Validation of an obstetric quality of recovery scoring tool (ObsQoR-11) after elective caesarean delivery in a developing country: a prospective observational study

BACKGROUND

The obstetric quality of recovery scoring tool (ObsQoR-11) was developed and validated in the United Kingdom for use after elective and emergency caesarean delivery. Quality of recovery scoring tools validated in one country may not be valid in other countries with significant cultural, socio-economic and linguistic variations. The aim of the current study was to validate a Hindi version of the ObsQoR-11.

METHODS

In this prospective observational study, 100 parturients who underwent elective caesarean delivery in a tertiary care obstetric referral university hospital in North India were asked to complete a Hindi version of the ObsQoR-11 scoring tool 24 h after surgery. The performance of the Hindi version of ObsQoR-11 was assessed using measures of validity, reliability, and feasibility.

RESULTS

The Hindi version of ObsQoR-11 correlated moderately with the global health visual analogue scale (r=0.45, 95% CI 0.27 to 0.59; P <0.0001) and discriminated well between good and poor recovery (mean (SD) score 84.6 (9.4) vs 75.0 (11.2); P <0.0001). The reliability and internal consistency were moderate (Cronbach's alpha=0.66; Spearman-Brown Prophesy Reliability estimate=0.57) with good repeatability (intraclass correlation coefficient 0.85, 95% CI 0.69 to 0.93; P <0.0001) and no floor or ceiling effects. All parturients completed the questionnaire (median (IQR) time of completion of 3 (1.5 - 5.5) min).

CONCLUSION

The Hindi version of the ObsQoR-11 questionnaire is a promising scoring tool to evaluate quality of recovery after elective caesarean delivery. Further research is needed to evaluate the Hindi tool in other institutions in India, as well as in other languages.

1300 Version Abnormalities of the Femur and Acetabulum in Patients with Femoroacetabular Impingement: A Systematic Review

Aim

This systematic review aims to understand the relationship between version abnormalities of the femur and acetabulum in patients with primary and secondary femoroacetabular impingement (FAI).

Method

A systematic review was conducted according to PRISMA guidelines. A computer-based search was performed using the EMBASE, MEDLINE, PubMed and Cochrane databases for articles relating to version and torsional abnormalities in FAI, Legg-Calve-Perthes disease (LCPD) and slipped capital femoral epiphysis (SCFE). The study was registered in the Open Science Framework. Two authors independently performed title/abstract and full text screening according to predetermined inclusion criteria.

Results

A total of 1206 articles were identified 55 articles, involving 10, 091 hips, met the inclusion criteria. All studies evaluating femoral/acetabular version in FAI reported ‘normal’ mean version values (10o to 25o). However, distribution analysis revealed that an estimated 31.4% and 51.3% of patients with FAI displayed abnormal acetabular and femoral version, respectively. Abnormal femoral version was reported in an estimated 74.5% of hips with LCPD, and abnormal acetabular version in an estimated 20%. Acetabular version was significantly lower in hips with SCFE compared to controls (Z=-3.26, P &lt; 0.01).

Conclusions

Patients presenting with hip pain attributed to FAI are likely to display an abnormality in femoral or acetabular version. This highlights the importance of evaluating these parameters during assessment of these patients, in order to guide clinical decision making.

283 Salvage Versus Primary Robot-Assisted Radical Prostatectomy: A Propensity-Matched Comparative Effectiveness Study from A High-Volume Tertiary Centre

Aim

Salvage Robot-Assisted Radical Prostatectomy (sRARP) is a potential treatment option for locally recurrent Prostate Cancer after non-surgical primary treatment. There are minimal data comparing outcomes between propensity-matched salvage and primary Robot-Assisted Radical Prostatectomy (RARP). We compare perioperative, oncological, and functional outcomes of sRARP with primary RARP and between sRARP post-whole and focal gland therapy.

Method

1:1 propensity-matched comparison of 146 sRARP with primary RARP from a cohort of 3,852 consecutive patients from a high-volume tertiary centre.

