Minimal Symptoms Research Articles

A-04 Play After Concussion on Initial Symptom Burden and Length of Recovery

Abstract Purpose Removal from play after a concussion is a standard requirement across sports in order to reduce risk of re-injury. This study examines the effect of ongoing play on early symptom status and overall length of recovery. Methods 191 adolescents aged 11-19 (mean age=15.3± 1.6, 57% male) presenting within 30 days of a concussion completed the Post-Concussion Symptom Inventory-2 (PCSI-2). Participants were recovered when their PCSI-2 Total Retrospective Adjusted Post-Injury Difference (RAPID) scores fell below the psychometrically established cut-off for minimal symptoms. ANOVAs compared initial symptom status and length of recovery (LOR) between those who continued play (CTP) and who were removed from play (RFP) after injury, by sex. Results No difference in initial symptom level was found between individuals who CTP versus those RFP (PCSI-2 RAPID mean 24.7 vs. 22.1, p=.41). A marginal difference was found in LOR between CTP versus RFP (31.7 vs. 27.2 days, p=.088). Marginally higher symptom levels were found for females vs. males (mean=26.4, 20.4, respectively, p=.055). Females took longer to recover than males (33.7 vs. 25.2 days, p=.001, η2=.05). There was no interaction between CTP by sex on symptom levels (p=.92) or on LOR (p=.10), after accounting for CTP and sex alone. However, females who CTP had longer LOR compared with females who were RFP (38.0 vs 29.3 days, p=.029). Conclusions Findings show marginal overall difference in symptom status but not LOR based on immediate removal from play. Females who CTP had longer recovery suggesting a possible sex-specific interaction effect of ongoing play after concussion.

Self-Care Behaviour: The Life-Changing Magic in Type 2 Diabetes Mellitus Care

Diabetes Mellitus is a ‘silent disease’ with minimal symptoms at the beginning and rapidly progresses until target organ damage. Moreover, because of its serious consequences, it has become a significant public health concern. Though genetics play an essential role in the development of diabetes, studies on monozygotic twins have shown the importance of environmental influences. Diabetes education is essential but must ultimately be transferred to action to benefit the patient. Individuals with diabetes have been shown to dramatically impact their disease’s progression and development by participating in their care. Because a high percentage of the world’s diabetes cases belong to Type 2 Diabetes (T2D) with modifiable risk factors such as an unhealthy diet, being obese or overweight, a sedentary lifestyle, and smoking, therefore, individuals with T2DM can be helped to modify these factors through behavioural changes to achieve and maintain optimum blood glucose levels.

Examination of real-world data from geriatric assessments in a comprehensive cancer center to explore predominant and cancer-specific domains for intervention.

e24027 Background: Older adults (OA) with cancer have a higher risk of harm with cancer treatment. Geriatric Assessment (GA) based treatment modifications can help mitigate toxicity and functional impairment. The Geriatric Oncology Assessment and Plan (GOAL) Clinic was established with the aim of providing age-friendly care to OA with cancer at Huntsman Cancer Institute. This retrospective study presents the needs identified using GA in the real-world setting. Methods: Patients (pts) aged ≥65 years are referred to the GOAL clinic by their oncologists/hematologists for age-related concerns. A geriatrics nurse practitioner administers a GA upon initial visit, communicates specific age-related concerns with the referring provider, and subsequently manages any geriatric syndromes that may interfere with their treatment tolerance or outcomes. We analyzed GA data to identify the specific needs of OA with cancer referred to the GOAL clinic. Results: We evaluated 222 pts in the GOAL clinic between September 2020 and January 2023. The median age was 77 years, 52% were female. The most common cancer diagnosis was prostate, followed by breast, colorectal, pancreatic, and bladder. Of the pts assessed, the median Eastern Cooperative Oncology Group (ECOG) was 1, and the median body mass index (BMI) was 26.4 kg/m2. 12% of pts had a moderate to high risk for malnutrition. A Patient Health Questionnaire-9 (PHQ-9) showed minimal, mild, moderate, moderately severe, and severe depression in 35%, 20%, 14%, 7%, and 3% of pts, respectively. The Generalized Anxiety Disorder scale-7 (GAD-7) showed minimal, mild, moderate, and severe anxiety symptoms in 35%, 19%, 9%, and 7% of pts respectively. The median Mini-cog score was 4, and those who reflexed to testing with Montreal Cognitive Assessment (MOCA) had a median score of 22 out of 30 suggesting mild cognitive impairment (MCI). A greater proportion of pts with prostate cancer (PC) were overweight and had MCI by MOCA (Table 1). Multidisciplinary interventions were implemented, and GA was used to determine the appropriateness of cancer treatment. Conclusions: Cognitive dysfunction and depression were this population's most common geriatric syndromes. PC pts had a higher median BMI and greater proportion of patients with MCI than pts with other cancers. Dysmetabolic syndrome associated with elevated BMI is not a domain of GA but is pertinent to treatment toxicity in PC. MCI is not apparent on a routine oncology evaluation. Interventions are needed to prevent, screen, and treat MCI in OA with cancer, especially PC, and dysmetabolic syndrome in OA with PC.[Table: see text]

