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In this single center case series with nine percent primary diversion, 86 of 94 patients alive and with complete follow-up at one year had a functioning anastomosis. Seventy-five of the initial 99 patients never had a stoma. Meaning: Highly selective fecal diversion in combination with proactive leakage management, low anastomoses can be preserved safely, and the majority of patients will be spared all disadvantages of a diverting stoma.

Introduction Catheter-related infections such as exit site infection (ESI) and tunnel infection (TI) are major causes of peritoneal dialysis (PD) discontinuation. For ESI/TI treatment, catheter diversion procedure (CDP) with exit-site renewal for catheter salvage presents an alternative to catheter removal. Nevertheless, CDP capability of improving PD catheter survival remains unclear. Methods We retrospectively reviewed our hospital patients who started PD during 2001–2019 (n=148): 33 treated for ESI/TI by CDP (CDP group) and 115 treated for ESI/TI using conservative therapy or none (non-CDP group). A “virtual discontinuation group” was designated for patients in the CDP group who had received PD catheter removal instead of CDP and who had stopped PD. Kaplan-Meier analysis and log-rank test PD were used for intergroup catheter survival comparison. Associations between clinical factors and PD discontinuation or death were examined using Cox proportional hazards regression analyses. Results For patients (76% male, mean age of 61.7±13.0 years), 40 CDP were performed for 33 CDP group patients. Infection-free rates at 30 and 90 days after CDP were, respectively, 90% and 67%. The CDP group PD catheter survival rate was significantly higher than that of virtual discontinuation group (P < .01) and higher than that of the non-CDP group (P = .03). Multivariate analysis revealed independent association of serum albumin concentration (hazard ratio 0.33, 95% confidence interval 0.17–0.67), PD+HD combination therapy (hazard ratio 0.29, 95% confidence interval 0.17–0.49), and CDP (hazard ratio 0.44, 95% confidence interval 0.24–0.80) with PD discontinuation or death. Conclusion Results show that CDP may improve PD catheter survival as an effective and less-invasive surgical treatment for ESI/TI to avoid withdrawal of PD., Graphical abstract

This cross-sectional study compares adverse outcomes and health care use associated with primary anastomosis with proximal diversion vs Hartmann procedure for patients with acute diverticulitis., Key Points Question Among patients with acute diverticulitis treated with an urgent surgical procedure (ie, Hartmann procedure [HP] or primary anastomosis with proximal diversion [PAPD]), is the procedure used associated with index readmission outcomes and resource use? Findings In this cross-sectional study of an estimated 1 072 395 hospitalized patients with acute diverticulitis, 34 126 patients required diversion within 48 hours of admission, and PAPD was associated with comparable index outcomes vs HP but an increased rate of readmission and risk of ostomy reversal. Total index and readmission hospitalization costs were similar between procedures. Meaning These findings suggest that PAPD is associated with increased risk of ostomy reversal compared with HP and that patient characteristics that bias operative strategy selection are the primary factors associated with index patient outcomes., Importance Diverticulitis of the colon is an increasingly prevalent disease with significant implications for patient quality of life and health system resource expenditure. Although several randomized clinical trials and meta-analyses of Hartman procedure (HP) and primary anastomosis and proximal diversion (PAPD) have found surgical equipoise, questions regarding the relative performance of these treatments when applied broadly remain. Objective To examine use of and outcomes after urgent sigmoid colectomy with end colostomy (ie, HP) vs PAPD in management of complicated diverticulitis. Design, Setting, and Participants This retrospective cross-sectional study was a multicenter, population-based examination of inpatient hospitalizations, not including long-term rehabilitation facilities, using data from the 2014 to 2017 Nationwide Readmissions Database. It was performed from November 2020 to January 2021. Included patients were adults admitted with acute diverticulitis requiring HP or PAPD within 48 hours of admission. Exposures Undergoing HP vs PAPD. Main Outcomes and Measures Inverse probability treatment analysis was used to compare outcomes, including index mortality, composite complications (ie, neurologic, infectious, and cardiovascular complications), length of stay, and readmissions within 90 days. Results During the study period, an estimated 1 072 395 adults (615 954 [57.4%] women; median [IQR] age, 64 [52-76] years) required nonelective hospitalization for acute colonic diverticulutus. A total of 34 126 patients required diversion, with 32 326 patients (94.7%) undergoing HP and 1800 patients (5.3%) undergoing PAPD within 48 hours of admission. Patients undergoing PAPD had a decreased median (IQR) age (60 [51-70] years vs 65 [54-74] years; P

