COVID-positive ankle fracture patients are at increased odds of perioperative surgical complications following open reduction internal fixation surgery

Introduction Ankle fractures have continued to occur through the COVID pandemic and, regardless of patient COVID status, often need operative intervention for optimizing long-term outcomes. For healthcare optimization, patient counseling, and care planning, understanding if COVID-positive patients undergoing ankle fracture surgery are at increased risk for perioperative adverse outcomes is of interest. Methods The COVID-19 Research Database contains recent United States aggregated insurance claims. Patients who underwent ankle fracture surgery from April 1st, 2020 to June 15th, 2020 were identified. COVID status was identified by ICD coding. Demographics, comorbidities, and postoperative complications were extracted based on administrative data. COVID-positive versus negative patients were compared with univariate analyses. Propensity-score matching was done on the basis of age, sex, and comorbidities. Multivariate regression was then performed to identify risk factors independently associated with the occurrence of 30-day postoperative adverse events. Results In total, 9,835 patients undergoing ankle fracture surgery were identified, of which 57 (0.58%) were COVID-positive. COVID-positive ankle fracture patients demonstrated a higher prevalence of comorbidities, including: chronic kidney disease, diabetes, hypertension, and obesity (p<0.05 for each). After propensity matching and controlling for all preoperative variables, multivariate analysis found that COVID-positive patients were at increased risk of any adverse event (odds ratio [OR] = 3.89, p = 0.002), a serious adverse event (OR = 5.48, p = 0.002), and a minor adverse event (OR = 3.10, p = 0.021). Discussion COVID-positive patients will continue to present with ankle fractures requiring operative intervention. Even after propensity matching and controlling for patient factors, COVID-positive patients were found to be at increased risk of 30-day perioperative adverse events. Not only do treatment teams need to be protected from the transmission of COVID in such situations, but the increased incidence of perioperative adverse events needs to be considered.

Is percutaneous radiologic gastrostomy safer than percutaneous endoscopic gastrostomy?

Objectives: The objectives of the study were to compare the indications, adverse events, removal rates, and mortality of percutaneous endoscopic gastrostomy (PEG) and percutaneous radiologic gastrostomy (PRG) techniques at our tertiary care institution from 2014 to 2019. Material and Methods: We undertook a 5-year retrospective review of patients who underwent either PEG or PRG at our institution from 2014 to 2019. Common adverse events include tube clogs, leaks, minor bleeds, and wound infections, while more rare major complications include peritonitis, intra-abdominal infection, and major hemorrhage. The procedures were all performed with either conscious sedation or general anesthesia. A total of 789 patients were reviewed, of whom 519 (65.8%) had a PRG and 270 (34.2%) had a PEG. PRGs were more likely to be placed for head-and-neck cancer (P < 0.0001) and amyotrophic lateral sclerosis (P < 0.0001), while PEGs were more likely to be placed for gastric outlet obstruction (GOO) (P <.0001) and malnutrition (P < 0.0001). Results: The rate of major adverse events was similar between the two groups (P = 0.938). GI placed gastrostomy tubes were more likely to have a minor adverse event (P < 0.0001), however, this was secondary to a significant increase in tube clog in the PEG/J group as compared to PEG (P < 0.0001). Conclusion: The decision to place a PEG or PRG should be individualized to the patient’s specific condition and indication. Both procedures have favorable safety profiles, and it is likely that institutional expertise and procedural access will be the primary determinants of the procedural technique chosen for minimally invasive gastrostomy.

Breakthrough infection after COVID-19 vaccination: A threat for Nepal due to SARS-CoV-2 variants circulating in 2nd wave ravaging India

After a year of the COVID-19 pandemic, the meta-analysis in Dec 2020 did not support its reinfections. Now it’s clear that not only reinfection following earlier exposure is a reality, but also breakthrough infections after vaccinations have been increasingly reported. A breakthrough infection means that the infection has broken through the protection provided by the vaccine. The course of the disease, strict observation for preventive measures, together with safe vaccines is necessary long-term solutions. The effectiveness of the vaccine, durability of immunity, the role of the virus variants, the incidence and severity of breakthrough infections are the challenges in real life. A breakthrough infection is the detection of SARS-CoV-2 RNA or antigen in the respiratory specimen ≥14 days after inoculation of a vaccine. A breakthrough infection of 0.04 to 13% has been reported in the literature. Nepal began vaccine rollout in late Jan 2021. Nearly 3 million population has been vaccinated by two vaccines, the Covishield (AstraZeneca, from India) and Vero Cell (Sinopharm, China). Only minor ‘Adverse Event Following Immunization’ after the initial vaccine rollout has been reported. There is a lack of reports on the breakthrough infection for these vaccines in the local population. Analysis of the data on breakthrough infection from the vaccine rollouts in Nepal is awaited.

