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Postoperative air leak is one of the most common complications after pulmonary resection and contributes to postoperative pain, complications, and increased hospital length of stay. Several risk factors, including both patient and surgical characteristics, increase the frequency of air leaks. Appropriate intraoperative tissue handling is the most important surgical technique to reduce air leaks. Digital drainage systems have improved the management of postoperative air leak via objective data, portability, and ease of use in the outpatient setting. Several treatment strategies have been used to address prolonged air leak, including pleurodesis, blood patch, placement of endobronchial valves, and reoperative surgery.

Background: There is no consensus among clinicians regarding recommencement of antithrombotic agents following conservative management of a Chronic Subdural Hematoma (cSDH). Thus, the primary objective of this study was to determine the most commonly recommended interval and whether the data reveal a general consensus that should be adopted. Methods: A retrospective analysis of Salford Royal Foundation Trust’s Neurosurgical referral database for patients referred with a cSDH between March 2017 and March 2020 was carried out. Patients were sorted by whether they were on blood-thinning medications. Results: Over the 3-year period, there were a total of 1220 referral and 1099 patients. 502 (41.14%) of these referrals and 479 (43.59%) patients were on one more blood thinning agent. Of these patients 221 (46.13%) conservative management, there was a clear male predominance (M: F ≈ 2.5:1) in this cohort. 2 weeks was the most commonly advised time-frame (n = 76, 36.36%) to withhold. Of the 234 referrals, there were 13 (5.88%) re-referrals in total. Crucially, there was no significant difference in reaccumulation rates between patients asked to withhold their blood thinners for 2 weeks versus those asked to stop for longer than 2 weeks (P = 0.57). Conclusion: For the majority of bleeds, there is no clear benefit from asking patients to withhold their anticoagulant/antiplatelet for longer than 2 weeks. In cases, where it is deemed appropriate to stop for longer than 2 weeks, clear instructions should be provided and documented along with reasons behind the decision.

Objective: To establish the prevalence of dural ectasia in patients with complex neurofibromatosis type-1 (NF-1) and its association with spinal deformities that manifest alongside.Methods: Analysis of the neuroradiological notes from 24 months of multidisciplinary team meetings for patients with complex NF-1 (equating to 378 patients). Review of the MRI scans of all patients with dural ectasia with each scan graded using a novel grading system.Results: A total of 38 of the 378 patients were found to have dural ectasia (10.05%). The median age of these 38 patients was 36 years ranging from 18 to 64. The male: female ratio was 16:22. In all, 90.9% of patients with a 'major' form of dural ectasia had a concurrent spinal deformity present compared to 18.18% of patients with a minor form.Conclusions: The more severe the dural ectasia, the greater the likelihood a concurrent deformity with NF-1. The vertebral bodies and pedicles are more commonly involved than the posterior elements.

Recent studies have provided substantial knowledge regarding the genetic and immunological landscape for penile squamous cell carcinoma (PSCC). This new information paved the way for exploring new therapies that might be of use. This chapter will tackle specific techniques involving targeted, immune, and viral therapies. In targeted therapy, dacomitinib, PARP inhibitors, and NOTCH1 targeted therapies may hold potential promise. As for immune therapy, immune checkpoint blockade (ICB) combination therapy and PD-L1 expression studies showed promising results with a good response rate. Finally, HPV targeting studies offered exciting results that could be of use in the management of PSCC patients.

