Disruption of proteome by an oncogenic fusion kinase alters metabolism in fibrolamellar hepatocellular carcinoma

Fibrolamellar hepatocellular carcinoma (FLC) is a usually lethal primary liver cancer driven by a somatic dysregulation of protein kinase A. We show that the proteome of FLC tumors is distinct from that of adjacent nontransformed tissue. These changes can account for some of the cell biological and pathological alterations in FLC cells, including their drug sensitivity and glycolysis. Hyperammonemic encephalopathy is a recurrent problem in these patients, and established treatments based on the assumption of liver failure are unsuccessful. We show that many of the enzymes that produce ammonia are increased and those that consume ammonia are decreased. We also demonstrate that the metabolites of these enzymes change as expected. Thus, hyperammonemic encephalopathy in FLC may require alternative therapeutics.

Pancreatoduodenectomy for suspected malignancy: nonmalignant histology confers increased risk of serious morbidity

BACKGROUND/AIMS

A tissue diagnosis is not always obtained prior to pancreatoduodenectomy (PD) and a proportion of patients are found to have noncancerous histology postoperatively. It is unknown if these patients have different outcomes when compared with those who have malignancy confirmed.

METHODS

A retrospective paired case matched control study was undertaken. Patients who underwent PD for suspected malignancy but ultimately had nonmalignant histology were identified. Each was matched to a confirmed malignant control using the following criteria: age, gender, body mass index, American Society of Anesthesiologists grade, neoadjuvant treatment, preoperative serum bilirubin, preoperative biliary stenting and type of pancreatic anastomosis. Matching was blinded to the measured outcomes, which included perioperative morbidity and mortality.

RESULTS

Forty-five cases were compared with 45 well-matched controls. There was no difference in 30- or 90-day mortality, or length of stay. While overall morbidity rates were the same, patients with nonmalignant disease were more likely to experience major (Clavien-Dindo grade III-IV) morbidity (40.0% versus 17.8%, p = 0.0352). Independently, rates of clinically relevant pancreatic fistula (CR-POPF) were higher in the nonmalignant group (22.2% versus 4.44%, p = 0.0131).

CONCLUSIONS

In our study, PD patients with nonmalignant histology had significantly higher incidence of major morbidity and CR-POPF when compared with those who had malignancy confirmed. This should be considered when planning the management of patients with known or presumed benign/premalignant disease.

1195 EFFECTIVENESS OF A NEW PROACTIVE MULTIDISCIPLINARY CARE SERVICE FOR OLDER PEOPLE WITH FRAILTY: A NON-RANDOMISED CONTROLLED TRIAL

Introduction

Integrated care potentially improves health outcomes for older people with frailty. We aimed to assess the effectiveness of a new, proactive, multidisciplinary care service in improving the wellbeing and quality-of-life of older people with frailty.

Methods

A community-based non-randomised controlled trial. Participants (≥65 years, electronic Frailty Index ≥0.36) received either this new integrated care service plus usual care, or usual care alone. Data collection was at 3 time points: baseline, 2-4 weeks, and 10-14 weeks; the primary outcome was patient well-being at 2-4 weeks, measured using the Integrated Patient Outcome scale, IPOS. The secondary outcome was quality-of-life, measured using EQ-5D. Wellbeing and quality-of-life at 10-14 weeks were measured to test safety and duration of effect. Data was analysed with STATA v17.

Results

199 intervention and 54 control participants were recruited. At baseline, participants were similar in age/gender/body mass index/ethnicity/living status. At 2-4 weeks, the intervention group had improved well-being (median IPOS reduction 5, versus control group increase 2, p<0.001) and improved quality of life (median EQ-5D index values increase 0.12, versus control 0.00, p<0.001); these were clinically significant. After adjusting for age, gender and living status, intervention group had an average total IPOS score reduction of 6.34 (95% CI: -9.01: -4.26, p<0.05). Propensity score matching analysis based on functional status/deprivation score showed similar results (reduction in IPOS score in intervention group 7.88 (95% CI: -12.80: -2.96, p<0.001). At 10-14 weeks, the intervention group sustained well-being improvement (median IPOS score reduction 4, versus control increase 2, p<0.001) and improved quality of life (median EQ-5D index values increase 0.06, versus control -0.01, p<0.001).

Conclusion

This new integrated care service improves the overall wellbeing and quality of life of older people with frailty at 2-4 weeks; improvement was sustained at 3 months.

Ethics Approval: IRAS-250981 and NHS Research Ethics Committee 18/YH/0470.

Can virtual reality technology be considered as a part of the surgical care pathway?

INTRODUCTION

Virtual reality (VR) is emerging as a new technology in the healthcare sector. It has been shown to enhance the patient's experience and satisfaction in various settings. This review aims to give a brief description of the use of VR and establish validity of its applications to improve the patient's pathway through surgery.