Results

There were no significant differences in patient characteristics between the salvage and primary RARP groups. Grade III-V Clavien-Dindo complication rates were 1.3% and 0% in the salvage and primary groups, respectively (p = 0.310). Median (IQR) follow-up was 16 (10,30) and 21 (13,33) months in the salvage and primary groups, respectively. BCR rates were 30.8% and 13.7% in the salvage and primary groups, respectively (p &lt; 0.001). Pad-free continence rates were 79.1% and 85.4% at two years in the salvage and primary groups, respectively (p = 0.160). ED rates were 95.2% and 77.4% in the salvage and primary groups, respectively (p &lt; 0.001). Comparing the whole gland and focal gland groups, BCR rates were 33.3% and 29.1%, respectively (p = 0.687), pad-free continence rates were 66% and 89.3%, respectively (p = 0.001), and ED rates were 98.3% and 93%, respectively (p = 0.145).

Conclusions

SRARP has similar perioperative but inferior oncological outcomes to primary RARP. Continence rates are similar to primary RARP, but potency is worse. Perioperative and oncological outcomes of sRARP after focal gland therapy are similar but continence outcomes are superior compared to sRARP after whole gland therapy.

1124 Is Delayed Presentation A Prognostic Factor for The Survival of Patients with Esophageal Atresia More Than Associated Anomalies? Comparison Between Different Social Realities

Background

The aim is to evaluate if different social reality could represent a prognostic factor as associated anomalies affecting survival of neonates with esophageal atresia (EA).

Method

Retrospective analysis of records of neonates with EA with or without Tracheoesophageal Fistula (TEF) from January 2011 to September 2018 at Policlinico San Matteo Pavia, Italy(SMAT) and the All India Institute of Medical Sciences New Delhi, India (AIIMS).Survival was correlated with the presence of anomalies, different types and the number of organ systems involved.Age at presentation and birth weight were considered to find an association with mortality.

Results

Out of 180 patients,162 were from AIIMS and 18 from SMAT.The overall mortality was 28.85%, which occurred at AIIMS, being 0% at SMAT.83.33% at SMAT and 72.84% at AIIMS had associated anomalies.The mortality was 25% for neonates without an anomaly, being 26.15% for those with one (p &gt; 0.05).No statistically significant correlation between outcome and associated anomalies was found.Instead, survival declines gradually as the age at presentation increases.

Conclusions

The presence of associated anomalies paradoxically does not affect the outcome because incidence of delayed presentation has a stronger effect than the presence of associated anomalies. Sensibilization is necessary to improve survival in EA neonates in developing countries, such as India.

1079 Analysis of Human Papilloma Virus (HPV) Status in Metastatic Oropharyngeal Squamous Cell Carcinoma (OPSCC)

Introduction

OPSCC often (80%) presents with ipsilateral neck metastasis. Presentation may be as carcinoma of unknown primary (CUP). Sampling via ultrasound guided Fine Needle Aspiration Cytology (FNAC) and/or Core Biopsy (CB) from nodal metastases is required for diagnosis, comparison with primary tumour and to assess human papilloma virus (HPV) status. HPV positive biopsy from CUP may indicate oropharynx primary. HPV positive OPSCC has better prognosis. HPV association is ascertained by p16 immunocytochemistry (p16- IHC) and HPV DNA in situ hybridization (HPV-ISH). In a cohort of OPSCC patients from a single referral centre 68% had metastatic disease. Core biopsy was optimal for HPV testing.

Method

Retrospective review of records from Transoral Robotic Surgery (TORS) patients treated for OPSCC between December 2017-2019 was conducted. Cohort included patients undergoing TORS for diagnostic purposes and with curative intent.

Results

Data was available from 23 patients who had TORS for OPSCC. 47.8% (n = 11) presented with lymphadenopathy. 82.6% (n = 19) underwent FNAC. 68.4% (n = 13) were diagnosed with metastatic OPSCC and 56.5% (n = 13) underwent neck dissections. 52.2% (n = 12) had confirmed HPV positive metastases, 75% (n = 9) had 1 node positive, 25% (n = 3) had &gt;1 node positive. FNAC yielded enough tissue for p16 IHC and HPV-ISH in 10.5% (n = 2). CB yielded sufficient tissue for analysis in all cases 39.1% (n = 9).

