Complaints Of Fatigue Research Articles

Metabolic Acidosis and its Predisposing Factor: Euglycemic Ketoacidosis Caused by Empagliflozin and Low-Carbohydrate Ketogenic Diet in Type 2 Diabetes Mellitus. Case Report

Sodium-glucose co-transporter-2 inhibitors (SGLT2i) are medications used in type 2 diabetes mellitus (T2DM) that control high blood sugar levels and promote normoglycemia by preventing glucose reabsorption and facilitating glucosuria. Three SGLT2i (canagliflozin, dapagliflozin, and empagliflozin) are approved in the United States. Euglycemic ketoacidosis or ketoacidosis with a lower than expected hyperglycemia is a rare adverse event associated with SGLT2i. Low-carbohydrate ketogenic diet (LCKD) may lower the threshold for the development of SGLT2i-induced ketoacidosis in T2DM. We report a rare case of diabetic ketoacidosis in a type 2 diabetic patient with a blood glucose level of 159 mg/dl in the presence of empagliflozin and LCKD. He had recently started eating a LCKD. He presented with the nonspecific complaints of fatigue, headache, nausea, abdominal pain, and chest discomfort. He had run out of his anti-diabetic medications and started retaking them a week ago. Labs showed metabolic acidosis with ketonuria and glucosuria. His presentation was attributed to the reintroduction of empagliflozin in the presence of a LCKD. SGLT2i put patients at risk of euglycemic ketoacidosis in T2DM due to glucosuria, euglycemia, and suppressed insulin release. Lifestyle changes, such as LCKD, may lower the threshold further due to excessive lipolysis, beta-oxidation, and hepatic ketogenesis. Practitioners should educate patients about this adverse effect. Patients should consult with their physicians before incorporating a LCKD in their lifestyle if they are using SGLT2i.

Impact of Psycho-Social Factors on Non-Adherence: A Case Study of Chronic Kidney Disease (CKD)

Chronic Kidney Disease (CKD) is progressively increasing in South Asian countries like Pakistan. This case study is describing, the psychosocial factors of non-adherence (medication, fluid and dietary). The patient was 19 years un-married male, diagnosed with End Stage Renal Disease (ESRD) and was on Hemodialysis for 3 years i.e. 2013 on thrice a week basis. He was rickshaw driver and first born among 2 siblings; 1 sister and 1 brother. He was referred to psychological assessment for non-adherence (medication, dietary and fluid). He had developed Drug Induced i.e. NSAID (Non-Steroidal Anti-Inflammatory Drugs) ESRD at the age of 16 years. He had secondary Hypertension and was presented with the physical complaints of fatigue, shortening of breath due to low Hb level. Psychosocial assessment was done by taking detailed case history interview assessing illness perceptions, health locus of control, health beliefs, perceived health status, doctor-patient relationship, adherence (medication, dietary and fluid) and life orientation. Target areas identified as result of psychosocial assessment, included non-adherence (medication, fluid and dietary), dissatisfactory doctor patient relationship, poor health status, pessimistic life orientation, mal-adaptive health beliefs and low socio-economic status. 12 sessions have been conducted with the patients. He was psycho-educated relevant to his financial management plan due to distress of low socio-economic status. Insight in patient about the non-adherence (medication, dietary and fluid) was developed through CBT specific technique i.e. cost and benefits analysis. Counseling was given to him by maximizing the positive aspect of his life for his pessimistic life orientation. He was psycho-educated for his dissatisfactory doctor patient relationship. Coping statements was given to him to improve his self-efficacy relevant to his condition.

Women with low quality of life by cervantes-short form scale choose menopausal hormone therapy

ObjectivesThe aim of the study is to assess whether women who choose to use menopausal hormone therapy (MHT) have lower quality of life (QoL) than those who do not initiate it using Cervantes short form scale (C-SF), and analyze sociodemographic factors associated with lower QoL in women. Study designA cross-sectional descriptive observational study was made in four hundred and eighty women with climacteric symptoms. ResultsMean age was 51.1 years. Two hundred and sixty-one women (54.3 %) started MHT. The sample´s global mean in C-SF score was 51.3 ± 13.9. Women who choose to use MHT have higher score in C-SF (lower QoL) than women who reject it (58.7 ± 15.9 vs 46.7 ± 12.8; p < 0.001). We found higher score in women with early menopause (53.7 ± 15.9 vs 49.7 ± 13.1; p = 0.037); with no obesity (<30 vs >30 BMI) (52.8 ± 13.5 vs 41.0 ± 8.2; p = 0.002); with previous malignancies (56.2 ± 18.2 vs 50.2 ± 13.5; p = 0.020) and without sexual activity (58.0 ± 25.4 vs 50.4 ± 13.1; p = 0.009. No differences were found in C-SF score with respect to tobacco habits or physical activity. In the multivariate analysis, the variable independently associated to lower QoL by C-SF (high score) was to be a woman who want to initiate MHT (p = 0.004). ConclusionsWomen who choose to use MHT due to menopausal symptoms have lower quality of life measured by C-SF scale. Women with early menopause, with no obesity (<30 BMI), without sexual activity and with previous malignances have lower quality of life measured by C-SF scale. Women with early menopause have more psychic symptoms like nervousness, fatigue and sleep complaints by C-SF scale than women with natural menopause.

