Treatment Thresholds Research Articles

Development and Validation of a Nomogram for Axillary Lymph Node Metastasis Risk in Breast Cancer.

Purpose: Preoperative assessment of axillary lymph node (ALN) status is essential for breast cancer treatment planning. This study prospectively analyzed risk factors for ALN metastasis by comparing high-resolution computed tomography (HRCT) imaging with pathology and developed a nomogram to aid in diagnosis. Methods: From April 2023 to May 2024, breast cancer patients confirmed by pathology participated in the study. All had chest HRCT before surgery, and ALN samples were anatomically matched to HRCT imaging and pathology. The least absolute shrinkage and selection operator (LASSO) regression helped refine metastasis features, and a nomogram was constructed using the final selected features determined by multivariate logistic regression. The nomogram's performance was evaluated with concordance index (C-index), calibration plot, and decision curve analysis, with internal validation through bootstrapping. Results: A total of 302 ALN from 98 patients were included in this study. The predictors included in the nomogram encompassed the mean CT value, short diameter, border, and shape of ALN, as well as the Ki-67 status and histological grade of the primary tumor. The model exhibited satisfactory discrimination, with a C-index of 0.869 (95% CI: 0.826-0.912) and an AUC of 0.862 (95% CI, 0.815-0.909). The calibration curve demonstrated a high degree of concordance between the predicted and actual probabilities. The decision curve analysis demonstrated that the nomogram was clinically useful when the threshold for intervention was set at the metastasis possibility range of 1% to 86%. Conclusion: The nomogram combined with preoperative pathology and HRCT imaging have the potential to improve the evaluation of ALN status.

Management of hyperkalemia: Expert consensus from Kuwait - a Modified Delphi Approach.

Hyperkalemia is common in heart failure (HF) patients on renin angiotensin aldosterone inhibitors (RAASi), in chronic kidney disease (CKD), and in hemodialysis, and it negatively impacts their management. New potassium binders, such as sodium zirconium cyclosilicate (SZC), are effective in management of acute and chronic hyperkalemia. However, guidelines inconsistencies and lack of standardized treatment protocols are hindering proper and wider use of such agents. Therefore, an expert panel from Kuwait developed a consensus statement to address hyperkalemia management in acute settings, in HF, in CKD, and in hemodialysis. A three-step modified Delphi method was adopted to develop the present consensus, which consisted of two rounds of voting and in-between a virtual meeting. Twelve experts from Kuwait participated in this consensus. Statements were developed and shared with experts for voting. A meeting was held to discuss statements that did not reach consensus at the first round and then the remaining statements were shared for final voting. The consensus consists of 44 statements involving an introduction to and the management of hyperkalemia in acute settings, HF, CKD, and hemodialysis. Thirty-six statements approved unanimously in the first vote. In the second vote, four statements were removed and four were approved after editing. Hyperkalemia management lacks standardized definitions, treatment thresholds and consistent guidelines and laboratory practices. This consensus is in response to lack of standardized treatment in the Arabian Gulf, and it aims to establish guidance on hyperkalemia management for healthcare practitioners in Kuwait and highlight future needs.

The dynamics and control of a multi-lingual rumor propagation model with non-smooth inhibition mechanism.

In this paper, the dynamic behaviors and control strategies of a rumor propagation model are studied in multi-lingual environment. First, an S2E2I2R rumor propagation model is proposed, which incorporates a non-smooth inhibition mechanism. Meanwhile, the existence and stability of the equilibrium are analyzed, grounded in the spreader threshold of the government intervention. Finally, the optimal control and the event-triggered impulsive control strategies are proposed to mitigate the spread of rumors, and the comparison of their effectiveness is further presented by the numerical simulation and a practical case.

A Case of Necrotizing Fasciitis of the Breast Following Lumpectomy and Oncoplastic Closure

Background. NF is a life-threatening soft tissue infection that most commonly occurs in the lower extremity. While presenting symptoms such as erythema, severe pain, sepsis, and wound crepitation are well documented, diagnosis of NF of the breast often is obscured by a low clinical index of suspicion due to its relative rarity as well as by the breast parenchyma that physically separates the underlying fascia and overlying skin. Several risk factors have previously been identified, such as underlying infection, diabetes, advanced age, and immunosuppression. However, the gross morbidity and high mortality associated with NF warrant continued surveillance of contributing factors across any anatomic location. Fifteen cases in the literature document the development of NF following breast surgery. Case Report. The authors of this case report aim to expand on the current literature through the presentation of a unique case of NF of the breast following right breast lumpectomy and oncoplastic closure with left reduction mammaplasty in an immunocompromised patient found to have concurrent perforated sigmoid diverticulitis. Conclusion. This case exemplifies how frequent postoperative surveillance, a low threshold for intervention, and efficient coordination of care are vital to minimizing the morbidity and mortality risks associated with NF of the breast.

