Standard Of Care For Management Research Articles

Mandibular Distraction in Patients With Pierre Robin Sequence: A Multisurgeon Experience.

Mandibular distraction osteogenesis (MDO) is rapidly becoming a standard of care for management of patients with severe Pierre Robin sequence. The tongue is brought forward to alleviate airway obstruction. This study will look at an institutional, multisurgeon experience with MDO over 10 years. A retrospective chart review was conducted. All patients who underwent MDO at the authors' institution from 2012 to 2022 were included. Three craniofacial surgeons performed all interventions. Demographics, preoperative and postoperative respiratory and feeding status, and distraction data were collected for 27 patients meeting inclusion criteria. Primary outcomes were avoidance of a gastrostomy tube, avoidance of a tracheostomy, discharge from hospital on room air, and complications. A significance value of 0.05 was utilized. The average age at MDO was 135 days, mean activation phase was 13.6 days, mean distraction length was 14.9 mm, and mean consolidation phase was 64.2 days. A longer activation phase was associated with discharge with a gastrostomy tube and a shorter activation phase was associated with discharge on full oral feeds. The ability to discharge on room air was associated with a shorter latency phase, shorter activation phase, and decreased distance of distraction. The goal of MDO is to achieve full oral feeds with no respiratory support. Several different latency periods were used in this study, and a short latency period was demonstrated to be safe.

Automated Text Message–Based Program and Use of Acute Health Care Resources After Hospital Discharge

Postdischarge outreach from the primary care practice is an important component of transitional care support. The most common method of contact is via telephone call, but calls are labor intensive and therefore limited in scope. To test whether a 30-day automated texting program to support primary care patients after hospital discharge reduces acute care revisits. A 2-arm randomized clinical trial was conducted from March 29, 2022, through January 5, 2023, at 30 primary care practices within a single academic health system in Philadelphia, Pennsylvania. Patients were followed up for 60 days after discharge. Investigators were blinded to assignment, but patients and practice staff were not. Participants included established patients of the study practices who were aged 18 years or older, discharged from an acute care hospitalization, and considered medium to high risk for adverse health events by a health system risk score. All analyses were conducted using an intention-to-treat approach. Patients in the intervention group received automated check-in text messages from their primary care practice on a tapering schedule for 30 days following discharge. Any needs identified by the automated messaging platform were escalated to practice staff for follow-up via an electronic medical record inbox. Patients in the control group received a standard transitional care management telephone call from their practice within 2 business days of discharge. The primary study outcome was any acute care revisit (readmission or emergency department visit) within 30 days of discharge. Of the 4736 participants, 2824 (59.6%) were female; the mean (SD) age was 65.4 (16.5) years. The mean (SD) length of index hospital stay was 5.5 (7.9) days. A total of 2352 patients were randomized to the intervention arm and 2384 were randomized to the control arm. There were 557 (23.4%) acute care revisits in the control group and 561 (23.9%) in the intervention group within 30 days of discharge (risk ratio, 1.02; 95% CI, 0.92-1.13). Among the patients in the intervention arm, 79.5% answered at least 1 message and 41.9% had at least 1 need identified. In this randomized clinical trial of a 30-day postdischarge automated texting program, there was no significant reduction in acute care revisits. ClinicalTrials.gov Identifier: NCT05245773.

Efficacy of acellular fish skin graft in the management of chronic ulcer: a systematic review and meta-analysis.

The wounds failing to heal through a timely and orderly standard of care (SOC) treatment are considered as chronic wounds, which add significant burden to healthcare systems around the world. SOC treatment has been commonly applied for management of chronic wounds, but SOC alone may not be adequate to heal all ulcers effectively. Fish skin graft (FSG) is a xenogenic skin substitute which could be used for accelerating skin healing. The current study was performed with the view of evaluating the effectiveness of FSG as an adjuvant treatment of SOC for chronic ulcer treatment. Two authors independently searched the following electronic databases: PubMed, Embase, and CENTRAL, using keywords including "diabetic foot ulcer," "fish skin graft," and "wound healing." Clinical studies that evaluated the clinical outcomes of FSG in treatment of chronic ulcers were included in this meta-analysis. Random- or fixed-effect modeled meta-analyses were performed according to the heterogeneity test result (i.e., I2), to analyze the clinical outcome of FSG. A total of 8 studies were included in qualitative synthesis and meta-analysis, with 145 patients treated by SOC and 245 patients treated by SOC plus FSG. There was no significant difference between two groups for time to healing (MD = 1.99, 95% CI: -3.70~7.67, p = 0.493). The complete healing rate was significantly higher in FSG group compared with SOC alone (OR = 3.44, 95% CI: 2.03~5.82, p < 0.001***). Mean percentage area reduction (PAR) was reported in six studies, with a range of 71.6~97.3%. However, many of these studies did not report the value of standard deviation (SD), so we could not pool the data. No significantly different ulcer recurrence rate (RR = 0.60, 95% CI: 0.07~5.27, p = 0.645) and severe adverse events (SAEs) risk (RR = 1.67, 95% CI: 0.42~6.61, p = 0.467) were found between two groups. The application of FSG treatment for patients with chronic ulcers that do not respond well to SOC management could significantly increase the complete healing rate compared with SOC alone, without increased recurrence rate and SAEs risk.