Differences in psychological factors, disability and fatigue according to the grade of chronification in non-specific low back pain patients: A cross-sectional study.

Differences in pain processing, muscle structure and function have been reported in patients with low back pain (LBP) with different grades of pain chronicity. The present study aims to examine differences in psychological factors, disability and subjective fatigue between subgroups of LBP based on their chronification grade. Twenty-one healthy controls (HC) and 54 LBP patients (categorized based on the grades of chronicity into recurrent LBP (RLBP), non-continuous chronic LBP (CLBP), or continuous (CLBP)) filled out a set of self-reporting questionnaires. The Hospital Anxiety and Depression Scale (HADS) and Multidimensional Pain Inventory (MPI) scores indicated that anxiety, pain severity, pain interference and affective distress were lower in HC and RLBP compared to non-continuous CLBP. Anxiety scores were higher in non-continuous CLBP compared to RLBP, continuous CLBP and HC. The Pain Catastrophizing Scale for Helplessness (PSCH) was higher in non-continuous CLBP compared to HC. The Survey of Pain Attitudes (SOPA) showed no differences in adaptive and maladaptive behaviors across the groups. The Pain Disability Index (PDI) measured a higher disability in both CLBP groups compared to HC. Moreover, the Rolland Morris Disability Questionnaire (RMDQ) showed higher levels of disability in continuous CLBP compared to non-continuous CLBP, RLBP and HC. The Checklist Individual Strength (CIS) revealed that patients with non-continuous CLBP were affected to a higher extent by severe fatigue compared to continuous CLBP, RLBP and HC (subjective fatigue, concentration and physical activity). For all tests, a significance level of 0.05 was used. RLBP patients are more disabled than HC, but have a tendency towards a general positive psychological state of mind. Non-continuous CLBP patients would most likely present a negative psychological mindset, become more disabled and have prolonged fatigue complaints. Finally, the continuous CLBP patients are characterized by more negative attitudes and believes on pain, enhanced disability and interference of pain in their daily lives.

THE FUNCTIONAL READINESS OF ATHLETES FROM CYCLIC SPORTS

Aim. The study aims at assessing the functional status of highly skilled athletes from track-and-field and ski sports and determining fatigue criteria. Materials and methods. Highly skilled track-and-field athletes (43) and skiers (16) underwent examination at the preparatory stage of a training cycle. The functional readiness of athletes was assessed using questionnaires, anthropometric, physiological and biochemical research methods. Results. According to the medical history and questionnaire data, all athletes were divided into two groups: the first group included subjects without any signs of fatigue, the second group comprised athletes with fatigue complaints. In athletes with fatigue complaints, increased heart rate was recorded both at rest and after the recovery period; physical efficiency reduced by 28 %, maximum oxygen consumption – by 17.7 %. Heart rate variability in these athletes demonstrates the increased activity of the sympathetic nervous system and increased stress index of the regulatory systems. Glutathione content and the activity of antioxidant enzymes (superoxide dismutase, glutathione peroxidase and glutathione reductase) were lower in the erythrocytes of the second group. Some alterations in physiological and biochemical data of the second group demonstrated the presence of physical fatigue. Conclusion. 37.3 % of athletes from cyclic sports experienced any fatigue. The data of antioxidant protection, physical efficiency, maximum oxygen consumption and heart rate variabi­lity can be used for a comprehensive assessment of functional readiness and physical fatigue in athletes.

THU0093 EARLY REMISSION IS ASSOCIATED WITH LOWER FATIGUE LEVELS ON THE LONG TERM IN PATIENTS WITH RECENT ONSET RHEUMATOID ARTHRITIS