Conclusions

The study confirms high incidence of neck metastases in HPV associated OPSCC patients. Needle core biopsy appears superior to FNAC for tissue sampling to assess HPV status in tumours metastatic to neck.

1692 No Longer Unknown: A Systematic Review & Meta-Analysis of The Effectiveness of Trans-Oral Surgical Techniques in Identifying Head and Neck Primary Cancer in Carcinoma Unknown Primary

Aim

The use of transoral robotic surgery (TORS), transoral laser microsurgery (TLM) and more recently reported transoral endoscopic electrocautery (TOEC) in the identification of the primary cancer in CUP patients has gained popularity. This systematic review aims to assess the effectiveness of TORS, TLM and TOEC.

Method

A systematic review and meta-analysis using the Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA) reporting methodology was carried out to assess the effectiveness of the three trans-oral surgical techniques. EMBASE, MEDLINE and CINAHL databases were searched from inception to September 2020. Primary outcome measure was detection rates of primary cancer of the different techniques. Secondary outcome measures were complications and length of hospital stay.

Results

289 studies were identified of which 30 met the inclusion criteria (28 case series and 2 case reports). The overall combined primary identification rate was 72.3% (567 /777 patients). The primary identification rates were 49.7% and 34.2% in lingual (n = 273) and palatine tonsillectomy (n = 118) respectively. The primary cancer identification rates by surgical techniques are: TORS was 60% (CI 0.49, 0.70), TLM was 80% (CI 0.58, 1.01), TOEC was 41% (CI 0.05, 0.76). The commonest complication was haemorrhage (5.3%).

Conclusions

This is the largest systematic review in the subject and incorporates the more recently published surgical technique of TOEC. Lingual tonsillectomy is an effective procedure in CUP work up. Further larger, multi-centre, prospective studies of PET CT negative CUP patients is needed to draw conclusive results

Treating early-stage Hodgkin lymphoma in resource-limited settings: InPOG-HL-15-01 experience

BACKGROUND

Hodgkin lymphoma (HL) in childhood is an eminently curable disease. Excellent outcomes can be achieved even in resource-limited settings and increasingly, the focus is on limiting long-term toxicity. Contemporary treatment incorporates a risk-stratified, response-adapted approach using multiagent chemotherapy with or without low-dose radiotherapy (RT). Many developing countries continue to use ABVD (adriamycin, bleomycin, vinblastin, and dacarbazine)-based regimen owing to limited acute toxicity, cost, and ease of delivery. We report outcomes of children with early-stage HL using limited cycles of ABVD-based treatment in the first prospective multicentric collaborative study from India InPOG-HL-15-01.

METHODS

Children <18 years with biopsy-proven HL were enrolled. Patients with stages I and IIA with or without bulky disease were classified as having early-stage disease. Patients were planned to receive four cycles of ABVD subject to satisfactory early response assessment (ERA) scheduled after two cycles of chemotherapy. RT was limited to patients with bulky disease or those with suboptimal ERA.

RESULTS

Four hundred ten patients were enrolled over 30 months from 27 centers. One hundred thirty-four were classified as having early-stage disease. Fifty-three (40%) of these had bulky disease. One hundred ten (83%) of this cohort achieved complete or very good partial ERA. Fifty-four (40%) received RT. At a median of 52 months since diagnosis, 5-year event-free survival (EFS) and overall survival (OS) is 94% and 95.5%, respectively. Treatment-related mortality and abandonment were <1%.

CONCLUSION

Limited cycles of ABVD with RT to selected patients is a very effective option for patients with early-stage disease in resource-limited settings.

Snapshots Quiz

A 55-year-old male presented with a 6 month history of multiple swellings on the right buttock and sacral region with yellowish discharge. The patient frequently walked bare foot, but denied any history trauma. Fine needle aspirate cytology showed acute dense inflammation, nuclear debris and numerous filamentous bacilli, which on staining revealed gram positive bacilli. What is the diagnosis?