Human Rabies Treatment-From Palliation to Promise.

Rabies encephalitis has plagued humankind for thousands of years. In developed countries, access to preventive care, both pre-exposure and post-exposure, has significantly reduced the burden of suffering and disease. However, around the world, rabies remains a neglected tropical disease, largely due to uncontrolled dog rabies, and tens of thousands perish each year. Currently, the standard of care for management of rabies encephalitis is palliation. Heroic attempts to treat human rabies patients over the last few decades have yielded glimpses into our understanding of pathophysiology, opening the door to the development of new antiviral therapies and modalities of treatment. Researchers continue to investigate new compounds and approaches to therapy, yet there remain real challenges given the complexity of the disease. We explore and review some of the promising therapies on the horizon in pursuit of a salvage treatment for rabies.

Lymphatic Mapping in the Repair of Adult-acquired Buried Penis: Proof of Concept

Summary: Adult-acquired buried penis (AABP) is an acquired clinical entity where a normal sized phallus is concealed by prepubic skin, fat, or subcutaneous tissue, often caused by obesity, lymphedema, or trauma. Surgical repair is the standard of care in management of AABP; however, up to 60% of patients have developed bothersome genital lymphedema postoperatively. Despite the rates of postoperative scrotal lymphedema, and lymphedema itself representing a risk for AABP, very little data exist on the role of lymphatic evaluation in this patient population. We present the previously unreported use of indocyanine green (ICG) for lymphatic mapping as an adjunct to buried penis repair. Using 0.1 mL 25 mg per mL of indocyanine green and SPY Portable Handled Imaging, lymph mapping is performed, identifying lymph channels that seem obstructed as possible targets for lymphovenous bypass. In addition, lymph mapping can be used as an adjunct to surgical resection so as to not disrupt the intact channels, reducing the risk of postoperative lymphedema. Through this article, we offer emerging clinical insight into the possible use of lymphovenous bypass, particularly in patients with AABP due to lymphedema or those who experience lymphedema as a complication of AABP repair.

Abstract 16368: Opioid Withdrawal-Induced Takotsubo Cardiomyopathy in Hypertrophic Cardiomyopathy

Introduction: This case highlights opioid withdrawal-induced Takotsubo cardiomyopathy (TCM) in a patient with pre-existing hypertrophic cardiomyopathy (HCM) and discusses the concurrent management. Clinical Presentation: An 85-year-old female with HCM, depression, and chronic back pain presented with generalized weakness five days after opioid discontinuation. She exhibited elevated troponin levels and ST elevation in anteroseptal leads, concerning for STEMI. Coronary angiogram revealed nonobstructive coronary artery disease. Transthoracic echocardiogram revealed newly reduced EF 45%, hyperdynamic basal left ventricle, and akinetic mid-distal left ventricle, consistent with TCM. Notably, marked basal anteroseptum thickness and systolic anterior mitral valve motion with left ventricular outflow tract obstruction (LVOTO) and a peak gradient of 92 mmHg. Presentation was complicated by hypotension, pulmonary edema and cardiorenal syndrome. β-blocker use initially deferred, opting for phenylephrine and diuresis until stabilization permitted β-blocker introduction. Discussion: We present a unique case of TCM precipitated by opioid withdrawal in a patient with existing HCM. Standard critical care management for TCM involves hemodynamic support until cardiac function recovers, though the use of vasopressors and inotropes remains controversial. Importantly, this case demonstrates severe provoked LVOTO, mimicking acute myocardial ischemia. Recognizing such scenarios is vital, as inappropriate use of vasodilators or inotropes can be fatal. Class I-IIa recommendations endorse β-blockers and vasoconstrictors for severe provoked LVOTO with hypotension and pulmonary edema. Phenylephrine, a selective α-agonist, maintains LVOT turgidity through preload enhancement, while β-blockers facilitate ventricular filling and reduce LVOT pressure gradient. Further research is warranted as current evidence level remains class C.