Description of the ARMADA (assessing reliable measurement in Alzheimer’s disease) general population study cohorts

AbstractBackgroundGiven the growing population of aging adults, and subsequently individuals with dementia, there is a need for instruments that can detect cognitive impairment in early stages. The NIH Toolbox® for Assessment of Neurological and Behavioral Function (NIHTB) is a computerized battery of assessments measuring multiple domains cognition, emotion, sensation, and motor abilities. The goal of the ARMADA study is to validate the NIHTB in individuals with mild cognitive impairment (MCI) and dementia of the Alzheimer type (DAT). Here, we describe the demographic and clinical characteristics of participants ages 65 to 85 from the general population sample.MethodNormal control (NC), MCI, and DAT groups racially proportional to the US population were recruited from existing cohorts across nine Alzheimer’s Disease Research Centers and sites with cognitive aging studies. Diagnoses were based on the Uniform Data Set methodology, and included multiple clinical and cognitive assessments. Participants completed the NIH Toolbox at baseline, 12‐, and 24‐month visits.ResultGroups were matched with respect to multiple demographic characteristics. There were some differences in age and sex, such that the NC group had more female participants and was the youngest. Dementia severity levels differed as expected, with the DAT group demonstrating greater cognitive and functional impairment compared to the MCI group, and the NC group demonstrating minimal cognitive or functional symptoms. Additionally, the DAT group reported more neuropsychiatric symptoms compared to the NC and MCI groups. There was no difference in reported family history of cognitive impairment across groups. Many participants across groups had at least one Alzheimer biomarker collected.ConclusionThe study cohorts included in the ARMADA study accurately reflect their respective clinical syndromes for validating the NIHTB across the cognitive aging spectrum. The goals for the ARMADA study include comparing performance on all four modules of the NIHTB across groups, evaluating the relationship between Alzheimer biomarkers and NIHTB measures, and measuring changes in performance longitudinally. Special emphasis groups, including individuals over age 85, African American participants, and Spanish‐Speaking participants, were also recruited and are reported elsewhere.

Relation of modifiable lifestyle and mood factors to subjective cognitive concerns among participants and their study partners in the A4 screen data

