Use of Closed Incision Negative Pressure Therapy (ciNPT) in Breast Reconstruction Abdominal Free Flap Donor Sites

Background: Closed incision negative pressure therapy (ciNPT) may reduce the rate of wound complications and promote healing of the incisional site. We report our experience with this dressing in breast reconstruction patients with abdominal free flap donor sites. Methods: A retrospective cohort study was conducted of all patients who underwent breast reconstruction using abdominal free flaps (DIEP, MS-TRAM) at a single institution (Royal Melbourne Hospital, Victoria) between 2016 and 2021. Results: 126 female patients (mean age: 50 ± 10 years) were analysed, with 41 and 85 patients in the ciNPT (Prevena) and non-ciNPT (Comfeel) groups, respectively. There were reduced wound complications in almost all outcomes measured in the ciNPT group compared with the non-ciNPT group; however, none reached statistical significance. The ciNPT group demonstrated a lower prevalence of surgical site infections (9.8% vs. 11.8%), wound dehiscence (4.9% vs. 12.9%), wound necrosis (0% vs. 2.4%), and major complication requiring readmission (2.4% vs. 7.1%). Conclusion: The use of ciNPT for abdominal donor sites in breast reconstruction patients with risk factors for poor wound healing may reduce wound complications compared with standard adhesive dressings; however, large scale, randomised controlled trials are needed to confirm these observations. Investigation of the impact of ciNPT patients in comparison with conventional dressings, in cohorts with equivocal risk profiles, remains a focus for future research.

Hospital in the Home Delivery of Supportive Care for Autologous Stem Cell Transplantation: A Novel Single Centre Patient Focused Approach

