Future Episodes Research Articles

Risk factors for recurrent acute mastoiditis in pediatric patients: a registry-based cohort study.

To describe characteristics of pediatric patients with recurrent acute mastoiditis, and to identify risk factors for this condition. A retrospective cohort study. Data based on electronic medical records of the largest Health Maintenance Organization in Israel. Children hospitalized due to acute mastoiditis during the years 2008-2018 were identified, and their diagnosis was verified. Patients with recurrent acute mastoiditis were identified and grouped, and their characteristics were outlined and compared to those of the original group to identify risk factors for recurrence. During the 11-year period, a total of 1115 cases of children hospitalized due to acute mastoiditis were identified with a weighted incidence rate of 7.8/100,000. Of this group, 57 patients were diagnosed with recurrence following a full clinical recovery. The incidence proportion of recurrent acute mastoiditis was 5.1% (57/1115), male-to-female ratio was 27:30, 73.4% were younger than 24 months, the median period from the first episode was 3.4 months (IQR 2.0;10.0), and 82.5% of the patients (n = 47) had a single recurrence, whereas 18.5% (n = 10) had two recurrences or more. Mastoidectomy and swelling over the mastoid area during the first episode were identified as the main risk factors for recurrent mastoiditis HR = 4.7 [(2.7-8.2), p < 0.001] and HR = 2.55 [(1.4-4.8), p = 0.003], respectively. Mastoidectomy was the only independent significant risk factor for recurrence in a multivariate analysis. Mastoidectomy and swelling over the mastoid area during the first episode of acute mastoiditis were found strongly related independent risk factor for future recurrent episodes of acute mastoiditis.

Incidence and patterns of atrial fibrillation after catheter ablation of typical atrial flutter-the FLUTFIB study.

In patients with atrial flutter (AFL), ablation of the cavotricuspid isthmus (CTI) is a highly effective procedure to prevent AFL recurrence, but atrial fibrillation (AF) may occur during follow-up. The presented FLUTFIB study was designed to identify the exact incidence, duration, timely occurrence, and associated symptoms of AF after CTI ablation using continuous cardiac monitoring via implantable loop recorders. One hundred patients with AFL without prior AF diagnosis were included after CTI ablation (mean age 69.7 ± 9.7 years, 18% female) and received an implantable loop recorder for AF detection. After a median follow-up of 24 months 77 patients (77%) were diagnosed with AF episodes. Median time to first AF occurrence was 180 (43-298) days. Episodes lasted longer than 1 h in most patients (45/77, 58%). Forty patients (52%) had AF-associated symptoms.Patients with and without AF development showed similar baseline characteristics and neither HATCH- nor CHA2DS2-VASc scores were predictive of future AF episodes. Oral anticoagulation (OAC) was stopped during FU in 32 patients (32%) and was re-initiated after AF detection in 15 patients (15%). No strokes or transient ischaemic attack episodes were observed during follow-up. This study represents the largest investigation using implantable loop recorders (ILRs) to detect AF after AFL ablation and shows a high incidence of AF episodes, most of them being asymptomatic and lasting longer than 1 h. In anticipation of trials determining the duration of AF episodes that should trigger OAC initiation, these results will help to guide anticoagulation management after CTI ablation.

Repurposing antibiotic resistance surveillance data to support treatment of recurrent infections in a remote setting

