Clinico-Pathological Profile and Outcome of Multiple Ultrasonogram Guided Aspiration of Breast Abscess in Outpatient Department Setup: A Prospective Study

Treating breast abscess by conventional incision and drainage, followed by regular dressing with prolonged hospital stay, anesthesia, unsatisfactory scar and chances of developing milk fistula in lactating mother is unsatisfactory. Here we study the outcome of ultrasonogram guided multiple aspirations in non-admitted outpatient setup, for its effectiveness as a replacement of conventional surgery. This descriptive, prospective and observational study was carried out from July 2018 to December 2020 with purposive sampling of all cases of breast abscess in a secondary care hospital who underwent ultrasonogram guided aspiration and oral antibiotics, on multiple visits in outpatient department and followed up for three months to study outcome. Mean age of patient was 28.19 years. Fifteen (46.9%) were non-lactating women. The right breast 18(56.3%) and upper outer quadrant 8(25.0%) was affected slightly more. All cases had tender lump except one (3.1%) who had a non-tender lump, but 20(62.5%) had no maximum fluctuating point, usually found in abscesses of other parts of the body. Fever was not a common feature in 8(25.0%) patients and axillary lymph node was not palpable in 26(81.3%) patient. Eighteen (56.3%) patients had healthy nipple, 8(25%) patients had cracked and 5(15.6%) had retracted nipple 11(34.4%) with pus discharge from nipple. Mean duration of symptom was 7 days. Mean sonographic diameter was 5.53cm and volume was 21.09ml. Mean aspirated total volume was 28±10.5 ml. Fifteen (46.9%) patients required 3 aspirations, 10(31.3%) needed 4 aspirations. Success rate was 84.4%, while 25(78.1%) had no complications. Mean healing time in this study was 14 days. We conclude that multiple aspirations under ultrasonogram guidance in outpatient setup day care procedure, is equally effective as conventional surgery and also devoid of many avoidable complications, but meticulous evaluation and high suspicion of background pathology for non-responding case is crucial.

Proton Single-Energy Bragg-Peak FLASH Using Clinical Systems Can Achieve IMPT-Equivalent Plan Quality for Breast and Prostate Cancers

PURPOSE/OBJECTIVE(S)

Most current proton FLASH-RT studies focus on transmission proton techniques. In this study, we propose a novel method for achieving FLASH dose rate in hypofractionated proton radiotherapy using the Bragg peak of a single-energy proton beam. The dosimetric characteristics using this novel technique for proton pencil beam scanning (PBS) stereotactic body radiation therapy (SBRT) of prostate and breast cancers were first investigated based on the clinically available cyclotron beam parameters.

MATERIALS/METHODS

This novel approach uses the distal tracking technique that enables PBS Bragg-peak of the highest proton energy to adapt to the target distally. Positioning of the Bragg peak at different depths is achieved using a universal range shifter and range compensator. To investigate the feasibility of this approach, we developed an in-house treatment planning platform for intensity-modulated proton therapy (IMPT) delivery and performed dosimetric studies on prostate and breast SBRT cases previously treated with conventional proton PBS technique. FLASH plans were generated using a similar clinical beam arrangement to deliver 40 Gy (RBE) in 5 fractions. Dose metrics were compared between the clinical and FLASH plans. Dose-rate volume histograms (DRVH) were also calculated to investigate the 40 Gy/s coverage (V40 Gy/s) of organs-at-risk (OARs) for FLASH plans.

RESULTS

The distal tracking can precisely stop the Bragg peak at the target distal edge, and Bragg peak plans achieved tumor coverage and dose conformality equivalent to IMPT plans. The clinical IMPT plans yielded slightly superior target dose uniformity -CTV Dmax of FLASH plans was 10% higher for prostate and 2% higher for breast. There was no significant difference between the clinical and FLASH plans in dose metrics for major OARs, including rectum, large bowel, heart, and lung. Higher maximal doses to femoral heads (∼2 Gy) and urethra (∼6 Gy) were observed in prostate FLASH plans than in the clinical plans but were still within clinically accepted dose limits. The V40 Gy/s for OARs were >90% for prostate FLASH plans and >76.5% for breast FLASH plans.

CONCLUSION

The proposed single-energy Bragg-peak FLASH technique eliminates exit dose associated with transmission proton FLASH and can still yield comparable plan quality and OAR sparing while preserve sufficient FLASH dose rate coverage for prostate and breast proton SBRT. This study demonstrates the potential application of Bragg peaks for highly conformal FLASH-RT using clinical cyclotron systems to treat prostate and breast cancer patients, which moves towards clinical application.

Pencil Beam Scanning Proton Stereotactic Body Radiation Therapy (SBRT): A Robust Single Institution Experience

PURPOSE/OBJECTIVE(S)

To describe the feasibility of treating a complex and diverse group of patients using pencil beam scanning (PBS) proton stereotactic body radiation therapy (SBRT: 5 or fewer fractions, with a fraction size of at least 5 Gy).

