Significant Medical Comorbidities Research Articles

Clinical characteristics of hospitalized male adolescents and young adults with atypical anorexia nervosa.

To describe the clinical characteristics of male adolescents and young adults hospitalized for medical complications of atypical anorexia nervosa (atypical AN) and to compare their clinical characteristics with females with atypical AN and males with anorexia nervosa (AN). A retrospective review of electronic medical records for patients with atypical AN and AN aged 9-25 admitted to the UCSF Eating Disorders Program from May 2012 to August 2020 was conducted. Among 21 males with atypical AN (mean age 15.1 ± 2.7, mean %mBMI 102.0 ± 11.8), medical complications evidenced by admission laboratory values included anemia (52.9%), vitamin D insufficiency/deficiency (52.6%), and zinc deficiency (31.6%). Compared with females with atypical AN (n = 69), males with atypical AN had longer length of stay (11.4 vs 8.4 days, p = .004), higher prescribed kcal at discharge (4114 vs 3045 kcal, p < .001), lower heart rate nadir (40.0 vs 45.8, p = .038), higher aspartate transaminase (AST, 37.9 vs 26.2 U/L, p = .032), higher alanine transaminase (ALT, 30.6 vs 18.3 U/L, p = .005), and higher rates of anemia (52.9% vs 19.4%, p = .005), with no differences in vitamin D, zinc, and vital signs. Compared with males with AN (n = 40), males with atypical AN had no significant differences in vital signs or laboratory assessments during the hospitalization. Atypical AN in males leads to significant medical comorbidity, and males with atypical AN require longer hospital stays compared to females with atypical AN. Rates of abnormal vital signs and abnormal serum laboratory values during hospital admissions do not differ in males with atypical AN compared to AN. Adolescent and young adult males with atypical anorexia nervosa experience significant medical complications. Males with atypical anorexia nervosa had longer hospitalizations and higher prescribed nutrition at discharge than females. Medical complications of atypical anorexia nervosa in male adolescents and young adults were generally equal to those of male adolescents and young adults with anorexia nervosa. Clinicians should be aware of unique medical complications of males with atypical anorexia nervosa.

A Diagnostic Conundrum in Case of Primary Central Nervous System Vasculitis Presenting as Young Stroke

Primary Central Nervous System Vasculitis (PCNSV) is a rare inflammatory condition affecting the blood vessels in the brain and spinal cord, without signs of systemic vasculitis. The symptoms of PCNSV are typically non-specific and varied. This case involves a 16-year-old female who arrived at the emergency department with tingling and numbness in her left upper and lower extremities since waking up that morning. Within hours, she developed significant weakness in her left arm and leg. She had no significant medical history, comorbidities, or history of substance use. On examination, her vitals were stable, and she was fully conscious and oriented. Neurological examination revealed right-sided mouth deviation and decreased muscle power in her left limbs, while sensory function remained normal. Routine blood tests were normal, except for mildly elevated Erythrocyte Sedimentation Rate (ESR) and C-Reactive Protein (CRP). Autoimmune markers and complement levels were within normal limits. Cerebrospinal Fluid (CSF) analysis showed lymphocytic pleocytosis and mildly elevated protein levels. Magnetic Resonance Imaging (MRI) brain imaging revealed multiple small, acute, non-haemorrhagic infarcts in the right frontoparietal and temporo-occipital regions. MR angiography indicated thrombosis in the right internal carotid artery, with extensive thickening and constriction in various segments, consistent with PCNSV. She was treated with dual antiplatelet therapy, antiepileptics, methylprednisolone pulse therapy, and intravenous cyclophosphamide, followed by maintenance therapy with methotrexate and oral steroids. This case underscores the importance of early recognition and aggressive treatment of PCNSV to prevent longterm neurological deficits. Reporting this case is crucial as it highlights an atypical presentation in a young female, emphasising the need for awareness and comprehensive diagnostic approaches.

QTc interval changes among patients on psychotropic medications: A prospective observational study

Background: Psychotropic medications are commonly prescribed for the treatment of psychiatric disorders. Various studies have reported QT interval (QTc) prolongation with the use of psychotropics. However, some studies have found no significant risk of QTc changes with these medications. Aim: To assess the effect of psychotropics on QTc in drug-naive psychiatric patients. Materials and Methods: Our study was a prospective observational study, conducted at a tertiary care hospital. Patients aged 18–45 years, drug-naïve, with no medical comorbidity or substance use history, were recruited for the study. ECG to assess QTc was recorded at baseline, second and fourth week after the starting of psychotropic medications. Results: N=8 (4%) patients had QTc prolongation at baseline and were excluded. No clinically significant QTc prolongation was noticed, after 2 weeks and 4 weeks of treatment with any of the psychotropic medications. However, among patients on escitalopram, a significant effect on QTc was noted (P = 0.001) as compared to those on sertraline, risperidone, and olanzapine (P &gt; 0.05). Conclusion: The short-term risk of QTc prolongation with the use of newer psychotropics at optimal doses appears low among young patients with normal baseline QTc and no significant medical or substance use comorbidity.

