Chronic Steroid Use Research Articles

Outcomes of Percutaneous Coronary Intervention in Patients With Acquired Immunosuppression

There are limited data on the clinical outcomes of percutaneous coronary intervention (PCI) in patients with acquired immunosuppression who are frequently underrepresented in clinical trials. All PCI procedures between October 2015 and December 2018 in the Nationwide Inpatient Sample were retrospectively analyzed, stratified by immunosuppression status. Multivariable logistic regression models were performed to examine (1) the association between immunosuppression status and in-hospital outcomes, expressed as adjusted odds ratio (aOR) with 95% confidence intervals (CIs) and (2) predictors of mortality among patients with severe acquired immunosuppression. In this contemporary analysis of nearly 1.5 million PCI procedures, approximately 4% of patients who underwent PCI had acquired immunosuppression. Of these, chronic steroid use accounted for approximately half of the cohort who underwent PCI who had acquired immunosuppression, with the remainder divided between hematologic cancer, solid organ active malignancy, and metastatic cancer, with the latter group having the highest rates of composite of in-hospital mortality or stroke (9.3%) (mortality 7.5% and acute ischemic stroke 2.4%). In conclusion, immunosuppression was independently associated with increased adjusted odds of adverse clinical outcomes, specifically mortality or stroke (aOR 1.11, 95% CI 1.06 to 1.15, p <0.001) and in-hospital mortality (aOR 1.21, 95% CI 1.13 to 1.29, p <0.001), with outcomes dependent on the cause of immunosuppression.

Incidence, risk factors and clinical implications of postoperative urinary tract infection in geriatric hip fractures

IntroductionPostoperative urinary tract infection (UTI) is common in geriatric patients; however, little is known about the impact of UTI in orthopedic trauma. The present study was designed to determine the risk factors and clinical impact of postoperative urinary tract infection (UTI) in acute geriatric hip fractures. Patients and methodsGeriatric patients (≥65 years of age) undergoing hip fracture surgery were identified within the American College of Surgeons National Surgical Quality Improvement Program between 2016 and 2019. Patients presenting with UTI at the time of surgery were excluded. Baseline characteristics and outcomes were compared between patients with and without postoperative UTI. Multivariate logistic regression was performed, controlling for potential confounders. ResultsA total of 46,263 patients included in the study. Overall, 1,397 (3.02%) patients had postoperative UTI. Patients who developed postoperative UTI had higher rates of pneumonia (6.44% vs. 3.76%, p < 0.001), DVT (2.22% vs. 1.04%, p < 0.001), sepsis (7.73% vs. 0.62%, p < 0.001), and more frequently experienced postoperative hospital lengths of stay exceeding 6 days (37.94% vs. 20.33%, p < 0.001). Hospital readmission occurred more frequently in patients with postoperative UTI (24.55% vs. 7.85%, p < 0.001), but surprisingly, these patients had a lower mortality rate (1.36% vs. 2.2%, p < 0.001). Adjusted analysis demonstrated the following variables associated with postoperative UTI: age ≥ 85 (OR = 1.37, 95%CI = 1.08 - 1.73), ASA class ≥ 3 (OR = 1.59, 95%CI = 1.21 – 2.08,), chronic steroid use (OR = 1.451, 95%CI = 1.05 - 1.89), blood transfusion (OR = 1.24, 95%CI = 1.05 - 1.48), and >2 days delay from admission to operation (OR = 1.37, 95%CI = 1.05 - 1.79). Postoperative UTI was significantly associated with sepsis (OR = 7.65, 95%CI = 5.72 – 10.21), postoperative length of stay >2 days (OR = 1.83, 95%CI = 1.07 – 3.13), and readmission (OR = 3, 95%CI = 2.54 – 3.55). ConclusionsIn our study, postoperative UTI was found in 3% of geriatric hip fracture patients. Predictors of postoperative UTI were age ≥ 85, ASA class ≥ 3, chronic steroid use, blood transfusion, and time to operation > 2 days from admission. Results showed that postoperative UTI is independently associated with sepsis, postoperative length of stay beyond 2 days, and hospital readmission. To diminish the risk of UTI and its consequences, we recommend operating geriatric hip fractures in 24–48 hours after admission.

Vaginal Hysterectomy Performed Under General Versus Neuraxial Regional Anesthesia: Comparison of Patient Characteristics and 30-Day Outcomes Using Propensity Score–Matched Cohorts

Compared with surgery under general anesthesia (GA), surgery under neuraxial regional anesthesia (RA) has been associated with economic and clinical benefits in certain populations. Our aim was to compare preoperative and postoperative characteristics and 30-day outcomes, including intraoperative complications, for patients undergoing benign vaginal hysterectomy under GA versus RA.This is a retrospective cohort study of patients who underwent vaginal hysterectomy for benign indications between 2015 and 2019 using the American College of Surgeons National Surgical Quality Improvement Program database. Patients were identified using Current Procedural Terminology codes and stratified into GA and RA groups. Propensity score matching was performed to account for selection bias between anesthesia groups.Of 18,030 vaginal hysterectomies performed during this study period, 17,472 (96.9%) were performed under GA and 558 (3.1%) under RA. The RA group was older, more likely to be White, and more likely to have a history of chronic obstructive pulmonary disease and chronic steroid use (P < 0.01 for all); they were less likely to be discharged the same day (8.6% vs 12.2%, P = 0.01). In the matched cohort, there were similar proportions of major, minor, and composite complications between RA and GA groups (major: odds ratio [OR], 0.95; 95% confidence interval [CI], 0.51-1.78; minor: OR, 1.18; 95% CI, 0.74-1.88; composite: OR, 1.10; 95% CI, 0.75-1.64). Similar proportions of same-day discharge were observed (OR, 0.72; 95% CI, 0.47-1.10).Although RA comprises only 3% of the anesthetic modalities used for benign vaginal hysterectomies, it is associated with a similar incidence of postoperative complications compared with general anesthesia.

