Contraindications Research Articles

EGS SO15 - The “Not” Cholecystectomy: Barriers to Early Cholecystectomy in a District General Hospital

Abstract Background The benefit of early or “hot” cholecystectomy in acute cholecystitis and pancreatitis is now widely recognised and recommended by NICE guidelines. However, in reality, surgery within the index admission is not always universally practised. We aim to report our experience of barriers to performing emergency cholecystectomy in the context of a district general London hospital. Method Data from patients admitted within a 1 month period with acute calculous cholecystitis, gallstone pancreatitis or recurrent biliary colic were retrospectively collected. Data points included patient demographics, reasons for not having emergency surgery and time to subsequent elective surgery. Any patients who underwent early emergency cholecystectomy were excluded from analysis. Results Twenty six (76.5%) out of 34 admissions did not receive emergency cholecystectomy. Eight (30.8%) were male and mean age was 69. Most common presentation was acute calculous cholecystitis (13, 50%). Reasons for not having surgery included frailty (7, 26.9%), waitlisted for endoscopic investigation (5, 19.2%), lack of emergency theatre capacity (4, 15.4%), unknown (3, 11.5%), severe disease (2, 7.7%), patient refusal (3, 11.5%) and acute medical contraindication (2, 7.7%). Four (15.4%) patients had repeat acute admission. To date, 4 patients subsequently underwent elective cholecystectomy with one procedure within 3 months. Conclusion Early cholecystectomy rates in district general hospitals can be affected by availability of local resources. By identifying the key factors for not proceeding to surgery, we can increase efforts to improve access to emergency theatre space, high-risk anaesthetic input and acute endoscopy services.

Outcomes of Pediatric Hepatocellular Carcinoma: A Single‐Center Experience With Resection Versus Transplantation

ABSTRACTBackgroundPediatric hepatocellular carcinoma (HCC) presents significant challenges due to its aggressive nature, with survival depending on complete resection. We aimed to assess outcomes between liver resection (LR) and liver transplantation (LT).MethodsA total of 25 patients were retrieved, four of whom were classified as palliative at diagnosis. A subanalysis comparing cirrhotic liver (n = 14) versus de novo (n = 11) HCC was performed to identify confounding variables. Further evaluation focused on the 21 children with histologically confirmed HCC who underwent LR (n = 7) versus LT (n = 14). Kaplan–Meier survival curves were constructed.ResultsThe mean age was 7.8 ± 6.1 years for patients with cirrhotic liver and 12.1 ± 3.5 years for de novo HCC. Our group observed overall total survival rates of 100%, 85%, and 77% at 12, 36, and 60 months, respectively. De novo tumors had a higher recurrence rate and a poorer prognosis (p = 0.039 and p = 0.045). The disease‐free survival at 60 months in our cohort was significantly lower among the LR group compared to the LT group (14% vs. 82%; p = 0.0081). Recurrence after initial management (n = 8) showed location differences between LR and LT. Preoperative alpha‐fetoprotein (AFP) was elevated in 71% of children, but did not correlate with recurrence or compromised survival. Elevated AFP 3 months post‐operation affected the course negatively (p = 0.044). Tumor number and diameter exhibited a trend towards poorer outcomes.ConclusionsThese findings emphasize the need for comprehensive pediatric surgical guidelines for HCC. We recommend LT over LR in pediatric cases. Extrahepatic disease post‐neoadjuvant chemotherapy remains the only absolute contraindication.

Colostomy formation in a peritoneal dialysis patient

This case report discusses the complex management of a 46-year-old man with poorly controlled type 1 diabetes mellitus, stage 5 chronic kidney disease, and severe neuropathic complications, which led to bilateral leg amputations. The patient experienced persistent diarrhea due to diabetic neuropathy, significantly impairing his daily functioning. Despite transitioning from hemodialysis to peritoneal dialysis, the diarrhea persisted. A colostomy was subsequently performed, which, although it did not completely resolve the diarrhea, allowed for better control, improving the patient's self-care and independence. Notably, the catheter exit site was maintained on the opposite side of the abdomen. Despite initial concerns about the feasibility of peritoneal dialysis (PD) in patients with stomas, including the challenges of creating a stoma in patients with an existing PD catheter, this case demonstrates the successful continuation of PD following a colostomy. Traditionally, intestinal stomas have been viewed as a relative contraindication to PD due to risks such as leakage and infection. However, current guidelines recommend using extended catheters with a presternal exit site to minimize these risks. The patient's quality of life improved significantly after the colostomy, with no major complications observed during follow-up. This report underscores the importance of tailoring treatment to individual patient needs, balancing risks with potential well-being benefits, and highlights the necessity of interdisciplinary collaboration and adherence to best practices. Given the limited literature on PD in patients with intestinal stomas, this case contributes valuable clinical insights for future management.