Development and Validation of a Protein Risk Score for Mortality in Heart Failure : A Community Cohort Study.

Heart failure (HF) is a complex clinical syndrome with high mortality. Current risk stratification approaches lack precision. High-throughput proteomics could improve risk prediction. Its use in clinical practice to guide the management of patients with HF depends on validation and evidence of clinical benefit. To develop and validate a protein risk score for mortality in patients with HF. Community-based cohort. Southeast Minnesota. Patients with HF enrolled between 2003 and 2012 and followed through 2021. A total of 7289 plasma proteins in 1351 patients with HF were measured using the SomaScan Assay (SomaLogic). A protein risk score was derived using least absolute shrinkage and selection operator regression and temporal validation in patients enrolled between 2003 and 2007 (development cohort) and 2008 and 2012 (validation cohort). Multivariable Cox regression was used to examine the association between the protein risk score and mortality. The performance of the protein risk score to predict 5-year mortality risk was assessed using calibration plots, decision curves, and relative utility analyses and compared with a clinical model, including the Meta-Analysis Global Group in Chronic Heart Failure mortality risk score and N-terminal pro-B-type natriuretic peptide. The development (n = 855; median age, 78 years; 50% women; 29% with ejection fraction <40%) and validation cohorts (n = 496; median age, 76 years; 45% women; 33% with ejection fraction <40%) were mostly similar. In the development cohort, 38 unique proteins were selected for the protein risk score. Independent of ejection fraction, the protein risk score demonstrated good calibration, reclassified mortality risk particularly at the extremes of the risk distribution, and showed greater clinical utility compared with the clinical model. Participants were predominantly of European ancestry, potentially limiting the generalizability of the findings to different patient populations. Validation of the protein risk score demonstrated good calibration and evidence of predicted benefits to stratify the risk for death in HF superior to that of clinical methods. Further studies are needed to prospectively evaluate the score's performance in diverse populations and determine risk thresholds for interventions. Division of Intramural Research at the National Heart, Lung, and Blood Institute of the National Institutes of Health.

Explaining the Elusive Nature of a Well-Defined Threshold for Blood Transfusion in Advanced Epithelial Ovarian Cancer Cytoreductive Surgery.

There is no well-defined threshold for intra-operative blood transfusion (BT) in advanced epithelial ovarian cancer (EOC) surgery. To address this, we devised a Machine Learning (ML)-driven prediction algorithm aimed at prompting and elucidating a communication alert for BT based on anticipated peri-operative events independent of existing BT policies. We analyzed data from 403 EOC patients who underwent cytoreductive surgery between 2014 and 2019. The estimated blood volume (EBV), calculated using the formula EBV = weight × 80, served for setting a 10% EBV threshold for individual intervention. Based on known estimated blood loss (EBL), we identified two distinct groups. The Receiver operating characteristic (ROC) curves revealed satisfactory results for predicting events above the established threshold (AUC 0.823, 95% CI 0.76-0.88). Operative time (OT) was the most significant factor influencing predictions. Intra-operative blood loss exceeding 10% EBV was associated with OT > 250 min, primary surgery, serous histology, performance status 0, R2 resection and surgical complexity score > 4. Certain sub-procedures including large bowel resection, stoma formation, ileocecal resection/right hemicolectomy, mesenteric resection, bladder and upper abdominal peritonectomy demonstrated clear associations with an elevated interventional risk. Our findings emphasize the importance of obtaining a rough estimate of OT in advance for precise prediction of blood requirements.