METHODS

A literature search was conducted using the PubMed and Embase™ databases to identify fields in which VR technology has been trialled in relation to surgery. The search terms 'virtual reality' and 'surgery' were employed.

RESULTS

Although benefits relating to VR use have been identified in mental health, obesity management, and physical and cognitive rehabilitation, those in surgery have been less well documented. There are, however, some important but limited benefits reported in managing surgery related stress and improving preoperative patient education as well as VR being an adjunct to some level of postoperative analgesia.

CONCLUSIONS

The current applications of VR in relation to surgical care fall into four main categories: preoperative education, supporting mental health, postoperative pain management, and pre and postoperative patient optimisation. Future studies and validation of VR applications should be carried out so the technology can be utilised throughout the entire patient pathway as VR surgical care bundles.

Small-molecule inhibitors of P-Rex guanine-nucleotide exchange factors

P-Rex1 and P-Rex2 are guanine-nucleotide exchange factors (GEFs) that activate Rac small GTPases in response to the stimulation of G protein-coupled receptors and phosphoinositide 3-kinase. P-Rex Rac-GEFs regulate the morphology, adhesion and migration of various cell types, as well as reactive oxygen species production and cell cycle progression. P-Rex Rac-GEFs also have pathogenic roles in the initiation, progression or metastasis of several types of cancer. With one exception, all P-Rex functions are known or assumed to be mediated through their catalytic Rac-GEF activity. Thus, inhibitors of P-Rex Rac-GEF activity would be valuable research tools. We have generated a panel of small-molecule P-Rex inhibitors that target the interface between the catalytic DH domain of P-Rex Rac-GEFs and Rac. Our best-characterized compound, P-Rex inhibitor 1 (PREX-in1), blocks the Rac-GEF activity of full-length P-Rex1 and P-Rex2, and of their isolated catalytic domains, in vitro at low-micromolar concentration, without affecting the activities of several other Rho-GEFs. PREX-in1 blocks the P-Rex1 dependent spreading of PDGF-stimulated endothelial cells and the production of reactive oxygen species in fMLP-stimulated mouse neutrophils. Structure-function analysis revealed critical structural elements of PREX-in1, allowing us to develop derivatives with increased efficacy, the best with an IC₅₀ of 2 µM. In summary, we have developed PREX-in1 and derivative small-molecule compounds that will be useful laboratory research tools for the study of P-Rex function. These compounds may also be a good starting point for the future development of more sophisticated drug-like inhibitors aimed at targeting P-Rex Rac-GEFs in cancer.

SP1.1.14Future Insights on Virtual Reality Potential Uses as a Care Package for Colorectal Patients

Aim

To provide an insight on current applications of immersive virtual reality (VR) on patients undergoing surgery and to project the potential uses of these applications on colorectal population.

Methods

A non-systematic literature search of PubMed using key subject “Virtual Reality and Surgery” to identify relative articles. On reviewing applications of VR in surgery we identified four main areas of interest: preoperative education, perioperative support, postoperative pain management and rehabilitation.

Results

VR technology showed promising results in all three stages of patient’s journey ; In pre-surgery, VR was used as a powerful educational tool for vascular patients. Intraoperatively, it showed promising results as a distraction method to relief stress and discomfort in patients undergoing colonoscopy and gynaecology procedures. Postoperatively, VR was utilized in pain management in orthopaedics, cardiothoracic populations with acceptable results. Moreover, physical rehabilitation showed a strong outlet of the technology due to its engaging properties.

Conclusion

VR has been showing applicable benefits in different stages of patient’s care undergoing surgery. With proper future development of Its applications, VR potentials in colorectal population could be numerous; education on stoma and type of surgery with help of 3D environment, distraction tool for colonoscopy screening and postoperative pain. In addition, VR could help with enhanced recovery inform of physical and mental rehabilitation. Future uses of VR in colorectal population could be a key in improving outcomes and overall satisfactions. However, formulated studies and validated applications should be tackled to apply the technology safely in the standard care of colorectal patients.

Impact of COVID-19 on angioplasty service and outcome of patients treated for critical limb ischaemia

Background

Peripheral artery disease (PAD) is a major challenge worldwide and endovascular revascularization is an important component of treatment that is affected by COVID-19 restrictions.

Purpose

Here, we evaluated the impact of COVID-19 restriction on angioplasty service and outcome of patients undergoing lower limb angioplasty.

Methods

Consecutive patients undergoing endovascular revascularisation between August 2018-March 2021 in a UK district general hospital were analysed retrospectively. Indications for angioplasty of all patients were discussed and agreed upon in multi-disciplinary teams. We compared time from referral to angioplasty, patient and procedural characteristics, technical success, peri-procedural complications, and outcome (wound healing, major amputation, target lesion revascularization, death) in patients treated 'before' and after February 2020 (“during COVID-19”).