Physicians' and pharmacists' perspective on clarity and clinical relevance of absolute contraindications in "Summaries of Product Characteristics".

Previous work has identified several limitations in "Summaries of Product Characteristics" (SmPCs), which are associated with risks for patients. The aim of this study was to evaluate pharmacists' and physicians' interpretation of contraindications in SmPCs and reasons for their nonadherence in clinical routine. For 20 commonly missed or ignored absolute contraindications, an anonymous online survey providing 24 clinical example cases (one or two per contraindication) for physicians and pharmacists was developed. Experts in medication safety were asked whether the respective case fulfilled the definition of the contraindication in the SmPC: (a) formally, irrespective of the clinical relevance of the contraindication (17 cases), and (b) whether the contraindication was deemed clinically relevant in each respective case (24 cases). Twenty-seven pharmacists and 27 physicians completed the survey. For only one case (1/17; 5.8%) did all experts agree on the same answer option regarding the formal fulfilment of a given contraindication statement. Experts gave heterogeneous answers regarding the interpretation of a contraindication. For instance, among 10 predefined answer options for the contraindication "active liver disease" in the SmPC of simvastatin, every option was selected by at least six experts. In 17/24 (70.8%) clinical example cases a majority of experts agreed on the clinical relevance of a given contraindication. Key reasons for nonadherence to contraindications were "patient monitoring possible", "lack of alternative treatment" and "acute/severe situations". Experts' disagreement on the interpretation of contraindications in SmPCs using clinical example cases indicates that further efforts are needed to improve their usability in clinical routine.

Electroconvulsive Therapy in a Left Ventricular Assist Device Recipient With Treatment-Resistant Depression

Abstract Depression and heart failure are highly comorbid, with up to 35% of heart failure patients suffering from comorbid depression. Left ventricular assist devices (LVADs) serve as a major lifeline for patients with heart failure; however, despite the drastic improvement in cardiac function following LVAD implantation, up to 24% of LVAD recipients suffer from depression. Depression management in LVAD recipients is often complicated by the recipient's increased risk for antidepressant side effects, adverse drug reactions, and inability to safely receive certain interventional psychiatry therapies, as the LVAD is either a relative or absolute contraindication. Electroconvulsive therapy (ECT) is highly effective for treatment-resistant depression; although it carries increased cardiovascular risks for the LVAD population (particularly bradycardia/hypotension and tachycardia/hypotension), these can be continuously monitored, along with LVAD function, such that with the close cooperation of a multidisciplinary team, the risks of ECT can be minimized. To our knowledge, there is only one published case report of ECT in an LVAD recipient. We present a case of an LVAD recipient with treatment-resistant depression who was successfully treated with ECT. Our case describes an approach by which ECT can be safely delivered to LVAD recipients with a collaborative multidisciplinary team approach.

The addition of cannabis to prescription drug monitoring programs and medication fills in Medicaid.

To date, there is considerable evidence of the medical applications of cannabis, however concerns regarding the safety of cannabis are also mounting. To improve the safety of cannabis, nine states have added medical cannabis to their state PDMPs, helping providers to take patient cannabis use into consideration when making prescribing decisions. Across a variety of models using Medicaid State Drug Utilization claims data, I find statistically significant reductions in severely and moderately contraindicated medication fills across two outcomes. In my main specification, adding cannabis to a state PDMP is associated with a 14.4% (p<0.01) and 7.74% (p<0.001) decrease in the units per prescription, for severely and moderately contraindicated medications, respectively, as compared to states with legal medical cannabis dispensaries open. An interesting spillover effect of adding cannabis to PDMPs is an apparent decrease in the prescribing of scheduled narcotics, with Schedule II medications seeing a moderately significant decrease and Schedule IV medications seeing a 11.4% decrease (p<0.01) in the prescribing rate and a 16.2% decrease (p<0.001) in the units per prescription. The main analysis was conducted using the Borusyak etal. (2023) Imputation Estimator with a robustness check using the Callaway and Sant'Anna (2021) difference-in-difference. This work presents evidence that adding cannabis to a state PDMP impacts provider prescribing decisions involving medications that are contraindicated for use with cannabis as well as controlled substances. This paper demonstrates that adding cannabis to PDMPs influences prescribing and thus has the potential to make medical cannabis use safer. Conversely, this work indicates providers may have bias against patients who use cannabis and deny them life-improving medications (like controlled ADHD medication or opioids) on the basis of medical cannabis use. This paper also contributes to the literature comparing DD outcomes estimated using Borusyak, Jaravel, and Spiess' (2023) Imputation Estimator and Callaway and Sant'Anna's (2021) DD Estimator.

