Accuracy of Store-and-Forward Teledermatology for the Diagnosis of Skin Cancer: The Nouvelle-Aquitaine Experience

Background In Nouvelle-Aquitaine (a French region with a population of almost 6 million), the density of dermatologists is less than 3.8/100,000 inhabitants. This lack of dermatological care is delaying diagnosis and management, especially for skin cancer. The SmartDerm Project is a store-and-forward (SAF) teledermatology platform for primary care in Nouvelle-Aquitaine providing dermatological counselling to general practitioners (GPs). Objective The main objective was to determine the concordance between the diagnosis of skin cancer made by dermatologists and the pathologists’ diagnosis. Methods GPs in 3 pilot departments of Nouvelle-Aquitaine (Lot-Et-Garonne, Deux-Sèvres, Creuse) sent their dermatology requests using their smartphone, via an app called PAACO/Globule; dermatologists at the University Hospital of Bordeaux answered within 48-72 hours. Consecutive cases of skin cancer suspected by the referent dermatologists during the intervention were included, if the result of biopsy interpreted by a certified pathologist was available at the time of the study. Results Among the 1727 requests, 163 (9%) concerned a possible diagnosis of skin cancer and were eligible. For 61 cases, the histopathological findings were not available. Eventually, 93 patients with a total of 102 skin lesions were included. Median age was 75 years (range 26-97 years), with 53% women. The skin lesions had progressed for 8 months on average (range 0.5-36 months). The median response time was 1 day (range 0-61 days); 65 days (range 1-667 days) elapsed on average between the SAF opinion and the histological sample. Histopathology diagnosed 83 malignant lesions (57 basal cell carcinomas, 69%; 18 squamous cell carcinomas, 22%; 6 melanomas, 7%; 1 cutaneous lymphoma, 1%; 1 secondary location of a primary cancer, 1%), 1 precancerous lesion, and 18 benign lesions. The concordance between the opinion of the referent dermatologist and the final pathological finding was 83% for nonmelanocytic lesions and 67% for melanocytic lesions. Conclusions This study showed the reliability of SAF teledermatology in the diagnosis of skin cancer, comparable to literature data in the absence of dermatoscopy. The median delay of about two months between request and histology was an improvement compared to the delay of usual appointments in the intervention area. The lack of data for 61 patients showed that SAF telemedicine requires better coordination and follow-up, especially for the management of skin cancer. With this reservation in mind, teledermatology offers an alternative answer for the triage of patients with skin cancer residing in areas with low medical density. Conflicts of Interest None declared.

Preliminary Exploration of Transpedal Lymphangiography With High-Dose Ethiodized Oil Application in the Treatment of Postoperative Chylothorax

Objective: To preliminarily explore the safety and effectiveness of transpedal lymphangiography (TL) with high-dose ethiodized oil application (>20 ml) in the treatment of high-output postoperative chylothorax.Methods: From 1 July 2020 to 1 July 2021, a total of 7 patients with high-flow postoperative chylothorax (> 1,000 ml/d) were retrospectively reviewed in a single center. Clinical data, including surgery types, technical and treatment success of TL, and adverse events of TL, were collected and analyzed.Results: Seven patients (5 cases of non-small cell lung cancer; 2 cases of esophageal carcinoma) with a median age of 62 years (range: 30–70 years) occurred postoperative chylothorax after tumor resection with mediastinal lymphadenectomy. All patients received conservative treatment including total parenteral nutrition and somatostatin administration for a median of 20 days (range: 15–31 days) that failed to cure the chylothorax, so TL was performed as a salvage. Before TL, the median daily chyle output was 1,500 ml/day (range: 1,100–2,000 ml/day). The technical success rate of TL was 100% (7/7), with the median volume of ethiodized oil of 27.6 ml (range: 21.2–30.0 ml) injected in TL. Ruptured thoracic duct was identified in 5 patients (5/7, 71%) in fluoroscopy and chest CT after TL. The treatment success rate of TL was 86% (6/7). In 6 patients, the thoracic drainage was removed after a median of 7 days (range: 4–13 days) from TL performance. No adverse event of TL was reported.Conclusion: Transpedal lymphangiography with high-dose ethiodized oil application (>20 ml) is a feasible, safe, and effective modality for the treatment of high-flow (> 1,000 ml/day) postoperative chylothorax.