Long-term outcomes and risk factors for failure of glaucoma filtering surgery in eyes with vernal keratoconjunctivitis and steroid-induced glaucoma.

Purpose:To report outcomes and assess the risk factors for failure of trabeculectomy (trab), trabeculectomy with mitomycin-C (trabMMC), and combined trabeculectomy with cataract extraction (CT) in vernal keratoconjunctivitis (VKC) eyes with steroid-induced glaucoma (SIG).Methods:Trab was performed in 45 eyes of 30 subjects, trabMMC in 36 eyes of 25 subjects, and CT in 34 eyes of 27 subjects. Success was complete when intraocular pressure (IOP) was between 6 and 21 mm Hg without anti-glaucoma medications (AGM) and qualified with AGM.Results:Median age (14 vs. 16.3 and 17.4 years) was significantly less in the trab cohort (P = 0.007). Majority (88%–93%) were male (P = 0.78). Preoperatively, median duration of steroid usage was >2 years (P = 0.52), mean IOP (32, 29.4, and 28.4; P = 0.26) and median cup:disc ratio (CDR) (0.9; P = 0.27) were similar in the three groups. Complete success (76%, 71%, and 66% at 5 years; P = 0.91), and qualified success (88%, 97%, and 94% at 5 years; P = 1.0) with trab, trabMMC, and CT, respectively, were similar. Preoperative factors significantly associated with qualified failure (multiple logistic regression) were older children, longer duration of VKC, longer duration and mixed type of steroid use (all P < 0.001) and larger CDR (P < 0.02). At the last follow-up, 38% in trab, 33% in trabMMC, and 50% eyes in CT were blind (visual acuity ≤20/400 and/or visual field ≤10°) due to glaucoma (P = 0.33).Conclusion:The surgical success for all three types of surgery was similar at 5-years. Chronic VKC and long-term steroid use were associated with surgical failure. The majority had advanced disease and a significant proportion were blind due to glaucoma.

Abstract P3-11-02: Evaluation of the effects of anticancer treatments in cancer patients undergoing SARS-COV2 vaccination (VAX-on study: Breast cancer subgroup analysis)

Abstract Background: Since the beginning of the covid19 pandemic, clinical and demographic data showed that cancer patients are at high risk of developing severe consequences of Sars-Cov2 disease. For this reason, vaccination is strongly recommended, especially for patients on active treatment. Nevertheless, the efficacy of the Sars-Cov2 vaccine in cancer patients is not fully investigated. Our trial aim to explore the seroconversion in a large series of vaccinated cancer patients undergoing active treatment. Here we present a subgroup analysis concerning patients affected by breast cancer. Methods: The “VAX-on” is a single-center study that enrolled 366 cancer patients who underwent oncological treatment within the last six months. The study was approved by the ethics committee and all patients had to sign specific informed consent to be enrolled. Subjects were vaccinated against Sars-Cov2 with mRNA vaccine BNT162b2 (Comirnaty) - Pfizer BioNTech. Blood samples were obtained to quantify the production of specific anti-Spike IgG antibodies at day 21 from the first dose and at 6-8 weeks after the second dose. The antibody laboratory title cut-off of 50 U.A./mL defined the seroconversion. Results are shown as Mean and Standard Deviation for continuous variable, percentage (%) for categorical ones. The Mann-Whitney test or Chi-Square test were used to compare continuous or categorical groups, respectively. Results: A total of 100 patients with breast cancer were enrolled. Clinical and demographic data are summarized in Table 1. The median age was 60.5 years and the majority had an ECOG PS of 0 (75%). Almost all were women (97%), with advanced cancer in 60% of cases. In early or advanced setting 46% patients were treated with chemotherapy while 54% were on target therapy (also including monoclonal antibody and CDK4/6 inhibitors). The mean antibody title after the first dose of mRNA Comirnaty vaccine was 2185.03±9303.26 U.A./mL (M±SD), while after the second dose the mean antibody title rise to 6492.10±10425.95 (M±SD). After the first dose 61% of patients were considered as immunized, meanwhile after the second dose 86% of patients resulted immunized (defined as an antibody title &amp;gt;50 U.A./mL). In the 9 patients in treatment with steroids (prednisone &amp;gt; 10mg/die or equivalent), there was a trend to a decreased antibody development compared to patients without chronic use of steroids (p 0.06 and 0.05 after the first and second dose, respectively). Of interest, patients using G-CSF (12%) had a significant reduction in the production of Sars-Cov2 antibody after vaccination compared to patients who did not use them (p 0.02 and &amp;lt;0.001 after the first and second dose, respectively), with only 75% resulted positively immunized after the second dose (p=0.04). No differences were seen when comparing patients in advanced with non-advanced stage. Conclusions: Our study demonstrated 86% seroconversion in cancer patients after the second dose of mRNA vaccine regardless of disease stage or type of cancer treatment received. Further evaluations are needed to define whether the use of corticosteroids and G-CSF have an impact on seroconversion. Table 1.Parameters *Gender (F) (%)97 (97.00)Age (yrs)60.55±11.94Advanced Stage (Yes) (%)60 (60.00)ECOGPS (%)075 (75.00)121 (21.00)24 (4.00)Setting (%)Other Therapy60 (60.00)Adjuvant &amp; Neoadjuvant40 (40.00)Therapy (%)Other46 (46.00)Target54 (54.00)Last cycle &amp;lt;28 days (Yes) (%)81 (81.00)Timing CHT 1st Dose17.75±28.66Timing CHT 2nd Dose15.80±28.44Steroids (&amp;gt;10 mg)/&amp;gt; 7 days9 (9.00)FANS last 7 days (Yes) (%)15 (15.00)G-CSF last 21 days (Yes) (%)12 (12.00)Previous Allergies (Yes) (%)19 (19.00)Antibody Title 1st Dose2185.03±9303.26Antibody Level 1st Dose (&amp;gt;50) (%)61 (62.89)Antibody Title 2nd Dose6492.10±10425.95Antibody Level 2nd Dose (&amp;gt;50) (%)86 (92.47) Citation Format: Agnese Fabbri, Eleonora Marrucci, Fabrizio Nelli, Marco Mazzotta, Angelo Onorato, Primi Francesca, Mario Giovanni Chilelli, Antonella Virtuoso, Carlo Signorelli, Julio R Giron Berrios, Marta Schirripa, Rossella Donghia, Enzo Maria Ruggeri. Evaluation of the effects of anticancer treatments in cancer patients undergoing SARS-COV2 vaccination (VAX-on study: Breast cancer subgroup analysis) [abstract]. In: Proceedings of the 2021 San Antonio Breast Cancer Symposium; 2021 Dec 7-10; San Antonio, TX. Philadelphia (PA): AACR; Cancer Res 2022;82(4 Suppl):Abstract nr P3-11-02.

