Leg Swelling Research Articles

The Effect of Ginger Water Decoction on Leg Edema in Pregnant Mothers at Kasih Ibu Primary Clinic, 2024

The bending of the uterus restricts venous return and gravitational pull, which increases fluid retention and causes 80% of pregnant women in the third trimester to experience leg edema or swelling. Edema in pregnant women’s legs can be a sign of dangerous pregnancy conditions, such as pre-eclampsia. Edema is also very dangerous for pregnant women as it can lead to issues with the heart, kidneys, and other body parts, disrupting their functions. Foot soaking, or foot hydrotherapy, is an additional therapy that can be done independently. To improve blood circulation and trigger a systemic response (vasodilation) through the dilation of blood vessels, bathing with warm water will help. The authors aim to conduct research on "The Effect of Ginger Decoction on Edema in Pregnant Women's Legs at Kasih Ibu Pratama Clinic in 2024" based on the above information and data. They believe that foot soaks can also be combined with other herbal ingredients. The research method used a population of 100 with a sample of 17 individuals, employing a quantitative research design and a one-group pre-test post-test model, where observations were made before and after treatment with data analysis using the Wilcoxon test. The study found that ginger decoction has an effect on reducing edema in the legs of pregnant women. The test results showed a probability of 0.01. This means that the probability < level of significance (? = 0.05), so Ha is accepted, and H0 is rejected, indicating a significant difference between leg edema in pregnant women before (pre-test) and after (post-test) the administration of ginger decoction. Therefore, ginger decoction has an effect on reducing edema in pregnant women's legs.

Carbon dioxide (CO2) as an alternative contrast agent in percutaneous transluminal angioplasty procedures for chronic limb-threatening ischemia patients with chronic kidney disease

Background: Chronic limb-threatening ischemia (CLTI) is a very morbid illness that significantly reduces quality of life. The severity of this disease may necessitate revascularization or amputation. Arteriography is frequently performed for the planning of revascularization. Patients with compromised kidney function need alternative contrast agents. CO2 may be utilized in lower extremity vascular diagnostics and intervention, especially in patients at risk for contrast-induced nephropathy (CIN). Case Illustration: An 80-year-old female with bilateral leg pain and leg swelling had an ulcer on her toe for 2 weeks. She had a history of intermittent claudication for 1 year, hypertension for 5 years, kidney stones for 2 years, and chronic kidney disease for 1 year. She underwent an ECG, laboratory, USG, DUS, and CT-angiography examination. From her laboratory result, her initial creatinine was 5.02 mg/dL (eGFR 8 mL/m/1.73 m2). After good hydration, it became 1.28 mg/dL (eGFR 39 mL/m/1.73 m2). After a CT-angiography procedure, her creatinine level was increased (3.7 mg/dL; eGFR 10.9 mL/m/1.73 m2). She was diagnosed with CLTI Rutherford V Fontain 3 left lower extremity. She suggested doing an angioplasty procedure with a safer contrast agent. An angioplasty procedure was done at RSSA Malang with CO2 contrast. After the procedure, her leg pain improved, and her creatinine didn’t elevate. Conclusion: CO2 angiography might be used as a safe alternative contrast medium in patients with CLTI, which benefits the preservation of renal function and prevents limb amputations. Keyword: chronic limb-threatening, chronic kidney disease, CO2 angiography, contrast-induced nephropathy, peripheral artery disease

Development and validation of a prognostic score integrating remote heart failure symptoms and clinical variables for mortality risk prediction after myocardial infarction. The PragueMi score

Abstract Background While heart failure (HF) symptoms are associated with adverse prognosis after myocardial infarction (MI), they are not routinely used for patients’ stratification. Purpose The primary objective of this study was to develop and validate a score to predict mortality risk after MI, combining remotely recorded HF symptoms and clinical risk factors, and to compare it against the guideline-recommended GRACE score. Methods A cohort study design using prospectively collected data from consecutive patients hospitalized for MI at a large tertiary heart centre between June 2017 and September 2022 was used. Results Data from 1,135 patients (aged 64±12 years, 26.7% women), were split into derivation (70%) and validation cohort (30%). Components of the 23-item Kansas City Cardiomyopathy Questionnaire (KCCQ) questionnaire and clinical variables were used as possible predictors. The best model included the following variables – age, heart failure history, admission creatinine and heart rate, ejection fraction at hospital discharge, and HF symptoms 1 month after discharge including walking impairment, leg swelling, and change in HF symptoms. Based on these variables, the PragueMi score was developed. In the validation cohort, the PragueMi score showed superior discrimination to the GRACE score for 6 months (AUC 90.1, 95% CI 81.8-98.4 vs. 77.4, 95% CI 62.2-92.5, p=0.04) and 1-year risk prediction (AUC 89.7, 95% CI 83.5-96.0 vs. 76.2, 95% CI 64.7-87.7, p=0.004). Conclusion The PragueMi score combining heart failure symptoms and clinical variables performs better than the currently recommended GRACE score.