Background:Fatigue is mentioned as a symptom with high impact in many patients with Rheumatoid Arthritis (RA) and this symptom remains difficult to be managed by both the patient and the physician.Objectives:To investigate if rapid suppression of disease activity in early RA could impact fatigue complaints in the long run.Methods:For this study, we included patients from the 2-year pragmatic investigator-initiated Care in Early Rheumatoid Arthritis (CareRA) trial. Most patients were treated intensively, with different combinations of csDMARDs and glucocorticoid remission induction schemes, except one group without classic markers of poor prognosis that was treated with MTX weekly in monotherapy. Patients were followed up at least every 3 months, with more mandatory visits in the first 6 months of treatment. Clinical parameters including DAS28 components were registered at every visit. Fatigue was measured by the multi-dimensional fatigue inventory (MFI), a self-reported instrument consisting of 20 questions with a Likert scale from 1-5 as answer. These 20 questions can be subdivided in five subscales (0-20) of four questions (higher scores indicating higher fatigue levels): general fatigue, mental fatigue, physical fatigue, reduced activity and reduced motivation. General fatigue means the general feeling of being tired. Mental fatigue implicates concentration and memory problems. Physical fatigue implicates a lack of energy and strength. Reduced activity means that patients can do less activities for example on one day. Reduced motivation means that patients don’t want to plan or do things due to no motivation. MFI was obtained at baseline, at week 16, week 52 and week 104. Only patients with a filled-out MFI at baseline and available DAS28CRP at week 16 were included in this study.Patients were divided in 2 groups based on their response, defined as achieving or not achieving DAS28CRP remission (&lt;2.6) at week 16. These patients were classified as early responders and controls respectively. The 2 groups were compared by Mann-Whitney-U test. A generalized estimating equation (GEE) compared the 2 groups over the course of the 2-year trial per each of the 5 domains of the MFI, adjusting for baseline DAS28CRP and baseline MFI domain score.Results:Of the 379 patients recruited in the CareRA trial, 343 (90.5%) had a MFI score available at baseline and a DAS28CRP available at week 16 with 236 (68.8%) patients achieving remission, and 107 (31.2%) patients not achieving remission at week 16. After 2 years of treatment, the proportion of patients in DAS28CRP remission was still higher in the early responders versus controls (82.3% versus 63.5%, p=0.001). Every MFI domain after 2 years of treatment showed lower scores for early responders including general fatigue (p=0.017), physical fatigue (p=0.011), reduced activity (p=0.040) and mental fatigue (p=0.042) except reduced motivation (p=0.062) (see figure 1). GEE analysis demonstrated that all MFI domains differed over 2 years between patients in remission or not at week 16, including general fatigue (p&lt;0.001), physical fatigue (p&lt;0.001), reduced activity (p&lt;0.001), mental fatigue (p=0.037) and also reduced motivation (p=0.005).Figure 1.MFI domain scores at baseline and at week 104 per groupConclusion:Patients reaching remission after 16 weeks of treatment achieve lower fatigue levels over 2 years compared to patients not reaching this early remission. This study underlines the importance of early disease control. Successful early intensive treatment improves in the long run not only clinical outcomes but also an important patient preferred outcome such as fatigue.Disclosure of Interests:Diederik De Cock: None declared, Amber Nooyens: None declared, Delphine Bertrand: None declared, Veerle Stouten: None declared, Sofia Pazmino: None declared, Johan Joly: None declared, Rene Westhovens Grant/research support from: Celltrion Inc, Galapagos, Gilead, Consultant of: Celltrion Inc, Galapagos, Gilead, Speakers bureau: Celltrion Inc, Galapagos, Gilead, Patrick Verschueren Grant/research support from: Pfizer unrestricted chair of early RA research, Speakers bureau: various companies

Successful surgical treatment of Cronkhite-Canada Syndrome with bilateral flail chest: a case report

BackgroundDevelopment of multiple rib fractures leading to bilateral flail chest in Cronkhite–Canada Syndrome (CCS) has not been reported.Case presentationA 59-year-old man presented with complaints of fatigue, chest pain, respiratory distress and orthopnea requiring ventilatory support to maintain oxygenation. CCS with bilateral anterior and posterior flail chest due to multiple rib fractures (2nd-10th on the right side and 2nd-11th on the left side). He underwent open reduction and anterior and posterior internal fixation using a titanium alloy fixator and a nickel-titanium memory alloy embracing fixator for chest wall reconstruction. He recovered gradually from the ventilator and showed improvement in his symptoms. He gained about 20 kg of weight in the follow up period (6 months after discharge from the hospital).ConclusionCCS is a rare, complex disease that increases the risk of developing multiple rib fractures, which can be successfully treated with open reduction and internal fixation.

SAT-273 Case of Mistaken Identity?