In northern Australia, a region with limited access to healthcare and a substantial population living remotely, antibiotic resistance adds to the complexity of treating infections. Focussing on Escherichia coli urinary tract infections (UTIs) and Staphylococcus aureus skin & soft tissue infections (SSTIs) captured by a northern Australian antibiotic resistance surveillance system, we used logistic regression to investigate predictors of a subsequent resistant isolate during the same infection episode. We also investigated predictors of recurrent infection. Our analysis included 98,651 E. coli isolates and 121,755 S. aureus isolates from 70,851 patients between January 2007 and June 2020. Following an initially susceptible E. coli UTI, subsequent recovery of a cefazolin (8%) or ampicillin (13%) -resistant isolate during the same infection episode was more common than a ceftriaxone-resistant isolate (2%). For an initially susceptible S. aureus SSTI, subsequent recovery of a methicillin-resistant isolate (8%) was more common than a trimethoprim-sulfamethoxazole-resistant isolate (2%). For UTIs and SSTIs, prior infection with a resistant pathogen was a strong predictor of both recurrent infection and resistance in future infection episodes. This multi-centre study demonstrates an association between antibiotic resistance and an increased likelihood of recurrent infection. Particularly in remote areas, a patient’s past antibiograms should guide current treatment choices since recurrent infection will most likely be at least as resistant as previous infection episodes. Using population-level surveillance data in this way can also help clinicians decide if they should switch antibiotics for patients with ongoing symptoms, while waiting for diagnostic results.

Breaking boredom: Interrupting the residual effect of state boredom on future productivity.

Boredom is an emotion that constantly fluctuates in employees of all ages and occupations. Here, we draw on functional theories of boredom and theories of emotion regulation to develop an episodic model of how boredom shapes employee attention and productivity over time. We argue that employees often suppress boredom at work to "power through" boring tasks and objectives, resulting in residual bouts of mind-wandering-and thus productivity deficits-during future performance episodes. However, following boredom on an initial task, the commencement of a subsequent task that employees perceive to be meaningful creates an attentional pull that breaks the link between boredom and future mind-wandering, preventing the effects of boredom from spilling over to inhibit future productivity. Study 1 draws on archival experience sampling data to test our hypotheses and examine whether boredom exhibits reciprocal relationships with mind-wandering and productivity over time. Study 2 uses an experimental design to determine whether boredom and task meaningfulness interact to exert a causal effect on future mind-wandering. Study 3 uses a time-separated single-day design to replicate Studies 1 and 2 and examine our contention that employees often suppress boredom at work which, rather than preventing the effects of boredom, puts them "on hold" until a later point in time. Our findings provide insight into how to mitigate the far-reaching effects of boredom at work; they also advance episodic accounts of emotions, attention, and performance in organizations. (PsycInfo Database Record (c) 2024 APA, all rights reserved).

Surveying Bat-Hosted Adenoviruses and Herpesviruses: A Comprehensive Analysis

Bats have gained cumulative attention as potential reservoirs for viruses, being crucial to increase our ability to predict viral prevalence and transmissions, as well as support the possible management of future zoonotic episodes. Following the PRISMA standard systematic review protocols, we conducted a comprehensive search worldwide for scientific papers dealing with bat-hosted viruses of the Adenoviridae and Herpesviridae families. The search was completed using the Scopus, CABI, and SciELO, databases of bat-associated viruses of these two families as well as the Google Scholar search engine. Our search comprised a total of 2656 scientific papers. After a thorough review and screening of the papers, we selected for our study a total of 90 papers published between 1996 and 2022. We found marked taxonomic and spatial biases, the most studied bats being predominantly vespertilionids, rhinolophids, phyllostomids, and pteropodids, whereas other families (e.g., Natalidae, Noctilionidae, and Furipteridae) are still lacking information. The most studied areas are southern and east Asia, although there are large areas (north Africa, the Middle East, and all the way to central or northern Asia) still overlooked. Out of the total number of papers, as many as 55 identified bat-hosted Adenovirus (AdV) and 54 papers identified Herpesvirus (HSV). Our revision reveals the presence of AdVs in a total of 97 bat species from 42 genera and 11 families. The presence of HSVs is reported also in 109 bat species from 45 genera and 10 families. Although both AdVs and HSVs in general show a clear host specificity and parallel evolution with their hosts, these results also point to the potential of these viruses to cross, in some cases, species barriers.