Modified vertical osteotomy cut in bilateral sagittal split osteotomy

Bilateral sagittal split osteotomy (BSSO) is the most common orthognathic surgical procedure for the correction of facial deformities. Like any other surgical procedure, it is also associated with a risk of complications. One of these is described in the literature as notching at the lower inferior border of the mandible. Such discontinuity in the contour of the lower border is often a concern for patients. To overcome this complication, we recommend a modified vertical osteotomy cut while performing BSSO.

Is HRCT reliable in determining disease activity in pulmonary tuberculosis?

Aims and Objectives The purpose of our study is to [1] determine the activity of disease based on the HRCT findings (2) to define indications for the use of HRCT in evaluation of Pulmonary TB and (3) to determine whether additional information provided by HRCT alters clinical management of the disease. Materials and Methods The present study was carried out at Shree Sayajirao General Hospital (SSGH), Baroda, Gujarat, India from January 2002 to December 2002. Twenty five patients with sputum positive post-primary pulmonary TB were studied prospectively with chest radiographs and HRCT. The diagnosis of active TB was based on detection of acid-fast bacilli in sputum. None of the patients in our study population was HIV positive. All patients underwent x-ray chest and HRCT chest (Philips Tomoscan, Best, Netherlands). The pattern, extent and severity of HRCT findings were recorded and compared with the plain x-ray findings. The gathered information and investigations were subjected to statistical analysis. Results Our study population consisted of sputum positive (AFB positive) 25 patients, 22 of them were newly diagnosed/suspected post-primary tuberculosis (GROUP 1) and 3 of them had taken six months of AKT (GROUP 2). Our study included 22 males and 3 females with average age of 38 years (range, 14-65 years.) In total chest radiographic signs of active tuberculosis were seen in twelve (48%) patients. HRCT showed evidences of active tuberculosis in all 22 patients of newly diagnosed tuberculosis; and in 2 out of 3 patients with prior history of AKT. Thus, total of 24 (96%) patients had evidence of active pulmonary TB on HRCT. One patient with prior history of AKT showed evidence of pulmonary Koch′s sequel. Conclusion Although chest radiography remains the foremost imaging technique in the evaluation of pulmonary TB, HRCT can be useful in certain circumstances and can provide important information in the diagnosis and management of the disease. HRCT is helpful in the distinction of active form inactive TB. HRCT is better than plain chest radiograph in identification of extent of pulmonary TB, especially subtle areas of consolidation, cavitation, bronchogenic and miliary spread. HRCT is recommended when the radiographic findings are normal or inconclusive and tuberculosis is suspected clinically for the confirmation of diagnosis and determination of activity.

A65 ENDOSCOPIST-TARGETED INTERVENTIONS TO OPTIMIZE ADENOMA DETECTION RATE - A SYSTEMATIC REVIEW AND META-ANALYSIS

Background

Adenoma detection rate (ADR) has emerged as the strongest quality assurance metric that has consistently been shown to be inversely associated with the development of colorectal cancer after colonoscopy. Unfortunately, marked variability in ADR exists among endoscopists. A multitude of interventions targeted at endoscopists to optimize their ADR have been reported, including but not limited to withdrawal time, in room observers, physician report cards, and quality improvement and training programs. However, it is unclear which of them are truly effective.

Aims

We performed a systematic review and meta-analysis of the literature to evaluate the effectiveness of endoscopist-targeted interventions to improve adenoma detection rate (ADR) or polyp detection rate (PDR).

Methods

Systematic searches of major databases were conducted through to March 2018 to identify potentially relevant studies. Both randomized controlled trials and observational studies were included. Data for ADR and PDR were analyzed on the log-odds scale using a random-effects meta-analysis model using restricted maximum likelihood (with Mantel-Haenszel fixed-effect meta-analysis used for fewer than 4 studies). Statistical effect-size heterogeneity was assessed using a Chi2 test and quantifying the relative proportion of variation using the I2 statistic. Publication bias was assessed by the Harbord regression test.