Comparative Study to Assess the Safety and Effectiveness of Allopurinol &amp; Febuxostat in Patients Diagnosed with Gout

Introduction: Gout is placed under the umbrella term ‘arthritis’ - a wide variety of joint illness and joint pain. Some types of arthritis cause inflammation in the joints, while others do not. It is the most prevalent form of inflammatory arthritis which arises due to the elevated levels of Serum Uric acid (SUA), leading to the deposition of Mono Sodium Urate (MSU) crystals in and around joints. burden of gout has risen in recent decades with a prevalence rate of &lt;1% to 6.8% and the patients with gout may have significant medical comorbidity load asociated with pain, disability and activity limitation which inturn affects the patients’ Health-related quality of life (HRQOL). Several drugs are used to treat acute attacks of gout which includes Colchicine, Non steroidal anti inflammatory drugs (NSAIDs), and Corticosteroids. Long term management of gout focuses on lowering SUA level to normal (&lt;0.36mmol/L). There are two major classes of drugs used to reduce SUA levels, Urate-lowering therapy (ULT), specifically Uricosuric drugs and Xanthine oxidase inhibitors (XOIs). Hence, it is necessary to compare the safety and effectiveness of Allopurinol and Febuxostat used in the management of gout and there is a growing need to research the impact of gout on patients’ HRQOL inorder to improve productivity and QOL of patients. Objectives: The goal of the study was to compare the safety and effectiveness of Allopurinol and Febuxostat in patients diagnosed with Gout. The study also aimed to assess the effect of these on renal profile and the study further assessed the Health-related quality of life of the patients. Methodology: This was an observational study conducted in the selected Orthopedic clinics in T. Dasarahalli, Bengaluru District for a period of 6 months by enrolling 50 subjects, based on various inclusion and exclusion criteria. The subject’s demographic details, laboratory data and responses were collected with the help of a self-designed questionnaire. ...........

Prevalence and spectrum of infectious and inflammatory dermatologic conditions occurring in pediatric heart transplant patients on a predominantly mTOR-based immune suppressive regimen: A retrospective chart review.

Pediatric heart transplant patients are routinely followed in dermatology clinics due to elevated risk of cutaneous malignancy. However, transplant patients may experience other, non-cancer-related dermatologic conditions including skin infections, inflammatory diseases, and drug eruptions that can cause significant medical and psychosocial comorbidity. A retrospective chart review of all pediatric heart transplant patients at Mayo Clinic Children's Center in Rochester, MN, was performed to determine the prevalence and spectrum of non-cancer dermatologic conditions. Statistical analysis was conducted to look for associations between episodes of rejection and skin condition development. Of the 65 patients who received heart transplants under the age of 18 and were followed at Mayo Clinic, 69% (N = 45) were diagnosed with at least one skin condition between transplant and the time of most recent follow-up. Sixty-two percent (N = 40) of patients were diagnosed with an inflammatory skin condition (most commonly acne and atopic dermatitis), 45% (N = 29) with an infectious skin condition (most commonly warts and dermatophyte infection), and 32% (N = 21) with a drug eruption (most commonly unspecified rash and urticaria). No association was found between presence of skin disease and number of rejection episodes. Non-cancer dermatologic conditions are prevalent within pediatric heart transplant recipients and may directly impact their medical needs and quality of life. Dermatologist involvement in the care of post-transplant pediatric patients is important, not only for cancer screening but also for diagnosis and treatment of common infectious and inflammatory skin conditions.

Assessment of Quality of Life in Young Adults with Migraine

Migraine is a primary headache disorder with recurring headaches, nausea, vomiting, photophobia, and phonophobia. Migraine is believed to impact more than 10% of the world's population, is most prevalent between the ages of 20 and 50, and is about three times more prevalent in women than in males. Patients with Migraine may have significant medical comorbidity load associated with pain, disability, and activity limitation which in turn affects their Health-related quality of life (HRQOL). Hence, there is a growing need to research the impact of Migraine on patients HRQOL in order to improve the productivity and QOL of patient The goal of the study was to assess the quality of life in young adults with Migraine. The study also aimed to determine the Migraine triggers in individuals. The severity, duration, and frequency of Migraine attacks were also studied. A total of 84 subjects were enrolled in the study out of which 29.76% (n=25) were Male and 70.24% (n=59) were Female. Stress (42.85%) was found to be the more prevalent trigger. The severity of subjects was assessed, 35.71% are having severe migraine which is more prevalent. y. Almost half (47%) of the patients had migraine episodes 1-2 weeks back followed by 1 month back. . Most of the subjects (44%) had migraine attacks for 4-6 hours. The study concluded that migraine was more prevalent in women. The most common symptoms seen in this study population were pain followed by nausea &amp; vomiting. Out of this study, population stress was the common trigger followed by travel and noise. The results of the current study indicate the quality of life of migraine patients was significantly low almost half and the most affected domain in the majority of the patient was role function restrictive.