Introduction: High dose therapy with Autologous Stem Cell Transplantation (ASCT) has traditionally been performed as an inpatient procedure. However, with improvements in care and patient selection it is possible to safely deliver conditioning chemotherapy and supportive care in an Daytherapy setting (Kodad SG et al., 2019). While deemed an "outpatient procedure" this method is often delivered on large day units which requires the patient to attend daily, often only spending overnight at home. To reduce these daily visits the Clinical Haematology Department of Peter MacCallum and Royal Melbourne Hospital (CHD) in collaboration with the Hospital in the Home department (HIHD) at Royal Melbourne Hospital developed an innovative program to safely deliver supportive care for Myeloma Patients undergoing ASCT at home (HIH-ASCT). The HIHD is an acute inpatient unit that exists as a "virtual" inpatient ward. Patients are reviewed daily by a HIHD Doctor with twice daily visits by a HIHD Nurse for administration of supportive care measures (e.g. intravenous electrolyte and fluid replacement) in the comfort of their home. Here we report on the safety outcomes of our HIH-ASCT program, specifically patient complications and outcomes. Methods: A retrospective case note audit identified 54 consecutive HIH-ASCT patients who received HIH-ASCT for Myeloma between 2018 and 2021 under HIHD. Patients were eligible for our HIH-ASCT program if they had Myeloma requiring ASCT; an ECOG ≤1; had not been admitted to ICU previously; lived within 30 minutes drive of the hospital; had a safe home environment (for both the patient and visiting staff) and a carer who could stay with them throughout their HIH-ASCT. While undertaking HIH-ASCT patients did not receive prophylactic antibiotics and they were not routinely given GCSF to minimise the risk of engraftment fevers. Results: Of those treated as HIH-ASCT patients the median age was 60 years (range 33-72). 39% patients were female (n=21) and 61% male (n=33). Underlying disease groups included IgA (n=8; 15%), IgG (n=35; 64%), IgM (n=1; 2%), Light Chain (n=9; 17%) and Oligosecretory (n=1; 2%). 43% had High-risk Cytogenetics. ASCT-1 (n=48; 88%), ASCT-2 (n=5; 9%) and one patient underwent a ASCT-Tandem (both under HIHD). Conditioning regimes included Melphalan200 (n=37; 68%), Velcade-Melphan200 (n=13; 23%) and Carfilzomib-Melphalan200 (n=5; 9%). The average stem dose was 3.80 x10 6/kg (range 2.14-8.4). Median time to Neutrophil engraftment was 12 days (range = 10-21) and Platelet engraftment 12 days (range = 8-18). The total number of bed days saved through the HIH-ASCT program was 466, with a median length of stay (LOS) under the HIHD team of 9 days (Range = 3-14). In addition, 3 patients were not readmitted to the hospital (6%) and were discharged directly from the HIHD team. The most common reason for readmission was fever (n=43; 80%), of which only 11 were culture positive, and diarrhoea (n=44; 81%). Only 1 patient required intensive care support. There were no deaths. The median LOS as an inpatient once readmitted was 6 days (range = 2-27). In regards to cost savings, an acute inpatient bed under the CHD is approximately $1300 USD versus $900 USD per day for a HIHD bed. This equated to a potential cost saving for the CHD of approximately $186000 USD. Conclusion: The delivery of supportive care for patients undergoing HIH-ASCT in is both safe and effective with comparable outcomes for what would be expected for an inpatient cohort. It resulted in a median of 9 bed days saved per patient (total number of bed days saved = 466). This is important as it allowed our department to increase bed capacity across the unit without the associated costs of building a new ward. In addition, during our COVID-19 outbreaks the HIH-ASCT program has allowed us to continue to deliver optimal patient care, while minimising the infection risk for our patients. More recently we have introduced remote monitoring (e.g. temperature, heart rate, blood pressure and oxygen saturations) with video reviews with the aim of increasing the capacity of our HIHD and further improving the HIH-ASCT experience for our patients. Disclosures Routledge: Amgen: Honoraria, Speakers Bureau; Sandoz: Consultancy, Honoraria, Speakers Bureau; BMS: Honoraria. Harrison: Amgen: Consultancy, Honoraria, Membership on an entity's Board of Directors or advisory committees, Research Funding, Speakers Bureau; Abbvie: Consultancy, Honoraria, Membership on an entity's Board of Directors or advisory committees, Research Funding, Speakers Bureau; GSK: Consultancy, Honoraria, Membership on an entity's Board of Directors or advisory committees, Research Funding, Speakers Bureau; Eusa: Consultancy, Honoraria, Speakers Bureau; Takeda: Consultancy, Honoraria, Membership on an entity's Board of Directors or advisory committees; Celgene/ Juno/ BMS: Consultancy, Honoraria, Membership on an entity's Board of Directors or advisory committees, Research Funding, Speakers Bureau; Terumo BCT: Consultancy, Honoraria; Janssen Cilag: Consultancy, Honoraria, Membership on an entity's Board of Directors or advisory committees, Research Funding, Speakers Bureau; Novartis: Consultancy, Honoraria, Membership on an entity's Board of Directors or advisory committees, Research Funding, Speakers Bureau; Sanofi: Consultancy, Honoraria, Membership on an entity's Board of Directors or advisory committees, Research Funding, Speakers Bureau; Roche/Genentech: Consultancy, Honoraria, Membership on an entity's Board of Directors or advisory committees, Research Funding, Speakers Bureau; Haemalogix: Consultancy, Honoraria, Membership on an entity's Board of Directors or advisory committees, Research Funding, Speakers Bureau. Ritchie: CRISPR Therapeutics: Research Funding; Amgen Inc: Honoraria, Research Funding; Novartis: Honoraria; CSL: Honoraria; BMS: Research Funding; Takeda: Research Funding.

404 - Factors associated with diagnostic delay in younger-onset dementia iagnostic delay in younger-onset dementia

