Chronic Steroid Research Articles

8653 A Rare Cause of a Pituitary Mass

Abstract Disclosure: L. El Musa Penna: None. W. Medina-Torres: None. L.R. Sepulveda-Garcia: None. I.C. Arroyo Gomez: None. J. Segarra-Villafane: None. Z. Maisonet -Feliciano: None. M. Ramirez: None. L.A. Gonzalez-Rodriguez: None. M. Alvarado: None. J. Feneque González, MD: None. M. Marcos Martínez, MD: None. M. Correa Rivas: None. Pituitary gland masses are the second most common tumor of the central nervous system (CNS) across all age group, as per Central Brain Tumor Registry in the United States. Most common lesions are adenomas, which can be categorized as functional and non-functional based on the presence of hormonal hypersecretion. In the differential diagnosis, there is also craniopharyngiomas, Rathke’s cleft cysts, pituitary hyperplasia, inflammatory lesions, malignancy and abscess. Pituitary abscess is a rare condition, and only 0.2-0.6% of pituitary lesions are diagnosed as abscesses.This is the case of a 42-year-old female with history of hypothyroidism, chronic sinusitis with nasal polyps, severe asthma, and chronic steroid use complicated by iatrogenic adrenal insufficiency and osteonecrosis of the hips bilaterally, who was evaluated for intractable headaches. On brain imaging was found with a pituitary macroadenoma. She denied any symptoms suggesting hypersecretion of hormones and was scheduled for transsphenoidal surgery. All hormonal work up was found within normal limits, except for prior iatrogenic adrenal insufficiency due to multiple systemic steroids courses to treat asthma exacerbation throughout her life.During surgery, upon mass resection, purulent secretions were found. Frozen section was done intraoperatively, showing respiratory epithelium, pus and actinomyces species. All infectious material was removed. Infectious Diseases services was consulted and patient was promptly started on IV antibiotics. Blood cultures were negative, and patient remained afebrile. Final pathology confirmed the presence of respiratory epithelium, actinomyces colonization and a fibrous capsule with acute and chronic inflammation. Special stains report was negative for fungi. She was discharge to continue home infusion of antibiotic regimen to complete 8 weeks of treatment.There is no specific imaging finding to identify pituitary abscesses so, most of them, are diagnosed intraoperatively. They can arise from hematogenous spread or from adjacent tissues or structures (ie. patient with meningitis or sinusitis). The condition is considered a life-threatening however, the majority of cases have a chronic course. Based on different reports, theses abscesses have a higher female predominance; the age range is between 12 to 76 years and the average period between onset of symptoms and diagnosis is 8 months on average. Most pituitary abscesses are sterile, however most common organisms isolated are: Gram-positive cocci (Staphylococcus and Streptococcus), and Gram-negative organisms such as Neisseria, Escherichia coli and Corynebacterium. The rarity of cases often leads to delayed diagnosis and treatment initiation, contributing to increased morbidity and mortality. Presentation: 6/2/2024

8248 Glucocorticoid Induced Adrenal Crisis Masked By Metastatic Lung Carcinoma

Abstract Disclosure: N. Abrahimi: None. A. Abrahimi: None. Background: Chronic glucocorticoid use of three weeks or longer can cause hypothalamic-pituitary-adrenal axis inhibition by negative feedback, causing adrenal suppression. (1) Adrenal crisis is diagnosed by an acute clinical decompensation, persistent hypotension that resolves with high dose steroid administration. (2) Adrenal crisis is precipitated by several causes such as illness, dehydration, trauma, emotional distress and sometimes due to no identifiable cause. (2) Clinical Case: 64-year-old male past medical history of lung carcinoma metastatic to mediastinum who presented to the hospital with tachycardia. On presentation, patient was tachycardic, tachypneic, and hypotensive. Labs significant for WBC 22, Na+ 129, K+ 3.2, Cr 3.4. Patient received 2.5 L bolus of NS and was given one dose of azithromycin due to concern for sepsis. After fluid resuscitation, hypotension and tachycardia resolved. Presenting symptoms included ongoing nausea, decreased appetite and malaise for several weeks. Repeat labs post fluid resuscitation showed resolution of leukocytosis, improvement of AKI, and repletion of electrolytes. CT chest abdomen pelvis showed questionable pneumonia, however, consolidations were difficult to distinguish from known malignant masses. Clinical picture was not consistent with pneumonia and so additional antibiotics were held. Several hours later, blood pressure decreased, and patient began requiring vasopressors. Cefepime was started given concern for septic shock. Nearly 48 hours after initiation of broad-spectrum antibiotics hypotension persisted and patient remained on vasopressors. Given clinical decline, etiology of shock was reconsidered. Patient reported daily prednisone use over the last several months for COPD management. Given high clinical suspicion of adrenal crisis in setting of chronic steroid use and glucocorticoid withdrawal, patient was started on hydrocortisone 100 mg every 8 hours. Shortly after initiation of stress dosed steroids, the patient was successfully weaned off vasopressors with complete resolution of hypotension. Conclusion: Presentation and symptoms of adrenal insufficiency and crisis including nausea, anorexia, fatigue, malaise, hypotension and electrolyte abnormalities are nonspecific, can go unrecognized and be masked by other disease processes, such as metastatic cancer. (1) Adrenal crisis is life threatening and must be diagnosed and treated early to prevent mortality. (2) Therefore, adrenal crisis should always be on the differential in patients who present with shock.