7703 Adrenal Cortical Carcinoma With Vascular Involvement - Complex Case Requiring Life-Saving Surgery With Bovine Pericardium- IVC Reconstruction

Abstract Disclosure: V. mehta: None. M. Renzu: None. K.N. Pereira: None. S. Sampath: None. S. Sruthi: None. E.B. Ruby: None. Adrenocortical carcinomas (ACCs) are rare endocrine tumors that exhibit unusual biological characteristics. Roughly 66% of cases are functional and have excessive hormone release causing classic symptoms of hypercortisolism, including plethora, diabetes, muscle weakness/atrophy, virilization, and osteoporosis. Few present with vague signs due to mass effects, including but not limited to abdominal/flank pain, fullness, or early satiety; the rest are incidental findings. We present a case of a 55-year-old female with no medical history presented following weeks of progressive abdominal pain with abdominal wall erythema, leg swelling, and dyspnea along with hirsutism, leukocytosis, elevated BNP, hematuria concerning for abdominal wall cellulitis and new-onset CHF. Initial CT chest revealed incompletely visualized incidental adrenal mass. Further investigations with CT abdomen and lab work revealed a left adrenal mass suspicious for ACC, extending into the left renal vein and IVC, elevated urine metanephrines and normetanephrine, and elevated cortisol levels with low ACTH. The dexamethasone suppression test confirmed inadequate cortisol suppression. Patient underwent aggressive surgery with exploratory laparotomy revealing tumor thrombus in left renal vein extending into Inferior vena cava (IVC). A left adrenalectomy, nephrectomy, and IVC reconstruction using a Bovine Pericardial Patch (BPP), which is majorly used for arterial reconstruction, was performed. Pathology results indicated ACC, measuring 13.5 cm, with extension into renal vein and vascular invasion, staged as pT4pN0 cM0 without evidence of deficient mismatch repair protein expression. ACCs are rare and profoundly aggressive malignancies with an incidence rate of 0.7–2.0 per million per year with bimodal age distribution. Disease peaks before the age of five and in the fourth to fifth decade of life, with increased incidence in females. Diagnosis cannot be conclusively established by a single histological technique, imaging, hormonal work-up, or immunohistochemical labeling, but surgical excision is the gold standard. Complete surgical resection is the only possible approach for curing or improving survival chances in patients with adrenal mass/metastasis. A retrospective case study of 36 venous reconstructions using BPP showed few complications like thrombosis in 14% (versus 11% in autologous venous repair), 11% reoperated, 3-4% developed partial thrombus and hematoma. Our case exemplifies the successful management of challenging ACC with vascular involvement using BPP, which is mostly used for arterial repairs and is now expanding to venous repairs. Outcomes stress the ongoing need for research and collaborative efforts to refine and standardize the ideal approach to ACC patients with IVC thrombosis and the use of BPP in venous repair. Presentation: 6/1/2024