Introduction Pituitary adenomas occur in 10-15% of patients and the majority are benign. Prolactinomas are the most common form of secretory pituitary adenoma. Pituitary apoplexy, a medical emergency with resulting visual loss and hormonal hyposecretion, requires rapid surgical intervention. We present a case of pituitary macroadenoma that underwent pituitary resection for acute visual disturbance which was later discovered to be caused by undiagnosed demyelinating disease.Clinical Case Patient is a 32-year-old male who presented initially with complain of fatigue and decreased libido. Work up revealed elevated prolactin level and low testosterone. MRI showed a 2x3cm pituitary macroadenoma. At moment of diagnosis, patient was otherwise asymptomatic. He was started on bromocriptine. During follow up visits, patient reported visual disturbance. First MRI in our clinic showed no suprasellar extension, no impingement of optic chiasm and nonspecific white matter disease. At that time, visual field testing showed left temporal defect in superior quadrant. Follow up MRI 1 year later continued to show a stable macroadenoma without impingement of the optic chiasm, but patient reported progressive left vision disturbance and new right vision loss. He was evaluated in the emergency room where he was treated for pituitary apoplexy with steroids and surgery. Vision improved the next day. Despite uncomplicated post-operative course, patient developed proximal muscle weakness and exam notable for diffuse motor deficit in bilateral lower extremities with hyperreflexia. Endocrinology workup was negative for hypercortisolism and ophthalmology diagnosed him with optic neuropathy. Neurology evaluation led to a diagnosis of multiple sclerosis (MS). Patient was started on natalizumab with complete resolution of all visual and muscle symptoms.Clinical lesson Our patient presented with complaints of fatigue, decreased libido and work up that showed a macroprolactinoma without MRI evidence of optic chiasm impingement. During treatment, he developed acute visual deficits that were attributed to pituitary apoplexy. This visual disturbance improved after surgery and use of high dose IV steroids, with the latter likely treating what had been an MS flare. In hindsight, ophthalmologic evaluation before surgery had shown new color blindness, a sign of optic neuropathy. Despite temporary relief, patient progressed to develop new muscle weakness and recurrent visual disturbance which led to the diagnosis of MS. Since being diagnosed and treated for MS, he has had complete resolution of his symptoms. This case stresses the importance of considering other etiologies for visual defects in patients with pituitary adenomas.

SUN-183 Adrenalitis Induced by Nivolumab

Introduction: Tumor cells often express a programmed death-ligand 1 (PD-L1), which binds to the programmed death receptor-1 (PD-1) on activated T-cells to induce immune tolerance. Among the class of immune checkpoint inhibitors (ICI), Nivolumab is an anti-PD-1 antibody which blocks these tumor cell interactions. Although some endocrinopathies have been reported for other PD-1 inhibitors, the adverse event of adrenalitis with nivolumab has not been reported before. Clinical Case: A 65-year-old female presented to the hospital with complaints of nausea, vomiting, fatigue, and headache for five days. She was recently diagnosed with metastatic lung adenocarcinoma, complicated by cerebellar metastases, and the left cerebellar mass was resected. She was also started on Nivolumab. Her blood pressure was 98/65 mmHg on the presentation. Serum sodium was 122mEq/L (normal 135–145) and potassium was 5mEq/L (3.5–5). TSH, LH, and prolactin were all normal. Aldosterone was low: 23pmol/L (27.7–582.5) and renin was high: 11 ng/ml/h (0.167- 1.38). Morning cortisol levels were low: 2.2 ug/dl (5- 25) and concomitant ACTH was high: 78 pg/ml (7.2- 63.3). Upon standard high dose cosyntropin stimulation test, basal cortisol was 2.0 ug/dl (5- 25). Cortisol level 30 minutes post cosyntropin was 7.1 ug/dl, while Cortisol 60 minutes post cosyntropin was 12.2 ug/dl (normal >18 -20 ug/dl). Considering the low cortisol levels with high ACTH, and an inadequate rise in cortisol after the ACTH stimulation test, adrenal insufficiency was suspected as a result of adrenalitis due to Nivolumab. Hyponatremia along with low aldosterone and high renin levels also reinforced this clinical diagnosis. A computerized tomographic scan of the chest abdomen and pelvis only showed calcified uterine fibroids. She was initially resuscitated with intravenous fluids. Hydrocortisone 100 mg every 8 hours was started and then gradually tapered down to 60mg every 12 hours. Fludrocortisone was also initiated at 0.2mg daily. Symptoms began to improve, and sodium levels normalized to136 mEq/dl. She was discharged on 30mg of hydrocortisone and 0.1 mg of fludrocortisone daily and is stable since then. Conclusion: This is a rare case of Nivolumab-induced adrenalitis. It highlights the importance of checking for adrenal insufficiency in a patient who presents with symptoms of hypotension and hyponatremia while being on ICI drugs, as unidentified adrenal insufficiency and adrenal crisis can be fatal.