Monitoring commercial and smallholder production inequalities during South Africa's lockdown using remotely sensed data

AbstractSouth Africa's dualistic agricultural sector consists of many smallholders that operate adjacent to dominant commercial producers. While the smallholder sector contributes to food security, households depend primarily on market food consumption. Poverty reduction is constrained when smallholders have limited access to markets, technology, or cheap capital. We collate remotely sensed data from the South African National Land Cover map and moderate‐resolution imaging spectroradiometer to monitor land use changes as the country entered the coronavirus disease (COVID‐19) lockdown. Production growth sustained aggregate food security, but hunger rose in the poorest households. This inequality in food security is also reflected in growing inequalities in production. Commercially cultivated land areas grew significantly, with more modest gains in smallholder areas. Commercial farmers were better positioned to expand capital in a low interest rate environment during the COVID‐19 crisis. Without using technology and capital to adapt, smallholders can fall further behind during future crises and growth episodes.

Governance Quality And Economic Growth In The Caribbean In Times Of Covid-19

ABSTRACT: The Caribbean region faces a daunting challenge as it confronts the COVID-19 pandemic. This study aims to shed light on the intricate relationship between governance quality and the economic performance of Caribbean nations, especially in the context of a global health crisis. Our research method involves a panel-random effects model, which captures the effects of governance quality and the COVID-19 pandemic on economic growth. We utilize data from various Caribbean countries, considering six dimensions of governance quality, trade openness, inflation, investment, and human capital. This comprehensive approach ensures a nuanced understanding of the region’s economic landscape during these turbulent times. Our findings expose a significant negative association between the various dimensions of governance and the ongoing pandemic crisis. Specifically, governance indicators such as voice and accountability, rule of law, political stability, and absence of violence, along with government effectiveness, emerge as positive catalysts for economic growth. On the contrary, the control of corruption and regulatory quality demonstrate a notable negative impact on growth. Furthermore, our research unveils that investment and human capital significantly contribute to boosting output growth in the Caribbean. Conversely, the impact of the COVID-19 pandemic, inflation, and trade openness is observed to be detrimental to economic growth. These findings corroborate existing empirical evidence on the governance-growth nexus, underscoring the complex interplay between governance and economic development. These results emphasize the urgency of long-term strategies to enhance governance quality in Caribbean countries. It is imperative to bolster the capacity of governments to address future epidemic episodes, recognizing the persistent threat of pandemics. Policymakers should prioritize measures that promote voice and accountability, rule of law, political stability, and government effectiveness while addressing corruption and regulatory quality issues. This research holds profound significance for both academics and policymakers, offering a pathway to stable and sustainable long-term economic growth and calling for proactive preparedness in the face of future global health challenges. It also invites further research in this critical area.

Salvage Therapy and Allogeneic Hematopoietic Cell Transplantation for the Severe Cytokine Storm Syndrome of Hemophagocytic Lymphohistiocytosis.

Hemophagocytic lymphohistiocytosis (HLH) can be considered as a severe cytokine storm syndrome disorder. HLH typically manifests as a life-threatening inflammatory syndrome characterized by fevers, cytopenias, hepatosplenomegaly, and various other accompanying manifestations such as coagulopathy, hepatitis or liver failure, seizures or altered mental status, and even multi-organ failure. Standard up-front treatments do not always bring HLH into remission or maintain adequate response, and salvage or alternative therapies are often needed. For patients with genetic diseases that cause HLH, curative allogeneic hematopoietic cell transplantation is usually offered to prevent future episodes of life-threatening HLH. Here, we will discuss the options and approaches for salvage therapy and hematopoietic cell transplantation for patients with HLH.

The Spectrum of First-onset Seizures in Children Presenting at a Tertiary Care Centre

