice as "Treatment" for Behavioral Problems of Dementia

Patients with Behavioral and Psychological Symptoms of Dementia (BPSD) are among the most challenging patients to treat; these behaviors are estimated to occur in up to 90% of patients with dementia (Aigbogun 2019); of these, one in 5 patients displays aggression (Eastley 1997). The usual treatments have only modest efficacy at best and at times are ineffective in some individuals. Some behaviors such as physical aggression make it difficult, if not impossible, to find placement for these patients. Placement in nursing homes on a hospice status have traditionally required evidence of a 6 month life expectancy; placement in an inpatient hospice setting is usually reserved for patients with even shorter life expectancies such as 2 weeks. Prognosticating life expectancy in patients with dementia is challenging and often inaccurate (Jayes 2004). Furthermore the use of terminal palliative sedation is supposed to be confined to the last 2 weeks of life and/or extreme physical suffering (Schuman-Oliver 2008, AMA Opinion 2013).This session will present 2 cases of individuals with advanced dementia who did not meet the traditional Medicare criteria for hospice, as both were ambulatory and did not have significant co-morbid medical issues. Both had significant aggressive behaviors that responded poorly to extensive trials of various medications during extended stays on a geriatric psychiatry inpatient unit. Both were referred to a local inpatient hospice where the staff use “suffering" as a hospice criteria and were “treated” with the usual hospice medications and expired in less than 3 weeks.This session will use the two clinical cases to address the following: review the issue of prognostication of advanced dementia and the challenges of defining the end of life; review efforts to define “suffering” in advanced dementia in both the medical and ethics literature; review issues concerning palliative sedation; define how this differs from medical aid in dying and euthanasia. The experience of Dutch geriatricians addressing these issues will be presented (Veldwijck-Rouenhorst 2021). A geriatric psychiatrist will present the 2 cases and set up the questions and ethical issues that these cases pose. An ethics professor-scholar from Emory University will review the ethics literature and teachings that address these issues and help lead a discussion with the audience. The overall goal is to provide a framework of steps the audience members can take if confronted with similar cases.

Impact Of Comorbidities On Outcomes And Healthcare Costs Of Open Inguinal Hernia Repair In Patients With Diabetes Mellitus.

Inguinal hernia management in patients with diabetes mellitus (DM) and comorbidities presents challenges due to potential impacts on wound healing and infection risk. This study evaluates the influence of additional comorbidities on outcomes following open inguinal hernia repair in DM patients. A retrospective cohort study was conducted at Craiova Emergency Clinical County Hospital from 2015 to 2020. Patients with documented DM undergoing hernia repair were categorized into two groups based on comorbidity status. Data on presentation mode, hernia type, comorbidities, hospitalization, operative details, postoperative outcomes, and costs were collected and analyzed statistically. Among 38 DM patients undergoing hernia repair, 16 were in Group A (DM alone) and 22 in Group B (DM with comorbidities). Group B patients were older (p = 0.0002) and more likely to present emergently (OR: 13.81, p=0.0148) with incarcerated (OR: 22.733, p=0.0339) or strangulated hernias (OR: 9.4545, p=0.0390). Group B had longer hospitalizations (p=0.00132) and higher hospitalization costs (p = 0.00262). DM patients with comorbidities are at higher risk for complex hernias and prolonged hospitalizations. Pulmonary fibrosis emerges as a significant comorbidity requiring specific perioperative strategies. Tailored preoperative assessments and care plans can optimize outcomes.

A case report of an atypical severe case of skin picking disorder managed by a multidisciplinary team

BackgroundWhile skin picking disorder remains relatively common, it often does not present to psychiatry until significant morbidity or comorbidities are reached. It is described as recurrent picking of skin leading to skin lesions, with repeated attempts to decrease or stop skin picking. It is also often associated with significant distress or functional impairment. There has been limited research in this specific disorder and treatment efficacy has often been poor in severe cases. For various reasons, only a small amount of patients with this disorder present to care, and often to a multidisciplinary team prior to psychiatry.Case presentationThis is a case presentation of a 44 year old male with a complex past psychiatric history, ultimately untreated for an underlying skin picking disorder. He presented for urgent medical care following a self-inflicted wound through the central frontal bone and dura over the course of 2 years. He was treated with current psychiatric evidence based medicine, including an SSRI, antipsychotic augmentation and NAC, along with habit reversal techniques during the admission. He was concurrently managed with the neurosurgery team, initially with a poor prognosis due to the severity of his presentation. He required debriding of the devitalized bone within the adjacent brain to cover the dural defect, IV antibiotics for 6 weeks, and an initial skin graft on his initial admission.ConclusionsThis case in particular highlighted the importance of urgent treatment via a multidisciplinary approach to avoid mortality. It highlights the importance of increasing awareness about the disorder and that treatment with SSRI’s, along with antipsychotic and NAC adjuncts remains the mainstay of acute treatment.