Results

One hundred nineteen patients were treated 'before' (92% critical limb ischaemia [CLI]; 60% diabetes mellitus) and 72 were treated 'during COVID-19' (96% CLI; 61% diabetes mellitus). While the total monthly number of patients treated did not change, the number of outpatients treated as day cases increased (40% to 72%) and overnight stays for social reasons decreased (16% to 10%). Treatment of hospitalized patients decreased from 44% to 18%. The percentage of outpatients treated at <14 days after referral increased from 39% to 63% and hospitalized patients treated <5 days from 47% to 54%. Neither COVID-19 nor time to procedure affected wound healing (p(log Rank) = 0.451; median time to healing 168±25 days) and amputation free survival (p(log Rank) = 0.924; median survival 368±30 days) in all CLI patients significantly. However, amputation-free survival was significantly worse in hospitalized as compared to outpatients (p(log Rank) <0.001; median survival 155±20 vs 368±30 days) with similar wound healing in those that survived (p(log Rank) = 0.340; median time to wound healing 168±25 days). Of note, the known causes of death were sepsis (32%), pneumonia (18%), COVID pneumonia (18%), cardiac (16%) and stroke (8%).

Conclusions

Adapting to COVID-19 restriction we maintained a safe and effective angioplasty service while shortening waiting times. Very high mortality rates in patients after hospitalization indicated that CLI need to be treated much earlier and more aggressively to avoid disease progression requiring hospitalization.

Funding Acknowledgement

Type of funding sources: None.

156 Could a Cohort of Patients be Listed Directly from Video Clinic to Surgery with Assessment on Day of Surgery? The Implementation of Video Clinic in Surgical Patients During the COVID-19 Lockdown

Aim

To report the feasibly and the safety of utilizing video Clinic during the 2020 pandemic in scheduling a cohort of patients to laparoscopic cholecystectomy (LC) without the need of face-to-face assessment.

Method

A retrospective audit from May to October 2020 was conducted on patients with symptomatic biliary colic disease and selected low risk demographics who were vetted and scheduled for laparoscopic cholecystectomy through video clinic under one of the general surgeons (AC) in a large district hospital. All patients were given the option to have their face-to-face assessment on the day of surgery and if there would be any concerning signs, they would be postponed or investigated if required.

Results

33 patients agreed on the proposed option and were scheduled to LC based on virtual assessment, mean age of 42(±13) years old and 26(79%) were females. 16 (49%) patients had their surgery with average waiting time of 2.1(±1) months and mean BMI of 29.9(±7). 17 (51%) patients are pending future surgery dates. there was no cancellation based on surgery day assessment and or unexpected events intraoperatively.

Conclusions

As virtual clinics played a major role in providing healthcare services during the global pandemic, scheduling patients to surgery without face-to-face assessment was applicable and safe in selected demographics. This could have the potential of reducing waiting time, travelling costs and hospital visits. Moreover, communications with patients regarding the proposed same day assessment played a vital role in reaching a mutual agreement.

62 Evaluation of Laparoscopic Cholecystectomy with the help of AI-Video Analytics Platform

Aim

This report aims to evaluate the use of an AI video analytics platform in laparoscopic cholecystectomy (LC) based on the achievement of the critical view of safety (CVS) and to assess its ability to correctly comment on CVS.

Method

Touch surgery video platform, an AI-video based analytic tool, was screened for laparoscopic cholecystectomy in our institute and analysed from April 2019 till October 2020. Data collected by the AI included identification of the critical view of safety and time needed to achieve CVS. A reviewer graded the LC according to Nasser grading and evaluated the ability of AI to identify the CVS.

Results

66 LC were included from our video database. CVS was achieved in only 56% (37/66) in all LC videos included. Mean time spent to attend CVS from start of dissection of Calot’s triangle 16.8 (±13.6) mins. 26 (39.4%) LCs were Nasser grade 2 and 20 (30.3%) each were grade 1 and grade 3. There was no significant difference between number of CVS obtained between all grades. Time spent to achieve CVS from dissecting Calot’s triangle were the longest in grade 3 LCs (28.4±17.4 mins) with significant difference between all 3 grades. Finally, the platform correctly commented on CVS in 92.4% of the all LC videos.

Conclusions

AI video analytics can provide a useful tool to assess laparoscopic cholecystectomies and the critical view of safety. Additionally, more studies should explore the use of the platfrom and integrate the results with the clinical outcomes.

Antibiotic-exposed patients with non-small-cell lung cancer preserve efficacy outcomes following first-line chemo-immunotherapy

BACKGROUND

Prior antibiotic therapy (pATB) is known to impair efficacy of single-agent immune checkpoint inhibitors (ICIs), potentially through the induction of gut dysbiosis. Whether ATB also affects outcomes to chemo-immunotherapy combinations is still unknown.