Abstract Introduction: Seizure is the most common paediatric neurological condition with an increased predilection for early childhood. The recent definition of epilepsy includes first-onset seizures with an increased probability of future episodes. Thus, stringent evaluation of the initial episode of seizure is essential. Hence, this study estimated the aetiology, clinical profile, treatment and outcome of the first seizure episode in children at a tertiary hospital. Materials and Methods: This prospective observational study was carried out at a tertiary hospital in Barabanki, India. Children in the age group of 1 month to 12 years who presented with the first seizure episode and those admitted for other illnesses and developed the first seizure episode during hospital stay were included. Data collected were sociodemographics, clinical presentations, laboratory tests, brain imaging studies, electroencephalography (EEG), diagnosis, treatment and short-term outcomes. Results: A total of 113 patients were enrolled presenting with first-onset seizures. There were 78 (69%) males, 86 (76.1%) were below 5 years of age and 60 (53.1%) presented with fever. Most seizures had a generalised onset (58.4%). Febrile seizures (29.2%) were the most common type, followed by neurocysticercosis (20.3%). Central nervous system (CNS)-infective aetiology (58.7%) was the most common etiological classification. Abnormal findings were observed in cerebrospinal fluid examination of 24 out of 56, in brain imaging of 53 out of 80 and in EEG of 70 out of 113 cases examined. Anti-seizure medication (ASM) was prescribed to 68 patients, of which 10 had a recurrence in the 6-month follow-up period. Conclusion: The first episode of seizure in children usually had a generalised onset, with younger children of the male sex at an increased risk. CNS infections and febrile seizures were common causes. Complete history and neurological evaluation can guide the relevant investigations. ASM tailored to the aetiology controls the seizures in most cases.

Vitamin D status in active and inactive noninfectious uveitis - data from a reference university hospital in Rio de Janeiro, Brazil.

This study aimed to investigate the correlation between serum vitamin D levels and disease activity in patients with noninfectious uveitis. We conducted a prospective case-control study, assessing 51 patients with noninfectious uveitis, categorized into active (n=22) and inactive (n=29) groups, along with 51 healthy controls. Serum 25-hydroxy vitamin D [25(OH)D] levels were measured. The uveitis group also completed a questionnaire regarding sunlight exposure habits and vitamin D supplementation. Patients with inflammation-related uveitis exhibited low serum 25(OH)D levels in 68% of cases. The median 25(OH)D level in patients with active uveitis was 17.8 ng/mL (interquartile range [IQR], 15-21 ng/mL), significantly lower compared to the 31.7 ng/mL (IQR, 25-39 ng/mL) in patients with inactive uveitis (p<0.001) and the 27 ng/mL (IQR, 23-31 ng/mL) in the Control Group (p<0.001). Significantly, nearly all patients with uveitis taking vitamin D supplementation were in the Inactive Group (p<0.005). Moreover, reduced sunlight exposure was associated with active uveitis (p<0.003). Furthermore, patients with 25(OH)D levels below 20 ng/mL had ten times higher odds of developing active uveitis (p=0.001). This study revealed a prevalent 25(OH)D deficiency among patients with noninfectious uveitis and suggested a link between low 25(OH)D levels and disease activity. To prevent future episodes of intraocular inflammation, vitamin D supplementation and controlled sunlight exposure could be viable options.

Assessing consumer rationality during a pandemic: Panic buying behaviours and its association with online social media discourse

As an unprecedented, shared global experience in crisis, the Covid-19 pandemic witnessed unusual behaviours amongst populations. Large-scale panic buying was observed in numerous countries. Such behaviours can be detrimental to the population's wellbeing and societal functioning. As global pandemics are a relatively rare phenomenon in history, research examining panic buying behaviours during pandemics and actual panic buying behaviours has been scarce. Within the context of the Covid-19 pandemic, the prevalence of social media has made it possible to monitor panic buying discourse real-time. The present research aims to study the relationship between online public discourse and its relationship with abnormal surges in buying behaviours. We first examined Singapore residents' supermarket purchase patterns based on daily supermarket sales data during Covid-19 and investigated its relationship with parallel social media information on the internet. Analysis involving these two large-scale social media and supermarket datasets revealed distinct purchasing patterns for various types of products such as staple food items and home electronic products. While significant positive correlation was found between purchasing patterns of staple and long-lasting canned foods and online discourse, this was absent for items such as home appliances and entertainment products. The findings point to the potential role of social media data in predicting future abnormal food demand episodes, with implications on food security and crisis management.

