Hospitalization is a missed opportunity for HIV screening, pre-exposure prophylaxis, and treatment

BACKGROUND

Hospitalization is a "reachable moment" for people who inject drugs (PWID), but preventive care including HIV testing, prevention and treatment is rarely offered within inpatient settings.

METHODS

We conducted a multisite, retrospective cohort study of patients with opioid use disorder with infectious complications of injection drug use hospitalized between 1/1/2018-12/31/2018. We evaluated HIV care continuum outcomes using descriptive statistics and hypothesis tests for intergroup differences.

RESULTS

322 patients were included. Of 300 patients without known HIV, only 2 had a documented discussion of PrEP, while only 1 was prescribed PrEP on discharge. Among the 22 people with HIV (PWH), only 13 (59%) had a viral load collected during admission of whom all were viremic and 10 (45%) were successfully linked to care post-discharge. Rates of readmission, Medicaid or uninsured status, and unstable housing were high in both groups.

DISCUSSION

We observed poor provision of HIV testing, PrEP and other HIV services for hospitalized PWID across multiple U.S. medical centers. Future initiatives should focus on providing this group with comprehensive HIV testing and treatment services through a status neutral approach.

Undertreatment of opioid use disorder in patients hospitalized with injection drug use-associated infections

OBJECTIVE

To evaluate the association between medication for opioid use disorder (MOUD) initiation and addiction consultation and outcomes for patients hospitalized with infectious complications of injecting opioids.

METHOD

This was a retrospective cohort study performed at four academic medical centers in the United States. The participants were patients who had been hospitalized with infectious complications of injecting opioids in 2018. Three hundred and twenty-two patients were included and their individual patient records were manually reviewed to identify inpatient receipt of medication for opioid use disorder (MOUD), initiation of MOUD, and addiction consultation. The main outcomes of interest were premature discharge, MOUD on discharge, linkage to outpatient MOUD, one-year readmission and death.

RESULTS

Three hundred and twenty-two patients were predominately male (59%), white (66%), and median age 38 years, with 36% unstably housed, and 30% uninsured. One hundred and forty-five (45%) patients received MOUD during hospitalization, including only 65 (28%) patients not on baseline MOUD. Discharge was premature for 64 (20%) patients. In the year following discharge, 27 (9%) patients were linked to MOUD, and 159 (50%) patients had at least one readmission. Being on MOUD during hospitalization was significantly associated with higher odds of planned discharge [odds ratio (OR) 3.87, P  < 0.0001], MOUD on discharge (OR 129.7, P  < 0.0001), and linkage to outpatient MOUD (OR 1.25, P  < 0.0001), however, was not associated with readmission. Study limitations were the retrospective nature of the study, so post-discharge data are likely underestimated.

CONCLUSION

There was dramatic undertreatment with MOUD from inpatient admission to outpatient linkage, and high rates of premature discharge and readmission. Engagement in addiction care during hospitalization is a critical first step in improving the care continuum for individuals with opioid use disorder; however, additional interventions may be needed to impact long-term outcomes like readmission.

Use of nonstigmatizing language is associated with improved outcomes in hospitalized people who inject drugs

BACKGROUND

Stigma surrounding opioid use disorder (OUD) is a barrier to treatment. The use of stigmatizing language may be evidence of negative views toward patients.

OBJECTIVE

We aimed to identify associations between language and clinical outcomes in patients admitted for infectious complications of OUD.

DESIGNS

We performed a retrospective medical record review.

SETTINGS AND PARTICIPANTS

Four U.S. academic health systems. Participants were patients with OUD admitted for infectious complications of injection opioid use from January 1, 2018, to December 31, 2018, identified through international classification of diseases, 10th revision codes consistent with OUD and acute bacterial/fungal infection.

MAIN OUTCOME AND MEASURES

Discharge summaries were reviewed for language, specifically: abuse, addiction, dependence, misuse, use disorder, intravenous drug use, and others. Binary outcomes including medication for OUD, planned discharge, naloxone provision, and an OUD treatment plan were evaluated using logistic regressions and admission duration was evaluated using Gamma regression.

RESULTS

A total of 1285 records were reviewed and 328 met inclusion criteria. Of those, 191 (58%) were male, with a median age of 38 years. The most common term was "abuse" (219, 67%), whereas "use disorder" was recorded in 75 (23%) records. Having "use disorder" in the discharge summary was associated with increased odds of having a documented plan for ongoing OUD treatment (adjusted odds ratio [AOR]: 4.11, 95% confidence interval [CI]: 1.89-8.93) and having a documented plan for addiction-specific follow-up care (AOR: 2.31, 95% CI: 1.30-4.09).

CONCLUSIONS

Stigmatizing language was common in this study of patients hospitalized for infectious complications of OUD. Best-practice language was uncommon, but when used was associated with increased odds of addiction treatment and specialty care referrals.

Accuracy and reliability of tele-ultrasonography in detecting gastrointestinal obstruction in dogs and cats

OBJECTIVES

To assess the accuracy and interobserver agreement of tele-ultrasonography for the diagnosis of gastrointestinal obstruction in small animals by radiologists with different levels of experience.

MATERIALS AND METHODS

A retrospective cross-sectional study including dogs and cats admitted with gastrointestinal signs, between 2017 and 2019, that had abdominal ultrasonographic (US) examination performed and images saved for review. Patients were classified into two categories based on final diagnosis: animals with or without complete or partial gastrointestinal obstruction. Observers with four experience levels interpreted the archived ultrasound examinations, simulating a tele-ultrasonography consultation. Analyses of accuracy, sensitivity, specificity, positive and negative predictive values were obtained for each observer for detection of gastrointestinal obstruction. Agreement between observers for the gastrointestinal obstruction diagnosis was assessed using Fleiss's Kappa statistics.

RESULTS

Ninety patients with gastrointestinal signs were included. Of these, 23 of 90 had partial or complete gastrointestinal obstruction. Interpretation of the images by observers via tele-ultrasonography showed intervals of accuracy, sensitivity, specificity, positive and negative predictive values, respectively, of 78.9% to 87.8%, 73.9% to 100%, 77.6% to 89.6%, 55.9% to 70.8% and 90.9% to 100% for diagnosis of gastrointestinal obstruction. Agreement for the gastrointestinal obstruction diagnosis across all reviewers was moderate (Kappa 0.6).