Factors influencing management modifications following fiberoptic bronchoscopy in critically ill ICU patients.

Fiberoptic bronchoscopy (FOB) has evolved into a crucial diagnostic and therapeutic procedure for respiratory tract conditions over the years. Despite its benefits, this approach poses increased risks to critically ill patients. This study aimed to identify clinical parameters that influence management modifications after FOB in the general intensive care unit (ICU) population, an area not extensively explored. In this retrospective study, critically ill adults admitted to a medical ICU in Bangkok, Thailand, who underwent FOB between January 2013 and December 2022 were enrolled. Clinical parameters, imaging findings, and indications were analyzed to identify factors associated with modifications in post-bronchoscopic management. A total of 118 patients were reviewed and management modifications occurred in 69 patients (58.5%), in which antibiotic modification (78.3%) was the leading reason. Chronic steroid use and suspected interstitial lung disease were associated with management modifications after FOB, while alveolar infiltration on chest radiography was not. Although management modifications showed a trend toward lower mortality, statistical significance was not reached. Multivariate analysis identified chronic steroid use as the only independent factor [adjusted odds ratio (aOR): 2.26; 95% confidence interval (CI): 1.01-5.06; P=0.048]. Among critically ill patients, chronic steroid use was a predictor of management modifications after FOB and is likely to be beneficial.

Total Hip Arthroplasty for Osteonecrosis of the Femoral Head: A Mid-term Follow-Up in Patients From Northern India.

Osteonecrosis of femoral head (ONFH) is a disabling condition of the hip joint with multifactorial etiology and is associated with genetic predilection and exposure to certain risk factors most commonly being chronic alcohol or steroid intake. Total hip arthroplasty (THA) remains the gold standard for end-stage femoral head osteonecrosis. The outcome after the surgery is mainly affected by age, activity levels and other factors that affect the development of ONFH. Through this study we aimed to evaluate the clinical and radiological outcomes in the patients who have undergone uncemented THA for ONFH. We included 111 uncemented THA on 84 patients with ONFH done by a single surgeon in our institution. The patients were followed up postoperatively and were evaluated based on their functional outcome using Harris hip scores (HHS) and the radiological outcome by serial radiographs on every follow-up. The mean preoperative HHSwas 49.30 which showed significant improvement inthe final follow-up to96.17. The mean acetabular inclination and anteversion at final follow-up radiographs were 47.70 and 18.67 degrees respectively. Fifteen patients had complications which included post-operative surgical site infection (three), hip pain (six) and thigh pain (six). Complications like osteolysis, poly wear and femoral subsidence were recorded in a total of six patients at the final follow-up. Three patients underwent revision THA due to increased femoral subsidence, accelerated poly wear, and aseptic loosening due to osteolysis. Our current observational study, which included 84 patients and 111 hips affected by osteonecrosis of the femoral head, examined the outcomes of total hip arthroplasty using metal on ultra-high molecular weight polyethylene liners. The results showed excellent clinical and radiological outcomes at a mean follow-up period of 4.8 years, particularly in younger patients with a mean age of 37.05 years.

Diagnosis of Gout as a Correlative Risk for Acute Myocardial Infarction in the Absence of Traditional Cardiovascular Risk Factors.

We aimed to study the impact of gout as a correlative risk factor in the incidence of acute myocardial infarction (AMI) among patients without known MI risk factors. Our study population was obtained from the National Inpatient Sample (NIS) 2011-2018 using the International Classification of Diseases, Ninth and Tenth Revisions. This study included patients without cardiovascular disease (CVD), and various outcomes were compared among patients with and without gout. Cohorts were weighted using an algorithm provided by the NIS, which allows for national estimates. Our primary endpoint was the odds of developing an MI, and secondary endpoints were adverse hospital events and length of stay. In total, 117,261,842 patients without CVD risk factors were included in this study, 187,619 (0.16%) of whom had a diagnosis of gout. Patients without CVD risk factors who had gout were older and more likely to be male compared with patients without gout. Among patients without CVD risk factors, the odds of having an AMI were significantly higher in those with gout compared with those without, even after adjusting for chronic nonsteroidal anti-inflammatory drug and oral steroid use. Moreover, patients without CVD risk factors and with gout were more likely to develop acute renal failure, acute thromboembolic event, shock, acute gastrointestinal bleed, and arrhythmia compared with those without gout. Furthermore, patients without CVD risk factors who were admitted with gout had higher mortality compared with those without gout. In our study, we found that patients without risk factors for AMI who had gout were more likely to develop AMI compared with those without gout. Furthermore, the same patients were more likely to develop other adverse outcomes. Even with proper management, these individuals should be monitored closely for coronary events.