SAT-184 Silent Pheochromocytoma Complicated by Adrenal Insufficiency After Unilateral Adrenalectomy

Background: Adrenal insufficiency (AI) following unilateral adrenalectomy for pheochromocytoma (PCC) is an exceedingly rare occurrence described previously in 1 study in only 4 out of 13 patients with unilateral PCC. We discuss an unusual case of a patient with incidentally discovered PCC who underwent unilateral adrenalectomy and subsequently developed AI. Clinical Case: 61-year-old male in overall good health taking no medications presented with left flank and groin pain after a handlebar injury in a bicycle crash. CT angiogram Abdomen & Pelvis revealed a complex enhancing left adrenal mass with internal necrosis measuring 13 x 12 cm. He denied history of headaches, diaphoresis, chest pain or hypertensive crisis. He did endorse palpitations which had resolved with reduced caffeine intake. Labs showed plasma free metanephrine 3,295 pg/mL (ref range <57) and normetanephrine 68,472 pg/mL (<148), 24hr urine metanephrine 192,677 ug (52-341), 24hr urine normetanephrine 171,880 ug (88-444), 24hr urine vanillylmandelic acid (VMA) 182 mg (1.8-6.7), serum aldosterone 8.1 ng/dL (<39.2), serum free cortisol 0.47 ug/dL (0.07-0.93), 24hr urine cortisol 41.6 ug (<60), DHEA sulfate 37 ug/dL (42-290). He was started on phenoxybenzamine and underwent left adrenalectomy. Of note patient remained only minimally hypertensive with tumor manipulation intraoperatively. Pathology was consistent with PCC with no evidence of regional or distant metastases. Postop-labs showed plasma free metanephrine <25 pg/mL and normetanephrine 122 pg/mL. Calcitonin and parathyroid hormone levels were normal. Patient was evaluated in endocrinology clinic 4 weeks after surgery for complaint of severe fatigue, weight loss, anorexia and myalgias. Adrenocorticotropic hormone (ACTH) level was 31 pg/mL (7.2-63) with AM cortisol of 2.1 ug/dL (5-23) which increased to 7.4 ug/dL 1 hour after Cosyntoprin 250 mcg stimulation. He was started on prednisone 10 mg once daily with significant improvement in his symptoms. Conclusion: PCCs typically manifest as sustained or paroxysmal hypertension, episodic headaches, palpitations or diaphoresis. Our patient was found to have a PCC with strikingly elevated levels of catecholamines without typical signs and symptoms of PCC. To the best of our knowledge this is the 5th reported case where a patient developed AI after unilateral adrenalectomy for PCC. There are case reports describing PCCs which secrete both catecholamines and ACTH. However, our patient lacked clinical or biochemical evidence of hypercortisolism preoperatively and his tumor cells in path sample stained negative for ACTH. Other possible pathophysiologic mechanisms include ectopic corticotropin releasing factor production leading to subclinical Cushing syndrome (SCS). Clinicians should have a high suspicion for SCS in the setting of PCC to promptly diagnose and treat AI after unilateral adrenalectomy.

SAT-250 A Case of Late Recurrent Cushing’s Disease Presenting with Proximal Myopathy

Patients with Cushing’s disease (CD) present with a variety of symptoms and comorbidities including central obesity, hypertension, hyperglycemia, fatigue, weakness, insomnia and mood changes. Proximal myopathy is one of the classical signs of hypercortisolism and patients typically report difficulty rising from a seated position or climbing stairs. Due to variability in clinical presentation, with some patients showing subtle or few symptoms, the diagnosis of CD can be delayed. We describe a patient with late recurrent CD whose primary symptom was proximal myopathy. A 63 yr. old man presented to our clinic with complaints of progressive muscle weakness and fatigue. He had been successfully treated for CD at age 35 with transsphenoidal pituitary adenomectomy. He had been on hormonal replacement therapy for panhypopituitarism since surgery including levothyroxine, testosterone and glucocorticoids. He noted progressive weakness for several years prior to presentation in our clinic. Earlier evaluations revealed vitamin B12 and vitamin D deficiency, but supplementation did not lead to significant symptom improvement. He suffered two episodes of unprovoked deep venous thrombosis with pulmonary embolism and developed a left biceps tear that required hospital admission. During admission, his muscle weakness was exacerbated by immobility and he was subsequently referred to endocrinology for consideration of steroid induced myopathy. He had been on physiologic glucocorticoid replacement since diagnosed with panhypopituitarism. At the time of our evaluation, he was able to ambulate with a walker, but was unable to climb stairs, drive a car and required assistance with activities of daily living. His only other symptoms were fatigue and insomnia. Laboratory testing after holding prednisone revealed: morning cortisol 31.7 mcg/dl (reference interval [RI], 4.0-22.0), ACTH 128 pg/mL (RI 6 - 50), FSH <0.7 mIU/mL (RI 1.6 - 8.0), LH <0.2 mIU/mL (RI 1.6 - 15.2), testosterone 85 ng/dL (RI 250 - 827), IGF-1 55 ng/mL (RI 41 - 279), prolactin 4.9 ng/mL (RI 2.0 - 18.0), TSH 0.01 mIU/L (RI 0.40 - 4.50), free T4 1.5 ng/dL (RI 0.8 - 1.8), HbA1c 6.8% (RI <5.7%). Prednisone was discontinued and hypercortisolism was confirmed by 1 mg overnight dexamethasone (dex) suppression test (Cortisol 32.4 mcg/dL, dex 517 ng/dL, RI 180-550 ng/dL) and elevated 24 h urine free cortisol 315.4 mcg/24h (RI 4.0 - 50.0). 8 mg DST showed mild cortisol suppression (Cortisol 21.2 mcg/dL, dex >1000 ng/dl). MRI confirmed recurrent tumor (1.2 x 0.8 x 1.3 cm) extending into the right cavernous sinus and the patient underwent repeat transsphenoidal tumor resection. Pathology confirmed ACTH adenoma. Our case report highlights that patients with CD can have late recurrences and require long term monitoring for return of hypercortisolism, even in cases of prior panhypopituitarism.