CLINICAL SIGNIFICANCE

Tele-ultrasonography had good accuracy for detection of gastrointestinal obstruction, however had a rather low positive predictive value and only moderate interobserver agreement. Therefore, this technique should be used with caution in this clinical context, given the potential surgical decision at hand.

Abstract 35: Age, Gender And Race Bias In Provider Adherence To The 2018 AHA/ACC Cholesterol Guidelines: A Single-Center Retrospective Cohort Analysis

Background: Cholesterol treatment is central to cardiovascular risk reduction, but disparities in management may exist. Our hypothesis is that demographic factors may predict guideline adherence.

Methods: This retrospective cohort analysis included patients seen at an urban academic medical center between November 2018 to March 2021. Patient and provider demographics, cardiovascular comorbidities, and lab values were examined to determine if provider adherence to the 2018 AHA/ACC cholesterol guidelines demonstrated bias by age, gender, or race. Logistic models were estimated via generalized estimating equations to account for clustering by patient and provider and used to calculate odds ratios (OR), confidence intervals, and p-values.

Results: 24,733 lipid panels were obtained from patients with mean age 57.8 ± 15.6, BMI 29.4 ± 6.8, 56.9% female, 44.2% White, 42.1% Black, 6.8% Asian, 6.8% Other, 26.5% tobacco use, 12.7% ASCVD, 51.1% hypertension, 21.1% diabetes. Significant adjusted OR for appropriate treatment was 0.91 (p<0.001) for each 1-year increase in age, 2.2 (p<0.001) for female, 0.88 (p=0.02) for Black relative to White, 1.36 (p=0.003) for Asian relative to White, 0.73 (p<0.001) for BMI>40 relative to BMI<25. Providers had mean age 51.1 ± 12.2, 60.5%female, 73.2% White, 6.9% Black, 18.6% Asian, 1.3% Other. On univariate analysis, OR for appropriate statin prescription were 0.82 (p=0.016) for provider-patient race discordance; 0.90 (p=0.251) for gender discordance, 0.34 (p<0.001) if provider age 10+ years younger than the patient, and 4.72 (p<0.001) if provider age 10+ years older. On multivariate analysis adjusted for clinical risk factors, none of these OR for patient-provider discordance were significantly different from 1: race 1.06 (p=0.42), gender 0.96 (p=0.34), provider 10+ years younger 1.05 (p=0.61), provider 10+ years older 0.91 (p=0.32).

Conclusion: In this analysis, Black, male, morbidly obese and older patients were less likely to receive appropriate statin therapy. However, there was no evidence that inappropriate treatment was associated with patient-provider age, gender, or race discordance. Further investigation is needed to guide targeted interventions aimed at addressing these inequities.

611. No Source Control: Low Rates of Medication for Opioid Use Disorder in Individuals Hospitalized with Infectious Complications of Injection Opioid Use at Four Academic Medical Centers

Background

Rates of hospitalization for bacterial infections due to opioid use disorder (OUD) are rising. Medication for OUD (MOUD) is an evidence-based intervention to treat OUD; however, MOUD initiation during hospitalization remain suboptimal. We aim to understand the continuum of MOUD and impact of MOUD initiation on outcomes of patients hospitalized with infectious complications of OUD.

Methods

CHOICE is a retrospective review of adults hospitalized with an infectious complication of OUD and IDU at four academic medical centers (Figure 1). Patients were hospitalized between 1/1/2018 and 12/31/2018, had ICD9/10 diagnosis codes consistent with OUD and acute bacterial/fungal infection, and chart review verification of active infection associated with OUD. Data were abstracted regarding demographics, inpatient interventions, transitions of care, and 1 year outcomes. Linear regression model with generalized estimating equation was used to evaluate associations of MOUD initiation with outcomes.

Results

287 patients were predominately male (59%), white (63%), and median age 40 (32;52), with 72 (25%) uninsured, 103 (36%) unstably housed, and 84 (29%) were on MOUD prior to admission. 129 (45%) received MOUD during admission, 113 (39%) had MOUD prescribed on discharge, and 24 (8.4%) were linked to MOUD after admission [fig 2]. During sentinel admission, 62 (22%) were discharged prematurely/eloped, of whom 43 (69%) left without an antibiotic plan. Of the 202 (71%) not on MOUD at baseline, 55 (27%) initiated MOUD during admission. MOUD initiation was associated with higher odds of planned discharge (OR 6.7; p=0.0002) and being discharged on MOUD (OR 174; p< 0.0001) [fig 3]. Being uninsured was associated with lower odds of planned discharge (OR 0.55; < 0.0001) and discharge on MOUD (OR 0.59; p=0.02).

CHOICE Baseline Demographics (N=287)

Conclusion

Across four healthcare systems, we found that patients hospitalized with infectious complications of OUD had low rates of MOUD initiation and high rates of premature discharge with incomplete ID treatment. Interventions to increase MOUD initiation and expand access to insurance may serve to mitigate the morbidity and mortality associated with OUD-related infections.

Disclosures

Elana S. Rosenthal, MD, Gilead Sciences (Research Grant or Support)Merck (Research Grant or Support) Ellen Eaton, MD , Gilead (Grant/Research Support) Ellen Eaton, MD , Gilead (Individual(s) Involved: Self): Research Grant or Support Greer A. Burkholder, MD, MSPH, Eli Lilly (Grant/Research Support) Sarah Kattakuzhy, MD, Gilead Sciences (Scientific Research Study Investigator, Research Grant or Support)

868. HIV, Opioid Use Disorder, and Injection related Infections: Clinical Outcomes in 4 Academic Hospitals

Background

Because hospitals are a safety net for persons with injection drug use (IDU), they play a valuable role towards ending the HIV epidemic. The objective of this study is to evaluate the hospital outcomes of persons with HIV (PWH) and opioid use disorder (OUD).

Methods

CHOICE is a retrospective review of hospitalized persons with an infectious complication of OUD and IDU at University of Maryland, George Washington University, University of Alabama at Birmingham, and Grady Memorial Hospital. Participants were hospitalized between 1/2/2018-12/21/2018, had ICD9/10 diagnosis codes consistent with OUD and acute bacterial/fungal infection, and verification of OUD-associated infection. HIV was defined by chart review. We explored HIV viral load (VL), antiretroviral therapy (ART) and medications for opioid use disorder (MOUD) on admission, discharge, consultation, and community care.