7533 Mifepristone For Primary Hypercortisolism Contributing To Profound Hypokalemia

Abstract Disclosure: J. Watkins: None. J.G. Melendez-Rivera: None. E. Florin: None. K.B. Rivera: None. Background: Primary hypercortisolism is typically treated surgically, but when adrenalectomy is not pursued, medical therapy can be effective. Adrenal enzyme inhibitors or glucocorticoid antagonists can be used. Mifepristone is the only available glucocorticoid antagonist at this time. Mifepristone is approved specifically for glucose control in Cushing’s syndrome. Because mifepristone blocks cortisol action rather than production, hormone levels may increase and are unhelpful in titrating the mifepristone dose. Rather, titration is based on clinical manifestations of Cushing’s syndrome. Further, the increased hormone levels can lead to increased activation of mineralocorticoid receptor, in addition to the increased activation caused by hypercortisolism, which can cause hypokalemia. Clinical Case: An 82-year-old woman had been following with endocrinology for hypercortisolism found to be secondary to bilateral adrenal adenomas. She preferred medical therapy rather than surgery given her age, and she was started on mifepristone 300 mg/day. Within a few weeks, she developed leg swelling and was started on a low dose of chlorthalidone by her primary care doctor. She then presented to the emergency department after five days of nausea, abdominal pain, palpitations, and reduced oral intake. She was found to have severe hypokalemia (potassium 1.8 mEq/L, normal 3.5 - 5.0 mEq/L), and her creatinine was 0.97 µmol/L (baseline 0.6-0.75 µmol/L). Physical exam was unremarkable. CT abdomen/pelvis revealed three adrenal lesions, similar to a study from one year prior. Her mifepristone was stopped, and she was given potassium supplementation and started on spironolactone with eventual stabilization of her potassium level. She was also started on ketoconazole for management of her hypercortisolism. It was discussed that she might now consider adrenal vein sampling to pursue adrenalectomy. Severe hypokalemia and borderline metabolic alkalosis were most likely multifactorial in etiology. Hypercortisolism predisposed the patient to hypokalemia. She was then started on mifepristone, which inhibits the glucocorticoid receptor thereby increasing activation of the mineralocorticoid receptor, which likely further contributed to hypokalemia. The leg swelling that she developed and saw her primary doctor for may have been a sign of over-activation of the mineralocorticoid receptor due to the mifepristone, and prescription of chlorthalidone at that time would have worsened the hypokalemia that was likely present at that time. Conclusion: It is important to be aware of the possible severity of side effects of medical therapy for hypercortisolism, such as severe hypokalemia. There is a role for increased awareness of routine monitoring of potassium levels, as well as considering spironolactone in many patients even prior to onset of hypokalemia. Presentation: 6/3/2024

Lower Leg Swelling - Noncontact Injury

Lower Leg Swelling - Noncontact Injury

ThP8.2 - Degree of Lymphatic dysfunction in severe obesity

Abstract Aim Obesity can affect the lymphatic system through a multitude of ways with patients presenting to lymphoedema clinics. The aim of this present study is to assess the degree of lymphatic dysfunction through Lymphoscinigraphy (LSG) scans in severely obese patients. Methods All obese patients who presented with leg swelling and underwent LSG scans were included in the study. Based on NICE guidelines they were graded as class 1 (BMI of 30-34.9 kg/m2), class 2 (35-39.9 kg/m2) and class 3 (40 kg/m2 or more). Severity of their Lymphoedema were categorised as mild (uptake 5-8%), moderate (uptake 2-5%), and severe (Uptake <2%) in accordance with the worst affected leg. These two variables were then compared. Results Of the 133 patients with BMI provided, the average BMI was 37.18Kg/m2. 54.89% of patients with BMI provided were classed as Obese.19 (26.03%) of these patients were classed as class 1 obesity and of these 68% had severe Lymphoedema. 14 (19.18%) were classed as class 2 obesity and 28% had severe Lymphoedema. 40 (54.79%) were classed as class 3 obesity and 28% had severe Lymphoedema. Conclusion Majority (75%) of obese patients had lymphatic dysfunction on LSG scans. Majority (62%) had mild to moderate Lymphatic dysfunction. Only 38% of patients with severe Obesity (40 kg/m2 or more) had severe Lymphatic dysfunction. Lymphoedema in Obesity is often not constitutional lymphoedema.

Assessing risk factors for elevated creatine kinase levels as an indicator of compartment syndrome following laparoscopic or robot-assisted colorectal cancer surgery in the lithotomy-trendelenburg position

BackgroundWell-leg compartment syndrome (WLCS) can occur due to compression and lower limb circulation disturbances caused by the surgical position during the procedure. Although rare, with an incidence of 1 in 3500 surgeries performed in the lithotomy position, it can lead to serious complications. Therefore, prevention and early diagnosis are critical. Symptoms of WLCS, such as leg pain, swelling, paresthesia, and serum creatine kinase (CK) levels are useful for diagnosis. This study aimed to investigate the risk factors for postoperative CK elevation in laparoscopic or robot-assisted colorectal cancer surgery performed in the lithotomy-Trendelenburg position.MethodsPostoperative CK levels were measured in 178 patients who underwent laparoscopic or robot-assisted colorectal cancer surgery between February 2022 and March 2023. We compared patient backgrounds, short-term outcomes, and thigh/calf circumferences between patients with CK levels ≥ 250 (n = 62) and those with CK levels < 250 (n = 116). We investigated risk factors for elevated CK levels using both univariate and multivariate analyses.ResultsFour patients with CK levels of 22405 U/L, 4685 U/L, 4050 U/L, and 3824 U/L reported symptoms, which improved with conservative treatment. The following independent prognostic factors were identified by multivariate analysis: male sex (odds ratio [OR], 4.403; 95% CI, 1.960 to 9.892), rectal surgery (OR, 2.779; 95% CI, 1.249 to 6.184), continuous head-down position duration ≥ 180 min (OR, 3.523; 95% CI, 1.552 to 7.997), and preoperative calf circumference ≥ 33 cm (OR, 2.482; 95% CI, 1.154 to 5.339).ConclusionsRisk factors for CK elevation after colorectal cancer surgery in the lithotomy position include male sex, rectal surgery, an extended continuous head-down position without position changes, and a larger preoperative calf circumference. This study highlights the potential importance of intraoperative position changes every 3 h for preventing elevated CK levels, although the preventive effect was not specifically examined.