Results

From 4299 initial studies, 24 were included in the systematic review and 13 were included in the meta-analysis representing a total of 55,090 colonoscopies. Physician report card interventions (7 studies) and withdrawal time focused interventions (6 studies) were meta-analyzed. The pooled odds ratio for ADR for report card interventions was 1.31 (95% CI: 1.15, 1.50; p&lt;0.0001), favoring report cards to detect more adenomas. Statistical heterogeneity was detected with substantial relative effect-size variability (Chi2, p&lt;0.0001; I2=80.1%). No statistical evidence of publication bias was found. 6 studies reported data for PDR using withdrawal time focused interventions, with 3 of these reporting data on ADR. The pooled odds ratio for ADR was 1.02 (95% CI: 0.86, 1.22; p=0.81) and for PDR was 1.07 (95% CI: 0.88, 1.31; p=0.51) which were not statistically significant. Statistical heterogeneity was detected in both groups (Chi2, p&lt;0.001; I2=82.2% for ADR and I2=89.4% for PDR) and there was statistical evidence of publication bias. Figures 1 and 2 represent Forest plots for the effect of pre-and post-report card and withdrawal time focused interventions on ADR.

Conclusions

Our study provides evidence that the distribution of colonoscopy quality report cards to physicians significantly improves overall ADR and should strongly be considered as part of quality improvement programs aimed at optimizing colonoscopy performance.

Funding Agencies

None

Safety and outcomes of percutaneous tracheostomy in coronavirus disease 2019 pneumonitis patients requiring prolonged mechanical ventilation

OBJECTIVES

Tracheostomy for coronavirus disease 2019 pneumonitis patients requiring prolonged invasive mechanical ventilation remains a matter of debate. This study analysed the timing and outcomes of percutaneous tracheostomy, and reports our experience of a dedicated ENT-anaesthetics department led tracheostomy team.

METHOD

A prospective single-centre observational study was conducted of patients undergoing tracheostomy, who had been diagnosed with coronavirus disease 2019 pneumonitis, between 21st March and 20th May 2020.

RESULTS

Eighty-one patients underwent tracheostomy after a median (interquartile range) of 16 (13-20) days of invasive mechanical ventilation. Median follow-up duration was 32 (23-40) days. Of patients, 86.7 per cent were successfully liberated from invasive mechanical ventilation in a median (interquartile range) of 12 (7-16) days. Moreover, 68.7 per cent were subsequently discharged from hospital. On univariate analysis, there was no difference in outcomes between early (before day 14) and late (day 14 or later) tracheostomy. The mortality rate was 8.6 per cent and no deaths were tracheostomy related.

CONCLUSION

Outcomes appear favourable when patients are carefully selected. Percutaneous tracheostomy performed via a multidisciplinary approach, with appropriate training, was safe and optimised healthcare resource utilisation.

The role of transoral fine needle aspiration in expediting diagnosis and reducing risk in head and neck cancer patients in the coronavirus disease 2019 (COVID-19) era: a single-institution experience

OBJECTIVE

The global coronavirus disease 2019 (COVID-19) pandemic has necessitated rapid alterations to diagnostic pathways for head and neck cancer patients that aim to reduce risk to patients (exposure to the hospital environment) and staff (aerosol-generating procedures). Transoral fine needle aspiration cytology offers a low-risk means of rapidly diagnosing patients with oral cavity or oropharyngeal lesions. The technique was utilised in selected patients at our institution during the pandemic. The outcomes are considered in this study.

METHOD

Diagnostic outcomes were retrospectively evaluated for a series of patients undergoing transoral fine needle aspiration cytology of oral cavity and oropharyngeal lesions during the COVID-19 pandemic.

RESULTS

Five patients underwent transoral fine needle aspiration cytology, yielding lesional material in 100 per cent, with cell blocks providing additional information. In one case, excision biopsy of a lymphoproliferative lesion was required for final diagnosis.

CONCLUSION

Transoral fine needle aspiration cytology can provide rapid diagnosis in patients with oral cavity and oropharyngeal lesions. Whilst limitations exist (including tolerability and lesion location), the technique offers significant advantages pertinent to the COVID-19 era, and could be employed in the future to obviate diagnostic surgery in selected patients.