Overall CHOICE Study Enrollment

Results

Overall, 287 were admitted with OUD and infections over the study period; 22 had HIV of whom 3 (14%) were diagnosed during the admission. Of the HIV negative, 1 was discharged on PrEP. Of PWH, most were Black (55%), male (68%), and Medicaid recipients (77%); median age was 48. Median length of stay was 10 days. Common bacterial infections were skin/soft tissue (55%), Bacteremia (41%), and Osteomyelitis (18%). On admission, few were on antiretroviral therapy (ART; 32%) or MOUD (23%). Of the 13 with a VL during admission, 100% had viremia (median VL 6,226 copies/mL). During the admission, 81% were evaluated by Infectious Diseases consultant and 50% by Addiction Medicine. At discharge, 11 and 6 had documentation of an ART plan and MOUD receipt, respectively. In the year following the admission, of 21 with follow up data, a majority were evaluated in the emergency department (68%) and readmitted (57%).

HIV Outcomes for Hospitalized Persons with Injection Related Bacterial Infections

Conclusion

For patients with IDU, hospitalization is a missed opportunity to address HIV treatment and prevention through PrEP, VL surveillance, and ART linkage. Because addiction treatment improves HIV outcomes, Addiction consultation should be standard of care but was under-utilized. Subsequent ED visits and readmissions suggest that hospitals provide continuity of care for patients with IDU who would benefit from HIV, HCV, and other services in acute settings.

Disclosures

Greer A. Burkholder, MD, MSPH, Eli Lilly (Grant/Research Support) Elana S. Rosenthal, MD, Gilead Sciences (Research Grant or Support)Merck (Research Grant or Support) Ellen Eaton, MD , Gilead (Grant/Research Support) Ellen Eaton, MD , Gilead (Individual(s) Involved: Self): Research Grant or Support

907. The HCV Care Continuum Among Hospitalized Persons Who Inject Opiates: Missed Opportunities for Screening and Referral to Treatment

Background

Despite an effective cure, hepatitis C virus (HCV) remains a major public health problem for persons who inject opiates. Hospitalization provides an opportunity to identify chronic HCV infection and provide referral and linkage to outpatient care upon discharge. We examined the HCV care continuum among hospitalized persons who inject drugs and have opiate use disorder (OUD).

Methods

The CHOICE Study is a retrospective chart review of adults hospitalized with infectious complications of OUD and injection drug use at four academic medical centers (University of Maryland, George Washington University, University of Alabama, and Emory University). The sample included patients hospitalized between 1/1/2018-12/31/2018, had ICD9/10 diagnosis codes consistent with OUD and acute bacterial/fungal infection, and chart review verification of active infection associated with OUD. Data on HCV antibody (Ab) and RNA testing and referral to HCV treatment within the medical system were abstracted from medical records.

Results

Of 287 patients, median age was 40 (IQR: 32-52), 59% were male, and 63% were white and 34% black. Overall, 38% (n=108) had known HCV infection at hospitalization; of those with unknown status, only 41% (n=73) were screened for HCV. Among those, 67% were HCV Ab+. Of patients who were HCV Ab+ or had known HCV infection (n=157), only 52% were tested for HCV RNA, of whom 61% had detectable RNA. Only 40% of those with detectable RNA received a treatment referral prior to discharge (Fig. 1). The length of stay of the admission was not associated with treatment referral, but a shorter length of stay was significantly associated with not being screened for HCV Ab or RNA tested (p&lt; 0.05). Of five patients who were referred to care within the medical system, four initiated HCV treatment, and two achieved known sustained viral response.

Figure 1. HCV Continuum of care for hospitalized patients who inject drugs with opioid use disorder (OUD) at four academic medical centers in the United States, January 2018-December 2018

Conclusion

Hospitalization is a missed opportunity for HCV screening and linkage. Despite opportunities to address HCV infection among this highly impacted population, there were sizeable gaps in the HCV continuum of care among hospitalized persons who inject opiates. Structural reasons such as length of stay may be a factor in implementing HCV testing.

Disclosures

Sarah Kattakuzhy, MD, Gilead Sciences (Scientific Research Study Investigator, Research Grant or Support) Ellen Eaton, MD , Gilead (Grant/Research Support) Ellen Eaton, MD , Gilead (Individual(s) Involved: Self): Research Grant or Support Greer A. Burkholder, MD, MSPH, Eli Lilly (Grant/Research Support) Elana S. Rosenthal, MD, Gilead Sciences (Research Grant or Support)Merck (Research Grant or Support)

1362. Adding Insult to Injury: Association of Stigmatizing Language and Suboptimal Outcomes in People Who Inject Drugs

Background

The National Academy of Medicine has identified stigma surrounding substance use disorders (SUDs) and infectious diseases (ID) as a key barrier to integration of opioid use disorder (OUD) and ID services. Prior literature on stigmatizing language in OUD clinical care focuses on surveys and theoretical scenarios rather than real-world data. As part of a larger study of patients admitted for infectious complications of injection drug use (CHOICE), we sought to determine how inpatient physicians describe persons with OUD, as well as associations of this language with outcomes along the OUD continuum of care.

Methods

CHOICE is a retrospective review of adults hospitalized with an infectious complication of OUD and IDU at four academic medical centers. Included patients were hospitalized between 1/1/2018-12/31/2018, had ICD9/10 diagnosis codes consistent with OUD and acute bacterial/fungal infection, and chart review verification of active infection associated with OUD. Data was abstracted regarding demographics, inpatient interventions, transitions of care, and outcomes 1 year after admission. Potentially stigmatizing language was identified based on the discharge summary. “Abuse” and “misuse” were considered potentially stigmatizing; “use disorder” was considered best practice. Associations of language and outcomes were analyzed via logistic generalized estimating equations.

Results

A total of 287 subjects met inclusion criteria; 119 (42%) were female and the median age was 40 years (IQR: 32 – 52). The most common terms used to describe OUD were “abuse” (190, 66%) and “IVDU” (119, 42%). “Use disorder” was noted in only 72 (25%) charts. In a regression analysis, any mention of “use disorder” was associated with not leaving against medical advice (OR 2.48, 95% CI 1.24 – 4.95), a plan for ongoing OUD treatment (OR 5.17, 95% CI 2.05-13.0), and addiction-specific follow up (OR 2.94, 95% CI 2.34-3.68).