Factors determining the requirement of surgical intervention and prognosis in cases of traumatic bifrontal contusions: A prospective observational study

Background: Traumatic brain injury, being a notorious cause of mortality and morbidity across the globe, presents with a variety of lesions. One of the distinct patterns of injury is characterized by contusions of both frontal lobes, labeled “traumatic bifrontal contusions” (TBCs). TBC is often associated with the presence of significant edema and mass effect leading to rapid clinical deterioration after a usually benign presentation at the time of first evaluation. Formulating a management plan in a patient with TBC is often more difficult than in a patient with a major intracranial hematoma. Methods: A prospective observational study with aims and objectives to identify predictors of an unfavorable outcome, analysis of the evolution of TBC, evaluation of the specific indications for surgery, and determination of the prognosis. All head trauma patients harboring bifrontal contusions were included in the study. Patients with other associated operable injuries involving blunt trauma abdomen and orthopedic injuries, counter-coupe injuries, and obvious open fractures noted over calvaria were excluded from the study. Glasgow coma scale (GCS) was recorded during the first assessment, followed by non-contrast computerized tomography (NCCT) Head. Results: A total of 53 patients satisfying inclusion and exclusion criteria were included in the study. The average GCS score recorded before surgical intervention was 9. The mean and median best motor response noted was M5. The interval from the time of injury to the first NCCT of the brain at the study hospital ranged from 3 h to 163 h, averaging 17.66 h. The median category w.r.t Marshall’s CT classification observed was “Diffuse Injury IV.” The volume of the contusions in each scan was estimated, and the average anterior cranial fossa volume observed was 125 mL. “Upfront surgery” (“Bifrontal decompressive craniectomy” or “unilateral Fronto-Temporo-Parietal [FTP] decompressive hemicraniectomy”) was carried out on the day of admission based on the findings on the first NCCT brain. About 49% of patients at presentation needed surgical intervention as per existing protocols. The duration of observation for patients who were initially observed but eventually had to undergo surgery ranged from 1 to 5 days, with an average observation period of 2 days. The duration of observation in those who did not subsequently need surgery ranged from 7 to 10 days, with an average duration of 9 days. Conclusion: What leads to the poorly predictable, delayed, and rapid deterioration that sets TBCs apart from other traumatic brain injuries is still unclear. Our study finds that having a low threshold for repeat CT imaging of the patient led to earlier identification of progression, and a low threshold for surgical intervention led to favorable outcomes.

Management of Low Sodium in AMU

Hyponatremia is a common finding in acutely ill patients and is defined as serum sodium (Na) level less than 135 mEq/L which is due to a relative excess of water in relation to serum sodium. Reasons for hyponatremia are increase in water intake (hypotonic intravenous fluid therapy or primary polydipsia) or impaired water excretion due to renal failure or increase release of antidiuretic hormone. Optimum management depends on the duration and severity of hyponatremia and involves close monitoring and accurate fluid balance assessment. We will discuss in this article the basics of management, pitfalls to avoid in Hyponatremia and recommended approach based on literature review when reviewing a patient with Hyponatremia, firstly to enquire about the duration of Hyponatremia to differentiate acute from chronic as the threshold for treatment is different, following duration is assessment of severity (clinically by symptoms and signs as well as biochemistry) as severity will affect the management. Following duration and severity the acute physician should assess the volume status of the patient to hypovolemic, euvolemic or hypervolemic Hyponatremia which aids in reaching the possible cause of Hyponatremia and the right treatment.

A dedicated risk prediction model of 1-year mortality following endovascular aortic aneurysm repair involving the renal-mesenteric arteries