MATERIALS/METHODS

Our center treats on average 105-120 PBS proton treatments daily, of which 9.5% of treatment courses are proton SBRT. Statistics of disease sites, treatment planning parameters (target volume, prescriptions, number of fields, SFO vs. MFO), and treatment efficiencies (scheduled time slots, actual treatment time) are presented for 305 consecutive SBRT patients receiving 1507 fractions in the past three years. Thermoplastic masks or Vacuum-lock bags are used to immobilize SBRT patients and index the patients' treatment position. Imaging guidance of orthogonal kV images and volumetric cone-beam CT is routinely used for patient setup.

RESULTS

SBRT patients are grouped based on the target locations: pelvis (31%), liver (17%), thoracic (13%), spine (8%), abdominal (8%), brain (7%), non-spine bone (7%), ocular (6%), and head and neck (2%). Only 112 patients (37%) were receiving their 1st RT course, whereas 113 (37%) had one prior in-field RT course, and 80 (26%) had multiple prior in-field RT courses. The median [IQR] target volume was 65.4 [29.3, 168] cc (range: 0.3-2475 cc). 72% of cases were planned with SFO and 28% with MFO. On average, 3.76 fields (range: 2 to 12) were planned for each treatment. 44% of the treatments were planned with three or fewer fields, and 10% received more than five fields, most of which involved repainting for moving targets. Over 97% of treatments were delivered in 5 fractions, with ∼3% delivered in 3 fractions. The median [IQR] prescription per treatment was 8 [7, 10] Gy (range: 5-18 Gy per treatment). 85% (84%) of the SBRT treatments were scheduled (delivered) in a 45-minute or shorter slot, and 6% (7%) of treatments were scheduled (delivered) in over a one-hour slot, most commonly for multiple isocenter treatments. 93% of treatments were delivered within 15 minutes of the planned treatment time or shorter. Deep-inspiration breath-hold (DIBH) was applied to 45% of liver SBRT cases, with the remaining 55% planned on 4D CT with (14%) or without (86%) abdominal compression. DIBH was applied in 13% of lung SBRT cases. The application of other motion mitigation approaches, such as volumetric repainting, was determined by the target motion amplitude and whether the patient could tolerate DIBH.

CONCLUSION

In the most diverse and largest proton SBRT experience delivered in the world over the past 3 years, over 300 patients were treated, demonstrating the feasibility and efficiency of delivering proton SBRT in a very busy center. The planning and treatment parameter statistics reported serve as a helpful reference for the proton community.

Practice Patterns and Disparities of Fractionation Schemes for Post-Mastectomy Comprehensive Nodal Irradiation

PURPOSE/OBJECTIVE(S)

Hypofractionated (HF) radiotherapy is the established standard of care for whole breast irradiation and is being investigated for comprehensive nodal irradiation, but appropriate patient selection for the latter is currently undefined. This study aims to report national practice patterns and patient selection for HF comprehensive nodal irradiation compared to conventional fractionation (CF). The hypothesis is that the rate of HF for comprehensive nodal irradiation in breast cancer has been increasing over time and is more likely to be offered to disparate demographic populations.

MATERIALS/METHODS

We queried the National Cancer Database and identified 128,693 patients who received comprehensive nodal irradiation between 2008-2016 in the United States. No patient who underwent lumpectomy received HF nodal irradiation; therefore, only post-mastectomy patients were included in this study. After the exclusion, 29,053 post-mastectomy patients with adjuvant comprehensive nodal irradiation remained. A multivariable binomial regression analysis between HF and CF patients was performed.

RESULTS

Of the patients identified, 1,910 received HF (6.57%), and 27,143 received CF (93.43%) radiotherapy. All patients had locally advanced breast cancer treated with mastectomy, lymph node dissection, adjuvant radiation, and +/- chemotherapy. The median dose in the HF group was 4,256 cGy in 16 fractions, and in the CF group was 6,040 cGy in 33 fractions. HF rate grew from 3.56% in 2004-2007, 5.29% in 2008-2011, 7.42% in 2012-2013, and 12.05% in 2014-2016. HF was favored in older patients (median age 66 vs. 51, OR = 1.16, 95% Cl 1.11-1.22) and those who lived in suburban or rural regions compared to urban or metropolitan regions (OR = 9.48, 95% CI 1.17-76.9). However, there was no correlation when distance from treatment site was evaluated as a continuous variable. A "boost" dose was used in only 10.58% of HF patients compared to 54.6% of CF patients (OR = 0.17, 95% Cl 0.14-0.21). Chemotherapy was delivered in 36.91% of HF patients compared to 78.14% of CF patients (OR = 0.77, 95% Cl 0.59-0.99). There were no statistically significant correlates of either fractionation scheme for breast laterality, stage, grade, or receptor status. Notably, other than population density and age, demographic factors including race, Hispanic origin, insurance type, median income, and education level demonstrated no correlation with radiation fractionation scheme.