Effects of Ketoconazole On Clinical Recovery In Central Serous Chorioretinopathy

Background: Hypercortisolism has long been correlated with choroidal vasorelaxation in central serous chorioretinopathy (CSCR). This may explain the inconsistency of therapeutic responses of the mineralocorticoid receptor (MR) antagonist since hyperaldosteronism has rarely been detected in such cases. Hence, an early treatment using ketoconazole, the first line cortisol inhibitor that also blocks the MR ligand, appears to be rational. This study aimed to evaluate the effects of ketoconazole on CSCR, and to analyze correlations between choroidal thickness and steroid hormones.Method: In this three-center retrospective cohort, forty-one naïve CSCR eyes of 41 patients were categorized into control (20 eyes) and treatment group (21 eyes). Patients in the treatment group were given oral ketoconazole at a daily dose of 400 or 600 mg for three to six weeks. At week 12, rescue laser therapy was applied to patients exhibiting persistent subretinal fluid (SRF). We performed a survival analysis to determine the time interval from presentation to clinical resolution of SRF. The secondary outcomes consisted of proportion of eyes with persistent SRF, and factors affecting therapeutic response.Results: Mean 24-hour urinary free cortisol (UFC) were elevated at 181 ± 70 and 150 ± 68 µg/day (range = 20-150) in the treatment and control group (p = 0.21). After controlling for age and gender, baseline UFC levels demonstrated a positive correlation with choroidal thickness in both eyes (p < 0.05). Ketoconazole significantly accelerated the resolution of CSCR with the median time to resolution of 7 versus 16 weeks (p < 0.01), and reduced the proportion of eyes receiving rescue therapy at 12 weeks (23.8% versus 50%, p = 0.01). Prolonged CSCR durations were likely found in elderly patients who had thick choroid in fellow eyes.Conclusions: Elevated glucocorticoids are likely responsible for the pathogenesis of CSCR. Therefore, a temporary decrease in choroidal hyperpermeability using the cortisol blocker could reduce the persistency of CSCR.

Accuracy of Store-and-Forward Teledermatology for the Diagnosis of Skin Cancer: The Nouvelle-Aquitaine Experience (Preprint)

BACKGROUND In Nouvelle-Aquitaine (a French region with a population of almost 6 million), the density of dermatologists is less than 3.8/100,000 inhabitants. This lack of dermatological care is delaying diagnosis and management, especially for skin cancer. The SmartDerm Project is a store-and-forward (SAF) teledermatology platform for primary care in Nouvelle-Aquitaine providing dermatological counselling to general practitioners (GPs). OBJECTIVE The main objective was to determine the concordance between the diagnosis of skin cancer made by dermatologists and the pathologists’ diagnosis. METHODS GPs in 3 pilot departments of Nouvelle-Aquitaine (Lot-Et-Garonne, Deux-Sèvres, Creuse) sent their dermatology requests using their smartphone, via an app called PAACO/Globule; dermatologists at the University Hospital of Bordeaux answered within 48-72 hours. Consecutive cases of skin cancer suspected by the referent dermatologists during the intervention were included, if the result of biopsy interpreted by a certified pathologist was available at the time of the study. RESULTS Among the 1727 requests, 163 (9%) concerned a possible diagnosis of skin cancer and were eligible. For 61 cases, the histopathological findings were not available. Eventually, 93 patients with a total of 102 skin lesions were included. Median age was 75 years (range 26-97 years), with 53% women. The skin lesions had progressed for 8 months on average (range 0.5-36 months). The median response time was 1 day (range 0-61 days); 65 days (range 1-667 days) elapsed on average between the SAF opinion and the histological sample. Histopathology diagnosed 83 malignant lesions (57 basal cell carcinomas, 69%; 18 squamous cell carcinomas, 22%; 6 melanomas, 7%; 1 cutaneous lymphoma, 1%; 1 secondary location of a primary cancer, 1%), 1 precancerous lesion, and 18 benign lesions. The concordance between the opinion of the referent dermatologist and the final pathological finding was 83% for nonmelanocytic lesions and 67% for melanocytic lesions. CONCLUSIONS This study showed the reliability of SAF teledermatology in the diagnosis of skin cancer, comparable to literature data in the absence of dermatoscopy. The median delay of about two months between request and histology was an improvement compared to the delay of usual appointments in the intervention area. The lack of data for 61 patients showed that SAF telemedicine requires better coordination and follow-up, especially for the management of skin cancer. With this reservation in mind, teledermatology offers an alternative answer for the triage of patients with skin cancer residing in areas with low medical density.

