Short-term Outcome of Peroral Endoscopic Myotomy Performed by the Same Endoscopist on Achalasia and Nonachalasia Esophageal Motility Disorders

BACKGROUND

Peroral endoscopic myotomy (POEM) is a relatively new but increasingly therapeutic option for achalasia. In recent years, POEM has been used for nonachalasia esophageal motility disorders (NAEMDs), such as diffuse esophageal spasm, esophagogastric junction outlet obstruction, and hypercontractile disorder, with some clinical success. No studies thus far compare the outcomes of these two groups. We perform the first head-to-head comparison of outcomes after POEM in patients with achalasia and NAEMD.

PATIENTS AND METHODS

A retrospective analysis of all patients undergoing POEM at one university hospital by a single expert endoscopist from July 2021 to December 2022 was performed. All patients were symptomatic, and the presence of esophageal motility disorders was confirmed using multiple diagnostic modalities. These patients were then divided into 2 groups, achalasia and NAEMD, based on the underlying diagnosis. Statistical analysis of different clinical outcomes, including effectiveness and safety, was performed.

RESULTS

Thirty-seven patients (mean age: 59.55, females: 22) underwent POEM in the study period. Twenty patients had achalasia and 17 patients had NAEMD. The median myotomy length was 5.5 cm for the achalasia group and 10 cm for the NAEMD group. This excluded patients with esophagogastric junction outlet obstruction in which the median myotomy length was 3 cm. The procedure time, the duration of hospital stays, the rates of same-day discharge, and complications were similar between the two. Short-term outcomes of POEM for the two groups were similar with improvement in 94% of patients in the achalasia group and 93.75% in the NAEMD group.

CONCLUSION

Contrary to prior observations, our study highlights that POEM is equally effective in achieving clinical improvement in patients with NAEMD as achalasia over 6 months of follow-up. In addition, POEM has a comparable safety profile in both patient groups making it a feasible therapeutic option for these debilitating and challenging disorders.

De novo monocytic-M5b AML with t(8;16) (p11.2; p13.3) KAT6A/CREBBP fusion and FLT3-TKD mutation complicated by chemotherapy-induced Takotsubo cardiomyopathy

Acute myeloid leukemia (AML) with t(8;16) is a rare cytogenetic abnormality that presents unique characteristics such as hemophagocytosis, disseminated intravascular coagulation, leukemia cutis and varying levels of CD45 expression. It is more common in women and usually associated with prior cytotoxic therapies, accounting for <0.5% of all AML cases. We present a case of de novo t(8;16) AML with FLT3-TKD mutation who relapsed after initial induction and consolidation. Mitelman database analysis reveals only 175 cases with this translocation, majority of which are M5 (54.3%) and M4 (21.1%) AML. Our review reveals very poor prognosis with overall survival ranging from 4.7 to 18.2 months. She also developed Takotsubo cardiomyopathy after receiving 7+3 induction regimen. Our patient died in 6 months from the date of diagnosis. Although a rare occurrence, it has been discussed in literature to identify t(8;16) as a separate subtype of AML due to unique characteristics.

896 Improving Intravenous Fluid Therapy to Reduce the Incidence of Acute Kidney Injury in Hip Fracture Patients

Background

Acute kidney injury (AKI) in hip fracture patients is associated with morbidity, mortality, and increased length of stay. To avoid this our unit policy recommends maintenance crystalloid IV fluids of &gt; 62.5mL/Hr for hip fracture patients.

Method

Three prospective audits, each including 100 consecutive acute hip fracture patients, were completed with interventional measures employed between each cycle. Data collection points included details of IV fluid administration and pre/post-operative presence of AKI. Interventions between cycles included implementation of admission/post-take checklist tools and various educational measures for Emergency Department, nursing and admitting team staff with dissemination of infographic posters, respectively.

Results

In cycle one and two, many patients received inadequate fluids (46/100 and 56/100 respectively). There was no significant difference in the incidence of AKI between patients receiving adequate or inadequate fluid in either cycle (p &lt; 0.05).

In cycle three, more patients received adequate fluids (79/100, p &lt; 0.05). Patients prescribed adequate fluids were less likely to develop post-operative AKI (2/79, 2.5% vs 3/21, 14.3%; p &lt; 0.05).

Discussion

This audit demonstrates the importance of administering appropriate IV fluid in hip fracture patients to avoid AKI. Improving coordination with Emergency Department and ward nursing/medical ward staff was a critical step in improving our unit’s adherence to policy.

113 Improving Intravenous Fluid Therapy to Reduce the Incidence of Acute Kidney Injury in Elderly Hip Fracture Patients

Background

Acute kidney injury (AKI) in hip fracture patients is associated with morbidity, mortality, and increased length of stay. To avoid this our unit policy recommends maintenance crystalloid IV fluids of &gt;62.5 mL/Hr for hip fracture patients. However, audits have shown that many patients still receive inadequate IV fluids.

Methods

Three prospective audits, each including 100 consecutive acute hip fracture patients aged &gt;55, were completed with interventional measures employed between each cycle. Data collection points included details of IV fluid administration and pre/post-operative presence of AKI. Interventions between cycles included a revised checklist for admissions with a structured ward round tool for post-take ward round and various educational measures for Emergency Department, nursing and admitting team staff with dissemination of infographic posters, respectively.

