Single Private Institution Research Articles

Evolution of a Cocurricular Program to Support Student Professional Identity Formation

ObjectiveDescribe the development, implementation, and assessment of a cocurricular program intentionally designed to foster professional identity formation at a private institution. MethodsA cocurricular committee was established which developed a cocurriculum program in 3 phases. The committee utilized a gap analysis to inform the development of a continuing-education-based elective program (phase I), broadened program components and enhanced assessment (phase II), and continued to strengthen select areas of the affective domains through a second gap analysis and implement a summative assessment (phase III). ResultsOver 2 academic years, the completion rates for reflections, continuing education programming, and community outreach in the most recent academic year were consistently above 80% by the final due date. Rates of the mentor-mentee meetings fell below 50%; however, this component is tracked by the faculty member and not the students. Community outreach monitoring was managed by the committee for the first time in the 2021–2022 academic year and completion rates increased from 64% to 82%. Student reflections indicated consistent progression toward practice readiness from first- to third-year pharmacy students. For the Pharmacy Affective Domain Situational Judgment test, 22% and 16% of first-year pharmacy students were flagged during the first and second year implemented, respectively, and only 8% of the third-year pharmacy students were flagged in both years. ConclusionUtilization of a cocurricular committee has been vital for the development, progression, and assessment of the cocurriculum at a single private institution.

Liver Abscess: Current Management in a Single Private Institution in Chile. A Case-series

Liver Abscess: Current Management in a Single Private Institution in Chile. A Case-series

Financial Impact of Imatinib Discontinuation in Brazil - a Real World Evidence Pharmacoeconomic Study in Chronic Myeloid Leukemia of a Private Institution

Introduction Recent studies showed that tyrosine kinase inhibitors (TKI) treatment could be safely discontinued in a selected group of chronic phase (CP) chronic myeloid leukemia (CML) patients that achieved deep molecular response (DMR), making treatment-free remission (TFR) a new goal of therapy. The discontinuation treatment in patients with sustained molecular response to MR4 or MR4.5, a practice that has been performed and consolidated since 2011 in other countries, is not feasible in Brazil outside clinical trials because of the lack of coverage for performing RQ-PCR as recommended by the international guidelines. For all these aspects, it seemed essential to us to analyze the financial impact of TKI discontinuation, following strict monitoring criteria, and perform a projection of economic costs in a population of CML patients treated in first-line with imatinib eligible for discontinuation. Aims: To demonstrate the feasibility of coverage of Q-PCR to perform discontinuation of imatinib treatment on eligible patients [ treatment free-response (TFR)] in Brazil based on the financial impact Material and Methods From 2020 -2021, 26 eligible patients from a single private institution in Brazil were invited to participate in a single-arm trial of Imatinib discontinuation (DIP). Inclusion criteria: age > 18 years, chronic phase, minimum of 04 years of Imatinib therapy, a deep molecular response sustained > or = 02 years (confirmed by 04 tests in the last two years, defined MR4.0 or MR 4.5 and a confirmatory exam at the moment of the screening). After discontinuation, patients were monitored by RT- PCR monthly in the first year, every two months in the second year, and every three months after the third year. Criteria for Imatinib re-initiation were the same of the Euro-Ski trial. Considering that US$ 1.00 are R$ 5.3 ( Brazilian currency- March /2022 ) for Branded Imatinib - 400 mg/d, the monthly cost has been estimated at R$ 16,933.90 or US$ 3,95.07 and the generic imatinib- 400mg/d monthly R$ 13,048.90 or US$ 2,462.05 ( CEMED- March/2022). The unitary value for the Q-PCR exam has been estimated, with a large price range at R$ 1,311.25 (R$790.00 to R$ 2,159.00) or US$ 247.40. Results Of 26 patients, 20 consent to discontinuation of imatinib. Six patients declined despite information because of their insecurity about TFR. Twelve patients (60%) presented MR4. The median age was 52.3, and 13 (65%) were female. Median time diagnosis to discontinuation of imatinib 8.5 (4.6-15.5) years. Twelve (60%) patients sustained TFR. . In this interim analysis, the median time of follow-up was 14.5 (2.7-18.8) months. During the follow-up, 244 RQ-PCR were performed. The cumulative time without treatment was 224.5 months. The costs with Q-PCR were R$ 319,945.00 or US$ 60,366.98 (244 exams during follow-up (median time 14,4 months). The average time of months without treatment was 224.5 months. The cost of treatment without discontinuation would be R$ 4,131,871.60 or US$ 779,598.41 (Branded Imatinib) or R$ 2,929,478.05 or US$ 552,731.70 (imatinib copies). The saving on median time of follow-up (14.4 months ) were R$ 3,811,926.60 or US$ 719,231.43 (Branded Imatinib) or R$ 2,609,533.05 or US$ 492,364.72 (imatinib copies). Discussion: Considering the methodology of Cost-Utility, the saving resulting from the discontinuation of treatment for 20 patients for 14.4 months despite the loss of MR of 40 % of patients were R$ 3,811,926.60 or US$ 719,231.43 (Branded Imatinib) or R$ 2,609,533.05 or US$ 492,364.72 (imatinib copies). The results show that if Q-PCR tests were available in clinical practice, within pre-established protocols, there would be equalization and adequacy with the international monitoring guidelines, and discontinuation protocols could be feasible in clinical practice. Conclusion: The possibility of discontinuation would have a huge financial impact on the Brazilian Health System, resulting in the economic viability of treating hundreds of patients and performing thousands of Q-PCR exams, creating a rational and balanced model of clinical efficacy coupled with basic sustainability premises of modern oncology.