Introduction Diffuse leptomeningeal glioneuronal tumor (DLGNT) is a rare diagnosis first incorporated into the WHO Classification of Tumors of the Central Nervous System in 2016. Though historically considered indolent, emerging evidence suggests that the biological behavior of these tumors may be further classified by molecular features of prognostic significance. Methods A retrospective review was conducted in accordance with IRB approval of patients with the histologic diagnosis of DLGNT. Demographic, clinical, and molecular data where abstracted from the medical record when available. Results 10 patients were identified (M = 8, F = 2). Median age at diagnosis was 6 years (range 0.3–21 years), and the most common symptoms at diagnosis were related to obstructive hydrocephalus, for which 3 patients required CSF diversion. MRI findings included diffuse leptomeningeal thickening, nodularity, or coating of the subarachnoid or ependymal surfaces. Histologically, these tumors expressed variable features of neuronal and/or glial differentiation. Four patients (40%) were treated with radiation therapy (all craniospinal), which was upfront for 2 patients. Chemotherapy regimens used included temozolomide, carboplatin and vincristine and vinblastine. NTRK or BRAF-targeted therapy were used upon progression. At follow-up, 6/10 had stable disease (4/6 of whom were on second line therapy), 1 had partial response, 1 passed away from sepsis and 2 were lost to follow-up. The median progression-free survival for the four patients who developed disease progression was 26 months (range 12–34 months). Next generation sequencing of the tumor tissue performed using a high-multiplex PCR-based NGS panel detected BRAF-KIAA1549 (4 patients) and NTRK (1 patient) fusions. Conclusions DLGNT are rare tumors with scarce data about imaging characteristic and standard of care treatment. Our case series reinforces current literature that although these tumors appear low-grade, they can be clinically aggressive. Further study is needed regarding molecular diagnosis and profiling treatment strategies.

Background: Persistent or progressive hydrocephalus is one of the complex problems of posterior fossa tumors associated with hydrocephalus. The author evaluated the effectiveness of single-stage tumor decompression associated with a stent technique (trans aqueductal third ventricle – Cervical subarachnoid stenting) as an adjuvant cerebro spinal fluid (CSF) diversion procedure in controlling the midline posterior fossa tumors with hydrocephalus. Materials and Methods: Prospective clinical case series of 15 patients was evaluated from July 2006 to April 2012. Fifteen clinicoradiological diagnosed cases of midline posterior fossa tumors with hydrocephalus were included in this study. All the tumors were approached through the cerebello medullary (telo velo tonsilar) fissure technique. Following the excision of the posterior fossa tumor, a sizable stent was placed across the aqueduct from the third ventricle to the cervical subarachnoid space. Results: There were nine male and six female patients with an average age of 23 years. Complete tumor excision could be achieved in 12 patients and subtotal excision with clearance of aqueduct in remaining three patients. Hydrocephalus was controlled effectively in all the patients. There were no stent-related complications. Conclusions: This study showed the reliability of single-stage tumor excision followed by placement of aqueductal stent. The success rate of this technique is comparable to those of conventional CSF diversion procedures. This is a simple, safe, and effective procedure for the management of persistent and or progressive hydrocephalus. This technique may be very useful in situations where the patient's follow-up is compromised and the patients who are from a poor economic background. Long-term results need further evaluation to assess the overall functioning of this stent technique.