PATIENTS AND METHODS

In this international multicentre study, we evaluated the association between pATB, concurrent ATB (cATB) and overall survival (OS), progression-free survival (PFS) and objective response rate (ORR) in patients with non-small-cell lung cancer (NSCLC) treated with first-line chemo-immunotherapy at eight referral institutions.

RESULTS

Among 302 patients with stage IV NSCLC, 216 (71.5%) and 61 (20.2%) patients were former and current smokers, respectively. Programmed death-ligand 1 tumour expression in assessable patients (274, 90.7%) was ≥50% in 76 (25.2%), 1%-49% in 84 (27.9%) and <1% in 113 (37.5%). Multivariable analysis showed pATB-exposed patients to have similar OS {hazard ratio (HR) = 1.42 [95% confidence interval (CI): 0.91-2.22]; P = 0.1207} and PFS [HR = 1.12 (95% CI: 0.76-1.63); P = 0.5552], compared to unexposed patients, regardless of performance status. Similarly, no difference with respect to ORR was found across pATB exposure groups (42.6% versus 57.4%, P = 0.1794). No differential effect was found depending on pATB exposure duration (≥7 versus <7 days) and route of administration (intravenous versus oral). Similarly, cATB was not associated with OS [HR = 1.29 (95% CI: 0.91-1.84); P = 0.149] and PFS [HR = 1.20 (95% CI: 0.89-1.63); P = 0.222] when evaluated as time-varying covariate in multivariable analysis.

CONCLUSIONS

In contrast to what has been reported in patients receiving single-agent ICIs, pATB does not impair clinical outcomes to first-line chemo-immunotherapy of patients with NSCLC. pATB status should integrate currently available clinico-pathologic factors for guiding first-line treatment decisions, whilst there should be no concern in offering cATB during chemo-immunotherapy when needed.

Use of MASCC score in the inpatient management of febrile neutropenia: a single-center retrospective study

Purpose

The Multinational Association for Supportive Care in Cancer (MASCC) score is used to risk stratify outpatients with febrile neutropenia (FN). However, it is rarely used in hospital settings. We aimed to describe management, use of MASCC score, and outcomes among hospitalized patients with FN.

Methods

We conducted a retrospective cohort study of patients with cancer and FN. We collected patient demographics, cancer characteristics, microbiological profile, MASCC score, utilization of critical care therapies, documentation of goals of care (GOC), and inpatient deaths. Outcomes associated with low- (≥ 21) versus high-risk (< 21) MASCC scores are presented as absolute differences.

Results

Of 193 patients, few (2%, n = 3) had MASCC scores documented, but when calculated, 52% (n = 101) had a high-risk score (< 21). GOC were discussed in 12% (n = 24) of patients. Twenty one percent (n = 40) required intermediate/ICU level of care, and 12% (n = 23) died in the hospital. Those with a low-risk score were 33% less likely to require intermediate/ICU care (95% CI 23 to 44%) and 19% less likely to die in the hospital (95% CI 10% to 27%) compared to those with high-risk score.

Conclusions

MASCC score was rarely used for hospitalized patients with FN, but high-risk score was associated with worse outcomes. Education efforts to incorporate MASCC score into the workflow may help identify patients at high risk for complications and help clinicians admit these patients to a higher level of care (e.g., intermediate/ICU care) or guide them to initiate earlier GOC discussions.

Nosocomial COVID-19: experience from a large acute NHS Trust in South-West London

Transmission of coronavirus disease 2019 (COVID-19) in healthcare settings has significant implications for patients and healthcare workers, may amplify local outbreaks, and may place additional burden on already stretched resources. Risk of missed or late diagnosis of COVID-19 was high during the UK's initial 'containment phase', because of strict criteria for testing. The risk remains due to asymptomatic/pre-symptomatic transmission, complicated by challenges faced with laboratory testing. We present a case study of potential nosocomial transmission associated with the first case of COVID-19 at a large acute NHS Trust in South-West London, and we describe the prevailing burden of nosocomial infections.

Recent declines in salmon body size impact ecosystems and fisheries

Declines in animal body sizes are widely reported and likely impact ecological interactions and ecosystem services. For harvested species subject to multiple stressors, limited understanding of the causes and consequences of size declines impedes prediction, prevention, and mitigation. We highlight widespread declines in Pacific salmon size based on 60 years of measurements from 12.5 million fish across Alaska, the last largely pristine North American salmon-producing region. Declines in salmon size, primarily resulting from shifting age structure, are associated with climate and competition at sea. Compared to salmon maturing before 1990, the reduced size of adult salmon after 2010 has potentially resulted in substantial losses to ecosystems and people; for Chinook salmon we estimated average per-fish reductions in egg production (-16%), nutrient transport (-28%), fisheries value (-21%), and meals for rural people (-26%). Downsizing of organisms is a global concern, and current trends may pose substantial risks for nature and people.