A Clinical Study of Anterior Abdominal Wall Hernias and Its Management: A Medical College Experience.

Objective We aim to evaluate the various risk factors contributing to the occurrence of anterior abdominal wall hernias and assess the various surgical modalities. Materials and methods This prospective observational research was conducted between 2022 and 2024 at a tertiary care health center, involving 100 participants with an anterior abdominal wall hernia diagnosis aged over 14 years. The study excluded patients under 14 years with bleeding diathesis, inherited coagulopathies, inguinal or femoral hernias, or recurrent ventral hernias. Participants underwent detailed clinical examinations and biochemical evaluationsand underwent a primary ultrasonography (USG)/contrast-enhanced computed tomography (CECT) to determine defect size. Risk factors were documented, including age, gender, occupation, body mass index (BMI), comorbidities, previous surgery history, multiparity, smoking, chronic straining due to constipation or benign prostatic hyperplasia (BPH), malnutrition, chronic steroid use, chronic renal failure, and chronic liver disease. The surgical procedure was determined by the same surgical team for all cases. Standard antibiotic prophylaxis and preoperative painting/draping protocols were followed in all cases. Intraoperatively, intraoperative time (in hours) was documented. Postoperative parameters included pain, hematoma formation, seroma formation, surgical site infections (SSIs), and early recurrence. These intra- and postoperative findingsconstituted the primary outcome parameters. Secondary outcome parameters included hospital stayduration and time taken to return to work. Data analysis was performed using Statistical Package for the Social Sciences (SPSS) version 16 (IBM SPSS Statistics, Armonk, NY) software. Results The study analyzed the occurrence of ventral hernias in 100 patients, with the fourth decade having the highest occurrence (n=42 (42%)). The majority of the participants were male (female: n=47 (47%), male: n=53 (53%)). The majority of the participants were laborers, and 24% (n=24) were office workers. The study found that hypertension, diabetes mellitus, and chronic obstructive pulmonary disease were risk factors for hernias. Other risk factors included obesity, previous history of surgery, multiparity, smoking, chronic straining, malnutrition, and chronic steroid use. The most common type of ventral hernia was umbilical hernia (n=33 (33%)), followed by paraumbilical hernias (n=30 (30%)), and incisional hernias (n=20 (20%)). Of the 100 patients, 74% underwent open hernia repair, with the mean operation time being minimal in cases managed with laparoscopic repair (2.5±0.67 hours). Postoperative painwas highest with the Rives-Stoppa (RS) repair with component separation group. The incidence of surgical site infection was the maximum among cases of open anatomical repair (41.7%), followed by RS repair (31.3%), while it was the minimum in laparoscopic repair (3.7%). Early recurrence was lower in the laparoscopic group (n=1 (3.7%)). Conclusion The study highlights risk factors for abdominal wall hernia and management approaches. Understanding these is crucial for identifying and preventing recurrence. Surgeons must choose the right surgical approach based on patient health and symptoms to achieve desired outcomes and minimize complications. In addition, surgical expertise, availability of resources, and knowledge of what works best for the surgeon constitute important determinants of surgical outcomes.

Greater readmission rates after total hip arthroplasty with discharge to a facility vs. home: A propensity score matched analysis

PurposeProvided that total hip arthroplasties (THA) are some of the most common surgical procedures performed, there is a necessity to understand all factors that contribute to risks of adverse outcomes postoperatively and to find solutions to avoid these events with preventive measures. This retrospective cohort study sought to assess differences in (1) postoperative complication rates, (2) readmission rates and reasons, and (3) demographic variables that contribute to readmissions based on discharge destination within the first 30 days after a THA. MethodsPatients undergoing THA (27130) between 2015 and 2020 were extracted from the American College of Surgeons National Surgical Quality Improvement Program (ACS-NSQIP) database based on procedural codes. Propensity score matching was then employed to reduce selection bias, and Chi-square tests and one-way analysis of variance (ANOVA) were performed. Multivariable analysis was then used to look for other factors associated with readmission risk. Results219,960 patients were identified with 189,841 discharged to home, 19,355 to a skilled nursing facility (SNF), and 10,764 to a rehabilitation facility. The rehabilitation and SNF cohorts both had greater rates of readmission (4.56 % home vs. 6.88 % SNF vs. 6.90 % rehabilitation, P<0.001) and any adverse event (AAE, 9.02 % vs. 18 % vs. 21.3 %, P<0.001) after matching. Older age, longer operative time, American Society of Anesthesiologists (ASA) classification four, chronic obstructive pulmonary disease (COPD), bleeding disorders, steroid use, and smoking were associated with an increased risk of readmission after THA. ConclusionOverall, THAs were shown to have low postoperative complications and readmissions in all patient populations despite differences in discharge destination which continues to demonstrate the safety and validity of this often elective procedure. However, the statistically significant risk of complications and readmissions in addition to the higher costs associated should be accounted for when considering patient discharges to a non-home facility.