Case Report on a Cocktail Drug Abuser Developing Rhabdomyolysis

Rhabdomyolysis is a medical emergency characterized by the break down of skeletal muscle leading to the release of intracellular contents into the blood stream, which can lead to acute kidney injury and even death. Drug abuse is one of the potential causes of rhabdomyolysis. This case report describes a 18-year-old male with a history of drug abuse who presented to the emergency department with severe muscle pain, weakness, dark and reduced amount of urine. The patient was diagnosed with rhabdomyolysis, which was likely due to a combination of high doses Marijuana, Chlorpheniramine, Dextromethorphan (Corex Syrup), Dicyclomine, Tramadol, Acetaminophen and cigarette smoking over period of 4-5 years, landed up in rhabdomyolysis after joining gym. The patient was immediately started on aggressive intravenous fluid resuscitation, and his urine output and electrolyte levels were closely monitored. Patient required initiation of Hemodialysis over period of 15 days. Patient's muscle pain and weakness gradually improved over the next few days, and he was discharged with a diagnosis of AKI due to Rhabdomyolysis due to drug abuse. Prompt recognition and treatment of rhabdomyolysis are crucial to prevent serious complications, and addiction treatment should be pursued to prevent future episodes of rhabdomyolysis and other drugrelated complications.

The role of intracranial pressure variability as a predictor of intracranial hypertension and mortality in critically ill patients.

Intracranial pressure (ICP) monitoring is a widely utilized and essential tool for tracking neurosurgical patients, but there are limitations to the use of a solely ICP-based paradigm for guiding management. It has been suggested that ICP variability (ICPV), in addition to mean ICP, may be a useful predictor of neurological outcomes, as it represents an indirect measure of intact cerebral pressure autoregulation. However, the current literature regarding the applicability of ICPV shows conflicting associations between ICPV and mortality. Thus, the authors aimed to investigate the effect of ICPV on intracranial hypertensive episodes and mortality using the eICU Collaborative Research Database version 2.0. The authors extracted from the eICU database 1,815,676 ICP readings from 868 patients with neurosurgical conditions. ICPV was computed using two methods: the rolling standard deviation (RSD) and the absolute deviation from the rolling mean (DRM). An episode of intracranial hypertension was defined as at least 25 minutes of ICP > 22 mm Hg in any 30-minute window. The effects of mean ICPV on intracranial hypertension and mortality were computed using multivariate logistic regression. A recurrent neural network with long short-term memory was used for time-series predictions of ICP and ICPV to prognosticate future episodes of intracranial hypertension. A higher mean ICPV was significantly associated with intracranial hypertension using both ICPV definitions (RSD: aOR 2.82, 95% CI 2.07-3.90, p < 0.001; DRM: aOR 3.93, 95% CI 2.77-5.69, p < 0.001). ICPV was significantly associated with mortality in patients with intracranial hypertension (RSD: aOR 1.28, 95% CI 1.04-1.61, p = 0.026, DRM: aOR 1.39, 95% CI 1.10-1.79, p = 0.007). In the machine learning models, both definitions of ICPV achieved similarly good results, with the best F1 score of 0.685 ± 0.026 and an area under the curve of 0.980 ± 0.003 achieved with the DRM definition over 20 minutes. ICPV may be useful as an adjunct for the prognostication of intracranial hypertensive episodes and mortality in neurosurgical critical care as part of neuromonitoring. Further research on predicting future intracranial hypertensive episodes with ICPV may help clinicians react expediently to ICP changes in patients.

