Predicting surgical outcome in posterior retroperitoneoscopic adrenalectomy with the aid of a preoperative nomogram

Background Posterior retroperitoneoscopic adrenalectomy (PRA) has several advantages over transperitoneal laparoscopic adrenalectomy (TLA) regarding operative time, blood loss, postoperative pain, and recovery. However, it can be a technically challenging procedure. To improve patient selection for PRA, we developed a preoperative nomogram to predict operative time. Methods All consecutive patients with tumors of ≤ 7 cm and a body mass index (BMI) of < 35 kg/m2 undergoing unilateral PRA between February 2011 and March 2020 were included in the study. The primary outcome was operative time as surrogate endpoint for surgical complexity. Using ten patient variables, an optimal prediction model was created, with a best subsets regression analysis to find the best one-variable up to the best seven-variable model. Results In total 215 patients were included, with a mean age of 52 years and mean tumor size of 2.4 cm. After best subsets regression analysis, a four-variable nomogram was selected and calibrated. This model included sex, pheochromocytoma, BMI, and perinephric fat, which were all individually significant predictors. This model showed an ideal balance between predictive power and applicability, with an R2 of 38.6. Conclusions A four-variable nomogram was developed to predict operative time in PRA, which can aid the surgeon to preoperatively identify suitable patients for PRA. If the nomogram predicts longer operative time and therefore a more complex operation, TLA should be considered as an alternative approach since it provides a larger working space. Also, the nomogram can be used for training purposes to select patients with favorable characteristics when learning this surgical approach.

Surgical outcomes of endoscopic transsphenoidal pituitary adenoma resection in elderly versus younger patients

Introduction Pituitary adenomas (PAs) are one of the most common type of intracranial neoplasm with increased incidence in elderly patients. The outcomes of endoscopic transsphenoidal surgery (ETS) specifically on elderly patients remains unclear. Methods We performed a retrospective cohort study to compare elderly patients (age 65 years) with non-elderly patients (age <65 years) who underwent ETS for PA from January 2005 to December 2021. Surgical outcomes, including extent of resection, complication profile, length of stay, and endocrinopathy rates, were compared between elderly and non-elderly patients. Results A total of 690 patients were included with 197 (29%) being elderly. Elderly patients showed higher rates of hypertension (p<0.05), myocardial infarction (p<0.01), and atrial fibrillation (p=0.01) but not other comorbidities. Elderly patients also had more frequent optic nerve involvement (72% of cases vs. 61%, p=0.01). Tumor characteristics and other patient variables were otherwise similar between younger and elderly patients. Postoperative CSF leaks (2% vs. 2%, p=0.8), 30-day readmission, reoperation, postoperative complications, and postoperative endocrinopathies were similar between younger and older patients. Subdividing patients into age <65, 65-79, and >80 also did not demonstrate a worsening of surgical outcomes with age. Conclusion For well selected elderly patients in experienced endoscopic skull base centers, good surgical outcomes similarly to younger patients may be achieved.

Predictors of Aspiration and Silent Aspiration in Patients With New Tracheostomy

Purpose Hospitalized, medically complex patients with new tracheostomy are at risk for aspiration. This study reports incidence of aspiration in these patients with new tracheostomy and investigates possible risk factors for aspiration and silent aspiration in this patient population. Method Retrospective review of instrumental swallowing evaluations from hospitalized inpatients with new tracheostomy tubes to determine frequency of aspiration and silent aspiration and patient factors associated with aspiration. Patient variables including sex, age, reason for hospital admission, reason for tracheostomy, duration of intubation, time since tracheostomy placement, and tracheostomy cuff and cap status were examined as possible risk factors for aspiration and silent aspiration. Results Of the 272 patients with new tracheostomies who underwent instrumental swallowing evaluation, 59% aspirated on at least one consistency. Odds of aspiration were twice as high in patients with uncapped tracheostomy compared to closed (i.e., cap or speaking valve in place). Odds of aspiration were 3.4 times greater with patients who underwent tracheostomy for an oropharyngeal etiology (oropharyngeal or laryngeal tumor, surgery, or infection). Of the patients who aspirated, 81% aspirated silently on at least one consistency. Odds of silent aspiration was 4.5 greater with an uncapped tracheostomy. Conclusions Medically complex patients with new tracheostomy are at risk for aspiration and benefit from instrumental swallowing evaluations. Future prospective research is warranted to determine contributing factors responsible for this risk. Lastly, speech pathologists play an important role in the patient’s recovery.