Preoperative chronic steroid use as a risk factor for complications following open reduction internal fixation for proximal humerus fracture.

The primary objective of this study was to investigate the association between preoperative chronic steroid use and postoperative complications following open reduction internal fixation(ORIF) for proximal humerus fractures(PHF). The American College of Surgeons National Surgical Quality Improvement (ACS-NSQIP) database was queried for all patients who underwent PHF ORIF between 2015 and 2021. A total of 6,273 patients were included in this study, of which 3.4% (n = 212) were in the chronic steroid use cohort. Patient characteristics including demographics, comorbidities, and 30-day postoperative complications after PHF ORIF were collected. Bivariate logistic regression and multivariate logistic regression analysis, adjusted for all significantly associated variables, was conducted to investigate the relationship between preoperative chronic steroid use and postoperative complications. Chronic steroid use was significantly associated with age ≥ 75 (p < 0.001), male gender (p =0.006), dependent functional status (p = 0.008), American Society of Anesthesiologist (ASA) ≥ 3 (p < 0.001), CHF (p = 0.007), hypertension (p < 0.001), COPD (p < 0.001), bleeding disorder (p = 0.007), ascites (p = 0.040), disseminated cancer (p< 0.001), and systemic sepsis (p < 0.001). After adjusting for all significantly associated variables, chronic steroid use was independently associated with major complication (OR 1.60, 95% CI 1.06-2.43; p = 0.026), and non-home discharge (OR 1.05, 95% CI 1.01-1.08; p = 0.014). Preoperative chronic steroid use is associated with increasing rate of postoperative complications following PHF ORIF. Better understanding and characterizing chronic steroid use as a preoperative risk factor can aid physicians in risk stratification to reduce rates of postoperative complications following PHF ORIF. III. Retrospective Cohort Comparison; Prognosis Study.

Pneumocystis jirovecii pneumonia secondary to chronic steroid use: An uncommon cause of pneumocystis pneumonia

Patients on long-term immunosuppression, including corticosteroids or immunomodulatory drugs, are susceptible to opportunistic infections, such as like Pneumocystis jirovecii pneumonia (PJP). Corticosteroid use can increase the frequency of fungal infection, mask symptoms, and delay the diagnosis, and thus warrant preventive measures. Maintaining a high index of suspicion is important, and prophylactic antibiotics, particularly trimethoprim-sulfamethoxazole, should be considered for high-risk patients. This case underscores the diagnosis of PJP in a patient with interstitial lung disease receiving prolonged steroid therapy, despite lacking HIV and conventional risk factors for this infection. Notably, PJP can present as a more severe infection in non-HIV patients, leading to higher mortality rates and stressing the need for swift and effective diagnosis and treatment by healthcare providers. Keywords: Pneumocystis jirovecii; pneumonia; chronic corticosteroid treatment use; fungal pneumonia; interstitial lung disease

Effect of Chronic Steroid Use on Postoperative Wound Complications in Patients Undergoing Arterial Bypass Surgery for Lower Extremity Peripheral Arterial Disease

ObjectiveWhile existing literature reports adverse effects of chronic steroid use on surgical wound outcomes, there remains lack of data exploring the effect of steroids on postoperative outcomes following lower extremity arterial bypass surgery. This study aims to explore the effect of chronic steroid use on surgical outcomes in patients undergoing open revascularization for lower extremity arterial occlusive disease. MethodsUsing the American College of Surgeons National Surgical Quality Improvement Program (ACS-NSQIP) files between 2005 and 2020, all patients receiving aortoiliac or infrainguinal arterial bypass for peripheral arterial disease (PAD) were identified by Current Procedural Terminology (CPT) codes. Patient characteristics and 30-day outcomes were compared using χ2 test and independent t-test, and association of chronic steroid use with wound complications was studied using multivariable logistic regression analysis. ResultsA total of 44,675 patients undergoing open lower extremity revascularization were identified, of which 1,807 patients were on chronic steroids and 42,868 patients were not on chronic steroids. On multivariable logistic regression analysis, being on chronic steroids was associated with higher rates of deep SSI (OR 1.37, 95% CI 1.03-1.83), any SSI (OR 1.22, 95% CI 1.04-1.43) and wound dehiscence (OR 1.42, 95% CI 1.03-1.96). Chronic steroid users also had significantly increased odds of developing sepsis (OR 1.56, 95% CI 1.19-2.04), pneumonia (OR 1.44, 95% CI 1.08-1.91), UTI (OR 1.54, 95% CI 11.13-2.09), DVT (OR 1.60, 95% CI 1.01-2.53), and 30-day readmission (OR 1.30, 95% CI 1.12-1.50), reoperation (OR 1.17, 95% CI 1.01-1.37) and mortality (OR 1.33, 95% CI 1.01-1.76) compared to non-chronic steroid users. ConclusionThis study confirms that chronic corticosteroid use is associated with higher risk of surgical site infections (SSIs) in patients undergoing lower extremity arterial bypass surgery. These patients typically have various underlying health issues, emphasizing the need for personalized treatment and management to reduce steroid-related postoperative complications and improve survival.