Treatment- Free Remission in Chronic Myeloid Leukemia -Experience of a Single Brazilian Private Institution Using Imatinib Copies

Introduction: In addition to the best possible overall survival, discontinuation of the tyrosine kinase -inhibitor (TKI) treatment [treatment free response (TFR)] without observing a recurrence of the disease has become a standard part of chronic myeloid leukemia (CML) care. Evidence of several studies suggest that patients who have achieved a sustained stable deep molecular response (DMR) as MR4 and MR4.5 can be safely discontinued with close monitoring without relapse, despite BCR/ABL1 DNA remaining detectable. In Brazil, CML patients have received almost exclusively Imatinib as first-line treatment and since 2013, only generics and copies of imatinib mesylate have been used in first-line throughout the whole Public Health System and in several institutions within the private system. However, in both scenarios there is a limit coverage of PCR exams/ year which allows for adequate monitoring but it is not sufficient for the implementation of TFR safely in eligible patients Aims: To report a Brazilian single institution Imatinib discontinuation trial and to evaluate factors impacting treatment -free response (TFR) and treatment free survival (TFS) Methods: From 2020 -2021 , 26 eligible patients were invited to participate in a single arm trial of Imatinib discontinuation (DIP). Inclusion criteria: age > 18 years, chronic phase, minimum of 04 years of Imatinib therapy, deep molecular response sustained > or = 02 years (confirmed by 04 tests in the last two years, defined MR4.0 or MR 4.5 and a confirmatory exam at the moment of the screening). Atypical transcripts were excluded. After discontinuation, patients were monitored by RT- PCR monthly in the first year, every two months in the second year and every three months since the third year. Criteria for Imatinib re-initiation: loss of MMR confirmed by two exams, loss of cytogenetic response, loss of hematologic response, disease progression. TFR was calculated from the date of discontinuation until first event: loss of MMR, Imatinib reintroduction, death any cause or last follow up. TFS was calculated from the date of imatinib discontinuation until reintroduction or last follow- up (censoring deaths not related to CML). The costs of exams were provided by own founds of our institution. Results: From 26 patients, 20 patients agreed to consent inform to discontinuation of imatinib. 06 patients declined despite information because their insecurity about TFR. Twelve patients (60%) presented MR4 . Median age was 52.3 years old and 13 (65%) were female. Median time diagnosis to discontinuation of imatinib 8.04(4.6-15.5) years. Twelve (60%) patients sustained TFR. Seven patients of twelve had presented MR 4 and five had MR 4.5 in the screening, respectively . (p=0,85) .It means 58,3% of the total of patients with MR 4 and 62,5% with MR 4.5 . In this interim analysis the median time of follow up was 14.5 (2.7-18.8) months. One patient died due to COVID19 with major molecular response (MMR). Eight (40%) lost MMR and imatinib was restarted. In this group the median time until MMR loss was 7.24 (2.1-13.8) months. At this moment, 07 patients (87,5 %) recovered MMR . In addition , in this group 06 patients (75%) achieved the same level of MR with reintroduction of imatinib with median 5.2 (3.7-6.3) months. Regarding adherence, 4 (20%) had some absences in monthly medical consultations and 1(5%) missed follow-up. Fifteen tests (6.14%) were performed to confirm MR loss, however only in 8 tests (53.3%) were confirmed. In fact, 04 patients (33,33%) still in TFR because of the double confirmatory test. There was no transformation to advanced phases. Gender, age at de diagnosis , age at discontinuation, Sokal , BCR-ABL trasncripts type , duration of Imatinib therapy , duration of MR 4.0 or MR4.5 did not affect TFR. Withdrawal syndrome occurred in 05 patients (25%) ; 04 patients with grade 1 and 01 patient with grade 2, had been used corticosteroid for few days. Conclusions: Despite the small number of patients included and short time of follow-up, the preliminary results of this trial demonstrated the feasibility and safety of Imatinib discontinuation , even using Brazilian copies, and the results were similar of that presented in another trials . The confirmatory exam to establish the loss of TFR was useful and safe. Adhesion of a discontinuation is one of the most important keys of the success of TFR.