Sequential surgeries following transversus abdominis release for abdominal wall reconstruction: Insights from a single-center analysis

IntroductionAbdominal surgery following transversus abdominis release (TAR) procedure commonly involves incisions through the previously implanted mesh, potentially creating vulnerabilities for hernia recurrence. Despite the popularity of the TAR procedure, current literature regarding post-AWR surgeries is limited. This study aims to reveal the incidence and outcomes of post-TAR non-hernia-related abdominal surgeries of any kind. MethodsAdult patients who underwent non-hernia-related abdominal surgery following ventral hernia repair with concurrent TAR procedure and permanent synthetic mesh in the Cleveland Clinic Center for Abdominal Core Health between January 2014 and January 2022 were queried from a prospectively collected database in the Abdominal Core Health Quality Collaborative. We evaluated 30-day wound morbidity, perioperative complications, and long-term hernia recurrence. ResultsA total of 1137 patients who underwent TAR procedure were identified, with 53 patients (4.7%) undergoing subsequent non-hernia-related abdominal surgery post-TAR. Small bowel obstruction was the primary indication for reoperation (22.6%), and bowel resection was the most frequent procedure (24.5%). 49.1% of the patients required urgent or emergent surgery, with the majority (70%) having open procedures. Fascia closure was achieved by absorbable sutures in 50.9%, and of the open cases, fascia closure was achieved by running sutures technique in 35.8%. 20.8% experienced SSO, the SSOPI rate was 11.3%, and 26.4% required more than a single reoperation. A total of 88.7% were available for extended follow-up, spanning 17–30 months, resulting in a 36.1% recurrent hernia diagnosis rate. ConclusionsAbdominal surgery following TAR surgery is associated with significant comorbidities and significantly impacts hernia recurrence rates. Our study findings underscore the significance of making all efforts to minimize reoperations after TAR procedure and offers suggestions on managing the abdominal wall of these complex cases.

Therapeutic adjuncts in the endoscopic management of urethral stricture disease: past, present, and future

Urethral stricture disease is a recurrent and debilitating condition affecting many men of all ages. Management may involve endoscopic or surgical treatment. Surgical urethral reconstruction remains the gold standard treatment and is associated with higher success rates in terms of stricture recurrence free-survival. However, urethroplasty is not available to patients with significant medical comorbidities, or those wishing to forego invasive surgery. Endoscopic treatment is aimed at improving lower urinary tract symptoms and relieving obstruction while maximizing time to stricture recurrence with the aid of therapeutic adjuncts. The aim of this review is to discuss the mechanism of action and role of therapeutic adjuncts and highlight some of the lesser-known adjuncts that have been utilized with success in this space.

Reinfection Rates Following Cardiovascular Implantable Electronic Device Reimplementation Post-device Primary Infection

Cardiovascular implantable electronic device (CIED) infections have become an increasing problem around the world, affecting one in 20 patients within 3 years of device implementation. Prevention of reinfection following CIED reimplantation is a prominent challenge. One of the most difficult aspects of managing CIED infections is the complexities of their diagnosis: with the complexities of many infections, timely and correct diagnosis becomes complicated, frequently causing delays in commencing proper therapy, and worsening disease severity. As patients receiving CIED therapy are now older, and possess significant comorbidities, they are at a higher risk of infection. The American Heart Association (AHA) has issued a statement to educate clinicians about CIED infections, and the required care for those with suspected or diagnosed infections. To prevent an infection from spreading, it is important to isolate the causative pathogen and perform testing for susceptibility, which is required for crucial choices, including routes and duration of antimicrobial therapy. This review aims to serve as a valuable resource for healthcare professionals, by synthesising current knowledge and best practices; and providing insights into preventive measures, diagnostic challenges, therapeutic strategies, and evidence-based approaches to diagnose and improve the management of CIED infections in an ageing and medically complex patient population.