The utility of postoperative radiotherapy in intermediate-risk oral squamous cell carcinoma

The effectiveness of postoperative radiotherapy (PORT) in improving outcomes remains debatable for oral squamous cell carcinoma (OSCC) patients with pathological intermediate-risk factors (IRFs) after surgery. A retrospective analysis was conducted on 432 intermediate-risk OSCC patients defined by histological reporting of close margin (<5mm), early nodal disease (pN1), depth of invasion/tumour thickness ≥5mm, perineural invasion, and/or lymphovascular invasion. Outcomes measured were disease-free survival (DFS), disease-specific survival (DSS), and overall survival (OS). PORT was associated with an improvement in 5-year DFS on univariable analysis (80% vs 71%; P=0.044), but this did not remain significant on multivariable analysis. PORT was not associated with differences in DSS or OS. The surgical salvage rate was similar in the PORT and surgery-only groups (41% vs 47%; P=0.972). Perineural invasion was found to be an independent predictor of inferior DSS (hazard ratio (HR) 2.19), DFS (HR 1.89), and OS (HR 1.97). Significantly worse outcomes were observed for patients with ≥4 concurrent IRFs. The application of PORT was associated with lower rates of recurrence, but the benefit was less apparent on mortality. Patients with perineural invasion and multiple concurrent IRFs were found to be at greatest risk, representing a subset of intermediate-risk OSCC patients who may benefit from PORT.

Retrospective study of the evaluation and management of febrile neutropenia in cancer patients in a tertiary center

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Background: Febrile neutropenia is a medical emergency often managed by internists, but adherence to guidelines has not been well-described. We aimed to describe care and outcomes of a retrospective cohort of patients hospitalized with febrile neutropenia at a single tertiary care hospital. Methods: We included adults ≥18 years old who had a cancer diagnosis and required hospital admission for a principal diagnosis of fever and neutropenia (ANC < 500) from October 2015 - April 2019. We reviewed records to identify demographics, cancer diagnosis and stage, and outcomes, including death. Results: We included 193 patients; all were cared for by hospitalists. About half (52%) were classified as high risk [ < 21 Multinational Association of Supportive Care in Cancer (MASCC)score], but only 1 patient had a documented MASCC score in hospital progress notes. The majority of patients were female (55%) and white (84%). Twenty-three percent had a stage IV diagnosis. Most (89.1%) patients were within their first chemotherapy cycle, and 23% received GCSF. Approximately half (47%) had solid tumors; the remainder had hematologic malignancies. About one quarter (27%) had positive blood cultures (of these, 43.4 % were gram positive cocci (GPC); 49.1% were gram negative rods (GNR)). Most patients received empiric coverage for GPC and GNR: 82% received cefepime and 42% received empiric MRSA coverage. Few patients had cultures positive for resistant organisms such as MRSA (n = 3) or pseudomonas (n = 4). Hematology/Oncology was consulted for most (82%) cases. Inpatient mortality occurred in 12% of patients. Compared to those who survived, patients who died had lower MASCC score 13.9 (vs. 19.1) and were more likely to receive critical care therapies during hospitalization (70% vs. 14%). Few patients (n = 24, 12%) had documented goals of care (GOC) discussions. Conclusions: Although MASCC is predictive of outcomes, internists caring for patients with fever and neutropenia do not document this score. Hospitalist-focused education efforts about MASCC score could improve care. Few patients had documented GOC discussions. Oncologists should maintain good communication with internal medicine colleagues, who may be hesitant to address GOC in patients receiving chemotherapy.

A qualitative risk assessment of cleansing and disinfection requirements after an avian influenza outbreak in commercial poultry

1. During an avian influenza (AI) outbreak in the United Kingdom, the joint aim of the poultry industry and the Government is to eliminate and prevent the spread of infection, through control measures based on the current European Union (EU) Council Directive (2005/94/EC). An essential part of these measures is the cleansing and disinfection (C&D) of infected premises.2. This risk assessment assessed the differences in re-infection in a repopulated flock if the EU Directive is interpreted to permit secondary C&D to be undertaken either with or without dismantling complex equipment. The assessment estimated the probability of virus survival on different types of equipment in a depopulated contaminated poultry house before and after preliminary and secondary C&D procedures. A risk matrix spreadsheet tool was used to carry out the assessment and concluded that, provided secondary C&D is carried out with due diligence (i.e. carried out to a defined code of practice as agreed by both industry and policymakers), the risk of re-infection from equipment is negligible, both with and without dismantling complex equipment in all farm types considered.3. By considering the equipment types individually, the assessment identified those areas of the house which may still contain viable virus post-preliminary C&D and on which attention should be focussed during secondary C&D. The generic risk pathway and matrix spreadsheet tool have the potential to be used for other pathogens and species, given appropriate data.

