P-P24 Optimising post-operative nutrition in patients undergoing pancreaticoduodenectomy

Background A considerable number of patients undergoing pancreaticoduodenectomy require supplemental nutrition in the postoperative period. However, there remains no national consensus on the optimal postoperative supplemental feeding modality. Furthermore, at our institution a variation in practice exists when considering post-operative entera (via the naso-jejunal (NJ)) or parenteral nutrition (PN). This study aimed to evaluate the utility of post-operative enteral or parenteral nutrition at our centre and to explore risk factors predisposing patients to post-operative nutritional deficits requiring supplementation. Methods We retrospectively analysed the electronic case records of all patients undergoing a pancreaticoduodenectomy between November 2019 and November 2020 at our HPB specialist centre. Key patient demographic data and post-operative nutritional requirements with route, length and indication for supplemental feeding as well as biochemical markers, length of stay (LoS) and complications were collected and analysed. Data were analysed via intention to treat analysis. Results 48 patients underwent a pancreaticoduodenectomy, of which 26 had an NJ tube inserted intra-operatively. 16 (33%) patients required supplemental feeding, via NJ route in 7 and PN in 9. 2 patients were intolerant to NJ feeds and progressed to PN. NJ fed patients had shorter LoS (12(10-42) vs. 28(14-63) days)(p = 0.09) compared to PN feeding. PN-related line infection or thrombosis in 4 (36%) patients. Supplemental feeding met daily kcal requirements in 13 (81%) patients, but PN was associated with greater weight loss (-5%) than NJ feeding (-3%). Significantly increasing the risk of needing supplemental nutrition: advanced age(p = 0.04), ASA≥2(p = 0.04) and anastomotic leak(p = 0.02). Conclusions In this group of patients, NJ feeding was largely well-tolerated and the majority of patients met their required daily kcal via this route. Due to the increased incidence of complications associated with PN, NJ feeding should be considered as the 1st line option for post-operative nutritional supplementation, with intra-operative insertion of an NJ tube considered for higher-risk patients.

Modeling and analyzing predictive monthly survival in females diagnosed with gynecological cancers

Cancer ranks as a leading cause of death worldwide; an estimated 1.7 million new diagnoses were reported in 2021. Ovarian cancer, the most lethal of gynecological malignancies, has no effective screening with over 70% of patients being diagnosed in an advanced stage. The aim of this study was to determine the most statistically significant contributing factors through a multivariate regression into the severity of female gynecological cancers. Data from the surveillance, epidemiology, and end results program (SEER) cancer database were utilized in this study. Several attempted multivariate linear regressions were implemented with further reduced models; however, a linear model could not be properly fit to the data. Because of unmet assumptions, a nonparametric moving, local regression, locally estimated scatterplot smoothing (LOESS), was performed. After smoothing factors were included to reduced-models, residual information was minimized although few conclusions can be drawn from the resulting statistics. These issues were prevalent mainly because of the massive variability in the data and inherent lack of linearity. This can be a significant issue with clinical data that does not dive deeper into cancer-dependent factors including genetic expression and cell surface receptor overexpression. General patient demographic data and diagnostic information alone does not provide enough detail to make a definite conclusion or prediction on patient survivability. Increased attention to the acquisition of tumor tissue for genomic and proteomic analysis in addition to next-generation sequencing methods can lead to significant improvements in prognostic predictions.

The role of multi-generational household clusters in COVID-19 in England

Background Household transmission has been demonstrated to be an important factor in the population-level growth of COVID-19. UK Health Security Agency (UKHSA) maintains data on positive tests for COVID-19 and the residential addresses of cases. We sought to use this information to characterise clusters of COVID-19 in multi-generational households in England. Methods Using cross-sectional design, cases of COVID-19 were assigned to clusters if they occurred in the same residential property in a 14-day rolling window. Patient demographic data were supplemented with reference to the ONS index of multiple deprivation and population density. Multi-generational households were defined as a cluster with at least three people, with one case in a person who was 0-16 years old and one case in a person who was ≥ 60 years old, with at least 16 years between two members of each age group. Results A total of 3,647,063 COVID-19 cases were reported between 01 April 2020 and 20 May 2021. Of these, 1,980,527 (54.3 %) occurred in residential clusters. Multi-generational households formed 1.5 % of clusters, with these more likely to occur in areas of higher population density and higher relative deprivation. Multi-generational clusters were more common among households of non-White ethnicity and formed larger clusters than non-multi-generational clusters (median cluster size 6, IQR 4-11 vs 3, IQR 3-4, respectively). Conclusion Multi-generational clusters were not highly prevalent in England during the study period, however were more common in certain populations.