Сравнение методик пункционно-дилатационной трахеостомии Фрова и Григгс у пациентов с избыточной массой тела и ожирением: рандомизированное контролируемое исследование

INTRODUCTION: Tracheostomy is one of the most frequently performed operations in intensive care patients. This is due to the fact that in the population of intensive care patients, puncture tracheostomy has a number of advantages compared to surgical tracheostomy (ST). This determines the urgency of finding ways to reduce the risk of perioperative complications during puncture tracheostomy in intensive care patients, especially in overweight and obese patients. OBJECTIVE: To study the advantages and limitations of puncture dilation tracheostomy (PDT) performed using the Frova method under ultrasound control in intensive care patients with overweight and obesity, in comparison with the Griggs PDT method under fibrobronchoscopic (FBS) control. MATERIALS AND METHODS: The presented prospective study was conducted in the departments of anesthesiology and intensive care of the A.I. Burnasyan Federal Medical Biophysical Center FMBA from 2017 to 2021, which included 92 overweight and obese patients whose body mass index (BMI) was more than 25 kg/m2 and required tracheostomy. Two groups were identified: group (n = 48) — Frova tracheostomy under ultrasound control, group (n = 44) — Griggs tracheostomy under FBS control. RESUITS: Performing PDT using the Frova technique under ultrasound control is feasible and safe in intensive care patients with overweight and obesity, whereas with grade 3 obesity with a BMI of more than 41 kg/m2 and/or with a thickness of pretracheal soft tissues of more than 40 mm, PDT using the Frova technique should be abandoned and should be considered as absolute contraindications for performing PDT using the Frova method under ultrasound control. CONCLUSIONS: PDT using the Frova method under ultrasound control, when compared with the Griggs method with FBS control, can significantly reduce the incidence of intraoperative desaturation, arterial hypotension, intraoperative severe hemorrhagic complications, postoperative soft tissue infection around a tracheostomy wound.

Association between infant feeding behavior and maternal choice of breastfeeding type

Abstract Introduction Feeding in infants is a fundamental process influenced by the mother-child relationship during the early months of life. The regulation of feeding behavior, and hunger and satiety cues may be interpreted by the mother, potentially relating to the type of feeding chosen. Objectives To determine the association between infant feeding behavior and the type of breastfeeding chosen by the mother. Methods A cross-sectional and prospective study was conducted, including mothers with children aged between 6 and 18 months. Those with medical contraindications for immediate postpartum breastfeeding or with suspension of exclusive breastfeeding during the first 6 months of life due to medical prescription were excluded. The Baby Eating Behavior Questionnaire was used to evaluate the baby’s enjoyment of food, appetite response, eating speed, and satiety response. Results 108 mothers were included, with 87% in agreement with exclusive breastfeeding (EBF), 43.3% using breastfeeding as the primary feeding method, and only 33.3% practicing EBF during the first 6 months. Food response (FR) scored 19.6 (±4.3), enjoyment of food (EF) 17.6 (±2.1), satiety response (SR) 7.1 (±2.0), eating speed (ES) 8.8 (±2.3), and appetite (AP) 4.2 (±0.7). Comparing FR, EF, SR, ES, and AP scores between those who practiced EBF and those who did not showed p &amp;gt; 0.05. sociodemographic characteristics, perinatal factors, stance on EBF, number of hours per day with the child, feeding location, poor technique, breastfeeding pain and lack of medical guidance, all showed p &amp;gt; 0.05 when comparing between those who practiced EBF and those who did not; in contrast to perceiving that the baby wanted to breastfeed (2.5/1.0-6.2), having time to feed (3/1.2-7.2) and having no health problems (10/1.2-78.7) all with p-value &amp;lt;0.05. Conclusions The mother’s perception identifying the baby’s desire to breastfeed, having time to feed the baby and not having health problems favor exclusive breastfeeding. Key messages • Maternal perception plays an important role in deciding to give SCI, so it is the physician’s job to educate the mother so that she has additional arguments for choosing SCI. • The infant’s feeding behavior does not have a significant impact on the mother’s behavior in choosing SCI feeding.