A comparison of symptoms between Swedish and American post-polio individuals and assessment of lower limb strength--a four-year cohort study.

A cohort study with initial and 4-year follow-up evaluations was performed in 78 post-polio volunteers aged 34-65 years at the time of enrolment in the study, which was made to compare post-polio individuals living in Sweden and the United States, to determine whether lower limb musculature becomes weaker over time, and to determine whether individuals with complaints of post-polio syndrome, new weakness, fatigue, walking or stair climbing difficulty were weaker or lost more strength over a 4-year interval than those individuals without such complaints. Dynametrically-measured knee extensor and flexor strength and questionnaire data were obtained initially and 4 years later. The two cohorts were fairly similar, though they differed in weight gain. The Americans gained significantly (p &lt; 0.05) more weight than the Swedish subjects. Both groups lost significant (p &lt; 0.05) knee extensor strength (approximately 8%), but the loss was not significantly (p &lt; 0.05) different between the groups. Knee flexor strength did not change significantly (p &lt; 0.05) over time. Subjects acknowledging new strength loss were not significantly (p &lt; 0.05) weaker than those denying strength loss; however, they lost significantly (p &lt; 0.05) more isometric knee extensor strength than the other individuals. Subjects acknowledging new fatigue, walking or stair climbing difficulty were significantly (p &lt; 0.05) weaker in both muscle groups than those without such complaints. Subjects acknowledging post-polio syndrome were significantly (p &lt; 0.05) weaker than those denying this symptom, but the amount of loss of strength over time was not significantly (p &lt; 0.05) different. We conclude that the two cohorts were quite similar. Knee extensor strength decreased during the study interval. Individuals acknowledging post-polio syndrome had weaker knee extensor musculature. Subjects with new fatigue, walking difficulty, or stair climbing difficulty were weaker in both the knee extensors and the knee flexors than the other subjects. Subjects reporting new muscle weakness also had a greater decline in isometric knee extensor strength during the study interval than those without such complaint.

Obstructive sleep apnea in head and neck cancer survivors

Chronic fatigue is present in 33.0% of all head and neck cancer (HNC) survivors; this impacts their quality of life negatively. A plausible cause is obstructive sleep apnea (OSA) after HNC treatment. However, studies regarding this topic are scarce. To confirm if OSA is more prevalent after receiving radiotherapy for HNC. In addition, investigation of the risk factors for developing OSA in this population. A retrospective review of prospective data. Treatment for HNC took place between 2016 and 2017 at the University Hospital of Leuven. One hundred sixty-four patients were eligible for participating in this study. Sixty-five responded (39.4%). Upon consulting their medical files, 15 patients were excluded based on the in- and exclusion criteria. Presence of OSA was estimated using standardized questionnaires, namely the Berlin Questionnaire, the Epworth Sleepiness Scale, and the CIS-20. This was compared to the proportion of OSA in the general population. Fifty patients (33 men, 17 women) with a mean age of 64.2years (range 32-88) were included. Based on the questionnaires, OSA was suspected in twenty. The prevalence of suspected OSA in our study group (40.0%) was significantly greater (p < 0.0001) than our estimated prevalence of OSA in the general population (10.9%). No significant risk factors could be identified. Patients treated for HNC are at risk of developing OSA. When complaints of fatigue and sleeping problems persist, referral to a sleep clinic is suggested. Further investigation remains necessary to identify potential risk factors along with prevention and treatment strategies.