Binge-eating disorder.

Binge-eating disorder (BED) has the highest prevalence of any eating disorder in the US today. However, the condition is frequently not recognized as an eating disorder by healthcare providers or patients. Patients with this diagnosis often have significant psychiatric and medical comorbidities that might respond to evidence-based treatments. NPs in primary care with awareness of the diagnostic criteria for BED and knowledge of its assessment and treatment options can coordinate care for patients experiencing this health challenge.

Clinical and Epidemiological Characteristics of Patients Admitted with Acute Chest Syndrome on a National Scale and Factors Affecting Clinical Outcomes in Inpatient Setting

Introduction Acute chest syndrome (ACS) is a clinical presentation of fever, chest pain, pulmonary symptoms, and new infiltrates on lung imaging. It affects nearly 50% of patients with sickle cell disease during their lifetime and often leads to hospitalization. The mortality rate is variable ranging from 3 to 9 %. and depends on several factors. We aimed to identify the clinical and epidemiological characteristics of patients admitted with ACS on a national scale and factors affecting clinical outcomes in inpatient setting. Methods: We utilized the National Inpatient Sample (NIS) database 2019 for the purpose of this study. Using this database, we identified patients with a principle diagnosis of ACS using International Classification of Diseases (ICD-10) codes. Data on demographic characteristics such as age, sex, race, insurance type were collected. Additionally, we selected clinically significant medical comorbidities such as asthma, chronic obstructive pulmonary disease (COPD), coronary artery disease (CAD), chronic kidney disease (CKD), heart failure, hypertension, diabetes mellitus (DM), sepsis, obesity, and others. The primary endpoint of this study was to identify factors influencing all-cause mortality, while the secondary endpoint was to identify factors influencing mechanical intubation, in-patient blood transfusion, and length of stay. We used multivariate logistic regression analysis to adjust for confounders. A p value of ≤0.05 considered statistically significant. Results: Baseline Characteristics Our analysis consisted of 22,459 patients who were admitted with principal diagnosis of ACS. 49.5% were female and 50.5% were male. Mean age was 30.5 years. African American race was predominant (92%) with sickle cell Hb-SS disease (87%). Major insurance payer was Medicaid (47%) followed by Medicare (27%) and then private insurance (21%). Asthma was the most common comorbidities (24%) and majority of patient had Charlson Comorbidity Index (CCI) score of zero (55%). The details of clinical and epidemiological characteristics are shown in Table 1. Clinical outcomes and factors influencing mortality Only 0.89% patient died of ACS. Average length of stay was 6.86 days. 34% of the patient required packed red blood cell (pRBC) transfusion. 3.2% needed mechanical ventilation. In multivariate analysis, factors associated with mortality included age of patient, CCI and sepsis. Younger patient had higher odds of mortality however this was not statistically significant. There was no difference in mortality with sex, race and insurance status of the patients. Factors affecting inpatient transfusion, mechanical ventilation and length of stay Female, higher CCI score and sepsis on admission were associated with higher needs of inpatient pRBC transfusion. Within race, White (OR 3.16, CI 1.44-6.93, P &amp;lt;0.01) and Hispanics (OR 2.68, CI 1.59-4.51, P&amp;lt;0.01) had higher odds of receiving transfusion compared to African Americans (OR 1.84, CI: 1.17-2.89, P &amp;lt;0.01). Similarly patient with sepsis, supraventricular tachycardia had more odds of needing mechanical ventilation. Patient's insurance status was also related to increased odds of intubation. Comorbidities such as asthma and CAD were not associated with need of mechanical ventilation and in fact our study shows they had less odd of needing mechanical ventilation. Length of stay was influenced by several of epidemiological and clinical comorbidities. Females had less odds of longer length of stay compared to male (OR: 0.65, P &amp;lt;0.01). Comorbidities such as asthma, heart failure, CAD, DM2 and hypertension did not increase the length of stay while patients with sepsis and high CCI score had higher odds of hospitalization for extended period of time. The details are in Table 2. Conclusion We found mortality was 0.89% in patients admitted with ACS compared to 3 to 9% previously reported. Sepsis and CCI were one of the predictors for odds of having higher mortality, need of blood transfusion, mechanical ventilation and increased length of stay in patient with ACS. Female, White and Hispanic had higher odds of needing transfusion then African Americans. Comorbidities such as asthma, heart failure, CAD, DM 2 and hypertension did not increase the odds of prolonged hospital stay.