CONCLUSION

HF for comprehensive nodal irradiation in breast cancer is still uncommon but growing in popularity. Currently, HF is more likely to be used in elderly patients and lower population density centers and less likely to be used in those determined to benefit from receipt of a boost or chemotherapy.

Prospective Evaluation of Patient-Reported Outcomes of Invisible Ink Tattoos for the Delivery of External Beam Radiation Therapy: The PREFER Trial

PURPOSE/OBJECTIVE(S)

Invisible ink tattoos allow for setup accuracy while avoiding the cosmetic permanence of visible ink tattoos. The goal of this trial was to evaluate patient-reported preference for the use of invisible ink tattoos in a radiation oncology clinic.

MATERIALS/METHODS

In an IRB-approved, prospective, feasibility trial, patients at a single institution receiving pencil beam scanning proton therapy to the thorax, abdomen, or pelvis underwent invisible ink tattoo-based treatment setup. Patient preference surveys comparing visible and invisible ink tattoos were completed prior to simulation (17 questions), immediately following simulation (5 questions), and at the end of treatment (18 questions), with preference scored on a 5-point Likert scale from strongly disagree to strongly agree, and cosmesis scored on a 4-point Likert scale of excellent-good-fair-poor. Differences in distributions were examined using Wilcoxon rank-sum tests, Fisher's exact tests, or chi-square tests, where statistical significance was considered at p<0.05.

RESULTS

Of 107 patients screened, 102 were enrolled and 94 completed all surveys. Mean age was 55.0 years, and 58.5% were female. Most patients were white (79.1%) and non-Hispanic (92.6%). Patients most commonly had breast (34.0%), prostate (16.0%), and lung (9.6%) cancer. An average of 5 (range 3-8) invisible ink tattoos were placed per patient. Overall, 75.5% of patients reported that they would prefer to receive invisible tattoos vs. visible tattoos, and 88.3% rated the overall cosmetic outcome of invisible ink tattoo marks as excellent or good. Compared to males, females were more willing to travel farther from their home in order to avoid receiving visible tattoos (45.4% vs. 23.1%, p = 0.035) and would pay additional money to avoid receiving visible tattoos (34.5% vs. 5.1%, p = 0.002). Patients who had previously received any tattoo (cosmetic or visible RT tattoos) were more satisfied with the appearance of their invisible ink tattoos compared to those who had never previously received tattoos (82.9% vs. 61.5%, p = 0.022). Patients receiving definitive intent RT were more satisfied with the appearance of the tattoos compared to those receiving palliative intent RT (67.1% vs. 38.9%, p = 0.011). Patients with at least a college education were less satisfied with the appearance of tattoos compared to those without a college education (67.0% vs. 95.0% p = 0.018).

CONCLUSION

These findings demonstrate stronger avoidance of visible tattoos and patient preference for invisible tattoos. The standard incorporation of invisible ink tattoos for patient setup should be strongly considered.

Survivability of Lactobacillus plantarum in nutmeg (Myristica fragrans Houtt) flesh extract and its effect on the performance of broiler chicken

Objective

This study aimed to see if increasing the concentration of nutmeg flesh extract in vitro could increase the growth of Lactobacillus plantarum bacteria and if it had any effect on broiler chicken performance.

Materials and Methods

Different concentrations of nutmeg flesh extract (5, 10, 15, and 20/100 ml distilled water) were combined with 10 ml L. plantarum (bacterial concentration 1 × 10⁹ cfu/ml) to produce synbiotics. A total of 250 unsexed Lohmann broiler chickens were reared together from 0 to 7 days of age in the in vivo study. Beginning on day 8, synbiotics nutmeg flesh extract and L. plantarum were added to the ration in amounts of 0.5, 1, 1.5, and 2 ml/kg for T1, T2, T3, and T4, respectively, while no synbiotics were added to the control diet (T0).

Results

The levels of nutmeg flesh extract had a significant (p < 0.05) effect on L. plantarum growth. In the survival test against gastric acid, bile salts, and temperature, the addition of nutmeg flesh extract (20/100 ml distilled water) significantly (p < 0.05) maintained the population of L. plantarum. In vivo studies showed that the T1,T2,T3, and T4 groups gained more body weight (p < 0.05) than the T0 group during the rearing period but had no effect (p > 0.05) on the internal organ weight and carcass of broiler chickens.

Conclusions

Nutmeg flesh extract could stimulate the growth of L. plantarum bacteria, and using it as a synbiotic could improve broiler chicken performance.