ObjectiveTreatment goals of prophylactic endovascular aortic repair of complex aneurysms involving the renal-mesenteric arteries (complex endovascular aortic repair [cEVAR]) include achieving both technical success and long-term survival benefit. Mortality within the first year after cEVAR likely indicates treatment failure owing to associated costs and procedural complexity. Notably, no validated clinical decision aid tools exist that reliably predict mortality after cEVAR. The purpose of this study was to derive and validate a preoperative prediction model of 1-year mortality after elective cEVAR. MethodsAll elective cEVARs including fenestrated, branched, and/or chimney procedures for aortic disease extent confined proximally to Ishimaru landing zones 6 to 9 in the Society for Vascular Surgery Vascular Quality Initiative were identified (January 2012 to August 2023). Patients (n = 4053) were randomly divided into training (n = 3039) and validation (n = 1014) datasets. A logistic regression model for 1-year mortality was created and internally validated by bootstrapping the AUC and calibration intercept and slope, and by using the model to predict 1-year mortality in the validation dataset. Independent predictors were assigned an integer score, based on model beta-coefficients, to generate a simplified scoring system to categorize patient risk. ResultsThe overall crude 1-year mortality rate after elective cEVAR was 11.3% (n = 456/4053). Independent preoperative predictors of 1-year mortality included chronic obstructive pulmonary disease, chronic renal insufficiency (creatinine >1.8 mg/dL or dialysis dependence), hemoglobin <12 g/dL, decreasing body mass index, congestive heart failure, increasing age, American Society of Anesthesiologists class ≥IV, current tobacco use, history of peripheral vascular intervention, and increasing extent of aortic disease. The 1-year mortality rate varied from 4% among the 23% of patients classified as low risk to 23% for the 24% classified as high risk. Performance of the model in validation was comparable with performance in the training data. The internally validated scoring system classified patients roughly into quartiles of risk (low, low/medium, medium/high and high), with 52% of patients categorized as medium/high to high risk, which had corresponding 1-year mortality rates of 11% and 23%, respectively. Aneurysm diameter was below Society for Vascular Surgery recommended treatment thresholds (<5.0 cm in females, <5.5 cm in males) in 17% of patients (n = 679/3961), 41% of whom were categorized as medium/high or high risk. This subgroup had significantly increased in-hospital complication rates (18% vs 12%; P = .02) and 1-year mortality (13% vs 5%; P < .0001) compared with patients in the low- or low/medium-risk groups with guideline-compliant aneurysm diameters (≥5.0 cm in females, ≥5.5 cm in males). ConclusionsThis validated preoperative prediction model for 1-year mortality after cEVAR incorporates physiological, functional, and anatomical variables. This novel and simplified scoring system can effectively discriminate mortality risk and, when applied prospectively, may facilitate improved preoperative decision-making, complex aneurysm care delivery, and resource allocation.

Clinical Use of Trabecular Bone Score: The 2023 ISCD Official Positions

Osteoporosis can currently be diagnosed by applying the WHO classification to bone mineral density (BMD) assessed by dual-energy x-ray absorptiometry (DXA). However, skeletal factors other than BMD contribute to bone strength and fracture risk. Lumbar spine TBS, a grey-level texture measure which is derived from DXA images has been extensively studied, enhances fracture prediction independent of BMD and can be used to adjust fracture probability from FRAX® to improve risk stratification. The purpose of this International Society for Clinical Densitometry task force was to review the existing evidence and develop recommendations to assist clinicians regarding when and how to perform, report and utilize TBS. Our review concluded that TBS is most likely to alter clinical management in patients aged ≥ 40 years who are close to the pharmacologic intervention threshold by FRAX. The TBS value from L1-L4 vertebral levels, without vertebral exclusions, should be used to calculate adjusted FRAX probabilities. L1-L4 vertebral levels can be used in the presence of degenerative changes and lumbar compression fractures. It is recommended not to report TBS if extreme structural or pathological artifacts are present. Monitoring and reporting TBS change is unlikely to be helpful with the current version of the TBS algorithm. The next version of TBS software will include an adjustment based upon directly measured tissue thickness. This is expected to improve performance and address some of the technical factors that affect the current algorithm which may require modifications to these Official Positions as experience is acquired with this new algorithm.

Effect of Race/Ethnicity on United States FRAX Calculations and Treatment Qualification: A Registry-Based Study.