A-66 Wechsler Test of Adult Reading is a More Useful Indicator of Premorbid Cognitive Functioning than the Reynolds Intellectual Screening Test in Blast Exposed Veterans

Objective

The primary objective of this study was to compare the utility of the Wechsler Test of Adult Reading (WTAR) with the Reynolds Intellectual Screening Test (RIST) as a measure of premorbid cognitive functioning among blast-exposed Veterans.

Method

Sixty-nine Operation Iraqi Freedom/Operation Enduring Freedom (OIF/OEF) Veterans enrolled at the VA Portland Health Center who passed the Test of Memory Malingering (TOMM) were given the WTAR, RIST, and the Neuropsychological Assessment Battery (NAB). Data was analyzed using bi-variate correlational analyses and linear regressions.

Results

Scores on the WTAR were correlated significantly ( p < .05) with RIST, academic achievement, executive functioning (phonemic fluency), and multiple measures of attention, verbal learning and memory, and visuospatial skills. The WTAR was more consistently and strongly associated with those cognitive outcomes than the RIST. A stepwise linear regression was conducted to examine which of these cognitive domains loaded the highest on the WTAR. The overall attention index was the single most significant contributor to WTAR score, F(1,67) = 23.23, p < .001. Phonemic fluency added a significant proportion to the variance in WTAR scores Δr2 = .10, F (2, 66) = 18.30, p < .001.

Conclusions

The utility of word reading measures as indicators of premorbid functioning across multiple domains has been recently questioned. The current data suggests that for blast-exposed Veterans, the WTAR is indeed associated with cognitive functioning in attention, learning/memory, and executive functioning, even more so than the RIST. In particular, the WTAR appears related to attention.

A-70 Beyond Validity: The Utility of the Test of Memory Malingering in Assessing Cognitive Functioning in Veterans

Objective

The objective of the present analyses was to replicate analyses from an interim sample which found that scores on the Test of Memory Malingering (TOMM) predicted objective cognitive outcomes in the domains of attention and verbal learning even when invalid TOMM scores were excluded.

Methods

Participants consisted of 92 United States Veterans from Operation Enduring Freedom/Operation Iraqi Freedom (OEF/OIF) enrolled at the VA Portland Health Care System and recruited for a larger study on the role of blast exposure. Veterans were included if they had a valid performance on the TOMM (Trial 2 score > 47) were not currently substance dependent. Data was analyzed through linear regressions examining raw TOMM Trial 1 scores to predict objective cognitive performance on measures of memory and attention from the Neuropsychological Assessment Battery (NAB).

Results

In performance on the tasks of Driving Scenes (Beta = .328, p < .01), Initial Story Learning (Beta = .209, p < .05), and Attention Index Percentile (Beta = .208, p < .05) of the NAB, TOMM Trial 1 was a significant predictor. TOMM scores were also predictive of years of education (Beta = .303, p < .01).

Conclusion

These findings replicate results derived from interim data. TOMM Trial 1 significantly predicted objective cognitive performance in OEF/OIF Veterans even when invalid performance was excluded. This suggests that TOMM has a utility in assessing cognitive functioning and not just valid performance. Similarly, results also suggest that the TOMM may be sensitive to education as well.

Intention to Treat Laparoscopic Versus Open Hemi-Hepatectomy: A Paired Case-Matched Comparison Study

BACKGROUND

The benefits of laparoscopic hemi-hepatectomy compared to open hemi-hepatectomy are not clear.

OBJECTIVE

This study aims to share our experience with the laparoscopic hemi-hepatectomy compared to an open approach.

METHODS

A total of 40 consecutive laparoscopically started hemi-hepatectomy (intention-to-treat analysis) cases between August 2012 and October 2015 were matched against open cases using the following criteria: laterality of surgery and pathology (essential criteria); American Society of Anesthesiologists score, body mass index, pre-operative bilirubin, neo-adjuvant chemotherapy, additional procedures, portal vein embolization, and presence of cirrhosis/fibrosis on histology (secondary criteria); age and gender (tertiary criteria). Hand-assisted and extended hemi-hepatectomy cases were excluded from the study. The two groups were compared for blood loss, operative time, hospital stay, morbidity, mortality, and oncological outcomes. All complications were quantified using the Clavien-Dindo classification.

RESULTS

Two groups were well matched (p = 1.00). In the two groups, 10 patients had left and 30 had right hemi-hepatectomy. Overall conversion rate was 15%. Median length of hospital and high dependency unit stay was less in the intention to treat laparoscopic hemi-hepatectomy group: 6 versus 8 days, p = 0.025 and 1 versus 2 days, p = 0.07. Median operative time was longer in the intention to treat laparoscopic hemi-hepatectomy group: 420 min (range: 389.5-480) versus 305 min (range: 238.8-348.8; p = 0.001). Intra-operative blood loss was equivalent, but the overall blood transfusions were higher in the intention to treat laparoscopic hemi-hepatectomy (50 vs 29 units, p = 0.36). The overall morbidity (18 vs 20 patients, p = 0.65), mortality (2.5%), and the positive resection margin status were similar (18% vs 21%, p = 0.76). The 1- (87.5% vs 92.5%, p = 0.71) and 3-year survival (70% vs 72.5%, p = 1.00) was also similar.