Urinary tract mycosis masquerading as renal papillary necrosis post-COVID: A case report

Urinary tract mycosis is more often seen in hospitalized patients than in community-acquired ones. Funguria is common but becomes invasive and life-threatening in immunosuppressed patients such as with diabetes mellitus, post-transplant, chronic antibiotic usage, cancer chemotherapy, and long-term steroids. In the last 2 years, the world has witnessed one of its worst pandemics with the COVID-19 infection, killing millions of people. Deaths have been due to the virus or secondary complications thereafter. Secondary fungal infections, especially those caused by mucormycosis, have been on the rise, the majority of which have been reported from India. The rhino-cerebral-pulmonary form is the most common, followed by isolated case reports of gastrointestinal, cutaneous, and musculoskeletal mucormycosis. Isolated renal and urinary tract mycosis in COVID-19 is an extremely rare association. We report a case of a middle-aged man with fairly well-controlled diabetes who received steroids for COVID-19 infection and, about 8 weeks later, presented with non-invasive mixed mycosis of the urinary tract that was managed conservatively without any surgical intervention.

Abstract 1067: Floating Through The Aorta; Aortic Thrombus Takes It Course

Background: Aortic thrombus is an uncommon condition that is usually discovered as an incidental finding but in rare cases can be the cause of fatal conditions. The reported incidence of its intramural, pedunculated and floating types. The most common location is reported to be the descending aorta followed by the aortic arch. The pathophysiology remains unclear but possible predisposing factors include atherosclerosis, hypercoagulability disorders, malignancy, dissections, aneurysm, chronic inflammatory states, substance use and chronic steroid use. Treatment can vary from anticoagulation to thrombolysis and surgical removal based on the clinical presentation. Clinical presentation: 48-year-old male with a past medical history of hyperparathyroidism presented with three days of nausea, vomiting and lower abdominal pain. CT abdomen showed pancreatic inflammation and he was admitted for pancreatitis. MRCP was completed to evaluate for organic causes of pancreatitis which revealed left renal infarction. CTA C/A/P was done to evaluate infarction and was found to have large 1.5 x 1.1 x 2.1 cm mural thrombus, partially free-floating in distal thoracic aortic arch/proximal descending segment and focal narrowing at the origin left renal artery presumed to be of embolic origin. He was started on heparin drip for the rest of his hospital course and continued to improve. Hypercoagulable work up was unrevealing for any specific etiologies of the thrombus. Pancreatitis was determined as the presumed cause of thrombus as thromboembolism is a known possible complication of pancreatitis and splenic vein thrombosis may be seen in up to 12% of patients .Surgical intervention was initially considered, however repeat CT angiogram of chest/abdomen prior to discharge showed near resolution of thrombus with stable left renal infarct. He was discharged with apixaban and was recommended to follow-up outpatient. Conclusion: Aortic thrombus is rare due to the constant flow of pressure within the aorta. Early detection and management are crucial to avoid embolization which can lead to end organ dysfunction, limb ischemia, mesenteric ischemia, and stroke. DOAC anticoagulation is a viable and efficient therapy option if surgical intervention is not feasible

Abstract CT286: TILVANCE-301, a phase 3 study of lifileucel tumor-infiltrating lymphocyte (TIL) cell therapy in combination with pembrolizumab vs pembrolizumab alone in treatment-naive unresectable or metastatic melanoma