281 Background: Many of the 40,000 veterans annually diagnosed with cancer have limited access to Hematology/Oncology care. An existing method to improve access in the Veterans Affairs (VA) system is the e-consultation, which allows text-based consultation by specialty services. However, many patients require more in-depth care than is feasible by e-consult. Amidst the COVID-19 pandemic, the James A. Haley VA (JAHVA) Hematology/Oncology department implemented VA video connect (VVC) telehealth visits to allow providers to connect with patients in their homes. Our aim was to assess the implementation of this novel telehealth service and assess provider perceptions via questionnaires. Methods: We reviewed charts of patients seen via VVC by the JAHVA Hematology/Oncology department. We gathered data including patient demographics, zip code, primary visit diagnosis, and date of visit. We adapted a previously validated telehealth usability questionnaire by Parmanto et al. Providers were surveyed about perceptions of VVCs prior to implementation and 1 year later. Responses were assessed via 5-point Likert scale. Results: From May 2020 to April 2021, 1290 VVCs were conducted. Median VVCs per month was 106 (range 26 to 161), with peak in June 2020. 71% of patients were ³65 years, 24% were 45-64 years, and 5% were

Ruxolitinib is a JAK1/2 inhibitor that is effective in managing symptoms and splenomegaly related to myelofibrosis (MF). Unfortunately, many patients must discontinue ruxolitinib, at which time treatment options are not well defined. In this study, we investigated salvage treatment options and clinical outcomes among MF patients who received and discontinued ruxolitinib outside the context of a clinical trial. Among 145 patients who received ruxolitinib, 23 died while on treatment, 58 remained on treatment at time of analysis, leaving 64 people available for analysis. Development of cytopenias was the most common reason for discontinuation (38%) after median treatment time of 3.8 months (mo). The majority of patients received some form of salvage therapy after ruxolitinib discontinuation (n = 42; 66%), with allogeneic hematopoietic stem cell transplant (alloHSCT) (n = 17), being most commonly employed. Lenalidomide, thalidomide, hydroxyurea, interferon, and danazol were used with similar frequency. The response rate to salvage treatment was 26% (8 responses) and responses were most often seen with lenalidomide or thalidomide. Improved outcomes were observed in patients who underwent alloHSCT or received salvage therapy compared to those who did not receive additional therapy. Median overall survival (OS) after ruxolitinib discontinuation was 13 months. These findings show that salvage therapy can provide clinical responses after ruxolitinib discontinuation; however, these responses are rare and outcomes in this patient population are poor. This represents an area of unmet clinical need in MF.

e21584 Background: Predicting immune-related adverse events (irAEs) resulting from immune checkpoint inhibitors (ICIs) as well as the likelihood of clinical benefit is an area of great interest. irAEs have been associated with clinical outcome measures and we were interested in examining somatic mutations that may correlate with irAEs and subsequently with relapse free survival (RFS) and overall survival (OS). Methods: Our irAEs of interest for this analysis were rash and colitis based on prior data and these were tested for association with RFS and overall OS. Nonsynonymous somatic mutations were identified utilizing tumor and matched blood samples from 22 metastatic melanoma patients treated with neoadjuvant ipilimumab. Whole exome sequencing was performed using the SOLiD 5500 Next-Generation Sequencing platform. Somatic mutations were identified by subtraction of germline variants. Total mutational burden was assessed, and individual mutations were correlated with irAEs and with clinical outcome. Results: MUC16 was the most commonly mutated gene (82%). Of notable known oncogenic mutations, BRAF was the most common (50%) followed by NRAS (23%). Among known oncogenic signaling pathways, enrichment was most common in RTK-RAS (58%), followed by NOTCH and WNT. Development of colitis showed a strong trend in association with RFS. Development of rash indicated a similar trend. 20 different statistically significant mutations (p < 0.05) were identified among patients with colitis and these were also associated with OS and RFS. Notably, PTPRO mutation status (known to antagonize PDL1 expression) appeared protective against colitis and associated with worse RFS and OS. Similarly, ADGB mutation was significantly associated with developing rash and also associated with improved RFS and OS. Correcting for TMB in a multivariate model confirmed the associations. Conclusions: Somatic mutations were found to be associated with the irAEs of rash and colitis and with clinical outcome following ipilimumab treatment of melanoma. Our findings warrant further investigation and validation in independent cohorts.