Impact of coronary revascularization on clinical outcomes of post-acute myocardial infarction patients with left ventricular thrombus

Abstract Background Left ventricular thrombus (LVT) is an uncommon, but dangerous complication seen in post-acute myocardial infarction (AMI). With advances in percutaneous coronary intervention (PCI) techniques, the incidence of post-AMI LVT has declined in the contemporary era. However, a minority of patients do not undergo coronary revascularisation due to medical contraindications or patient preference. This study aimed to evaluate the clinical characteristics and outcomes of post-AMI LVT patients treated with and without coronary revascularisation. Methods This was a retrospective study of 263 consecutive post-AMI patients diagnosed with LVT from November 2012 to January 2021, retrieved from a echocardiography database. Patients were stratified by the presence or absence of revascularisation treatment. Baseline clinical characteristics, treatment and outcomes data were collected and analysed. Results The median follow-up duration was 2.9 years (IQR: 0.9 – 4.7). A majority of post-AMI LVT patients underwent revascularisation via PCI (71.5%, n = 188), CABG (4.2%, n = 11) or thrombolysis (0.4%, n = 1). Unrevascularised patients (24.0%, n = 63) were older (p &amp;lt;0.001), more likely to be female (p &amp;lt;0.001), and had more co-morbidities such as previous stroke (p &amp;lt;0.001), heart failure (p = 0.001), chronic kidney disease (p = 0.020), and malignancy (p = 0.021). More unrevascularised patient had NSTEMI (p &amp;lt; 0.001), and significantly fewer were treated with triple therapy (p &amp;lt; 0.001). Incidence of LVT resolution was lower (p &amp;lt; 0.001) while all-cause mortality was higher (p &amp;lt; 0.001) for unrevascularised patients on univariate survival analyses. On multivariable Cox regression, revascularisation status was not an independent predictor of LVT resolution, bleeding, stroke, or all-cause mortality outcomes. Conclusion While unrevascularised post-AMI LVT patients had poorer outcomes compared to revascularised patients overall, revascularisation status itself was not independently associated with poorer clinical outcomes. Optimising medical therapy such as triple therapy remains a key treatment goal for post-AMI LVT patients.

Vaccine awareness and hesitancy among Ukrainian refugee mothers in Bulgaria

Abstract Issue Migration carry out risk of disrupting the epidemiological well-being among refugees and host populations. Since the beginning of Ukraine crisis over 50 000 refugees remain in Bulgaria; 92% are women and children. There is suboptimal childhood immunization coverage among Ukrainian refugee community prior to arrival in Bulgaria. Description of the problem Childhood vaccination is mandatory in Bulgaria for TB, hepatitis B, diphtheria, tetanus, pertussis, poliomyelitis, rubella, measles, mumps, Haemophilus influenzae B and pneumococci. Refugees with uncertain immunization status are vaccinated according to the national immunization schedule and receive personal immunization card. As of March 2024, we conducted cross-sectional study to assess knowledge and attitudes of Ukrainian mothers through an interview. Results Of 105 mothers interviewed, 72.38% were with higher education. Arrived women were not familiar with Bulgarian health system and especially with vaccination. Absence of language barrier and presence of doctors among them facilitated our study.56.19% believe that migration has disrupted their children’s vaccinations. 56.19% consider that migration has disrupted their children’s vaccination. Aware of benefits of vaccines were 91,43%, they mainly trust doctors-84.76%, they pay attention to the positive discussion in the media-55.77%.Mothers realize the importance of herd immunity, considering that vaccinated children protect the others-68.57%.Leading reasons for mistrust of vaccines, mothers indicate - doubt in favor of vaccine-24.76%, medical contraindications for child-21.90% and doubts about quality of the vaccine-19.05%.They pay attention to positive discussion in the media-55.77% and have confidence in Bulgaria’s institutions. Lessons The Government of Bulgaria provided significant support and medical care for the prevention of vaccinepreventable diseases among Ukrainian children. Institutions and volunteers work for successful integration of refugees. Key messages • Need to know the immunization status of Ukrainian children admitted to Bulgaria. • Increasing trust in vaccines and the health system in general in Bulgaria requires additional explanatory campaigns among refugees.

