Medical Etiology Research Articles

Sensate focus touch in sexual health and sex therapy: A critical literature review

ABSTRACT Introduction Sensate Focus Touch forms the foundation of modern sex therapy and continues to be widely used in both medical and mental health. Seen initially as purely a behavioral and educational technique, its similarities to mindfulness and somatic approaches have expanded our understanding of the mechanisms involved in its’ use. Masters & Johnson's more recent instructional modifications were poorly disseminated and have been the subject of a number of publications endeavoring to update the field. A preliminary literature review was conducted in 2015 to investigate the use of Sensate Focus. The most recent literature review covers the period 2014-2019 and was a follow up to that initial study. Objective The objective of the study was to examine the use and efficacy of Sensate Focus especially with varied populations, therapies and applications and to note instructional variations in medical and mental health publications. Methods A systematic database search of scholarly works published between January 2015 and June 2018 in medicine and mental health was conducted using the search term “sensate focus”. Non-English, duplicate, unrelated and publications by the authors were removed. The 48 works which met full criteria were reviewed. Results Publications in both medical and mental health continue to reflect the widespread use of Sensate Focus for a variety of sexual concerns with medical, psychosocial and mixed etiologies. The application of Sensate Focus to more diverse populations including cancer survivors, individuals with chronic pain, sexual trauma survivors, individuals with addictions and others was represented in the literature as well as the innovative use of group and online treatment programs. The literature also showcased a variety of therapeutic approaches combined with Sensate Focus including medical interventions, psychoanalytic, CBT, somatic and mindfulness. However, many studies simply mentioned the use of Sensate Focus without specifically defining its use, and other studies overwhelmingly utilized the 1970 version of “touching to give and receive pleasure” rather than the updated version which emphasizes touching in a mindful way without regard for pleasure in the initial stages. Numerous studies identified Sensate Focus as efficacious but extrapolation remains difficult due to the use of combined therapies such as CBT in the research design. Conclusion The use of Sensate Focus continues to be reflected in the medical and social science literature with evidence of efficacy in treating a wide variety of sexual concerns, including those of combined etiology. More diverse populations are being served in increasingly innovative ways with a new understanding of the somatic and mindfulness elements of Sensate Focus. Confusion remains about the specific updated instructions and the difference between use of Sensate Focus for sexual distress vs optimization of intimate sexual interactions. In general, more rigorous investigation is needed including operational definitions of variables, randomized control trials, long term follow up and isolating Sensate Focus as independent from other treatment modalities. Disclosure Work supported by industry: no.

Psychiatric Emergencies in Pediatrics

Key Points A youth’s mental health is highly dependent on the functioning of the family, school, and community; any disturbance in the functioning of these systems has the potential to precipitate an emergency requiring immediate mental health evaluation.Common types of psychiatric emergencies include suicidal threats or behavior; assaultive, destructive, otherwise violent behavior; and acute mental status changes (ie, intoxication, agitation, psychosis, delirium, or extreme anxiety with physical symptoms when a medical etiology has not been excluded).Circumstances warranting urgent (within 48–72 hours), but not necessarily emergent, evaluation include significant exacerbation of symptoms, distress, and/or functional impairment, which may be accompanied by highly concerning contextual circumstances, and/or overwhelming caregiver distress.Exposure to trauma (eg, violence, disaster) may precipitate a spectrum of psychological effects that vary according to developmental stage and, in some circumstances, present as a psychiatric emergency.Preparation of the pediatric practice for an effective emergency response includes an office emergency protocol (equivalent to a "code") and well-established connections to community mental health specialists and emergency service providers.The pediatric clinician’s roles may includeScreening for symptoms warranting emergent or urgent assessmentGathering of data from multiple informants (as available) when a youth is identified with potentially emergent or urgent symptomsConsensus with the caregiver, other referring party, and the patient on the nature of the encountered problem, its precipitants, and optimal next stepsReferral for emergency or urgent assessment and ongoing specialty management, as indicatedFollow-up to ensure completion of the referral and to support specialty management