Neuroinflammation in Parkinson's disease [PD] is a process that occurs alongside the loss of dopaminergic neurons, and is associated with alterations to many cell types, most notably microglia. This review examines the key evidence contributing to our understanding of the role of inflammation-mediated degeneration of the dopaminergic (DA) nigrostriatal pathway in PD. It will consider the potential role inflammation plays in tissue repair within the brain, inflammation linked gene products that are associated with sporadic Parkinsonian phenotypes (alpha-synuclein, Parkin and Nurr 1), and developing anti-inflammatory drug treatments in PD. With growing evidence supporting the key role of neuroinflammation in PD pathogenesis, new molecular targets are being found that could potentially prevent or delay nigrostriatal DA neuron loss. Hence, this creates the opportunity for disease modifying treatment, to currently what is an incurable disease.

Background: We describe the safety, feasibility and patient satisfaction using telemedicine in the preoperative as well as postoperative period of thoracic surgery. Methods: A prospective safety, proof of concept and quality improvement project on a consecutive series of patients who had preoperative and/or part of their postoperative care via telemedicine. Results: Fifty-six patients (18% outside the United States) agreed to participate. A video conversation with patients and families was used to decide resectability, discuss risks, benefits, and alternatives of treatment and to agree on the date and type of surgery after medical records and imaging reviewed initially via email. All 56 underwent the planned operation, 55 on the date agreed upon. Eight (14%) patients met the surgeon for the first time on the morning of surgery: 38 (68%) had robotic pulmonary resection, 9 (16%) robotic esophagectomy and 9 (16%) robotic thymectomy. All had R0 resection. There was minor morbidity in 10 patients. There was no major morbidity or 30- or 90-day mortality. Postoperative visits via telemedicine only was performed in 25 of 56 patients (45%). Unscheduled postoperative telemedicine visits prevented six patients from unnecessary visits to local emergency departments. Patient satisfaction achieved the highest scores in the four areas of provider communication. Conclusions: Telemedicine is safe and avoids some preoperative and postoperative visits to surgeons’ offices. In selected patients it safely determines oncologic surgical resectability and patient fitness for major thoracic surgery, provide outstanding early safety and oncologic outcomes and high patient satisfaction. In addition, it reduces the need for some postoperative emergency department visits and in most patients it can eliminate postoperative travel to the surgeon’s office.

Background: Alzheimer’s disease (AD) is one of the most common forms of dementia worldwide with only symptomatic therapies available. In India, there seems to be a scarcity of data regarding drugs prescribed for symptomatic treatment of AD. Aims and Objectives: The objective of this study was to find out drug prescription patterns in AD patients in an urban neuro-speciality clinic in Western India. Materials and Methods: Retrospective data were collected from 100 case files of patients diagnosed with AD visiting a private neuro-speciality clinic. Descriptive statistics were used to analyze the data. Results: The mean age of patients suffering from AD was 74.9 ± 0.9 years. About 90% of patients were >65 years old, with a female preponderance of 56%. About 60% of patients belonged to rural areas and 40% belonged to urban areas. Mini-mental state examination scores revealed a mean score of 14.84 ± 1.20. Regarding drug utilization pattern, 73% of patients were prescribed Donepezil, 15% were on donepezil and memantine, 7% on rivastigmine, and 5% on Galantamine. Donepezil, memantine, donamem, and galantamine were prescribed in tablet form while rivastigmine in capsule form. Only in 15% prescriptions brand name and fixed-dose combinations were used. Conclusion: Despite decades of study of basic etiology and pathogenesis of AD and significant pharmaceutical industrial efforts to develop therapies, till date, there is no effective therapy available to cure AD. AD needs to be understood and analyzed in terms of its prescribing. Patients suffering from dementia and AD should be screened and treated at an early stage. Anticholinesterase drugs and N-methyl-D-aspartate receptor blockers were the most common drugs used for symptomatic treatment of AD.