Evaluation of treatment outcome in extrapulmonary tuberculosis: A mixed method study from Puducherry

BackgroundExtrapulmonary tuberculosis (EPTB) is also a public health problem and involves other parts of the body other than lung. During the quarterly review meeting of State Task Force (STF), Puducherry the members raised concern about the outcome of patients referred from the medical colleges. Even though we receive 60 % feedback of initiation of treatment from the PHI but the treatment outcome of EPTB is not clear. Hence primary agenda of this research was to identify the gap in adherence to diagnostic criteria and treatment. AimTo assess the methods adopted for diagnosis of EPTB and to find out the compliance and outcome of the treatment and to identify the patient and health providers related factors that contribute to the outcome of the treatment. Material and methodStudy design: An explanatory mixed method study. Data collection: The information on methods adopted for diagnosis and category of treatment followed in EPTB was extracted from TB register and patient record sheets from the Medical College. House visits was made to trace the patients and the information related to duration of treatment and the outcome of treatment was found. Free listing was conducted to explore the reasons (facilitating and barriers) contributed to the outcome of the EPTB patients. Data analysis: Using EpiData (version 3.1, EpiData Association, Odense, Denmark), data was entered and analysed. The qualitative data was entered and analysed using Visual Anthropac (Ver_1.0.1.36; Analytic Technologies, Inc., USA) software package. ResultsMore than three-fourth (83.6%) of the patients completed extrapulmonary tuberculosis treatment. The site of EPTB emerged as significant predictor for disease outcome. The most salient facilitating factors and barriers contributed to the outcome of treatment were “periodic reminders and care by the family members” and Side effects such as giddiness, loss of sleep and appetite, discolouration of urine, gastritis, difficulty in breathing and walking, swelling of legs, weight and hair loss and myalgia” respectively. ConclusionThe study found that there is good compliance and outcome in treatment outcome. Efforts should be made to overcome the barriers to the outcome of treatment.

Angiographic Profile of Coronary Artery Disease in Patients of Heart Failure Attending in BPKIHS, Nepal

INTRODUCTION Coronary Angiography in heart failure is one of the diagnostic modalities that acts as complementary tool in the management. Very few studies are conducted in Nepal regarding prevalence of CAD in HF. CAD has been one of the etiologies in 18% patients of Heart failure.1 On categorizing heart failure patients into ischemic and non-ischemic groups and knowing any anomalous anatomy would be feasible to intervene as essential and decrease in recurrent hospital admissions and improve quality of life. Our current study aimed to evaluate various characteristics and profiles of Coronary Arteries in the heart failure subjects after Coronary Angiography. METHODS It was a single center hospital based descriptive cross-sectional study conducted at BPKIHS from October 2022 to October 2023 in heart failure patients who underwent CAG. Heart failure patients were selected based on Framingham criteria. RESULTS Out of total 78 patients 64.15 were males and mean age was 62.4±13.69 years. There were 47.4% patients with HFrEF, 28.2% with HFmrEF and 24.4% were having HFpEF. Significant CAD was found in 70.5%, normal Coronary artery was present in 2.8%, 2.5% had anomalous coronary artery, minor CAD was found in 2.6% while 5.1% had moderate CAD. Prevalence of significant CAD was found in 70.3% patients with HFrEF, 68.2% in HFmrEF whereas HFpEF had significant CAD in 73.7% subjects. Significant CAD in males and females were 48.7% and 70.5% respectively. Smoking was the most common risk factor present in our study population. Most common presentation were Basal Lung Crepitations, Raised JVP, Hepatomegaly and Leg Swelling. CONCLUSION Our result suggests higher prevalence of CAD in HFpEF (73.7%) followed by HFrEF (70.3%) and HFmrEF (68.2%). Coronary anomaly was seen in 2.5% while angiographic profile revealed abnormal coronary artery to be more frequent in HF subjects which was quite comparable to other similar studies of Heart failure.