Effectiveness of progressive muscle relaxation and aromatherapy on fatigue in pregnant mothers

Background: Fatigue in pregnant women can lead to cesarean delivery, also triggering problems during pregnancy, childbirth, and the puerperium. Therefore, there is a need for non-pharmacological interventions to reduce the level of fatigueObjective: This study aims to determine the effectiveness of giving progressive muscle relaxation (PMR) and aromatherapy to complaints of fatigue in pregnant womenMethods: This is a quasi-experiment with pretest and post-test with control group design. The sampling technique was simple random sampling, consisted of 52 respondents who were divided into two groups. The statistical using a paired t-test and independent t-testResults: After the administration of PMR and aromatherapy interventions, the fatigue score decreased significantly from 5.15 to 3.15; p&lt;0.001. In the control group, the fatigue score was reduced from 5.04 to 4.00; p&lt;0.0001. There was a significant difference in fatigue scores in the intervention and control groups (3.15 ± 1.592 vs. 4.00 ± 0.980; p&lt;0.05).Conclusion: Combination progressive muscle relaxation exercises and aromatherapy are effective in reducing fatigue scores in pregnant women

Relationship between Fatigue and Musculoskeletal Complaints on Pedicab drivers in the Pedicab Association Solo Balapan Station

Musculoskeletal complaints can occur when muscles or skeletons receive a load or work is done repeatedly and the work is done for a long time. Pedaling a pedicab every day for a long time can cause fatigue. The fatigue felt by the pedicab drivers will have an impact on the pain in the muscles both in the legs, back, hands, shoulders, and neck. The aim of the study was to determine the relationship between the level of work fatigue and musculoskeletal complaints on pedicab drivers in the pedicab association Solo Balapan Station. This type of research is quantitative research. The research method used observational research. The study design was cross-sectional. The population in this study were 35 pedicab drivers, a sample of 33 people. Instrument research uses a questionnaire. Data analysis used the test Fisher exact. The results showed that there was a relationship between the level of work fatigue and musculoskeletal complaints (p=0.001). There is no relationship between age of workers and musculoskeletal complaints (p=1). There is no relationship between work periods drivers and musculoskeletal complaints (p=1). There is no relationship between the length of work/day with musculoskeletal complaints (p=0.273). There is no relationship between the average distance traveled with musculoskeletal complaints (p = 0.273)

Asthenia as a pressing health issue FOR women with non-psychotic mental disorders: age perspective

The aim of the study was to investigate the clinical phenomena of asthenia and subjective well-being of women aged 40–65 with non-psychotic mental disorders. Materials and methods. A complete examination of 204 women aged 40–65 who received treatment for non-psychotic mental disorders within 1 year has been conducted. The data on the clinical phenomena of asthenia were supplemented by patients’ rank assessment of fatigue and mood, determination of asthenia severity using the Multidimensional Fatigue Inventory (MFI-20), a calculation of the Kupperman menopausal index, and an assessment of the emotional component of well-being on the subjective well-being scale. For statistical processing, the methods of descriptive statistics and non-parametric statistics were used (for comparing independent samples – the Kruskal–Wallis criterion and Mann–Whitney U -criterion were applied; for identifying the connection of signs – Spearman rank correlation was used). Results. The profile of the identified disorders included neurotic, stress-related and somatoform disorders (F40-49) – 67.7%, organic non-psychotic disorders (F06.4; F06.6) – 27.0%, and affective disorders (F34.1) – 5.4%. The organic asthenic disorder was also the second most frequent diagnosis among 69 patients. 196 women complained of fatigue. Patients with complaints of constant fatigue were significantly more likely to report headache, irritability, low mood, pessimistic thoughts, drowsiness, and asthma attacks. Their low level of subjective well-being correlated with higher rates of asthenia on MFI-20 subscales, except for the “Reduced Motivation” subscale. The rates for all MFI-20 subscales among women with asthenic syndrome were lower than for patients with the depressive syndrome. A lower level of subjective well-being was revealed in patients with depressive, anxiety-depressive and anxiety-phobic syndromes, which differed by more pronounced manifestations of asthenia. Conclusion. The conjugation and complementarity of the scales used in the study made it possible to measure both asthenia and the emotional state and subjective well-being of women with non-psychotic mental disorders associated with it.

Результати застосування комбінованого препарату магнію і вітаміну В6 у дітей із поєднаним перебігом хронічного гастродуоденіту та первинної артеріальної гіпертензії

