Organic Etiology Research Articles

Effects of training in voice auditory-perceptual skills.

This study was designed based on the need to verify the effectiveness of education in the vocology area concerning refining perceptual auditory skills. The purpose of the project described in this paper was to examine the effect of knowledge and skills training during a 2-week voice disorders graduate course on auditory-perceptual skills of pre-professional speech-language pathologists. The training effect was evaluated by comparing pre- and post-course results of ratings of voice quality using auditory-perceptual measures. A cohort of 24 graduate students in speech-language pathology participated in this study. Each student rated a total of 24 voice samples of typical and disordered voice quality from a database using Consensus Auditory-Perceptual Evaluation of Voice (CAPE-V). The same voice samples were rated before and after the training, in randomised order. The speakers ranged in age from 35 to 80 years; 16 identified as females and 8 as males. A total of 16 samples were associated with various degrees of dysphonia of organic and functional aetiologies; the remaining 8 voice samples included in the study were classified as normal. The training involved different components including knowledge and auditory-perceptual skills as part of a voice class offered as an intensive 2-week course with daily blocks of 4h sessions. Exploratory comparisons of results to objective outcomes were conducted through comparisons with computer-generated indicators of the Cepstral Spectral Index of Dysphonia (CSID), a component of the Analysis of Dysphonia in Speech and Voice (ADSV) software from Pentax for capturing the CSID. There was a significant increase in ratings of roughness, breathiness, loudness, pitch and overall severity after the course. Furthermore, there was a significant increase in the intra- and interrater reliability post training. Statistically significant positive indications were found in correlations between mean perceptual ratings and the acoustic measure of CSID. Reliability of data was measured by using Pearson's correlations. Intrarater reliability resulted in values of ≥0.90 in all parameters. Similar findings were demonstrated by intraclass coefficients used to estimate interrater consistency: all values were >0.90 but in the Loudness parameter [r (22) = 0.60]. Effectiveness of the training in improving the auditory perceptual skills of students was based on the increased reliability of ratings. Indications of successful implementation and outcomes on auditory-perpetual training procedures in classroom environments will support the development of effective educational methods, which will in turn lead to increased efficacy of service delivery in voice disorders. What is already known on this subject The effects of training on perceptual assessment performance have been indicated in the literature. Past evidence has demonstrated that various types of training produce a significant impact on auditory perceptual skills. Although dedicated research has been advancing over the past decade, further aspects of auditory-perceptual reliable assessment include queries about specific training approaches, optimal duration, and interval time for recalibration. What this paper adds to existing knowledge While past research suggests that increased exposure in identifying voice characteristics impacts assessment skills, there are limited published data on the relationship of knowledge and skill in association with teaching and learning environments, particularly at the pre-professional stage. Practical data from actual classroom application constitute an ideal scenario for inspecting effectiveness of graduate training in voice disorders involving acquiring knowledge and applied skills, including auditory-perceptual voice evaluation. This study is an attempt to expand on previous literature, particularly by examining effects of auditory-perceptual skills training in graduate students following teaching and learning in a systematic 2-week voice disorders course. What are the clinical implications of this work? Outcomes indicative of successful training procedures in a classroom environment will support the development of effective educational methods to increase efficacy of service delivery in voice disorders.

Erectile Dysfunction in Adolescents and Young Adults.

The goal of this paper is to provide a summary of the recent research, evaluation, work-up, and treatment recommendations regarding erectile dysfunction in adolescents and young adults to better equip pediatric urologists to manage patients with this condition. The latest research regarding erectile dysfunction in this population includes organic and psychogenic etiologies, correlations between the COVID-19 pandemic, and online pornography consumption. In our large pediatric urology practice, we found an 31x increase of adolescent males presenting with erectile dysfunction since 2014. The majority of cases are attributed to a psychogenic etiology such as anxiety or depression. It is likely that with stress from anxiety and depression, cortisol levels rise, increasing vascular resistance and leading erectile dysfunction in this population. Most patients want to be reassured of normal testosterone levels, offered cognitive behavioral therapy, and be rehabilitated with tadalafil starting at 5mg p.o. daily until tapered.

Case report: Dissociative neurological symptom disorder with gait disturbance: taking after the father?

Dissociative neurological symptoms disorder (DNSD), or conversion disorder, frequently manifests with unexplained neurological symptoms, necessitating referral to psychiatry following preliminary diagnosis in neurology. We present a case of an adolescent female patient with gait disturbance as the predominant clinical presentation, and delve into the diagnosis and interdisciplinary intervention process. Given neuroimaging deviations detected and familial similar presentations, the organic etiology was confirmed. However, the aberrant gait remained unexplained ultimately prompting psychiatric consultation resulting in the diagnosis of DNSD. Interventions consisting of health education, suggestive therapy, and physiotherapy notably improved gait disturbance. However, at follow-up, the patient presented with a depressive episode. It was deduced that undiagnosed psychosocial factors, notably familial dynamics, likely contributed to this decline. Eventually, transformed relation patterns among family members as well as antidepressant treatment were instrumental in attaining symptom remission.