PSYCHOSOCIAL INTERVENTION FOR REDUCING RELAPSE AND IMPROVING TREATMENT ADHERENCE IN BIPOLAR AFFECTIVE DISORDER WITH POOR SOCIO-OCCUPATIONAL FUNCTIONING AND HIGH EXPRESSED EMOTION IN THE FAMILY: A CASE REPORT

Introduction: Bipolar affective disorder (BPAD) is a chronic psychiatric disorder with an admixture of frequent and recurrent episodes of mania, hypomania, depression, or mixed episodes. More than 1% of the world's population and at least 0.3% of the Indian population are affected by BPAD. We have chosen a case of BPAD with multiple episodes to study the impact of psychosocial intervention in the management of the illness of the affected person and family. The index client, a male, Presentation of the case: 32 years of age, visited the Institute of Psychiatry (IOP) with caregivers and was referred to the psychiatric social work department of the IOP on April 24, 2019, with symptoms of mania and psychosis. He had 7-years history of psychiatric illness, including multiple episodes of mania and depression, as well as frequent irregular medication; burden and conict, insufcient social support, poor communication and interaction patterns, poor coping and problem-solving skills in the family. Therapists imparted Interpersonal and Social Rhythm Therapy (IPSRT) and family-focused therapy to the client and family members. It was found that there Discussion: was a signicant difference between pre- and postpsychosocial interventions in the life and wellbeing of a person with BPAD and his family. Post intervention, client's level of social and occupational functioning was increased, high expressed emotion had been notably decreased, adaptive patterns had been improved, and cohesion in the family had been strengthened. The client and his family members learned to prevent development of future episodes. Conclusion: Psychiatric social work interventions have been a key area in the management of BPAD involving the family, which helps in maintaining a prolonged euthymic period and better treatment compliance.

Patient perspectives on treatment and prevention of recurrent urinary tract infections: a focus group study.

We sought to understand factors that are important to patients for the management of recurrent urinary tract infections (UTI) during both an acute episode and for the prevention of future episodes. This was a qualitative study with focus groups in women with recurrent UTIs. Participants filled out information about prior recurrent UTI treatment and the Belief about Medicines Questionnaire (BMQ). Each 90-minute focus group was moderated by a nonphysician psychologist. Line-by-line coding of each transcript by three independent physicians was used to develop emergent concepts and themes using Grounded Theory methodology. Twenty-six women participated in six focus groups. The average age of participants was 62 years and 77% were post-menopausal. All women had already tried multiple prevention strategies for their recurrent UTIs. The average BMQ-specific scores indicated a net positive attitude toward medicines specifically prescribed for recurrent UTI prevention. Several themes emerged from the focus groups. First, patients wanted providers to acknowledge the high burden imposed by frequent interactions with the health care system for the management of recurrent UTI. Second, patients wanted earlier access to providers knowledgeable in the management of this condition. Third, patients wanted to self-manage their condition through a structured treatment plan with support from their providers. Finally, patients wanted greater emphasis on education and prevention strategies to reduce their antibiotic intake. Patients with recurrent UTI want more efficient workflows, a framework that promotes self-management in partnership with their providers, and a greater emphasis on prevention.

Hydrological and climate impacts on river characteristics of pahang river basin, Malaysia

The climate, geomorphological changes, and hydrological elements that have occurred have all influenced future flood episodes by increasing the likelihood and intensity of extreme weather occurrences like extreme precipitation events. River bank erosion is a natural geomorphic process that occurs in all channels. As modifications of sizes and channel shapes are made to transport the discharge, sediment abounds from the stream catchment, and floods are triggered dramatically. The aim of this study is to analyze the flood-sensitive regions along the Pahang River Basin and determine how climate and river changes would have an impact on flooding based on hydrometeorological data and information on river characteristics. The study is divided into three stages, namely the upstream, middle stream, and downstream of the Pahang River. The main primary hydrometeorological data and river characteristics, such as Sinuosity Index, Dominant Slope Range and Entrenchment Ratio collected as important inputs in the statistical analysis process. The statistical analyses, namely HACA, PCA, and Linear Regression applied in river classification. The result showed that the middle stream and downstream areas demonstrated the worst flooding affected by anthropogenic and hydrological factors. Rainfall distribution is one of the factors that contributed to the flood disaster. There are strong correlations between the Sinuosity Index (SI) and water level, which indicates that changes occurred at both planform and stream classification. The best management practices towards sustainability are based on the application of the outcomes that have been obtained after the analysis of Pahang River planform changes, Pahang River geometry, and the local rainfall pattern in the Pahang River Basin.