AbstractBackgroundSubjective cognitive decline (SCD) is associated with future cognitive decline, elevated amyloid levels, and non‐specific variables, including mood. Participants often endorse higher cognitive concerns than their study partners (SPs), raising the possibility that participant complaints reflect multiple factors, including mood, lifestyle variables, and amyloid status. To determine the predictive value of modifiable factors, we examined the relation between SCD, lifestyle habits, amyloid, and mood among cognitively unimpaired older adults from a multi‐site secondary prevention trial (A4 screen data).MethodParticipants were 6943 individuals from A4 assessed pre‐randomization [mean(SD): age = 71.6(4.9), education = 16.4(3.0); 58% women, 95% non‐Hispanic or Latino, 90% white)]. Using descriptive analyses and linear regression models, we examined whether amyloid status (amyloid+: n = 1329/4492) and self‐reported mood (Geriatric Depression Scale [GDS]) or lifestyle habits (exercise, sleep) predicted subjective cognitive concerns (CFI; participant‐ and SP‐reported).ResultParticipants endorsed healthy lifestyle habits (mean hours of aerobic exercise/week = 2.9; mean hours of sleep/night = 7.1), minimal mood symptoms (mean GDS = 1.1), and higher cognitive concerns than SPs (t(5996) = ‐25.08, p<.001). Lower mood (t = 29.49, p<.001), older age (t = 5.75, p<.001), and lower education (t = ‐3.92, p<.001) predicted participant concerns on the CFI, with additive predictive value of lower self‐reported exercise (t = ‐2.90, p = .004) and sleep duration (t = ‐2.12, p = .035); however, only lower participant‐reported mood (t = 12.90, p<.001) and older participant age (t = 6.54, p<.001) predicted SP concerns. Adding amyloid to the model in a subset, all predictors for participant concerns remained except sleep, while only amyloid status (t = 4.59, p<.001), lower mood (t = 11.53, p<.001), and older age (t = 4.72, p<.001) predicted SP concerns.ConclusionCognitively unimpaired participants endorsed higher cognitive concerns on the CFI compared to their SPs. Participant concerns were associated with multiple predictors (age, education, mood, amyloid status, exercise, sleep), while SP concerns were only associated with age, mood, and amyloid status. Participants may be more aware of early changes and endorse concerns reflecting various factors, including personal lifestyle habits, while SP report may be more specific to cognitive changes due to age and amyloid burden. These findings expand understanding of how various factors (e.g., biomarkers, mood, lifestyle habits) may contribute differently to participant and SP cognitive concerns, which may inform research recruitment and clinical care.

Predictors of Post-traumatic Stress Symptoms (PTSS), Depression, and Anxiety among Caregivers of Children with Acute Lymphoblastic Leukaemia (ALL).

The caregivers of children diagnosed with acute lymphoblastic leukaemia (ALL) are believed to experience post-traumatic stress symptoms (PTSS), depression and anxiety. This present study endeavoured to explore the prevalence and predictors of PTSS, depression, and anxiety among the caregivers of children with ALL. Purposive sampling was used to select the 73 caregivers of children with ALL who participated in this cross-sectional study. The Post-traumatic Stress Disorder Checklist for DSM-5 (PCL-5), Beck Depression Inventory (BDI), and Beck Anxiety Inventory (BAI) were used to measure psychological distress. There was a low prevalence (11%) of post-traumatic stress disorder (PTSD) among the participants. Although all the criteria for PTSD were not met, a few post-traumatic symptoms remained, suggesting that PTSS was likely present. Most of the participants reported minimal symptoms of depression (79.5%) and anxiety (65.8%). Anxiety, depression, and ethnicity predicted the PTSS scores (R2 = .77, p =.000). Subsequently, depression predicted the PTSS scores (R2 = 0.42, p =0.000). Participants of 'Other' or 'Indigenous' ethnicity had lower PTSS scores and higher anxiety scores (R2 = 0.75, p =0.000) than participants of Malay ethnicity. The caregivers of children with ALL experience post-traumatic stress symptoms (PTSS), depression, and anxiety. These variables co-exist and may have different trajectories in different ethnic groups. Therefore, healthcare providers should take ethnicity and psychological distress into consideration when providing paediatric oncology treatment and care.

Virtual Reality Simulation for Suicide Risk Assessment Training: Prevalence of Adverse Effects.

Virtual reality (VR) simulation is changing the landscape of simulation-based medical education. Immersive VR allows users to interact with a computer-generated environment and digital avatars using a VR headset and controllers. However, current literature regarding the use of immersive VR simulation in psychiatric medical education is sparse. This study describes its use and considerations regarding tolerability. At a mental health hospital in Canada, two immersive VR suicide risk assessment (SRA) case simulations were developed. These simulations have participants interview VR patients to characterize their suicide risk, offering a novel and safe way to engage healthcare providers in SRA training. Regarding user tolerability of these VR simulations, the Simulator Sickness Questionnaire (SSQ) was administered to participants after the simulation to characterize any motion sickness symptoms experienced. Of the 22 participants in this study, the overall SSQ scores demonstrated good tolerability of the VR SRA, with the majority of participants reporting no or minimal simulator sickness symptoms. Moreover, the majority of participants reported being satisfied with this training and that the VR SRA simulation enhanced their learning experience. These study findings are novel, given the current dearth of data regarding the use of immersive VR in simulation-based psychiatric medical education. Further studies exploring the educational effectiveness of VR SRA in simulation-based psychiatric medical education are indicated.