Home-based Cardiac Rehabilitation in Covid Era: Is it a safe option?

Funding Acknowledgements Type of funding sources: None. Introduction Home-based Cardiac Rehabilitation (CR-HB) models have been shown to be effective, however, there is a large variation of protocols and minimal evidence of effectiveness in higher risk populations, in which exercise at distance might be concerning. In addition, lack of reimbursement models has discouraged the widespread adoption of CR-HB. During the coronavirus 2019 (COVID-19) pandemic, an even greater gap in CR care has emerged due to the decreased availability of on-site services. Purpose Evaluation of the safety of a CR-HB program during COVID-19 pandemic. Methods Prospective cohort study which included patients (pts) who were participating in a centre-based CR program and accepted to participate in a CR-HB after the centre-based CR program closure due to COVID-19. The CR-HB consisted in a multidisciplinary digital CR program, including: 1.pts regular clinical and exercise risk assessment; 2.psychological tele-appointments and group sessions; 3. online exercise training sessions, which consisted of recorded videos and real time online exercise training sessions (each session recommended 3 times per week, during 60 minutes); 4.structured online educational program for pts and family members/caregivers, including educational videos and webinars; 5. follow-up fortnightly questionnaire to evaluate risk factors control and need for appointments or directing to hospital; 6. nutrition tele-appointments; 7. physician tele-appointments, scheduled according to follow-up questionnaire or at patients request (e-mail or telephone) to avoid unnecessary exposure and overload in the hospital. Minor and major adverse events such as hospitalizations due to cardiac event or other non CV reason, cardiac or noncardiac death, during or immediately after the exercise sessions, were collected. Results 116 cardiovascular disease (CVD) pts (62.6 ± 8.9 years, 95 males) who were attending a Centre-based CR program were included in a CR-HB program. Almost 90% (n = 103) of the participants had coronary artery disease; 13.8% pts had heart failure. The mean LVEF was 52 ± 11%; 31,1% of the population had at least moderate risk. Regarding risk factors, obesity was the most common risk factor (74.7%) followed by hypertension (59.6%), family history (41.8%), dyslipidaemia (37.9%), diabetes (18.1%), and smoking (12.9%). 98 CVD pts (85.5%) successfully completed all the online assessments. Three male participants dropped out for hospitalization due to knee surgery, pacemaker implantation and in-stent restenosis without relation to exercise sessions. No major events were registered during the exercise training sessions and only one minor adverse event, sprained ankle, was reported during the training sessions. Conclusions This CR-HB program, originated by the need of social distancing during COVID-19 pandemic, revealed to be a valuable and safe strategy to reach at distance most patients previously in a Centre-based CR program.

Left Gastric Artery Embolization for Weight Loss

Purpose To conduct a prospective clinical trial to evaluate the feasibility, safety and efficacy of left gastric artery embolization as a minimally-invasive way for the treatment of obesity. Materials & Methods Patients were recruited with respect to detailed inclusion and exclusion criteria. A baseline clinical history taking and physical examination including anthropometric measurements was undertaken. A baseline EGD was performed to rule out any pre-existing pathology in the esophagus, stomach or duodenum. Baseline serum Ghrelin level was assessed. Embolization was performed using non-spherical polyvinyl alcohol particles sized 355–500 µm (Bearing nsPVA®, Merit Medical) until complete stasis of flow within the LGA and its branches. Patients were followed up weekly for 1 month then monthly for 6 months by anthropometric measurements by the clinical nutritionists from the Physical Medicine department. At 1 month, EGD was repeated to assess for any complications or adverse effects. Another blood sample was withdrawn to assess the change in serum Ghrelin level. Results Left gastric artery embolization was performed on six obese to morbidly obese patients (four women and two men; average age, 44 years; range, 24–62 years), with a mean weight of 113.67 kg (range 86–133 kg), a mean BMI of 44.45 kg/m2 (range 33.6–51.2 kg/m2) Technical success rate was 100%. There was one minor adverse event in the form of a small asymptomatic superficial gastritis in the fundus/lesser curvature. There were no major adverse events. Mean excess weight loss of 5.58% and 2.91% was noted at 1 month and at 6 months, respectively. Mean change in serum ghrelin was −35.57% at 1 month. Conclusion LGA embolization is technically feasible and safe. There is considerable drop in serum ghrelin level at 1 month. However, the weight loss appears to be transient. Future studies can opt for smaller-sized particles and probably embolization of the right gastro-epiploic artery together with the left gastric artery. Abbreviations BMI = Body Mass Index, EGD = Esophagogastroduodenoscopy, LGA = Left Gastric Artery, NSAID = Non-steroidal anti-inflammatory drugs, PPI = Proton pump inhibitors, WHO = World Health Organization.