Ensemble Approach to Combining Episode Prediction Models Using Sequential Circadian Rhythm Sensor Data from Mental Health Patients.

Managing mood disorders poses challenges in counseling and drug treatment, owing to limitations. Counseling is the most effective during hospital visits, and the side effects of drugs can be burdensome. Patient empowerment is crucial for understanding and managing these triggers. The daily monitoring of mental health and the utilization of episode prediction tools can enable self-management and provide doctors with insights into worsening lifestyle patterns. In this study, we test and validate whether the prediction of future depressive episodes in individuals with depression can be achieved by using lifelog sequence data collected from digital device sensors. Diverse models such as random forest, hidden Markov model, and recurrent neural network were used to analyze the time-series data and make predictions about the occurrence of depressive episodes in the near future. The models were then combined into a hybrid model. The prediction accuracy of the hybrid model was 0.78; especially in the prediction of rare episode events, the F1-score performance was approximately 1.88 times higher than that of the dummy model. We explored factors such as data sequence size, train-to-test data ratio, and class-labeling time slots that can affect the model performance to determine the combinations of parameters that optimize the model performance. Our findings are especially valuable because they are experimental results derived from large-scale participant data analyzed over a long period of time.

Real Time Patient Vital Monitoring and Alarm System with Prediction of Anomalies and Future Clinical Episodes using Machine Learning Models

Heart disease is a leading cause of death in India. Many times, heart diseases do not show symptoms until they become a matter of concern. This silent nature calls for real time monitoring of vitals. In this paper, we propose a healthcare monitoring system which makes use of existing wearable devices to measure vitals of the user’s body. The data gathered is used to perform real time analysis to detect any irregularities and simultaneously to predict if there are any underlying problems that might be of future concern.

SAT620 Dopamine Challenge: Treatment Of Pituitary Macroadenoma/Prolactinoma In Patient On Antipsychotic Medication

Abstract Disclosure: A. Bazhenov: None. I. Alpertunga: None. Background When hyperprolactinemia is a well-known side effect of antipsychotic medications1, the link between prolonged treatment with dopamine antagonist and the development of lactotroph adenomas is still unclear4. Treating a patient with prolactinoma and psychotic disorder may pose a challenge. Antipsychotic agents can cause increases in prolactin levels. Additionally, treatment of prolactinoma with dopamine agonists may worsen psychotic symptoms. Case presentation We present a case of 56 yo male with a PMH of bipolar disorder with psychotic features who was found to have a macroprolactinoma after 18 years of treatment with antipsychotic medications. At age 30, the patient was diagnosed with Bipolar Disorder with psychotic features. The course of the disease was complicated by numerous hospitalizations and frequent changes to the treatment plan, with different combination of second-generation antipsychotic, haloperidol and antiseizure medications. The patient’s prolactin level was 50 ng/ml at the time. 18 years after the diagnosis, the patient developed severe headaches. An MRI revealed a pituitary macroadenoma measuring 1.3 cm, and a repeat prolactin level resulted in 729 ng/ml. He was started on cabergoline 0.5 mg twice a week. As a result, the prolactin level dropped to 32 ng/ml and the macroprolactinoma size decreased to 1.1 cm. Unfortunately, the patient was lost to follow up. Once he re-established his care, he was started on Olanzapine 15 mg daily, Lamotrigine 200 mg daily and cabergoline 0.5 mg twice a week. After reinitiating cabergoline, the patient developed three maniac episodes, two of which required hospitalization. The dose of the cabergoline was decreased to avoid future maniac episodes. Neurosurgery will be consulted for possible surgery treatment. Discussion The treatment of a patient with prolactinoma and a psychotic disorder poses a particular challenge. We believe that care of these patients requires a multidisciplinary approach, and surgical treatment should be considered for those who cannot tolerate dopamine-agonist therapy. Literature 1. Bostwick JR, et al. Antipsychotic-induced hyperprolactinemia. Pharmacotherapy. 2009;29(1):64-73. 2. Lertxundi U et al. Antipsychotics and pituitary tumors. Int Clin Psychopharmacol. 2019;34(2)89. 3. Andrade EH, et al. Insights in the management of antipsychotics. Case Rep Med. 2010;2010. 4. McCarren M,et al. Follow-up study of a pharmacovigilance signal. J Clin Psychopharmacol. 2012;32(6)743. 5. Bakker IC, et al. Successful treatment of a prolactinoma on antipsychotic drug. Endocrinol Diabetes Metab Case Rep. 2016. 6. The challenges in managing prolactinomas SFEBES2009 Accessed April 11 2023. https://endocrine-abstracts.org 7. Howes OD et al. The role of dopamine in schizophrenia. Biol Psychiatry. 2017;81(1)9. 8.Bamarinejad A, et al. Schizophrenia and Macroprolactinoma: Adv Biomed Res. 2020;9(1)38. Presentation: Saturday, June 17, 2023