Oral health care among patients with diabetes in Australia: A snapshot

Background

Diabetes increases the risk of periodontal disease, which in turn negatively impact on diabetes control and complications. Therefore, awareness about the diabetes-oral health link and dental problems is important for people with diabetes. This study aimed to assess self-reported oral health status and knowledge of people living with diabetes.

Methods

A survey was conducted among patients who attended four public diabetes clinics in Sydney, Australia. The questionnaire included 10 knowledge items and a validated Oral Health Impact Profile (OHIP-14) scale. A convenience sample of 200 patients were recruited. The data were analysed using SPSS software with descriptive and Pearson's Chi-Squared tests reported.

Results

The mean age of participants was 62.4(±13.5) years. More than half were males (54.5%), born overseas (64%), not working (73%) and had type 2 diabetes (88%). More than half (55.1%) of the patients reported having one or more dental problems and this was negatively associated with their oral health-related quality of life (p &lt; 0.001). The most common dental problems were: gaps between teeth, pain in teeth and dry mouth. Only 46.2% of the participants had adequate oral health knowledge (&gt; the mean correct score 5.2 (±2.6). The main areas with poor knowledge were around the impact of gum disease on blood glucose levels (29.6%), effects of dry mouth on tooth decay (33.8%) and the link between diabetes and teeth and gums (44.5%). Only 13% of the patients reported receiving oral health information from diabetes care providers (diabetes educator, general practitioner/diabetes specialist and dietitian/nutritionist). Receiving oral health information was found to be significantly associated with higher oral health knowledge scores (p &lt; 0.05).

Conclusions

Considering that a majority of patients with diabetes have dental problems and inadequate oral health knowledge, diabetes care providers should take the opportunity to educate patients about oral health risks.

Key messages

People living with diabetes found to have dental problems and inadequate oral health knowledge. Considering that diabetes and dental problems adversely affect each other, it is crucial to educate patients about good oral hygiene and regular dental visit.

Haploinsufficiency of X-linked intellectual disability gene CASK induces post-transcriptional changes in synaptic and cellular metabolic pathways

Heterozygous mutations in the X-linked gene CASK are associated with intellectual disability, microcephaly, pontocerebellar hypoplasia, optic nerve hypoplasia and partially penetrant seizures in girls. The Cask^+/- heterozygous knockout female mouse phenocopies the human disorder and exhibits postnatal microencephaly, cerebellar hypoplasia and optic nerve hypoplasia. It is not known if Cask^+/- mice also display seizures, nor is known the molecular mechanism by which CASK haploinsufficiency produces the numerous documented phenotypes. 24-h video electroencephalography demonstrates that despite sporadic seizure activity, the overall electrographic patterns remain unaltered in Cask^+/- mice. Additionally, seizure threshold to the commonly used kindling agent, pentylenetetrazol, remains unaltered in Cask^+/- mice, indicating that even in mice the seizure phenotype is only partially penetrant and may have an indirect mechanism. RNA sequencing experiments on Cask^+/- mouse brain uncovers a very limited number of changes, with most differences arising in the transcripts of extracellular matrix proteins and the transcripts of a group of nuclear proteins. In contrast to limited changes at the transcript level, quantitative whole-brain proteomics using iTRAQ quantitative mass-spectrometry reveals major changes in synaptic, metabolic/mitochondrial, cytoskeletal, and protein metabolic pathways. Unbiased protein-protein interaction mapping using affinity chromatography demonstrates that CASK may form complexes with proteins belonging to the same functional groups in which altered protein levels are observed. We discuss the mechanism of the observed changes in the context of known molecular function/s of CASK. Overall, our data indicate that the phenotypic spectrum of female Cask^+/- mice includes sporadic seizures and thus closely parallels that of CASK haploinsufficient girls; the Cask^+/- mouse is thus a face-validated model for CASK-related pathologies. We therefore surmise that CASK haploinsufficiency is likely to affect brain structure and function due to dysregulation of several cellular pathways including synaptic signaling and cellular metabolism.