Case method to increase student participation and problem-solving skills in biochemistry subject lesson study integrated at Khairun University

The Biochemistry course is a basic and compulsory subject for Biology Education students. This study aims to determine students' level of participation and problem-solving skills through the ability to solve cases of Biomolecules and proteins on Student Worksheets (LKM). This is an Action Research integrated with lesson study with two cycles. The instruments used were student participation rubrics in the case method and LKM problem-solving skills in the Biochemistry course. The subjects in this study were 24 third-semester students of the Biology Education Study Program. Data analysis techniques through descriptive statistics with percentages. The results showed an increase in the percentage from cycle 1 to cycle 2. Student participation in collaborative activities increased from 71.5% to 73.3%, while problem-solving skills increased from 53.5% to 71.7%. Based on the observer transcripts, some students still do not understand the material and cases discussed in lectures in class and the laboratory. This is because students do not actively ask questions and do not have curiosity about the material and case explanations presented by lecturers or fellow students. This study shows that implementing the integrated case method in lesson study can increase student participation activities and problem-solving skills in Biochemistry courses.Abstrak Matakuliah Biokimia merupakan matakuliah dasar dan wajib bagi mahasiswa Pendidikan Biologi. Penelitian ini bertujuan untuk mengetahui tingkat partisipasi dan problem-solving skill mahasiswa melalui kemampuan menyelesaikan kasus-kasus konsep Biomolekul dan protein pada Lembar Kerja Mahasiswa (LKM). Ini adalah penelitian Action Reseach terintegrasi lesson study dengan dua siklus. Instrumen yang digunakan adalah rubrik pertisipasi mahasiswa dalam case method dan LKM problem-solving skill matakuliah Biokimia. Subjek dalam penelitian ini adalah 24 mahasiswa semester 3 prodi Pendidikan Biologi. Teknik analisis data melalui statistik deskriptif dengan persentase. Hasil penelitian menunjukkan peningkatan persentasi dari siklus 1 ke siklus 2. Aktivitas partisipasi mahasiswa dalam kolaborasi dari 71,5% menjadi 73,3%, sedangkan problem-solving skill mahasiswa dari 53,5% menjadi 71,7%. Berdasarkan transkrip observer masih ada mahasiswa yang kurang memahami materi dan kasus yang didiskusikan dalam perkuliahan di kelas maupun di laboratorium. Hal ini karena mahasiswa tidak aktif bertanya dan tidak memiliki rasa ingin tahu terhadap materi dan penjelasan kasus yang disampaikan oleh dosen atau sesama mahasiswa. Penelitian ini menunjukkan bahwa implementasi case method terintergrasi dalam lesson study dapat meningkatkan aktivitas partispasi dan problem-solving skill mahasiswa pada matakuliah Biokimia.

Provision of eye care services and interventions in care homes: a narrative synthesis review

BACKGROUND

The prevalence of eye disease and visual impairment in care home residents is disproportionately higher compared to the general population. Access to eye care services and treatment can be variable for this vulnerable population.

OBJECTIVE

This paper reviews the available evidence of services and interventions for delivering eye care to care home residents. The key review questions are: (1) What is the existing evidence for eye care interventions or services (including service configuration) for care home residents? (2) Does the provision of these interventions or services improve outcomes?

METHODS

Literature search of EMBASE/MEDLINE for original papers published since 1995. Two reviewers independently reviewed abstracts/papers. Data were extracted and evaluated using narrative synthesis.

RESULTS

13 original papers met the inclusion criteria. Domiciliary optometrist services improved diagnosis and management of eye conditions, with one study showing 53% of residents benefited from direct ophthalmology intervention. Provision of interventions, such as cataract surgery, refractive error correction and low-vision rehabilitation, improved visual acuity and vision-related quality of life but did not improve cognitive or physical function, depression or health-related quality of life. There was little UK-based literature to inform eye service design or interventions to improve outcomes such as falls.

CONCLUSION

Care home-based eye assessments improve the management of eye conditions. Interventions improve visual acuity and vision-related quality of life. Further research is needed to better understand current UK services, access difficulties or examples of good practice as well as to identify and test cost-effective service models for this vulnerable group.

1210 PROVISION OF EYE CARE SERVICES AND INTERVENTIONS IN CARE HOMES - A NARRATIVE SYNTHESIS REVIEW

Introduction

The prevalence of eye disease and visual impairment in care home residents is disproportionately higher compared to the general population. Access to eye care services and treatment can be variable for this vulnerable population.

Objective

This narrative synthesis reviews the available evidence of services and interventions for delivering eye care to care home residents. The key review questions:

Methods

Literature search of EMBASE/MEDLINE for original papers published since 1995. Two reviewers independently reviewed abstracts/papers. Data was extracted and evaluated using narrative synthesis.

Results

13 original papers met the inclusion criteria. On-site optometrist-led services improved diagnosis and management of eye conditions, with one study showing 53% of residents benefited from direct ophthalmology intervention. Provision of interventions such as cataract surgery, refractive error correction and low vision rehabilitation improved visual acuity and vision-related quality of life but did not improve cognitive or physical function, depression or health-related quality of life. There was little UK-based literature to inform eye service design or interventions to improve outcomes.

Conclusion

Care home-based eye assessments improve the management of eye conditions. Interventions improve visual acuity and vision-related quality of life. Further research and/or clinical service scoping is needed to better understand current UK services, access difficulties or examples of good practice as well as to identify and test cost-effective service models for this vulnerable group.