Conclusion

In this multicenter retrospective study, inpatient physicians commonly referred to patients with OUD using stigmatizing language. When NIH-preferred language was used this was associated with improved outcomes along the OUD continuum of care, possibly reflecting increased awareness of best practices for treating patients with OUD.

Disclosures

Ellen Eaton, MD , Gilead (Grant/Research Support) Ellen Eaton, MD , Gilead (Individual(s) Involved: Self): Research Grant or Support Greer A. Burkholder, MD, MSPH, Eli Lilly (Grant/Research Support) Sarah Kattakuzhy, MD, Gilead Sciences (Scientific Research Study Investigator, Research Grant or Support) Elana S. Rosenthal, MD, Gilead Sciences (Research Grant or Support)Merck (Research Grant or Support)

Water Jet Erosion Performance of Carbon Fiber and Glass Fiber Reinforced Polymers

Complex engineering challenges are revealed in the wind industry; one of them is erosion at the leading edge of wind turbine blades. Water jet erosive wear tests on carbon-fiber reinforced polymer (CFRP) and glass-fiber reinforced polymer (GFRP) were performed in order to determine their resistance at the conditions tested. Vacuum Infusion Process (VIP) was used to obtain the composite materials. Eight layers of bidirectional carbon fabric (0/90°) and nine glass layers of bidirectional glass cloth were used to manufacture the plates. A water injection platform was utilized. The liquid was projected with a pressure of 150 bar on the surface of the specimens through a nozzle. The samples were located at 65 mm from the nozzle at an impact angle of 75°, with an exposure time of 10, 20 and 30 min. SEM and optical microscopy were used to observe the damage on surfaces. A 3D optical profilometer helped to determine the roughness and see the scar profiles. The results showed that the volume loss for glass fiber and carbon fiber were 10 and 19 mm³, respectively. This means that the resistance to water jet erosion in uncoated glass fiber was approximately two times lower than uncoated carbon fiber.

[Surgical site infection after abdominal surgery in China: a multicenter cross-sectional study]

Objective: Surgical site infection (SSI) can markedly prolong postoperative hospital stay, aggravate the burden on patients and society, even endanger the life of patients. This study aims to investigate the national incidence of SSI following abdominal surgery and to analyze the related risk factors in order to provide reference for the control and prevention of SSI following abdominal surgery. Methods: A multicenter cross-sectional study was conducted. Clinical data of all the adult patients undergoing abdominal surgery in 68 hospitals across the country from June 1 to 30, 2020 were collected, including demographic characteristics, clinical parameters during the perioperative period, and the results of microbial culture of infected incisions. The primary outcome was the incidence of SSI within postoperative 30 days, and the secondary outcomes were ICU stay, postoperative hospital stay, cost of hospitalization and the mortality within postoperative 30-day. Multivariable logistic regression was used to analyze risk factors of SSI after abdominal surgery. Results: A total of 5560 patients undergoing abdominal surgery were included, and 163 cases (2.9%) developed SSI after surgery, including 98 cases (60.1%) with organ/space infections, 19 cases (11.7%) with deep incisional infections, and 46 cases (28.2%) with superficial incisional infections. The results from microbial culture showed that Escherichia coli was the main pathogen of SSI. Multivariate analysis revealed hypertension (OR=1.792, 95% CI: 1.194-2.687, P=0.005), small intestine as surgical site (OR=6.911, 95% CI: 1.846-25.878, P=0.004), surgical duration (OR=1.002, 95% CI: 1.001-1.003, P<0.001), and surgical incision grade (contaminated incision: OR=3.212, 95% CI: 1.495-6.903, P=0.003; Infection incision: OR=11.562, 95%CI: 3.777-35.391, P<0.001) were risk factors for SSI, while laparoscopic or robotic surgery (OR=0.564, 95%CI: 0.376-0.846, P=0.006) and increased preoperative albumin level (OR=0.920, 95%CI: 0.888-0.952, P<0.001) were protective factors for SSI. In addition, as compared to non-SSI patients, the SSI patients had significantly higher rate of ICU stay [26.4% (43/163) vs. 9.5% (514/5397), χ(2)=54.999, P<0.001] and mortality within postoperative 30-day [1.84% (3/163) vs.0.01% (5/5397), χ(2)=33.642, P<0.001], longer ICU stay (median: 0 vs. 0, U=518 414, P<0.001), postoperative hospital stay (median: 17 days vs. 7 days, U=656 386, P<0.001), and total duration of hospitalization (median: 25 days vs. 12 days, U=648 129, P<0.001), and higher hospitalization costs (median: 71 000 yuan vs. 39 000 yuan, U=557 966, P<0.001). Conclusions: The incidence of SSI after abdominal surgery is 2.9%. In order to reduce the incidence of postoperative SSI, hypoproteinemia should be corrected before surgery, laparoscopic or robotic surgery should be selected when feasible, and the operating time should be minimized. More attentions should be paid and nursing should be strengthened for those patients with hypertension, small bowel surgery and seriously contaminated incision during the perioperative period.

[Risk factors for surgical site infection after emergency abdominal surgery: a multicenter cross-sectional study in China]