CONCLUSIONS

We observed lower hospital and high dependency unit stay in the laparoscopic group. However, the laparoscopic approach was associated with longer operating time and a non-significant increase in blood transfusion requirements. There was no difference in morbidity, mortality, re-admission rate, and oncological outcomes.

A nationwide study for patterns of immune thrombocytopenia treatment in patients with chronic lymphocytic leukemia

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Background: Steroids and Intravenous immunoglobulin (IVIG) are considered as the first line of therapy in immune thrombocytopenia (ITP) when treatment is indicated. Approximately 5% of patients with untreated CLL and 25-30% of patients with previously treated CLL have thrombocytopenia. There is limited data about ITP treatment patterns and therapeutic responses in patients with CLL. Methods: This is a retrospective cohort study using the 2016 National Inpatient Sample of adults ( > 18 years) hospitalized for ITP as the admitting diagnosis and CLL as a secondary diagnosis based on ICD-10 codes. Primary outcomes were rate of administration of IVIG, splenectomy, platelet transfusion and packed red blood cell transfusion during same admission. Length of hospitalization was a secondary outcome. Multivariate linear regression was used to adjust for cofounders of age, gender, race and Charlson comorbidity Index. STATA 15 was used for analysis. Results: 14,490 patients were admitted for ITP (56% females, mean age 46), of which 255 had CLL (95 females, mean age was 72.4). On multivariate linear regression there was a significant increase in the use of IVIG among ITP patients with CLL (OR: 2.11; 95%-CI 1.05-4.23, P = 0.03). While there was no difference in terms of splenectomy rate ( OR: 0.35, 95% CI 0.05 to 2.52, p = 0.28 ) or rate of platelet transfusion (Odds ratio 1.15, 95% CI 0.63 to 2.08, p = 0.65) and packed red blood cell transfusion (Odds ratio 1.03, 95% CI 0.44 to 2.39, p = 0.94) between patients who have ITP with CLL and patients admitted with ITP without CLL. No statistical difference was found in hospitalization length. Conclusions: Patients hospitalized for ITP with CLL were more likely to require IVIGs. This could be explained by several theories including the need for a more rapid increase in platelet count as thrombocytopenia may be more severe due to bone marrow infiltration by CLL, immune dysfunction and/or treatment induced thrombocytopenia. Additionally, CLL patients can have hypogammaglobinemia making them more likely to get IVIG as a treatment of choice for ITP and as an immune replacement. Also ITP patients with CLL may have less response to steroids, as was noted in a previous study. Fear of atypical infections due to steroids in CLL patients may result in increased IVIG use. Further research of the microenvironment of ITP in CLL patients might explain the difference in treatment pattern and therapeutic response in this population.

Evidence-Based Guideline on Laparoscopy in Pregnancy: Commissioned by the British Society for Gynaecological Endoscopy (BSGE) Endorsed by the Royal College of Obstetricians & Gynaecologists (RCOG)

Laparoscopy is widely utilised to diagnose and treat acute and chronic, gynaecological and general surgical conditions. It has only been in recent years that laparoscopy has become an acceptable surgical alternative to open surgery in pregnancy. To date there is little clinical guidance pertaining to laparoscopic surgery in pregnancy. This is why the BSGE commissioned this guideline. MEDLINE, EMBASE, CINAHL and the Cochrane library were searched up to February 2017 and evidence was collated and graded following the NICE-approved process. The conditions included in this guideline are laparoscopic management of acute appendicitis, acute gall bladder disease and symptomatic benign adnexal tumours in pregnancy. The intended audience for this guideline is obstetricians and gynaecologists in secondary and tertiary care, general surgeons and anaesthetists. However, only laparoscopists who have adequate laparoscopic skills and who perform complex laparoscopic surgery regularly should undertake laparoscopy in pregnant women, since much of the evidence stems from specialised centres.