BACKGROUND The is no consensus in best practices for the management of hydrocephalus in patients with Diffuse Intrinsic Pontine Glioma (DIPG). To date, the impact on survival of hydrocephalus and Cerebro-Spinal Fluid (CSF) diversion in this population remains to be elucidated. Herein, we describe our institutional experience. METHODS Patients with a clinical and radiological diagnosis of DIPG were identified at the Hospital for Sick Children between 2000–2019. Images at diagnosis and at disease progression were assessed for hydrocephalus using the frontal-occipital ratio (FOR) method. Proportional hazard analyses were used to identify factors correlated with survival. RESULTS Eighty-nine consecutive patients diagnosed with DIPGs were treated at our institution. At diagnosis, 29% (n=26) of patients presented with hydrocephalus, seven patients underwent CSF diversion. Out of the remaining nineteen patients, n=6 had stable or improved hydrocephalus in follow-up scans, n=6 had persistent hydro and n=2 required CSF diversion at the time of disease progression. Seven did not undergo a follow-up scan. Out of sixty-five patients with imaging at the time of progression, fifty-five percent of patients (n=36) presented with hydrocephalus and ten of them required CSF diversion. On univariate analysis, the presence of hydrocephalus or CSF diversion at diagnosis and/or did not correlate with a survival advantage. CONCLUSIONS CSF diversion for the management of hydrocephalus in patients with DIPG does not impact survival and in some cases resolves spontaneously after the initiation of radiotherapy and steroids. This observation needs to be validated in a prospective cohort.

BACKGROUND Traditionally patients presenting with hydrocephalus in the setting of brain metastases were associated with poor outcomes. However, in the area of improved systemic therapies, the prognosis of brain metastases has improved, warranting investigation into the management of concomitant hydrocephalus. METHODS We conducted a retrospective review of 12 consecutive patients with brain metastases presenting with hydrocephalus treated with either endoscopic third ventriculostomy (ETV) or ventriculoperitoneal shunt (VPS) from June 2013 to December 2018. We then compared our outcomes to 77 historical controls from the literature to test the hypothesis that management of hydrocephalus in patients who respond to systemic therapy is associated with improved outcomes. RESULTS The medial overall survival in our cohort was 182 days compared with 91 days in the reported previous studies, with an odds ratio of 0.5 (95% CI 0.24-1.04). In the 5 patients who underwent ETV, the median survival was 182 days versus 77 days reported in the literature, an odds ratio of 0.42 (95% CI 1.28-1.40). Patients with one brain metastasis did not reach median survival with 4 of 5 patients alive at last follow up, while only 3 of 7 patients with at least two metastases were alive at follow up with a median survival of 182 days. Patients who had immunotherapy were associated with improved survival, while leptomeningeal carcinomatosis still was associated with a negative outcome. CONCLUSIONS Patients with brain metastases and hydrocephalus who underwent neurosurgical CSF diversion had improved survival compared with historical controls, particularly in patients with one metastasis or who received immunotherapy. This study supports initial interdisciplinary evaluation of patients with brain metastases by medical and radiation oncology together with neurosurgery to facilitate immediate systemic therapy after relief of hydrocephalus.

OBJECTIVES: This analysis describes differences in household-level use of four specialized nutritious foods (SNFs) for treatment of moderate acute malnutrition (MAM) in children 6–59 months of age in Sierra Leone and explores whether these behaviors influenced recovery. METHODS: From 4/2017 to 11/2018, sub-samples of caregivers whose children were enrolled in a supplemental feeding program (SFP) for a MAM treatment study were randomly selected for in-depth interviews and in-home observations. This was a cluster-randomized trial of 2653 children with MAM in Sierra Leone evaluating cost-effectiveness of 4 SNFs: Super Cereal Plus w/amylase (SC + A), Corn-soy Blend Plus w/oil (CSB + w/oil), Corn-soy-whey Blend w/oil (CSWB w/oil), and Ready-to-Use Supplementary Food (RUSF). Caregivers received bi-weekly isocaloric distributions of 1 of the 4 SNFs until recovery or up to 12 weeks. The purpose of the in-depth interviews was to understand caregivers’ experiences with the SFP and the SNF which they received. In-home observations gathered information about observed behaviors related to SNF use over 5 consecutive days. Descriptive statistics were calculated and stratified by study arm and by outcome to explore: consumption of the SNF by the target child, sharing and selling, and diversion of other household foods. RESULTS: A total of n = 949 caregivers completed an in-depth interview. Of these, n = 323 also had an in-home observation. Observed consumption of the SNF was high in all study arms (>60%), with no discernible differences among arms. Consumption of the study food by anyone other than the beneficiary child (i.e., sharing) was similar across arms (9–12% reported, 19–27% observed), with the lowest reported and highest observed in RUSF. Very few reported giving the SNF away or selling it to others (