Use of Non-Psychiatric Medications With Potential Depressive Symptom Side Effects and Level of Depressive Symptoms in Major Depressive Disorder

Objective: To determine whether use of medications with potential depressive symptom side effects is associated with a higher level of depressive symptoms in adults with antidepressant-treated major depressive disorder (MDD).Methods: The study was based on the 2013-2014, 2015-2016, and 2017-2018 National Health and Nutrition Examination Survey (NHANES)-a nationally representative cross-sectional survey of the US general population. In 885 adult participants from these NHANES cycles who reported receiving antidepressants for treatment of International Classification of Diseases, Tenth Revision, Clinical Modification MDD, the association between the number of medications with potential depressive symptom side effects and the level of depressive symptoms was assessed.Results: A majority (66.7%, n = 618) of the participants with antidepressant-treated MDD used at least 1 non-psychiatric medication with potential depressive symptom side effects, and 37.3% (n = 370) used more than 1 such medication. The number of medications with depressive symptom side effects was significantly associated with lower odds of no to minimal depressive symptoms, defined as a Patient Health Questionnaire-9 (PHQ-9) score < 5 (adjusted odds ratio [AOR] = 0.75, 95% confidence interval [CI] = 0.64-0.87, P < .001), and higher odds of moderate to severe symptoms, defined as a PHQ-9 score ≥ 10 (AOR = 1.14, 95% CI = 1.004-1.29, P = .044). No such associations were found for medications without potential depressive symptom side effects.Conclusions: Individuals treated for MDD frequently use non-psychiatric medications for comorbid medical conditions that are associated with an increased risk of depressive symptoms. In evaluating the response to antidepressant medication treatment, side effects of concomitantly used medications should be considered.

Open Volar STT Ligament Reconstruction to Augment the Mathoulin's Arthroscopic Dorsal Capsuloligamentous Reconstruction: Technique Description and Case Reports.

Background The results of Mathoulin's arthroscopic dorsal capsuloligamentous reconstruction (ADCLR) are excellent in many patients with scapholunate instability, though less consistently good in higher grade instabilities. The purpose of this article is to describe a novel technique of volar scaphotrapeziotrapezoid (STT) reconstruction which may be used to augment rotational control of the scaphoid, in conjunction with the ADCLR, for use in European Wrist Arthroscopy Society (EWAS) grade IV/V instabilities. Description of Technique Following completion of ADCLR, the STT joint is approached through the flexor carpi radialis sheath. The palmaris longus tendon is harvested. Fluoroscopy is used to site guide wires for tunnel placement in the distal scaphoid and the proximal trapezium; 3.5-mm tunnels are overdrilled in both bones, to a depth of 8 mm. The palmaris graft is then anchored in the scaphoid tunnel with a mini-DX SwiveLock anchor. The graft is tensioned, then anchored in the trapezium tunnel with another anchor. Patients and Methods We retrospectively selected two young men heavy manual workers who had this procedure more than 12 months previously for scapholunate instability, with static radiographic abnormalities and a drive through sign (EWAS grade V). The patients were reviewed after 12 months, for assessment of visual analog scale, quick disabilities of the arm, shoulder, and hand, and patient-rated wrist/hand evaluation scores, range of motion, and grip strength. Results Both patients had marked improvements of wrist comfort and function at 1 year, and were able to return to their normal duties at work and complete all activities of daily living with minimal symptoms. Conclusion This volar STT reconstruction may expand the success of the Mathoulin's ADCLR into higher grade instabilities.