Late Onset Psychosis and Grave's Disease: A Case Report

<h3>Introduction</h3> Prevalence of late life psychosis is 23%, however 60% of new onset psychosis in older individuals are of secondary etiology (Cohen, 2015). Psychosis in the elderly individuals could be primarily due to Very Late Onset Schizophrenia Like Psychosis (VLOSLP) vs secondary causes (Delirium, Dementia, Drugs/illicit substances/toxin, Medical conditions including autoimmune conditions.) The apparent link between autoimmune disorders and psychotic disorders has received increased interest in the last decades (Benros, 2019). A significant positive association was observed for pernicious anemia (OR = 1.91; 95% CI, 1.29–2.84), pemphigoid (OR = 1.90; 95% CI, 1.62– 2.24), psoriasis (OR = 1.70; 95% CI, 1.51–1.91), celiac disease (OR = 1.53; 95% CI, 1.12–2.10), and Graves' disease (OR = 1.33; 95% CI, 1.03–1.72) (Cullen, 2019). In this poster, we are presenting a case of a patient with Grave's disease presenting with first episode of psychosis at late age. <h3>Methods</h3> Elmhurst Hospital Center (EHC) is uniquely placed 545 bedded Hospital having 6 psychiatric inpatient units. We are presenting a case of a patient who was admitted in one of the psychiatric inpatient units. We reviewed studies and reviews over the past 10 years using PubMed, Medline and Google Scholar. Search terms included "psychosis", "autoimmune psychosis", "grave's disease" "autoimmune disorders" "very late onset psychosis" "geriatric psychosis". We reviewed available literature with regards to first episode of psychosis in old age and psychosis in autoimmune disorders specially Grave's disease. <h3>Results</h3> Stratified analyses revealed that not only is there increased comorbidity between NNAI (Non-Neurological Autoimmune) disorders and psychosis, but also NNAI disorders increase the risk for subsequent psychosis and vice versa (Alexis E. Cullen, 2019). Graves' disease which is the most common cause of hyperthyroidism, is also known to be linked to neuropsychiatric issues, and some even present with psychotic disorders (Benros, 2019). A German study found that in a cohort of 100 patients with a schizophreniform illness, 19 had increased antithyroid autoantibodies in sera, and 13 showed signs of intrathecal synthesis hereof (Endres D, 2017). Multiple factors have been suggested to underlie the observed association between NNAI disorders and psychosis, including inflammation, shared genetic vulnerability, predisposing infections, and brain-reactive antibodies (Benros ME, 2014). Along with the abovementioned possible mechanisms, in Grave's disease or hyperthyroidism, adrenergic hyperactivity is hypothesized to be a major cause of psychiatric symptoms (Bunevic?ius, 2010). Our patient's psychotic presentation substantially subsided as pharmacological interventions were taken for both hyperthyroidism and psychotic symptoms. While there have been gradually increasing literature on the association between autoimmune disorder such as Grave's disease and psychosis, there is limited work on the treatment recommendations and prognosis. <h3>Conclusions</h3> Our case is an example of psychosis of secondary etiology (due to autoimmune condition). Research on the field of psychoimmunology is gradually evolving. Most of the available literature is on the possible mechanisms of the association between autoimmune disorders including Grave's disease and psychosis. When patients present with first episode of psychosis at late age, a thorough evaluation and examination are required to rule out possible underlying medical etiologies. Similarly, when patients are diagnosed with Grave's disease and other autoimmune disorders, careful longitudinal monitoring is warranted for the early signs of psychosis. Further expansion of studies is required for targeted treatment recommendations and overall prognosis in such cases. <h3>This research was funded by</h3> No conflict of interest. <h3>References</h3> Jeppesen R and Benros ME (2019) Autoimmune Diseases and Psychotic Disorders. Front. Psychiatry 10:131. doi: 10.3389/fpsyt.2019.00131 Endres D, Dersch R, Hochstuhl B, Fiebich B, Hottenrott T, Perlov E, et al. Intrathecal thyroid autoantibody synthesis in a subgroup of patients with schizophreniform syndromes. J Neuropsychiatry Clin Neurosci. (2017) 29:365–74. doi: 10.1176/appi.neuropsych.16110296 Benros ME, Eaton WW, Mortensen PB (2014): The epidemiologic evidence linking autoimmune diseases and psychosis. Biol Psychiatry 75:300–306. Alexis E. Cullen, S. H. (2019). Associations Between Non-neurological Autoimmune Disorders and Psychosis: A Meta-analysis. Biological Psychiatry, 85:35–48.

Etiology and prognostic significance of ictal EEG patterns in patients with non-convulsive seizures.