Results

Cycle 1: 64/100 (64%) patients received adequate fluids. No significant difference in developing AKI post operatively was seen in patients given adequate fluids (2/64, 3.1%) compared to inadequate fluids (4/36, 11.1%; p = 0.107). More patients with pre-operative AKI demonstrated resolution of AKI with appropriate fluid prescription (5/6, 83.3%, vs 0/4, 0%, p &lt; 0.05) Cycle 2: Fewer patients were prescribed adequate fluids (54/100, 54%). There was no significant difference in terms of developing AKI post operatively between patients with adequate fluids (4/54, 7.4%) or inadequate fluids (2/46, 4.3%; p = 0.52). Resolution of pre-operative AKI was similar in patients with adequate or inadequate fluid administration (4/6, 67% vs 2/2, 100%). Cycle 3: More patients received adequate fluids (79/100, 79%, p &lt; 0.05). Patients prescribed adequate fluids were less likely to develop post-operative AKI than those receiving inadequate fluids (2/79, 2.5% vs 3/21, 14.3%; p &lt; 0.05).

Discussion

This audit demonstrates the importance of administering appropriate IV fluid in hip fracture patients to avoid AKI. Improving coordination with Emergency Department and ward nursing/medical ward staff was a critical step in improving our unit’s adherence to policy.

P5307A consumer-direct digital health intervention for cardiovascular risk management in primary care: the Consumer Navigation of Electronic Cardiovascular Tools (CONNECT) randomised controlled trial

Background

Digital health interventions linked to electronic health records offer patients an innovative approach to support cardiovascular disease (CVD) risk management.

Purpose

Test the effectiveness of a consumer-directed digital health strategy on medication adherence and cardiovascular health outcomes in patients presenting to primary care who are at moderate to high risk of CVD.

Methods

Randomised controlled trial (RCT) with 12 month follow-up. Intervention group received an interactive digital health strategy for CVD management. The intervention was integrated with patient's electronic health record to enable automated population of risk factor and medication data (Figure). Control group received usual care. Primary outcome was the proportion of patients taking guideline-recommended BP and cholesterol-lowering medications on at least 80% of days (administrative data). Secondary outcomes included mean SBP, LDL-cholesterol, BMI and proportion meeting risk targets for physical activity, achieving smoking cessation, quality of life (EQ5D) and ehealth literacy (eHEALS).

Results

Intervention (n=486) and control (n=448) groups were well matched at baseline (Table). Mean age of participants was 67±8.1 years, 77% were male, 41% had existing CVD. At 12 months, there was no significant difference between the groups for medication days covered or mean cholesterol and BP (Table). However, there were significantly more patients in the intervention than control group who were physically active and had high ehealth literacy (Table).

Table 1. Primary and Secondary Outcomes Baseline 12 months Outcome Control (n=448) Intervention (n=486) Control (n=431) Intervention (n=460) p value* Taking BP and cholesterol medication on ≥80% of days, % 29.7 28.9 29.9 32.8 0.485 SBP (mmHg), mean±SD 139.0±16.6 137.3±15.9 136.3±16.1 136.4±17.6 0.921 LDL (mmol/L), mean±SD 2.6±1.0 2.6±1.0 2.5±0.9 2.4±1.0 0.240 BMI (kg/m2), mean±SD 29.7±5.1 29.9±5.7 29.4±5.0 29.7±5.7 0.508 Proportion achieving BP and LDL target, % 11.2 12.3 11.7 16.5 0.065 Physically active, % 84.0 85.4 79.7 87.0 0.016 Current smoker, % 12.9 13.0 12.0 8.1 0.087 eHEALS, mean±SD 27.0±6.4 27.0±6.4 26.4±7.5 28.3±6.3 0.002 *Comparing intervention and control at 12 month follow-up.

Conclusions

The integrated digital health strategy did not significantly impact on days of medication covered however, patients in the intervention had higher physical activity and ehealth literacy. The RCT highlights the importance of conducting robust research if we are to understand the potential value of digital health interventions.

Acknowledgement/Funding

This work was supported by a Project Grant from the National Health and Medical Research Council of Australia

The Serrated Polyp Pathway: Is It Time to Alter Surveillance Guidelines?

PURPOSE OF REVIEW

In this manuscript, we review current surveillance guidelines for serrated polyps (SPs) and discuss how recent studies inform the selection of appropriate surveillance intervals for patients with SPs.

RECENT FINDINGS

Large and/or proximal SPs, particularly sessile serrated polyps (SSPs), are associated with increased risk of both synchronous and metachronous neoplasia, including advanced adenomas and colorectal cancer (CRC). Persons harboring multiple SSPs or dysplastic SSPs are at the highest risk. Moreover, a high percentage of large and/or proximal SPs are reclassified as SSPs when read by trained gastrointestinal pathologists, even if they were originally reported as hyperplastic polyps. These findings support the adoption of surveillance guidelines that prescribe closer surveillance of large and/or proximal SPs, regardless of subtype. SSPs remain a challenge to reliably identify, resect, and diagnose via histology. The increased risk of future neoplasia in patients with SSPs is likely driven by a combination of underdetection, inadequate removal, misclassification, and biology. Until further evidence emerges, we support guidelines that recommend close surveillance of patients with a history of large and/or proximal SPs and SSPs specifically in order to mitigate the threat of interval CRC.

A case of bilateral aberrant pectoralis minor insertion with absent coracohumeral ligament: Clinical relevance and controversies

Aberrant insertions of the pectoralis minor tendon are quite rare. Most cases are incidental findings during cadaver dissections, on an MRI or during surgical procedures of the shoulder joint. Rarely the aberrant insertion points can be a source of pain or restriction of the shoulder joint. From the literature review, we found that there has been no mention regarding the frequency of occurrence of this variation with respect to unilateral or bilateral occurence, and only three cases have been reported, in which aberrant bilateral insertions have been documented of which two were noted during cadaveric dissection and one radiologically. We report a rare case of aberrant bilateral insertions of the pectoralis minor, which was found during an arthroscopic procedure, and we discuss its clinical and surgical implications.