Can Obesity Serve as a Barrier to Minimally Invasive Mitral Valve Surgery? Overcoming the Limitations—A Multivariate Logistic Regression Analysis

Background/Objectives: Over the past two decades, significant advancements in mitral valve surgery have focused on minimally invasive techniques. Some surgeons consider obesity as a relative contraindication for minimally invasive mitral valve surgery (MIMVS). The aim of this study is to evaluate whether the specific characteristics of obese patients contribute to increased surgical complexity and whether this, in turn, leads to worse clinical outcomes compared to non-obese patients. Furthermore, we aim to explore whether these findings could substantiate the consideration of limiting this treatment option for obese patients. We investigated the outcomes of MIMVS in obese and non-obese patients at a high-volume center in Germany staffed by an experienced surgical team well-versed in perioperative management. Methods: A total of 934 MIMVS were performed in our high-volume center in Germany from 2011 to 2023. Of these, 196 patients had a BMI of 30 or higher (obese group), while 738 patients had a BMI below 30 (non-obese group), all of whom underwent MIMVS by right minithoracotomy. Demographic information, echocardiographic assessments, surgical data, and clinical outcome parameters were collected for all patients. Results: There was no significant difference in in-hospital, 30-day, and late mortality between groups (obese vs. non-obese: 6 [3.0%] vs. 14 [1.8%], p = 0.40; 6 [3.0%] vs. 14 [1.8%], p = 0.40; 13 [6.6%] vs. 39 [5.3%], p = 0.48, respectively). Respiratory insufficiency and arrhythmia occurred more frequently in the obese group (obese vs. non-obese: 25 [12.7%] vs. 35 [4.7%], p &lt; 0.001; 35 [17.8%] vs. 77 [10.4%], p = 0.006). Conclusions: Obesity was not associated with increased early or late mortality in patients undergoing MIMVS. However, obese patients experienced higher incidences of postoperative complications, including respiratory insufficiency, arrhythmias, delirium, and wound dehiscence. Nonetheless, a multivariate logistic regression analysis indicated that obesity itself does not contraindicate MIMVS and should not be viewed as a barrier to offering this minimally invasive approach to obese patients.

Thoracic Continuous Spinal Anesthesia in Patients With Destroyed Lung Resulted in Favorable Perioperative Outcome.

Among patients needing open abdominal surgery, those with high-risk medical conditions impose significant challenges from an anesthesia point of view. Thoracic continuous spinal anesthesia (TCSA) is an evolving technique that may be beneficial for a subset of patients with underlying high-risk medical conditions where general anesthesia (GA) becomes a relative contraindication. TCSA, as a primary anesthesia technique, is gaining favor for its advantages over GA in open abdominal surgery as it avoids airway intervention and mechanical ventilation. The current article focuses on TCSA in 2 patients at high risk for GA, which resulted in favorable perioperative outcomes.

SUBSTANTIATION OF THE PROFESSIONAL STANDARD OF "PERSONAL FITNESS TRAINER" IN UKRAINE

Professional staff is needed for the effective functioning of health fitness. There are no professional standards for fitness staff in Ukraine, so there is no single standardized approach to determining the list of job functions, general and special competencies, the required knowledge, skills and practical abilities. The purpose of the study is to substantiate and develop a professional standard of "Personal Fitness Trainer" taking into account international experience. Methods: analysis and generalization of scientific and methodical literature, pedagogical observation, functional analysis, documentary method, method of expert evaluations, methods of mathematical statistics. Results. The development of a professional standard for "Personal Fitness Trainer" was based on regulatory acts and the algorithm formed for the health fitness system. There have been identified 60 necessary labor actions which ensure the performance of 9 labor functions of a fitness trainer. The professional standard takes into account the needs of employers, consumer requirements and will be the basis for the industry standard of higher education in the relevant specialty. Conclusions. The developed professional standard for "Personal fitness trainer" is relevant, complies with regulatory acts and established algorithm, adapted to the system of fitness. The expediency of developing a professional standard "Personal fitness trainer" was based on the study of the actual state and prospects of application of fitness staff. The professional standard provides requirements for the content and quality of professional activity; list of general competencies; requirements for the level of qualification, medical contraindications to work, work experience, level of education of a fitness trainer; a list of labor functions and labor actions and the necessary knowledge, skills and abilities; list of subjects and means of work and definition of professional competencies, etc. The professional standard "Personal fitness trainer" should be the basis for the industry standard of higher education in the relevant specialty.

Impact of Age on the Occurrence of Vascular Complications in Patients Undergoing Anterior Lumbar Approach Surgery.