SAT169 Sugar Crash: A Case Of Recurrent Hypoglycemia

Abstract Disclosure: C.T. Malvar: None. P. Patel: None. H. Moran: None. D. Bleich: None. Introduction: Post-prandial hypoglycemia is a rare complication following Roux-en-Y gastric bypass surgery (RYGB). Some theories suggest that post-operative beta cell expansion and altered beta cell function may lead to increased secretion of insulin, thereby causing hypoglycemia. We report a 39-year-old female with multiple episodes of recurrent post-prandial hypoglycemia following RYGB. Case Report: A 39-year-old female with a past medical history of type 2 diabetes managed with insulin, hypertension, hyperlipidemia, and obesity underwent RYGB and developed multiple episodes of fatigue, diaphoresis, palpitations, and tremulousness a year later. The patient continued to have worsening symptoms, leading to multiple hospitalizations for hypoglycemia. During her initial presentation to the emergency department, she was found to be afebrile, tachycardic with stable blood pressure. Work up revealed a glucose of 34 mg/dl (70 - 109 mg/dl), insulin of 40.1 (2.6 - 24.9 uIU/mL), C-peptide of 3.8 (1.1 - 4.4 ng/mL), potassium of 3.2 (3.5 - 4.8 meq/l), negative sulfonylurea screen, normal renal function, and a mild leukocytosis of 12.6 (4.0 - 11.0 x 10*3/µL). CT abdomen/pelvis, chest x-ray, and urinalysis were normal and did not reveal any infection. The patient denied taking any hypoglycemic agents and reported consuming high glycemic index meals. During her hospitalization, she received a bolus of dextrose followed by a continuous dextrose drip; however, she continued to experience recurrent hypoglycemic events requiring glucagon and dextrose tablets. Subsequent morning labs showed elevated insulin levels at 34.6 (2.6 - 24.9 uIU/mL) and a normal IGF-1 level. Her 8AM cortisol level was 2.3 (6.0 - 18.4 ug/dl). Due to high suspicion of adrenal insufficiency, she was started on Hydrocortisone. Pituitary MRI was negative for any adenoma. Hydrocortisone was held and a cosyntropin stimulation test established appropriate adrenal response. Hydrocortisone and dextrose tablets were discontinued. She was educated on eating low glycemic index meals to prevent future hypoglycemic episodes. She was started on acarbose as it delays carbohydrate degradation, thereby preventing reactive hypoglycemia. Conclusion: This case highlights the importance of having a thorough differential diagnosis in patients with a history of bariatric surgery and hypoglycemic episodes including adrenal insufficiency, which in this case was ruled out. RYGB increases stimulation of islet β-cells by enteral signals and enhances GLP-1 sensitivity and insulin secretion, predisposing some individuals to hypoglycemic episodes. Patients may have remission of diabetes and no longer need medications post-operatively. Dietary modification is fundamental in the management of hypogylcemia after RYGB. Pharmacotherapy is an adjunctive treatment if symptoms persist. Presentation: Saturday, June 17, 2023