Prevalence and Predictors of Leg Cramps in the Third Trimester of Pregnancy: A Cross-Sectional Study.

This study aimed to estimate the prevalence and determine predictors of leg cramps among pregnant women in their third trimester. A sample of pregnant women in their third trimester who routinely visited local clinics in Jordan was recruited. Participants completed a socio-demographic and clinical characteristics questionnaire, the numeric pain rating scale (NPRS) for leg cramp pain intensity, the Arabic version of the Pregnant Physical Activity Questionnaire (PPAQ), the Nordic Musculoskeletal Questionnaire (NMQ), Short Form Health Survey (SF-12), Pittsburgh Sleep Quality Index (PSQI), and Hospital Anxiety and Depression Scale (HADS). In addition, magnesium (Mg) and calcium (Ca) serum levels were examined. Logistic regression analyses were used to identify predictors of leg cramps occurrence. A linear regression model was used to investigate predictors of leg cramps pain intensity among pregnant women who reported leg cramps. Two hundred and five (n=205) pregnant women completed the study. The estimated prevalence of leg cramps was 58%. Logistic regression results showed that not receiving assistance with housework (OR 0.46, p=0.025), progress in the number of gestational weeks (OR 1.10, p=0.021), the number of previous pregnancies (OR 1.21, p=0.049), having leg swelling (OR 2.28, p=0.019), and having gastrointestinal (GIT) problems (OR 2.12, P=0.046) were associated with a higher odds of leg cramps occurrence. In the subsample with pregnant women with leg cramps, linear regression results showed that pregnant women with high school education versus elementary school (β=0.70, p=0.012), number of working hours (β=0.11, p=0.010), using vitamins supplements (β=-1.70, p=0.043), having diabetes after pregnancy (β=1.05, p=0.036), having sciatica (β=0.58, p=0.028), having hip pain (β =-.33, p=0.029), and higher PSQI total score (β=0.09, p=0.020) were the significant predictors of leg cramp pain intensity. Many health-related conditions, as well as work and home-related work characteristics, may be considered risk factors for the occurrence of leg cramps and increased leg cramps pain intensity in pregnancy.

A Case Report of Crotalidae Immune F(ab')2-associated Coagulopathy Recurrence in a Preschool-age Child.

Pit viper envenomation may cause coagulopathy. The coagulopathy has been treated with crotalidae polyvalent immune fragment antigen-binding (Fab) ovine antivenom for the last few decades in the United States and usually corrects the acute coagulopathy within hours. Days after receiving Fab, coagulopathy may recur in approximately half of the patients. Another divalent antivenom, crotalidae immune F(ab')2 (equine)-F(ab')2-was approved by the US Food and Drug Administration for the treatment of pit viper envenomation. F(ab')2 is composed of two linked antigen-binding fragments of immunoglobulin G. Several studies have demonstrated that F(ab')2 is less likely to be associated with recurrence. There is no reported case of F(ab')2-associated late coagulopathy in very young patients. We report the first case of recurrence associated with F(ab')2 use in a preschool-age child. A preschool-age male developed leg swelling and hypofibrinogenemia after rattlesnake envenomation. F(ab')2 was administered to stabilize the leg edema and to correct the hypofibrinogenemia. The patient improved clinically and was discharged on hospital day five. Seven days after the rattlesnake envenomation, he returned to the emergency department as instructed. Laboratory data revealed recurrent hypofibrinogenemia. There are two antivenoms available in the US to treat crotalid envenomation, Fab and F(ab')2. F(ab')2 is less likely to be associated with recurrent coagulopathy in comparison to Fab. We report the first case of recurrence associated with F(ab')2 in a preschool-age child. It is important that the emergency physician be aware of potential F(ab')2-associated recurrent coagulopathy. Adult and pediatric patients may need to follow up to be evaluated for hypofibrinogenemia and/or thrombocytopenia after receiving F(ab')2.