1226 A MULTI-DISCIPLINARY APPROACH TO TRANSFORMING EYE CARE SERVICES FOR CARE HOME RESIDENTS

Introduction

Care home residents can have variable access to eye care services and treatments. We developed a collaborative approach between optometrists, care homes, and primary and secondary care to enable personalised patient-centred care.

Objective

To develop and evaluate an integrated model of eye care for care home residents.

Methods

Small scale plan-do-study-act (PDSA) service tests were completed in three care-homes in Southwark (2 residential, 1 nursing) between November 2021 to May 2022. Processes were compared to historical feedback and hospital-based ophthalmology clinic attendances (Mar 2019-2020). Hospital-like assessments were piloted at two care homes for feasibility and acceptability. Further piloting utilised usual domiciliary optometry-led assessment with multidisciplinary meeting access (including optometrist, GP, geriatrician, ophthalmologist and care home nurse) to reduce duplication of assessments and to evaluate MDM processes and referral rates.

Results

Examination was 100% successful at home (visual acuity and pressure measurement) compared to hospital outpatients (71.7% success visual acuity, 54.5% pressures). Examination was faster than in hospital settings (16 minutes vs 45 minutes-1 hour). Residents were away from usual activities for 32 minutes vs 6 hours for hospital visits including transport. Residents were less distressed with home-based assessments. Did-Not-Attend (DNA) rates reduced (26.7% to 0%), secondary care discharge rates improved (8.4% to 32%). Hospital eye service referral were indicated in 19% -23%, half of which were for consideration of cataract surgery. Alternative conservative plans were agreed at MDM for nursing home residents who were clinically too frail or would not have been able to comply with treatments avoiding 33% unnecessary referrals.

Conclusions

Home-based eye care assessments appear better tolerated and are more efficient for residents, health and care staff. Utilising an MDM for optometrists to discuss residents with ophthalmologists and wider MDT members enabled personalised patient-centred decision-making. Future work to test this borough wide is in progress.

A119 ACUTE DIVERTICULITIS & CONCURRENT DIVERTICULAR BLEED: A RARE CLINICAL ENTITY

Aims

Colonic diverticula are mostly asymptomatic incidental findings on cross sectional imaging or colonoscopy. In the setting of known diverticulosis, complications like diverticulitis and diverticular bleeding occur in only 4% and 1% of patients respectively. It is unusual to see both complications expressed in the same patient and moreover, rare to see them expressed concurrently. We report a case of concurrent diverticulitis with diverticular bleed and expand on the clinical course.

Methods

Case report

Results

A 73-year old was diagnosed with sigmoid diverticulitis based on her clinical presentation and an abdominal CT scan. She was discharged home on oral antibiotics but presented a week later with painless rectal bleeding. In view of the ongoing diverticulitis, a colonoscopy was not pursued although it is the typical procedure of choice to manage active gastrointestinal bleeding. A CT scan was recommended as the alternate initial investigation, which revealed active colonic bleeding in the region of the hepatic flexure immediately adjacent to a diverticulum. A subsequent CT angiogram identified the middle colic artery to be the responsible blood supply to the region and embolization coils were deployed within this vessel in an attempt to achieve hemostasis.

Despite vascular intervention the patient continued to bleed and resuscitation with blood products was insufficient. A repeat CT scan ruled out any areas of colonic ischemia as well as any further active areas of extravasation. A decision was made to proceed with a total colectomy to provide definitive treatment of the diverticular disease and manage the bleeding. An urgent intraoperative colonoscopy was attempted but quickly abandoned due to suboptimal preparation and ongoing bleeding obscuring the view. The patient underwent a total colectomy with ileorectal anastomosis. On pathology there was extensive diverticulosis of the ascending and the sigmoid colon with diverticulitis and diverticular abscess cavities within the sigmoid colon.

Conclusions

Diverticulitis and diverticular bleed are thought to be unrelated complications of diverticulosis involving distinct physiologic pathways (Figure 1). Although diverticular bleed may occur in patients with a history of prior diverticulitis, concurrent presentation of these two entities is extremely rare. In addition, diverticular bleed is mostly self-limiting. While endoscopic and vascular embolization are established treatment options, colectomy is rare for the management of diverticular bleeding.

We report a rare case of concurrent diverticulitis and lower GI bleeding. The presence of the sigmoid diverticulitis made interventional radiology a relatively safer option over endoscopy, which is the typical first line diagnostic and interventional procedure. Ongoing bleeding led to total colectomy and provided the patient with a definitive cure for her diverticular disease.