2050P Integrating ayurveda herbs with standard of care for management of cancer or cancer treatment related anorexia

2050P Integrating ayurveda herbs with standard of care for management of cancer or cancer treatment related anorexia

Cognitive Training for Visuospatial Processing in Children Aged 5½ to 6 Years Born Very Preterm With Working Memory Dysfunction

Compared with term-born peers, children born very preterm generally perform poorly in executive functions, particularly in working memory and inhibition. By taking advantage of neuroplasticity, computerized cognitive training of working memory in those children could improve visuospatial processing by boosting visual inhibition via working memory. To evaluate the long-term effect of cognitive working memory training on visuospatial processing in children aged 5½ to 6 years born very preterm who have working memory impairment. This multicenter (18 French university hospitals), open-label randomized clinical trial with 2 parallel groups (EPIREMED) was conducted from November 2016 to April 2018, with the last follow-up during August 2019. Eligible children from the EPIPAGE 2 cohort were aged 5½ to 6 years, were born between 24 and 34 weeks' gestation, and had a global intelligence quotient greater than 70 and a working memory index less than 85. Data were analyzed from February to December 2020. Children were randomized 1:1 to standard care management and a working memory cognitive training program (Cogmed software) for 8 weeks (25 sessions) (intervention) or to standard management (control). The primary outcome was the visuospatial index score from the Wechsler Preschool and Primary Scale of Intelligence, 4th Edition. Secondary outcomes were working memory, intellectual functioning, executive and attention processes, language skills, behavior, quality of life, and schooling. Neurobehavioral assessments were performed at inclusion and after finishing training at 6 months (intermeditate assessment; secondary outcomes) and at 16 months (final assessment; primary outcome). There were 169 children randomized, with a mean (SD) age of 5 years 11 months (2 months); 91 (54%) were female. Of the participants, 84 were in the intervention group (57 of whom [68%] completed at least 15 cognitive training sessions) and 85 were in the control group. The posttraining visuospatial index score was not different between groups at a mean (SD) of 3.0 (1.8) months (difference, -0.6 points; 95% CI, -4.7 to 3.5 points) or 12.9 (2.6) months (difference, 0.1 points; 95% CI, -5.4 to 5.1 points). The working memory index score in the intervention group significantly improved from baseline at the intermediate time point (difference, 4.7 points; 95% CI, 1.2-8.1 points), but this improvement was not maintained at the final assessment. This randomized clinical trial found no lasting effect of a cognitive training program on visuospatial processing in children aged 5½ to 6 years with working memory disorders who were born very preterm. The findings suggest that this training has limited long-term benefits for improving executive function. Transient benefits seemed to be associated with the developmental state of executive functions. ClinicalTrials.gov Identifier: NCT02757794.

Synthèse des principes et schémas de prise en charge dans les troubles neurologiques fonctionnels

After more than twenty years of academic research on functional neurological disorders (FND) throughout the world, a standardized care management strategy has emerged to allow a more adapted care offer to patients with FND, as close as possible to their experience and their needs. With regard to this special issue on FND in collaboration with L’Encéphale and at the initiative of the Neuropsychiatry section of the AFPBN (French Association of Biological Psychiatry and Neuropsychopharmacology), we would like to suggest a summary of all topics discussed in more detail in each article of this special issue, in order to facilitate its reading. We therefore cover the following themes: the initial contact with a patient with FND, the diagnostic process in favor of a positive diagnosis, the physiological, neural and psychological basis of FND, the diagnostic announcement (and its intangibles), the therapeutic patient education in FND, the general principles of therapeutic management through a personalized and multidisciplinary care program, and the validated therapeutic tools available according to the symptoms identified. This article is designed to be of broad interest on FND, supported by tables and figures showing the key points of all these steps, to keep an educational purpose at most. We hope that through this special issue, each health professional will be able to grasp this knowledge and this framework of care as easily and quickly as possible, in order to participate in the standardization of the care offer.

The impact of standardized perioperative care management on improving outcomes in patients with peptic ulcer disease.