Radiation therapy is a known risk factor for leukoencephalopathy and ventriculomegaly in patients with brain metastasis (BM). However, whether repeat stereotactic radiosurgery (SRS) contributes to these complications remains poorly studied. The question is pertinent since the cerebrum is exposed to a variable amount of radiation during each round of SRS. We performed a retrospective analysis of patients who underwent SRS for BM between 2007 and 2017 at our institution and had > 3 months of MRI follow-up. MRIs were assessed for ventriculomegaly based on published morphometric criteria. Statistical analysis was accomplished using Student’s t-test, Pearson’s chi-squared test, and univariate and multivariate logistic regression. We identified 214 patients who underwent 1,106 SRS for BM. Sixty-three patients (29%) presented with ventriculomegaly prior to SRS. Risk factors for presenting with ventriculomegaly prior to first SRS were female sex (odds ratio (OR) 0.373, 95% CI 0.176 - 0.767, p=0.008) and older age (OR 1.096, 95% CI 1.06 - 1.137, p< 0.001). Of the other 151 patients with normal ventricular size at the time of SRS, 29 patients (19%) developed ventriculomegaly after SRS. Of the 29 patients who developed ventriculomegaly, ten patients (34%) required operative CSF diversion for symptomatic relief. We identified two risk factors that were associated with increased odds of ventriculomegaly: receiving > 4 rounds of SRS (OR 4.1, 95% CI 0.8 - 20.6, p=0.038) and prior history of whole-brain radiation therapy (WBRT, OR 5.6, 95% CI 2.3 – 13.9, p< 0.001). The association between > 4 rounds of SRS and ventriculomegaly remained robust in patients without prior history of WBRT, which suggests that both forms of radiation contribute to the risk of developing new ventriculomegaly. Our results suggest that prior history of WBRT and > 4 rounds of SRS independently contribute to the risk of ventriculomegaly in SRS-treated BM patients.

Background The 2017–2018 influenza season was characterized by high illness severity, wide geographic spread, and prolonged duration compared with recent years in the United States – resulting in an increased number of emergency department evaluations and hospital admissions. The current study explored how US hospitals perceived the impact of influenza during this time period, including effects on patient volumes, ways in which hospitals responded, and how lessons learned were incorporated into future influenza preparedness. Methods We conducted semi-structured phone interviews with capacity management personnel in short-term acute care hospitals across the United States. A random hospital sample was created using Centers for Medicare and Medicaid Services annual reports. Hospitals self-identified key informants who were involved with throughput and capacity. The interview guide was developed and pilot tested by a team of clinicians and qualitative researchers, with interviews conducted between April 2018 and January 2019. We performed thematic content analysis to identify how hospitals experienced the 2017–2018 influenza season. Results We achieved thematic saturation after 53 interviews. Responses conformed to three thematic domains: impacts on staff and patient care, immediate staffing and capacity responses, and future preparedness (Table 1). Hospitals almost universally reported increased emergency department and inpatient volumes that frequently resulted in strain across the hospital. Strain was created by both increased patient volume and staff shortages due to influenza illness. As strategies to address strain, respondents reported the use of new protocols, new vaccination policies, additional staffing, suspected-influenza treatment areas, and more frequent hospital administration meetings. Many hospitals reported increased diversion time. Despite experiencing high levels of strain, some hospitals reported no changes to their future influenza preparation plans. Conclusion Acute care hospitals experienced significant strain as a result of the 2017–2018 influenza season. Hospitals implemented a range of immediate responses to seasonal influenza, but generally did not report future planning specific to influenza. Disclosures All authors: No reported disclosures.