Post-traumatic canalicular fistula: description and review of literature – SALDO update study (SUP) – paper II

ABSTRACT Purpose To discuss the clinical spectrum and management strategies in patients with post-traumatic canalicular fistula (PTCF). Methods Retrospective, interventional case series of consecutive patients diagnosed with PTCF over a 6-year study period between June 2016 and June 2022. The demographics, mode of injury, location, and communication of the canalicular fistula were noted. The outcomes of several management modalities including dacryocystorhinostomy, lacrimal gland therapies, and conservative approaches were assessed. Results Eleven cases with PTCF over the study period were included. The mean age at presentation was 23.5 years (range: 6–71 years), with male: female ratio of 8:3. The median time interval between trauma to presentation at the Dacryology clinic was 3 years (range: 1 week to 12 years). Seven had iatrogenic trauma and four had the canalicular fistula following primary trauma. Management modalities pursued include conservative approach for minimal symptoms, and dacryocystorhinostomy, dacryocystectomy, and lacrimal gland botulinum toxin injection. The mean follow-up period was 30 months (range: 3-months−6 years). Conclusion PTCF is a complex lacrimal condition and the management of the PTCF needs a tailored approach guided by its nature and location and patient symptomatology.

COVID-19 and Cardiomyopathy in African Americans: An Early Single-Center Experience.

Introduction The 2019 coronavirus pandemic has taken a toll on our society. Although most patients report minimal symptoms, a small proportion of patients have reported significant respiratory symptomsthat led to admission to the inpatient medical ward or even the intensive care unit. Complications and long-term sequela of COVID-19 are still being reported and studied. The presence of cardiomyopathy, whether established or new-onset and its effect on inpatient mortality, admission to the intensive care unit or length of stay hasn't been studied. Methods All inpatient hospitalizations in our database between March 1, 2020, and April 30, 2020, due to COVID-19 were reviewed. Patients who had at least a limited echocardiogram during this time were included in the study if they were above the age of 18. Patients were then assigned to three groups. The first group had patients with normal left ventricular systolic function. The second group had established cardiomyopathy that persisted throughout admission. The third group had patients who were found to have new-onset cardiomyopathy during admission. Results The inpatient mortality, although high and variable, wasn't significantly different between the three groups. Also, there was no significant difference between admission to the intensive care unit, disposition at discharge, or oxygenation status at 24 hours between the three groups. The length of stay in the established cardiomyopathy group was markedly lower, and we suspect that could be due to more aggressive discussions about end-of-life care. Conclusion Early COVID-19 experience at our center revealed a relatively high mortality rate that was primarily due to respiratory failure. The presence of established or new cardiomyopathy didn't appear to alter the outcomes significantly early in the pandemic.

SARS-CoV-2 infection and recovery in children: Distinct T cell responses in MIS-C compared to COVID-19.

SARS-CoV-2 infection for most children results in mild or minimal symptoms, though in rare cases severe disease can develop, including a multisystem inflammatory syndrome (MIS-C) with myocarditis. Here, we present longitudinal profiling of immune responses during acute disease and following recovery in children who developed MIS-C, relative to children who experienced more typical symptoms of COVID-19. T cells in acute MIS-C exhibited transient signatures of activation, inflammation, and tissue residency which correlated with cardiac disease severity, while T cells in acute COVID-19 upregulated markers of follicular helper T cells for promoting antibody production. The resultant memory immune response in recovery showed increased frequencies of virus-specific memory T cells with pro-inflammatory functions in children with prior MIS-C compared to COVID-19 while both cohorts generated comparable antibody responses. Together our results reveal distinct effector and memory T cell responses in pediatric SARS-CoV-2 infection delineated by clinical syndrome, and a potential role for tissue-derived T cells in the immune pathology of systemic disease.

Pediatric and Adolescent Flatfoot: A Questionnaire Based Middle East and North Africa Study.

Flatfoot is commonly seen in the community and is a common cause of concern for parents because it could become symptomatic and lead to decreased quality of life. One of the most used management approaches is foot orthoses, although no clear evidence supports their use. We aimed to study flatfoot symptoms' prevalence, effect on activities of daily living, and the use and effectiveness of orthoses. This was a cross-sectional study that included five countries from the Middle East and North Africa region (Jordan, Palestine, Syria, Egypt, and Iraq). Data were collected using an online questionnaire directed toward parents of children aged 0 to 16 from September to December 2020. The demographic factors were expressed as frequencies (percentages) using standard descriptive statistical parameters, and Pearson's chi-square test was used to examine the relationship between study factors. 1256 participants were recruited using this online survey. The majority (29.6%) of children were diagnosed in the age group of 0 to 2. The abnormal appearance of the foot was the most common (78.7%) complaint. Overall, 54.2% of patients were prescribed orthoses, of which 36.8% noticed improvement in flatness and 37.6% reported relief of symptoms. This study demonstrated that most participants have no or minimal symptoms and that there is a mismatch between participants' expectations and the actual effectiveness of orthoses. Taking into consideration that there is no clear evidence to support the corrective effect of orthoses, we recommend that physicians prescribing them adhere more to their proper indications and spend more time and effort counseling and addressing patients' and parents' concerns about this developmental stage.