Objective: Surgical site infection (SSI) is the most common infectious complication after emergency abdominal surgery (EAS). To a large extent, most SSI can be prevented, but there are few relevant studies in China. This study mainly investigated the current situation of SSI occurrence after EAS in China, and further explored risk factors for SSI occurrence. Methods: Multi-center cross-sectional study was conducted. Clinical data of patients undergoing EAS in 33 hospitals across China between May 1, 2019 and June 7, 2019 were prospectively collected, including perioperative data and microbial culture results from infected incisions. The primary outcome was the incidence of SSI after EAS, while the secondary outcomes were postoperative hospital stay, ICU occupancy rate, length of ICU stay, hospitalization cost, and mortality within postoperative 30 days. Univariate and multivariate logistic regression models were used to analyze the risk factors of SSI after EAS. Results: A total of 660 EAS patients aged (47.9±18.3) years were enrolled in this study, including 56.5% of males (373/660). Forty-nine (7.4%) patients developed postoperative SSI. The main pathogen of SSI was Escherichia coli [culture positive rate was 32.7% (16/49)]. As compared to patients without SSI, those with SSI were more likely to be older (median 56 years vs. 46 years, U=19 973.5, P<0.001), male [71.4% (35/49) vs. 56.1% (343/611), χ(2)=4.334, P=0.037] and diabetes [14.3% (7/49) vs. 5.1% (31/611), χ(2)=5.498, P=0.015]; with-lower preoperative hemoglobin (median: 122.0 g/L vs. 143.5 g/L, U=11 471.5, P=0.006) and albumin (median: 35.5 g/L vs. 40.8 g/L, U=9452.0, P<0.001), with higher blood glucose (median: 6.9 mmol/L vs. 6.0 mmol/L, U=17 754.5, P<0.001); with intestinal obstruction [32.7% (16/49) vs. 9.2% (56/611), χ(2)=25.749, P<0.001], with ASA score 3-4 [42.9% (21/49) vs. 13.9% (85/611), χ(2)=25.563, P<0.001] and with high surgical risk [49.0% (24/49) vs. 7.0% (43/611), χ(2)=105.301, P<0.001]. The main operative procedure resulting in SSI was laparotomy [81.6%(40/49) vs. 35.7%(218/611), χ(2)=40.232, P<0.001]. Patients with SSI experienced significantly longer operation time (median: 150 minutes vs. 75 minutes, U=25 183.5, P<0.001). In terms of clinical outcome, higher ICU occupancy rate [51.0% (25/49) vs. 19.5% (119/611), χ(2)=26.461, P<0.001], more hospitalization costs (median: 44 000 yuan vs. 15 000 yuan, U=24 660.0, P<0.001), longer postoperative hospital stay (median: 10 days vs. 5 days, U=23 100.0, P<0.001) and longer ICU occupancy time (median: 0 days vs. 0 days, U=19 541.5, P<0.001) were found in the SSI group. Multivariate logistic regression analysis showed that the elderly (OR=3.253, 95% CI: 1.178-8.985, P=0.023), colorectal surgery (OR=9.156, 95% CI: 3.655-22.937, P<0.001) and longer operation time (OR=15.912, 95% CI:6.858-36.916, P<0.001) were independent risk factors of SSI, while the laparoscopic surgery (OR=0.288, 95% CI: 0.119-0.694, P=0.006) was an independent protective factor for SSI. Conclusions: For patients undergoing EAS, attention should be paid to middle-aged and elderly patients and those of colorectal surgery. Laparoscopic surgery should be adopted when feasible and the operation time should be minimized, so as to reduce the incidence of SSI and to reduce the burden on patients and medical institutions.

[Investigation of treatment and analysis of prognostic risk on enterocutaneous fistula in China: a multicenter prospective study]

Objective: To investigate the diagnosis and treatment for enterocutaneous fistula (ECF) in China, and to explore the prognostic factors of ECF. Methods: A multi-center cross-sectional study was conducted based on the Registration System of Chinese Gastrointestinal Fistula and Intra-Abdominal Infections to collect the clinical data of ECF patients from 54 medical centers in 22 provinces/municipalities from January 1, 2018 to December 31, 2018. The clinical data included patient gender, age, length of hospital stay, intensive care unit (ICU) admission, underlying diseases, primary diseases, direct causes of ECF, location and type of ECF, complications, treatment and outcomes. All medical records were carefully filled in by the attending physicians, and then re-examined by more than two specialists. The diagnosis of ECF was based on the clinical manifestations, laboratory/imaging findings and intraoperative exploration. Results: A total of 1521 patients with ECF were enrolled, including 1099 males and 422 females, with a median age of 55 years. The top three primary diseases of ECF were malignant tumors in 626 cases (41.2%, including 540 gastrointestinal tumors, accounting for 86.3% of malignant tumors), gastrointestinal ulcers and perforations in 202 cases (13.3%), and trauma in 157 cases (10.3%). The direct causes of ECF were mainly surgical operation in 1194 cases (78.5%), followed by trauma in 156 (10.3%), spontaneous fistula due to Crohn's disease in 92 (6.0%), radiation intestinal injury in 41 (2.7%), severe pancreatitis in 20 (1.3%), endoscopic treatment in 13 (0.9%) and 5 cases (0.3%) of unknown reasons. All the patients were divided into three groups: 1350 cases (88.7%) with simple ECF, 150 (9.9%) with multiple ECF, and 21 (1.4%) with combined internal fistula. Among the patients with simple ECF, 438 cases (28.8%) were jejuno-ileal fistula, 313 (20.6%) colon fistula, 170 (11.2%) rectal fistula, 111 (7.3%) duodenal fistula, 76 (5.0%) ileocecal fistula, 65 (4.3%) ileocolic anastomotic fistula, 55 (3.6%) duodenal stump fistula, 36 (2.4%) gastrointestinal anastomotic fistula, 36 (2.4%) esophagogastric/esophagojejunal anastomotic fistula, 29 (1.9%) gastric fistula and 21 (1.4%) cholangiopancreatiointestinal. Among all the simple ECF patients, 991 were tubular fistula and 359 were labial fistula. A total of 1146 patients finished the treatment, of whom 1061 (92.6%) were healed (586 by surgery and 475 self-healing) and 85 (7.4%) died. A total of 1043 patients (91.0%) received nutritional support therapy, and 77 (6.7%) received fistuloclysis. Infectious source control procedures were applied to 1042 patients, including 711 (62.0%) with active lavage and drainage and 331 (28.9%) with passive drainage. Among them, 841 patients (73.4%) underwent minimally invasive procedures of infectious source control (replacement of drainage tube through sinus tract, puncture drainage, etc.), 201 (17.5%) underwent laparotomy drainage, while 104 (9.1%) did not undergo any drainage measures. A total of 610 patients (53.2%) received definitive operation, 24 patients died within postoperative 30-day with mortality of 3.9% (24/610), 69 (11.3%) developed surgical site infection (SSI), and 24 (3.9%) had a relapse of fistula. The highest cure rate was achieved in ileocecal fistula (100%), followed by rectal fistula (96.2%, 128/133) and duodenal stump fistula (95.7%,44/46). The highest mortality was found in combined internal fistula (3/12) and no death in ileocecal fistula. Univariate prognostic analysis showed that primary diseases as Crohn's disease (χ(2)=6.570, P=0.010) and appendicitis/appendiceal abscess (P=0.012), intestinal fistula combining with internal fistula (χ(2)=5.460, P=0.019), multiple ECF (χ(2)=7.135, P=0.008), esophagogastric / esophagojejunal anastomotic fistula (χ(2)=9.501, P=0.002), ECF at ileocecal junction (P=0.012), non-drainage/passive drainage before the diagnosis of intestinal fistula (χ(2)=9.688, P=0.008), non-drainage/passive drainage after the diagnosis of intestinal fistula (χ(2)=9.711, P=0.008), complicating with multiple organ dysfunction syndrome (MODS) (χ(2)=179.699, P<0.001), sepsis (χ(2)=211.851, P<0.001), hemorrhage (χ(2)=85.300, P<0.001), pulmonary infection (χ(2)=60.096, P<0.001), catheter-associated infection (χ(2)=10.617, P=0.001) and malnutrition (χ(2)=21.199, P<0.001) were associated with mortality. Multivariate prognostic analysis cofirmed that sepsis (OR=7.103, 95%CI:3.694-13.657, P<0.001), complicating with MODS (OR=5.018, 95%CI:2.170-11.604, P<0.001), and hemorrhage (OR=4.703, 95%CI: 2.300-9.618, P<0.001) were independent risk factors of the death for ECF patients. Meanwhile, active lavage and drainage after the definite ECF diagnosis was the protective factor (OR=0.223, 95%CI: 0.067-0.745, P=0.015). Conclusions: The overall mortality of ECF is still high. Surgical operation is the most common cause of ECF. Complications e.g. sepsis, MODS, hemorrhage, and catheter-associated infection, are the main causes of death. Active lavage and drainage is important to improve the prognosis of ECF.