We aimed to study the ictal EEG patterns in patients with non-convulsive seizures (NCS) and their relationship with underlying etiology and patient outcome. We conducted a retrospective review of EEG studies from patients undergoing continuous EEG (cEEG) monitoring for indication of altered mental status with a suspicion of NCS. Ictal EEG findings of NCS were categorized as three patterns: focal or generalized epileptiform discharges (EDs) at frequencies >2.5Hz (Pattern 1); EDs at frequencies of ≤2.5Hz or rhythmic activity >0.5Hz with spatiotemporal evolution (Pattern 2); and EDs with ≤2.5Hz with subtle clinical correlate during the ictal EEG or clinical and EEG improvement after a trial of IV anti-seizure drugs (Pattern 3). Patients with anoxic brain injury were excluded from the study. Associations between ictal EEG patterns and underlying etiology and their impact on in-hospital mortality was measured. Of 487 patients included in the study, NCS was recorded on cEEG monitoring in 57 (12%). The ictal EEG Pattern 2 was the most commonly seen ictal EEG finding in our cohort of patients with NCS (70%, n=40/57), followed by Pattern 3 (15%, n=9/57) and Pattern 1(14%, n=8/57). In patients with acute brain injury, Pattern 2 (67%, n=27/40) was a commonly seen ictal EEG finding, whereas Pattern 1 (62% n=5/8) was seen in patients with underlying acute medical illness. No statistically significant difference was found between ictal EEG patterns and underlying neurological versus medical etiologies (p=0.27) or in-hospital mortality (p=0.5). Spatiotemporal evolution of epileptiform discharges at a lower frequency was the most commonly recorded ictal EEG pattern in our cohort. Further prospective studies with a larger sample size of patients with NCS may provide valuable clinical data that could be used to evaluate the etiologic correlate of the various ictal EEG patterns and their effect on outcome.

The epidemiology of out-of-hospital cardiac arrest in Australia and New Zealand: A binational report from the Australasian Resuscitation Outcomes Consortium (Aus-ROC)

IntroductionThe Australasian Resuscitation Outcomes Consortium (Aus-ROC) out-of-hospital cardiac arrest (OHCA) Epistry (Epidemiological Registry) now covers 100% of Australia and New Zealand (NZ). This study reports and compares the Utstein demographics, arrest characteristics and outcomes of OHCA patients across our region. MethodsWe included all OHCA cases throughout 2019 as submitted to the Epistry by the eight Australian and two NZ emergency medical services (EMS). We calculated crude and age-standardised incidence rates and performed a national and EMS regional comparison. ResultsWe obtained data for 31,778 OHCA cases for 2019: 26,637 in Australia and 5,141 in NZ. Crude incidence was 107.9 per 100,000 person-years in Australia and 103.2/100,000 in NZ. Overall, the majority of OHCAs occurred in adults (96%), males (66%), private residences (76%), were unwitnessed (63%), of presumed medical aetiology (83%), and had an initial monitored rhythm of asystole (64%). In non-EMS-witnessed cases, 38% received bystander CPR and 2% received public defibrillation. Wide variation was seen between EMS regions for all OHCA demographics, arrest characteristics and outcomes. In patients who received an EMS-attempted resuscitation (13,664/31,778): 28% (range across EMS = 13.1% to 36.7%) had return of spontaneous circulation (ROSC) at hospital arrival and 13% (range across EMS = 9.9% to 20.7%) survived to hospital discharge/30-days. Survival in the Utstein comparator group (bystander-witnessed in shockable rhythm) varied across the EMS regions between 27.4% to 42.0%. ConclusionOHCA across Australia and NZ has varied incidence, characteristics and survival. Understanding the variation in survival and modifiable predictors is key to informing strategies to improve outcomes.

Images Made by Contagion: On Dermatological Wax Moulages

Moulages are contact media – images made by contagion in the most literal sense: their production relies on a process in which the object to be reproduced is touched by the reproducing material. In the case of dermatological moulages, the plaster touches the infected skin of the sick and, once dried, serves as the negative form for the waxen image of a disease. Focussing on the collection of the Hôpital Saint-Louis in Paris, the article situates the production of dermatological moulages within the visual culture of 19th-century medicine and raises the question how an ancient technique of image production could become such a prevalent tool for the documentation of skin diseases during a period usually associated with the rise of scientific medicine and a reconsideration of theories of contagion in medical aetiology.