Neck and supraclavicular lymphadenopathy secondary to 9-valent human papillomavirus vaccination

We present two clinical cases of lymphadenopathy after vaccination with the human papillomavirus (HPV) 9-valent vaccine: an asymptomatic 11-year-old boy with inferior cervical and supraclavicular lymphadenopathy, and a 13-year-old girl who presented with lymphadenopathy. In both cases, medical history was unremarkable and there was no recent infection, or other clinical findings. Both adolescents had received the HPV 9-valent vaccine in the previous week. In the first case, blood tests, ultrasonography and biopsy were performed, while in the second, a watchful waiting strategy was adopted. In both cases, the lymphadenopathy resolved spontaneously. The boy received the second dose of the vaccine 6 months later and lymphadenopathy reappeared. The Naranjo scale was applied, classifying the events as definite (in the case of the boy) and probable (girl) adverse drug reactions. The vaccine is safe, but recognising this minor adverse event is important to prevent unnecessary investigation and reduce patient and parental anxiety.

P5538Safety and efficacy of acetylcholine provocation test for diagnosis of vasospastic angina in young patients

Background Vasospastic angina (VSA) is considered as a cause of myocardial infarction with nonobstructive coronary arteries. Given the previous reports of higher incidence of cardiovascular events in young VSA patients, early diagnosis and optimal treatment are important for these patients. While acetylcholine provocation test (ACh test) for VSA diagnosis is well reported, ACh test among young patients is not as commonly performed, therefore its safety and usefulness for this patient subset have not been fully evaluated. Purpose The purpose of this study was to evaluate the safety and the proportion of positive results of ACh test for young patients. Methods Data from patients who underwent ACh test in our institution from May 2012 to September 2018 were retrospectively analyzed. A total of 669 patients were enrolled and divided into 2 groups according to age: Young group (Age≤50, n=106); and Senior group (Age>50, n=563). Results The senior group had a higher incidence of hypertension, dyslipidemia, diabetes mellitus, and coronary artery disease. On the other hand, the young group had a significantly higher incidence of current smoker and tendency of daily alcohol. The rate of positive ACh test was similar, and there were no significant differences in major or minor complications between the 2 groups. Patient characteristics and outcome Young group Senior group p (n=106) (n=563) Age (years) 42.8±7.3 68.0±9.0 <0.001 Male (%) 56.6 52.2 0.407 Current smoker (%) 34.9 15.4 <0.001 Daily alcohol (%) 31.1 22.9 0.070 Hypertension (%) 33.0 66.6 <0.001 Dyslipidemia (%) 50.0 68.4 <0.001 Diabetes (%) 12.3 20.8 0.047 ACh positive (%) 52.8 49.9 0.581 Minor adverse event (%) 4.7 5.9 0.820 Major adverse event (%) 0.9 1.4 1.000 Major adverse event: composite of death, ventricular fibrillation, sustained ventricular tachycardia (VT), myocardial infarction and stroke. Minor adverse event: non-sustained VT and paroxysmal atrial fibrillation. Conclusion ACh provocation test for young patients can be safely performed, and the rate of positive results was similar to that of senior patients. In young patients suspected of having VSA, ACh test should be actively performed to identify optimal medical therapy for prevention of cardiovascular events. Acknowledgement/Funding None

Penggunaan Anestesi Lokal dan Adjuvan pada Analgesi Epidural di Wilayah Jawa Barat Tahun 2015