A multicenter phase Ib/II study of liposomal-irinotecan, 5-fluorouracil (5-FU), and leucovorin (LV) with nivolumab as second-line therapy for patients with advanced biliary tract cancer (BilT-03).

438 Background: Patients (pts) with advanced biliary tract cancers (BTC) have poor prognosis despite systemic chemotherapy and treatment beyond first-line platinum doublet remains largely investigational. The immunomodulatory properties of conventional cytotoxic therapy, particularly in regard to the upregulation of PD-L1 expression rendering tumor cells less sensitive to T cell-mediated lysis, rapid emergence of chemotherapy resistance, and known modest efficacy of single agent anti-PD-1 antibody in BTC provide a rationale for combination chemoimmunotherapy. We conducted a multi-center, phase Ib/II, single-arm study to investigate the role of liposomal-irinotecan, 5FU and LV in combination with nivolumab as second-line therapy in pts with advanced BTC. Methods: Key eligibility criteria include histologically confirmed unresectable or metastatic BTC after progression or intolerance of first-line systemic therapy, measurable disease per RECISTv1.1, ECOG PS 0-1, and absence of autoimmune disease or chronic steroid use. The limited phase Ib portion evaluated 10 pts to determine the recommended phase 2 dose (RP2D) based on the probability of dose-limiting toxicity (DLT) rate &lt;30% during days 1-29. Study treatment included 5FU 2400 mg/m2 over 46 hrs, LV 400 mg/m2, liposomal-irinotecan 70 mg/m2 at dose level 0 along with nivolumab 240 mg every 2 wks for up to 2 yrs in absence of disease progression or unacceptable toxicity. The primary endpoint was median progression-free survival (PFS) rate with an alternative and null hypothesis of 5.0 mo and 2.9 mo (two-sided alpha 0.05, power 80%), respectively. Secondary endpoints included best overall response rate (ORR) per immune related (ir)RECIST, median overall survival (OS), 75th percentile estimates of PFS and OS, and safety. Exploratory objectives include biomarker analysis using include targeted panel exome/transcriptome and immune cell subsets in tissue. Results: 30 eligible pts (60% men, 83% Caucasian) including 10 pts in phase Ib and 20 pts in phase II with a median age of 63.5 yrs (range 36-75) were enrolled across 4 US sites between June 2019 and July 2021. In phase Ib, one pt experienced DLT (grade 3 enterocolitis); RP2D was confirmed at dose level 0. All 30 pts were included in study reported outcomes with a median follow-up time of 10.7 mo. Median PFS was 4.2 mo (95% CI, 1.9-10.2) and failed to reject the null hypothesis. Median OS was 7.5 mo (95% CI, 5.8-21.4). The 75th percentile estimates for PFS and OS are 10.2 mo (95% CI, 5.4-NE) and 21.4 mo (95% CI, 7.8-21.4). ORR estimates and toxicity data are pending and will be presented at the meeting. Conclusions: The observed median PFS is insufficient to reject the null hypothesis. The 75th percentile estimates for PFS and OS are suggestive of prolonged benefit with chemoimmunotherapy in a small fraction of patients with BTC. Clinical trial information: NCT03785873.