FINANCIAL IMPACT OF IMATINIB DISCONTINUATION IN BRAZIL – A PHARMACOECONOMIC STUDY IN CHRONIC MYELOID LEUKEMIA OF A PRIVATE INSTITUTION

Recent studies showed that tyrosine kinase inhibitors (TKI) treatment could be safely discontinued in a selected group of chronic phase (CP) chronic myeloid leukemia (CML) patients that achieved deep molecular response (DMR), making treatment-free remission (TFR) a new goal of therapy. The discontinuation of treatment in patients with sustained molecular response to MR4 or MR4.5, a practice that has been performed in other countries is not feasible in Brazil outside clinical trials because of the lack of coverage for performing RQ-PCR as recommended by the international guidelines. For all these aspects, it seemed essential to us to analyze the financial impact of TKI discontinuation, following strict monitoring criteria, and perform a projection of economic costs in a population of CML patients treated in first-line with imatinib eligible for discontinuation. To demonstrate the feasibility of coverage of Q-PCR to perform discontinuation of imatinib treatment on eligible patients [ treatment free-response (TFR)] in Brazil based on the financial impact. From 2020 -2021, 20 eligible patients from a single private institution in Brazil were invited to participate in a single-arm trial of Imatinib discontinuation (DIP). After discontinuation, patients were monitored by RT- PCR monthly in the first year, every two months in the second year, and every three months after the third year. Criteria for Imatinib re-initiation were the same of the Euro-Ski trial. Considering that US$ 1.00 are R$ 5.3 (Brazilian currency- March /2022) for Branded Imatinib – 400 mg/d, the monthly cost has been estimated at R$ 16,933.90 or US$ 3,95.07 and the generic imatinib- 400mg/d monthly R$ 13,048.90 or US$ 2,462.05 (CEMED- March/2022). The unitary value for the Q-PCR exam has been estimated, with a large price range at R$ 1,311.25 (R$790.00 to R$ 2,159.00) or US$ 247.40. Of 26 patients, 20 consent to discontinuation of imatinib. Twelve patients (60%) presented MR4. Median time diagnosis to discontinuation of imatinib 8.5 (4.6-15.5) years. Twelve (60%) patients sustained TFR. During the follow-up, 244 RQ-PCR were performed. The cumulative time without treatment was 224.5 months. The costs with Q-PCR were R$ 319,945.00 or US$ 60,366.98 (244 exams during follow-up (median time 14,4 months). The average time of months without treatment was 224.5 months. The cost of treatment without discontinuation would be R$ 4,131,871.60 or US$ 779,598.41 (Branded Imatinib) or R$ 2,929,478.05 or US$ 552,731.70 (imatinib copies). The saving on median time of follow-up (14.4 months) were R$ 3,811,926.60 or US$ 719,231.43 (Branded Imatinib) or R$ 2,609,533.05 or US$ 492,364.72 (imatinib copies). Considering the methodology of Cost-Utility, the saving resulting from the discontinuation of treatment for 20 patients for 14.4 months despite the loss of MR of 40 % of patients were R$ 3,811,926.60 or US$ 719,231.43 (Branded Imatinib) or R$ 2,609,533.05 or US$ 492,364.72 (imatinib copies). The results show that if Q-PCR tests were available in clinical practice, within pre-established protocols, there would be equalization and adequacy with the international monitoring guidelines, and discontinuation protocols could be feasible in clinical practice. The possibility of discontinuation would have a huge financial impact on the Brazilian Health System, resulting in the economic viability of treating hundreds of patients and performing thousands of Q-PCR exams, creating a rational and balanced model of clinical efficacy coupled with basic sustainability premises of modern oncology.

The American College of Surgeons National Surgical Quality Improvement Program surgical risk calculator is not reliable in predicting complications and length of stay after primary total hip arthroplasty at an institution implementing clinical pathways.