Global, Regional, and National Levels and Trends in Burden of Oral Conditions from 1990 to 2017: A Systematic Analysis for the Global Burden of Disease 2017 Study

Government and nongovernmental organizations need national and global estimates on the descriptive epidemiology of common oral conditions for policy planning and evaluation. The aim of this component of the Global Burden of Disease study was to produce estimates on prevalence, incidence, and years lived with disability for oral conditions from 1990 to 2017 by sex, age, and countries. In addition, this study reports the global socioeconomic pattern in burden of oral conditions by the standard World Bank classification of economies as well as the Global Burden of Disease Socio-demographic Index. The findings show that oral conditions remain a substantial population health challenge. Globally, there were 3.5 billion cases (95% uncertainty interval [95% UI], 3.2 to 3.7 billion) of oral conditions, of which 2.3 billion (95% UI, 2.1 to 2.5 billion) had untreated caries in permanent teeth, 796 million (95% UI, 671 to 930 million) had severe periodontitis, 532 million (95% UI, 443 to 622 million) had untreated caries in deciduous teeth, 267 million (95% UI, 235 to 300 million) had total tooth loss, and 139 million (95% UI, 133 to 146 million) had other oral conditions in 2017. Several patterns emerged when the World Bank’s classification of economies and the Socio-demographic Index were used as indicators of economic development. In general, more economically developed countries have the lowest burden of untreated dental caries and severe periodontitis and the highest burden of total tooth loss. The findings offer an opportunity for policy makers to identify successful oral health strategies and strengthen them; introduce and monitor different approaches where oral diseases are increasing; plan integration of oral health in the agenda for prevention of noncommunicable diseases; and estimate the cost of providing universal coverage for dental care.

A199 BLACK ESOPHAGUS: AN UNDER-RECOGNIZED CAUSE OF UPPER GASTROINTESTINAL BLEEEDING

Background

“Black esophagus” is a term that refers to the endoscopic manifestation of acute esophageal necrosis (AEN), a rare but potentially under-recognized cause of upper gastrointestinal bleeding, characterized by the presence of strikingly black necrotic esophagus on upper endoscopy. The etiology is unclear although ischemic insults and caustic injury from gastric acid exposure are thought to play prominent roles. This condition is often seen in patients who are systemically unwell and have underlying comorbidities such as diabetes mellitus and vascular diseases.

Aims

We present a case of an elderly woman with diabetes and poor glycemic control who developed coffee ground emesis with her upper endoscopy revealing evidence of acute esophageal necrosis. AEN is an important diagnosis to consider in diabetic patients, as it generally carries a poor prognosis with mortality rates as high as 32% reported in the literature.

Methods

Case report and review of the literature

Results

A 61-year-old woman with medical history significant for poorly controlled insulin dependent diabetes (hemoglobin A1c, 11%) developed coffee ground emesis (confirmed via insertion of nasogastric tube) three days after initial admission to hospital for left tibial plateau fracture. Her bloodwork did not reveal any underlying diabetic ketoacidosis or hyperosomlar hyperglycemic state. Her esophagogastroduodenoscopy (EGD) showed black, necrotic-appearing discoloration of the esophageal mucosa circumferentially within the mid to distal part of the esophagus with a sharp transition point towards normal appearing mucosa at the gastroesophageal junction. Biopsies were deferred due to high risk of bleeding and perforation, and the previously placed nasogastric tube was not removed.

After endoscopy, conservative management was advised with restricted oral intake, intravenous proton pump inhibitor (PPI) inhibitor therapy for 72 hours and aggressive treatment of ongoing hyperglycemia. There were no signs or symptoms of esophageal rupture. The patient gradually recovered and in fact had her orthopedic surgery within a week of EGD. Furthermore, three days into the post operative period she developed venous thromboembolism and was placed on full dose oral anticoagulation and tolerated this without any further gastrointestinal bleeding.

Conclusions

AEN is an important diagnostic consideration in elderly diabetic patients presenting with acute upper gastrointestinal bleeding, particularly as timely recognition and management can significantly lower the unfavorable mortality associated with this condition.

Funding Agencies

None