Since 2008. the United States has had four race/ethnic fracture risk assessment tool (FRAX) calculators: White ("Caucasian"), Black, Asian, and Hispanic. The American Society for Bone and Mineral Research Task Force on Clinical Algorithms for Fracture Risk has been examining the implications of retaining race/ethnicity in the US FRAX calculators. To inform the Task Force, we computed FRAX scores according to each US calculator in 114,942 White, 485 Black, and 2816 Asian women (self-reported race/ethnicity) aged 50 years and older. We estimated treatment qualification based upon FRAX thresholds (3% for hip fracture, 20% for major osteoporotic fracture [MOF]). Finally, we examined measures for a hypothetical population-based FRAX calculator derived as the weighted mean for the US population based upon US Census Bureau statistics. With identical inputs, the highest FRAX measurements were found with the White FRAX calculator, lowest measurements with the Black calculator, and intermediate measurements for the Asian and Hispanic calculators. The percentage of women with FRAX scores exceeding the hip fracture treatment threshold was 32.0% for White, 1.9% for Black, and 19.7% for Asian women; the MOF treatment threshold was exceeded for 14.9% of White, 0.0% of Black, and 3.5% of Asian women. Disparities in treatment qualification were reduced after considering additional criteria (fracture history and dual-energy X-ray absorptiometry [DXA] T-score -2.5 or lower). When fracture risk was recalculated for non-White women using the White FRAX calculator, mean values for Asian women slightly exceeded those for White women but for Black women remained substantially below those for White women. When using a single population-based FRAX calculator, the mean probability of fracture and treatment qualification increased for non-White women across the age range. In summary, use of a single population-based FRAX calculator, rather than existing US race/ethnic FRAX calculators, will reduce differences in treatment qualification and may ultimately enhance equity and access to osteoporosis treatment. © 2023 The Authors. Journal of Bone and Mineral Research published by Wiley Periodicals LLC on behalf of American Society for Bone and Mineral Research (ASBMR).

Clinical study to determine the predictability of significant rebound hyperbilirubinemia in neonates after phototherapy and conditions likely to be associated with it: Prospective observational study in a teaching hospital in Eastern India.

Neonatal hyperbilirubinemia is defined as yellowish discoloration of the skin, conjunctive, and sclera from the elevated serum or plasma bilirubin in the newborn. The standard of care for the management of neonatal hyperbilirubinemia is phototherapy to prevent long-term neurological sequelae. The aim of this study was to ascertain the predictability of significant rebound hyperbilirubinemia (SRH) in neonates after phototherapy and the factors associated with it. Neonates ≥ 35 weeks of gestation, who received treatment for hyperbilirubinemia and admitted in our hospital from 15th of March 2019 to 15th of September 2020 were enrolled after taking parental consent. SRH was defined as bilirubin levels crossing the treatment threshold within 72 hours of phototherapy termination. Logistic regression analysis was used to identify the predictability of SRH. Out of 400 neonates treated with phototherapy, 10% developed SRH. Prematurity (Gestational age < 37 weeks), low birth weight (Birth weight < 2000 gram), ABO and Rh incompatibility, Glucose-6-phophate dehydrogenase deficiency (G6PD) deficiency, sepsis, and longer duration of primary phototherapy were found to be significantly associated with rebound hyperbilirubinemia. The probability of SRH increases for all American Academy of Paediatrics (AAP) risk categories as the gestational age decreases and total serum bilirubin at the stoppage of phototherapy increases. The presence of risk factors should be taken into account while planning discharge and follow-up of neonates admitted for neonatal hyperbilirubinemia to prevent long-term complication of bilirubin neurotoxicity.

A modeling study of the impact of treatment policies on the evolution of resistance in sea lice on salmon farms.

Salmonid aquaculture is an important source of nutritious food with more than 2 million tonnes of fish produced each year (Food and Agriculture Organisation of the United Nations, 2019). In most salmon producing countries, sea lice represent a major barrier to the sustainability of salmonid aquaculture. This issue is exacerbated by widespread resistance to chemical treatments on both sides of the Atlantic. Regulation for sea lice management mostly involves reporting lice counts and treatment thresholds, which depending on interpretation may encourage preemptive treatments. We have developed a stochastic simulation model of sea lice infestation including the lice life-cycle, genetic resistance to treatment, a wildlife reservoir, salmon growth and stocking practices in the context of infestation, and coordination of treatment between farms. Farms report infestation levels to a central organisation, and may then cooperate or not when coordinated treatment is triggered. Treatment practice then impacts the level of resistance in the surrounding sea lice population. Our simulation finds that treatment drives selection for resistance and coordination between managers is key. We also find that position in the hydrologically-derived network of farms can impact individual farm infestation levels and the topology of this network can impact overall infestation and resistance. We show how coordination and triggering of treatment alongside varying hydrological topology of farm connections affects the evolution of lice resistance, and thus optimise salmon quality within socio-economic and environmental constraints. Network topology drives infestation levels in cages, treatments, and hence treatment-driven resistance. Thus farmer behaviour may be highly dependent on hydrologically position and local level of infestation.