Regressive autism with autoimmune encephalitis: case report and literature review of subtype of autism spectrum disorder

About one-third of individuals with autism spectrum disorder (ASD) show a sudden loss of acquired skills between the 2nd or 3rd years of life. The primary areas of loss were grouped into language skills, social interest, adaptive functioning, and motor skills. A 4-year and 2-month-old boy presented to the child and adolescent mental health and disease outpatient clinic with his parents with complaints of decreased eye contact, and regression in speech. His developmental milestones were within the typical range of three years and two months. During the investigation into the organic etiology of regression, serum anti-CASPR2 positivity was detected, and intravenous immunoglobulin administration was initiated. After 6 months of treatment and special education, there was a slight decrease in the CARS score along with improvements in adaptation to change, visual response, and non-verbal communication. This rare case of regressive autism accompanied by autoimmune encephalitis provides further evidence in the field that autoimmune encephalitis may influence the development of the regressive subtype of ASD. Differential diagnosis is crucial because additional immunotherapy may be beneficial in these cases. Further investigation is needed to identify the relationship.

Neuropsychiatric manifestations inaugurating Biermer’s disease

IntroductionVitamin B12 deficiency gives rise to a wide spectrum of hematological, gastrointestinal, psychiatric, and neurological disorders. Notable among the neuropsychiatric symptoms are mood disturbances, cognitive decline, and psychotic manifestations.ObjectivesWe present a case of a woman with neuropsychiatric symptoms linked to vitamin B12 deficiency to highlight certain organic aetiologies with psychiatric symptoms in the foreground.MethodsWe discussed through a clinical case and a literature review, the relationship between neuropsychiatric symptoms and vitamine B12 deficiency in the context of biermer’s disease.Results We presented a patient aged 51-years-old without neurological or psychiatric history, she was hospitalised in a psychiatry department for behavioral disturbances, hetero-aggression, and incoherent speech. The psychiatric examination revealed distant contact, inappropriate affects, disorganized speech with persecutory delusions, memory problems, and poor insight. Neurological et physical examinations were normal, and cerebral magnetic resonance imaging (MRI) showed no abnormalities. First, haloperidol 25mg was prescribed, however, there was only partial improvement. Complete blood counts revealed macrocytic anemia (Hemoglobin: 8 g/dL, mean corpuscular volume: 106 fL). Her serum B12 assay was 48.19 pmol/L.Given these results we proceed to a Fundic biopsy, performed by fibroscopy, that revealed fundic atrophy and intestinal metaplasia compatible with Biermer’s disease. Vitamin B12 replacement therapy began with hydroxocobalamin at 1000 μg/day intramuscularly for 15 days, followed by 1000 μg every 15 days for one month. Subsequently, there was a remarkable improvement in psychotic symptoms and cognitive function. Follow-up assessments demonstrated a return to baseline functioning.ConclusionsThis case, coupled with prior studies, emphasizes the importance of considering vitamin B12 deficiency in the differential diagnosis of neuropsychiatric symptoms. Therefore, prompt diagnosis and treatment of vitamin B12 deficiency are imperative in preventing potential irreversible neurological damage.Disclosure of InterestNone Declared

Forearm bisection task suggests an alteration in Body Schema in patients with Motor Conversion Disorders (Functional Movement Disorders)

IntroductionMotor Conversion Disorders (also called Functional Movement Disorders, FMD) are a group of neuropsychiatric conditions characterized by neurological symptoms of altered voluntary motor function that cannot be explained by typical neurological diseases or other medical conditions. In the last decade, several hypotheses have been formulated with respect to their pathophysiology, and a major line of research, trying to integrate psychological, cognitive, and neurobiological factors, focused on the subjective experience that patients feel of their own bodies. However, no study has, so far, directly investigated their Body Schema (the implicit sensorimotor representation of one’s own body) and its plasticity.ObjectivesTo investigate the Body Schema in patients with FMD through a paradigm specifically designed to assess their perceived body metrics, through a spatial estimation of body parts length, and to compare their results with the ones obtain on a group of healthy control subjects (HC)Methods10 patients with FMD and 11 HC underwent the Forearm Bisection Task, aimed at assessing perceived body metrics, which consists in asking the subject, blindfolded, to repeatedly point at the perceived middle point of their dominant forearm with the index finger of their contralateral hand, and a psychometric assessment for anxiety, depression, alexithymia, and tendency to dissociation.ResultsFMD patients bisected their forearm more proximally (with an increased shift towards their elbow equal to 7.5%) with respect to HC; average bisection point was positively associated with anxiety levels in the whole sample, and with the tendency to dissociation in the FMD group.ConclusionsFMD patients seem to perceive their forearm as shorter than HC do, which might suggest an alteration of their Body Schema. The Body Schema can go through short- and long-term plastic changes in the life course, mainly related to the use of each body segment; we speculate that, despite FMD being a disorder of functional nature, characterized by variability and fluctuations in symptomatology, the lack of sense of agency over a body part might be interpreted by the nervous system as disuse and hence influence the Body Schema, as deficits of organic aetiology do.Disclosure of InterestNone Declared