Abstract Introduction: Novel early-line therapies for advanced (unresectable or metastatic) melanoma are needed to improve the rate of deep and durable responses and increase the proportion of patients with long-term benefit. TILVANCE-301 will evaluate the efficacy and safety of lifileucel autologous TIL cell therapy plus pembrolizumab in patients with untreated advanced melanoma. Methods: TILVANCE-301 (NCT05727904) is a phase 3, multicenter, randomized, open-label, parallel group study that will randomize ~670 patients (1:1; Day 0) to Arm A: lifileucel plus pembrolizumab (Day 3: tumor tissue resection for TIL manufacturing; Day 5: pembrolizumab 200 mg; Day 26: pembrolizumab 400 mg; Day 28-29: cyclophosphamide 60 mg/kg; Day 28-32: fludarabine 25 mg/m2; Day 33: lifileucel; Day 34-37: ≤6 doses of high-dose IL-2; Week 10: pembrolizumab 400 mg Q6W) or Arm B: pembrolizumab alone (same pembrolizumab dosing as Arm A). Patients in Arm B with confirmed progressive disease verified by blinded independent review committee (BIRC) have the option to receive lifileucel monotherapy as immediate next treatment and may continue pembrolizumab until start of nonmyeloablative lymphodepletion. Eligible adults have histologically confirmed advanced melanoma, Eastern Cooperative Oncology Group performance status of 0-1, estimated life expectancy &amp;gt;6 months, ≥1 resectable lesion to generate lifileucel, and ≥1 remaining measurable lesion. Prior neoadjuvant or adjuvant treatment including immune checkpoint inhibitors may be allowed. Prior therapy for metastatic disease, symptomatic untreated brain metastases, organ allograft or prior cell therapy, uveal/ocular melanoma, and chronic systemic steroid therapy are not permitted. The dual primary efficacy endpoints are BIRC-assessed (RECIST v1.1) objective response rate (ORR) and progression-free survival (PFS). Key secondary efficacy endpoint is overall survival. Additional secondary efficacy endpoints include BIRC-assessed complete response (CR) rate, duration of response (DOR), and event-free survival (EFS); investigator-assessed ORR, PFS, CR rate, DOR, EFS, and PFS2; and safety as characterized by severity and seriousness of treatment-emergent adverse events and relationship to study drug. Exploratory endpoints include in vivo T-cell persistence (unique CDR3 sequences in peripheral blood mononuclear cell [PBMC] over time) and correlative biomarkers (eg, lifileucel phenotypic and functional characteristics; lifileucel, tumor, and PBMC gene expression profiles; tumor mutational landscape). The study will enroll globally, with initial sites in Europe, North America, and Australia. Trial registration: NCT05727904 Citation Format: Sajeve Thomas, Young Ki Hong, Yazan Samhouri, James Larkin, David J. Olson, Gino K. In, Victoria Atkinson, Philip Lammers, Andrew J. Furness, Juan Martin-Liberal, Patrick Terheyden, Andrew S. Poklepovic, Ryan H. Nguyen, Idit Peretz, Marcus Butler, Adnan Khattak, Lavinia Spain, E.M. Gaughan, Melissa Wilson, John W. Dubay, Anja Williams, Stephanie Goff, Gary C. Doolittle, Jason Chesney, Friedrich Graf Finckenstein, Jeffrey Chou, Xiao Wu, Giri Sulur, Wen Shi, John Haanen. TILVANCE-301, a phase 3 study of lifileucel tumor-infiltrating lymphocyte (TIL) cell therapy in combination with pembrolizumab vs pembrolizumab alone in treatment-naive unresectable or metastatic melanoma [abstract]. In: Proceedings of the American Association for Cancer Research Annual Meeting 2024; Part 2 (Late-Breaking, Clinical Trial, and Invited Abstracts); 2024 Apr 5-10; San Diego, CA. Philadelphia (PA): AACR; Cancer Res 2024;84(7_Suppl):Abstract nr CT286.

Recurrent Vision Loss in a Patient with Giant Cell Arteritis while on High Dose Corticosteroids

Giant cell arteritis (GCA) is a chronic vasculitis that can lead to permanent vision loss. In this case we describe a patient with permanent monocular vision loss from GCA, managed with long-term glucocorticoids, who presented with elevated erythrocyte sedimentation rate and acute visual loss. This patient was promptly given intravenous steroids, with initial improvement, however, she again experienced acute vision loss on the fourth day of treatment. Given the rare nature of this recurrent GCA-related vision loss during treatment, a broader workup was pursued without an alternative cause identified. Temporal biopsy was not performed due to concern of a false-negative in the setting of chronic steroid use. In this report we discuss the long-term monitoring and management of GCA, recurrence in the acute treatment setting, and present evidence related to diagnosis of GCA in the context of long-term steroid use.