The present study investigated the impact of standardized perioperative nursing management on improving outcomes in patients with peptic ulcer disease. A total of 90 patients with peptic ulcers were admitted to the Wuhan Wuchang Hospital between July 2020 to July 2022. These patients were included in the present study. They were divided into 2 groups based on the nursing management that they received, with 45 patients classified into each group. The control group received routine nursing care, while the observation group received standardized perioperative nursing management. The improvement in clinical symptoms, recurrence rate, negative emotions and disease management capacity were compared between the 2 groups. The results demonstrated that the improvement rate of clinical symptom in the observation group was significantly higher as compared with the control group (P < .05). The recurrence rate in the observation group was significantly lower than in the control group (P = .026). Patients in the observation group had better psychological status, and better disease management capacity as compared with those in the control group (P < .05). The application of standardized perioperative nursing management for patients with peptic ulcer can help improve the patients' clinical symptoms, enhance their disease management capacity, reduce anxiety, and ensure the quality of nursing care.

SP27. Mandibular Distraction in Patients with Pierre Robin Sequence: A Multi-surgeon Experience

PURPOSE: Mandibular distraction osteogenesis (MDO) is rapidly becoming a standard of care for management of patients with severe Pierre Robin Sequence. The tongue is brought forward to alleviate the airway obstruction. This study will look at an institutional, multi-surgeon experience with MDO over ten years. METHODS: This study was conducted as a retrospective chart review including all patients who underwent MDO at the authors’ institution from 2012 to 2022. Demographics, preoperative and postoperative respiratory and feeding status, and distraction data were collected. Primary outcomes were achievement of full oral feeds, avoidance of a gastrostomy tube (GT), avoidance of a tracheostomy, discharge from hospital on room air and complications. A significance value of 0.05 was utilized. RESULTS: Twenty-eight patients met inclusion criteria. Three craniofacial surgeons performed all interventions. The average age at MDO was 135 days, mean activation phase was 13.6 days, mean distraction length was 14.9 mm and mean consolidation phase was 64.2 days. MDO showed a significant improvement in apnea-hypopnea index (AHI) (p < 0.001) and %O2 Nadir (p < 0.001) on postoperative polysomnography. Syndromic patients were associated with discharge with a GT and negatively associated with avoidance of tracheostomy. Patients with preoperatively diagnosed tracheomalacia and subglottic stenosis were negatively associated with avoidance of a tracheostomy. Preoperative diagnosis of gastroesophageal reflux disease (GERD) was negatively associated with extubation immediately to room air (RA) following index procedure. A shorter duration of intubation following index procedure was associated with discharge on RA and a longer duration of intubation was associated with unilateral pan-facial nerve palsy. A longer activation phase was associated with discharge with a GT and a shorter activation phase was associated with discharge on full oral feeds. The ability to discharge on RA was associated with a shorter latency phase, shorter activation phase, and decreased distance of distraction. Repeat MDO was associated with postoperative infection requiring operative management. CONCLUSIONS: The goal of MDO is to achieve full oral feeds with no respiratory support. Several interesting findings are described in this study. When assessing patients preoperatively it is important to note the higher rate of failure to avoid a tracheostomy in patients with a syndrome and those with tracheomalacia and subglottic stenosis noted on airway evaluation. Syndromic patients were also noted to be more likely to be discharged with a GT. Several different latency periods were used in this study, and it appears that not only is a short latency period safe, but that it may be correlated with successful discharge on RA. This should be tempered with the finding that a decreased time spent intubated following surgery, decreased distance distracted and time spent in activation was also associated with discharge on RA, which may be a function of the severity of micrognathia in these patients. Of note, patients that spent a longer period intubated following surgery experienced a higher rate of facial nerve palsy. The reason for this correlation is unclear but may represent more severe cases that resulted in more forced retraction during surgery.