Analgesi epidural yang optimal akan menghasilkan penanganan nyeri yang baik dengan efek samping minimal dan meningkatkan kepuasan pasien. Sampai saat ini belum terdapat data di Indonesia khususnya di wilayah Jawa Barat mengenai penggunaan anestesi lokal dan adjuvan pada analgesi epidural. Tujuan penelitian ini mecari data mengenai penggunaan anestesi lokal dan adjuvan yang digunakan oleh dokter spesialis anestesi di wilayah Jawa Barat pada tahun 2015. Penelitian ini dilakukan pada bulan Agustus hingga September 2016 di Departemen Anestesiologi dan Terapi Intensif Rumah Sakit Dr. Hasan Sadikin Bandung. Penelitian ini bersifat deskriptif dengan pengambilan data menggunakan kuesioner dan pendekatan cross sectional. Kuesioner dikirimkan kepada 120 dokter spesialis anestesi di Jawa Barat melalui jasa pos dan 30 kuesioner diberikan langsung kepada dokter spesialis anestesi yang bekerja di Rumah Sakit Dr. Hasan Sadikin Bandung. Angka respons yang didapatkan sebesar 47,3%. Hasil penelitian ini didapatkan dokter spesialis anestesi di Jawa Barat yang masih melakukan analgesi epidural pada tahun 2015 sebesar 73,2%. Obat anestesi lokal yang paling banyak digunakan untuk analgesi epidural adalah bupivakain sebesar 94,23%. Konsentrasi terbanyak 0,125% sebesar 82%. Adjuvan yang paling banyak digunakan adalah fentanil sebesar 96,9%. Simpulan penelitian ini sebagian besar dokter spesialis anestesi masih menggunakan epidural sebagai analgesi sehingga bupivakasin dan fentanil menjadi obat terbanyak yang digunakan.Kata kunci: Analgesi epidural, anestesi lokal, adjuvan Local Anesthetic and Adjuvan Used for Epidural Analgesia in West Java in 2015Optimal analgesia epidural technique should promote effective pain relief with minor adverse event and major pastient satisfactory. Up till now, there was no data about local anesthetic and adjuvan agent used for epidural analgesia by anesthesiologist in Indonesia, especially in West Java. The purpose of this study to find data regarding local anesthetic and adjuvan agent used for epidural analgesia by anesthesiologist in Indonesia, especially in West Java in 2015. This research was conducted from August to September 2016 in the Department of Anesthesiology and Intensive Therapy Dr. Hasan Sadikin Hospital in Bandung. This is a descriptive study with cross sectional approach using questionairre. Questionairre was sent to 120 anesthesiologist through mail and 30 questionairre was given to anesthesiologists worked at Dr. Hasan Sadikin General Hospital Bandung. Response was obtained 47.3%. This study shows that there were 73.2% anesthesiologist performed epidural analgesia in 2015. The most local anesthetic used in epidural blockade was bupivacaine, amounted 94.23% and the most concentration is 0.125%, amounted 82%. The most used adjuvant was fentanyl, 96.9%. In Conclusion, most of the anesthesiologist used epidural as an analgesia so bupivacaine and fentanyl used most frequentKey words: Epidural analgesia, local anesthetic, adjuvan

Safety of adjuvant trastuzumab (T) in elderly patients with breast cancer.

282 Background: T is a mainstay in adjuvant therapy for HER2+ breast cancer (BC) patients (pts). Safety and efficacy of T in elderly patients are largely unknown. In HERA trial, NSABP B-31, NCCTG N9831 only 16% of pts were older than 60 years. Risk factors for T related cardiotoxicity are age (>50 y/o), hypertension, baseline LVEF (left ventricular ejection fraction <55%), previous antracycline therapy and BMI. Methods: Charts of pts >65 y/o with early HER2+ BC treated with T as adjuvant or neoadjuvant therapy at our institution were retrospectively reviewed. Primary endpoint was the evaluation of T cardiac toxicity and safety. Results: 22 elderly out of 172 pts (12%) were identified: 19 pts were treated only with surgery and adjuvant chemotherapy with concomitant or sequential T, 3 more pts also received neoadjuvant chemotherapy concomitant with T. According to Balducci’s criteria, fit, vulnerable and frail pts were 20, 2, 0 respectively. Median age was 69 y/o (range 65-76). Hormonal status was negative in 10/22 (45%). 21/22 were histologic grade 3. Median follow-up was 33 months. Baseline comorbidities were the following: hypertension (G2-3) in 17 pts, diabetes mellitus in 1, supra/infraventricular arrhythmia (G1-2) in 3 and 1 pts. Antracyclines were administered in 16 pts (liposomal-doxorubicin in 5 pts), a sequential taxane-regimen was used in 3 more pts. Neoadjuvant weekly Paclitaxel and concomitant T was used in 3 pts. Median basal LVEF was 65% (range 59-74%). 2 pts developed an asymptomatic 10% LVEF drop from baseline (left ventricular systolic dysfunction G1) during T treatment. Known cardiac risk factors were hypertension in 1 pt and previous antracycline based chemotherapy in both. They recovered within 9 months. One minor adverse event was atrial fibrillation (G2) during T treatment. Conclusions: T was well tolerated in elderly pts. More data are needed in order to understand the correlations between T related toxicity and cardiovascular risk factors. Long term safety of T treatment should verify the reversibility of cardiac T related toxicity on elderly pts.