Inpatient versus outpatient shoulder arthroplasty outcomes: A propensity score matched risk-adjusted analysis demonstrates the safety of outpatient shoulder arthroplasty

ObjectivesBeginning January 1, 2021 total shoulder arthroplasty (TSA) was removed from the Medicare (U.S national healthcare for patients ≥ 65years of age) inpatient-only list. Furthermore, there is limited data comparing outpatient and inpatient TSA among recent contemporary large population databases. This study aimed to analyze shoulder arthroplasty outcomes between inpatient and outpatient procedures at the national level. MethodsThe American College of Surgeons National Surgical Quality Improvement Program (ACS-NSQIP) database was utilized (2015–2019). Cases with a current procedural terminology of 23472 indicative of primary TSA and reverse total shoulder arthroplasty were included (N = 22,452). Outcomes were then analyzed in two approaches: unmatched analysis and propensity score matched risk-adjusted analysis. ResultsOverall, 9.7% (N = 2,185) of cases were performed outpatient and 90.3% (N = 20,357) of cases were performed inpatient. The rate of outpatient procedures has been steadily increasing (2015: 8.3%, 2016: 14.7%, 2017: 15.8%, 2018: 26.5%, 2019: 34.6%; P < 0.001). Outpatients were more likely to be male (50.7% vs. 43.7%) and younger (age < 65; 37.0% vs. 27.9%) and less likely to be ASA class 3 or 4 (49.5% vs. 58.3%). Outpatients had fewer comorbidities including obesity (46.1% vs. 51.9%), hypertension (60.5% vs. 67.4%), diabetes (15.1 vs. 18.2%), chronic obstructive pulmonary disease (4.8% vs. 7.0%), bleeding disorders (1.3% vs. 2.5%), or chronic steroid use (3.5% vs. 5.0%; all P < 0.001). In a non-risk matched analysis of outcomes, outpatient procedures displayed lower rates of any adverse event (3.5% vs. 5.3%; P < 0.001), minor adverse events (1.5% vs. 3.0%; P = 0.001), and readmission (2.2% vs. 2.8%; P = 0.025). Following a propensity score matched analysis, two risk matched cohorts of outpatient (N = 2,172) and inpatient (N = 2,172) procedures were identified. Subsequent analysis of outcomes revealed no significant differences in outcome metrics between risk-matched outpatient and inpatient procedures. ConclusionsFrom 2015 to 2019, there has been a four-fold increase in the proportion of outpatient shoulder arthroplasty cases in the ACS-NSQIP database. This study shows that outpatient shoulder arthroplasty may be safely performed in a select cohort of patients without increased risk of adverse events. After adjusting for comorbidities, there were no differences in clinical outcomes or rates of adverse outcomes between inpatient and outpatient shoulder arthroplasty. Level of evidenceRetrospective Observational Study, Level IV.

Tubercular Meningitis Presenting as Section Multiple Cranial Nerve Palsy

Tubercular Meningitis (TBM) is caused due to the seeding of meninges with mycobacterium tuberculosis and about one-third of the world’s population is infected with it. The risk of contracting the infectionincreases in immunocompromised states which includes diabetes mellitus, chronic use of steroids, chronic alcoholism and Human Immunodeficiency Virus (HIV) co-infection. Here, a case of 47-year-old female has been presented, who reported to the Department of Medicine with complaints of weakness overthe leftside of the face associated with diminished hearing and tinnitus in the left ear and subjective vertigo since 20 days. Initially, all the above involvement was attributed to bell’s palsy but no improvement was seen with its treatment. Incidentally, she was found to be HIV positive and lumbar puncture was done and eventually, she was diagnosed as a case of TBM. The patient was successfully treated with antitubercular medications and supportive measures and she responded well. She was discharged with antitubercular medications with regular follow-up in view of starting antiretroviral therapy after 6 weeks.

COVID19 associated mucormycosis: A review.

Mucormycosis, a rare fungal disease has emerged as a new epidemic in India, during the CoronaVirus Disease 2019 (COVID-19) pandemic. Mucormycosis is caused by the mucormycetes group of molds. Immunocompromised states such as diabetes, chronic steroid use, and patients receiving immunosuppressant drugs are the risk factors for mucormycosis. The second wave of the COVID-19 pandemic has also invited the notorious mucormycosis in the current scenario. India has announced mucormycosis as a notifiable disease in May 2021, as the number of COVID-19-associated mucormycosis cases has increased swiftly. There are different opinions and evidence for the emergence of mucormycosis or the so-called ‘black fungus’. It is proposed that the use of steroids, monoclonal antibodies, and prolonged hospitalization in the treatment of COVID-19 has substantially decreased the immunity in COVID-19-affected patients and maybe the reason for the emergence of fungal infections. The other hypothesis is that improper disinfection procedures such as using non-sterile water for humidification of oxygen can be the reason. Or, the COVID-19 infection itself produces an immunocompromised and diabetic-like state is again a question. This review mainly focuses on the discussion and identification of the most common risk factor for mucormycosis, investigations, and management of mucormycosis.