노인의 우울 증상이 일반 및 암 건강검진 수검에 미치는 영향

Objective: In this study, we investigate the effect of depressive symptoms in elderly on general and cancer health screening participation using the large epidemiological study data in South Korea.&#x0D; Methods: This study was conducted on 1,977 people who responded to a health examination questionnaire among 2,360 adults aged 60 or older who participated in the Korea National Health and Nutrition Examination Survey (KNHANES) in 2020. Depressive symptoms were measured by the Patient Health Questionnaire-9 and classified as minimal (0-4), mild (5-9), and moderate and severe (10-27). To investigate the relationship between depressive symptoms and health screening participation, a multiple logistic regression model controlling covariates was used.&#x0D; Results: Compared to the group with minimal depressive symptoms, the mild group did not show a significant difference (odd ratio [OR]=0.71, 95% confidence interval [95% CI]=0.45-1.13), but the moderate to severe group showed a significant negative relationship with general health screening participation (OR=0.59, 95% CI=0.35-0.99). There was a significant negative relationship between depressive symptoms and cancer health screening participation (mild group OR=0.77, 95% CI=0.48-1.23; moderate to severe group OR=0.50, 95% CI=0.28-0.87).&#x0D; Conclusion: This study showed that people with depressive symptoms are less likely to get a general and cancer health screening. In order to promote health screening participation, policies that consider health behavior promotion programs and psychiatric interventions targeting moderate to severe depressive symptom groups are necessary

Surgical and Patient-Reported Outcomes of Open Perforator-Preserving Anterior Component Separation for Ventral Hernia Repair.

Abdominal wall reconstruction is challenging for surgeons and may be life altering for patients. There are scant high-quality studies on patient-reported outcomes following abdominal wall reconstruction. We assess long-term surgical and patient-reported outcomes of perforator-preserving open anterior component separation (OPP-ACS) following large ventral hernia repair. A retrospective review of patients with large ventral hernia defects who underwent OPP-ACS performed by the authors (B.A.S., M.J.T.) was conducted between 2015 and 2019. Demographics, surgical history, operative details, outcomes, and complications were extracted. A validated questionnaire, Carolinas Comfort Scale (CCS), was used to assess postoperative quality of life. Twenty-two patients (12 males and 10 females) with a mean age and BMI of 60.9 ± 10 years and 28.9 ± 4.8 kg/m2, respectively, were included. Mean follow-up was 28.5 ± 16.3 months. All had prior abdominal surgery; 15 (68%) for abdominopelvic malignancy, 3 (14%) for previous failed hernia repair, and 8 (36%) had history of abdominopelvic radiation. Overall, 16 (73%) hernias were in the midline, 4 (18%) in the right lower quadrant, 1 (4.5%) in the right upper quadrant, and 1 (4.5%) in the left lower quadrant. Mean hernia defect surface area was 145 ± 112 cm2. A total of 9 patients (40.9%) underwent bilateral component separation, whereas 13 (59.1%) had unilateral. Bioprosthetic mesh was used in all patients as underlay. Mean mesh size and thickness were 545.6 ± 207.7 cm2 and 3.4 ± 0.5 mm, respectively. One patient presented with a minor wound dehiscence, and two presented with seromas not requiring aspiration/evacuation. One patient had hernia recurrence 22 months after surgery. One patient was readmitted for partial small bowel obstruction and one required wound revision. A total of 14 (65%) patients responded to the CCS questionnaire. At 12 months, mean score for all 23 items was 0.29 ± 0.21 (0.08-0.62), which corresponds to absence or minimal symptoms. The OPP-ACS is a safe surgical option for large, complex ventral hernias. Our cases showed minimal complication rate and hernia recurrence, and our patients reported significant improvement in life quality.

Treatment of Rectovaginal Fistula.