Background: Primary myelofibrosis (PMF) is a myeloproliferative neoplasm that is marked by bone marrow fibrosis, cytopenias, extramedullary hematopoiesis, and a increased risk of acute leukemia. Leukocytosis is frequently seen and a white blood cell count (WBC) > 25,000/uL has been shown to convey an inferior prognosis. Rarely, patients develop severe leukocytosis (defined as WBC > 50,000/uL) either at presentation or during the course of their disease. Genomic characterization, management, and outcomes of these patients are not well defined. In this study, we aimed to further characterize PMF patients with severe leukocytosis and assess their clinical outcomes. Methods: We retrospectively reviewed PMF patients who presented to our institution between 2001 and 2018. We included patients who developed a WBC count > 50K at any time during their clinical course. Patients who developed acute myelogenous leukemia (AML) were censored at the time of disease diagnosis. Overall survival (OS) defined from first date that WBC documented as > 50K. Results: Among 493 PMF patients treated at our institution, 71 (14.4%) developed severe leukocytosis during the course of their disease. Ten (14%) had severe leukocytosis at the time of diagnosis and 30 (42%) developed it within 1 year of diagnosis and 40 (56%) developed it more than 1 year after diagnosis. Eight (11.3%) patients demonstrated peripheral blast percentage > 10% blasts at the time severe leukocytosis first documented. Compared to patients who did not develop severe leukocytosis, those with severe leukocytosis had an increased frequency of EZH2 (p < 0.001), RAS (p < 0.001), and KIT (p = 0.04) mutations. ASXL1 mutations were seen in a similar proportion of patients (p = 0.41). A similar proportion of patients were high risk by GIPSS (26% v 24%) prognostic model. From the time development of severe leukocytosis, the median overall survival (mOS) was 13.3 months. Median OS from diagnosis was significantly shorter for patients who developed severe leukocytosis (35.4 mo v 63.5 mo; p = 0.02) compared to those that did not. Eleven (15%) patients with severe leukocytosis developed AML compared to 38 (9%) patients who did not develop severe leukocytosis (p = 0.13). Median time to development of AML was 13.3 months from time of severe leukocytosis. At development of severe leukocytosis, 12 patients (17%) received hydrea (mOS 14.0 months) and 9 patients (13%) received ruxolitinib (mOS 21.2 months). The remaining cohort which either received no documented treatment, an alternative treatment or unknown treatment had a mOS of 5.3 months. This was not statistically significant. Ten patients (14%) ultimately underwent allogeneic stem cell transplantation after the development of hyperleukocytosis. Conclusion: Severe leukocytosis occurs rarely in primary myelofibrosis. RAS, KIT, and EZH2 mutations are enriched in these patients. Management strategies in these patients is varied and outcomes are poor. Further studies assessing the benefit of cytoreductive therapies in this population should be performed. Figure Figure. Disclosures Sallman: Celgene: Research Funding, Speakers Bureau. Sweet:BMS: Honoraria; Astellas: Consultancy; Jazz: Speakers Bureau; Novartis: Consultancy, Honoraria, Speakers Bureau; Jazz: Speakers Bureau; Phizer: Consultancy; BMS: Honoraria; Celgene: Honoraria, Speakers Bureau; Astellas: Consultancy; Agios: Consultancy; Phizer: Consultancy; Celgene: Honoraria, Speakers Bureau; Novartis: Consultancy, Honoraria, Speakers Bureau; Agios: Consultancy. List:Celgene: Research Funding. Komrokji:Novartis: Honoraria, Speakers Bureau; Celgene: Honoraria, Research Funding; Celgene: Honoraria, Research Funding; Novartis: Honoraria, Speakers Bureau; Novartis: Honoraria, Speakers Bureau; Novartis: Honoraria, Speakers Bureau. Kuykendall:Janssen: Consultancy; Celgene: Honoraria.