491 Scalp Incisions With Stairstep Pericranial Edges to Minimize Sequalae of Poor Wound Healing in Supratentorial Brain Tumor Surgery

INTRODUCTION: Wound healing problems are especially prevalent in craniotomies for intra-axial brain tumors as patients often require radiation, chemotherapy, and chronic steroids. All surgeons have postoperative patients with poor skin healing (i.e., excessive scabbing) at follow up, some of whom progress to infections that may involve the bone graft or hardware. While newer techniques like minimally invasive approaches and routine vancomycin powder use have helped overall complication rates, poor skin healing remains a frustratingly persistent cause of morbidity. METHODS: Ninety-one consecutive patients underwent supratentorial, intra-axial brain tumor surgery with a single surgeon at a single institution using this technique. Patient demographics, pathology, adjuvant interventions, and other independent risk factors were analyzed. RESULTS: No wound-related complications requiring readmission, intravenous antibiotics, or reoperation were encountered at a median 3-month follow up. There were also no surgical site infections, dehiscences, or CSF leaks. Fifty-one patients (57.3%) had postoperative radiotherapy, eighty-five patients (93.4%) had perioperative steroids, and fifty-six patients (61.5%) had postoperative chemotherapy. Six patients (6.5%) had concerns for poor initial scalp healing at routine follow up and were placed on a short course of oral antibiotics prophylactically. None (0%) of these individuals progressed to infection or required further intervention. One other patient developed a shunt infection in this interval that required removal unrelated to the craniotomy site. CONCLUSIONS: Here we outline the principles and demonstrate the execution of stairstep pericranial edges in supratentorial brain surgery. This technique, designed with plastic surgeons, provides an intact, vascularized layer of pericranium beneath the incision and over the bone graft/hardware to optimize wound healing and prevent morbid sequelae in inevitable cases of poor initial skin healing.

1080 Preoperative Prealbumin Level as a Risk Factor for Pseudoarthrosis Following Lumbar Spine Surgery

INTRODUCTION: Preoperative nutritional status is essential for predicting postoperative outcomes. Studies have shown that prealbumin levels can be a prognostic indicator for surgical outcomes in spine surgery. METHODS: A retrospective cohort study of 697 patients was conducted between April 1st, 2018, to October 31st, 2022. Collected data included patient demographics, PPL, chronic steroid use, index surgery, length of surgery, postoperative hospital length of stay, 30-day return, and pseudoarthrosis (verified by a board certified neuroradiologist via radiographic imaging). PPL were first analyzed as absolute values, and then categorized as binary values. The first cut point used for binary categorization was =30 and &gt;30. We then repeated statistical analyses similarly using =25, =20, and =15 as additional cut points (all as binary values). RESULTS: Fifty-six patients had pseudoarthrosis (8%), while 641 (92%) did not. There was no statistical difference between patients who had pseudoarthrosis and patients who did not, in terms of age (62 vs. 62.9, p=0.298), BMI (29.9 vs. 29.8, p=0.441), and preoperative prealbumin level (26.6 vs 26.4, p=0.387). There was a significant difference regarding the length of surgery (337.9 mins vs. 253.8, p=0.008) and hospital length of stay (6.2 days vs. 4.2 days, p&lt;0.001) in patients with pseudoarthrosis. Finally, there was no significant difference between PPL and developing pseudoarthrosis when the data was categorized as binary values with cut points at =30 (p=0.595), =25 (p=0.987), =20 (p=0.799), and =15 (p=0.333). CONCLUSIONS: Preoperative nutritional assessment is essential in spine surgery as it can predict postoperative outcomes and recovery. In our cohort of patients, low serum prealbumin levels did not correlate with a higher rate of pseudoarthrosis following lumbar spine surgery.

Achilles tendon rupture primary repair technique: A comparative retrospective study between graft versus no-graft

IntroductionAchilles tendon rupture is one of the most common musculoskeletal injuries and accounts to 20 % of all large tendon ruptures The surgical choice of a procedure might play a role in the incidence of postoperative complications. This study aimed to estimate and compare the incidence of complications occurring within a 30-day window following primary surgical repair of the Achilles tendon with or without a graft. MethodsA retrospective cohort study was conducted using the ACS NSQIP database from 2005 to 2021. Patients were divided into 2 cohorts (primary surgical repair with and without graft). ResultsA total of 7010 patients were included in the analysis. Among the graft group, 10.9 % reported any complication which was double the percentage of complications in the no graft group. Only 3.8 % of the no graft patients had reported systemic complications compared to 8.3 % in the graft group. Chronic steroid use was found to be an effect modifier in the incidence of any complications after primary surgical repair when comparing graft versus no graft (P-value 0.016). ConclusionSurgical repairwith tendon graft develops more complications than repairing without graft. Therefore, it is imperative for physicians to strive for an early diagnosis, as any delay in treatment significantly raises the likelihood of complications. Levels of evidenceIII, Retrospective Cohort Study.