Genes and pathways identified in thyroid carcinoma based on bioinformatics analysis

The objective of this study was to investigate the key genes and pathways associated with thyroid carcinoma. Based on the microarray data of GSE27155, we identified the differentially expressed genes (DEGs) between four types of thyroid carcinoma samples (papillary carcinoma (PTC), oncocytic carcinoma (OTC), follicular carcinoma (FTC) and anaplastic carcinoma (ATC)) and normal controls. With the obtained DEGs, we performed gene functional interaction (FI) network analysis. Then we conducted Venn diagram analysis to identify the intersection and specific DEGs of the four types of thyroid carcinomas. The intersections DEGs were performed by functional enrichment and transcription factor (TF) prediction analyses. These specific DEGs were performed by pathway enrichment analysis. There were respectively 323, 318, 118 and 1005 DEGs identified in PTC, OTC, FTC and ATC. Twelve sub-network modules were extracted based on gene FI network analysis and eight thyroid carcinoma-associated DEGs were involved in the network, such as TIMP1. Based on the Venn diagram analysis, 27 common DEGs were identified, such as HMGB3 which was regulated by TF of NKX3-1. There were 149 PTC-specific DEGs (like CLDN1), 160 OTC-specific DEGs, 94 FTC-specific DEGs (like PPARG), and 789 ATC-specific DEGs (like CDK1). They were enriched in some pathways, such as Cell cycle, Citrate cycle, and Oxidative phosphorylation. TIMP1, HMGB3, CLDN1, CDK1 and PPARG as well as pathways of Cell cycle, Citrate cycle, and Oxidative phosphorylation may play important roles in the progression of thyroid carcinoma.

Osteocondromatose em gato: relato de caso

RESUMO A osteocondromatose é caracterizada por nódulos únicos ou múltiplos decorrentes de um crescimento ósseo excessivo benigno. É encontrada em cães, gatos, equinos e humanos. Em felinos, tem maior incidência dos dois aos quatro anos de idade. A etiologia em gatos está relacionada ao vírus da leucemia felina, e também já foi encontrada relação com o fibrossarcoma. A manifestação clínica depende do local acometido e do tamanho da lesão. O diagnóstico definitivo é por meio de histopatologia e o prognóstico é desfavorável, pois ocorrem muitas recidivas. Este relato de caso objetiva descrever a apresentação dessa enfermidade em um felino jovem.

Key genes and pathways predicted in papillary thyroid carcinoma based on bioinformatics analysis

PURPOSE

The aim of this study was to predict the key genes and pathways associated with papillary thyroid carcinoma (PTC).

METHODS

Based on the microarray data of GSE3467 from Gene Expression Omnibus database, we identified the differentially expressed genes (DEGs) between 9 PTC samples and 9 normal controls. With the identified DEGs, functional enrichment analyses were performed. Additionally, a protein-protein interaction network was constructed to screened out some key gene nodes. These key nodes were then performed clustering analysis and pathway enrichment analysis. Furthermore, human PTC-associated network was constructed based on these key genes to investigate the potential relationships between genes and PTC.

RESULTS

A total of 651 up-regulated and 692 down-regulated DEGs were identified in PTC samples compared with controls. The up-regulated DEGs, such as complement component 3 (C3), were mainly enriched in hsa04610:Complement and coagulation cascades. The down-regulated DEGs, including paired box 8 (PAX8), peroxisome proliferator-activated receptor gamma (PPARG), and cadherin 1, type 1 were found enriched in hsa05216:Thyroid cancer. Total 33 DEGs were considered as key genes, such as PAX8, PPARG and Jun proto-oncogene (JUN). Disease-associated network analysis found that 15 key genes such as JUN, PPARG and matrix metallopeptidase 9 (MMP9) were involved in this network.

CONCLUSIONS

DEGs of C3, PPARG, PAX8, JUN and MMP9 were differentially expressed in PTC samples and may be used as potential biomarkers in the diagnosis and treatment of PTC. Additionally, pathways of complement and coagulation cascades and thyroid cancer may also play important roles in the development of PTC.

Expression level of microRNA-195 in the serum of patients with gastric cancer and its relationship with the clinicopathological staging of the cancer

OBJECTIVE

To study miroRNA-195 (miR-195) expression in the serum and cancer tissue of patients with gastric cancer and to investigate the relationship between its expression and clinicopathological features of gastric cancer.

PATIENTS AND METHODS

Sixty-two patients with gastric cancer admitted to our institution were included in the study group, and 36 healthy persons undergoing health check-up at our institution served as control group. miR-195 expressions in the serum, gastric cancer tissue and corresponding paracancerous tissue in subjects of two groups were measured by using quantitative fluorescent real-time PCR (QF-RT-PCR), and the relationship between miR-195 and the clinicopathological features of the cancer was investigated.

RESULTS

miR-195 expression level in the serum of gastric cancer patients was significantly lower than that in the control group (p <0.05). miR-195 expression in gastric cancer tissue was also significantly lower than that in corresponding paracancerous tissue (p <0.05). The results of correlation analysis showed that low expression of miR-195 was negatively correlated with the infiltration depth, the extent of differentiation, the clinical staging and lymph node metastasis, all with statistical significance (p <0.05), but not significantly correlated with tumor locations (p >0.05).