The authors aimed to: (1) determine how length of stay (LOS) and complication rates changed over the past 10 years, in comparison to values estimated by the ACS-NSQIP surgical risk calculator, at a single private institution open to external surgeons; and (2) determine preoperative patient factors associated with complications. We retrospectively assessed 1018 consecutive patients who underwent primary elective THA over 10 years. We excluded 87 with tumours and 52 with incomplete records. Clinical data of the remaining 879 were used to determine real LOS and rate of 9 adverse events over time, as well as to estimate these values using the risk calculator. Its predictive reliability was represented on receiver operating characteristic curves. Multivariable analyses were performed to determine associations of complications with age, sex, ASA score, diabetes, hypertension, heart disease, smoking and BMI. Over the 10-year period, real LOS and real complication rates decreased considerably, while LOS and complication rates estimated by the surgical risk calculator had little or no change. The difference between real and estimated LOS decreased over time. The overall estimated and real rates of any complication were respectively 3.3% and 2.8%. The risk calculator had fair reliability for predicting any complications (AUC 0.72). Overall estimated LOS was shorter than the real LOS in 764 (86.9%) patients. Multivariable analysis revealed risks of any complication to be greater in patients aged ⩾75 (OR = 4.36, p = 0.002), and with hypertension (OR = 3.13, p = 0.016). Since the implementation of clinical pathways at our institution, real LOS and complication rates decreased considerably, while LOS and complication rates estimated by the surgical risk calculator had little or no change. The difference between real and estimated LOS decreased over time, which could lead some clinicians to reconsider their discharge criteria, knowing that advanced age and hypertension increased risks of encountering complications.

Estimating the Employment and Educational Effects of Vocational Training: the Role of School Quality

This paper provides new evidence of the short and long-run effects of vocational training (VT) on labor market and educational outcomes, with a particular interest in how school quality may confound estimates. VT schools may differ from regular schools not only in terms of type of training, but also in the availability of resources. We take advantage of a particular institutional arrangement in the state of Parana, Brazil, where a single private institution named FIEP provides both VT and regular education under two separate but closely related entities, while non-FIEP institutions provide regular education. As both VT and regular schools within FIEP have more resources and better inputs than non-FIEP schools, simply comparing outcomes of VT and regular students can be misleading even if students were assigned randomly to schools. Using a unique survey applied to different cohorts of high school graduates, we show that quality plays an important but nuanced role when comparing the effects of general and VT in the short and long run. In particular, our propensity score estimates indicate that FIEP VT graduates have higher short-run employability than both FIEP and non-FIEP non-VT students. However, non-VT graduates from the better-funded FIEP system are more likely to continue to higher education, so that the short-run employment effect all but dissipates as they enter the labor force in the long-run.

Primary Repair of Esophageal Perforation Following Anterior Cervical Fusion.

IntroductionAnterior cervical fusion has been performed safely and effectively for decades for the treatment of multiple pathologies, with low rates of morbidity and mortality. Esophageal perforation is a rare but potentially serious complication of anterior cervical spine approaches. There is no consensus regarding the best treatment strategies for this complication.ObjectivesTo determine the prevalence of esophageal perforation following anterior cervical fusion in a single institution and to describe two cases of this complication that were treated with primary repair.MethodsWe retrospectively analyzed all consecutive patients who underwent anterior cervical fusion in a single private institution from January 1999 to August 2017. Patients who developed esophageal perforation per- or postoperatively were included in the analysis.ResultsA total of 830 anterior cervical fusion surgeries were performed during the analyzed period. Two cases (0.24%), both of male patients, were complicated by esophageal perforation, one intraoperatively and the other four years after the first surgery. Both patients were treated with primary esophageal repair, and good outcomes were obtained.ConclusionPrimary repair is a therapeutic option in cases of esophageal perforation after anterior cervical fusion. Satisfactory results were obtained in both cases. Further studies are necessary to elucidate the best therapeutic options for this rare complication.

The Utility of Obtaining a Complete Blood Count After Total Knee Arthroplasty in the Era of Tranexamic Acid.

Questioning the routine use of postoperative laboratory tests is a strategy to combat rising health care costs. The goal of this study was to determine the utility and cost of routine postoperative complete blood count (CBC) testing after primary total knee arthroplasty (TKA) in the era of tranexamic acid (TXA). This retrospective chart review identified patients who underwent primary TKA performed by a single surgeon at a single private institution during a 2-year period. All patients received TXA intraoperatively. Exact tests were used to determine whether there was a significant difference in transfusion rates between patients with and without preoperative anemia. Of 628 primary TKA procedures, 390 patients (62.10%) had anemia postoperatively. However, only 1 patient (0.16%) required transfusion. A total of 956 CBC tests were performed without intervention, at a total cost of $116,804.08. In addition, 1 of 26 patients with preoperative anemia vs 0 of 602 patients without preoperative anemia required transfusion (P=.04). Healthy patients undergoing primary TKA who receive TXA do not require postoperative CBC. This change has the potential to reduce this laboratory cost by more than 97% compared with the current practice of obtaining postoperative CBC testing for every patient undergoing TKA. Only patients with preoperative anemia should undergo postoperative CBC testing to help to identify those who require transfusion. The potential health care savings associated with eliminating routine postoperative CBC testing are substantial and should be considered by arthroplasty surgeons. [Orthopedics. 2021;44(1):e26-e30.].