Background:Younger-onset dementia (YOD) is a dementia of which symptom onset occurs at 65 years or less. There are approximately 27000 people in Australia with a YOD and the causes can range from Alzheimer’s dementia (AD), frontotemporal dementia (FTD), metabolic and genetic disorders. It is crucial to obtain a definitive diagnosis as soon as possible in order for appropriate treatment to take place and future planning. Previous research has reported 4-5 years to get a diagnosis (Draper et al. 2016) and factors associated with delay include younger age (van Vliet et al. 2013) and psychiatric comorbidity (Draper et al. 2016). We report on our experience of diagnostic delay.Methods:This was a retrospective file review of 10 years of inpatients from Neuropsychiatry, Royal Melbourne Hospital, Australia. Neuropsychiatry is a tertiar service which provides assessment of people with cognitive, psychiatric, neurological and behavioural symptoms. Factors such as age of onset, number of services/specialists seen were extracted and analysed using multivariate regression.Results:Of the 306 individual patients who had a YOD, these were grouped into the major dementia groups (such as AD, FTD, Huntington’s disease, vascular dementia, alcohol-related dementia). The most commonly occurring dementia was AD (24.2%), followed by FTD (23%). There was an average of 3.7 years (SD=2.6), range 0.5-15 years, of delay to diagnosis. Cognitive impairment, as measured using the Neuropsychiatry Unit Cognitive Assessment (NUCOG) was moderate, with a mean score of 68.9 (SD=17.9). Within the groups of dementia, patients with Niemann-Pick type C (NPC) had the longest delay to diagnosis F(11,272)=3.677, p<0.0001, with 6.3 years delay. Age of symptom onset and number of specialists/services seen were the significant predictors of delay to diagnosis F(7, 212)=3.975, p<0.001, R211.6.Discussion and conclusions:This was an eclectic group of people with YOD. The results of regression suggests that there are other factors which contribute to the delay, which are not just demographic related. Rarer disorders, such as NPC which present at an early age, and present with symptoms that are not cognitive in nature, can contribute to diagnostic delay.

Automated Inter-Ictal Epileptiform Discharge Detection from Routine EEG

Epilepsy is the most common neurological disorder. The diagnosis commonly requires manual visual electroencephalogram (EEG) analysis which is time-consuming. Deep learning has shown promising performance in detecting interictal epileptiform discharges (IED) and may improve the quality of epilepsy monitoring. However, most of the datasets in the literature are small (n≤100) and collected from single clinical centre, limiting the generalization across different devices and settings. To better automate IED detection, we cross-evaluated a Resnet architecture on 2 sets of routine EEG recordings from patients with idiopathic generalized epilepsy collected at the Alfred Health Hospital and Royal Melbourne Hospital (RMH). We split these EEG recordings into 2s windows with or without IED and evaluated different model variants in terms of how well they classified these windows. The results from our experiment showed that the architecture generalized well across different datasets with an AUC score of 0.894 (95% CI, 0.881–0.907) when trained on Alfred’s dataset and tested on RMH’s dataset, and 0.857 (95% CI, 0.847–0.867) vice versa. In addition, we compared our best model variant with Persyst and observed that the model was comparable.

The prevalence of epileptic seizures in multiple sclerosis in a large tertiary hospital in Australia

Rationale To determine the prevalence of epileptic seizures in multiple sclerosis (MS) at an Australian tertiary hospital and to define their clinical features. Methods We retrospectively analysed adult patients at the Royal Melbourne Hospital electronically identified to have ICD codes for MS and seizures and/or epilepsy between 1996 to 2019, utilising paper and electronic-based records. Results Of the 2,125 MS patients identified, 16 (0.75%) experienced epileptic seizures during a mean follow-up period of 12.9 years. Median age of MS diagnosis (SD) was 38 (9.3) years. Four patients had relapsing remitting MS (25%), 10 secondary progressive MS (63.5%), and 2 primary progressive MS (12.5%). More than two-thirds of patients had seizure onset following the diagnosis of MS, and the majority of these had advanced disease (approximate EDSS >6) at the time of seizure onset. Focal onset-seizures occurred in 87.5% of patients with seizures. Conclusion The estimated prevalence of seizures in our cohort was lower than in previous studies (0.75 vs 2–4%). In most cases, seizures occurred after the diagnosis of MS in the context of advanced disease. Further studies are required to determine if MS disease modifying treatments reduce the risk of seizures in this cohort.