CONCLUSIONS

Low expression of miR-195 in patients with gastric cancer may play a certain role in promoting the genesis and development of gastric cancer and it can function as a potential novel tumor marker for the early diagnosis and prognosis evaluation of gastric cancer.

Radiographic kidney measurements in North American pet ferrets (Mustela furo)

OBJECTIVES

The purpose of the current study was to determine normal radiographic kidney -measurements in pet ferrets.

METHODS

Kidney length and width dimensions and the length of the second lumbar vertebra (L2) were determined from survey ventrodorsal radiographs in 53 neutered ferrets of various ages, weight and sex, with no evidence of urogenital disease. Kidney dimensions were expressed as a ratio to the body length of L2.

RESULTS

All ferrets in this study had six lumbar vertebrae. The median length of L2 was 13·3 mm, and was longer in males than females (P=0·0001). The 95% confidence interval for kidney-length-to-L2 ratios was 2·21 to 2·31 for the right and 2·15 to 2·25 for the left. For the kidney-width-to-L2 ratios these intervals were 1·09 to 1·14 for the right and 1·07 to 1·12 for the left kidney. There was a significant association between kidney size and weight or sex but not with age.

CLINICAL SIGNIFICANCE

The results of this radiographic study may allow practitioners to have a more -objective clinical radiographic evaluation of kidney size of pet ferrets based on individual traits.

Cerebrospinal Fluid Levels of Soluble Amyloid Precursor Protein and β-Amyloid 42 in Patients with Multiple Sclerosis, Neuromyelitis Optica and Clinically Isolated Syndrome

Amyloid precursor protein (APP) accumulation in axonal ovoids is a sensitive marker for acute axonal injury in multiple sclerosis (MS) lesions. This study measured levels of α-cleaved soluble APP (αsAPP) and β-amyloid 42 (Aβ42) in the cerebrospinal fluid (CSF) of 42 MS, 10 neuromyelitis optica and 25 clinically isolated syndrome patients and 21 healthy controls, and analysed the correlation between αsAPP and Aβ42 levels and relevant clinical parameters. The CSF concentrations of αsAPP and Aβ42 in patients and controls were not significantly different. There was a significant inverse correlation in patients between CSF asAPP concentration and the Expanded Disability Status Scale (EDSS), but no significant correlation between CSF Aβ42 concentration and EDSS. The concentration of αsAPP in the CSF of statin-treated patients was significantly higher than in those not treated with statins, suggesting that statins may have a neuroprotective effect. In conclusion, αsAPP was present at similar levels in the CSF of patients with neuromyelitis optica, MS and clinically isolated syndrome and healthy controls, and an inverse correlation existed between CSF αsAPP concentration and neurological disability.

Reliability of T2-weighted sagittal magnetic resonance images for determining the location of compressive disk herniation in dogs

Magnetic resonance imaging is used commonly to diagnose intervertebral disk herniation in dogs. It is common to locate areas of suspected compression on sagittal T2-weighted (T2-W) images and then obtain limited transverse images in these areas to reduce the acquisition time (a step-by-step approach). Our objective was to assess the frequency of correct localization of spinal cord compression due to disk herniation using only the sagittal images. The results from isolated readings of the sagittal T2-W images alone or combined with a single-shot fast spin echo (SSFSE) slab in 118 dogs were compared with a gold standard, based on a consensual reading of all images available, including complete transverse images across the entire spinal segments under study. The sites of compression were localized correctly from the sagittal images in 89.8% of dogs. If only the most significant lesions were accounted for, the percentage increased up to 95.2%. In 54.9% of the readings with incorrect localization, the actual compressive site was immediately adjacent to the one suspected from review of the sagittal images. The frequency of correct localization was higher in the cervical region, and was increased by examination of the SSFSE slab. The most common cause of disagreement was the presence of multiple degenerate bulging disks. Based on these results we recommend obtaining transverse images across the entire segment when multiple bulging disks are present. It is also recommended to obtain transverse images across the spaces immediately adjacent to the suspected site of herniation from review of the sagittal images.

Pseudolayering artefact on postcontrast magnetic resonance images of the bladder of 18 dogs and three cats

An artefact was observed on postcontrast magnetic resonance imaging (mri) of the urinary bladder of several small animals; it took the form of a dark layer in the dependent (dorsal) part of the bladder, with a thin hyperintense layer on top of it, and a hypointense signal in the rest of the non-dependent (ventral) part. The mri database was searched for animals with T1-weighted images of the urinary bladder after the injection of gadolinium. Eighteen dogs and three cats were included in the study. The artefact was observed in 16 of the animals on the postcontrast images but not on the T1-weighted and T2-weighted precontrast images. A phantom experiment showed that the signal intensity observed on T1-weighted images decreased rapidly as the concentration of gadolinium increased from 6.25 mmol/l to 25 mmol/l. It is hypothesised that the early excretion of concentrated gadolinium into the bladder causes the pseudolayering artefact observed, which has also been reported in human patients.

Five year follow up of a phase II study of cytotoxic immunotherapy combined with radiation in newly diagnosed prostate cancer

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Background: In the U.S. there are about 70,000 annual prostate cancer recurrences. The purpose of this study is to evaluate a product to decrease incidence of recurrence. This study is based on objective clinical responses in Phase I studies with AdV-tk (ProstAtak™, Advantagene, Inc) as monotherapy in recurrent disease and preclinical data demonstrating synergy between AdV-tk and radiation. AdV-tk is an adenoviral vector expressing the herpes thymidine kinase gene delivered to the prostate via TRUS-guided injection followed by 14 days of oral prodrug. The mechanisms of function involve direct tumor cytotoxicity, local elicitation of danger signals, recruitment and activation of antigen presenting cells and stimulation of systemic anti-tumor T-cell immunity. Method: AdV-tk was evaluated in combination with radiation in 66 newly diagnosed patients: 33 low risk (Arm A, PSA <10, Gleason <7, and T1c-T2a) and 33 intermediate-high risk (Arm B, PSA ≥10, Gleason ≥7, or T2b-T3). Arm A received two treatments with AdV-tk, immediately before and 14 days into radiation. Arm B received an additional treatment at initiation of androgen deprivation therapy. Results: Two surrogate and one definitive end-point were evaluated. Frequency of patients in Arm A with PSA nadir ≤0.2 ng/ml was 71% vs 56% in a control group of concurrent patients without AdV-tk. The two-year pathologic complete response (pCR) rate by sextant biopsy was 90% in Arm A and 94% in Arm B, compared to an expected range of 70–73%. Freedom from failure (FFF) after 60 month median follow up is 100% for Arm A and 90% for Arm B (95% for intermediate, 75% for high risk) vs best reported results of 79–90% for low risk and 48–79% for intermediate-high risk patients. The three failures in Arm B occurred within months after treatment leading to a Kaplan-Meier curve that plateaus at 90% beyond year 3. This is notably different than previous reports in which the curves continue to drop beyond year 5. Conclusion: These results suggest that AdV-tk combined with radiation therapy may significantly reduce the recurrence rate in patients with prostate cancer, particularly in patients with intermediate-high risk disease. A randomized controlled trial is warranted.