CoCM Helps Duke Primary Care Meet Standards of Care

Back to table of contents Previous article Next article ProfessionalFull AccessCoCM Helps Duke Primary Care Meet Standards of CareMark MoranMark MoranSearch for more papers by this authorPublished Online:2 Mar 2023https://doi.org/10.1176/appi.pn.2023.04.4.14aAbstractThe program at Duke is another example of how North Carolina is expanding collaborative care services.Use of the Collaborative Care Model (CoCM) at Duke University began on a pilot basis five years ago, when the University Health System awarded the Department of Psychiatry an innovation grant to establish the model at a handful of primary care sites.Today the model has been implemented throughout Duke’s primary care system.Marvin Swartz, M.D., said collaborative care offered a way for primary care practices to meet standards of depression care requiring follow-up with patients within a month after being prescribed an antidepressant.Marvin Swartz, M.D., a professor of psychiatry and behavioral health at Duke, said a selling point was that CoCM allowed primary care practices to meet standards of care for depression that require physicians to see a patient within one month of prescribing an antidepressant. As part of the pilot program, Duke had developed its own patient registry, which allows the CoCM team—which typically consists of the primary care physician, behavioral health care manager, and consulting psychiatrist—to track patients’ progress.Swartz is also director of the Duke Area Health Education Center (AHEC), which is providing training and technical support to practices implementing collaborative care.“Primary care physicians really liked the model,” he said. “When we presented it to our health system leadership after the success of the pilot, we said we thought it was the only way that primary care could meet standards of care for management of depression. We argued ‘If that’s how we achieve the standard of care, then we need to do it.’ That led to its spreading across Duke’s primary care sites.”In a state that has one of the fastest growing populations and a small number of psychiatrists who are clustered in urban areas, CoCM is a population health solution to a vast need, Swartz said. “This is a way we can address the shortage in the mental health workforce in an efficient way and be sure all primary care offices have at least this base to meet their needs and can address the large proportion of people with mild to moderate conditions.”Swartz said that measurement-based care—using scales and validated instruments to assess progress of treatment—and communication of patients’ scores is a great improvement in cross-disciplinary communication.“Everyone knows what a PHQ-9 is. Primary care physicians typically don’t have the time to weave through a narrative. What they get back from the consulting psychiatrist is an efficient response with not a lot of verbiage.“Primary care doctors can also know that every one of their patients is evaluated by the behavioral health care manager using a variety of scales,” Swartz continued. “It’s a new language in collaboration.” ■ ISSUES NewArchived

Safety and efficacy of Siddha management as adjuvant care for COVID-19 patients admitted in a tertiary care hospital - An open-label, proof-of-concept Randomized Controlled Trial

BackgroundCOVID-19 resulted in loss of human lives owing to respiratory failure caused by dysregulated immune system. Though many treatments are evaluated, the most appropriate is yet to be established. ObjectiveTo determine the safety and efficacy of Siddha add-on therapy in COVID -19 in terms of accelerated recovery, reduced hospital stay & mortality and follow up assessment of post discharge status until 90 days as compared to the Standard Care management. MethodsIn a randomized, controlled, single-center, open-label trial conducted on 200 hospitalized COVID-19 patients, they were allocated equally to be treated with add-on Siddha regimen with Standard care or only Standard care. Standard care was in accordance to the Government norms. Recovery was defined as amelioration of symptoms, viral clearance and attaining SpO2 > 94% in room air indicating the derived score of zero on WHO clinical progression scale. The primary and secondary end points were accelerated recovery (≤ 7 days) and mortality comparison between the groups respectively. Also, disease duration, length of hospital stays and laboratory parameters were assessed for safety and efficacy. Patients were followed through for 90 days after admission. ResultsIn this study the accelerated recovery was 59.0% and 27.0% in treatment and control groups (ITT analyses) (p < 0.001) respectively and Odds for it were four times higher in the treatment group (OR: 3.9; 95% CI: 1.9, 8.0). The estimated median time for recovery in the treatment group was 7 days (95% CI: 6.0, 8.0; p=0.003) and 10 days (95% CI: 8.7, 11.3) in control. Hazard ratio for death in control was 2.3 times that of treatment group. No adverse reactions or alarming laboratory values were observed in response to intervention. In Severe COVID treatment group (n=80), mortality was 15.0% and 39.5% in control (n=81). The COVID stage progression was 65% less in test group. Mortality during treatment and 90 days follow up in Severe COVID patients were 12 (15%) and 35 (43.2%) in treatment and control groups respectively. ConclusionThe selected Siddha regimen when co-administered with Standard of Care have demonstrated that they can synergistically act to improve oxygenation status of patients, enhance the recovery rate from COVID-19 and reduce the mortality better when compared to administration of only Standard of Care. Clinical Trial Registry of IndiaCTRI/2020/06/025768 Registered on: 09/06/2020.

Total abdominal colectomy to facilitate complete cytoreduction in 56 patients with mucinous appendiceal neoplasms with peritoneal metastases.