Small Cell Lung Cancer with Pituitary Metastasis Presenting as Secondary Adrenal Insufficiency: A Case Report and Literature Review

BACKGROUND Pituitary gland metastasis is rarely the initial presentation of metastatic cancer. Most cases of pituitary gland metastasis are asymptomatic with diabetes insipidus being the most common symptomatic presentation. It can rarely present with symptoms of hormone underproduction such as secondary adrenal insufficiency. Although pituitary gland metastasis is rare, it is underestimated, as it is commonly misdiagnosed with pituitary gland adenoma due to the lack of clear radiological criteria differentiating between both. CASE REPORT We present a case of a 62-year-old male who presented with weakness, blurry vision, and persistent hypoglycemia despite intravenous dextrose infusion and having discontinued taking his diabetes medications. Chest x-ray showed a left hilar mass, while computed tomography scan demonstrated a left superior hilar mass and hilar lymphadenopathy with bilateral adrenal nodules and a T6 vertebral lesion suspicious for metastasis. Further workup showed secondary adrenal insufficiency with a low adrenocorticotropic hormone (ACTH) level. Vertebral biopsy was performed and confirmed the diagnosis of small cell carcinoma of the lung. This was followed by a brain magnetic resonance imaging (MRI), which showed multiple metastatic lesions with an enhancing mass involving the right clivus, sella, and suprasellar cistern with mass effect on the optic chiasm and involvement of the cavernous sinus supporting the diagnosis of pituitary gland metastasis of small cell lung cancer. The patient received brain radiation, and repeated MRI showed regression of the previous MRI findings. CONCLUSIONS Secondary adrenal insufficiency is an unusual presentation of pituitary gland metastasis. Physicians should take into consideration both radiological findings and presentation to differentiate between pituitary gland metastasis and pituitary adenoma.

Pathways to Diagnosis and Treatment of Patients With Oropharynx, Oral Cavity, and Cutaneous Squamous Cell Carcinoma in New South Wales, Australia

Background: Early cancer diagnosis is a critical component of comprehensive cancer control, however more than 50% of head and neck cancers (HNCs) are diagnosed at advanced stage. HNC patients from regional/remote areas are less likely to use radiotherapy during treatment and have poorer survival outcomes than metropolitan patients. Aim: The aim of this study was to examine pathways to treatment of patients with HNC in New South Wales (NSW) and associations between duration of components of the pathway with survival. Methods: Patients diagnosed with squamous cell carcinoma (SCC) of the oral cavity, oropharynx, or cutaneous SCC from 1st July 2008 to 30th June 2013 were identified from a prospectively maintained database. Data were extracted and supplemented by a retrospective audit of medical records at Royal Prince Alfred Hospital and specialists' records. Results: Two hundred and fifty eligible patients were identified (78% male) with mean (SD) age at diagnosis 64.5 (13.5) years. At diagnosis, 75%, 24% and 1% lived in metropolitan, regional and remote areas of NSW, respectively. Twelve per cent of patients lived > 100 km from a hospital with a HNC multidisciplinary team (median [IQR] 7.5 km [25.1]). More than two-thirds (69%) of tumors were diagnosed as advanced stage, and mean follow-up time was 3.5 years. We will present additional findings quantifying intervals along the pathway to treatment (from symptom onset, first specialist visit, diagnosis and treatment), and the associations with survival, and compare findings to those from a second regional site on the mid north coast of NSW. Conclusion: An increasing proportion of the NSW population resides outside major cities. This study is the first step in understanding patient and health system factors that facilitate and impede early diagnosis of HNC. Findings from this study may be used to develop interventions aimed at improving early HNC diagnosis.

Gender differences in hemostatic and inflammatory factors in patients with acute coronary syndromes: a pilot study

Many studies have shown gender differences in the progress of acute coronary syndromes (ACS). These differences include, amongst others, processes involved in hemostasis and inflammation, and in the present study we put forward the hypothesis that these are the primary cause of other differences. The study included 66 ACS patients (27 women and 39 men) aged 43 - 83 years, 23 with non-ST-elevation myocardial infarction (NSTEMI) and 43 with ST-elevation myocardial infarction (STEMI). Blood samples were taken on day 3 (NSTEMI) or day 5 (STEMI) after hospitalization, and fibrinogen, D-dimers, von Willebrand factor, C-reactive protein and interleukin-6 levels measured. Men, compared to women, had significantly higher levels of fibrinogen (STEMI: P = 0.028; NSTEMI: P = 0.008), C-reactive protein (STEMI: P <0.0001; NSTEMI: P = 0.004) and interleukin-6 with STEMI (P = 0.015), but a lower D-dimer concentration with NSTEMI (P = 0.042). In women fibrinogen concentration was significantly higher with STEMI compared to NSTEMI (P = 0.052). Significant correlations were found between hemostatic and proinflammatory factors, especially in men, regardless of ACS type. In addition, correlations between fibrinogen and D-dimers were found: negative for women (r = -0.67) ) and positive for men (r = +0.60), as was that between C-reactive protein and interleukin-6: women (r = -0.72); men (r = +0.56). Based on these findings, we conclude that acute coronary syndromes in men may be potentially related to inflammatory processes, as indicated by strong associations between elevated C-reactive protein, interleukin-6 and hyperfibrinogenemia, most clearly shown in STEMI. By contrast in women, factors possibly most important for the course of acute coronary syndrome are D-dimer concentrations and an increased turnover of fibrin with NSTEMI and hyperfibrinogenemia with STEMI.