Depersonalization and derealization as sequelae of a temporal lobe lesion: a case report

BackgroundDepersonalization and derealization can occur not just from psychiatric causes but also from various organic etiologies, such as seizures and intracerebral structural abnormalities. However, there have been no previous reported cases to the authors’ knowledge detailing isolated depersonalization and derealization in the absence of clinical seizure activity or other psychiatric pathology, as sequelae of structural intracerebral lesions.Case presentationIn this case report, we detail the unique presentation of a 68-year-old woman under the care of palliative medicine who experienced depersonalization and derealization secondary to a metastatic lesion in her temporal lobe, in the parahippocampal gyrus to medial occipitotemporal gyrus region. These symptoms were present in the absence of any clinical seizure activity or other psychiatric symptomatology and largely resolved with the use of steroidal therapy, before returning secondary to disease progression.ConclusionsWe discuss the relationship among isolated depersonalization and derealization with pathology of the left posterior temporal lobe in the context of this interesting case. This case expands our knowledge of the neurobiology of these phenomena, given the specific localization of the intracerebral pathology and temporal specificity of symptoms relative to tumor growth and treatment course.

(202) Comparative Study of the Efficacy of Avanafil and Atorvastatin Daily Dose in Management of Vasculogenic Erectile Dysfunction

Abstract Introduction Erectile dysfunction (ED) is defined as the “consistent inability to attain or maintain a penile erection, or both, sufficient for adequate sexual relations”. ED is not only a medical problem but affects the marital relations and patient's self-esteem and causes the quality of life to decrease. which in turn causes the patient to go into depression or develop anxiety. In the past, erectile dysfunction was considered, in most cases, to be a purely psychogenic disorder, but current evidence suggests that more than 80% of cases have an organic aetiology. Causes of organic erectile dysfunction can now be broadly divided into nonendocrine and endocrine. Of the nonendocrine aetiologies, vasculogenic (affecting blood supply) is the most common and can involve arterial inflow disorders and abnormalities of venous outflow (corporeal veno-occlusion). Avanafil is a second-generation phosphodiesterase type 5 inhibitor approved for erectile dysfunction by the FDA on 2012 and by EMA in 2013. With a high selectivity for phosphodiesterase type 5 isoform AND faster onset of action compared with other PDE5 inhibitors, it offers more tolerability and less adverse events. Atorvastatin is 3-hydroxy-methylglutaryl (HMG)-CoA reductase inhibitor act on the rate-limiting step in cholesterol biosynthesis (the conversion of HMG-CoA to mevalonate) and are effective in treating dyslipidemia. statins reverse endothelial dysfunction by decreasing the action of oxidized low-density lipoprotein (LDL) on endothelial cells, resulting in an increase of NO activity. Objective is to evaluate and compare the efficacy of avanafil and atorvastatin daily dose in management of patients with vasculogenic erectile dysfunction. Methods A 60 adult heterosexual males complaining of vasculogenic erectile dysfunction proven by penile duplex were collected from outpatient andrology clinics of Al-Azhar University Hospitals. The patients were divided into two treatment groups: (Group A): 30 patients received daily dose of 100 mg avanafil. (Group B): 30 patients received daily dose of 40 mg atorvastatin, The main outcome measures and the difference in penile duplex ultrasound results and IIEF-EF scores between the two groups are evaluated and compared at the end of the study, Age of patients between 20 and 50 years, established diagnoses of Vasculogenic erectile dysfunction, Normal lipid profile, Normal Total and Free testosterone levels and No contraindications to the study medications were included criteria. However patients who failed to fulfill any of the inclusion criteria, psychogenic or neurogenic erectile dysfunction, dyslipidemia Patients with Renal or Hepatic insufficiency and Patients with advanced cardiovascular diseases such as heart failure and coronary artery disease on antianginal drugs especially nitrates were excluded. Results Our study revealed statistically significant improvement in Penile Doppler ultrasonography parameters (PSV, EDV& RI) and IIEF-EF scores in avanafil group compared to atorvastatin group. Conclusions avanafil 100 mg daily dose leads to significant improvement in men with vasculogenic erectile, while atorvastatin 40 mg caused no significant differences, neither positively nor adversely. In summary, avanafil at dose of 100 mg can be a therapeutic appropriate choice in cases of vasculogenic ED. Disclosure No.

