Complaints Of Fatigue Research Articles

IgG4-related Retroperitoneal Fibrosis: An Emerging Masquerader With a Sinister Presentation

ObjectiveRetroperitoneal fibrosis (RPF) is a rare proliferative fibro-inflammatory disease involving the soft tissues of the retroperitoneum. IgG4 related retroperitoneal fibrosis is an emerging entity which needs to be distinguished from idiopathic RPF. We describe a clinical case of IgG4 related RPF highlighting the importance of clinching this diagnosis. MethodsA 70 year old female was referred to the outpatient department of our institute with complaints of fatigue, bilateral flank pain and loss of appetite for the past 1 month. The CT and PET scan demonstrated a uniformly enhancing bulky retroperitoneal mass causing bilateral hydroureteronephrosis. The biopsy from the mass lesion revealed IgG4 related disease. The patient was started on corticosteroids after percutaneous nephrostomy placement. ResultsThree months post induction of therapy, repeat PET-CT shows resolution of the mass with no FDG avid lesion. Serum IgG4 levels were reduced to normal (27 mg/dL) suggestive of response to treatment. The percutaneous nephrostomies were removed and the patient is doing well on maintenance dose of corticosteroids for her disease. ConclusionThe availability of serum IgG4 levels for monitoring treatment response and follow-up can curtail the repeated radiological imaging and associated contrast exposure as compared to idiopathic RPF. Secondly, the diagnosis of IgG4-related RPF shall alert the clinician to look out for extra-retroperitoneal diseases on follow up of this multi-organ disease.

Pregnancy complications, sick leave and service needs of women who experience perinatal distress, weak social support and dissatisfaction in their partner relationships.

Although perinatal distress is acknowledged as a burdening condition for pregnant women, its effects on pregnancy are not well known. This study was conducted to increase knowledge regarding the effects of distress on pregnancy-related problems. The study also assessed women's need for sick leave and increased prenatal care due to distress, and the effects of weak social support and dissatisfaction with their partner relationships. In total, 2523 women were screened for perinatal distress three times during pregnancy in this quantitative cohort study. Structured psychiatric interviews were conducted following the screening, with 562 of the participants. Data from participants' pregnancy records were also analysed. The study was conducted in primary healthcare centres in Iceland after receiving approval from the Icelandic National Bioethical Committee. The main outcome measures were pregnancy problems, sick leave issued and prenatal service needs. Data from 503 women were analysed. The perinatal distress group (PDG) was significantly more likely than was the nondistressed group (NDG) to experience fatigue, vomiting and pelvic pain after controlling for background variables. Distressed women who reported weak family support experienced symptoms of nausea and heartburn. The PDG needed more frequent prenatal care than did the NDG and was issued sick leave for up to 42days longer. Dissatisfaction in the partner relationship and with the division of household tasks and childcare was strongly associated with distress, the development of complications and the need for sick leave. Identification of perinatal distress by midwives and other healthcare professionals is important, since distress may be linked to women's complaints of fatigue, vomiting, pelvic pain and need for prolonged sick leave, and additional prenatal care services will be needed. Perceived dissatisfaction in the partner relationship and with the division of household tasks should also form part of clinical practice and assistance provided.

Application of RULA analysis on work posture improvement to reduce workers’ fatigue and musculoskeletal complaints and to accelerate processing time of wok molding

The aim of the research was to analyze the work posture of the workers using the RULA method. The research was conducted experimentally by applying the treatment by subject design using 12 samples which were given two treatments; wok molding workers with the former molding facility (P0), and wok molding workers with the new molding facility with the ergonomic intervention (PI). Conclusion of this research is the RULA analysis result on the work posture of placing the end work on the temporary place (P0) gave a score of 7. This score shows a high-risk level and needs work posture improvement immediately. The work on PI showed the RULA score of 3, which means that there is a decrease from a high risk at a low-risk level. The average time needed to mold a wok on P0 was 1.46 minutes/unit, and on PI was 1.23 minutes/unit or down 18.7%. Therefore it recommended for wok molding worker to use ergonomic work posture (PI).