Rectovaginal fistula (RVF) is a challenging complication with unsatisfactory success and a significant burden for the patients. With insufficient clinical data due to the rare entity, the present state of treatments for RVFs was reviewed especially form the point of factors to determine management, classifications, principle of treatment, conservative and surgical treatments with outcomes. Size, fistula localization and etiology, type of fistula; "simple" or "complex," status of anal sphincter complex and surrounding tissue, presence or absence of inflammation, presence of diverting stoma, previous attempted repair and radiation therapy, patient's condition with co-morbidities, and surgeon's experience are important factors to determine the management of RVF. The inflammation should initially subside in cases with infection. Starting with conservative surgical options and interposing healthy tissue for complex or recurrent fistulas, invasive procedures will be performed if conservative treatment failed. Conservative treatment may be effective in RVFs with minimal symptoms and should be done for small RVFs for a 36 months usual period. Anal sphincter damage might need a repair of sphincter muscles along with RVF repair. Diverting stoma can initially be constructed in patients with severe symptoms and larger RVFs to relief the patient's pain. Simple fistula is usually indicated for local repair. Local repairs to transperineal and transabdominal approaches can be used for complex RVFs. Interposition of healthy, well-vascularized tissue can be required for more complex fistulas and abdominal procedures for high RVFs.

Scurvy presenting with difficulties to walk and weakness in pediatric patients; 2 case reports. (P11-9.009)

<h3>Objective:</h3> Vitamin deficiency should be considered during differential diagnosis of neurological symptoms in patients presenting with subacute progressive gait instability and weakness. <h3>Background:</h3> Despite the perception that scurvy is a rare disorder (1,2), clinicians should have a high index of suspicion in patients at risk for nutritional deficiencies including picky eater, behavioral or sensory issues. <h3>Design/Methods:</h3> We report 2 patients of ascorbic acid deficiency who presented with subacute progressive gait instability and weakness. <h3>Results:</h3> Case 1 is a 12-year-old male with autism spectrum disorder who presented with 3 weeks of progressive bilateral lower extremity weakness resulting in wheelchair dependence. Cranial nerves, deep tendon reflexes, and sensory exam were normal. Motor exam notable for proximal &gt; distal lower extremity weakness. Skin and mucosal examination revealed gingival bleeding and corkscrew hair. Detailed dietary history revealed a severely restricted diet. He was found also to have low vitamin D. Patient treated empirically with vitamin C supplementation resulted in marked improvement within 24 hours, so no additional work up was recommended. Ascorbic acid level was extremely low confirming the diagnosis. Case 2 is a 4-year-old with history of mild hypotonia who presented with subacute progressive lower extremities weakness exacerbated by physical activity. Cranial nerves, deep tendon reflexes, and sensory exam were normal. Motor exam notable for proximal &gt; distal lower extremity weakness, waddling gait, and positive Gowers maneuver. Dietary history revealed restricted diet for the last 3 months. CK normal. Supplementation with Vitamin C resulted in minimal symptoms improvement so additional neuroimaging was recommended such as magnetic resonance imaging (MRI) of brain, spine and thigh/leg as well as lumbar puncture (LP) all unremarkable. Ascorbic acid level was low confirming the diagnosis. <h3>Conclusions:</h3> Dietary restriction and subacute progressive weakness should raise concern for nutritional myopathies. Refusal to bear weight is a frequent presentation of ascorbic acid deficiency (3). <b>Disclosure:</b> Dr. Railean has nothing to disclose. Dr. Martindale has received personal compensation in the range of $0-$499 for serving on a Speakers Bureau for Tourette Association of America. The institution of Dr. Martindale has received research support from Tourette Association of America.

Etiology, Classification, Diagnostics, and Conservative Management of Osteochondral Lesions of the Talus. 2023 Recommendations of the Working Group "Clinical Tissue Regeneration" of the German Society of Orthopedics and Traumatology.