Retrospective cohort study. To investigate the impact of age on the incidence of vascular complications in patients undergoing anterior lumbar approach surgery. Anterior approach lumbar spinal surgery may facilitate the use of intervertebral devices with larger endplate coverage and increased lordosis. Despite the advantages of this approach, risks related to vascular injury in older patients have been described in the literature. In total, 751 consecutive patients with degenerative spinal pathology who underwent stand-alone anterior lumbar interbody fusion (ALIF), ALIF combined with posterior fusion and/or instrumentation (360), total disc replacement, or hybrid procedures (ALIF and total disc replacement) were included. Data collected included general patient descriptive data, surgery details, intraoperative vascular injury, and postoperative vascular complications (deep vein thrombosis and/or pulmonary embolism). Rates of vascular complications were compared across age groups. In addition, the mean age of patients was compared between those with versus without vascular complications. Overall mean age was 50.4 years (range: 20-83 yr). The mean estimated blood loss was 91.3mL (range: 10-2800mL). A total of 15 patients, 2.0%, had vascular complications. There were 10 cases (1.3%) of intraoperative injury to iliac arteries or iliolumbar veins (mean blood loss was 721mL, and all were repaired intraoperatively). Postoperatively, 6 patients (0.8%) developed deep vein thrombosis and/or pulmonary embolism (one patient had both). With respect to age, there were no significant differences in rates of intraoperative, postoperative, or combined vascular complication rates across the age group ( P > 0.38). In addition, there were no statistically significant differences in the mean ages of patients with versus those without vascular complications ( P > 0.17). Overall incidence of vascular complications was 2.0%. No relationship between vascular complications and age was demonstrated. These data suggest that increased age may not necessarily be an absolute contraindication for anterior lumbar approach surgery. Level III.

Regarding the employment of persons with disabilities

The article examines the performance indicators of the program objectives of the Cabinet of Ministers of Ukraine regarding the realization of the right to work for persons with disabilities. Based on a comparison of employment rates for persons with disabilities in Ukraine and the European Union, a conclusion is drawn about the need to achieve the declared indicators and to adopt European practices for the inclusion of such individuals in labour relations. The article analyses the provisions of the Laws of Ukraine «On the Fundamentals of Social Protection of Persons with Disabilities» and «On Psychiatric Assistance» concerning the procedure for fulfilling employment quotas for persons with disabilities. Attention is drawn to their inconsistencies and the necessity of harmonizing their content. The article addresses problematic aspects of realizing the right to work for persons with disabilities who have been legally recognized as incapable. It presents statements from scholars and legislative provisions that define the legal labour capacity of persons with disabilities who have been declared legally incapable. It is argued that the legal basis for the inability of such individuals to exercise their constitutional right to work, due to incapacity, can be interpreted as discrimination against them from a certain perspective. It is emphasized that implementing employment support programs for persons with mental and intellectual disabilities is one way to reduce their discrimination and violations of their labour rights, counteract their stigma, and prevent social isolation. To enable persons with disabilities suffering from mental disorders, including those legally declared incapacitated, to exercise their right to work, it is proposed to introduce supported employment mechanisms. The article underscores the necessity of the principle of equal pay for equal work. It substantiates the possibility of engaging persons with disabilities who have been declared incapacitated in labour activities based on an employment integration agreement. Such a mechanism could effectively replace labour rehabilitation, which is one of the forms of individual rehabilitation. It is argued that such activities can only be carried out in the absence of medical contraindications to the person performing a certain type of work. The need to ensure these employees’ rights to remuneration, rest, and other benefits is emphasized. The article analyses the provisions of the draft law on social protection of persons with disabilities concerning the types of social enterprises. The article suggests the possibility of employing persons with disabilities who have been declared incapacitated at sheltered employment enterprises provided for by this draft law.

8282 A Diagnostically Challenging Case of Ectopic ACTH Secreting Pancreatic Neuroendocrine Tumor Presenting with Cushing’s Syndrome