Seroepidemiological Study of Hepatitis A in Medical Students of Mazandaran University of Medical Sciences in 2019

Introduction: Hepatitis A (HA) is a common infectious disease caused by the HA virus that primarily affects the liver. We need to determine the safety status and infection rate in the community. Therefore, we decided to study the Seroepidemiological of HA in medical students of Mazandaran University of Medical Sciences in 2019.Material and Methods: This was a cross-sectional descriptive-analytical study prospectively examining anti-HAV antibodies in medical students of Mazandaran University of Medical Sciences in 2019. Patient demographic data, laboratory results of anti-HAV IgG and vaccination history were recorded. Four cc of blood were drawn from each student for the anti-HAV IgG test and after the test was performed. Data were analyzed using SPSS 24 software.Results: One hundred and fifty-five students were interviewed. The mean age (standard deviation) of the students in this study was 23.81 (1.47) years. Ninety-nine (63.9%) of the students were male. Therefore, it was caused by previous infection with HAV and 120 (77.4%) cases were considered susceptible individuals whose serum anti-HAV IgG was negative. This was not seen to be statistically significant (P=0.754). According to the test, 77.4% of the predictions were correct. None of the variables of sex, age, history of underlying disease, place of residence, and history of travel had a significant effect on the incidence and positivity of anti-HAV IgG.Conclusion: This study showed that the incidence of anti-HAV IgG was positive in 22.6% of the students, which is much lower than previous studies. This may be due to the higher level of health in this segment of the population.

Targeted Therapy in CD38 + Acute Myeloid Leukemia

The expression rate of CD38 in acute myeloid leukemia is high. It is reported that the expression of CD38 in myeloid leukemia is stable and can be used as a potential therapeutic target for leukemia. Daratumumab is a therapeutic drug targeting CD38. It is widely used in myeloma, but it has not been applied in AML. The prognosis of 4 patients with acute myeloid leukemia treated with CD38 monoclonal antibody combined with demethylating drugs / traditional chemotherapy was reviewed. Patient demographic data and clinical characteristics see table 1. One patient with de novo AML in the high-risk group achieved remission after Dara combined with azacytidine and venetoclax. The other three patients were suffering Relapsed/Refractory AML. Two of them achieved remission after Dara combined with azacytidine and venetoclax. The patient, who was non-remission after Dara combined with IA chemotherapy (Idarubicin, Cytosine Arabinoside), achieved remission after CART targeting CD38. In this paper, four cases were reported, and the rationality of CD38 targeted therapy was further analyzed. Figure 1 Figure 1. Disclosures No relevant conflicts of interest to declare.

THE ROLE OF A SPECIALIST PHARMACIST IN THE MANAGEMENT OF ADALIMUMAB IN PATIENTS WITH INFLAMMATORY BOWEL DISEASE

Objective: The management of inflammatory bowel disease (IBD) patients on complex medications such as biologic disease-modifying anti-rheumatic drugs (DMARD) requires close supervision. At East Sussex NHS Healthcare Trust (ESHT), the multi-disciplinary team (MDT) already looking after these patients could benefit from the additional knowledge and support from a specialist pharmacist (SP). Methods: To assess if the MDT could benefit from an SP, all IBD patients on the DMARD adalimumab were identified. The patient records were screened for patient demographic data, clinical assessment and investigations, treatment, and follow-up clinics. Results: 162 patients at ESHT were identified as being on adalimumab treatment for either Crohn’s Disease (77%) or Ulcerative Colitis (23%). Disease activity scores, a clinical measure of IBD severity, were infrequently recorded (1%) on patient letters. Evidence of a biologic screen, a series of investigations to ensure safety in a biologic treatment, was only evident in one-third of patients. Clinic review of patients recently started on adalimumab and annual review of stable patients occurred 43% and 26% respectively. Conclusion: The results indicate that there is a need for an additional member to support the IBD MDT in managing this cohort of patients. An SP is uniquely positioned to fill this gap. They have extensive knowledge in drug indication, therapeutic drug monitoring, and side-effect profiles. Similar studies have been identified that support SP in this role.

The Learning Curve of the Deliberate Practice of Phacoemulsification in the Ophthalmic Training System