Antimicrobial use and other risk factors for infections with antimicrobial-resistant bacteria and fungi bacteria and fungi in an intensive care unit

Introduction: Resistant infections are especially problematic in the intensive care unit (ICU), but risk factors remain unclear. We hypothesized that the risk factors for resistant Gram-negative rods (rGNR), resistant Gram-positive cocci (rGPC), and secondary fungal infections differed.Materials and Methods: A single-center cohort study of patients with ICU-acquired infections from 1997 to 2017 was performed. Inclusion was conditioned on the presence of rGNR, rGPC, or fungi. Risk factors studied included demographics, medical comorbidities, Acute Physiology and Chronic Health Evaluation (APACHE) II score, and previous antimicrobial exposure.Results: Four thousand three hundred and nineteen ICU-acquired infections were identified. One thousand nine hundred and ninety-eight were considered resistant and 2321 were considered nonresistant. Identification of any resistant organism was significantly associated with female sex, nontrauma diagnosis, APACHE II score, liver disease, chronic steroid use, history of any prior infection, and history of a resistant infection, but not days of prior antimicrobial use. Infections with rGNR were associated with days of therapeutic antimicrobials given for a previous infection, but not total prior antimicrobial days during hospitalization. rGPC infections were associated with both previous infections treated with antimicrobials and total prior antimicrobial days during hospitalization. Fungal infections were not associated with any measure of prior antimicrobial exposure. Controlling for the severity of illness and demographics, resistant infections were not associated with mortality compared to nonresistant infections.Conclusions: The likelihood of rGNR infection is closely linked to recent antimicrobial exposure, while rGPC infection appears to be associated with prior antimicrobial exposure. Fungal infections may not be associated with prior antimicrobial exposure. These findings suggest disparate mechanisms of dysbiosis for different classes of resistant pathogens.

The Case of a Scaly Hand: Burrowing into a Diagnosis.

A 60-year-old female patient, housewife, belonging to the upper-middle class, hailing from Kerala, India, presented with complaints of itching and scaling, solely involving the left hand for 3 months. She gave a history of aggravation of symptoms after exposure to detergents. There was no contact with other irritants/allergens prior to the onset of the lesions. There were no similar complaints in other family members. She gave a history of applying a topical preparation composed of salicylic acid 3% and clobetasol propionate 0.05% on and off for 1 month with no improvement in lesions. On examination, the patient had scaling, desquamation, and accentuation of skin markings predominantly involving the left palm extending to involve the dorsum of the fingers. The patient also had underlying erythema and mild edema of the affected hand [Figure 1a and b]. Minimal scaling was noted over the right hand.Figure 1: (a) Scaling, desquamation, accentuation of skin markings over the left palm with erythema and mild edema. (b) Scaling, desquamation over the dorsum of fingers of the left hand with mild edemaThe lesions were nontender. No nail changes were seen. Soles were normal. No other lesions were present on the body. With a provisional diagnosis of Tinea manuum and hand eczema, 10% potassium hydroxide mount was done to arrive at a final diagnosis. The image we found through the lens caught us by surprise. We expected to find fungal hyphae, but surprisingly we found an eight-legged arthropod, the Sarcoptes scabiei mite with scybala! [Figure 2].Figure 2: 10% potassium hydroxide mount showing mite of Sarcoptes scabiei and scybalaThe patient was treated with permethrin 5% cream and antihistamines. The patient was reviewed back after 2 weeks with complete improvement in her symptoms and lesions [Figure 3].Figure 3: After treatment, the scaling and desquamation over the left hand has resolvedScabies, a parasitic infestation of the skin is caused by the mite Sarcoptes scabiei.[1] Burrows are the primary lesions in scabies. Secondary lesions include papules, vesicles, pustules, and excoriations.[2] The typical distribution of lesions includes web spaces of fingers, the wrists, axillae, groins, buttocks, genitals, and the breasts in women.[3] Scabies can also manifest with atypical morphological forms such as bullae, crusting, ecchymoses, urticaria, and eczema. Scabies surrepticius is a term that has been proposed to describe the atypical morphological presentations of this infestation.[4] Wilson et al.[5] reported an atypical appearance of scabies in the form of papulosquamous lesions among inmates of a nursing home. Usually, in chronic infestation and use of long-term topical steroids, eczematous lesions may be the presenting picture as was in our case.[6] We would also like to emphasize the predominantly unilateral involvement of the left hand in this patient. Such atypical presentations often confound the diagnosis of scabies and hence this case emphasizes the importance of potassium hydroxide mount, a very simple but essential tool to confirm the diagnosis in doubtful cases. Declaration of patient consent The authors certify that they have obtained all appropriate patient consent forms. In the form, the patient(s) has/have given his/her/their consent for his/her/their images and other clinical information to be reported in the journal. The patients understand that their names and initials will not be published and due efforts will be made to conceal their identity, but anonymity cannot be guaranteed. Financial support and sponsorship Nil. Conflicts of interest There are no conflicts of interest.