Abstract 17614: “Watchful Waiting” - Successful Medical Management of an Infected Watchman Device

Description of Case: A 68-year-old male with a past medical history of alcoholic cirrhosis, ischemic cardiomyopathy, atrial fibrillation, ventricular tachycardia, and sick sinus syndrome presented with exertional dyspnea and lower extremity edema consistent with acutely decompensated systolic heart failure. He had multiple implantable cardiac devices including a watchman device. He was subsequently found to have methicillin-sensitive staphylococcus aureus (MSSA) bacteremia and developed sepsis. A transesophageal echocardiogram (TEE) was done to evaluate for infective endocarditis and a 1 cm mobile echodensity attached to the anterior aspect of the watchman device was found. Given active bacteremia, the echocardiographic appearance was felt to be most likely consistent with a vegetation. Due to significant medical and cardiac comorbidities, device extraction was deemed very high risk and deferred in favor of antibiotic therapy by a multi-disciplinary team. The patient was treated with intravenous cefazolin and oral rifampin. Clinical defervescence and clearance of bacteremia were achieved. A follow-up TEE in 6 weeks showed complete resolution of the watchman device vegetation. Discussion: Cardiac implantable devices provide significant morbidity and mortality benefits to patients but incur the potential risk of infection. Watchman device infection, though rare, has been reported. The current guidelines recommend the removal of all hardware in patients with established device infection. However, percutaneous, or surgical extraction of the watchman device bears significant risk and may not be feasible in all patients. Our case demonstrates the potential role of antimicrobial therapy alone with close surveillance in treating high-risk patients with watchman device infection.

Tibiotalocalcaneal Arthrodesis with Hybrid Nail-Plate Constructs: A Novel Technique for Treatment of Unstable Ankle &amp; Hindfoot Deformities

Category: Ankle; Hindfoot Introduction/Purpose: Tibiotalocalcaneal (TTC) arthrodesis is a treatment option for several pathologies of the hindfoot and ankle. Traditional fixation options include intramedullary nailing or plate-screw constructs. In certain patients, for example when bone quality or post-operative compliance are of concern, more robust fixation may be desired. Charcot neuroarthropathy (CN) patients in particular often have complex deformities, poor bone quality, and impaired sensation. New trauma literature shows hybrid nail-plate constructs (NPCs) may permit early weight bearing in osteoporotic distal femur fractures. We report early results of TTC arthrodesis using NPCs in patients with complex deformities of the ankle and hindfoot. Methods: Patients undergoing TTC arthrodesis via intramedullary nail fixation plus plating by a single surgeon from September 2020 to December 2022 were included in our study. Indications included CN, post-traumatic deformities, and advanced arthritis. Age, comorbidities, Hemoglobin A1c, presence of an ulcer, implants, bone graft used, and postoperative complications were retrospectively recorded. Results: Fifteen patients met inclusion criteria. Six patients had CN; eight patients had post-traumatic complications; and one patient had an arthritic cavovarus deformity. Average age was 55 years (range 31-72). Eleven patients were treated with a lateral TTC locking plate; three were treated with an anterior tibiotalar arthrodesis plate; and one was treated with a 3.5mm reconstruction plate. All patients were treated with a TTC arthrodesis nail. In all cases, cellular bone matrix was used; in fourteen cases, autograft was also used. Average follow-up was 35 weeks (min. 12). Three patients underwent below-knee amputation, two for infection and the other for hardware failure. Two others required postoperative debridements but subsequently cleared their infections. Twelve patients have a stable, non-infected, ulcer free foot at latest follow-up. Conclusion: TTC arthrodesis can be used for a variety of indications, and many of these patients present complex challenges. Patients with CN in particular often have severe deformities and poor bone quality. Hybrid fixation methods provide added stability in complex cases, possibly allowing for more powerful deformity correction and earlier weight-bearing. We report a 80% favorable outcome rate in our case series, with major complications confined to patients with significant medical comorbidities (poorly controlled diabetes, peripheral vascular disease). We believe that TTC arthrodesis with hybrid nail-plate constructs represents an attractive solution to complex ankle and hindfoot deformities.

3.20 Catatonia: Characteristics and Challenges in Youth With Significant Medical Comorbidities

3.20 Catatonia: Characteristics and Challenges in Youth With Significant Medical Comorbidities

Regional gray matter volume correlates with anxiety, apathy, and resilience in geriatric depression.