Some features of magnetic elements at Trivandrum and Annamalainagar, situated near the geomagnetic equator in the Indian Peninsula

The Sq diurnal variation in H at Trivandrum and Annamalainagar are found to be large compared with those at Alibag. The quiet day range in H at Trivandrum in the month of March is abnormally large. Though the Sq variations in V at Trivandrum are not abnormal they are larger than those at Annamalainagar and Alibag. The response of the H elements to disturbance at Trivandrum, Annamalainagar as well as Alibag are similar in sense. But the V element at Annamalainagar shows a difference in its response to disturbance. When the V elements at both Alibag and Trivandrum show an increase in numerical magnitude the V element at Annamalainagar shows a decrease and vice versa. When the magnitudes of disturbance are examined they are found to be almost the same in the H element at all the observatories (including Alibag) during night hours. But during the day the magnitudes of disturbance in H element at Trivandrum and Annamalainagar are always greater than that at Alibag, a station away from the geomagnetic equator. Effects of disturbance in the V element are greatest at Trivandrum both during the day as well as the night. The lines of force of an average disturbance field in a longitudinal plane over the region of the Indian Peninsula appear to be smooth curves with their concave side turned upwards, their turning points occurring between Annamalainagar and Alibag during the day and close to Alibag in the night.

RADT-15. FIRST EXPERIENCE WITH MAXIMAL SAFE RESECTION AND GAMMATILE BRACHYTHERAPY AS TREATMENT FOR RECURRENT GLIOBLASTOMA

INTRODUCTION Gammatile (GT) is a recently FDA-cleared brachytherapy platform with 131Cs seeds imbedded into a resorbable collagen carrier for surgically targeted radiation delivery. We report the first experience for recurrent glioblastoma patients who underwent GT treatment following surgical resection. METHODS Twenty-two consecutive patients with 23 isocitrate dehydrogenase (IDH) wild-type glioblastomas (14 second; eight third recurrence) who underwent intra-operative MRI/5-ALA guided maximal safe resection followed by GT placement were prospectively followed. There were 6 methylguanine-DNA-methyltransferase promoter methylated (MGMTm) and 17 unmethylated (MGMTu) glioblastomas. RESULTS The median hospital stay was one day (range:1-15 days). There was one 30-day readmission (4.5%) for a cerebrospinal fluid leak from the incision site, which resolved with lumbar drainage. There were no other wound complications. One patient (4.5%) suffered new post-operative seizure. Eight patients experienced worsened neurological deficit (8/22 or 36%). While all deficits improved by the 30-day follow-up, 7 of these 8 patients suffered KPS decline due to persistent deficits. There was one 30-day mortality (4.5%) from intracranial hemorrhage secondary to heparinization for an ischemic limb. The median follow-up after GT placement for the remaining 21 patients was 296 days (range:111-931 days). Six months local control (LC) was achieved in ~75% of the patients irrespective of MGMT status. Median overall survival (OS) was 715 days for the MGMTu patients, and not reached (&gt;1000 days) for MGMTm patients. These outcomes compared favorably to the published literature (LC: 3-49%; OS MGMTu: 135-285 days; OS MGMTm: 174-564 days) and an age, KPS, extent of resection matched glioblastoma cohort who underwent maximal safe resection without GT at our institution (LC: 52%; OS MGMTu: 462 days; OS MGMTm: 821 days; p=0.0089 and p=0.0271, respectively when compared to the GT treated patients). CONCLUSION This clinical experience supports the safety and efficacy of GT brachytherapy as a treatment option for recurrent glioblastomas.