Seronegative atypical anti-glomerular basement membrane crescentic glomerulonephritis

A 46-year-old female presented with a chief complaint of fatigue and intermittent painless gross hematuria for one month. The patient was fluid overloaded on physical examination and noted to be in acute renal failure with a serum creatinine of 10.8 mg/dL. The patient was emergently started on hemodialysis. Serologies were negative for antinuclear antibody (ANA), anti-neutrophilic cytoplasmic antibody (ANCA), and anti-glomerular basement membrane (anti-GBM) antibody. However, renal biopsy revealed 90% glomerular involvement by temporally heterogeneous crescents ranging from cellular to fibrous. Immunofluorescence studies revealed strong, linear glomerular capillary wall staining for immunoglobulin G (IgG). Although the patient was treated with pulse dose steroids and cyclophosphamide, the patient ultimately developed infectious complications from immunosuppression, and treatment was terminated. This case highlights the atypical presentation of anti-GBM disease diagnosed based on renal biopsy with negative serologies. Although rare, the possibility of atypical anti-GBM antibodies which are not detected by standard commercial assays should be considered in such cases.

Describiendo el síndrome pospolio

IntroductionPatients presenting sequelae of poliomyelitis may present new symptoms, known as post-polio syndrome (PPS). ObjectiveTo identify the clinical and functional profile and epidemiological characteristics of patients presenting PPS. Patients and methodsWe performed a retrospective study of 400 patients with poliomyelitis attended at the Institut Guttmann outpatient clinic, of whom 310 were diagnosed with PPS. We describe patients’ epidemiological, clinical, and electromyographic variables and analyse the relationships between age of poliomyelitis onset and severity of the disease, and between sex, age of PPS onset, and the frequency of symptoms. ResultsPPS was more frequent in women (57.7%). The mean age at symptom onset was 52.4 years, and was earlier in women. Age at primary infection >2 years was not related to greater poliomyelitis severity.The frequency of symptoms was: pain in 85% of patients, loss of strength in 40%, fatigue in 65.5%, tiredness in 57.8%, cold intolerance in 20.2%, dysphagia in 11.7%, cognitive complaints in 9%, and depressive symptoms in 31.5%. Fatigue, tiredness, depression, and cognitive complaints were significantly more frequent in women.Fifty-nine percent of patients presented electromyographic findings suggestive of PPS. ConclusionsWhile the symptoms observed in our sample are similar to those reported in the literature, the frequencies observed are not. We believe that patients’ clinical profile may be very diverse, giving more weight to such objective parameters as worsening of symptoms or appearance of weakness; analysis of biomarkers may bring us closer to an accurate diagnosis.

Is Fibromyalgia Syndrome a Neuropathic Pain Syndrome?

This study aims to investigate whether fibromyalgia syndrome (FMS) represents a neuropathic pain syndrome through the use of neuropathic pain scales. The study included 99 female patients (mean age 44.21 years; range, 18 to 65 years) who referred to Physical Therapy and Rehabilitation Department Outpatient Clinics with complaints of widespread pain and who received a clinical diagnosis of fibromyalgia based on the 1990 American College of Rheumatology diagnostic criteria and a control group consisting of 86 female patients (mean age 49.21 years; range, 18 to 65 years) who were diagnosed with acute subacromial impingement as a nociceptive pain model. All patients completed the Turkish version of the Fibromyalgia Impact Questionnaire (FIQ), the Beck Depression Scale (BDS), the 10 cm Visual Analog Scale for pain assessment, the Leeds Assessment of Neuropathic Symptoms and Signs (LANSS) pain questionnaire for neuropathic pain assessment and the painDETECT scale. An evaluation of the patients' symptoms indicated that complaints of numbness, burning, tingling, morning stiffness, insomnia, fatigue and weakness were significantly more common in the fibromyalgia group compared to the controls. Moreover, the mean scores of the BDS, FIQ, painDETECT and LANSS pain scale were significantly higher in the fibromyalgia group compared to the controls. Statistically significant correlations were noted between FIQ values and LANSS, and the BDS and painDETECT results in the fibromyalgia group. The present study demonstrates that sensorial symptoms such as paraesthesia, hyperalgesia and allodynia were more common and the scores of neuropathic pain scales such as painDETECT and LANSS were significantly elevated in the fibromyalgia patients compared to the control group, and these findings suggest that FMS may have a neuropathic pain component.

Adverse Events Associated with Nonsurgical Treatments for Urinary Incontinence in Women: a Systematic Review.