P117. Navigated robotic assistance improves pedicle screw accuracy in minimally invasive surgery of the thoracolumbar spine: 341 patients in a single institution

BACKGROUND CONTEXT As the field of robot-assisted spine surgery continues to progress and grow, radiographic evaluation of pedicle screw accuracy in a surgical setting is of high interest. Advances in medical imaging and technology have improved pedicle screw placement accuracy, from fluoroscope-guided placement to computer-aided navigation. PURPOSE The purpose of this study is to assess the pedicle screw accuracy of 341 consecutive cases in which navigated robotic assistance was used in a private practice clinical setting. STUDY DESIGN/SETTING Retrospective chart review. PATIENT SAMPLE A total of 341 consecutive patients. OUTCOME MEASURES Screw accuracy, screw offset, complications. METHODS A retrospective, Institutional Review Board-exempt review of 341 navigated robot-assisted spine surgery cases was performed at a single private institution. Radiographic evaluation of screw tip and screw tail offset distance and angulation from preoperative plan to actual final placement based on intraoperative computerized tomography (CT) images was analyzed and calculated. Additionally, pedicle screw malposition, reposition and return to operating room (OR) rates were reviewed. A CT-based Gertzbein and Robbins System (GRS) was used to classify pedicle screw accuracy. The GRS system classifies screws with the rating of A or B as accurate, and C, D, or E as inaccurate placement. The accuracy percentage was calculated by dividing the number of accurate screws placed with robotic navigation by the total cohort. RESULTS In the 341 cases analyzed, 1,929 thoracolumbar pedicle screws were placed. Thirty-one screws (6 patients) deviated from robot use due to surgeon discretion. Of the 1,929 pedicle screws inserted by navigated robotic guidance, only .005% (9/1929) were repositioned intraoperatively. The average age was 66.8 years, and 48% of the patients were male. Average body mass index was 29.31 kg/m2. The majority of the surgical diagnoses were degenerative disc disease (248) and adjacent segment disease (72). The average offset from preoperative plan to actual final placement was 1.7±1.3mm from the tip, 1.6±1.0mm from the tail, and 2.0±1.4° of angulation. Based on the GRS CT-based grading, 97.8% (1,886/1,928) screws were graded A or B, 2.0% (40/1,928) screws were graded C, and 0.2% (3/1,928) screws were graded D. A total of three complications that required a return to the OR were reported: interbody removal, deep wound infection, and wound vacuum-assisted closure. None were related to robotic guidance or pedicle screws. CONCLUSIONS This study demonstrated a high level of accuracy (97.8%) in the clinical use of navigated, robot-assisted surgery in 341 cases. FDA DEVICE/DRUG STATUS ExcelsiusGPS (Globus Medical) (Approved for this indication)

Post-PACIFIC trial era: Patterns of outcomes and toxicities from a single private institution in a developing country.

e21005 Background: Despite the twenty-first century, NSCLC remains the leading cause of cancer related deaths in a great variety of nations around the globe. However, the scenario has changed dramatically in the past 5 years. Immunotherapy features have opened a gigantic range of combinations now possible towards a better suited treatment for these patients. And we have seen results as we have never before - even in developing countries. Therefore, the goal of this study was to retrospectively analyze the patterns of outcomes, toxicities and safeness in the post-PACIFIC trial era, reporting results on patients that underwent chemoradiation followed by immunotherapy. Methods: We retrospectively collected and analyzed data on patients diagnosed with locally-advanced NSCLC treated in a single private institution in Rio de Janeiro, Brazil, between January 2017 and May 2019. All electronic medical records were accessed in order to obtain demographics, treatment and follow-up pattern data. Patients that received full chemoradiation treatment were included. Patients that did not meet the inclusion criteria were excluded from the study. Results: 121 patients were analyzed. 38 did not meet the inclusion criteria, and were excluded. The median age was 73.5y (50-95). 55% (46) were females. 59% (49) patients were smokers, 12% non-smokers. 29% of them did not have that info on their EMR. Adenocarcinoma was the most common histologic subtype (67%). All patients received chemotherapy regimen according to the best suited to patient, being carbo-taxol the most commonly used one (73%). All patients received radiation therapy, and the mostly used scheme was 60Gy in 30 fractions (38.5%). During a medium follow-up of 1.2 years on Durvalumab, 8 patients died (9.6%), none of them being a treatment-related death. Most toxicities presented during treatment and follow-up were mucositis (62.5%), cough (52%), cutaneous rash (48.8%). Other minor toxicities were nauseas (22.9%) and hematologic (14.5%). No grade 5 toxicity was reported. Conclusions: This study carries limitations inherent to retrospective analysis. Yet, we found the utmost importance on understanding how our patient population is responding to this new era of NSCLC-oncology. Despite all issues related within a developing nation, we showed that our results are compatible with the current data published. The treatment of locally advanced NSCLC brings exciting results and a big hope for these patients.