An Interesting Case of Cushing Syndrome

An Interesting Case of Cushing Syndrome A 36 year old female presented to dermatology department with Multiple ulcers present in B/L axilla, B/L inframammary fold and B/L gluteal fold (Left &gt; Right) since 3 months. Patient was referred from dermatology department to General Medicine for opinion on puffiness of face and swelling of legs . Patient had history of topical steroid use for itchy lesions in B/L axilla and inframammary folds 4 months back . H/o weight gain present. (6 kg). H/o puffiness of face and striae present over the abdomen. Patient had no known comorbidities previously. On physical examination patient had moon face ,facial plethora + ,Buffalo hump ,Loss of axillary hair, centripetal obesity , Abdominal striae , Sparse pubic hair , Pallor +. Systemic examination was normal. Investigations revealed new onset diabetes , serum cortisol was low (&lt;0.5 mcg/ml) , serum acth was low (1pg/ml) , HB was low (7.9gm/dl) , total count was elevated (15,600) . Patient was diagnosed to have Iatrogenic (Topical steroid induced) Cushing Syndrome with Steroid induced atrophy and ulceration of skin &amp; subcutaneous tissue leading to secondary fungal and bacterial infection , tinea incognito with secondary bacterial infection , iron deficiency anemia and newly detected Type 2 Diabetes mellitus. Patient was appropiately treated with iv antibiotics (Inj Piperacillin Tazobactum 4.5 g iv thrice daily), daily dressing on other supportive measures along with discontinuation of steroids. Patient improved symptomatically after discontinuing topical steroids, the cushingoid features started decreasing. The ulcers also started to heal. The patient was started on Tab. Hydrocortisone 10mg - 0 – 5mg and was referred for Endocrinologist opinion

Nephrotic syndrome and adrenoleukodystrophy in a 5-year-old boy.

Nephrotic syndrome is a common condition characterized by filtration of large amounts of protein, hypoalbuminemia, reduced plasma oncotic pressure, sodium retention, and edema. The mechanism responsible for sodium retention in this condition is still controversial. Two different pathophysiological pathways have been proposed to explain edema formation: activation of neurohumoral effector mechanisms, including the renin-angiotensin-aldosterone system, or abnormal intrinsic/primary renal sodium retention. A 5-year-old boy with X-linked adrenoleukodystrophy presented with bilateral leg swelling, massive proteinuria, and hypoalbuminemia. Minimal change disease was diagnosed. The patient was initially treated with corticosteroids and experienced several relapses. The progression of fractional excretion of sodium correlated with proteinuria and undetectable aldosterone levels. This unusual finding suggests that the mechanism of tubular sodium avidity in this child with mineralocorticoid insufficiency was independent of the renin-angiotensin-aldosterone system.

Insulin-induced Lipohypertrophy in a Patient with Type 2 Diabetes

Abstract Lipohypertrophy (LH) is a common side effect of insulin treatment in patients with diabetes, characterized by soft, benign nodules in the subcutaneous tissue. This case report describes the management of insulin-induced LH in a 66-year-old male with type 2 diabetes. The patient had been on a combination of oral antidiabetic agents (ODAs) and biphasic human insulin for 5 years, experiencing the symptoms of numbness, leg swelling, fatigue, and frequent hypoglycemic episodes. Upon examination, LH with skin pigmentation was observed at the insulin injection sites on both calves. The patient’s laboratory investigations revealed poor glycemic control with high glycated hemoglobin percentage. To address the condition, the patient was advised to change the injection site, use proper site rotation, and change the insulin needle daily. The insulin therapy was modified by switching to biphasic premixed analog insulin injected 5 min before meals using the insulin pen. In addition, ODAs were adjusted for better glycemic control. Following these interventions, the patient reported improved glucose levels and stable kidney function. This case report emphasizes the importance of early detection and appropriate management of insulin-induced LH through patient education and insulin therapy adjustments. Health-care providers should remain vigilant for LH and educate patients on proper injection practices to optimize diabetes management and prevent complications.

Poster 367: Nano-Semiconductor Fibers in a Commercial Compression Sleeve Accelerates Healing of Achilles Tendon Injury in a Rat Model