Geriatric depression (GD) is associated with significant medical comorbidity, cognitive impairment, brain atrophy, premature mortality, and suboptimal treatment response. While apathy and anxiety are common comorbidities, resilience is a protective factor. Understanding the relationships between brain morphometry, depression, and resilience in GD could inform clinical treatment. Only few studies have addressed gray matter volume (GMV) associations with mood and resilience. Forty-nine adults aged >60 years (38 women) with major depressive disorder undergoing concurrent antidepressant treatment participated in the study. Anatomical T1-weighted scans, apathy, anxiety, and resilience data were collected. Freesurfer 6.0 was used to preprocess T1-weighted images and qdec to perform voxel-wise whole-brain analyses. Partial Spearman correlations controlling for age and sex tested the associations between clinical scores, and general linear models identified clusters of associations between GMV and clinical scores, with age and sex as covariates. Cluster correction and Monte-Carlo simulations were applied (corrected alpha = 0.05). Greater depression severity was associated with greater anxiety (r = 0.53, p = 0.0001), lower resilience (r = -0.33, p = 0.03), and greater apathy (r = 0.39, p = 0.01). Greater GMV in widespread, partially overlapping clusters across the brain was associated with reduced anxiety and apathy, as well as increased resilience. Our results suggest that greater GMV in extended brain regions is a potential marker for resilience in GD, while GMV in more focal and overlapping regions may be markers for depression and anxiety. Interventions focused on improving symptoms in GD may seek to examine their effects on these brain regions.

Improving the treatment of functional seizures through a public specialist outpatient clinic

ObjectivesWe performed an audit of the first 12 months of clinical operations to assess the feasibility of a newly established public outpatient clinic for the assessment and treatment of functional (psychogenic nonepileptic) seizures (FS). MethodClinical notes for the first 12 months of the FSclinic weresystematicallyreviewed with data compiled onreferral pathways, clinic attendance, clinical features, treatments, and outcomes. ResultsOf eighty-two new FS patients referred to the clinic, over 90% attended. Patients were diagnosed with FS after comprehensive epileptological and neuropsychiatric review, mostly with typical seizure-like episodes captured during video-EEG monitoring, and most accepted the diagnosis. Most had FS at least weekly, with little sense of control and significant impairment. The majority of individuals had significant psychiatric and medical comorbidity. Predisposing, precipitating, and perpetuating factors were readily identified in >90% of cases. Of 52 patients with follow-up data within12 months, 88% were either stable or improved in terms of the control of their FS. ConclusionThe Alfred functional seizure clinic model, the first dedicated public outpatient clinic for FS in Australia, provides a feasible and potentially effective treatment pathway for this underserved and disabled patient group.

A novel pharmacy liaison program to address health-related social needs at an urban safety-net hospital.

Patients with unmet health-related social needs (HRSNs) often experience poor health outcomes and have high levels of healthcare utilization. We describe a program where dually trained pharmacy liaison-patient navigators (PL-PNs) screen for and address HRSNs while providing medication management services to patients with high levels of acute care utilization in a Medicaid Accountable Care Organization. We are unaware of prior studies that have described this PL-PN role. We analyzed case management spreadsheets for the 2 PL-PNs who staffed the program to identify the HRSNs that patients faced and the ways PL-PNs addressed them. We administered surveys, including an 8-item client satisfaction questionnaire (CSQ-8), to characterize patient perceptions of the program. Initially, 182 patients (86.6% English speaking, 80.2% from a marginalized racial or ethnic group, and 63.2% with a significant medical comorbidity) were enrolled in the program. Non-English-speaking patients were more likely to receive the minimum intervention dose (completion of an HRSN screener). Case management spreadsheet data (available for 160 patients who engaged with the program) indicated that 71% of participants faced at least one HRSN, most often food insecurity (30%), lack of transportation (21%), difficulty paying for utilities (19%), and housing insecurity (19%). Forty-three participants (27%) completed the survey with an average CSQ-8 score of 27.9, indicating high levels of satisfaction with the program. Survey participants reported receiving medication management services, social needs referrals, health-system navigation assistance, and social support. Integration of pharmacy medication adherence and patient navigation services is a promising approach to streamline the HRSN screening and referral process at an urban safety-net hospital.

Did the centers for medicare &amp; medicaid services’ 2018 policy change removing total knee arthroplasty from the inpatient-only list affect overall patient outcomes in the medicare population?