746 Single-Centre Experience with Three Metallic Ureteric Stents (Allium URS, Memokath-051 and Resonance) for Chronic Ureteric Obstruction

Aim To evaluate efficacy of Allium URS, Memokath 051 and Resonance metallic ureteric stents as an alternative to polymer stents/nephrostomy in managing chronic ureteric obstruction (CUO). Method Retrospective analysis of consecutive patients with CUO managed with Allium URS, Memokath-051 or Resonance (September 2015/July 2020). Baseline patient variables (age, gender, underlying aetiology, ASA) and stricture characteristics (length, level, continuity) were recorded. Intra- and post-operative clinical and radiological follow-up assessments at 6 weeks, 3 months and then every 6 months, as well as any emergency attendances, were reviewed for placement success, stent complications, serum creatinine, and mortality. Outcomes included placement success rate, functional stent survival, and mean renal function. Results Overall, 129 stent insertion episodes (SIEs) (Allium URS: 23, Memokath 051: 48, Resonance: 58) occurred in 76 patients (Allium URS: 16; Memokath-051: 31; Resonance: 29). Placement success was high (Allium URS: 95.7%; Memokath-051 and Resonance: both 100%). Median functional stent survival was 11.4 months for Allium URS, 5.5 months for Memokath-051 and 11.7 months for Resonance. 47.8% of Allium URS SIEs (11/23), 64.6% of Memokath-051 SIEs (31/48) and 19% of Resonance SIEs (11/58) experienced complication (most frequently obstruction followed by migration and infection). There were no complications for Resonance SIEs for benign indication. In the first year following SIE, serum creatinine ranged from +21.3% to + 46.7% for Allium URS, -7.8% to + 8.9% for Memokath-051, and -9.4% to + 27.3% for Resonance. Conclusions Allium URS, Memokath 051 and Resonance metallic ureteric stents are all viable management options of CUO. Resonance was particularly efficacious for patients with benign aetiology.

Effect of Patient Clinical Variables in Osteoporosis Classification Using Hip X-rays in Deep Learning Analysis

Background and Objectives: A few deep learning studies have reported that combining image features with patient variables enhanced identification accuracy compared with image-only models. However, previous studies have not statistically reported the additional effect of patient variables on the image-only models. This study aimed to statistically evaluate the osteoporosis identification ability of deep learning by combining hip radiographs with patient variables. Materials andMethods: We collected a dataset containing 1699 images from patients who underwent skeletal-bone-mineral density measurements and hip radiography at a general hospital from 2014 to 2021. Osteoporosis was assessed from hip radiographs using convolutional neural network (CNN) models (ResNet18, 34, 50, 101, and 152). We also investigated ensemble models with patient clinical variables added to each CNN. Accuracy, precision, recall, specificity, F1 score, and area under the curve (AUC) were calculated as performance metrics. Furthermore, we statistically compared the accuracy of the image-only model with that of an ensemble model that included images plus patient factors, including effect size for each performance metric. Results: All metrics were improved in the ResNet34 ensemble model compared with the image-only model. The AUC score in the ensemble model was significantly improved compared with the image-only model (difference 0.004; 95% CI 0.002–0.0007; p = 0.0004, effect size: 0.871). Conclusions: This study revealed the additional effect of patient variables in identification of osteoporosis using deep CNNs with hip radiographs. Our results provided evidence that the patient variables had additive synergistic effects on the image in osteoporosis identification.