Abstract Disclosure: O.A. Aluko: None. S. Patel: None. S.V. Silparshetty: None. T. Gallagher: None. Introduction: Ectopic ACTH mediated Cushing’s syndrome is an uncommon but treatable condition that poses time constrained diagnostic and therapeutic challenge due to severe morbidity as illustrated by our case below. Clinical case:A 65-year-old male was admitted with profound generalized weakness. He became restricted to wheelchair from being able to hike a trail at Yosemite national park 8 weeks prior. Recent history included hospitalization with uncontrolled diabetes and hypertension, new vertebral compression fractures, AKI, hypokalemia, proximal myopathy, anasarca, upper GI bleed and acute upper extremity DVT. Initial testing there revealed hypercortisolemia, elevated ACTH and a normal pituitary MRI. Further workup at our center revealed elevated 24hr urinary cortisol 2598 (n = 5 - 64 μg/24hr), random cortisol 55 (n= 4.2 -22.4 μg/dL) with elevated ACTH 194 (n= 7.2 - 63.3 pg/mL) consistent with ACTH dependent hypercortisolism. IPSS deferred due to AKI, underlying comorbidities and severe cervical stenosis with myelopathy. ACTH and cortisol remained elevated with an 8mg dexamethasone suppression test suggesting ectopic source ACTH. CT with contrast of chest, abdomen and pelvis showed 5mm right lower lobe lung nodule and bilateral adrenal nodularity. Bronchoscopic FNAC was negative for NET.Ketoconazole 400 mg twice daily was started pending localization of culprit lesion with improvement in 24 hr urinary cortisol to 554μg/24 hr however this was stopped within 4 weeks due to acute transaminasemia. Repeat imaging with Gallium-68 dotatate PET CT showed a 1.8 X 2.4 X 1.7 cm pancreatic mass. He underwent distal pancreatectomy with splenectomy. Pathology confirmed a 2.2cm well differentiated neuroendocrine tumor limited to the pancreas with immunohistochemistry strongly for ACTH and weakly for Gastrin. Postoperatively, patient was given hydrocortisone replacement. ACTH was 14.3 pg/mL and cortisol 6.2μg/dL a few weeks later. His diabetes, hypertension, hypokalemia, transaminasemia and proximal myopathy improved. Discussion:Ectopic ACTH mediated Cushing’s syndrome is responsible for about 5 - 20% of all Cushing’s syndrome cases. Pancreatic neuroendocrine tumor secreting Ectopic ACTH is rarer but can be aggressive. Clinical presentation can be confounding due to secretion of &amp;gt;1 neurohormone i.e ACTH and Gastrin in our patient. Gallium-DOTATATE PET/CT tracer has a very high sensitivity and specificity. Early use of this imaging may prevent comorbidity and mortality as surgical resection of ectopic ACTH secreting neuroendocrine tumor is first line therapy. Other diagnostic principles to consider are that severely elevated ACTH levels correlate only with a pituitary macroadenoma, IPSS is invasive and has relative contraindication in sick patients and Desmopressin stimulation test is not widely available. Presentation: 6/1/2024

8443 Incretin-Mimetic Therapy In Hypertriglyceridemia-Induced Pancreatitis - A Case Report

Abstract Disclosure: A. Iqbal: None. U. Alwahab: None. Introduction The use of incretin-mimetic therapy (IMT), which includes human glucose-dependent insulinotropic polypeptide (GIP) and glucagon-like peptide-1 (GLP-1) agonists, in patients with a history of pancreatitis is controversial. While clinical trials have demonstrated a slightly increased incidence of acute pancreatitis (AP) in patients on IMT, it is unclear if patients with hypertriglyceridemia (HTG)-induced pancreatitis areat similar risk. In patients with type 2 diabetes (T2D) and HTG, control of diabetes and improvement of metabolic profile using IMT could decrease the risk of HTG-induced pancreatitis. Case Description We report a case of a patient with diabetes and a history of HTG-induced pancreatitis where IMT was successfully used without precipitation of AP. Patient A is a 44-year-old male with obesity (BMI 38.25 kg/m2 ), T2D, and severe HTG associated with recurrent episodes of AP. His triglyceride (TG) level has ranged from 983 to &amp;gt;4,000 mg/dL. He is on fenofibrate, icosapent ethyl, and rosuvastatin. His last hospitalization for acute pancreatitis was 3months prior. His most recent hemoglobin A1c is 7.4%, TG is 302mg/dL, and he is being treated with glipizide, metformin, empagliflozin, and multiple daily injections of insulin. For management of his obesity and T2D, he is then started on tirzepatide, in conjunction with diet and lifestyle modification, which is slowly up-titrated to 7.5 mg weekly. After 12 months of tirzepatide treatment, he has lost 10 lbs, his A1C is now 5.9%, triglycerides have improved to 172 mg/dL, and he has had no precipitation of AP. Discussion While a history of pancreatitis is a relative contraindication to the use of IMT, attention should be paid to the cause of pancreatitis. Obesity and uncontrolled diabetes are frequent triggers of AP. IMT helps improve metabolic profile in patients with obesity, uncontrolled diabetes, and hypertriglyceridemia, thus decreasing triglyceride levels and preventing further episodes of AP as seen in our patient. The use of IMT in patients with a history of AP should be done on an individualized basis. Controlling the trigger for the AP (such as hypertriglyceridemia) should be prioritized and shared medical decision-making with the patient should be done regarding the benefits and risks of IMT. Presentation: 6/3/2024