Peer-reviewed literature was analyzed regarding different topics relevant to osteochondral lesions of the talus (OLTs) treatment. This process concluded with a statement for each topic reflecting the best scientific evidence available for a particular diagnostic or therapeutic concept, including the grade of recommendation. Besides the scientific evidence, all group members rated the statements to identify possible gaps between literature and current clinical practice. In patients with minimal symptoms, OLT progression to ankle osteoarthritis is unlikely. Risk factors for progression are the depth of the lesion on MRI, subchondral cyst formation, and the extent of bone marrow edema. Conservative management is the adaptation of activities to the performance of the ankle joint. A follow-up imaging after 12 months helps not to miss any progression. It is impossible to estimate the probability of success of conservative management from initial symptoms and imaging. Cast immobilization is an option in OLTs in children, with a success rate of approximately 50%, although complete healing, estimated from imaging, is rare. In adults, improvement by conservative management ranges between 45% and 59%. Rest and restrictions for sports activities seem to be more successful than immobilization. Intra-articular injections of hyaluronic acid and platelet-rich plasma can improve pain and functional scores for more than 6 months. If 3 months of conservative management does not improve symptoms, surgery can be recommended.

An innovative inpatient protocol for alcohol withdrawal prevention in a 16-year-old adolescent: a case report

BackgroundAlcohol cessation in youth with daily drinking poses a risk of severe and life-threatening alcohol withdrawal. If unsupervised, alcohol withdrawal in heavy users can cause severe complications, such as seizures, delirium tremens, and death. We present the case of a teenager admitted at our pediatric center for the prevention of alcohol withdrawal using an innovative protocol, including a fixed-dosage benzodiazepine regimen.Case descriptionA 16-year-old Caucasian male, known to have anxiety and an attention deficit disorder, was electively admitted for medical stabilization and surveillance of alcohol withdrawal. He had been previously diagnosed with alcohol use disorder and had a past history of withdrawal symptoms. He was prescribed a course of thiamine, folic acid, as well as a fixed-dosage benzodiazepine taper over 5 days. His withdrawal symptoms were evaluated using a standardized Clinical Institute Withdrawal Assessment for Alcohol scale. During his stay, he reported minimal symptoms, as well as a score on the Clinical Institute Withdrawal Assessment for Alcohol scale consistently lower than 5. His mood, motivation, eating habits and sleeping patterns significantly improved during his stay. He developed no medical complications and demonstrated pride in his successes. He was successfully transferred to a long-term rehabilitation center.ConclusionsA withdrawal prevention protocol was developed on the basis of existing literature. It included a soothing environment, basic laboratory work evaluating the medical complications of alcohol use, as well as medication aiming to prevent and reduce potential withdrawal symptoms. The patient responded well to the fixed-dosage taper with minimal symptoms and discomfort. Although alcohol use in adolescents is frequent, alcohol withdrawal in this population is rarely seen in a pediatric hospital setting. Nonetheless, given the lack of existing guidelines regarding alcohol withdrawal in adolescents, standardized protocols could be greatly beneficial for the prevention of this condition in this population.

Psychopathology and Pattern of Remission of Cannabis-Induced Psychotic Disorder.

Objective: To analyze the psychopathology and pattern of remission in cannabis-induced psychotic disorder with treatment.Methods: This was a prospective cohort study of a group of patients admitted with new-onset psychosis, cannabis use, and no evidence of other drug abuse from January 1 to June 31, 2019, to the psychiatry inpatient department of a multispecialty tertiary care hospital in Kerala, India. Patients were evaluated at admission and after 1 week in the hospital and 1 month after discharge using the Structured Clinical Interview for the Positive and Negative Syndrome Scale and the Clinical Global Impressions-Severity of illness scale.Results: Fifty-six male subjects were recruited for the study. The mean age of the subjects was 22.2 years, and the majority were active smokers of nicotine and cannabis. Total duration of abuse and family history of substance use in first-degree relatives correlated with severity of psychosis. Hostility, excitement, and grandiosity were the predominant positive symptoms, and these symptoms showed a steady reduction toward the end of the study. The most frequent negative symptoms were emotional withdrawal, passive or apathetic social withdrawal, and difficulty in abstract thinking, and these symptoms also showed significant improvement (P < .001 for all). For symptoms such as somatic concern and guilt feelings, significant treatment response was noted only in the initial week (P < .001).Conclusions: Cannabis-induced psychosis in the Indian setting presents with predominant positive symptoms and minimal affective symptoms. The steady improvement noted with complete cessation of cannabis indicates a possible contributory role for cannabis in precipitating psychosis.