Use of olanzapine compared with clozapine for treatment-resistant schizophrenia in a real-world setting: nationwide register-based study

Background Clozapine is generally considered as the treatment of choice for patients with treatment-resistant schizophrenia (TRS). However, its superiority has recently been questioned because olanzapine has been suggested as non-inferior to clozapine in its effectiveness. Aims We aimed to investigate the current status of clozapine prescriptions to identify any disparity between clinical guidelines and real-world practices. Method In this study, we utilised the Health Insurance Review Agency database in the Republic of Korea to investigate the real-world effectiveness of clozapine for patients with TRS. We compared differences in patient variables before and after clozapine administration, and we also performed survival analyses for both psychiatric admissions and emergency room visits among patients who used clozapine or olanzapine. Results This study investigated an incident cohort of 64 442 patients, and 2338 patients have been prescribed clozapine. Of these, 998 patients had TRS. In survival analysis, clozapine showed a worse survival rate for psychiatric admissions than olanzapine (hazard ratio 0.615). We also identified that clinicians tended to try a number of antipsychotics, as recommended, before starting patients on clozapine. Conclusions In conclusion, we found that olanzapine led to higher survival rates for psychiatric admissions than clozapine. Thus, considering the risk of serious adverse effects, clozapine may be used conservatively. Considering several studies advocating superior efficacy of clozapine, further studies with extensive data are recommended.

An International Survey of the Concept of Effective Psychodynamic Treatment During the Pandemic

Introduction: Most psychotherapists had no choice during the COVID-19 pandemic but to offer teletherapy in order to provide needed treatment. Several psychoanalytic theorists wondered if the very concept of treatment would change without an embodied relationship in an office setting. Methods: To attempt to understand the current concept of effective psychodynamic treatment in the new norm of teletherapy, we surveyed practitioners from 56 countries and regions who remotely treated patients psychodynamically during the beginning months of the pandemic. We asked the practitioners to rank six factors felt to be important to psychodynamic treatment: use of the couch during sessions, session in-office or via teletherapy, cultural similarity between therapist and patient, number of sessions a week, patient factors (motivation, insightfulness, and high functioning) and therapist factors (empathy, warmth, wisdom, and skillfulness). Results: We received 1,490 survey responses. As predicted, we found that the therapist and patient variables were considered much more important (both tied as highest rankings) to effective treatment than any of the other variables, including if the therapy was in-office or by teletherapy. Discussion: Psychodynamic practitioners worldwide confirmed that the empathy, warmth, wisdom, and skillfulness of the therapist and the motivation, insightfulness, and level of functioning of the patient are most important to treatment effectiveness regardless if the treatment is remote or embodied.

Vexing visits: Variables correlating with physician perceptions of patients as “difficult” and overall enjoyment of their delivery of primary ambulatory care

All physicians experience some patients described as “difficult.” Their prevalence negatively impacts work satisfaction. Prior research identified factors present when physicians perceive patients as difficult. Numerous variables are unrelated to vexing patient visits. Three additive patient characteristics predict difficult encounters: 1) depressive or anxiety comorbidity, 2) polysymptomatic patients, and 3) high symptom severity. The sole physician variable was their score on the Physician Belief Scale (PBS) which quantifies negative attitudes towards psychosocial problems. When all three patient predictors exist, high PBS scorers judge twice as many patients as difficult. Five clinic milieu variables correlated weakly with clinic satisfaction among primary care residents. They are: 1) minimal role conflict, 2) autonomy, 3) collegiality, 4) encouragement of professional growth, and 5) work group loyalty. “Positive affect” was among the strongest physician variables but the author labeled it a confounding variable. Finally, a small “n” QI study conducted in this author’s residency explored the role of physician affectivity and identified additional physician characteristics and clinic milieu factors correlating with overall enjoyment of ambulatory clinic practice. Surprisingly, none of the five previously identified clinic milieu variables correlated directly with resident clinic satisfaction. “Supportive staff cohesion” was one milieu variable that correlated significantly with clinic satisfaction. Resident affective characteristics that significantly reduced clinic satisfaction were “hostility” and “negative affectivity.” “Joviality” was positively related to clinic satisfaction. While patient variables are uncontrollable, it is plausible that by physicians changing their beliefs and affectivity the percentage of vexing visits could be cut in half improving work satisfaction.