Objective: To determine the number of surgeries needed for trainees to achieve competence in performing phacoemulsification with deliberate practice (DP). Materials and Methods: The present study was a prospective observational study, the residents were observed as they progressed through their third year of residency. Resident and patient demographic data were recorded. Complexities of the cases and surgical steps and rate of surgical complications were recorded. Self and staff assessments as to the DP learning zone attained by the trainees were collected. Risk adjusted-cumulative summation (RA-CUSUM) was used to evaluate the competency of the trainees to achieve the acceptable posterior capsule rupture (PCR) rate of 5%. Kaplan-Meier analysis was used to determine the median number of surgeries required to attain competency. Results: Eight of the 10 trainees achieved competence in performing phacoemulsification. A median of 28 cases and 278 days was required before competence was attained. There were no statistically significant associations between the achievement of competence and the gender of the trainees, perceived complexity of the cases, or the grade-point average of the residents during their tenure in medical school. A median of four cases were required for a shift in the trainees’ DP confidence levels from “panic” to “learning” from self-assessment, while the median of ten case were required from staff assessment. The PCR was 8.53% and dropped to 6% at two years after the trainees finished residency training. Conclusion: Trainees require at least 28 cases of non-complicated phacoemulsification surgery to achieve a minimum level of competency. The perceived skill in performing phacoemulsification differs between novice and experienced surgeons. Phacoemulsification skills can be further developed after graduating from the training program. Assisting staff should be attentive when trainees perform lens nucleus division and lens nucleus removal to avoid complications. Keywords: Residency training; Phacoemulsification; CUSUM; Deliberate practice; Cataract

Retrospective Analysis of Adult Patients Presenting to the Acute Care Setting Requesting Prescriptions

Introduction: Patient visits to the emergency department (ED) or urgent care centre (UCC) for the sole purpose of requesting prescriptions are challenging for the patient, the physician, and the department. The primary objective of this study was to determine the characteristics of these patients, the nature of their requests, and the response to these requests. Our secondary objective was to determine the proportion of these medication requests that had street value. Methods: This was a retrospective, electronic chart review of all adult patients requesting a prescription from a two-site ED and/or an UCC in a medium-sized Canadian city between April 1, 2014–June 30, 2017. Recorded outcomes included patient demographic data and access to a family doctor, medication requested, whether or not a prescription was given, and ED length of stay. Medication street value was determined using a local police service listing. Results: A total of 2,265 prescriptions were requested by 1,495 patients. The patient median [interquartile range] age was 43 [32-54] years. A family doctor was documented by 55.4% (939/1,694) of patients. The two most commonly requested categories of medications were opioid analgesics 21.2% (481/2,265) and benzodiazepine anxiolytics 11.7% (266/2,265). Of patients requesting medication, 50.5% (755/1,495) requested medications without street value including some with potential to cause serious adverse health effects if discontinued. The requested prescription was received by 19.9% (298/1,495) of patients; 15.3% (173/1,134) returned for further prescription requests. The 90th percentile length of stay was 3.2 and 5.6 hours at the UCC and ED, respectively. Conclusion: Patients who presented to the ED or UCC sought medications with and without street value in almost equal measure. A more robust understanding of these patients and their requests illustrates why a ‘one-size-fits-all’ response to these requests is inappropriate and signals some fault lines within our local healthcare system.

Effective response to a regional outbreak of COVID-19 – Experience of a tertiary emergency center

Objective: This study evaluates the usefulness, safety, and outcomes of operating a pretriage screening clinic and an expanded preemptive quarantine area in the ED during a regional COVID-19 outbreak. Methods: A descriptive cross-sectional, retrospective study conducted in a single institution. General patient demographic data, initial vital sign, symptoms, and patient outcome was collected from January to March of 2020. Data were compared according to the implementation of a new protocol involving pretriage screening and risk stratification. Outcome was also analyzed according to quarantine areas, including conventional, negative pressured, cohort, or preemptive quarantine area. Results: The pretriage clinic lowered the volume of low severity patients entering emergency department. Preemptive and cohort quarantine area provided more care to febrile patients compared to conventional quarantine area with longer length of hospital stay and lower mortality. After implementing the new protocol, emergency department in the study hospital was not closed again. Conclusions: In a regional outbreak of an epidemic, pretriage clinic safely screened infectious patients from entering ED. Expanded preemptive quarantine area increased surge capacity on quarantine area. An infectious disease protocol implementing two treatment area may contribute to preserve and maintain ED function.

Treatment strategies for inverted papillomas with intracranial or intraorbital involvement

Objective Sinonasal inverted papillomas are challenging benign tumours of the nasal cavity because of their high recurrence rates and the lifetime malignant transformation risk of 10 per cent as well as their locally aggressive behaviour. This study aimed to describe treatment strategies for inverted papillomas with intracranial or intraorbital involvement. Method This was a prospective case series study of 18 patients with inverted papilloma with intracranial or intraorbital involvement. Patient demographic data, imaging, pathology, surgical technique and recurrences were recorded prospectively over a period of seven years. Results A total of 83 per cent of the patients in this study had been previously operated on, consisting of 8 cases with intracranial involvement, 1 case with intraorbital involvement and 9 with both. During follow up with a medium of 37 months (range, 13–115 months) there were two recurrences. Conclusion It was postulated that intracranial or intraorbital involvement observed in this series was the result of multiple revisions. However, using accurate imaging protocols and the pedicle-oriented approach for tumour excision, complete tumour removal was achieved in most cases with minimal post-operative complications.