Funding Agencies

None

Efficacy of Intra-peritoneal Tramadol Instillation for Postoperative Pain Management after Laparoscopic Cholecystectomy

Gall stone disease is one of the most common conditions encountered in general surgical practices in adult population. The gold standard treatment for symptomatic gall stone disease is laparoscopic cholecystectomy. It results in less post-operative pain as compared to open cholecystectomy but post-operative pain may be mild, moderate or even severe in some patients. This Randomized control trail was conducted to In-patient department of Surgery, Mymensingh Medical College & Hospital (MMCH), Mymensingh, Bangladesh from April 2018 to September 2018. It was undertaken to evaluate the analgesic effect of intra-peritoneal tramadol instillation in patients undergoing laparoscopic cholecystectomy. Total 70 patients with symptomatic gallstone disease undergoing laparoscopic cholecystectomy were randomized equally in two groups. Then patients were selected in according to the inclusion and exclusion criteria. In first group (Group A), patients were received intra-peritoneal tramadol 100mg (diluted in 20.0ml distilled water). Sprayed 10.0ml diluted tramadol into the sub diaphragmatic area, 5.0ml into the area of gall bladder bed and 5.0ml into the space between the liver and kidney under direct vision just before removal of trocars. In second group (Group B) the conventional operative procedure was followed. Postoperatively, patient was extubated and shifted to recovery room. Data recorded and analyzed, such as post-operative pain score at 1, 4, 8, and 24 hour; cumulative 1, 8 and 24 hour analgesic consumption. In addition that postoperative hospital period monitoring of heart rate, blood pressure, respiratory rate, temperature at 0, 4, 8, 24 hours was also analyzed. Intensity of pain was assessed by Visual Analogue Scale (VAS) scoring system. Patients showed a VAS ≥3 or patients who requested for analgesia was administrated a supplemental dose of analgesic. In the present study the mean pain scores in Group A were found to be low at1hourpost-operative was 0.60±0.56 and there was a gradual increase in score in respect of time interval with peak of 2.07±0.91 at 24 hours. Whereas, in Group B the mean pain scores immediate post-operative period were at its peak was, 2.50±0.82 which decreased to 1.30±0.84 at 1 hour and further there was rise at 4 hours (2.10±0.71) and 24 hours (2.33±0.0.71). But at any point of time the mean VAS remained significantly low (p<0.050) in patients with Group A compared to Group B except at 1st 24 hours (p=0.210). Intra-peritoneal instillation of tramadol for postoperative pain control in laparoscopic cholecystectomy has beneficial effect in terms of postoperative pain relief following laparoscopic cholecystectomy.

A255 EMPHYSEMATOUS CYSTITIS: A MARKER OF SEVERE CROHN’S DISEASE?

Background

Emphysematous cystitis (EC) is characterized by the presence of air within the bladder walls, a complication of infection by gas producing organisms within the urinary system. However, rare cases of EC in the setting of infectious gastroenteritis have been reported suggesting an alternate etiology. We report a case of EC in the setting of severe Crohn’s colitis with no clinical evidence of urinary tract infection.

Aims

This report outlines the rare case of a patient with active Crohn’s disease who presented with bloody diarrhea, anemia, hypoalbuminemia and initial radiological evidence of EC. We expand on the subsequent clinical investigations, diagnosis, treatment plan and hospital course of the patient.

Methods

Case report, review of literature.

Results

A 43-year old female presented with a 2-month history of bloody diarrhea consisting of 8–12 bowel movements a day, 10 kg of weight loss and peripheral edema. She also had multiple ulcerated lesions on her abdominal wall and in the perianal region. Initial CT scan was significant for pancolitis, anasarca and EC. The follow-up CT cystogram, flexible cystoscopy and pelvic MRI confirmed the diagnosis of EC and ruled out any fistulous tracts in the pelvis including enterovesical/colovesical fistula. The patient did not report any urinary symptoms and the urinalysis was within normal limits. Infectious workup including urine and blood cultures, stool ova and parasite, stool C. difficile PCR, TB IGRA, Hep A, Hep B, Hep C and HIV serologies were all negative. Despite the paucity of infectious findings, the EC was empirically treated with an intravenous third-generation cephalosporin. Colonoscopy was significant for multiple ulcerated and hyperemic areas with pseudopolyps all throughout the right, transverse and left colon. Biopsies confirmed Crohn’s colitis with no evidence of granulomata or dysplasia, and were also negative for CMV immunohistochemistry. The perianal and abdominal wall lesions were suspected to be pyoderma gangrenosum although biopsies were equivocal. The colitis was initially treated with intravenous steroids followed by biologic therapy with Infliximab. While there was some interval improvement of symptoms, the in-hospital course was further complicated by a rectal bleed requiring surgical obliteration of the rectal artery, then a colonic perforation requiring total colectomy.

Conclusions

This is a rare case of EC in a patient with severe Crohn’s colitis. There was no clinical evidence of urinary tract infection or fistulising disease. According to our review, this is the first reported incident of EC in a patient with inflammatory bowel disease without any prior intra-abdominal surgeries. While active Crohn’s disease alone is a critical illness, we conclude that concomitant EC is a poor prognostic factor.