Partial Flap Loss in Gender Affirming Phalloplasty

Background Flaps used in phalloplasty are larger than described for other indications, with a design that is tubularized up to two times. While the incidence of partial flap loss (PFL) is well described, current literature lacks granularity comparing donor sites and techniques with minimal discussion of etiology and management. The purpose of this study was to review our experience with PFL in phalloplasty. Methods This was a retrospective cohort study of patients who underwent phalloplasty by a single surgeon at a single institution between 2016 and 2020. PFL was defined as any patient requiring sharp excision of necrotic tissue and reconstruction. Patient variables (demographics, body mass index, American Society of Anesthesiologists physical status classification, comorbidities), flap variables (donor site, design, dimensions, perforator number) and intraoperative variables (use of vasopressors, intraoperative fluid volume) were collected. Results Of 76 phalloplasties, 6 patients suffered PFL (7.9%). 5/6 patients were radial forearm free flap tube-within-tube (TWT) and 1/5 patients were pedicled anterolateral thigh TWT. 4/6 cases involved the shaft only and were treated with excision ± Integra and full-thickness skin grafting. 2 cases of PFL involved the urethral extension requiring excision of the necrotic segment. Conclusion PFL occurred in 7.9% of cases and was solely found in the TWT cohort. The majority of cases involved the shaft, sparing the urethral segment. Cases in the acute postoperative period appeared to be related to macrovascular venous congestion, while cases in the subacute period appeared to be due to microvascular arterial ischemia.

P–164 Mulitcentre derived time lapse algorithms developed using 6228 transferred embryos with known birth outcome incorporating novel morphological and morphokinetic markers

Study question Can incorporation of novel markers of morphology with known temporal events successfully rank embryos to enable prediction of propensity for live birth? Summary answer Incorporation of variables for trophectoderm and morula grading demonstrably enhanced the model to rank embryos in order of potential for live birth. What is known already Models built using morphokinetic markers of development are widely used to rank embryos within a cohort. Such models include defined temporal parameters which are closely related to morphological grade. However, morphological grading by an embryologist is subjective and is not strongly correlated to outcome. Combining with defined kinetic events has been suggested to improve prediction of outcome. Study design, size, duration Data from 6228 known live birth outcome embryos from 8 UK clinics between 2011 – 2018 were investigated using an exploratory approach to identify novel markers of development. Participants/materials, setting, methods Five significant variables were defined, a derivative of time to start of blastulation; a derivative of trophectoderm grade; a kinetic variable utilising t3, t4, t5 and t8; an interval variable of tB-tSB and a variable based on novel morula classification. To maximise the output, a proxy value was derived for missing datapoints. The model was built using logistical regression and validated using fivefold cross validation with the data split as 80% training and 20% test. Main results and the role of chance An algorithm was developed including the five significant variables identified with an AUC of 0.685 demonstrating reliable prediction of live birth. Without morphological variables, the AUC was 0.674 demonstrating the improvement in the prediction value by including the derivative of the trophectoderm and morula grade. This resulted in ten classes of algorithm scores, 1–10, giving a live birth rate from 2% to 46%, irrespective of patient variables, for chance of live birth. Limitations, reasons for caution Successful application of the algorithm is reliant on stringent quality assurance for maintenance of accurate annotation and grading, and may not be transferable between laboratories with different SOPs. Wider implications of the findings: The addition of a trophectoderm and morula grade in combination with morphokinetic parameters, increases the predictive value of the algorithm in relation to live birth outcome. Using proxy values allows maximization of data for model generation, and allows the model to be applied when missing values are present. Trial registration number Not applicable