ASSOCIATION OF LATTICE DEGENERATION IN PATIENTS WITH CHRONIC SEROUS CHORIO-RETINOPATHY

Objective: To establish the association of lattice degeneration in patients with chronic serous chorio-retinopathy at tertiary care ophthalmology hospital.&#x0D; Study Design: Comparative cross-sectional study.&#x0D; Place and Duration of Study: Armed Forces Institute of Ophthalmology, Rawalpindi, from Sep 2019 to Dec 2020.&#x0D; Methodology: The sample population comprised of 80 subjects which included 40 cases of chronic serous chorio-retinopathy and 40 controls. Chronic serous chorio-retinopathy was diagnosed by consultant ophthalmologist on basis of fluorescein angiography and spectral-domain optical coherence tomography. Peripheral retinal examination was done among all the study participants to look for lattice degeneration. Pearson chi-square test was applied to look for the relationship of various factors with lattice degeneration including the presence of chronic serous chorio-retinopathy.&#x0D; Results: Two groups with equal number of subjects were included in the study. Mean age of the study participants was 49.14 ± 2.93 years. 60 (75.0%) participants were male while 20 (25%) were female. Fifty four (67.5%) had no lattice degeneration while 26 (32.5%) showed the presence of lattice degeneration on detailed ophthalmic examination. Chi-square test showed that having chronic serous chorio-retinopathy and use of steroids were statistically significantly associated with presence of lattice degeneration among the study participants.&#x0D; Conclusion: Chronic serous chorio-retinopathy emerged as a condition strongly associated with lattice degeneration of peripheral retina. Use of topical or systemic steroids also increased the chances of developing lattice degeneration in our study population.

Who will be readmitted? Evaluation of the laparoscopic hysterectomy readmission score in a gynecologic oncology population undergoing robotic-assisted hysterectomy

ObjectivesThe laparoscopic hysterectomy readmission score (LHRS) was created to identify patients for whom same day discharge (SDD) after minimally invasive hysterectomy (MIH) may not be advisable and includes diabetes, chronic obstructive pulmonary disease, disseminated cancer, chronic steroid use, bleeding disorder, length of surgery, and any postoperative complication prior to discharge. We evaluated the performance of the score at predicting readmission in a gynecologic oncology population, and additionally sought to determine if any factors known prior to surgery could replace those that are not known until the time of surgery (operative time and postoperative complication). MethodsThis was a single-institution retrospective cohort study of women undergoing robotic hysterectomy by a gynecologic oncologist in 2018. Associations between pre-operative, operative and post-operative factors and 30-day readmission, SDD and postoperative complications were assessed using logistic regression. ResultsThe 30-day readmission rate among the 423 women in the cohort was 4.5% and 1.9% in those undergoing SDD. Readmission rates by LHRS were: score 1 (4.9%), score 2 (7.8%), score 3 (13.6%), score 4 (16.7%). Patients with a LHRS of ≥3 had higher odds of readmission compared to those with a lower score (OR 4.20, p = 0.02). Infectious morbidity accounted for the majority of postoperative complications, emergency room visits and readmissions. We did not identify preoperative factors to replace the intra- and post-operative factors used in the score. ConclusionsThe readmission rate following MIH is low, and a LHRS of ≥3 is associated with increased risk of readmission. Our findings support the applicability of the LHRS to a gynecologic oncology population; addressing risk factors for postoperative infection or closer follow up for patients with a LHRS ≥3 could reduce postoperative readmissions.

Osteoporosis Complications in Crohn's Disease Patients: Factors, Pathogenesis, and Treatment Outlines.

The causes of osteoporosis in Crohn’s disease (CD) are multifactorial; cytokines, steroids, and vitamin deficiency all have an essential role. It is imperative to distinguish the factors that contribute to bone resorption, potentially increasing the risk of low bone mineral density (BMD), osteoporosis, and fracture. However, the pathogenicity of osteoporosis associated with CD remains unclear. Although osteoporosis treatment may vary between bisphosphonate and corticosteroid, infliximab's efficacy, when combined with immune modulators, suppresses both CD symptoms and osteoporosis progression. In this review, we aim to understand the present pathogenicity of osteoporosis, including the factors pro-inflammatory cytokines, chronic steroid use, and malnutrition, developing osteoporosis in a different pathological way, and to assist the treatment lines implying a positive outcome of osteoporosis in CD patients.Osteoporosis is considered to be one of the early complications of CD where early detection can prevent osteoporosis progression. This can be done by utilizing dual-energy X-ray-absorptiometry (DEXA) to evaluate the Z-score and treat the existing factors that have a role in the progression of osteoporosis in CD patients.

Comparison of Functional Outcome Between Intra-Articular Injection of Corticosteroid Versus Platelet-Rich Plasma in Frozen Shoulder: A Randomized Controlled Trial.