Cytoreductive surgery (CRS) and perioperative intraperitoneal chemotherapy are currently the standard of care for management of appendiceal mucinous neoplasms with peritoneal metastases. The goal of the CRS is complete removal of all visible disease through the use of peritonectomy procedures and visceral resections. One of the major resections that may be required is total abdominal colectomy (TAC). From a database and secured files of patients having a complete CRS, all patients who had TAC were identified. The clinical and histologic variables associated with these patients were identified and assessed for their impact on overall survival. The 450 complete CRS with low-grade appendiceal mucinous neoplasms had 26 TAC (5.8%) with a 16.0-year median survival. The mucinous adenocarcinoma (MACA)-Intermediate (MACA-Int) group consisted of 37 patients with 8 patients (21.6%) having TAC that resulted in a median survival of 11.5 years. The 159 complete CRS with MACA had 22 TAC (13.8%) with a median survival of 7.5 years. There was a single mortality with a class 4 adverse event in 5 patients (10.7%). With a class 4 adverse event, survival decreased significantly (p = 0.0006, hazard ratio: 6.2). Complete CRS required TAC in 56 of 646 patients (8.7%) with appendiceal mucinous neoplasms. With TAC, median survival was 12.0 years. A class 4 adverse event markedly reduced survival.

P140 Costs of home-monitoring by telemedicine versus standard care management of Inflammatory Bowel Disease – a Danish register-based five-year follow-up study

Abstract Background The increasing incidence of Inflammatory bowel diseases (IBD) with subsequent increasing use of costly biological treatments such as well as the need for tight control of IBD places a significant economic direct and indirect cost burden on health care systems. Thus, eCare Constant-Care APP, home-monitoring of Patient Reported Outcome (PROs-SCCAI/HB-I, quality of life QoL, Disability index WEB-DI) and calprotectin (POCT-Point of Care Test) was introduced at North Zealand Hospital (NOH) in Denmark in 2015. The aim of this study was to assess long-term cost effectiveness of remote telemedicine services (eCare) compared to standard care (sCare) for IBD patients during 5 years follow-up. Methods A retrospective register-based study was carried out among patients with ulcerative colitis (UC) or Crohn’s disease (CD) continuously included in the telemedicine service Constant Care (CC) in 2015-2020. Direct and indirect healthcare costs over a 5-year period were obtained from Danish registers and compared to a control group of IBD patients from all five regions in Denmark who were 1:5 matched on year of birth, gender, education, income, disease, use of biologics, duration of disease and Charlson Comorbidity index. The IBD patients (cases and controls) were identified in the National Patient Register (NPR) via registered ICD-10 diagnosis codes. Direct and indirect costs were estimated on a yearly basis from two years before inclusion in CC (i.e., the index year) and five years after using a linear regression model. Results A total of 572 IBD patients were included in the study. Average annual costs of IBD-related outpatient visits were significantly (P&amp;lt;.005) higher among patients enrolled in CC compared to controls before and after index date whereas costs of hospital admissions were non-significant (ns). However, a slight decrease was observed in year 2 and 5 from index year (ns). The total direct costs were higher among CC patients compared to controls in the year prior to enrollment in CC and the five years after (Figure 1) primarily driven by the costs of outpatient visits. Significantly (P&amp;lt;.05) fewer CC patients were on early retirement compared to controls and CC patients received less public transfer payments compared to controls (ns). Conclusion Telemedicine care was associated with higher cost than standard care. One potential confounder is inefficient out-patient registration in NRP which highlights the need for continuous validation of clinical registration approaches in Denmark. A prospective RCT is warranted in future.

1146: EARLY VERSUS LATE ADMINISTRATION OF PHENOBARBITAL IN ACUTE ALCOHOL WITHDRAWAL

Introduction: Alcohol withdrawal syndrome (AWS) is the leading cause of mortality in patients with alcohol use disorder due to complications like seizures and delirium tremens. The current standard of care for management is Clinical Institute Withdrawal Assessment (CIWA)-guided benzodiazepine administration. Phenobarbital in addition to a CIWA protocol is shown to be a safe adjuvant in patients with AWS but optimal timing has not been established. The purpose of this study is to evaluate the effects of early vs. late vs. no administration of phenobarbital for the management of AWS. Methods: A retrospective chart review of adult patients in the emergency department (ED) for AWS who received a benzodiazepine or phenobarbital. Exclusion criteria included: pregnancy, study drug use for an indication other than AWS, left against medical advice/discharged within 48 hours, and primary seizure disorder. Study groups were as follows: early (phenobarbital before receiving >30mg of lorazepam equivalents), late (phenobarbital after receiving >30mg of lorazepam equivalents), and none. The primary outcome was cumulative dose of benzodiazepine per day. Secondary outcomes included ICU admissions, reduction of CIWA score from baseline, need for adjuvant agents, and safety outcomes. Results: Seventy-five patients were included in this study (29 early group, 20 late group, 26 none group). Early phenobarbital patients received less benzodiazepines compared to the late and none groups (11.88 mg vs. 36.21 mg vs. 21.29 mg). Average change from baseline CIWA was greater in the early group than in the late and none groups (12.94 vs. 7.89 vs. 5.25). Early phenobarbital compared to late resulted in lower ICU admissions (67.7% vs. 88.0%) and less need for adjuvant therapy (34.3% vs. 64%). More intubations were seen in the early and late groups compared to the no phenobarbital group, but all intubations were due to severe AWS requiring continuous sedation. Conclusions: Phenobarbital led to decreased benzodiazepine requirements, greater change from baseline CIWA score, and less need for adjuvant therapy without an increased risk of adverse effects. Early phenobarbital administration was associated with decreased benzodiazepine requirements, greater change from baseline CIWA score, less ICU admissions, and less need for adjuvant therapy.