Outcomes following operatively managed acetabular fractures in patients aged 60 years and older

Aims Acetabular fractures in older adults lead to a high risk of mortality and morbidity. However, only limited data have been published documenting functional outcomes in such patients. The aims of this study were to describe outcomes in patients aged 60 years and older with operatively managed acetabular fractures, and to establish predictors of conversion to total hip arthroplasty (THA). Methods We conducted a retrospective, registry-based study of 80 patients aged 60 years and older with acetabular fractures treated surgically at The Alfred and Royal Melbourne Hospital. We reviewed charts and radiological investigations and performed patient interviews/examinations and functional outcome scoring. Data were provided by the Victorian Orthopaedic Trauma Outcomes Registry (VOTOR). Survival analysis was used to describe conversion to THA in the group of patients who initially underwent open reduction and internal fixation (ORIF). Multivariate regression analyses were performed to identify factors associated with conversion to THA. Results Seven patients (8.8%) had died at a median follow-up of 18 months (interquartile range (IQR) 12 to 25), of whom four were in the acute THA group. Eight patients (10%) underwent acute THA. Of the patients who underwent ORIF, 17/72 (23.6%) required conversion to THA at a median of 10.5 months (IQR 4.0 to 32.0) . After controlling for other factors, transport-related cases had an 88% lower rate of conversion to THA (hazard ratio (HR) 0.12, 95% confidence interval (CI) 0.02 to 0.91). Mean standardized Physical Component Summary Score (PCS-12) of the 12-Item Short Form Health Survey (SF-12) was comparable with the general population (age-/sex-matched) by 12 to 24 months. Over half of patients working prior to injury (14/26) returned to work by six months and two-thirds of patients (19/27) by 12 months. Conclusion Patients over 60 years of age managed operatively for displaced acetabular fractures had a relatively high mortality rate and a high conversion rate to THA in the ORIF group but, overall, patients who survived had mean PCS-12 scores that improved over two years and were comparable with controls. Cite this article: Bone Joint J 2020;102-B(12):1735–1742.

A hospital-wide response to multiple outbreaks of COVID-19 in Health Care Workers Lessons learned from the field

Objective: To describe COVID-19 infections amongst healthcare workers (HCWs) at the Royal Melbourne Hospital from 1st July to 31st August 2020 Design: Prospective observational study Setting: A 550 bed tertiary referral hospital in metropolitan Melbourne Participants: All HCWs identified with COVID-19 infection in the period of interest Results: 262 HCW infections were identified over 9 weeks. 68.3% of infected HCWs were nurses and the most affected locations were the geriatric and rehabilitation wards. Clusters of infection occurred in staff working in wards with patients known to have COVID-19 infection. Staff infections peaked when COVID-19 infected inpatient numbers were highest, and density of patients and certain patient behaviours were noted by staff to be linked to possible transmission events. Three small outbreaks on other wards occurred but all were recognised and brought under control. Availability of rapid turn-around staff testing, and regular review of local data and obtaining feedback from staff helped identify useful interventions which were iteratively implemented. Attention to staff wellbeing was critical to the response and a comprehensive support service was implemented. Conclusion(s): A comprehensive multimodal approach to containment was instituted with iterative refinement based on frontline workers observations and ongoing analysis of local data in real time.

Clinical effectiveness of a silicone foam dressing for the prevention of heel pressure ulcers in critically ill patients: Border II Trial

• Objective: Critically ill patients are at high risk of developing pressure ulcers (PU), with the sacrum and heels being highly susceptible to pressure injuries. The objective of our study was to evaluate the clinical effectiveness of a new multi-layer, self-adhesive soft silicone foam heel dressing to prevent PU development in trauma and critically ill patients in the intensive care unit (ICU). • Method: A cohort of critically ill patients were enrolled at the Royal Melbourne Hospital. Each patient had the multi-layer soft silicone foam dressing applied to each heel on admission to the emergency department. The dressings were retained with a tubular bandage for the duration of the patients' stay in the ICU. The skin under the dressings was examined daily and the dressings were replaced every three days. The comparator for our cohort study was the control group from the recently completed Border Trial. • Results: Of the 191 patients in the initial cohort, excluding deaths, loss to follow-up and transfers to another ward, 150 patients were included in the final analysis. There was no difference in key demographic or physiological variables between the cohorts, apart from a longer ICU length of stay for our current cohort. No PUs developed in any of our intervention cohort patients compared with 14 patients in the control cohort (n=152; p<0.001) who developed a total of 19 heel PUs. • Conclusion: We conclude, based on our results, that the multi-layer soft silicone foam dressing under investigation was clinically effective in reducing ICU-acquired heel PUs. The findings also support previous research on the clinical effectiveness of multi-layer soft silicone foam dressings for PU prevention in the ICU.