Urinary incontinence (UI) is a common malady in women. Numerous nonsurgical treatments are available, each associated with risk of adverse events (AEs). We systematically reviewed nonsurgical interventions for urgency, stress, or mixed UI in women, focusing on AEs. We searched MEDLINE®, Cochrane Central Trials Registry, Cochrane Database of Systematic Reviews, and Embase® through December 4, 2017. We included comparative studies and single-group studies with at least 50 women. Abstracts were screened independently in duplicate. One researcher extracted study characteristics and results with verification by another independent researcher. When at least four studies of a given intervention reported the same AE, we conducted random effects model meta-analyses of proportions. We also assessed the strength of evidence. There is low strength of evidence that AEs are rare with behavioral therapies and neuromodulation, and that periurethral bulking agents may result in erosion and increase the risk of voiding dysfunction. High strength of evidence finds that anticholinergics and alpha agonists are associated with high rates of dry mouth and constitutional effects such as fatigue and gastrointestinal complaints. Onabotulinum toxin A (BTX) is also associated with increased risk of urinary tract infections (UTIs) and voiding dysfunction (moderate strength of evidence). Behavioral therapies and neuromodulation have low risk of AEs. Anticholinergics and alpha agonists have high rates of dry mouth and constitutional effects. BTX is associated with UTIs and voiding dysfunction. Periurethral bulking agents are associated with erosion and voiding dysfunction. These AEs should be considered when selecting appropriate UI treatment options. AE reporting is inconsistent and AE rates across studies tended to vary widely. Trials should report AEs more consistently.

Markers of Pulmonary Oxygen Toxicity in Hyperbaric Oxygen Therapy Using Exhaled Breath Analysis.

IntroductionAlthough hyperbaric oxygen therapy (HBOT) has beneficial effects, some patients experience fatigue and pulmonary complaints after several sessions. The current limits of hyperbaric oxygen exposure to prevent pulmonary oxygen toxicity (POT) are based on pulmonary function tests (PFT), but the limitations of PFT are recognized worldwide. However, no newer modalities to detect POT have been established. Exhaled breath analysis in divers have shown volatile organic compounds (VOCs) of inflammation and methyl alkanes. This study hypothesized that similar VOCs might be detected after HBOT.MethodsTen healthy volunteers of the Royal Netherlands Navy underwent six HBOT sessions (95 min at 253 kPa, including three 5-min “air breaks”), i.e., on five consecutive days followed by another session after 2 days of rest. At 30 min before the dive, and at 30 min, 2 and 4 h post-dive, exhaled breath was collected and followed by PFT. Exhaled breath samples were analyzed using gas chromatography-mass spectrometry (GC-MS). After univariate tests and correlation of retention times, ion fragments could be identified using a reference database. Using these fragments VOCs could be reconstructed, which were clustered using principal component analysis. These clusters were tested longitudinally with ANOVA.ResultsAfter GC-MS analysis, eleven relevant VOCs were identified which could be clustered into two principal components (PC). PC1 consisted of VOCs associated with inflammation and showed no significant change over time. The intensities of PC2, consisting of methyl alkanes, showed a significant decrease (p = 0.001) after the first HBOT session to 50.8%, remained decreased during the subsequent days (mean 82%), and decreased even further after 2 days of rest to 58% (compared to baseline). PFT remained virtually unchanged.DiscussionAlthough similar VOCs were found when compared to diving, the decrease of methyl alkanes (PC2) is in contrast to the increase seen in divers. It is unknown why emission of methyl alkanes (which could originate from the phosphatidylcholine membrane in the alveoli) are reduced after HBOT. This suggests that HBOT might not be as damaging to the pulmonary tract as previously assumed. Future research on POT should focus on the identified VOCs (inflammation and methyl alkanes).

MON-352 Feminizing Adrenal Adenoma in an Adult Man Presenting with Gynecomastia and Hypogonadism