Abstract- Poster

Background:- ”Catatonia” is characterized by alterations in motor, behavioral, and vocal signs occurring in the context of medical, neurologic, & psychiatric disorders. While considering medical etiology, renal failure has been described as one of the factors. It may result in seizures & catatonia. Furthermore, renal failure even though rare has also been implicated in the causation.Aim:- We aim to report a rare case describing multiple etiologies (Renal failure, Seizure, Covid-19) & treatment in a patient with catatonia.Result/Case report:- The patient had Covid-19 infection with concomitant renal insufficiency with uremia. He developed an episode of seizure on 3rd day of admission and subsequently developed catatonic symptoms in the post-ictal phase. He did not respond to anticonvulsive treatment but did so with Lorazepam.Discussion:- A variety of conditions can produce catatonia. It is less widely recognized that this state may be caused by seizures; which in turn can also be due to renal failure. Catatonia occurring in the wake of seizures generally responds to the anticonvulsive medication. Even though rare and anecdotal, catatonia has been reported in a few cases reports in patients suffering from Covid-19 infection & it can occur in both the para & post-infectious states.Conclusion:- We also want to highlight that lorazepam proved to be an effective and safe choice for the treatment of catatonic symptoms & eventually led to the improvement in the symptomatology of Covid-19. Therefore, we also propose further studies for the treatment of such patients.

Research Progress of TCM Treatment of Hysteromyoma

Hysteromyoma is a common disease that is difficult to cure in gynecology. In recent years, the incidence rate of hysteromyoma has gradually increased and Hysteromyoma patients are getting younger. Traditional Chinese Medicine (TCM) has the advantages of significant curative effect, appropriate price and no trauma. By exploring the modern medical research, etiology, pathogenesis and treatment of TCM, this paper hopes to contribute to the clinical treatment of this disease.

Effect of different combinations of initial body temperature and target temperature on neurological outcomes in out-of-hospital cardiac arrest patients treated with targeted temperature management

We hypothesized that different combinations of initial and target temperatures during targeted temperature management (TTM) may be associated with neurological outcomes in out-of-hospital cardiac arrest (OHCA) survivors. Adult patients with OHCA who underwent TTM were enrolled. The study participants were divided into four groups: lower initial body temperature and lower target temperature (Low-Low group), lower initial body temperature and higher target temperature (Low-High group), higher initial body temperature and lower target temperature (High-Low group), and higher initial body temperature and higher target temperature (High-High group). Initial body temperature was dichotomized based on the median value (35.6 ◦C) as a cutoff, and the target temperature was dichotomized with a target temperature of 34 ◦C as a cutoff. The primary outcome was defined as a favorable 28-day neurological outcome. In total, 231 patients were included in the analysis, and 74 (32.0%), 43 (18.6%), 82 (35.5%), and 32 (13.9%) patients were classified into the Low-Low, Low-High, High-Low, and High-High groups, respectively. The proportion of patients with favorable 28-day neurological outcomes differed among the study groups (Low-Low, 14 (18.9%); Low-High, 7 (16.3%); High-Low, 37 (45.1%); High-High, 11 (34.4%); p = 0.001). In the multivariable analysis, the Low-High group was independently associated with a less favorable 28-day neurological outcome compared to the High-Low group (adjusted odds ratio, 0.22; 95% confidence interval, 0.06–0.91; p = 0.036). In conclusion, higher initial body temperature and lower target temperature during TTM were independently associated with a more favorable 28-day neurological outcome compared to the lower initial body temperature and higher target temperature in patients resuscitated from OHCA of medical etiology.

The ED-PLANN Score: A Simple Risk Stratification Tool for Out-of-Hospital Cardiac Arrests Derived from Emergency Departments in Korea.

Early risk stratification of out-of-hospital cardiac arrest (OHCA) patients with insufficient information in emergency departments (ED) is difficult but critical in improving intensive care resource allocation. This study aimed to develop a simple risk stratification score using initial information in the ED. Adult patients who had OHCA with medical etiology from 2016 to 2020 were enrolled from the Korean Cardiac Arrest Research Consortium (KoCARC) database. To develop a scoring system, a backward logistic regression analysis was conducted. The developed scoring system was validated in both external dataset and internal bootstrap resampling. A total of 8240 patients were analyzed, including 4712 in the development cohort and 3528 in the external validation cohort. An ED-PLANN score (range 0–5) was developed incorporating 1 point for each: P for serum pH ≤ 7.1, L for serum lactate ≥ 10 mmol/L, A for age ≥ 70 years old, N for non-shockable rhythm, and N for no-prehospital return of spontaneous circulation. The area under the receiver operating characteristics curve (AUROC) for favorable neurological outcome was 0.93 (95% CI, 0.92–0.94) in the development cohort, 0.94 (95% CI, 0.92–0.95) in the validation cohort. Hosmer–Lemeshow goodness-of-fit tests also indicated good agreement. The ED-PLANN score is a practical and easily applicable clinical scoring system for predicting favorable neurological outcomes of OHCA patients.