Funding Agencies

None

Final results for the neutron -asymmetry parameter A0 from the UCNA experiment

The UCNA experiment was designed to measure the neutron β-asymmetry parameter A0 using polarized ultracold neutrons (UCN). UCN produced via downscattering in solid deuterium were polarized via transport through a 7 T magnetic field, and then directed to a 1 T solenoidal electron spectrometer, where the decay electrons were detected in electron detector packages located on the two ends of the spectrometer. A value for A0 was then extracted from the asymmetry in the numbers of counts in the two detector packages. We summarize all of the results from the UCNA experiment, obtained during run periods in 2007, 2008–2009, 2010, and 2011–2013, which ultimately culminated in a 0.67% precision result for A0.

Elevated fibrinogen, von Willebrand factor, and Factor VIII confer resistance to dilutional coagulopathy and activated protein C in normal pregnant women

BACKGROUND

Gestational changes in coagulation factor concentrations include elevations in fibrinogen, Factor VIII, and von Willebrand factor (vWF). We hypothesised that blood samples from term pregnant (TP) subjects are less prone to coagulation disturbances from haemodilution compared with those from non-pregnant (NP) females.

METHODS

Blood samples were collected from 15 NP and 15 TP subjects. In vitro haemodilution with normal saline was assessed by modified Clauss fibrinogen assay, factor activity, flow-chamber assay, and thromboelastometry. The impact of human fibrinogen concentrate (hFC), cryoprecipitate, and vWF/Factor VIII (FVIII) concentrate replacement in diluted TP and NP blood was compared. Thrombin generation and activated protein C sensitivity were assessed.

RESULTS

TP blood contained twice the concentrations of fibrinogen, FVIII, and vWF relative to NP blood (P<0.0001). Platelet thrombus formation (PTF) under flow was reduced by 99.2% and 69.2% in diluted NP and TP blood, respectively. Platelet thrombus formation was partially restored by adding vWF/FVIII, but not hFC or cryoprecipitate. Fibrin clot firmness approached the threshold of 10 mm in diluted NP blood, and clot firmness was effectively restored by hFC, but not by vWF/FVIII. In the presence of thrombomodulin, peak thrombin generation was decreased by 86.7% in NP plasma, but by 31.8% in TP plasma (P<0.0001 vs NP plasma), indicating reduced activated protein C sensitivity in TP plasma. Both elevated FVIII and haemodilution contributed to activated protein C insensitivity.

CONCLUSIONS

Our in vitro model showed relative resistance of TP blood to dilutional coagulation changes with respect to platelet adhesion, fibrin polymerisation, and thrombin generation. Careful therapeutic monitoring for different pro-haemostatic agents in pregnant women is warranted.

TP1-7 Extended glasgow outcome scale – when would you rather die?

Objectives

Extended Glasgow Outcome Scale is the primary outcome measure in trials involving neurotrauma patients. Conventional dichotomization characterises unfavourable outcomes as upper severe disability or worse, however RESCUE-ICP changed this to consider upper severe disability as a favourable outcome. As the recent consensus meeting in Cambridge proved, opinion of what constitutes acceptable recovery can vary widely between individuals.

Design

To survey patients with brain injury and compare them to the opinions of staff routinely involved in the care of such patients.

Subjects

Patients with brain injuries, neurosurgery staff and ITU staff.

Method

GOS-E sheets were given to neurotrauma patients and asked to circle the outcome they considered unfavourable and therefore would rather not survive. This was compared to the same question posed to neurosurgery staff members, and ITU staff members.

Results

67 responses collected (20 patients, 27 neurosurgery staff, 20 ITU staff). Mean GOS-E score deemed unfavourable and therefore not worth survival was 3.6, mode 3 (Patient mean 3.15, mode 3. Neurosurgery mean 3.63, mode 4. ITU mean 4.0, mode 5. p>0.05).

Conclusion

What constitutes unfavourable outcome varies between each group of people questioned. Patients who have experienced brain injuries were more likely to feel that upper severe disability was an acceptable outcome when compared to the staff that care for them. It is imperative we take this in to consideration when recommending treatment strategies in an acute setting.

Abstract P6-02-05: Downstream workup after post-treatment mammography in breast conservation therapy: Is there a significant difference between tomosynthesis and 2-dimensional mammograms?

Introduction:

Emerging data suggest that tomosynthesis mammograms (TS) are considerably superior to two-dimensional (2D) screening mammograms (2DMG) at reducing false positive biopsies for breast cancer screening. However, very little is reported about the comparative efficacy of the two modalities in the post-treatment setting. We compared the rate of downstream workup up after undergoing post-radiation screening 2DMG and TS following breast conservation therapy at our institution.

Methods:

Between the years 2011-2017, 712 breast cancer patients (range 31-91 years) were treated with lumpectomy and adjuvant radiotherapy. As per institutional standard, follow up included either screening 2DMG (n=569) or TS(n=143) and reviewed in this IRB-approved study. The primary endpoint for comparison was the rate of further imaging/workup post-treatment . Comparative analysis was conducted via multivariable binomial regression with propensity matching between the 2DMG and TS groups. Patients with clinical suspicion of recurrence otherwise were excluded.