Introduction: Feminizing adrenal tumors (FAT) are a rare cause of gynecomastia and hypogonadism in men. Most FATs are malignant and secrete other adrenal hormones and precursors. Rarely, benign adenomas solely secreting estrogens have been described. We present a patient with an estrogen-secreting adrenal adenoma with benign histology without secretion of other hormones or precursors. Case: A 43-year-old man presented with complaints of fatigue and erectile dysfunction for 24 months and painful bilateral breast growth for 12 months. Mammography revealed bilateral gynecomastia, and he was initially treated with tadalafil for erectile dysfunction. Due to persistent symptoms, labs were obtained revealing a low total testosterone level of 56 ng/dL (250-827 ng/dL). Further labs were obtained after an endocrinology evaluation: total testosterone 28 ng/dL, estradiol 44 pg/mL (≤29 pg/mL), estrone 192 pg/mL (≤68 pg/mL), estriol <0.10 ng/mL, FSH 0.8 mIU/mL (1.6-8.0 mIU/mL), and LH 3.1 mIU/mL (1.5-9.3 mIU/mL). Serum prolactin, β-hCG, AFP, ACTH, TSH and IGF-1 were all within normal ranges. Testicular ultrasound showed a left-sided varicocele. Adrenal protocol CT showed a 2.8 cm left adrenal nodule with characteristics of an adenoma (round, homogenous, pre-contrast Hounsfield units: 10, absolute washout: 68%). DHEAS, androstenedione, 11-deoxycortisol, 17-hydroxprogesterone, renin and aldosterone were all within normal ranges. 24-hour urine for cortisol, metanephrines and 17-ketosteroids were normal. He underwent laparoscopic left adrenalectomy. Pathology revealed a 2.5 cm well-circumscribed adrenal adenoma. Features favoring a benign histology included <1 mitotic figure/50 HPF, no atypical mitotic figures, no necrosis, and no capsular invasion. Repeat hormonal workup after surgery showed total testosterone 223 ng/dL, free testosterone 58 pg/mL (35-155 pg/mL), estradiol 16 pg/mL, estrone 39 pg/mL, and FSH 3.3 mIU/mL. On follow-up, the patient reported improvement in fatigue, decreased breast tenderness, and a slight decrease in breast size. Discussion: FATs most commonly present with painful gynecomastia and hypogonadism in males. Cosecretion of other adrenal hormones or precursors is suggestive of malignancy. Most FATs are malignant, and benign adenomas solely secreting estrogen are extraordinarily rare. Unfortunately, a benign appearance on histology may not predict a benign course. A case was previously reported with a young male child with FAT and initial benign histology, who later developed malignant metastases several years after the initial surgery. This demonstrates the importance of post-operative surveillance with imaging and serial hormonal evaluations.

SUN-LB065 A Rare Case of Adrenal Corticomedullary Adenoma: Coexistence of Cushing's Syndrome and Elevated Catecholamines in a Patient With an Incidental Adrenal Mass

Background:Most primary neoplasms of the adrenal gland arise from either adrenal cortical cells or the chromaffin cells of the adrenal medulla. Here we describe a case in which a patient was found to have an incidental adrenal mass with both cortical and medullary components on histology. Clinical Case:A 51-year-old female with DM2 and HTN, presented with an incidental left (L) adrenal mass. She had a 30-pound weight gain over 6 months with complaints of fatigue and easy bruising. CT of her adrenals demonstrated a 3.1 cm L adrenal mass with pre-contrast HU of 31 and washout >50%, suggesting a lipid poor adenoma with a normal contralateral adrenal gland. Her blood pressure was 165/88 mm Hg and BMI was 34. Dorsocervical fat pad enlargement and supraclavicular fullness were noted. A 1 mg dexamethasone suppression test (DST) was abnormal with a dexamethasone (DEX) level- 209 ng/dL (180-550) and cortisol- 8.2 mcg/dL. A late-night salivary test was normal with a cortisol- 0.05 mcg/dl (0.04-0.56). Basal am ACTH and cortisol levels were 24 pg/mL (6-50) and 20.5 mcg/dL (4-22) respectively. Plasma metanephrine- 114 pg/mL (<57), normetanephrine- 300 pg/mL (<148), and total metanephrine- 414 pg/mL (<205) were elevated. DHEA-S, plasma renin and aldosterone were all within normal range. These results suggested that both pheochromocytoma (Pheo) and Cushing’s syndrome (CS) were present. The differential diagnosis included ACTH- secreting Pheo, pituitary CS coexisting with a Pheo, or corticomedullary adenoma. After L adrenalectomy, histological examination showed positive immunohistochemical staining with chromogranin and intermingled adrenocortical components within the same mass, consistent with a corticomedullary adenoma. ACTH immunostaining was positive in a small subpopulation of cells. Post-operatively, the metanephrine levels normalized. The 1 mg DST improved but remained abnormal (DEX level- 245 ng/dL, cortisol- 3.4 mcg/dl). The basal 8 am ACTH and cortisol were 28 pg/mL and 12.7 mcg/dL respectively. She did not require hydrocortisone replacement. Her HTN improved and insulin was discontinued. There were no mutations found in a hereditary Pheo panel (Invitae- 14 genes). Conclusion:Corticomedullary adenomas associated with hypersecretion of cortisol and catecholamines have rarely been reported. All 5 of the previously reported cases have been unilateral with a predilection for females in the third to sixth decades of life1. In this case, the histologic diagnosis and clinical improvement after adrenalectomy supports a diagnosis of corticomedullary adenoma as the source of hypersecretion of both cortisol and catecholamines. This case demonstrates the importance of screening for CS and Pheo in all patients when evaluating an incidental adrenal mass. Reference:1.Lau, S., Annals of Diagnostic Pathology, 15:185, 2011 Unless otherwise noted, all abstracts presented at ENDO are embargoed until the date and time of presentation. For oral presentations, the abstracts are embargoed until the session begins. s presented at a news conference are embargoed until the date and time of the news conference. The Endocrine Society reserves the right to lift the embargo on specific abstracts that are selected for promotion prior to or during ENDO.