Stereotactic body radiation therapy (SBRT) in a developing country: Patterns of failure and response rates.

e21010 Background: Surgery remains the treatment of choice for early stage lung cancer. For patients without clinical conditions or those who refuse to this procedure, Stereotactic Body Radiation Therapy (SBRT) is the treatment of choice. It is important to understand the patterns of treatment response and toxicities within this practice. Therefore, we aim to analyze and review our data on lung SBRT for Non-Small Cell Lung Cancer (NSCLC) treated in our institution. Purpose: To describe response and toxicity patterns for NSCLC treatment with SBRT in a single third world country private institution. Methods: We retrospectively collected and analyzed data from patients treated at a single private institution in Rio de Janeiro between January 2017 and May 2019. Inclusion criteria were histopathological diagnosis of NSCLC, 18 years old or older, SBRT treatment, who were closely followed-up according to international guidelines. All data was analyzed and reviewed by the radiation oncologist and medical oncologist responsible, as well as kept in a reliable way for future comparisons. Results: 121 patients were analyzed. 77 were excluded. Only patients diagnosed with NSCLC from 2017 to 2019 who received SBRT as primary treatment. The average age was 74 (56-94). The highest prevalence among patients were females 68% (n = 30). 26 patients were smokers (59%), 4 non-smokers (9%) and 14 patients were not recorded in the medical records. Molecular assessment for non-smokers will not be described in this study. Adenocarcinoma was the most common subtype (77%, n = 35), 15% were squamous cell carcinoma subtype (n = 7), 4.4% poorly differentiated (n = 2). The patients were distributed between early stage lung cancer and metastatic disease - foreseeing oligometastatic disease being continuously treated as potentially curable. 11 patients are not classified in the medical record. Twelve patients had metastasis: central nervous system (33%), lung (41%), bone (8.3%) and patients with more than two metastases 16.6% (bone and CNS, bone and lung). Eleven patients had adjuvant chemotherapy (QT) 25%. Ten of the patients (22%) had toxicities, all with different doses and SBRT fractions. Among them, cough was the most prevalent (40%); nausea / vomiting and rash accounted for 30%; pneumonitis accounted for 17%; and mucositis in 10% of patients. Of the 44 patients, 7 died. Conclusions: The study data corroborates the worldwide published literature. SBRT in treating early stage lung cancer is a safe and effective treatment modality, with acceptable low-grade toxicities and high response rates.

Parsing the effects of comorbid adult ADHD and substance misuse on affective lability in bipolar disorder

IntroductionAttentional deficits, substance misuse, and affective lability are all common features among adults with bipolar disorder, but little research has attempted to parse their inter-relationships. MethodsUsing standardized scales and semi-structured interviews, we evaluated adult ADHD features and affective lability in 113 dually-diagnosed mood/substance use disorder inpatients (mean age 32.6 years, 63% female) drawn from one private suburban academically affiliated inpatient treatment program. Results24% of bipolar subjects had above-threshold ADHD screens. Affective Lability Scale (ALS) total and subscores were significantly associated with ADHD scores (univariate r's ranging from 0.38–0.63). ALS total and most subscale scores were significantly higher among bipolar subjects having above- (versus below-) threshold ADHD ratings. Linear regressions to predict affective lability revealed significant partial correlations between bipolar diagnoses and ALS total, depression, elation, and anger subscores, while controlling for significant effects from ADHD comorbidity. Inclusion of current substances of abuse did not change goodness-of-fit. LimitationsSubjects were drawn from a single private institution, potentially limiting generalizability. ConclusionsComorbid ADHD appears to moderate multiple domains of affective lability in bipolar disorder inpatients, independent of current substance misuse.

Mid-Term Outcomes of Laparoscopic Sleeve Gastrectomy in a Single Private Institution

Mid-Term Outcomes of Laparoscopic Sleeve Gastrectomy in a Single Private Institution

P1.11 Post-Pacific Trial ERA: Patterns of Outcomes and Toxicities From a Single Private Institution in a Developing Country

P1.11 Post-Pacific Trial ERA: Patterns of Outcomes and Toxicities From a Single Private Institution in a Developing Country

A retrospective comparison of biliopancreatic diversion with duodenal switch with single anastomosis duodenal switch (SIPS-stomach intestinal pylorus sparing surgery) at a single institution with two year follow-up