BackgroundIn this study, we compared the functional outcome of intra-articular injection of corticosteroid versus platelet-rich plasma (PRP) in patients with frozen shoulder (FS).MethodologyThis randomized controlled trial was conducted in the Department of Orthopedics, Mayo Hospital, Lahore, from January 2018 to December 2018.A total of 202 patients with FS aged 40 to 70 years were included. Patients with medical comorbidities such as chronic liver disease (assessed on history and serum bilirubin >2.0 mg/dl), chronic renal failure (assessed on history and serum creatinine >1.5 mg/dL), and chronic steroid use were excluded. Employing an anterior approach, subjects in groups A and B received one intra-articular injection of 2 mL PRP and 2 mL (80 mg) methylprednisolone acetate, respectively. Age, gender, duration of disease, and pre-injection and post-injection range of motion (ROM) (flexion, extension, abduction, external rotation, and internal rotation) were assessed. The University of California at Los Angeles Shoulder Score (UCLA) and visual analog scale (VAS) scores were measured and compared before and after the injection. All patients were followed at regular intervals post-therapy and the final functional outcome was measured after 12 weeks of therapy.ResultsData were analyzed using SPSS version 20 (IBM Corp., Armonk, NY, USA). A p-value of 0.05 was considered significant when comparing flexion, abduction, external rotation, and internal rotation in both groups using the independent t-test. The ROM in group A (intra-articular PRP) improved significantly (p < 0.05) after injection compared to group B (intra-articular corticosteroid). The ROM after PRP for abduction was 147.09 ± 7.78, forward flexion 154.52 ± 6.48, external rotation 71.59 ± 7.43, and internal rotation 59.20 ± 3.96. The ROM in the steroid injection group for abduction was 129.07 ± 4.72, forward flexion 127.14 ± 7.87, external rotation 56.27 ± 5.93, and internal rotation 48.86 ± 4.90.ConclusionsIntra-articular injection of PRP resulted in a substantial improvement in the VAS score, UCLA, and ROM when compared to intra-articular corticosteroid injection in patients with FS.

Immunogenicity and Safety of COVID-19 Vaccine BNT162b2 for Patients with Solid Cancer: A Large Cohort Prospective Study from a Single Institution.

We assessed the immunogenicity and safety of the BNT162b2 vaccine in a large cohort of patients with cancer (CP). From March 1, 2021 to March 20, 2021, this prospective cohort study included 816 CP afferent to our institution and eligible for the vaccination. A cohort of 274 health care workers (HCW) was used as age- and sex-matched control group. BNT162b2 was administered as a two-dose regimen given 21 days apart. Blood samples to analyze anti-Spike (S) IgG antibodies (Ab) were collected prevaccination [timepoint (TP) 0], and at 3 weeks (TP1) and 7 weeks (TP2) after the first dose. Patients characteristics: median age 62 (range, 21-97); breast/lung cancer/others (31/21/48%); active treatment/follow-up (90/10%). In the whole CP cohort, the serologic response rate (RR) and the titre of anti-S IgG significantly increased across the TPs; at TP2, the responders (IgG >15 AU/mL) were 94.2%. Active chemotherapy and chronic use of steroids were independent predictors of lower RR. Adverse events (AE) after the booster predicted higher likelihood of response (OR, 4.04; 95% confidence interval, 1.63-9.99; P = 0.003). Comparing the matched cohorts, the responders were significantly lower in CP than in HCW at TP1 (61.2% vs. 93.2%) and TP2 (93.3% vs. 100%), while the geometric mean concentration of IgG did not significantly differ at TP2 being significantly lower in CP (23.3) than in HCW (52.1) at TP1. BNT162b2 was well tolerated in CP; severe-grade AEs were 3.5% and 1.3% after the first and second doses, respectively. BNT162b2 assures serologic immunization without clinically significant toxicity in CP. The second dose is needed to reach a satisfactory humoral response.

75. Utility of Fungal Blood Cultures in Portland, Oregon

BackgroundFungal blood cultures (fungal isolators) should be used, if at all, primarily for identification of mold infections. At our institution we noted patients having fungal blood cultures drawn in many other situations, including when the primary team was concerned for candida bloodstream infection. We sought to describe the utility of this practice and of fungal blood cultures in general.MethodsWe retrospectively reviewed the results of fungal blood cultures for 2 years, from 3/1/2019-3/1/2021. We evaluated the number of episodes, culture results, whether there was a had prior bloodstream infection, and risk factors for fungal infection including renal replacement (RRT), ECMO, and immunosuppression (IS). Immunosuppression was defined as chronic systemic steroid use, recent receipt of high dose steroids within 2 weeks, history of organ transplantation, history of stem cell transplantation, hematologic malignancies, or receipt of a biologic agent.Results187 fungal blood cultures were drawn in 143 patients - 80 cultures in 70 patients from 3/2019-3/2020 and 107 cultures in 73 patients from 3/2020-3/2021. Only 3 patients had positive fungal blood cultures:1 (Candida krusei) from 3/2019-3/2020 and 2 (Candida albicans and Cyrptococcus neoformans) from 3/2020-3/2021; in all 3 cases the organism also grew from standard blood culture isolators. From 3/2019-3/2020, 1/80 cultures were drawn from an individual on ECMO while 15/80 were drawn from individuals on RRT, and 32/80 were in a IS individuals. From 3/2020-3/2021, 45/107 cultures were drawn from an individual on ECMO, 24/107 were drawn in an individual on RRT, and 73/107 were drawn in a IS individuals. The majority of individuals in whom a fungal blood culture was drawn during 3/2020-3/2021 were individuals with COVID-19. Upon chart review most of the cultures were drawn due to concern for candidemia. Results of fungal blood cultures drawn from 3/2019-3/2021 at OHSUConclusionFungal blood cultures have an extremely low yield at our institution, with a 1.6% positivity rate over a 2 year period, and all of those cultures were detected by standard blood culture isolators. Most of these cultures were drawn in situations where this test has no utility. Furthermore, the test has limited utility to detect dimorphic and mold bloodstream infections. Restriction of this test may limit inappropriate use.Disclosures All Authors: No reported disclosures

P065 A One-Time Education for Gastroenterologists Regarding Osteoporosis Screening for IBD Patients Improves Provider Knowledge But Not Screening Rates.