SUN-571 Thymic Hyperplasia: An Unusual Manifestation of Graves’ Disease

Background: The association of Graves’ Disease with thymic hyperplasia is often underrecognized, even though it was first described more than 100 years ago. We hereby present a case of a hyperthyroidism and thymic hyperplasia where surgery could have been avoided. Clinical Case: A 43-year-old female presented with complaints of palpitations, increased sweating, tremors and fatigue for 6 months. Labs showed undetectable TSH with elevated free T4 of 2.3 ng/dl (reference range 0.82-1.77 ng/dl) and free T3 7.7 pg/ml (reference range 2 - 4.4 pg/ml). TSI antibodies were elevated at 617 (Normal <150 %). Due to a previous history of lung nodules, the patient underwent a surveillance CT scan of the chest concurrently. This CT chest showed an anterior mediastinal mass measuring 5 cm×3 cm. The mass was highly suspicious for being thymic in origin. This mass was not noticed on the CT chest done a year ago. PET scan revealed hypermetabolic activity in the thymic and thyroid regions. It was recommended to the patient that this mass likely was thymic hyperplasia in the setting of Graves’ Disease which was amenable to conservative management. However, the patient chose to undergo trans-sternal thymectomy instead of active surveillance. Pathology showed true thymic hyperplasia and no evidence of malignancy. Conclusion: This case illustrates the benign nature of thymic enlargement in Graves’ Disease. The presence of thyrotropin receptors on the thymic epithelial cells which participate in the autoimmune response, leading to hyperplasia in Graves’ disease has been implicated in the pathogenesis of thymic enlargement (1). Pathologically, two distinct features are seen in the thymus in Graves’ disease: lymphoid hyperplasia and true thymic hyperplasia (2). In both these conditions, the thymus gland appears diffusely enlarged. The treatment of thymic enlargement in this condition is the treatment of Graves’ disease, thereby avoiding the need for surgical interventions.

SUN-591 Severe Iron-Deficiency Anemia Leading to Hypothyroidism

Background Patients with thyroid disease have a high prevalence of iron-deficiency, but this is often times overlooked in the medical community. Treating a patient’s iron levels may be all that is needed to reverse his or her thyroid condition. Iodine is one of the main components of thyroid hormones; however, iodine requires iron in order for it to be fully utilized. Iron is an element that is essential for the human body to synthesize and metabolize the thyroid hormones. The body is dependent upon iron to convert thyroxine (T4) into the active hormone triiodothyronine (T3) via thyroid peroxidase (TPO). As such, low iron levels can impede thyroid function and patients can present with hypothyroid-like symptoms. Clinical Case A 50-year old female with no significant past medical history presented to our facility with chief complaints of fatigue and dizziness. She was referred by her PCP to our ED for anemia after her labs drawn the day prior were remarkable for a hemoglobin of 4.5 g/dL (n=12-16 g/dL). In the ED, her workup was remarkable for a hemoglobin of 4.9 g/dL and a TSH of 870.44 mIU/L and 719.84 mIU/L on re-check (n=0.36-3.74 mIU/L). Therefore, she was admitted for iron-deficiency anemia (IDA) and hypothyroidism. Her free T4 was undetectable at <0.40 ng/dL (n=0.76-1.46 ng/dL), her free T3 was low at 1.0 pg/mL (n=2.3-4.2 pg/mL), her total T4 was undetectable at <3.0 ug/dL (n=4.8-11.7 ug/dL), and total T3 was low at 0.27 pg/mL (n=0.60-1.81 pg/mL). Patient was given 2 units pRBC and her hemoglobin improved to 8.7 g/dL. She had an iron panel drawn which showed decreased iron at 13 ug/dL (n=39-150 ug/dL), elevated TIBC at 680 ug/dL (n=241-421 ug/dL), elevated transferrin at 450 mg/dL (n=200-360 mg/dL), decreased transferrin saturation at 2% (n=15-50%), and decreased ferritin at 2 ng/mL (n=8-252 ng/mL). Patient was given a one-time dose of IV iron sucrose 200 mg as well as two injections of levothyroxine (100 mcg and 50 mcg, respectively) in the hospital. Pt was also given IV hydrocortisone 100 mg every 8 hours for 2 days. Patient was discharged from the hospital in a stable fashion on PO levothyroxine 125 mcg daily and PO hydrocortisone 20 mg in AM and 10 mg in PM. She was also started on ferrous sulfate 142 mg daily extended-release tablets. Patient followed-up with an endocrinologist as an outpatient, and she was encouraged to continue taking PO levothyroxine 125 mcg daily. Her last TSH was 0.28 mIU/L (n=0.36-3.74 mIU/L) and she now reports feeling well. Conclusion The etiology for patient’s hypothyroidism was due to iron-deficiency anemia. Upon further questioning, patient stated she was diagnosed with IDA at age 17 secondary to heavy menstrual periods; however, she did not take iron supplements. Patient reported her last menstrual period to be in May 2018. In conclusion, it is always imperative to consider iron-deficiency as an etiology for hypothyroidism.