Results:

The patient cohort in both groups included the following clinical characteristics,: 129 patients with ductal carcinoma in-situ (the remainder were invasive carcinoma; ductal or lobular). A total of 418 patients had T1 lesions, 143 T2, and 22 T3/T4. Eighty-five patients were node positive. Of those, 501 ER+/Her2-, 101 triple negative, and 96 triple positive. Adjuvant radiation included conventional fraction (457) or hypofractionation (153) with boost to the surgical cavity in523Accelerated Partial Breast Irradiation (APBI) was delivered in 106 patients. Post treatment scans occurred within 3 months (166), at 3-6 months (256), or 6+ months (281). The aforementioned characteristics were similarly distributed between 2DMG and TS groups, except for slightly more DCIS in the 2D group.

There was a significantly higher proportion of patients that were recommended for immediate downstream workup in the 2D group (40.7%) compared to in the tomo group (16.8%) (HR = 3.40, P &lt;0.001), leading to 12 biopsies in the 2D group (3 positive) and 4 biopsies in the TS group (0 positive). Upon multivariate analysis, the use of tomo was the lone correlate of reduced downstream workup (p &lt; 0.05), although there was a trend toward significance in patients who were first imaged at a post-treatment interval of 6+ months and in patients not undergoing a radiation boost (P &lt; 0.10).

Conclusion:

Post-breast conservation follow-up with tomo synthesis mammography resulted in significantly less downstream workup as compared to conventional 2D screening mammography. Further investigation is warranted to unveil the absolute and relative cost-effectiveness between the two modalities.

Citation Format: Colosimo BL, Weinberger K, Hasan S, Gresswell S, Anderson S, Wegner RE, Trombetta M. Downstream workup after post-treatment mammography in breast conservation therapy: Is there a significant difference between tomosynthesis and 2-dimensional mammograms? [abstract]. In: Proceedings of the 2018 San Antonio Breast Cancer Symposium; 2018 Dec 4-8; San Antonio, TX. Philadelphia (PA): AACR; Cancer Res 2019;79(4 Suppl):Abstract nr P6-02-05.

Search for neutron dark decay: n → χ + e+e−

In January, 2018, Fornal and Grinstein proposed that a previously unobserved neutron decay branch to a dark matter particle (χ) could account for the discrepancy in the neutron lifetime observed in two different types of experiments. One of the possible final states discussed includes a single χ along with an e+e− pair. We use data from the UCNA (Ultracold Neutron Asymmetry) experiment to set limits on this decay channel. Coincident electron-like events are detected with ∼ 4π acceptance using a pair of detectors that observe a volume of stored Ultracold Neutrons (UCNs). We use the timing information of coincidence events to select candidate dark sector particle decays by applying a timing calibration and selecting events within a physically-forbidden timing region for conventional n → p + e- + ν̅e decays. The summed kinetic energy (Ee+e−) from such events is reconstructed and used to set limits, as a function of the χ mass, on the branching fraction for this decay channel.

Late gestation diet supplementation of resin acid-enriched composition increases sow colostrum immunoglobulin G content, piglet colostrum intake and improve sow gut microbiota

Resin acid-enriched composition (RAC) mainly containing tall oil fatty acid with an active component of resin acid (RA) can improve the microbial population in the digestive system, change the microbial fermentation, and improve the feed conversion ratio. We investigated the effects of dietary supplementation of RAC on sow colostrum yield (CY), colostrum composition and gut microbiota. Tall oil fatty acid and RA are commonly termed RAC and CLA, pinolenic, abietic, dehydrobiotic acids are characteristic components of RAC. The experiment was conducted in three trials in three respective herds. Sows were fed with a control diet and the same diet supplemented with 5 g RAC/day per sow during the last week of gestation. The 16S ribosomal RNA gene sequencing technique was used to assess sows' faecal microbiota populations at farrowing. Colostrum nutritional composition, acute phase proteins (APPs) and immunoglobulin (Ig) content were also assessed. Individual piglets were weighed at birth and 24 h after the birth of first piglets in order to calculate CY and later at 3 to 4 weeks to calculate average daily gain. The RAC-fed sows had significantly higher IgG levels (P0.05), but those fed RAC had higher levels of colostrum serum amyloid A. Colostrum yield was significantly higher in RAC-fed sows in herds 2 and 3 with heavier piglets between 3 and 4 weeks of age (P0.05). Resin acid-enriched composition supplementation significantly increased some beneficial and fermentative bacteria (Romboutsia and Clostridium sensu stricto) than the control diet (P<0.01) while some opportunistic pathogens (Barnesiella, Sporobacter, Intestinimonas and Campylobacter), including Proteobacteria, were suppressed. Therefore, RAC added to the sow diet at late pregnancy increases colostrum IgG, colostrum availability for neonate piglets, and seems to promote better maternal intestinal microbial sources.