Objectives: Commercial compression sleeves have been promoted to ameliorate pain secondary to arthritis and tendinopathy. The fabric of one particular sleeve is embedded with nano-semiconductor fibers that reflect thermal energy produced by the body at a photonic wavelength mimicking low-level laser therapy. The device is theorized to accelerate the inflammatory stage of tissue healing to reach the proliferation and remodeling stages at faster rates. Previous clinical studies have shown a significant improvement in patient-reported outcomes between patients who did and did not use this sleeve to treat osteoarthritis. The objective of this investigation was to determine if compression sleeves embedded with nano-semiconductor fibers can accelerate Achilles tendon healing in a rabbit model. Methods: Twelve New Zealand White rabbits—under IACUC approval—were administered intratendinous injections of 0.2% collagenase into the right Achilles tendon to simulate an acute tendon injury. Rabbits were divided into three groups: group I received the commercial compression sleeve without nano-semiconductors (n = 4), group II received the sleeve with nano-semiconductors (n = 4), and group III received an alternate sleeve design also with nano-semiconductors (n = 4). Calf circumference measurements and thermal radiation imaging of the right lower leg of each rabbit were collected days 7, 14, 21, and 28 post-injection. Two rabbits from each group were sacrificed at the 14-day and 28-day marks and the right Achilles tendons were harvested. Histological analysis using picrosirius red staining was performed to evaluate tissue organization. A custom MATLAB program (MathWorks, Natick, MA) was used to quantify the collagen fiber dispersion within the Achilles tendon samples. Results: A statistically significant difference in calf circumference was found at the 28-day mark between group I versus groups II and III: group I had an average calf circumference of 5.2 cm while groups II and III had an average calf circumference of 4.85 cm (p = 0.036) and 4.60 cm (p = 0.021) respectively. Additionally, after 28 days, group I demonstrated an average pixel density intensity on thermal radiation imaging of 1,531,192 while groups II and III yielded average pixel density intensities of 1,363,515 (p = 0.008) and 1,335,456 (p = 0.003) respectively. Histological staining showed observable alterations in collagen architecture, with group I displaying widespread disorganization and degradation of type I and type III collagen fibers near the injection site. Groups II and III displayed greater organization at the 28-day mark in comparison to group I, with signs of tissue proliferation and remodeling evident. No statistically significant differences were found between group I versus groups II and III regarding collagen fiber dispersion at both the 2-week mark (p = 0.145, p = 0.236) and the 4-week mark (p = 0.113, p = 0.268), respectively. Conclusions: The nano-semiconductor fibers embedded within a commercial sleeve significantly decreased swelling and temperature of the lower leg 28 days following acute Achilles tendon injury in a rabbit model. Furthermore, histologic analysis demonstrated greater collagen fiber and extracellular matrix organization as well as greater proliferation of type III collagen suggesting a faster transition to the proliferation stage of tissue healing.

Cutaneous Metastasis of Ovarian Tumor after Hysterectomy and Bilateral Salpingo-oophorectomy: A Case Report

OBJECTIVES Cutaneous metastases are a very rare presentation of ovarian tumors (OV). They occur in about 3.5 percent of cases. The prognosis of cutaneous metastases is not good despite recent treatment modalities. Researchers are looking for much more personalized treatments. The patient had a history of ovarian tumor, for which she had a hysterectomy and bilateral salpingo-oophorectomy. She presented with multiple cutaneous eruptions. The histopathology shows high-grade serous carcinoma of the ovaries. Immunochemistry is positive for cytokeratin 7, WT1, and CAX. She had developed left leg swelling, generalized edema, and complaints of dysuria and difficulty defecating. Many targeted therapies have been developed, such as inhibiting growth factor receptors and immunological treatments that induce cell death, opening the door to precision medicine.

Transformation of t(14;18)-negative follicular lymphoma to plasmablastic lymphoma: a case report with analysis of genetic evolution

BackgroundFollicular lymphoma (FL) is characterized by t(14;18)(q32;q21) involving the IGH and BCL2 genes. However, 10–15% of FLs lack the BCL2 rearrangement. These BCL2-rearrangement−negative FLs are clinically, pathologically, and genetically heterogeneous. The biological behavior and histological transformation of such FLs are not adequately characterized. Here, we report the first case of t(14;18)-negative FL that rapidly progressed to plasmablastic lymphoma (PBL).Case presentationA previously healthy 51-year-old man presented with leg swelling. Computed tomography (CT) showed enlarged lymph nodes (LNs) throughout the body, including both inguinal areas. Needle biopsy of an inguinal LN suggested low-grade B-cell non-Hodgkin lymphoma. Excisional biopsy of a neck LN showed proliferation of centrocytic and centroblastic cells with follicular and diffuse growth patterns. Immunohistochemical analysis showed that the cells were positive for CD20, BCL6, CD10, and CD23. BCL2 staining was negative in the follicles and weak to moderately positive in the interfollicular areas. BCL2 fluorescence in situ hybridization result was negative. Targeted next-generation sequencing (NGS) revealed mutations in the TNFRSF14, CREBBP, STAT6, BCL6, CD79B, CD79A, and KLHL6 genes, without evidence of BCL2 or BCL6 rearrangement. The pathologic and genetic features were consistent with t(14;18)-negative FL. Two months after one cycle of bendamustine and rituximab chemotherapy, the patient developed left flank pain. Positron emission tomography/CT showed new development of a large hypermetabolic mass in the retroperitoneum. Needle biopsy of the retroperitoneal mass demonstrated diffuse proliferation of large plasmablastic cells, which were negative for the B-cell markers, BCL2, BCL6, and CD10; they were positive for MUM-1, CD138, CD38, and C-MYC. The pathologic findings were consistent with PBL. The clonal relationship between the initial FL and subsequent PBL was analyzed via targeted NGS. The tumors shared the same CREBBP, STAT6, BCL6, and CD79B mutations, strongly suggesting that the PBL had transformed from a FL clone. The PBL also harbored BRAF V600E mutation and IGH::MYC fusion in addition to IGH::IRF4 fusion.ConclusionsWe propose that transformation or divergent clonal evolution of FL into PBL can occur when relevant genetic mutations are present. This study broadens the spectrum of histological transformation of t(14;18)-negative FL and emphasizes its biological and clinical heterogeneity.