SUN-168 HAART-Induced Hyperglycemic Hyperosmolar Syndrome: A Rare Manifestation of HAART Therapy

Methods: Analysis of case report Objective: Increase awareness of Hyperglycemic complications secondary to HAART therapy) : 59-year-Old Hispanic Male with past medical History of pre-diabetes and recently diagnosed with HIV presented to the Emergency Department with the complaint of fatigue for 3 days associated with nausea for same duration. He denied any other complaints. Patient's blood glucose was 1900 mg/dl, serum bicarbonate level: 22, Blood pH: 7.38, serum acetone negative, and urine ketones negative. Serum osmolarity was 340 mmol/kg and HBA1c was 19%. Based on above laboratory Values, Diagnosis of Hyperglycemic Hyperosmolar Syndrome (HHS), was made and patient was admitted to Medical ICU started with Intravenous (IV) fluids and IV insulin Infusion. After normalization of blood sugar, patient transferred to the medical floor and provided with diabetic teaching and started on subcutaneous Insulin Injection. On review of past medical history, patient was diagnosed with HIV 6 weeks ago and was started with HAART therapy containing a Protease inhibitor (ritonavir) as one of drug in the combination therapy. Blood work 8 weeks ago showed HAB1C 6.2% and blood glucose 115 mg/dl showing temporal relation of the start of HAART therapy and sudden change in blood glucose and increased HBA1c. Infectious disease team was consulted and patient's HIV regimen was switched and Protease inhibitor ( Ritonavir) was stopped, Patient was discharged with a new HAART therapy and also subcutaneous Insulin. We followed the patient closely in outpatient management and over the course of 3 months, HBA1C and blood sugar came back to baseline and subcutaneous insulin was stopped. Conclusion 1. Protease inhibitors are commonly associated with Metabolic Syndrome. This is first case to our best of knowledge in which protease inhibitors has been linked to pure Hyperglycemic Hyperosmolar Syndrome. 2. Patients starting with HAART therapy should be further investigated for possible hyperglycemia secondary to protease Inhibitors. Abbreviation: HHS: Hyperglycemic Hyperosmolar Syndrome HAART: Highly Active Anti-Retroviral Therapy MICU: Medical Intensive Care Unit IVF: Intravenous Fluids

Life-threatening Anemia Diagnosis Due to Myoma Uteri in the Emergency Department: A Case Report

Introduction: Uterine myoma is a benign tumor of the uterus and clinically apparent in up to 25% of reproductive-age women. Emerged silent uterine bleedings are commonly seen with myoma. Although therapies via surgical and radiological way are frequently used for the management of the tumor, medical therapies are considered as initial treatment. When the anemia diagnosis cannot be made and cannot properly treated; it is not only reduces the patient's life quality, but also threatens the patient's life. Case Report: In this case report; we aim to present a rare case of the lowest hemoglobin level in the literature by a value of 1.2 g/dL hemoglobin due to anemia resulted myoma uteri patient admitted to the emergency department by walk. All c ase with severe anemia at a level lower than 4 g/dL is rarely seen in the hospital emergency. Sometimes there are complaints of dysphagia, fragile nails, relative impotence, fatigue and cramps in the calves on climbing stairs, which are disproportionate to their anemia. Conclusion: In contrast to all recent reports, our case had the lowest hemoglobin levels reported ever, without a noisy clinical table indicating anemia.

Occupational fatigue and mental health complaints among 8-hour shift workers of petrochemical industries in Iran.