2951. Nursing home clinician characteristics associated with simulated urinary tract infection treatment decision-making

Abstract Background Antibiotic overuse and misuse are common in nursing homes (NHs). Urinary tract infection (UTI) is the most common indication for antibiotics in NHs. We conducted a clinical vignette experiment to identify clinician-level characteristics associated with suboptimal UTI treatment decision-making among a sample of NH clinicians. Methods Six clinical vignettes, two designed to assess clinicians’ treatment threshold and four designed to assess antibiotic choice decision-making, were created through an iterative process. NH clinicians were recruited nationally via professional organizations from December 2021 to April 2022. Clinical vignettes were shared using a web-based survey tool (Qualtrics) during which participants were asked if they would initiate antibiotics and which one. Participants provided demographic information, including degree, specialty training and NH experience. A multivariable logistic regression model with the decision to initiate antibiotic therapy (Yes/No) as the dependent variable and a multivariable ordinal regression model with number of vignettes for which a fluoroquinolone (FQ) was empirically chosen as the dependent variable were constructed in R. Results A total of 298 NH clinicians, whose characteristics are detailed in Table 1, responded to the survey. Despite national guidelines not recommending treatment for asymptomatic bacteriuiria (ASB), 10.4% of participants chose to initiate antibiotics when presented with the ASB vignette. Physicians (vs. APPs) and clinicians with ≥ 10 years NH experience were less likely to initiate antibiotics for ASB (Table 2). Empiric treatment was withheld for simple cystitis by 38.9% of clinicians, with APPs more likely to withhold antibiotics than physicians (Table 2). Across the four cases assessing empiric antibiotic choice, 38.3% of clinicians chose a FQ in at least one clinical case (Table 1). Clinicians with more years of NH-practice experience were more likely to prescribe a FQ (aOR 2.41, 95% CI 1.47-3.95, p&amp;lt; 0.01, Table 2). Respondent Characteristics Abbreviations: Advanced Practice Provider (APP); Asymptomatic bacteriuria (ASB); Fluoroquinolone (FQ), Nursing Home (NH). Effect of clinician credentials, training, and experience on antibiotic prescribing for urinary tract infection Abbreviations: * reference; Adjusted odds ratio (aOR); Confidence interval (CI); Asymptomatic bacteriuria (ASB); Advanced practitioner (APP) Conclusion Our results indicate that specific clinician characteristics are associated with suboptimal antibiotic prescribing. This suggests that tailoring stewardship interventions to clinician-specific factors may augment ongoing efforts to improve antibiotic use in NHs. Disclosures Lindsay Taylor, MD, MS, Merck: Grant/Research Support Robin Jump, MD, PhD, Merck: Grant/Research Support|Pfizer: Advisor/Consultant|Pfizer: Grant/Research Support

Neurodevelopmental outcome at 5.5 years in Dutch preterm infants born at 24–26 weeks’ gestational age: the EPI-DAF study

ObjectiveAfter lowering the Dutch threshold for active treatment from 25 to 24 completed weeks’ gestation, survival to discharge increased by 10% in extremely preterm live born infants. Now that this...

A Review of Various Clinical Practice Guidelines on Osteoporosis in the Last 5 Years.

Osteoporosis, also called the silent disease, affects the elderly with a significant contribution to their morbidity and mortality through fragility fractures. Most nations have developed their own guidelines on managing this condition. Clinical Practice Guidelines (CPGs) are the highest quality evidence documents on a particular topic prepared by expert panels. CPGs offer standardised recommendations on a particular topic. We looked at the CPGs of nations in the last five years and present the results of this review here. This review is divided into Risk assessment, prevention, diagnosis, Non pharmacological and pharmacological management with information from major CPGs only. Most CPGs agree on the broad principles of assessment , core risk factors, prevention and management with some finer differences in subtle aspects of assessment and management. There are differences in the use of screening tools based on the population numbers and affordability between nations. FRAX has been advocated for the screening with or without DEXA. Most CPGs use DEXA for confirmation of diagnosis. Intervention is based on FRAX scoring. Intervention thresholds vary. We discuss non-pharmacological management included diet and nutrition, calcium and Vitamin D, Exercise and physiotherapy, lifestyle changes and falls prevention. Pharmacological management included aspects of using different medications and their indications. The key agents recommended include Bisphosphonates, Teriparatide, Denosumab, SERMs, Hormone Replacement Therapy, and other agents including any drug holidays and duration of therapy. This review identified some key recommendations from CPGs from multiple nations in each of the above given aspects of osteoporosis.