Background: The 2018 Centers for Medicare &amp; Medicaid Services (CMS) removal of total knee arthroplasty (TKA) from the Inpatient-Only (IPO) list was accompanied by confusion, lack of central guidance on patient selection criteria, payor misinterpretation of the updated policy, and altered payor incentives. The purpose of this study was to assess how the CMS policy change affected overall patient outcomes in the Medicare population after TKA. Methods: Using the ACS-NSQIP database, patients 65 years and older who underwent primary, elective, unilateral TKA without any significant medical comorbidity were included. Complication rates before (2014-2017) and after (2018-2019) CMS removal of TKA from the IPO list were compared using interrupted time series analysis to gauge the impact of the policy shift. Results: A total 185,294 TKA cases were included in the analysis. Following the CMS removal of TKA from the IPO list in 2018, there were significant decreases in rates of any adverse event (RR 0.90, 95% CI 0.83-0.98, P=0.02), any minor adverse event (RR 0.84, 95% CI 0.73-0.97, P=0.02), and thromboembolic events (RR 0.76, 95% CI 0.64-0.89, P&lt;0.001) significantly decreased There were no significant changes in rates of readmission (RR 0.95, 95% CI 0.87-1.05, P=0.31), reoperation (RR 0.92, 95% CI 0.78-1.09, P=0.33), or any major adverse event (RR 0.92, 95% CI 0.83-1.01, P=0.07). Conclusions: Though the CMS removal of TKA from the IPO list in 2018 was accompanied by the emergence of key new issues, the policy change did not adversely affect 30-day postoperative outcomes in the Medicare TKA patient population. Level of Evidence: Level IV—retrospective cohort study.

Children hospitalized with community-acquired pneumonia complicated by effusion: a single-centre retrospective cohort study

ObjectivesTo describe children hospitalized with community-acquired pneumonia complicated by effusion (cCAP).DesignRetrospective cohort study.SettingA Canadian children’s hospital.ParticipantsChildren without significant medical comorbidities aged < 18 years admitted from January 2015-December 2019 to either the Paediatric Medicine or Paediatric General Surgery services with any pneumonia discharge code who were documented to have an effusion/empyaema using ultrasound.Outcome measuresLength of stay; admission to the paediatric intensive care unit; microbiologic diagnosis; antibiotic use.ResultsThere were 109 children without significant medical comorbidities hospitalized for confirmed cCAP during the study period. Their median length of stay was 9 days (Q1-Q3 6–11 days) and 35/109 (32%) were admitted to the paediatric intensive care unit. Most (89/109, 74%) underwent procedural drainage. Length of stay was not associated with effusion size but was associated with time to drainage (0.60 days longer stay per day delay in drainage, 95%CI 0.19-1.0 days). Microbiologic diagnosis was more often made via molecular testing of pleural fluids (43/59, 73%) than via blood culture (12/109, 11%); the main aetiologic pathogens were S. pneumoniae (40/109, 37%), S. pyogenes (15/109, 14%), and S. aureus (7/109, 6%). Discharge on a narrow spectrum antibiotic (i.e. amoxicillin) was much more common when the cCAP pathogen was identified as compared to when it was not (68% vs. 24%, p < 0.001).ConclusionsChildren with cCAP were commonly hospitalized for prolonged periods. Prompt procedural drainage was associated with shorter hospital stays. Pleural fluid testing often facilitated microbiologic diagnosis, which itself was associated with more appropriate antibiotic therapy.

Preoperative Corticosteroid Injections Are Not Associated with Deep Infection after Unicompartmental Knee Arthroplasty.

Prior to unicompartmental knee arthroplasty (UKA), corticosteroid injections (CSI) are a common nonoperative treatment for arthritis. It is unclear whether CSI prior to UKA impacts the likelihood of postoperative infection. This study sought to determine if there is a time- and/or dose-dependent relationship between preoperative CSI and postoperative infection. An administrative claims database was queried for patients undergoing UKA with more than 1 year of pre-enrollment and follow-up. Of 31,676 patients with a UKA who met enrollment criteria, 8,628 patients had a CSI 0 to 3 months prior to surgery, 111 had a CSI 3 to 12 months prior to surgery, and 22,937 never received an injection. Overall, 246 postoperative deep infections were reported (0.8%). Time-dependent and dose-dependent relationships were modeled using multivariable logistic regressions. Postoperative deep infections occurred in 64 patients with CSI 0 to 3 months prior to surgery (0.7%), compared with 0 patients with CSI 3 to 12 months before surgery (0.0%) and 182 controls (0.8%, p = 0.58). CSI within 1 month prior to UKA was not statistically associated with postoperative infection (p = 0.66). Two or more CSI within 3 months prior to UKA were associated with a twofold elevated odds of infection, compared with receiving a single injection (odds ratio [OR]: 2.08, p = 0.03). Univariable predictors of infection included younger age, increasing Charlson Comorbidity Index, smoking, asthma, chronic obstructive pulmonary disease, chronic kidney disease, diabetes, liver disease, and obesity. Multivariable analysis controlling for these characteristics elicited no relationship between recent CSI administration and postoperative infection. CSI within 3 months of surgery (1.5%) or 3 to 12 months (1.8%) were associated with increased conversion to total knee arthroplasty (TKA) compared with those who did not receive an injection (1.1%, p = 0.01), although TKA for indication of periprosthetic joint infection was not statistically different (p = 0.72). Preoperative CSI within 3 months of UKA is not associated with postoperative infection, although significant medical comorbidity does show an association. Preoperative CSI is associated with increased conversion from UKA to TKA for noninfectious indications.