BackgroundThe traditional duodenal switch is performed using a Roux-en-Y configuration. This procedure has proven to be the most effective procedure for long-term weight loss and co-morbidity reduction.Recently, stomach intestinal pylorus sparing surgery (SIPS) has been introduced as a simpler and potentially safer variation of the duodenal switch (DS). It is a single anastomosis end-to-side proximal duodeno-ileal bypass with a sleeve gastrectomy. In this study, we compare our outcomes between biliopancreatic diversion with duodenal switch (BPD-DS) and SIPS at 2 years. SettingThis is a retrospective analysis from a single surgeon at a single private institution. MethodsWe analyzed data from 182 patients retrospectively, 62 patients underwent BPD-DS while 120 other patients underwent SIPS between September 2011 and March 2015. A subset analysis was performed comparing data from both procedures to evaluate weight loss and complications. ResultsOf 182 patients, 156 patients were beyond 1 year postoperative mark and 99 patients were beyond 2 year postoperative mark. Five patients were lost to follow-up. None of our patients had complications resulting in death. BPD-DS and SIPS had statistically similar weight loss at 3 months but percent excess weight loss (%EWL) was more with BPD-DS than SIPS at 6, 9, 12, 18, and 24 months. Patient lost a mean body mass index (BMI) of 23.3 (follow-up: 69%) and 20.3 kg/m2 (follow-up: 71%) at 2 years from the BPD-DS and SIPS surgery, respectively. However, patients who had undergone SIPS procedure had significantly shorter operative time, shorter length of stay, fewer perioperative and postoperative complications than BPD-DS (P<.001). Interestingly, even though BPD-DS patients lost slightly more weight, the actual final BMI for SIPS group was lower than BPD-DS group (25.6 versus 26.9) (P<.05). There was no statistical difference between 2 groups for postoperative nutritional data such as vitamins D, B1, B12, serum calcium, fasting blood glucose, glycosylated hemoglobin (HbA1C), insulin, serum albumin, serum total protein, and lipid panel. ConclusionThe SIPS is a simplified DS procedure. The SIPS eliminates one anastomosis and compared with BPD-DS has fewer perioperative and postoperative complications, shorter operative time and length of stay, and similar nutritional results at 2 years. However, weight loss was more with BPD-DS. A fair criticism is that the vast majority of BPD-DS cases were done before the SIPS cases. As a result, experience and learning curve cannot be completely dismissed when viewing postoperative complications.

Laparoscopic adjustable gastric banding versus laparoscopic adjustable gastric banding with gastric plication: midterm outcomes in terms of weight loss and short term complications

BackgroundLaparoscopic adjustable gastric banding (LAGB) is a safe procedure with variable outcomes and large standard deviations. LAGB with gastric plication (LAGBP) is a new restrictive procedure that combines the lap band with gastric plication. This procedure, with its mechanism being below the band anatomically, should augment the weaknesses of the lap band: slips and inadequate weight loss. ObjectiveCompare the weight loss results and complication rates between the LAGB and LAGBP. SettingPrivate practice. MethodsData was analyzed data from 120 patients retrospectively from 2 surgeons at a single private institution. Seventy-six patients underwent LAGB, and 44 other patients underwent LAGBP between February 2011 and July 2013. All 120 patients are beyond the 1-year postoperative mark and 110 patients are beyond the 2-year postoperative mark. A subset analysis was performed comparing data from both procedures to evaluate weight loss and complications. ResultsThere were no significant differences between preoperative age, weight, and body mass index between the patients who underwent either procedure. We had 47.4% and 52.3% follow-up at 1 year for LAGB and LAGBP, respectively, with 91.5% and 92.3% follow-up at 2 year for LAGB and LAGBP, respectively. Complications were low with LAGBP; however, it was not statistically significant (P = .54). The LAGBP had a greater percent excess weight loss, percent total weight loss, and percent excess body mass index lost compared with the LAGB at 3, 6, 9, 12, and 24 months, and these differences were statistically significant. Mean percent excess weight loss for LAGB and LAGBP was 28.3% and 34.5% (P<.05) at 1 year and 32.1% and 39.2% (P<.05) at 2 years, respectively. ConclusionLAGBP is a safe, feasible, and reproducible bariatric procedure. The LAGBP performs significantly better than the LAGB for weight loss. The complication and revision rates were slightly higher with LAGB than LAGBP. However, it was not statistically significant.