446 Relationship between out of hospital cardiac arrest and COVID-19 pandemic: impact on outcome

AimsDuring 2020, Italy was hit by the pandemic of the ‘Coronavirus disease 2019’ (COVID-19) with an incidence/100 000 citizens characterized by two peaks. An increase in out-of-hospital cardiac arrest (OHCA) mortality during the first pandemic peak has already been described, but there are few data on the whole year. The goal of our study is to evaluate the impact of the pandemic on post-OHCA mortality.MethodsWe considered patients with OHCA in Varese territory from January to December 2020 with medical aetiology according with Utstein 2014 classification. The primary endpoint of the study was the assessment of acute post-arrest mortality and which parameters influence this outcome. In particular, both the role of pandemic peaks (‘first peak’ from 11 March 2020 to 23rd May 2020 and ‘second peak’ from 7 October 2020 to 31 December 2020) and the average rescue times, i.e.: (i) interval between OHCA and call for first aid (delay in activation of assistance); (ii) the interval between the call and the arrival of the rescue vehicles (delay in the arrival of the first aid) and finally; (iii) the time between the arrival of the rescue vehicles and the end of Cardiopulmonary Resuscitation (CPR), interrupted due to death or Recovery of Spontaneous Circulation (ROSC). Finally, we performed a multivariate analysis to assess which of the variables considered had the greatest impact on the outcome.ResultsWe analysed 708 patients (mean age 76 + 14.09 years; 40% women). Overall mortality was 89%. During the peaks there was an increase in mortality compared to the pre-pandemic period (first peak 96% vs. 83%, OR 4.49; second peak 92% vs. 83%, OR 2.45) (Figure 1). The time between the collapse and the call for help was significantly higher during the first pandemic peak compared to the second peak and the pre-pandemic period (P = 0.003); the time between the call and the arrival on the patient was significantly longer during both pandemic peaks than in the previous period (P = 0.002) and there was no significant difference in CPR duration time between the periods analysed. In a multivariate model, the only time associated with an increase in mortality is the period between the call for help and the arrival on the patient, regardless of the COVID-19 pandemic.Figure 1446 ConclusionsDuring the COVID-19 pandemic there has been an increase in mortality of patients with OHCA. Among the variables considered, the increase in mortality is mainly associated with the delay in the arrival of emergency vehicles on site. This delay, although decreasing, was also maintained during the second peak of the pandemic.

Abstract 8883: Pre-hospital Physician’s Presence and Neurological Outcome Among Patients Performed Pre-hospital Advanced Airway Management: A Nationwide Multicenter Observational Study in Japan (the Japanese Association for Acute Medicine-out-of-Hospital Cardiac Arrest Registry)

Purpose: Using the out-of-hospital cardiac arrest (OHCA) registry in Japan, we evaluated the effectiveness of pre-hospital advanced airway management under physicians’ presence after adjusting in-hospital treatments. Methods: This was a multicenter cohort study. We registered all consecutive OHCA patients in Japan who, from 1 June 2014 through 31 December 2017, were transported to institutions participating in the Japanese Association for Acute Medicine OHCA Registry. We included OHCA patients performed pre-hospital advanced airway management, who were ≥18 years of age with medical etiology and who received resuscitation from emergency medical services (EMS) personnel and medical professionals in hospitals. The primary outcome was one-month favorable neurological survival.We estimated the propensity score by fitting a logistic regression model that was adjusted for several variables before the arrival of EMS personnel and/ or pre-hospital physician. A multivariable logistic regression analysis in propensity score-matched patients was used to adjust confounders including extracorporeal membrane oxygenation, percutaneous coronary intervention, intra-aortic balloon pumping, and targeted temperature management. Results: We analyzed 9,672 patients. Among them, 2.3% (N = 218) had a neurologically favorable outcome. The adjusted odds ratio (AOR) of pre-hospital advanced airway management under physicians’ presence compared with their absence for primary outcome was 0.96 (95% confidence interval (CI): 0.61-1.51). Among first documented non-shockable cardiac rhythm, the AOR was 3.10 (95% CI: 1.05-10.77). Among first documented shockable cardiac rhythm, the AOR was 0.90 (95% CI: 0.53-1.53). Conclusion: In Japan, pre-hospital advanced airway management under physicians’ presence was not associated with one-month favorable neurological survival among patients with first documented shockable cardiac rhythm, whereas it was associated with a neurologically favorable outcome among patients with first documented non-shockable cardiac rhythm.