Shift working is unavoidable in many industries with continual material processing such as petrochemical plants. So, the adverse effects of shift working on workers should be seriously considered. This cross-sectional study evaluated occupational fatigue and mental health complaints and their relationship in rotating 8-hour shift workers. In this study, 287 shift workers participated. The Multidimensional Fatigue Inventory (MFI-20) and General Health Questionnaire (GHQ-28) were used to evaluate the level of fatigue and mental health, respectively. A relatively high prevalence of mental health complaints (particularly social dysfunction) and fatigue (especially general fatigue) were found among the study population. In general, 43.4% of participants reported a mental health problem. A moderate correlation was found between fatigue and mental health (r = 0.58). The stepwise regression model revealed that fatigue was significantly related only to "anxiety and insomnia" and "severe depression". This study revealed that the 8 h shift workers in studied areas are exposed to a considerable risk of mental health and fatigue. So, improving the ergonomics and health aspects of the workplace is recommended to reduce related risk factors.

PROMs following breast-conserving therapy for breast cancer: results from a prospective longitudinal monocentric study

Treatment of breast cancer includes many options and shared decision making is becoming standard practice. Within the context of treatment individualization, the omission of radiotherapy (RT) can be considered. It is thereby of great importance to correctly foresee the side effects attributed to RT. Data from longitudinal studies with contemporary techniques however are sparse. The purpose of the present study was to evaluate patient-reported outcome measures (PROMs) and long-term aesthetic outcome (AO) related to RT in the breast-conserving therapy (BCT) setting for breast cancer over time. Patients treated with BCT between April 2015 and April 2016 were prospectively included in the cohort. Evaluations were made at six time points: at baseline (before RT), during and at the end of RT, between 3 and 6months, 1year and 2years after RT. AO was scored by the patient and by the BCCT.core software. Further PROMs were measured with the European Organisation for Research and Treatment of Cancer (EORTC) Quality of Life Questionnaire QLQ-C30/-BR23 and the Body Image after Breast Cancer Questionnaire BIBCQ. Patients were evaluated over 2years. First, we assessed the evolution in time. Second, we tested the differences in mean scale scores of the PROMs between patients with a favourable and an unfavourable AO. One hundred seventy-five patients were included in the analysis. At baseline, unsatisfactory levels were already present for several scales. Most unsatisfactory PROMs improved up to 1year after RT. Complaints of fatigue increased at the start but decreased up to a lower level than that at baseline up to 1year after RT (mean difference (MD) 7.6, - 12.3, respectively). Cognitive functioning showed a small decrease at the start with no further significant decrease (MD - 4.73, - 0.21, respectively). Breast symptoms significantly increased during RT but decreased afterwards up to 2years after RT to lower values than those at baseline and were then considered satisfactory (MD 15.6, - 19.7, - 4.1, respectively). AO scored as PROM associated with BCCT.core and with the body image measures. The study suggests that quality of life and body image are temporarily impaired due to RT. Around one third of patients score their long-term AO as unfavourable. These results should be discussed with the patient and could help in the decision making of the treatment plan and in the clarification of the patient's expectations.

Is dietary supplement use longitudinally associated with fatigue in stage I-III colorectal cancer survivors?

Supplement use among colorectal cancer (CRC) survivors is common, yet evidence supporting its beneficial health effects is mostly lacking and cancer-specific lifestyle guidelines advise against the use of supplements. We aimed to describe the use of supplements by CRC survivors from diagnosis to 2 years post-treatment and investigate how overall supplement use is longitudinally associated with fatigue. In a prospective cohort study of stage I-III CRC survivors (n=325), information on supplement use was collected during repeated home visits at diagnosis and at 6 weeks, 6, 12, and 24 months post-treatment. Fatigue was assessed using the Checklist Individual Strength (score range 20-140) at all post-treatment time points. Linear mixed-models were applied to analyze longitudinal associations of overall supplement use with fatigue, adjusted for sex, age, comorbidities, chemotherapy, and physical activity. At all time points, about 40% of participants used supplements. Multivitamins/multiminerals were the most frequently used supplements at all time points. Of participants with at least two available measurements, 28% were consistent users, 45% consistent nonusers, and 27% inconsistent users (i.e.reported both use and nonuse). Reported fatigue levels declined significantly after treatment. Overall, no statistically significant differences in fatigue score over time were observed between supplement users and nonusers. Likewise, no intra-individual associations of supplement use and fatigue were found. However, in inter-individual analyses, supplement users reported to experience more fatigue compared to nonusers (β 7.0, 95% CI 0.3; 13.7). No overall association between supplement use and fatigue was found. Results of the current study do therefore not imply that supplement use alleviates complaints of fatigue among CRC survivors. However, increased levels of fatigue may be a reason for supplement use among CRC survivors.