Mid-term outcomes of gastric bypass weight loss failure to duodenal switch

BackgroundThe Roux-en-Y gastric bypass (RYGB) is a very effective treatment for obesity and its related co-morbidities. However, some patients fail to achieve>50% of their excess weight loss (EWL), and others regain much of the weight that they lost. ObjectiveThe purpose of this study was to analyze early outcomes after conversion of RYGB to duodenal switch (DS) in terms of weight loss, change in co-morbidities, and complications. SettingThis is a retrospective analysis from 1 surgeon at a single private institution. MethodsWe analyzed data from 32 obese patients retrospectively who underwent revision for failed RYGB. Nine patients underwent DS with Roux-en-Y reconstruction (RYDS), and 23 patients underwent single anastomosis DS between October 2012 and December 2015. Regression analyses were performed for all follow-up weight-loss data. ResultsThe patients experienced mean EWL of 16.2% over an average of 16 years (range: 0–38) with their primary RYGB surgery. Of 32 patients who underwent revision DS, 22 patients are beyond the 1-year postoperative mark (follow-up 81.8%), and 15 patients are beyond the 2-year postoperative mark (follow-up 73.3%). One patient was lost to follow-up. The patients experienced mean EWL of 31.2%, 45.1%, 51%, 54.2%, 56%, and 56.4% at 3, 6, 9, 12, 18, and 24 months, respectively, after their revisional surgery. Mean total weight loss achieved at 12 and 24 months was 27.7% and 29.2%, respectively. There was no statistical significant difference in mean %EWL at 12 months (P = .468) and 24 months (P = .266) between RYDS and single anastomosis DS. ConclusionA laparoscopic revision from RYGB to DS is an effective weight-loss operation with midterm follow-up of 2 years. Though long-term follow-up is warranted to measure recidivism, the initial data seem favorable.

Congenital Chikungunya Virus Infection in Sincelejo, Colombia: A Case Series.

Congenital chikungunya virus (CHIK) infection has been infrequently reported, even more so during the current 2013-15 outbreak in Latin America. In this study, the consequences of CHIK on pregnancy outcomes and particularly consequences in infants born to infected women were assessed in a case series from a single private institution in the north of Colombia. During September 2014 to February 2015, seven pregnant women with serological and reverse transcription-polymerase chain reaction-positive test for CHIK delivered eight infants with CHIK. These newborns required admission to pediatric intensive care, and related support, owing to severe clinical manifestations, which included respiratory distress, sepsis, necrotizing enterocolitis, meningoencephalitis, myocarditis, edema, bullous dermatitis and pericarditis. There were three deaths (case fatality rate of 37.5%). Pregnant women and newborns with CHIK long term should be followed up, given the implications of chronic sequelae (e.g. chronic inflammatory rheumatism in women) as well as recently described neurocognitive impairment in infants.

Effectiveness of Protocol Doppler Ultrasonography in Salvaging Grafts in Post Orthotopic Liver Transplant Patients

Background: Hepatic Artery Thrombosis (HAT) is a devastating complication that most commonly arises in post-orthotopic liver transplant (OLT) patients in the first one week after transplantation. But, HAT is also seen after that period. It commonly results in high mortality and graft loss and in many cases requires re-transplantation. Protocol Doppler ultrasonography (DUSG) has been proven to be a sensitive and inexpensive tool in the early detection of HAT and in salvaging grafts; hence, reducing the chance of undergoing a re-transplantation. Methods: Retrospective analysis of 279 cases of OLT both from deceased and living donors performed at a single private institution between March 2008 and October 2013. All the patients underwent DUSG intraoperatively after completion of vascular anastomosis. The first 5 post-operative days was the protocol period when DUSG was performed once every day and it was also performed once on the day of discharge. Further thrombosis detected through DUSG was confirmed by a CT angiography. After thrombectomy revascularization with native vessels or aortic conduit was attempted. This study evaluated the duration for detection of HAT, clinical correlation, surgical procedures, graft salvage and mortality rate. Results: Totally 11 patients out of 279 (4%) were diagnosed with HAT through DUSG. Out of the 11, 5 patients (45%) were diagnosed during the protocol period. Out of the 5 patients, 4 patients underwent revision anastamosis and 1 patient was conservatively managed with anti-coagulants. Six patients developed HAT within a period of 9-34 days after transplantation with a mean of 16 days. Five patients underwent re-exploration and 1 patient who also presented with biliary ischemia underwent re-transplantation. The results for liver function tests were normal or within appropriate levels for all the patients in the protocol period. Also, during that period they were asymptomatic. Nine patients (81%) at the time of discharge had normal liver function and arterial flows. 3 patients 19% who were diagnosed with HAT after the protocol period were critically ill due to sepsis and other issues. They were listed for re-transplantation but succumbed before it was performed. Conclusion: The rate at which HAT was presented in patients who underwent OLT in the specified period at our institute was 4%. It is evidently within the range reported in literatures. DUSG protocol screening was effective in identifying arterial flow abnormalities before clinical or biochemical manifestation and resulted in salvaging 5 out of 5 grafts 100% during the protocol period with good overall outcome.