205. Evaluating the Time to Oral Step-Down Therapy for Gram-Negative Bloodstream Infections Associated with a Genitourinary Source

Background The transition to oral antibiotics in gram-negative bloodstream infections (BSI) can decrease length of stay, avoid central line access, and improve patient convenience. Some studies suggest that the bioavailability of the oral agent selected can impact outcomes. The purpose of this study was to determine when the most appropriate time to oral step-down is, and assess if the bioavailability of the agent selected impacts outcomes. Methods This retrospective observational chart review evaluated adult patients admitted to Long Island Jewish Medical Center during the study period of January 2019 – December 2019 with a gram-negative BSI from a genitourinary source. The primary objective was to assess if the time to oral step-down therapy impacts clinical success. Secondary objectives included assessment of if continued IV therapy or oral step-down impacts outcome measures including clinical failure, length of stay, and duration of therapy, and to compare high versus low bioavailability agents on treatment outcomes. Results A total of 130 patients were included, with 88 patients in the oral step-down group and 42 patients in the IV therapy only group. Clinical failure occurred in 10 patients in the oral step-down group, with 2 de-escalated in the 1-3 day range and 8 de-escalated in the 4-6 day range (p=0.29). There was no difference in clinical failure when the oral step-down group was compared to the IV therapy group (11 vs. 17%; p=0.41). The length of stay was significantly shorter in the oral step-down group (p&lt; 0.0001), while the duration of therapy was shorter in the IV therapy group (p=0.0015). When comparing high and low bioavailability agents, there was no difference in the rate of treatment failure (p=0.74), length of stay (p=0.08), or duration of therapy (p=0.02). Conclusion There was no significant difference in outcomes if patients were de-escalated to oral therapy early versus late in their treatment course. Step-down to oral antibiotics led to decreased length of stay, and the bioavailability of the oral agent selected did not impact outcomes. This study demonstrates the safety and efficacy of prompt oral step-down for gram-negative bacteremia secondary to a genitourinary source which can have positive impacts on patient care. Disclosures All Authors: No reported disclosures

Electronically monitored occlusion therapy in amblyopia with eccentric fixation

Purpose Amblyopia with eccentric fixation, especially when not diagnosed early, is a therapeutic challenge, as visual outcome is known to be poorer than in amblyopia with central fixation. Consequently, treatment after late diagnosis is often denied. Electronic monitoring of occlusion provides us the chance to gain first focussed insight into age-dependent dose response and treatment efficiency, as well as the shift of fixation in this rare group of paediatric patients. Methods In our prospective pilot study, we examined amblyopes with eccentric fixation during 12 months of occlusion treatment. We evaluated their visual acuity, recorded patching duration using a TheraMon®-microsensor, and determined their fixation with a direct ophthalmoscope. Dose-response relationship and treatment efficiency were calculated. Results The study included 12 participants with strabismic and combined amblyopia aged 2.9–12.4 years (mean 6.5). Median prescription of occlusion was 7.7 h/day (range 6.6–9.9) and median daily received occlusion was 5.2 h/day (range 0.7–9.7). At study end, median acuity gain was 0.6 log units (range 0–1.6) and residual interocular visual acuity difference (IOVAD) 0.3 log units (range 0–1.8). There was neither significant acuity gain nor reduction in IOVAD after the 6th month of treatment. Children younger than 4 years showed best response with lowest residual IOVAD at study end. Efficiency calculation showed an acuity gain of approximately one line from 100 h of patching in the first 2 months and half a line after 6 months. There was a significant decline of treatment efficiency with age (p = 0.01). Foveolar fixation was achieved after median 3 months (range 1–6). Three patients (> 6 years) did not gain central fixation. Conclusion Eccentric fixation is a challenge to therapy success. Based on electronic monitoring, our study quantified for the first time the reduction of treatment efficiency with increasing age in amblyopes with eccentric fixation. Despite some improvement in patients up to 8 years, older patients showed significantly lower treatment efficiency. In younger patients with good adherence, despite poor initial acuity, central fixation and low residual IOVAD could be attained after median 3 months. Hence, the necessity of early diagnosis and intensive occlusion should be emphasized.