Left Main Coronary Artery Stenosis following Bentall Procedure: A case report.

Since its introduction, Bentall procedure has remained the standard of care for management of ascending aortic aneurysms with associated aortic valve pathologies. It involves replacement of aortic root, ascending aorta and the aortic valve, using a hybrid vascular graft with built in valves. The openings of the main coronary arteries are then rejoined with the graft. The procedure has satisfactory long term survival rate. However, there are some complications including graft infection, stroke from dislodged plaques and coronary insufficiency due to kinking of the reconnected main coronary arteries.&#x0D; Here, we report a rare and life-threatening complication following Bentall procedure. A 76-year-old female developed left main stenosis following Bentall procedure, successfully treated with percutaneous coronary intervention (PCI). We discuss various etiologies and treatment options for this complication. We recommend routine surveillance with coronary angiography at six months post Bentall.

PSAT277 Glucocorticoid Therapy for Management of Hypoglycemia in the context of Non-Islet Cell Tumor-Induced Hypoglycemia

Abstract Background Non-islet cell tumor-induced hypoglycemia (NICTH) is a rare paraneoplastic syndrome which can cause recurrent hypoglycemia. There is no clear standard of care for management of hypoglycemia. Often, these patients have high morbidity and therefore surgical tumor resection is not always possible. Clinical case: This is the case of a 69 year-old male presenting with altered mental status in the context of hypoglycemia without clear etiology with an initial serum glucose level of 32 mg/dL (normal range 60-100 mg/dL) which quickly corrected after administration of intravenous glucose. He was found to have a large bowel obstruction with CT abdomen revealing an underlying neoplasm. Biopsy of suspected lesion on colonoscopy revealed colorectal adenocarcinoma. Repeated episodes of hypoglycemia complicated by seizures required inpatient management. Workup included serum insulin level which resulted in suppressed level (&amp;lt;1. 0 uU/mL, normal range 1.9-23. 0 uU/mL), low c-peptide level (0.1 ng/mL, normal range 1.1-4.4 ng/mL), low beta hydroxybutyrate level (0. 07 mmol/L, normal level &amp;lt;0.3 mmol/L), cortisol level of 43.7 mcg/dL, undetectable insulin like growth factor-1 (IGF-1) level (&amp;lt;10 ng/mL, normal range 59-230 ng/mL) and low insulin like growth factor-2 (IGF-2) level (66 ng/mL, normal range 333 - 967 ng/mL). IGF2: IGF1 ratio was 66 (ratio &amp;gt;10 is indicative for diagnosis of non-islet cell tumor hypoglycemia). Due to extremely poor oral intake and recurrent episodes of hypoglycemia despite continuous dextrose infusion, the patient was started on 20 mg prednisone daily. Eventually, 40 mg of intravenous methylprednisolone in addition to dextrose infusion was needed as maintenance therapy effectively preventing hypoglycemia. Given his poor functional status, the surgical and oncology team decided he was no longer a surgical or chemotherapy candidate. Eventually, palliative medicine was consulted and the patient was transitioned to comfort care with a plan for outpatient hospice. Conclusion NICTH should be suspected in any patient with hypoglycemia without clear etiology, especially if there are suggestions to NICTH such as known malignancy or newly diagnosed mass. Once NICTH is identified and a primary tumor is found, complete tumor resection represents ideal management, however, not always attainable. In such cases, dextrose infusion might be insufficient to prevent hypoglycemia and is not always the preferred option given the required long-term venous access. In these circumstances, early high dose glucocorticoids are safe and appear to successfully prevent hypoglycemic events. Presentation: Saturday, June 11, 2022 1:00 p.m. - 3:00 p.m.