MP56-14 LONG-TERM RENAL FUNCTION IN PATIENTS UNDERGOING TRIMODAL THERAPY FOR BLADDER CANCER

You have accessJournal of UrologyCME1 Apr 2023MP56-14 LONG-TERM RENAL FUNCTION IN PATIENTS UNDERGOING TRIMODAL THERAPY FOR BLADDER CANCER Affan Zafar, Linda Nguyen, Alexandra Hunter, William Shipley, Niall Heney, Anthony Zietman, Matthew Wszolek, Jason Efstathiou, Michael Drumm, Hannah Roberts, and Adam Feldman Affan ZafarAffan Zafar More articles by this author , Linda NguyenLinda Nguyen More articles by this author , Alexandra HunterAlexandra Hunter More articles by this author , William ShipleyWilliam Shipley More articles by this author , Niall HeneyNiall Heney More articles by this author , Anthony ZietmanAnthony Zietman More articles by this author , Matthew WszolekMatthew Wszolek More articles by this author , Jason EfstathiouJason Efstathiou More articles by this author , Michael DrummMichael Drumm More articles by this author , Hannah RobertsHannah Roberts More articles by this author , and Adam FeldmanAdam Feldman More articles by this author View All Author Informationhttps://doi.org/10.1097/JU.0000000000003309.14AboutPDF ToolsAdd to favoritesDownload CitationsTrack CitationsPermissionsReprints ShareFacebookLinked InTwitterEmail Abstract INTRODUCTION AND OBJECTIVE: Trimodal therapy (TMT) is a standard treatment option for select patients with muscle-invasive bladder cancer. The efficacy of TMT has been shown in several randomized trials; however, the long-term effect on renal function has not been investigated. Furthermore, various types of chemotherapy agents (ie. mitomycin, 5-FU, cisplatin) used during TMT are nephrotoxic. As many bladder cancer patients are elderly with significant medical comorbidities, data on long term renal function would aid in management. We sought to evaluate the change in renal function over 10 years in bladder cancer patients who have completed TMT. METHODS: The Massachusetts General Hospital’s institutional TMT database was retrospectively reviewed to obtain baseline renal function (estimated GFR) at time of muscle-invasive bladder cancer (MIBC) diagnosis. The eGFR values were calculated using the CKD-EPI creatinine equation. Interval eGFR was obtained for years 1, 3, 5, and 10 after the date of bladder cancer diagnosis. RESULTS: 287 patients undergoing TMT treatment for muscle invasive bladder cancer were reviewed. Patients were excluded due to incomplete TMT treatment or missing data, resulting in 251 eligible patients for evaluation of baseline mean eGFR. Median follow up was 4.56 years. Baseline mean eGFR was 65.67 mL/min/1.73. Mean eGFR for years 1, 3, 5, and 10 were 58.43 mL/min/1.73, 55.4 mL/min/1.73, 54.54 mL/min/1.73, and 57.3 mL/min/1.73, respectively. CONCLUSIONS: Renal function for bladder cancer patients undergoing TMT declined slightly after 1 year of follow up but remained stable for the remainder of the 10 years of follow up. Further studies are needed to identify predictors of renal decline and compare these results with the overall bladder cancer and general population. Source of Funding: N/A © 2023 by American Urological Association Education and Research, Inc.FiguresReferencesRelatedDetails Volume 209Issue Supplement 4April 2023Page: e780 Advertisement Copyright & Permissions© 2023 by American Urological Association Education and Research, Inc.MetricsAuthor Information Affan Zafar More articles by this author Linda Nguyen More articles by this author Alexandra Hunter More articles by this author William Shipley More articles by this author Niall Heney More articles by this author Anthony Zietman More articles by this author Matthew Wszolek More articles by this author Jason Efstathiou More articles by this author Michael Drumm More articles by this author Hannah Roberts More articles by this author Adam Feldman More articles by this author Expand All Advertisement PDF downloadLoading ...