Evaluation of ciliary body cysts in candidates for phakic lens implantation

PurposePhakic lens implantation in the ciliary sulcus of the eye can be complicated by coincident ciliary body cysts (CBC). We developed an ultrasound imaging and mapping protocol for these cysts.MethodsThis is a retrospective case series of all patients who underwent ICL workup at a single institution from April 2015 to October 2019. A standardized ultrasound biomicroscopy (UBM) imaging protocol was developed to screen for CBCs in either the ciliary body or sulcus. The locations and dimensions of all CBCs were graphically represented.ResultsThe prevalence of CBCs in 158 patients undergoing ICL workup was 34.8%. Among the 159 CBCs detected in 55 patients, 83 were in the sulcus (52%) and 76 were restricted to the ciliary body (48%). ICLs were implanted in 40 eyes with CBCs and 3 eyes with CBCs located within the sulcus horizontally required ICL repositioning due to ICL rotation or iris chafing.ConclusionCBCs were incidentally found in 34.8% of patients undergoing ICL workup. ICL implantation was complicated in 3 of the eyes with CBCs in the horizontal sulcus. Although CBCs are not an absolute contraindication for ICL surgery, we recommend preoperative UBM screening of the ciliary sulcus.

Comparison of patients who meet criteria for surgical stabilization of rib fractures versus those who actually get rib fixation: A single center review

BackgroundSurgical stabilization of rib fractures (SSRF) has shown benefits for rib fracture patients. However, the incidence of SSRF performed remains low. We compare our institution's rib fracture patients meeting criteria for SSRF versus those actually receiving the operation, hypothesizing a significant portion are not undergoing SSRF. MethodsA retrospective review of rib fracture patients presenting to our Level 1 trauma center from 1/2016 to 4/2023. Patients were categorized as those who met SSRF inclusion criteria versus those who didn't based on the 2023 Chest Wall Injury Society (CWIS) SSRF Guidelines. Basic demographics were obtained. Patients meeting SSRF criteria were divided into those who received SSRF versus those who didn't. Outcomes of interest included type and frequency of SSRF indications and frequency of absolute/relative contraindications. Descriptive statistics were used. Median test and t-test were used for statistical analysis. Statistical significance was set at p < 0.05. ResultsA total of 3,432 patients presented with ≥1 rib fracture(s). Of those, 1,573(45.8 %) met SSRF inclusion criteria. These patients were predominantly male, with mean age of 57.4(±18.5) and a similar Injury Severity Score but significantly higher chest-Abbreviated Injury Score of 3 (Interquartile range 3,4)(p = 0.048). Only 458(29.1 %) patients underwent SSRF, leaving 1,115(70.9 %) managed non-operatively, of which 215(19.3 %) were ventilated and “failure to wean from the ventilator” was the most common (81.4 %) indication for SSRF. Of the 900(80.7 %) non-ventilated patients managed non-operatively, 659 (69.9 %) had ≥two indications for SSRF, 382(34.3 %) had zero relative contraindications and 394(35.3 %) had one relative contraindication for SSRF. Lastly, 52.6 % of patients in this cohort had reported “clicking/popping” of their fractures. ConclusionOnly 29.1 % of patients meeting criteria for SSRF had the operation based on data from our institution. There may be additional opportunity to benefit this cohort of patients meeting SSRF criteria but not undergoing surgery.

Recurrent atrial flutter after radiofrequency ablation for atrial fibrillation in a patient with hypertrophic obstructive cardiomyopathy undergoing repetitive transcoronary ablation of septal hypertrophy

IntroductionWe described the clinical characteristics of a patient with hypertrophic obstructive cardiomyopathy (HOCM) who had undergone transcoronary ablation of septal hypertrophy (TASH) twice and developed atrial flutter after radiofrequency ablation for atrial fibrillation (AF) due to pulmonary vein reconnection. This case of HOCM is unique because of its complex complications and multiple complex atrial arrhythmias. The treatment of HOCM was successful and the postoperative follow-up results was good.Methods and resultsA 71-year-oldfemale, developed exertional dyspnea with palpitations 12 years ago, with a valid diagnosis of HOCM according to the echocardiography which showed an absolute increase in the interventricular septum thickness (22.8 mm). She underwent two rounds of TASH and only the second round was successful. During a visit due to recurrent palpitations, the patient was diagnosed with AF based on electrocardiographic examination. Circumferential pulmonary vein isolation (CPVI) was performed to treat AF. However, the recurrence of atrial flutter was detected on her electrocardiograms (ECGs) three years after the operation. Since the patient had an interstitial lung injury, there were relative contraindications for antiarrhythmic drugs. Due to restrictive use of antiarrhythmic drugs and continuous palpitation, the patient agreed to receive a second radiofrequency ablation. Left-sided macroreentrant circuits were identified via high-density mapping and successful ablation was performed at the isthmus.ConclusionsPerforming catheter ablation and TASH respectively in patients with HOCM associated with AF would be tricky. But taking such a comprehensive and respective clinical treatment would be beneficial to patients in the long term.