EGS P23 A rare case of gallstone ileus post Roux-en-Y Gastric Bypass: Stone migration from large duodenal diverticulum

Abstract Background Small bowel obstruction following Roux-en-Y gastric bypass is common and is mainly attributed to adhesions or internal herniation. Intraluminal formation of stones, usually in areas of stasis due to the anatomical changes post-RYGB, and migration to the distal ileum to cause acute bowel obstruction is rare. Impacted stones at the duodenal diverticulum can trigger diverticular inflammation, back pressure to the common bile duct and pancreas resulting in abdominal pain, nausea and vomiting, intermittent derangement of liver enzymes and episodes of cholangitis and pancreatitis. The impaction at the distal ileum is an emergency requiring prompt diagnosis and intervention to prevent complications. Methods This is a case report of a 56-year-old female who presented at East Surrey Hospital in February 2023 with recurrent upper abdominal pain, nausea and vomiting. She previously underwent an open cholecystectomy for cholelithiasis and cholecystoduodenal fistula (2003) and a Roux-en-Y gastric bypass (2018). Her symptoms were initially thought to be secondary to inflammation and periduodenal abscess managed with antibiotics, but as time and scans (CT, MRCP, water-soluble contrast, gastroscopy) progressed without resolution of her symptoms it became evident that she had developed mechanical bowel obstruction. We described her case and the diagnostic challenges leading to the final surgical management. Results To investigate the patient’s symptoms, her intermittently raised inflammatory markers, deranged liver enzymes and amylase a series of radiological examinations was rperformed. Initial CT scan showed an inflamed large duodenal (D3) diverticulum and fluid filled proximal duodenum. Subsequent MRCP demonstrated dilated common bile duct and intrahepatic ducts without any ductal stone. Repeat CT scan two weeks later, confirmed small bowel obstruction due to a heterogenous bolus at the ileocecal valve with resolution of the duodenal inflammation and dilatation. The patient underwent a laparoscopic extraction of a stone impacted at the ileocecal valve causing small bowel obstruction and recovered well. Conclusions Even though small bowel obstruction due to stone aggregation is uncommon post-RYGB, a high index of suspicion for the diagnosis and a low threshold for early laparoscopic intervention can prevent further serious complications. Reporting these cases in literature offers a guidance for the workup and management of these unusual scenarios amongst surgical teams and improves patients’ outcomes.

EGS P04 Recent ten year experience of Boerhaave’s Syndrome Management in a tertiary Oesophago-gastric Surgery Centre

Abstract Background Oesophageal Perforation (OP) is a low incidence, high complexity gastrointestinal surgical emergency with associated high mortality rates. A consequence of UK centralisation of oesophago-gastric (OG) cancer surgery is passive centralisation of OG surgical emergencies leading to reduced mortality for OP and lower threshold for surgical intervention by high volume OG cancer surgeons. Boerhaave's Syndrome characterised by Mackler’s Triad (vomiting, thoracic pain and subcutaneous emphysema) represents 30% of OP. UCLH has an OG surgery catchment population of 3 million. We present our experience of managing Boerhaave’s syndrome as an OG cancer centre with a dedicated OG Consultant on-call rota. Methods A retrospective review of electronic health records of all adult patients with a radiological diagnosis of OP over a 10 year period from 01/01/2013 to 31/12/2022) at our institution was performed. The inclusion criteria were adult patients with a clinical and radiological diagnosis of Boerhaave’s syndrome. Those with OP due to malignancy, endoscopic, or foreign body perforation were excluded from further analysis. The primary outcome measure was 90-day mortality and the secondary outcome measures were length of stay and reintervention rate. Results 41 patients with Boerhaave’s syndrome were identified (31 male, 10 female) with median age of 62 (46 - 71). 17 (41.5%) patients presented directly to our institution and 24 (58.5%) were transferred from other hospitals. Primary intervention was surgical in 31 (75.6%), endoscopic in 3 (7.3%) and conservative in 7 (17.1%) patients respectively. Overall 90-day mortality was 12.2% but 6.5% in the surgically managed group. Median length of stay was 58 days (22 - 70). 9 patients had reintervention – 7 (17.1%) had a thoracotomy/thoracoscopic surgery for intrathoracic collections and 2 patients (9.8%) had endoscopic intervention. Conclusions This is a report of the experience of managing Boerhaave’s syndrome in a high volume tertiary OG centre. A favourable 90-day mortality rate of 12.2% compares to 38.8% described in a previous UK cohort is likely a result of management in a tertiary centre with appropriate multidisciplinary infrastructure to manage complex patients and provide a consistently high level of perioperative care. The lower mortality rate (6.5%) in the operatively managed group is likely due to patient selection and surgical techniques honed from familiarity with complex cancer and benign oesophageal surgery and working as part of an effective multidisciplinary team.