Abstract 12097: The Impact of a High-Performance Cardiopulmonary Resuscitation Protocol on Survival From Out-of-Hospital Cardiac Arrests Witnessed by Paramedics

Introduction: Some emergency medical services (EMS) have shown increases in survival from out-of-hospital cardiac arrest (OHCA) following the implementation of a high-performance cardiopulmonary resuscitation (CPR) protocol. Despite this, little is known about the effect of high-performance CPR on OHCA witnessed by EMS personnel. Methods: We performed a retrospective cohort study of adult, EMS-witnessed OHCA patients of medical etiology from a population-based registry in Victoria, Australia. Patients treated after the introduction of a high-performance CPR protocol and training program between February 2019 and January 2020 were compared to historical controls between January 2015 and January 2019. The effect of the intervention on survival to hospital discharge was examined using logistic regression models adjusted for temporal and arrest factors. Results: A total of 1,561 and 420 EMS-witnessed OHCA patients were treated in the control and intervention periods, respectively. Baseline characteristics were similar across control and intervention periods, including the median age of cases (69 vs. 69 years, p=0.97), male sex (65.2% vs. 60.5%, p=0.08) and initial shockable arrests (33.7% vs. 29.3%, p=0.09). Resuscitation interventions were similar across groups, except for the use of mechanical CPR which declined during the intervention period (17.0% vs. 10.7%, p&lt;0.001). Unadjusted survival to hospital discharge was similar across control and intervention periods for the overall population (29.4% vs. 32.1%, p=0.27), but significantly higher during the intervention period for initial shockable arrests (66.6% vs. 76.9%, p=0.03). After adjustment for confounders, cases in the intervention period were associated with a 43% increase (adjusted odds ratio [AOR] 1.43; 95% CI: 1.05, 1.94; p=0.02) in the risk-adjusted odds of survival to hospital discharge or a 79% increase (AOR 1.79, 95% CI: 1.09, 2.95; p=0.02) for initial shockable arrests. Conclusions: The implementation of a high-performance CPR quality improvement intervention was associated with significant improvement in survival from EMS witnessed OHCA. Efforts to monitor and improve CPR performance could yield further improvements in patient outcomes.

Abstract 12127: The Effect of Daylight Savings Time Transitions on the Incidence of Out-of-Hospital Cardiac Arrest: An Interrupted Time Series Analysis

Introduction: Many studies have reported increases in the risk of acute cardiovascular events following daylight savings time (DST) transitions. We sought to investigate the effect of DST transitions on the incidence of out-of-hospital cardiac arrest (OHCA) in Victoria, Australia. Methods: Between January 2000 and December 2020, we performed an interrupted time series analysis of the daily number of OHCA cases of medical etiology from the Victorian Ambulance Cardiac Arrest Registry. The effect of DST transition on OHCA incidence was estimated using negative binomial models and reported as either ‘immediate’ or ‘cumulative’ effects. Immediate effects were the average effects observed on the day of DST transition or each of the 6 days after DST transition. Cumulative effects were the sum of the average effects up to 6 days after the day of DST transition. Models were adjusted for population growth, temporal trends, and public holidays. Results: A total of 89,409 adult OHCA of medical etiology were included. Following the spring DST transition (i.e. shorter day), there was an immediate 13% (IRR 1.13, 95% CI: 1.02, 1.25; p=0.02) increased risk of OHCA on the day of transition (Sunday) and the cumulative risk of OHCA remained higher over the first 2 days (IRR 1.17, 95% CI: 1.02, 1.34; p=0.03) compared to non-transitional days. Following the autumn (fall) DST transition (i.e. longer day), there was a significant lagged effect on the Tuesday following transition, with a 12% (IRR 0.88, 95% CI: 0.77, 0.99; p=0.04) reduced risk of OHCA. The autumn (fall) DST transition also showed a cumulative effect on OHCA incidence, with a 30% (IRR 0.70, 95% CI: 0.51, 0.96; p=0.03) reduction in the incidence of OHCA by the end of the transitional week. Subgroups aged &gt; 65 years and cases with initial non-shockable rhythms were most vulnerable to DST transitions. Conclusions: This study showed that there is a modest increased risk of OHCA in the 2 days following the spring DST transition and a decreased risk of OHCA in the week following the autumn DST transition. These findings should promote further research exploring strategies to reduce the risk of OHCA in vulnerable populations.