Laparoscopic myomectomy (LM) offers considerable advantages over open myomectomy; however, LM is technically complex and associated with a steep learning curve. Few studies have evaluated the effect of the learning curve, and the limitations of most of these studies were the number of women included and the multiplicity of surgeons undertaking the procedure. The aim of this study is to evaluate the effect of a caseload of 100 patients during the learning curve of a single experienced surgeon performing LM. A prospective comparative analysis of 200 consecutive cases of LM was conducted between December 2004 and March 2013. Outcomes of the first 100 procedures (Group A) were compared with the later 100 (Group B). The mean age of the cohort was 39 years (24–54 years), with a mean BMI of 27 kg/m2 (16–46). Both the groups were very similar with regard to the number, size and weight of myomas removed, the duration of surgery, and blood loss. More women were sent home within 24 h in the second group (27 vs 10.2 %, p = 0.002). Group A suffered significantly higher complication rates compared to Group B (11 vs 7, p

Dear editor Smaller specialties such as dermatology, psychiatry, and radiology have often received less teaching time within the undergraduate medical curriculum.1 Some critics argue that this may be responsible for the low intake rates within postgraduate training for these specialties. The Royal College of Psychiatrists reported that only 83% of core training post vacancies were filled after two rounds of recruitment in 2012.2 Furthermore, the National Health Service identified a shortfall of 220 interventional radiologists in the UK.3 Similar workforce problems have been encountered in the USA.4 It has been suggested that increasing exposure to these specialties in medical school may allow students to gain a better insight into the specialty and consider it as a viable future career choice.1 Although incorporating more dedicated teaching time for small specialties within the curriculum may help to meet future workforce demands, there are strong arguments against implementing it. First of all, teaching time would have to be taken away from the core specialties to accommodate more teaching for smaller specialties. However, knowledge and skills within the core specialties is more important for building a strong foundation for any future career choice. There is no robust evidence to suggest that students would still receive adequate training in core specialties if smaller specialties are given more time. Second, the overall workforce requirements are much greater for the core specialties and the majority of graduates are more likely to enter the core rather than the smaller specialties. Perhaps a different approach is required. In order to tackle the current shortfall in psychiatrists, the Royal College of Psychiatrists has adopted a particularly strong strategy.2 This includes setting up/supporting medical school societies, regular career fairs, annual summer schools, intercalated Bachelor of Science programs, and student elective modules to engage and educate medical students. In addition, financial incentives (including bursaries/grants for conferences, electives, and research, essay prizes, and fellowships) have been used to promote and reward student activity across the variety of psychiatric subspecialties. Although these methods may not have the direct impact of dedicated teaching, they provide ample opportunity for students to explore the smaller specialties without detracting unnecessarily from the core curriculum.

Savan Shah,1,2 Alexandra C Ho,1,2 Bianca M Kuehler,1 Susan R Childs,1 Glyn Towlerton,1 Ian D Goodall,1 Carsten Bantel1,2 1Pain Medicine, Chelsea and Westminster Hospital, NHS Foundation Trust, 2Section of Anaesthetics, Department of Surgery and Cancer, Faculty of Medicine, Imperial College London, London, UK Background: Chronic pain clinics aim to improve challenging conditions, and although numerous studies have evaluated specific aspects of therapies and outcomes in this context, data concerning service impact on outcome measures in a general pain population are sparse. In addition, current trends in commissioning increasingly warrant services to provide evidence for their effectiveness. While a plethora of outcome measures, such as pain-intensity or improvement scores, exist for this purpose, it remains surprisingly unclear which one to use. It also remains uncertain what variables predict treatment success. Objectives: This cross-sectional study was conducted to evaluate clinic performance employing different tools (pain scores, pain categories, responder analysis, subjective improvement, satisfaction), and to determine predictors of outcome measures. Patients and methods: Patients attending scheduled clinic follow-up appointments were approached. They were asked to complete the modified short-form Brief Pain Inventory (BPI-SF) that also included assessments for satisfaction and subjective improvement. Comparisons were made with BPI-SF responses that were completed by each patient on admission. Nonparametric tests were employed to evaluate service impact and to determine predictors for outcome. Results: Data of 118 patients were analyzed. There was considerable variation in impact of pain clinics depending on the outcome measure employed. While median pain scores did not differ between admission and follow-up, scores improved individually in 30% of cases, such that more patients had mild pain on follow-up than on admission (relative risk 2.7). Furthermore, while only 41% reported at least moderate subjective improvement after admission to the service, the majority (83%) were satisfied with the service. Positive treatment responses were predicted by “number of painful regions” and “changes in mood”, whereas subjective improvement was predicted by “helpfulness of treatments”. Conclusion: Depending on the outcome measure employed, pain clinics showed varying degrees of impact on patients’ pain experiences. This calls into question the current practice of using nonstandardized outcome reporting for evaluation of service performances. Keywords: Brief Pain Inventory, chronic pain clinics, pain-intensity scores, patient satisfaction, responder analysis, subjective improvement