This study uses a random survey of US hospice agencies to estimate rates of confirmed and suspected cases of medication diversion away from patients in hospice and association of diversion rates with agency characteristics and state opioid death rates.

Tectal glioma (TG) is an uncommon pediatric low-grade tumor with limited data on long-term outcome. A retrospective review of TG diagnosed in patients ≤ 21 years at our center between 1986 and 2013 identified 19 patients (males=13; median age at diagnosis=10 years [yrs]; range, 0.01-19.99). All patients were diagnosed based on MRI. Initial CSF diversion was necessary in 16 patients (ventriculoperitoneal [VP] shunt= 10; endoscopic third ventriculostomy=6). Ommaya reservoir was inserted in 5 patients. VP shunt revisions (1-12 times) were required in 7 patients; while 2 patients had subdural hematoma due to over-shunting. Biopsy or resection was performed in 7 patients (upfront=5, at progression=2), with histology showing pilocytic astrocytoma (n=6) or low-grade glioma, NOS (n=1). Duplication of chromosome 7q34, marker of KIAA1549-BRAF fusion, was detected in 2 of 4 patients tested. Adjuvant therapy was delivered in 8 patients mostly upon progression, and included focal radiation (n=4), systemic therapy (n=3), or a combination (n=1). The median duration of follow-up was 9.57 yrs (range, 3.64-16.98): 7 experienced progression at median of 0.68 yrs (range, 0.28-8.98), including 2 with metastases. One patient each died due to suicide, obstructive hydrocephalus, and suspected shunt malfunction. Respective 5- and 10yr overall-survival were 92.9 ± 6.9% and 85.1 ± 9.7%. Long-term morbidities included persistent headache (n=8) and visual symptoms (n=7). Significant impairments were seen on measures of intelligence (n=2/9; 22%), working memory (n=2/7; 29%), and processing speed (n=6/6; 100%). Long-term survival of children with TG is satisfactory. Regular follow-up is recommended due to risks of shunt failure, progression, and long-term morbidities.

Importance: Plasma is frequently transfused to patients who are bleeding or require an invasive procedure and have a deficiency of coagulation factors. Despite published guidelines delineating optimal plasma use, two recent audits have suggested that over 50% of the plasma transfused is unnecessary. Inappropriate utilization of plasma has numerous adverse consequences for the recipient, as well as the health care system. Objective: To determine the proportion of inappropriate plasma use with a multicenter electronic data audit and identify focused areas for intervention to reduce inappropriate use. Setting: 3 tertiary care academic sites across Ontario, Canada: Hamilton Health Sciences Centre (Hamilton, Ontario), Sunnybrook Health Sciences Centre (Toronto, Ontario), London Health Sciences Centre (London, Ontario). Participants: All adult inpatients receiving plasma during the time period January 1, 2017 and December 31, 2017. Design: Four areas of inappropriate plasma use in adult patients were defined: (1) patients with a normal INR 1.5, without active bleeding or procedures in 6 hours after plasma transfusion (1 calendar day when time of procedure was not available); (3) no INR drawn before or after plasma infusion; (4) inappropriate non-therapeutic plasma dose of plasma (≤ 2 units) . Results: A total 4,385 plasma transfusion events occurred in 1,844 inpatient admissions. Appropriate indication and dosing was found in 813 (18.5%) of the events. Inappropriate compliance occurred in 3,572 (81.5%) of the events: 608 (13.9%) events occurred in the pre-specified criteria (1-3) above; inappropriate dosing alone occurred in 1,583 (36.1%) events; and, a combination of inappropriate dosing in addition to any 1-3 pre-defined categories occurred in 1,381 (31.5%) transfusion events. Patients transfused with a documented INR (81.5%) in the 24 hours preceding plasma transfusion had a mean INR value 1.8+1.7 (INR + SD). The mean overall reduction after 1-24 hours of plasma transfusion was -0.5+1.6 . Conclusions and Relevance: A significant amount of plasma is transfused inappropriately, leading to potential patient harm, significant unnecessary costs, and diversion of plasma away from fractionation impacting the supply of intravenous immunoglobulin. This study will inform a large quality improvement study aimed at reducing unnecessary plasma transfusion. Disclosures Heddle: Novartis: Research Funding. Arnold:Principia: Consultancy; Bristol-Myers Squibb: Research Funding; Novartis: Honoraria, Research Funding; Rigel: Consultancy, Research Funding. Hsia:Amgen: Honoraria; Jansen: Honoraria, Membership on an entity's Board of Directors or advisory committees; Novartis: Honoraria, Membership on an entity's Board of Directors or advisory committees; Pfizer: Membership on an entity's Board of Directors or advisory committees.