Abstract 4834: Racial disparities in pain and psychiatric medication use in patients with metastatic colorectal cancer

Abstract Background: In the United States, colorectal cancer (CRC) is a public health concern, as it is the second leading cause of cancer-related death, accounting for over 50,000 deaths annually. In addition to its high mortality, CRC is associated with significant comorbidities including pain and psychiatric symptoms, particularly in late-stage disease. Supportive care medications (SCM) are frequently used for symptom management and improving health-related Quality of Life (HRQoL). Racial disparities in clinical outcomes including HRQoL have been reported in CRC. While racial disparities have been described in the use of SCM for some cancer types, no investigation of SCM use in late-stage CRC have been performed. The purpose of our study was to explore the relationship between SCM use and race/ethnicity in patients with metastatic CRC. Methods: We used the National Cancer Institute Surveillance Epidemiology and End Results (NCI SEER)- Medicare-linked database to analyze all patients with a CRC diagnosis and a newly initiated outpatient prescription claim for an SCM of interest from 2009-2018. Patients on SCM before cancer diagnosis or who had non-metastatic CRC at diagnosis were excluded. We assessed six SCM classes: opioids, non-opioid analgesics, skeletal muscle relaxants, antidepressants, anxiolytics, and antipsychotics. Results: After application of inclusion/exclusion criteria, 28, 212 patients were included in the final analysis (White: 72.8%, Black: 12.7%, Hispanic: 9.5%, Asian: 4.6%, Native American: 0.4%). After controlling for socioeconomic factors and compared to non-Hispanic White patients, there were significant differences across multiple SCM drug classes. When considering pain medications, these differences were bi-directional. Black patients were less likely to receive opioids (adjusted Odds Ratio [aOR] 0.86, 95% CI: 0.80-0.93), while Hispanic patients were more likely to receive opioids (aOR: 1.12, 95% CI: 1.03-1.22) and non-opioid analgesics (aOR 1.22, 95% CI: 1.06-1.40). Asian patients were more likely to receive non-opioid analgesics (aOR 1.71, 95% CI: 1.45-2.03), but less likely to receive skeletal muscle relaxants (aOR 0.60, 95% CI: 0.43-0.82). When considering psychiatric medications, decreased use among all racial groups was noted for antidepressants (Black: aOR 0.53, 95% CI: 0.50-0.60; Hispanic: aOR 0.82, 95% CI: 0.75-0.90; Asian: aOR 0.48, 95% CI: 0.42-0.56), and anxiolytics (Black: aOR 0.43, 95% CI: 0.38-0.49; Hispanic: aOR 0.76, 95% CI: 0.67-0.85; Asian: aOR 0.45, 95% CI: 0.37-0.55). Among antipsychotics, only Asian patients had less use compared to non-Hispanic White patients. Conclusion: Racial disparities in the use of pain and psychiatric medications among patients with late-stage CRC were present, even after controlling for multiple confounders. Further investigation is needed to understand drivers and their impact on HRQoL outcomes. Citation Format: John M. Allen, Olga M. Trejos Kweyete, Yi Guo, Sherise C. Rogers, Lisa Scarton, David L. DeRemer, Chardae Whitner, Diana J. Wilkie. Racial disparities in pain and psychiatric medication use in patients with metastatic colorectal cancer [abstract]. In: Proceedings of the American Association for Cancer Research Annual Meeting 2024; Part 1 (Regular Abstracts); 2024 Apr 5-10; San Diego, CA. Philadelphia (PA): AACR; Cancer Res 2024;84(6_Suppl):Abstract nr 4834.

Inpatient education reduces length of outpatient oxygen therapy in bronchopulmonary dysplasia: A quality improvement project.

Patients discharged on home oxygen therapy (HOT) for bronchopulmonary dysplasia (BPD) often receive months of this therapy. A previous trial comparing two methods of HOT weaning showed that increased parent involvement in HOT weaning decreased HOT duration. Our outpatient team uses a standard protocol for outpatient HOT weaning, starting at the first clinic visit 4-6 weeks after discharge. To shorten HOT duration by teaching parents the outpatient HOT weaning process before neonatal intensive care unit(NICU) discharge. We launched a quality improvement program in April 2021 for preterm infants with BPD without significant comorbidities who were stable on ≤0.5 L nasal cannula. Eligible infants started the outpatient HOT weaning protocol while inpatient, with education for parents and nurses. The outcome measure was the duration of HOT after discharge. Process measures focused on protocol adherence. Balancing measures included NICU length of stay and appropriateness of parent-directed HOT weaning. During the study period, there were a total of 133 eligible patients discharged on home oxygen, with 75 in the baseline group and 58 in the intervention group. Forty-five (78%) participated in the HOT weaning protocol while inpatient. HOT was reduced from an average of 27 to 12 weeks after May 2021. We observed no change in NICU length of stay or inappropriate HOT weaning. Early introduction of HOT weaning with a focus on caregiver education is associated with a decreased duration of HOT.