Clinical prediction models assessing response to radiotherapy for rectal cancer: protocol for a systematic review

BackgroundRectal cancer has a high prevalence. The standard of care for management of localised disease involves major surgery and/or chemoradiotherapy, but these modalities are sometimes associated with mortality and morbidity. The notion of ‘watch and wait’ has therefore emerged and offers an organ-sparing approach to patients after administering a less invasive initial treatment, such as X-ray brachytherapy (Papillon technique). It is thus important to evaluate how likely patients are to respond to such therapies, to develop patient-tailored treatment pathways. We propose a systematic review to identify published clinical prediction models of the response of rectal cancer to treatment that includes radiotherapy and here present our protocol.MethodsIncluded studies will develop multivariable clinical prediction models which assess response to treatment and overall survival of adult patients who have been diagnosed with any stage of rectal cancer and have received radiotherapy treatment with curative intent. Cohort studies and randomised controlled trials will be included. The primary outcome will be the occurrence of salvage surgery at 1 year after treatment. Secondary outcomes include salavage surgery at at any reported time point, the predictive accuracy of models, the quality of the developed models and the feasibility of using the model in clinical practice.Ovid MEDLINE, PubMed, Cochrane Library, EMBASE and CINAHL will be searched from inception to 24 February 2022. Keywords and phrases related to rectal cancer, radiotherapy and prediction models will be used. Studies will be selected once the deduplication, title, abstract and full-text screening process have been completed by two independent reviewers. The PRISMA-P checklist will be followed. A third reviewer will resolve any disagreement. The data extraction form will be pilot-tested using a representative 5% sample of the studies reviewed. The CHARMS checklist will be implemented. Risk of bias in each study will be assessed using the PROBAST tool. A narrative synthesis will be performed and if sufficient data are identified, meta-analysis will be undertaken as described in Debray et al.DiscussionThis systematic review will identify factors that predict response to the treatment protocol. Any gaps for potential development of new clinical prediction models will be highlighted.Trial registrationCRD42022277704.

S1375 Role of Rifaximin in the Prevention of Acute Variceal Bleeding in Cirrhosis: A Systematic Review and Meta-Analysis

Introduction: Acute variceal bleeding is one of the most severe complications of cirrhosis and is associated with high mortality. Rifaximin has been shown to be efficacious in the treatment of hepatic encephalopathy (HE). Some studies have also shown rifaximin to be beneficial in decreasing the risk of initial episode of variceal bleeding and to decrease the risk of re-bleeding in those with prior variceal hemorrhage. We performed a systematic review and meta-analysis to evaluate the efficacy of rifaximin in prevention of acute variceal bleeding. Methods: A systematic literature search was performed at PubMed, Embase, Web of Science and Cochrane library database until March 2022. All studies that evaluated the role of rifaximin in prevention of initial episode of variceal bleeding or risk of re-bleeding in cirrhotic patients were included in the meta-analysis. The analysis was performed using Revman 5.4 software. Results: Seven studies including 1999 patients were included in the final meta-analysis. Of these, 3 studies were randomized controlled trials (RCTs) and 4 studies were observational studies. Out of 1999 included patients, 769 patients received rifaximin along with standard care management and 1230 patients received standard of care management only. Patients in the rifaximin group had significantly lower odds of acute variceal bleeding with OR= 0.43 (95% CI: 0.31, 0.58), I2=0. We also performed a subgroup analysis including only RCTs, which although showed trend toward lower risk of variceal bleeding in rifaximin group but did not reach statistically significance OR=0.58 (0.27, 1.28). In a second subgroup analysis, patients who received rifaximin also had significantly lower odds of spontaneous bacterial peritonitis (SBP) OR= 0.15 (0.10, 0.22), risk of acute kidney injury/hepatorenal syndrome (AKI/HRS) OR=0.39 (0.22, 0.68) and HE OR=0.37 (0.21, 0.68). Publication bias was deferred as number of studies were less than 10. (Figure) Conclusion: Rifaximin is associated with lower odds of variceal bleeding, SBP, AKI/HRS and HE in patients with cirrhosis. Although the overall analysis demonstrates rifxamin can decrease the risk of variceal bleeding this loses statistical significance when only RCTs were included in the analysis. Therefore, additional RCTs are needed to further evaluate if there is any benefit of rifaximin in reducing the risk of variceal bleeding and to justify its use aside from the treatment HE.Figure 1.: Forest plot for variceal bleeding.