The effect of anabolic androgenic steroids on heart rate recovery index and electrocardiographic parameters in male bodybuilders

BackgroundThe control of the cardiovascular system depends on the autonomic nerve system. Chronic anabolic andorogenic steroids (AAS) use causes sympathovagal imbalance and increases sympathetic nerve activity. ObjectiveThe reduction in heart rate from the peak exercise rate following the end of the exercise stress test is known as the heart rate recovery index (HRRI). Several methods have been utilized to assess myocardial repolarization, such as QT interval (QT), corrected QT interval (QTc), and T-wave peak-to-end interval (Tp-e interval). Based on a growing number of data a higher Tp-e/QT ratio is linked to malignant ventricular arrhythmias, and an increased Tp-e interval may correlate with the transmural dispersion of repolarization. Our hypothesis is that the use of chronic AAS was decrease HRRI during maximal exercise and increased risk of cardiac arrhythmias and sudden cardiac death. MethodsThis study included 44 male bodybuilders, with an average age of 29.7 ± 8.14 years, divided into AAS abuse [AAS users (n = 21) and AAS nonuser (n = 23)]. ResultsThe first (p = 0.001) and second minute (p = 0.001) HRRI of the subjects with AAS users were significantly lower than those of the control group. Additionally, HRRI after the third (p = 0.004) and fifth minutes (p = 0.007) of the recovery period were significantly lower in AAS group compared with the control group. Who used AAS had significantly higher QT, QTc, Tp-e, Tp-e/QT, and Tp-e/QTc values than non-users (all p = 0.001). ConclusionsChronic AAS use has been shown to cause sympathetic dominance, which may be a pro arrhythmic state.

The Determinants of Eosinophilia in Patients With Severe Asthma.

Asthma is defined by the Global Initiative for Asthma (GINA) as a heterogeneous disease characterized by chronic airway inflammation. The pathogenesis of the disease is better understood with the comprehension of immunological pathways. These pathways differ by the type of recruited cells and released interleukin (IL). Thus, asthma can be classified into subtypes based on the underlying immune mechanism: eosinophilic asthma (EA) and non-eosinophilic asthma (NEA). Patients with EA tend to respond better to inhaled corticosteroid as compared to those with NEA. The distinction of EA is very important in the light of emergent type 2 inflammation targeted therapies. We performed a 1-year (2018) retrospective cohort analysis of the Nationwide Inpatient Database (NIS). We included all adult patients presenting with severe asthma. Patients were stratified into two groups: eosinophilic severe asthma and non-eosinophilic severe asthma. The primary outcomes measures were the prevalence of chronic steroid use, status asthmaticus, family history of asthma, food, drug and environmental allergies, presence of nasal polyps, allergic rhinitis, allergic dermatitis, need for mechanical ventilation, need for oxygen supplementation, gastroesophageal reflux disease, in-hospital mortality, and length of stay. We performed descriptive statistics. Continuous parametric variables were reported using a mean and standard deviation. Continuous nonparametric variables were reported using a median and interquartile range. To compare the characteristics of the two groups, we used the independent t-test for continuous parametric variables and the Mann-Whitney U test for continuous nonparametric variables. The Chi-square test was used to assess differences in categorical variables. A total of 2,646 patients were included, out of which 882 belonged to the eosinophilic group and 1,764 were in the non-eosinophilic group. Comparing EA versus NEA, we have found that eosinophilic group was characterized by higher percentage of steroid use (18.3% vs. 9.5%, P < 0.001). This group also had higher rates of status asthmaticus and positive family history (P = 0.009 and 0.004, respectively). The presence of allergies, allergic rhinitis, nasal polyps, and allergic dermatitis was higher among patients with eosinophilia. The need for mechanical ventilation and supplemental oxygen was also higher among this group (P < 0.001 for both); however, there was no significant difference in mortality rate (P = 0.347) and the length of hospital stay was similar in both groups (P < 0.001). We showed herein that the eosinophilic subtype of asthma differs widely from the non-eosinophilic phenotype. Clinically, patients with eosinophilia might exhibit different symptomatology, more atopy, and concomitant comorbidities. However, this group might have better response to steroid therapy and might benefit from the new emergent T2 immune targeted therapy. The identification of EA is crucial for better disease control.

The Impact of Pre-Trauma Steroid Use on Wound Healing and Outcomes.

This study presents data on pre-trauma steroid use, a topic underrepresented in the trauma literature. Long-term steroid use has been linked to impaired wound healing, compromised immune responses, and hindrance of bone healing, alongside the potential for adrenal insufficiency during traumatic events. The aim of this study was to conduct a retrospective analysis of clinical outcomes for trauma patients with chronic steroid use. Examining adult trauma cases with pre-trauma steroid use at a level 1 trauma center (January 2016-September 2023), we identified 18 patients (58.6 ± 19.4years, 55.6% males). All were on prednisone prior to trauma activation and 66.7% had autoimmune disease. Complications included orthopedic fractures (72.2%), ICU admissions (16.7%), and low mortality (5.6%). Future larger, multi-center studies are needed to determine the impact of immunosuppression and pre-trauma steroids on clinical outcomes.