MP02-03 FASCIOCUTANEOUS FLAP CLOSURE OF THE PERINEUM AS AN ALTERNATIVE TO SCROTOPLASTY FOR EXTENSIVE GENITAL TISSUE LOSS

You have accessJournal of UrologyCME1 Apr 2023MP02-03 FASCIOCUTANEOUS FLAP CLOSURE OF THE PERINEUM AS AN ALTERNATIVE TO SCROTOPLASTY FOR EXTENSIVE GENITAL TISSUE LOSS Christopher Staniorski, Robin Vasan, Michael Pintauro, Michelle Yu, and Paul Rusilko Christopher StaniorskiChristopher Staniorski More articles by this author , Robin VasanRobin Vasan More articles by this author , Michael PintauroMichael Pintauro More articles by this author , Michelle YuMichelle Yu More articles by this author , and Paul RusilkoPaul Rusilko More articles by this author View All Author Informationhttps://doi.org/10.1097/JU.0000000000003213.03AboutPDF ToolsAdd to favoritesDownload CitationsTrack CitationsPermissionsReprints ShareFacebookLinked InTwitterEmail Abstract INTRODUCTION AND OBJECTIVE: Genital tissue loss is a surgical challenge often occurring in complex patients. Scrotoplasty with flaps and split thickness skin grafts (STSG) are two methods of closure but carry complication rates as high as 28% and may not be ideal for medically complex patients. However, closure by secondary intention is associated with wound care needs and patient discomfort. Our objective is to evaluate an alternative method of perineal closure in lieu of scrotoplasty in a complex population. METHODS: We retrospectively reviewed patient charts of adults who underwent perineal closure with fasciocutaneous flaps and thigh pouch creation. Our primary outcomes were complication rate and wound coverage. Secondary outcomes included measures of patient satisfaction and post-operative care needs. RESULTS: 20 patients were identified who underwent this closure, the majority following Fourniers gangrene. Patients had a median age of 64 (IQR 58 – 70), BMI of 34 (IQR 29 – 40) and Charlson comorbidity index of 5 (IQR 4 – 8) equating to a 21% 10-year survival. The median total wound dimension was 443 cm2 (IQR 225 – 600). Operative technique in all cases included testicular thigh pouch and fasciocutaneous flap creation from the thigh (n=18) or abdominal wall (n=8) and resulted in 100% closure rate of the perineum. Escutcheonectomy was used to increase the size of abdominal flaps in 2 patients with over 600 cm2 of skin loss. Only three patients required abdominal STSG to complete closure. Complication rate was 15% with 1 wound infection and 2 episodes of bleeding. Patients stayed a median of 7.5 days following closure (IQR 3-12.5) and 40% were discharged home. Median follow up was 9 months (n=16, IQR 3.25 – 14.75) with only 1 patient (6%) reporting pain related to thigh pouches and none desiring elective scrotoplasty. CONCLUSIONS: Despite large defects, this method of reconstruction allowed for perineal closure in all patients with minimal use of STSG. Despite significant medical comorbidity, complication rates were comparable to those previously reported and patients were largely satisfied with their reconstruction with none desiring formal scrotoplasty. While larger sample sizes are needed, this method of closure appears to add an option for the medically and surgically complex perineal reconstruction patient. Source of Funding: None © 2023 by American Urological Association Education and Research, Inc.FiguresReferencesRelatedDetails Volume 209Issue Supplement 4April 2023Page: e11 Advertisement Copyright & Permissions© 2023 by American Urological Association Education and Research, Inc.MetricsAuthor Information Christopher Staniorski More articles by this author Robin Vasan More articles by this author Michael Pintauro More articles by this author Michelle Yu More articles by this author Paul Rusilko More articles by this author Expand All Advertisement PDF downloadLoading ...

Early and Long-term Complications of Robotic Assisted Laparoscopy in Infants and Children

BackgroundRobotic-assisted laparoscopy still lacks wide acceptance in infants and children. We developed the service and report the largest single institution experience of complications over a period of 11 years. MethodsBetween March 2006 and May 2017, consecutive infants and children who underwent robotic assisted laparoscopy under the care of two laparoscopic surgeons were studied. Data for patients, surgeons, year of surgery, operation, and timing, nature, grades of complications were assessed. ResultsA total of 601 robotic procedures (45 different types) were carried out in 539 patients. Of these 31 (5.8%) were converted, none for operative complications. These and another 4 with complicated co-morbidity were excluded, leaving 504 patients for further analysis. There were 60 (11.9%) complications in 57 (11.3%) patients. Mean (SD) age was 7.7 years −/+5.1 with the youngest being 4 weeks. Concomitant or bilateral robotic and non-robotic procedures took place in 8.1% and 13.3% of patients respectively. Significant medical co-morbidity and abdominal scarring were present in 29% and 14.9% of patients respectively. Complications occurred in theatre 1.6%, hospital 5.6%, 28 days 1.2%, and late 3.6%. Mean follow up was 7.6 years −/+ 3.1 SD. Over-all postoperative complication rate was 10.3%: CD grade I 6.5% (33), II 0.6% (3), and IIIa/b 3.2% (16) which included 1.4% (7) re-do surgery. Most (11/16) grade III occurred late. There were no bleeding, grade IV or V complications, surgical mortality, or technology related complications. ConclusionsComplications are low even during the learning phase and while developing the new technique. Most complications occurred early and were minor. Most high-grade complications presented late. Levels of Evidence2B