#2026 Hypokalemia associated to neuroendocrine carcinoma of the cervix

Abstract Background and Aims Hypokalemia is one of the most common electrolyte disorders seen in clinical practice. Hypokalemia can be caused by decreased intake of potassium, redistribution of potassium (K+) in cells or by excessive gastrointestinal losses or renal losses. In this setting, hypokalemia may also be caused by the paraneoplastic production of ectopic adrenocorticotropic hormone (ACTH) by some tumors. Cancer of the uterine cervix is the fourth common cancer affecting women worldwide and the fourth most common gynecologic cancer in Spain. Neuroendocrine carcinoma of the cervix represents about 2% of all cervical neoplasms. Method We report the case of a 44-year-old Peruvian woman with hypokalemia who was diagnosed with Cushing syndrome secondary to paraneoplastic production of ACTH by neuroendocrine carcinoma of cervix. Results Patient was overweight and affected by uterine myoma and anemia without further investigations. She was admitted to our hospital due to lower back pain, leg swelling and constipation. Blood pressure was normal, chest radiography did not show abnormal findings and ECG showed the U wave. Laboratory tests at admission revealed hypokalemia (2.3 mmol/L), metabolic alkalosis, anemia (hemoglobin 9.5 g/dL), hyperkaliuria (K+ urine/Creatinine urine 70 mmol/g) with an elevated transtubular potassium gradient (TTKG=12) and normal renal function. Laboratory data are presented in Table 1. She developed hypertension in the first day of hospitalization. Renin, aldosterone and cortisol tests was performed. Hypercortisolism was observed and confirmed with 24-hour urinary cortisol excretion. Because of an elevated ACTH (263 pg/mL), pituitary magnetic resonance imaging was performed without lesions. Whole-body computed tomography revealed a cervical mass. PET scan showed pelvic, adrenal, hepatic and local lymphadenopathy activity (see Fig. 1). After the histopathological study, diagnostic of small cell neuroendocrine carcinoma of the cervix was made. Chemotherapy therapy was initiated with cisplatin/etoposide regimen. The patient decide to return to Peru because of the poor prognosis of her illness. At discharge, potassium level was 3 mmol/L despite the treatment with spironolactone, ramipril, losartan and oral potassium chloride (160 mmol). Conclusion Hypokalemia is a common clinical disorder. In some patients it may be caused by an increased mineralocorticoid activity due to ectopic ACTH-secreting tumors. Applying diagnostic algorithms to electrolyte disorders, beyond their simple treatment, can unmask secondary causes and serious diseases.

Synchronous Ewing sarcoma of the fibula with involvement of the orbit and abducens nerve palsy

Simultaneous or synchronous Ewing sarcoma (ES) is the occurrence of multifocal lesions without pulmonary involvement. This is a very rare condition. We present a case of multifocal synchronous ES of the fibula with orbital involvement and adducens nerve palsy. A 17-year-old boy presented with pain and swelling in both legs for 6 weeks. He was unable to walk due to pain. He was pale and cachexic. There was proptosis and ptosis in the right eye. His investigations were consistent with a multifocal malignant tumor. There were lesions in the left fibula, tibia, right tibia, and right orbit. The histopathological diagnosis was Ewing sarcoma (ES). This is the first report of synchronous ES involving the orbit and abducens nerve.