Radical Oophorectomy for Advanced Ovarian Cancer: A Feasibility Study from Tertiary Care Cancer Centre in Eastern India.

Radical oophorectomy was first performed by Hudson in order to remove an "intact ovarian tumour lodged in the pelvis, with the entire peritoneum remaining attached". We report 16 cases of radical oophorectomy done at our institute in the past 3years and have analysed the perioperative morbidity as well as feasibility of performing the surgery without much of perioperative complication. Twenty-three patients with advanced ovarian cancer who underwent modified en bloc pelvic resection at our institute, between November 2018 and October 2021, were initially enrolled. Patients below 70years, resectable disease on CT scan and no significant comorbidities were included. Exclusion criteria were extra-abdominal metastasis, secondary cancers or complete intestinal obstruction. Initially, 23 patients were enrolled out of which seven patients were excluded. Hence, a total of 16 patients with ovarian cancer extensively infiltrating into nearby pelvic organs and peritoneum were included. In Type 1 radical oophorectomy, retrograde modified radical hysterectomy alongwith in toto removal of the bilateral adnexae, pelvic cul-de-sac and affected pelvic peritoneum is done. Type 2 radical oophorectomy includes total parietal and visceral pelvic peritonectomy as well as an en bloc resection of the rectosigmoid colon below the peritoneal reflection. Radical oophorectomy is feasible with acceptable complication rate. In our study, only one patient had burst abdomen that too due to the poor nutritional status of the patient. There was no surgery-related deaths, but one patient succumbed to pulmonary embolism 5 days after the operation. Hence, radical oophorectomy proves to be an effective, feasible and secure surgical technique in cases of advanced ovarian malignancies with extensive involvement of peritoneum, pelvis and visceras.

Post-traumatic stress disorder in a national sample of preadolescent children 9 to 10 years old: Prevalence, correlates, clinical sequelae, and treatment utilization

Although posttraumatic stress disorder (PTSD) has been well characterized in adults, its epidemiology in children is unclear. The current study provides the first population-based examination of the prevalence of PTSD, sociodemographic and psychiatric correlates, clinical sequelae, and associations with psychiatric treatment in preadolescents 9-10 years old in the United States. Data from the Adolescent Brain and Cognitive Development (ABCD) Study (release 5.0) was analyzed. Participants (unweighted n = 11,875) were recruited from 21 sites across the United States. Current and lifetime PTSD prevalence were estimated, as was treatment use among children with PTSD. Sociodemographic, psychiatric correlates and sequelae of PTSD were analyzed using logistic regression, as was the association between PTSD and psychiatric treatment. After the application of propensity weights, lifetime prevalence of PTSD was 2.17%. Sexual minority status, being multiracial, having unmarried parents, and family economic insecurity were associated with greater odds of PTSD. Among psychiatric disorders, separation anxiety was most strongly associated with PTSD, although general comorbid psychopathology was associated with greater odds of PTSD. Prior history of PTSD predicted a new onset of other psychiatric disorders after PTSD remission. Nearly one in three children with lifetime PTSD did not receive psychiatric treatment, despite negative long-term outcomes of PTSD and significant psychiatric comorbidity. Even among preadolescents who experience full remission of PTSD, a significant risk for future psychiatric illness remains. Further, the current findings underscore the need for improved efforts to reduce unmet treatment needs among those with PTSD at this age.

Review of Abstinence Syndrome: A Comprehensive Analysis of Current Practices and Recommendations

Alcohol use disorder is frequently accompanied with the diverse and sometimes fatal consequence of alcohol withdrawal syndrome (AWS). Many patients with AUD may develop AWS during their Emergency Department stay, and AUD is one of the top causes of death worldwide. This study summarizes the etiology, epidemiology, and emergency management of Alcohol Withdrawal Syndrome and Alcohol Use Disorder.The influence of AWS on the therapy of ED is highlighted, along with its temporal course. Once AWS is diagnosed, the most common therapy is still symptom- triggered benzodiazepine injection; however, patients who have significant medical or psychiatric comorbidities or are about to be discharged may not be good candidates for this approachIn these circumstances, emergency department doctors can consider employing alternative regimens based on state-of-the-art anticonvulsants or shorter barbiturate durations. For clinical practice, specific treatment procedures are described. Lastly, in addition to managing acute patients' AWS, emergency physicians also need to provide the groundwork for effective AUD therapy. A strategy for the patient with AUD's disposition is offered.