Inflammatory Bowel Disease (IBD) is a chronic gastrointestinal inflammatory condition and has been increasing in prevalence in the United States, with a 30-40% increase over the past few decades. Osteoporosis can be seen in up to 40% of IBD patients. Screening for osteoporosis in IBD patients involves the use of DEXA scans and is recommended by the IBD Cornerstone Committee for select patients, including steroid use > 3 months consecutively or a total of 1 year in the past 2 years, family history of osteoporosis, malnutrition, amenorrheic or post-menopausal. Our quality improvement study looked to improve osteoporosis screening among gastroenterologists. We conducted a retrospective chart review on all IBD patients within the St. Luke's Network and extrapolated data on age (>50 in male and >65 in female), sex, chronic glucocorticoid use (3 month consecutively or cumulative), osteoporosis/osteopenia diagnosis, vitamin D (vit-D) levels, and DEXA scan between 2019 to 2021. We gave a 5-minute presentation on current DEXA screen recommendations for patients with IBD on 5/27/2021 to all the network's gastroenterologists, which totaled 12. We performed a pre and post education survey consisting of 5 questions on provider knowledge and comfortability with osteoporosis screening. We assessed provider knowledge, as well as rates of osteoporosis screening. All statistical analyses were conducted in IBM SPSS for Windows Version 26. Chi Square tests were used to compare two groups in categorical variables while Mann-Whitney tests were done to compare continuous variables like age and vit-D levels. There were a total of 5442 patients; 3927 patients before the educational intervention on 5/27/2021 and 1515 patients after the intervention. Both pre and post intervention groups were balanced in terms of age, gender, smoking status, and alcohol risk. Percent of DEXA scans were similar between both groups (13.0% vs 12.3%, p=0.5). DEXA screening rates among patients with chronic steroid use pre-intervention vs post-intervention was 44.45 vs 42.4% respectively. Vit-D levels compared between both groups was not statistically significant (30.5 vs 31.8, p=0.1). Surveys conducted before and after the intervention showed an overall increase in percentage of agreement responses about knowledge and confidence in DEXA screening (88.5% vs 97.5%). DEXA scanning can help detect premature decrease in bone mineral density and provide physicians with the opportunity to prevent further morbidity. Our study showed no difference in DEXA screening rates before and after intervention. However, there was an increase in provider knowledge based on post-intervention surveys. A similar study showed that it took three interventions, including educational presentation, flyers, and on screen EMR reminders for there to be a sustainable improvement in the rate of DEXA screening. Our project may have required additional interventions to produce an effect and thus reinforces the need for further efforts to improve osteoporosis screening in IBD patients.

Premaxillary and maxillary sinus mucormycosis post COVID: a rare case report

&lt;p&gt;Mucormycosis, previously termed as zygomycosis, is an opportunistic infection and is caused by fungi belonging to the order Mucorales. It is found in patients with predisposing conditions such as diabetic ketoacidosis, chronic kidney disease malignancy long-term steroid use and immunosuppressant drugs. Mucormycosis involving paranasal sinuses is a rare life-threatening opportunistic infection in a covid positive patient. The unprescribed use of corticosteroid in covid positive patient, the lymphopenia in severe covid 19 cases, preexisting diseases like uncontrolled diabetes mellitus, hematological malignancy, stem cell transplant causing weak immune system are the factors which are responsible for mucor infection in covid positive patients. We herein report the case of maxillary and premaxillary mucormycosis infection in the uncontrolled diabetic patient with post covid status in recovering phase of acute respiratory distress syndrome.&lt;/p&gt;

MRNA intramuscular vaccination produces a robust IgG antibody response in advanced neuromuscular disease

SARS-CoV-2 vaccines protect against symptomatic and severe COVID-19. The BNT162b2/Pfizer and mRNA-1273/Moderna vaccines represent new vaccine technology relying on administration of mRNA encoding SARS-CoV-2 viral spike protein encased in lipid nanoparticles. The vaccines are administered as two doses into muscle, which elicits a strong response, typically within 14 days after the second dose. Neuromuscular diseases are characterized by the progressive loss of muscle and are often treated with chronic glucocorticoid steroids, both of which may contribute to a blunted immune response to vaccination. Here, we measured IgG antibody content and neutralizing antibody response after mRNA COVID-19 vaccination in non-ambulatory neuromuscular disease patients. After two doses of mRNA COVID-19 vaccine, median anti-receptor binding domain IgG and percent surrogate viral neutralization in non-ambulatory neuromuscular disease samples were significantly elevated similar to healthy vaccinated controls. As in healthy controls, COVID-19 vaccines produce greater antibody levels compared to those with a history of outpatient COVID-19 infection. This data documents that non-ambulatory neuromuscular disease patients respond well to two doses of mRNA COVID-19 vaccine despite low muscle mass and even chronic steroid use.