REDESAIN ALAT KERJA BERBASIS ANTROPOMETRI ORANG BALI DAN REMODELING SIKAP KERJA MENURUNKAN POSTURAL STRES PRAMUGRAHA HOTEL PURI SARON SEMINYAK-KUTA BALI

Working with a trolley that is incompatible with anthropometry has risks in increasing postural stress, which manifests as fatigue and musculoskeletal complaints. This study aims to determine the room attendant fatigue and musculoskeletal complaints level when using a trolley; to find out the work posture score on activities using a trolley; to find out a trolley design which is compatible with Balinese anthropometry; to find out work posture score on the activity of using the trolley. This research was conducted experimentally using the same subject design (treatment by subject design). The number of samples was 14 employees. Two treatments were applied to the subjects, namely Period I or PI (the samples were working with the trolley) and Period II or PII (sample or room attendant Hotels working trolley according to Balinese anthropometry). Fatigue is measured using a questionnaire of 30 items of rating scale, musculoskeletal complaints using the Nordic body map. Measurement data were analyzed using descriptive and inferential analysis. Comparative analysis of the variables of fatigue, and muscle complaints using the Wilcoxon Test with a significance level of 5% (α = 0.05). The results showed that the mean fatigue and muscle complaints before and after work were significantly different where the value of p ​​​&lt;0.05. Total RULA analysis score before treatment 6, after treatment 3. Work tool design is based on total ergonomic approach through TTG and SHIP approach.&#x0D; Keywords: Trolley, Anthropometry, Postural Stress, RULA Analysis

Brain white matter damage and its association with neuronal synchrony during sleep.

The restorative function of sleep partly relies on its ability to deeply synchronize cerebral networks to create large slow oscillations observable with EEG. However, whether a brain can properly synchronize and produce a restorative sleep when it undergoes massive and widespread white matter damage is unknown. Here, we answer this question by testing 23 patients with various levels of white matter damage secondary to moderate to severe traumatic brain injuries (ages 18-56; 17 males, six females, 11-39 months post-injury) and compared them to 27 healthy subjects of similar age and sex. We used MRI and diffusion tensor imaging metrics (e.g. fractional anisotropy as well as mean, axial and radial diffusivities) to characterize voxel-wise white matter damage. We measured the following slow wave characteristics for all slow waves detected in N2 and N3 sleep stages: peak-to-peak amplitude, negative-to-positive slope, negative and positive phase durations, oscillation frequency, and slow wave density. Correlation analyses were performed in traumatic brain injury and control participants separately, with age as a covariate. Contrary to our hypotheses, we found that greater white matter damage mainly over the frontal and temporal brain regions was strongly correlated with a pattern of higher neuronal synchrony characterized by slow waves of larger amplitudes and steeper negative-to-positive slopes during non-rapid eye movement sleep. The same pattern of associations with white matter damage was also observed with markers of high homeostatic sleep pressure. More specifically, higher white matter damage was associated with higher slow-wave activity power, as well as with more severe complaints of cognitive fatigue. These associations between white matter damage and sleep were found only in our traumatic brain injured participants, with no such correlation in controls. Our results suggest that, contrary to previous observations in healthy controls, white matter damage does not prevent the expected high cerebral synchrony during sleep. Moreover, our observations challenge the current line of hypotheses that white matter microstructure deterioration reduces cerebral synchrony during sleep. Our results showed that the relationship between white matter and the brain's ability to synchronize during sleep is neither linear nor simple.

Subacute Combined Degeneration, Pernicious Anemia and Gastric Neuroendocrine Tumor Occured Simultaneously Caused by Autoimmune Gastritis.

Subacute combined degeneration (SCD) is a relatively rare myelopathy mainly caused by vitamin B12 (VitB12) deficiency. There are many causes contributing to VitB12 deficiency. Autoimmune gastritis might lead to severe VitB12 malabsorption and in its advanced stage pernicious anemia (PA) may occur. Besides, long-term hypergastrinemia arising from achlorhydria in autoimmune gastritis is associated with neuroendocrine tumors (NETs). Patients diagnosed with SCD coexistent with PA and NET are seldomly reported. We describe a 34-year-old woman with an initial complaint of progressive fatigue, weakness and numbness in her limbs and disturbed gait. Physical examination revealed appearance of anemia, ataxia, decrease of superficial and deep sense, and positive Babinski’s sign. Laboratory tests disclosed macrocytic anemia, elevated intrinsic factor antibody and spinal MRI showed extensive T2-weighted hyperintensity in the dorsal columns. A gastric polyp was revealed by gastroscopy and histology showed an NET in the background of severe atrophic gastritis. Symptoms of the patient were relieved by a multidisciplinary therapy. In patients with SCD, PA should be suspected and prompt further investigations to elucidate causes and direct treatment.