Implementation of eat, sleep, console for Neonatal Opioid Withdrawal Syndrome (NOWS): A quality improvement project

BackgroundThe opioid abuse crisis has caused a 6-fold increased incidence of neonatal opioid withdrawal syndrome (NOWS) from 2000 to 2017. The Finnegan Neonatal Abstinence Scoring System (FNASS) has been used to score withdrawal symptoms since 1975. New research using the Eat, Sleep, Console (ESC) assessment and model of care has improved the care of infants with in-utero exposure to opioids. MethodsThe QI project at 2 hospitals compared 12 months of retrospective data to a prospective 12-month trial of ESC implementation. One hospital also compared ESC and FNASS simultaneously. Nurses and providers received training and education. ResultsIn the baseline period, 142 infants were scored for withdrawal, with an ALOS of 7.6 days, an average NICU LOS of 118.7 h (4.9 days), and 32 required pharmacologic treatment with an average length of treatment of 369.8 h (15.4 days). In the study period, 142 were assessed for withdrawal, with a decreased ALOS of 6.5 days (p = 0.2287), a decreased NICU LOS of 89.6 h (p = 0.2295), and 10 required pharmacologic treatment (p = 0.00024) with an increased average length of treatment of 387.3 h (p = 0.8609). Out of 71 infants assessed simultaneously with FNASS and ESC, 37 had FNASS scores that met the threshold for pharmacologic treatment, and only 6 infants received pharmacologic treatment. ConclusionImplementation of ESC improves the care of infants and reduces hospital stays and the need for pharmacologic intervention in the management of NOWS. It optimizes the infant's functioning through nonpharmacologic care provided by parent(s) reserving pharmacologic treatment only for those infants unable to eat, sleep, or console.

Digital PCR to Measure SARS-CoV-2 RNA, Variants, and Outcomes in Youth.

The role of SARS-CoV-2 viral load in predicting contagiousness, disease severity, transmissibility, and clinical decision-making continues to be an area of great interest. However, most studies have been in adults and have evaluated SARS-CoV-2 loads using cycle thresholds (Ct) values, which are not standardized preventing consistent interpretation critical to understanding clinical impact and utility. Here, a quantitative SARS-CoV-2 reverse-transcription digital PCR (RT-dPCR) assay normalized to WHO International Units was applied to children at risk of severe disease diagnosed with COVID-19 at St Jude Children's Research Hospital between March 28, 2020, and January 31, 2022. Demographic and clinical information from children, adolescents and young adults treated at St Jude Children's Research Hospital were abstracted from medical records. Respiratory samples underwent SARS-CoV-2 RNA quantitation by RT-dPCR targeting N1 and N2 genes, with sequencing to determine the genetic lineage of infecting virus. Four hundred and sixty-two patients aged 0-24 years (median 11 years old) were included during the study period. Most patients were infected by the omicron variant (43.72%), followed by ancestral strain (22.29%), delta (13.20%) and alpha (2.16%). Viral load at presentation ranged from 2.49 to 9.14 log10 IU/ml, and higher viral RNA loads were associated with symptoms (OR 1.32: CI95% 1.16-1.49) and respiratory disease (OR 1.23: CI95% 1.07-1.41). Viral load did not differ by SARS-CoV-2 variant, vaccination status, age, or baseline diagnosis. SARS-CoV-2 RNA loads predict the presence of symptomatic and respiratory diseases. The use of standardized, quantitative methods is feasible, allows for replication, comparisons across institutions, and has the potential to facilitate consensus quantitative thresholds for risk stratification and treatment.