175 GPS Tracking Collars and Accelerometers Provide Detailed Tracking of Foraging Behavior and Space Use in Grazing Steers in Bermudagrass and Tall Fescue Pasture

Previous research in feedlot studies has demonstrated that cattle feeding behavior is driven by internal metabolic processes and external environmental stimuli and serves as an indicator of animal health, nutritional status, and growth and feed quality and availability. However, technology has only recently allowed measurement of foraging behavior in grazing cattle. Objectives of this study were to measure frequency and duration of foraging bouts, meals, and total distance traveled during meals in grazing steers. The study was conducted as part of a larger grazing study on a 10-hectare Bermudagrass and Tall Fescue pasture, overseeded with Annual Ryegrass, located at the HH Leveck Animal Research Center, Mississippi State, MS. Using tri-axial accelerometers and GPS information from 10 crossbred steers, we examined foraging and meal bout frequency and duration and distance and speed traveled per meal for the period of March 2019. Observed animal behavior was used to train a randomforest model to predict foraging behavior, with model accuracy and sensitivity of 0.95 and 0.93, respectively. We found individual foraging bouts occurred on average 2,849 bouts per day and took on average 5.0 ± 1.8 min (range: 3–9 min), and that steers fed on average 205 ± 52.8 min/day (range: 120–270 min/day). Steers had an average of 9.5 ± 2.9 meals/day, that took on average, 89.3 ± 93.9 min/meal (range: 0.5–938.5 min/meal). Steers traveled an average of 412.4 ± 93.9 meters per meal, with an average foraging speed between 0 and 0.63 m/s. Traveling distance while foraging was positively correlated with meal length (0.83, P &lt; 0.01) and foraging speed (0.70, P &lt; 0.01). These results show that cattle grazing behavior can be accurately quantified in grazing cattle and warrants further research to examine associations between animal efficiency and performance, forage quality, and pasture management.

SP3.2.10 Establishing an Emergency Surgical Ambulatory Care (ESAC) pathway for acute laparoscopic cholecystectomies: a single centre experience from a District General Hospital

Aims Early laparoscopic cholecystectomy is the gold standard for acute cholecystitis and gallstone pancreatitis. In order to deliver this service, a local Emergency Surgical Ambulatory Care (ESAC) pathway with a dedicated ESAC theatre list was established. The aim of this audit was to determine whether ESAC was associated with (1) improved length of stay and (2) cost efficiencies. Methods Consecutive patients who underwent an emergency laparoscopic cholecystectomy between October 2018 to October 2019 were identified. Data related to patient demographics, operating time, complications length of stay (LOS), reason for inpatient stay and re-admissions were collected. A dedicated ESAC service was introduced in July 2020. Outcomes were re-audited (July – December 2020). Results Prior to the introduction of ESAC, 142 patients (42% male, mean age 51 years (range 14 -82 years)) underwent an acute cholecystectomy, of which 13% were discharged on the same day. Median pre-operative LOS was 2 days (range 0-12 days) and median post-operative LOS was 1 day (range 1-16 days). Following the introduction of ESAC, 78 patients (32% male, mean age 49 years (range 22 – 89 years)) underwent an acute cholecystectomy, of which 76% were discharged on the same day and 90% within 1 day. Median pre-operative LOS was 0 days (range 0 to 7 days) and median post-operative LOS was 0 days (range 0-16 days). Conclusions Our results show that the introduction of a dedicated ESAC pathway improved both pre- and post-operative LOS. This subsequently saves approximately £80,000 per annum in hospital bed days.