Dear editor High levels of stress in medical students are a commonly accepted phenomenon within the medical education community and as a result medical schools are often arraigned for not doing enough.1 Several studies in the UK have reported that medical students suffer significantly higher levels of stress than the age-matched general population.1 However, it can be argued that comparisons with the general population are misleading. All university students experience high levels of stress due to the demands of the course, a new environment and learning to manage financially, emotionally, and socially with less parental support. Therefore it is more pertinent to determine if medical students in the UK suffer greater levels of stress compared to age-matched peers in other university courses. We conducted a systematic review of the literature in November 2014, selecting studies which compared British medical students with other students. We identified that only two studies within the last two decades compared medical student stress in the UK with other university courses. A cross-sectional study conducted at the University of York compared 1st year medical, dental, and nursing students.2 Dental students scored significantly higher on the perceived stress scale at the end of the academic year compared to medical students (mean score =19.3 versus 15.1, P=0.02). In contrast, Carson et al3 at the University of Edinburgh found psychological stress as measured by the 60-item General Health Questionnaire was more prevalent in 1st year medical students compared to all other university students (46% versus 42%) but this was not significant. Both studies suffered from significant limitations. Apart from assessing only 1st year students, they used inappropriate time points such as the start or end of the year when stress levels are particularly low and high. Furthermore, the Edinburgh study collected data from 91% of the year group but the York study managed only 33% (44 students). Excessive levels of stress can lead to burnout, dropping out, psychiatric problems, and impact on future performance. However, some stress is necessary to drive students to perform better, build character, and prepare them for the demands of future medical practice. The current evidence is inadequate in answering whether medical students suffer a disproportionate amount of stress compared to their peers. More robust studies are needed to answer this question before British medical schools and regulatory bodies can be lambasted for putting too much pressure on medical students or not doing enough to support stressed students.

Background: Headache is one of the most common complaints seen by primary care physicians, but very few well-planned studies have been conducted to know its prevalence. Aim: To study the prevalence of headache and associated psychiatric morbidity. Methods: A medical relief camp was held in village Mavta (near Ratlam in Madhya Pradesh) in 2002. Of a total of 1350 registered subjects, 80 with primary complaints of headache were referred to our expert team of psychiatrists. Results: Sixty-nine subjects (86.25%) had psychiatric morbidity-mainly affective disorders (depression) and panic disorder, dysthymia, alcohol and nicotine dependence. Subjects with migraine and depression were mostly women with onset of symptoms at an early age. Subjects with less education; who were unmarried or had lost a spouse; those with a nuclear family; who were unemployed and those with a family history and past history of mental illness, were all susceptible to headache and depression. Conclusion: Disturbed sleep, free floating anxiety, sad mood, lack of pleasure, body ache and fatigue were the main presenting complaints along with headache.