The objective: to optimize the treatment of children with the combined course of chronic gastroduodenitis (CGD) and primary arterial hypertension (PH) against the backdrop of hypomagnesemia by including the combined preparation of magnesium and vitamin В6 in the treatment regimen. Materials and methods. We examined 20 children aged 10 to 17 years with a combined course of CGD and PH and a serum magnesium content of ≤0.8 mmol/L. Children received non-drug treatment, treatment of CGD in accordance with the clinical protocol. PH treatment included an ACE inhibitor (enalapril) in an individual dose. Additionally preparation of magnesium and vitamin В6 was assigned. Results. Against the background of combined treatment, after 1 month, complaints of abdominal pain, nausea, headache and a feeling of heaviness in the stomach were decreased most intense in patients. After 3 months, complaints of fatigue significantly decreased and normalized tests of self-assessment of the functional state and subjective assessment of the quality of night sleep. According to the ABPM data, the average daily SBP and SBP load (p&lt;0.001) decreased most distinctly, and the SBP dipping increased (p=0.04). According to endoscopy results, the number of children with erythematous CHD after 3 months decreased from 40% to 10% (χ2=4.8; p=0.03), and erosive CHD was not diagnosed in any child (χ2=8.48; p=0.004 compared with the data before treatment). Conclusions. Children with a combined course of CGD and PН need complex therapy using a combination of magnesium and vitamin В6. This approach contributes to the normalization of serum magnesium levels, the rapid reduction of complaints, the improvement of blood pressure, the quality of night sleep and the endoscopic picture of the gastric mucosa and duodenum. Key words: chronic gastroduodenitis, primary arterial hypertension, children, treatment, magnesium preparations.

The objective: to optimize the treatment of children with the combined course of chronic gastroduodenitis (CGD) and primary arterial hypertension (PH) against the backdrop of hypomagnesemia by including the combined preparation of magnesium and vitamin В6 in the treatment regimen. Materials and methods. We examined 20 children aged 10 to 17 years with a combined course of CGD and PH

Uterine fibroids are the most common benign tumors of the female genital tract and are associated with numerous clinical problems. Laparoscopic myomectomy is an absolute altermative to standard open surgical technique with comparable long-term results. Due to the wide use and improvement of operational techniques with laparoscopic access, the pressing issue is possibility of its use in women, who have leiomyomas of the uterus and reрroductive intentions. The attitude to the quality of endoscopic suturing of the uterus after the enucliation of the knot and capability of suture during the next pregnancy is controversial. The technical aspects of suture of uterine incisions and also experience and skill of a surgeon during myomectomy deserves special attention. Uterine ruptures during the pregnancy and delivery are connected with violation of suture techniques – one-row uterine suture is compared with layering, and it’s extremely important for the full recreation of uterine-wall integrity after the removal of leiomyoma; wide use of electrocoagulation, which can lead to burns of myometrium with the further worsening of tissue regeneration.Given the need for an individual approach to each patient with uterine fibroids and reproductive intentions, surgical technique, access, choice of energy and suture are determined by each surgeon depending on the size, localization of uterine fibroids and clinical course to obtain the most effective postoperative result. The article is dedicated to peculiarities of the laparoscopic myomectomy in women of reproductive age. Laparoscopic myomectomy, when performed by an experienced surgeon, can be considered a safe technique with good results in terms of pregnancy outcome. Key words: uterine fibroids, fibroid, myomectomy, laparoscopy, surgical technique.

The Development of Green Technology Model in the Process of Making Gamelan, Klungkung Regency, Bali

The work bent on the smelting process which is very low and with the flame still open so that the heat from combustion is wasted into the environment has the potential to pollute the environment and expose the craftsmen to cause an increase in workload, subjective disorders and a decrease in work productivity. For this reason, one short case study was conducted with a pre and pos test group design that was carried out observationally on craftsmen in the bronze smelting process for gamelan raw materials. The workload was predicted by calculating the working pulse, fatigue and complaints of skeletal muscle craftsmen recorded by questionnaire. The results of the research data were analyzed descriptively to obtain a new design of the bronze metal smelting furnace model so that the work attitude was more ergonomic. The results showed that the work pulse increased to 132.42 ± 4.41 per minute or increased by 58.21 beats per minute, including in the category of "heavy" workload. The mean score of musculoskeletal disorders after work increased to 49.30 ± 4.98 and the mean score of fatigue complaints after work also increased to 50.12 ± 1.23. Work productivity decreased from 101.21 ± 5.21 at the beginning of work to be 95.42 ± 2.12 at the end of work. For that, a bronze metal smelting furnace is redesigned, namely redesigning the height of the work field to 60-65 cm from the floor so that the worker's work posture becomes natural and the top of the smelting furnace is equipped with a canopy to remove dust and heat from the workplace.

Fever of Unknown Origin.

Ms. Karin Collins: The case we will discuss today is that of a 35-year-old male who presented to our emergency department (ED) in late summer with chief complaint of fever and fatigue. Upon presentation, the patient reported undulating fevers and fatigue over the course of a month. The patient's symptoms initially began after a markedly stressful time at his work. Four weeks prior to presentation, the patient began to experience fevers and chills with night sweats every 2 to 3 days. Initially, he attributed these episodes to his increased burden at work and felt that his anxiety was worsening.