[Table: see text]

Ultrasound detection of spontaneous hepato-cellular carcinomas in X/myc bitransgenic mice

AIMS

To evaluate trans-abdominal ultrasound for the detection of Hepatocellular carcinoma (HCC) in a bitrasgenic murine (X/myc) model using a commercially available high-frequency ultrasound unit.

METHODS

Sixty-one female animals were included in this study. These animals were submitted to a single ultrasound examination of the liver under general anesthesia (isoflurane), and then euthanized. Results of ultrasound were compared with necropsy and histopathology.

RESULTS

The lesions demonstrated a fairly consistent aspect (oval- or round-shaped, well-defined hypoechoic homogeneous lesions), and lesions as small as 2 mm were identified. For detection of hepatic nodules per mouse the sensitivity was 75%, the specificity was 100% and the accuracy was 88.5%. For detection of hepatic focal lesions per lesions the overall sensitivity was 60%, the specificity was 97%, and the accuracy was 75.9%. Contrast-enhanced harmonic ultrasound imaging did not improve the identification of the lesions in our experimental conditions.

CONCLUSION

High-frequency ultrasound appears to be an efficient tool allowing new possibilities to use this animal model and evaluate new therapies in longitudinal studies, which are much more powerful.

[Important prognostic factors in patients with skull base erosion from nasopharyngeal carcinoma after radiotherapy]

OBJECTIVE

To evaluate the long-term outcome and prognostic factors in patients with skull base erosion from nasopharyngeal carcinoma (NPC) after initial radiation therapy.

METHODS

From January 1985 to December 1986, 100 patients (71 male, 29 female) with the diagnosis of NPC were found to have skull base erosion from computed tomography (CT). The mean age was 41 (16-66) years. Ninety-six patients had World Health Organization (WHO) type III undifferentiated carcinoma while four had type I carcinomas. Metastatic workup including chest radiography, liver ultrasound and liver function test were negative. All patients underwent external beam radiotherapy alone to 66-80 Gy over 6-8 weeks. Daily fraction size of 2 Gy was delivered utilizing cobalt-60 or linear accelerator. No patient received chemotherapy. All patients were followed up at regular intervals after irradiation. Median follow-up was 22.3 months (2 months-174 months). Overall survival of the cohort was computed by the Kaplan-Meier method. Potential prognostic factors on survival were examined. Multivariate analyses was performed using Cox regression model.

RESULTS

One, three, five, and ten year overall survival rates for the cohort were 79%, 38%, 27% and 13%, respectively. However, in the sub-group of patients with both anterior cranial nerves (I-VIII) and posterior cranial nerve (IX-XII) involvement had a five-year survival of only 7.7%. Causes of death included local recurrence (59 patients), distant metastases (21 patients), both local recurrence and distant metastases (1 patient) and unrelated causes (5 patients). After multivariate analysis, complete recovery of cranial nerve involvement, cranial nerves palsy and recovery of headache after irradiation were found to be independent prognostic factors in this cohort.

CONCLUSION

This report presents one of the longest follow-ups of patients with nasopharyngeal carcinoma invading skill base. It demonstrates the importance of cranial nerves involvement as well as recovery of headache and cranial nerve palsy. These factors should be evaluated carefully from history and physical examination as well as imaging studies. Currently available magnetic resonance imaging (MRI) is highly recommended as an additional test. A subgroup of patients with skull base involvement had long-term survival after radiotherapy alone. More aggressive strategy such as combined chemo-radiotherapy and altered fractionation radiotherapy may improve outcome in patients with poor prognostic factors.

[A comparative study of HLA-A locus in northern and southern Chinese bymeans of PCR/SSOP typing]

OBJECTIVE

To compare the HLA-A locus in a population selected from Beijing (northern group) with that in a population selected from Guangzhou (southern group).

METHODS

HLA typing was performed by using PCR/SSOP method. A pair of primer and 54 probes were used.

RESULTS

In 18 alleles identified, the differences in gene frequency between northern and southern Chinese were found. In northern group, A*0205, 0210 and 2901 were absent, and the frequencies of A*2601, 3001 and 3101 were higher than those of southern group; while in southern group, A*3103, 3201 and 6801 were absent, the frequencies of A*0203 and 1101 were higher than those of northern group; and in addition, six subtypes of A2 serological specificity, namely A*0201, 0203, 0205, 0206, 0207 and 0210, were found, in which A*0201 predominated.

CONCLUSION

There are some differences in the genetic background of northern and southern Chinese. A2 subtypes have important implications for unrelated-donor transplantation.

Diagnosis of pulmonary thromboembolism in a cat using echocardiography and pulmonary scintigraphy

A 10-year-old male cat was presented with sudden onset of respiratory difficulties. Clinical examination revealed an acute dyspnoea with cyanosis associated with a left systolic heart murmur. Standard thoracic radiographs excluded pulmonary oedema and showed very few pulmonary changes given the intensity of the respiratory compromise. Echocardiographic examination revealed hypertrophic cardiomyopathy and a thrombus in the right pulmonary artery. Pulmonary scintigraphy confirmed a pulmonary thromboembolism with hypovascularisation of the left cranial lobe and of the ventral segment of the right lobe. Conservative treatment was instituted using an antibiotic (doxycycline), anticoagulants (heparin, coumadine) and a calcium inhibitor (diltiazem). The cat was given absolute rest. The general condition of the animal improved.