A Clinical Review of the Psychiatric Sequelae of Primary Hyperparathyroidism.

Despite one-quarter of patients with primary hyperparathyroidism (PHPT) experiencing psychiatric symptoms, there remains a dearth of literature regarding the diagnosis and further management of psychiatric sequelae in PHPT. We aim to review the literature pertaining to the epidemiology, disease presentation, pathophysiology, diagnostics, and therapeutics regarding psychiatric sequelae of PHPT with an emphasis on clinical pearls for practicing psychiatrists. A literature search was conducted using the US National Library of Medicine’s PubMed resource using the following keywords in various combinations: primary hyperparathyroidism, neuropsychiatric, calcium, psychosis, mania, depression, catatonia, delirium, parathyroidectomy, and psychotropic medication. We discuss in depth all aspects of the diagnosis and management of psychiatric sequela in PHPT. We have also identified epidemiological trends, discussed the most common clinical presentations, and postulated possible mechanisms for psychiatric symptoms in PHPT. Psychiatrists should maintain diagnostic suspicion for PHPT in older adult female patients presenting with new-onset psychiatric illness. Several mechanisms involving the following may explain the variety of psychiatric symptoms in PHPT: tyrosine hydroxylase, parathyroid hormone, interleukin-6, monoamine oxidase, calcium, and the sodium-potassium adenosine triphosphatase transporter. We recommend psychiatrists take a symptom-oriented approach to management. Treating a patient’s psychosis, mania, depression, catatonia, delirium, or eating disorder pathology via conventional therapeutics seems like a rational approach despite the underlying medical etiology. Only parathyroidectomy has been proven to be definitive in the complete amelioration of psychiatric symptoms.

Helicopter Emergency Medical Services Out-of-Hospital Cardiac Arrests During the Initial COVID-19 Lockdown Versus Nonpandemic: A Comparison

ObjectiveCOVID-19 may have contributed to an excess of out-of-hospital cardiac arrests (OOHCAs). This observational study identified changes in OOHCA epidemiology pre– and post–COVID-19 lockdown in a single UK helicopter emergency medical service (HEMS). MethodsA retrospective, single-center (Essex & Herts Air Ambulance), observational study was undertaken with anonymized OOHCA data (demographics, etiology, and outcomes) from March 23, 2020, to June 23, 2020, and comparative data from March 23, 2019, to June 23, 2019. Supplementary data (total OOHCAs and patient outcomes) were provided by the East of England Ambulance Service National Health Service Trust. Data were analyzed using the Mann-Whitney U test and chi-square test; P < .05 was statistically significant.Results: Of the HEMS activations during national lockdown, 33.6% were for OOHCAs compared with 25.8% during the reference time frame. The frequency of young and female OOHCAs demonstrated a statistically significant increase. Statistically significant variations in medical etiology and initial cardiac rhythm were identified. ConclusionDuring the initial UK-wide lockdown, the OOHCA characteristics attended by 1 HEMS team were altered. The changes seen may be due to the pathophysiology of COVID-19 or an alteration in dispatch due to the demand placed on the wider ambulance service; this may require further consideration for any future lockdowns or pandemics.

Correction

Abdominal pain is a common cause of emergency department visits. It often poses a diagnostic challenge for physicians given the broad spectrum of its possible medical and surgical etiologies. We report the case of a 32-year-old man who presented to the emergency department with a complaint of lower abdominal pain for one week. Abdominal examination revealed suprapubic mass and tenderness. Laboratory investigation revealed elevated leukocyte count and inflammatory markers. An abdominal ultrasound examination showed a collection with poorly defined borders. Additionally, CT demonstrated a soft tissue mass adjacent to the anterior abdominal wall with an upward track to the umbilicus, conferring the diagnosis of a urachal abscess. The patient underwent successful management of the abscess with surgical excision. This case highlights the importance for clinicians to be aware of congenital urachal anomalies since early recognition of the urachal cyst is essential to determine the proper surgical management.