Primary diffuse leptomeningeal gliomatosis(PDLG) of high grade glioma(HGG) is a rarely documented phenomenon observed in less than 5% of glioblastoma(GBM). Purposes of this study are to investigate the clinical outcomes of PDLG of HGG and to analyze the results according to the procedures of operations. We retrospectively reviewed the medical records of 469 patients of HGG at our institute between 2004 and 2019 and 9 of who with PDLG were enrolled in our study. These 9 patients satisfying the condition of Karnofsky performance status ≥70 and Eastern Cooperative Oncology Group performance status ≤2 were conducted the primary surgical biopsy with or without intracranial pressure control. All patients finished the surgery within about 11 days after the detection of leptomeningeal seeding(LMS) on preoperative MRI images and completed the concurrent chemoradiotherapy(CCRT) with temozolomide(TMZ). Among 9 patients, 7 patients started adjuvant temozolomide and 3 patients completed the six cycles of it. 7 patients had done ICP control operation such as ommaya reservoir insertion, extraventricular drainage, and ventriculoperitoneal shunt within 23.3 days after defined as PLDG and survived nearly 10 months. Their pathologic findings were turned out to be seven glioblastomas and two anaplastic astrocytomas. Their median overall survival was 14 months and the 1- and 2-year overall survival rates were 50.8±17.7% and 16.9±15%, respectively. Compared to the 10-year study of GBM in the same institute between 2004 and 2011, in which 67 patients finished with CCRT with TMZ, the median overall survival was 19 months and the 1- and 2-year overall survival rates were 78.3% and 41.7%. The results indicate that PLDG has a worse outcome and overall survival rate is lower than GBM without LMS, so the earlier start of standard CCRT right after aggressive control of increased ICP like conducting CSF diversion might be helpful for the elongation of life expectancy.

Recent advancements in all phases of endovascular aneurysm treatment, including medical therapy, diagnostics, devices, and implants, abound. Advancements in endovascular technologies and techniques have enabled treatment of a wide variety of intracranial aneurysms. In this article, technical advances in endovascular treatment of cerebral aneurysms are discussed, with an effort to incorporate a clinically relevant perspective. Advancements in diagnostic tools, medical therapy, and implants are reviewed and discussed.

To understand the extent to which medication adherence was related to diversion of prescription analgesics.Cross-sectional analyses of data from the College Life Study, a prospective study of young adults.Participants were originally sampled as incoming first-time first-year college students from one large public university in the Mid-Atlantic United States.One hundred ninety-two young adults aged 21-26 who were prescribed an analgesic to treat acute pain in the past year.Diversion of prescription analgesics. The study tested two competing hypotheses: 1) individuals who skip doses (under-users) are at greatest risk for diversion because they have leftover medication; and 2) individuals who over-use their prescriptions (over-users) are at greatest risk for diversion, perhaps because of a general propensity to engage in deviant behavior.Fifty-eight percent followed physician's instructions regarding their prescription analgesic medication; 27% under-used their prescribed medication and 16% over-used their prescribed medication. Twenty-seven percent of the total sample diverted their medication, with over-users being the most likely to divert (63%). Holding constant demographic characteristics and perceived harmfulness of nonmedical use, over-users were almost five times as likely as adherent users to divert analgesic medications (P0.05).Further research is needed to better understand the relationship between adherence and diversion. If these findings are replicated, physicians who are involved in pain management for acute conditions among young adults should take steps to monitor adherence and reduce diversion of prescription analgesics.