Daylight savings time transitions and risk of out-of-hospital cardiac arrest: An interrupted time series analysis

BackgroundMany studies have reported increases in the risk of acute cardiovascular events following daylight savings time (DST) transitions. We sought to investigate the effect of DST transition on the incidence of out-of-hospital cardiac arrest (OHCA). MethodsBetween January 2000 and December 2020, we performed an interrupted time series analysis of the daily number of OHCA cases of medical aetiology from the Victorian Ambulance Cardiac Arrest Registry. The effect of DST transition on OHCA incidence was estimated using negative binomial models, adjusted for temporal trends, population growth, and public holidays. ResultsA total of 89,409 adult OHCA of medical aetiology were included. Following the spring DST transition (i.e. shorter day), there was an immediate 13% (IRR 1.13, 95% CI: 1.02, 1.25; p = 0.02) increased risk of OHCA on the day of transition (Sunday) and the cumulative risk of OHCA remained higher over the first 2 days (IRR 1.17, 95% CI: 1.02, 1.34; p = 0.03) compared to non-transitional days. Following the autumn DST transition (i.e. longer day), there was a significant lagged effect on the Tuesday with a 12% (IRR 0.88, 95% CI: 0.77, 0.99; p = 0.04) reduced risk of OHCA. The cumulative effect following the autumn DST transition was also significant, with a 30% (IRR 0.70, 95% CI: 0.51, 0.96; p = 0.03) reduction in the incidence of OHCA by the end of the transitional week. ConclusionWe observed both harmful and protective effects from DST transitions on the risk of OHCA. Strategies to reduce this risk in vulnerable populations should be considered.

A-41 Not Just a “Clumsy” Kid: A Case Study of Developmental Coordination Disorder

Abstract Objective Developmental Discoordination Disorder (DCD) is an often overlooked and seldom diagnosed neurodevelopmental condition marked by impairments in motor skills. Lacking identifiable medical or neurological etiology, children with DCD often have preserved intellectual abilities. Comorbidity is common, including ADHD and specific learning disability. Despite extensive evidence of significant impact on daily activities and academics due to differences in motor behaviors, DCD difficulties are regularly treated as behavioral problems. Method Neuropsychological evaluation of an 8-year-old boy with a possible reading delay and inability to perform some age-appropriate academic and self-care tasks. Results Average overall ability with very strong verbal performances; intact visual perceptual processing, memory, and non-written language. Academics are within expected range, although graphomotor weakness impacted academic performances on tasks with written demands. Patient appeared clumsy and awkward with low muscle tone, poor balance, and difficulty learning new motor skills. Impaired fine motor control, handwriting, gait, gross motor skills, motor planning, coordination, and oromotor weakness as well as inferior verbal language abilities were evident. Impulsivity, inattention, poor planning, and poor self-monitoring were also evident. Conclusions DCD is evidenced by impairment in fine and gross motor skills, oromotor skills, motor planning, energy, and coordination with clear discrepancy between motor abilities and abilities in other areas, specifically language. In our case, DCD features were overlooked despite wide ranging impact. ADHD and SLD with impairment in written expression were concurrent. This case highlights the need for greater appreciation of DCD so that children can benefit from early detection and intervention considering the life-long implications of the disorder.

Physician’s presence in pre-hospital setting improves one-month favorable neurological survival after out-of-hospital cardiac arrest: A propensity score matching analysis of the JAAM-OHCA Registry

BackgroundUsing the out-of-hospital cardiac arrest (OHCA) registry in Japan, we evaluated the effectiveness of physicians’ presence in pre-hospital settings after adjusting in-hospital treatments. MethodsThis was a multicenter cohort study. We registered all consecutive OHCA patients in Japan who, from 1 June 2014 through 31 December 2017, were transported to institutions participating in the Japanese Association for Acute Medicine OHCA registry. We included OHCA patients aged at least 18 years, with medical etiology, and who received resuscitation from emergency medical services (EMS) personnel and medical professionals in hospitals. The primary outcome was one-month favorable neurological survival. We estimated the propensity score by fitting a logistic regression model that was adjusted for several variables before the arrival of EMS personnel and/or pre-hospital physician. A multivariable logistic regression analysis in propensity score-matched patients was used to adjust confounders, including extracorporeal membrane oxygenation, percutaneous coronary intervention, intra-aortic balloon pumping, and targeted temperature management. ResultsWe analyzed 19,247 patients. Among them, 5.4% (N = 1040) had a neurologically favorable outcome. The adjusted odds ratio (AOR) of the physicians’ presence compared with their absence for primary outcome was 1.84 (95% confidence interval (CI): 1.43–2.37). Among first documented non-shockable cardiac rhythm, the AOR was 1.51 (95% CI: 1.04–2.22). Among first documented shockable cardiac rhythm, the AOR of the physicians’ presence for primary outcome was 1.15 (95% CI: 0.83–1.59). ConclusionThe improved one-month favorable neurological survival was significantly associated with the physicians’ presence in pre-hospital settings, compared with the physicians’ absence.