(141) Can a Nocturnal Penile Tumescence and Rigidity Test Detect Organic Aetiology of Erectile Dysfunction? A Peripheral and Penile Vascular Study

Abstract Introduction In the diagnostic workup of erectile dysfunction (ED) the Nocturnal Penile Tumescence and Rigidity test (NPTR) is being used less and less because of its inconvenience but also in part because of the intrinsic limits of this test. In particular, the NPTR has been considered very useful to diagnose psychogenic ED when it is positive (normal) but less informative when it is negative (pathological) because of the high incidence of false negatives. Other tests have been suggested to better diagnose an organic ED, especially the dynamic Penile Colour-Doppler Ultrasound (PCDU) to study the penile vascular response and detect a vasculogenic ED. Objective The purpose of the study was to explore the value of a pathological NPTR by investigating relationship between the NPTR result and the peripheral vascular health at the carotid, brachial and cavernous arteries. Methods We conducted an observational study involving patients with ED who had undergone a NPTR as part of their ED diagnostic workup. We assessed their peripheral vascular health through (1) the measurement of the intima-media thickness at the carotid arteries (cIMT), (2) the measurement of the flow-mediated dilation at the brachial artery (FMD), and (3) performing a PCDU. Results Globally, our patients presented with a normal cIMT, FMD and Peak Systolic Value (PSV) in the PCDU. The group with pathological NPTR were significantly older than patients with normal NPTR (55.6 vs 44.1 years, p=0.002), had a higher prevalence of hypertension (50.0 vs 6.8%, p=0.001), longer hypertension duration (8.0 vs 1.3 years, p=0.035), a higher prevalence of diabetes mellitus (42.9 vs 6.8%, p= 0.004), higher blood glucose (111 vs 92 mg/dl, p=0.004) and higher blood triglycerides levels (188 vs 96 mg/dl, p=0.002). Furthermore, they showed lower PSV (46.2 vs 71.0 cm/s, p=0.002) while we did not find significant differences as regards cIMT and FMD between the two groups. Interestingly, the prevalence of patients with pathological PSV (<35 cm/s) was higher among patients with a pathological NPTR but without reaching the statistical significance. However, when adopted an age-dependant cut-off described in the literature (PSV < age x 0.7 + 6.73) the difference between the two groups became significant (50.0 vs 11.4%, p=0.005). Finally, the correlation analysis showed a significant correlation between PSV and the cIMT (-0.352, ρ=0.009), the maximum number of events in the RPTR record (+0.344, ρ=0.012), and the mean tip tumescence (+0.303, ρ=0.036). When corrected for age, these associations lost their statistical significance. Conclusions This study demonstrates the diagnostic value of a pathological NPTR which suggests an organic aetiology of the ED and associates with pathological findings in the PCDU. Age appears to be one of the most important risk factors for ED, even when other risk factors are present. Finally, when using a PCDU to diagnose vasculogenic ED, a cut-off of 35 cm/s might be less sensitive than an age-dependent cut-off to detect early impairments of penile endothelial function. Disclosure No.

Central precocious puberty in boys: secular trend and clinical features.

Recent studies suggest that boys enter puberty at a younger age, and the incidence of male central precocious puberty (CPP) is increasing. In this study, we explore the incidence of male CPP and identify key clinical and auxological indicators for organic CPP (OCPP). A retrospective registry-based study. The medical records of 43 boys treated with CPP at the Helsinki University Hospital between 1985 and 2014 were reviewed. Clinical, auxological, and endocrine data of the CPP patients were included in the analyses. Based on brain MRI, 26% of patients had OCPP. Between 2010 and 2014, the CPP incidence in boys was 0.34 per 10 000 (95% CI 0.20-0.60). Between 1990 and 2014, the male CPP incidence increased (incidence rate ratio [IRR] 1.10, P = .001). This increase was driven by rising idiopathic CPP (ICPP) incidence (IRR 1.11, 95% CI 1.05-1.19, P < .001), while OCPP incidence remained stable (P = .41). Compared with the patients with ICPP, the patients with OCPP were younger (P = .006), were shorter (P = .003), and had higher basal serum testosterone levels (P = .038). Combining 2 to 4 of these readily available clinical cues resulted in good to excellent (all, area under the curve 0.84-0.97, P < .001) overall performance, differentiating organic etiology from idiopathic. The estimated incidence of CPP in boys was 0.34 per 10 000, with 26% of cases associated with intracranial pathology. The increase in CPP incidence was driven by rising ICPP rates. Patients with OCPP were characterized by shorter stature, younger age, and higher basal testosterone levels, providing valuable cues for differentiation in addition to brain MRI. Utilizing multiple cues could guide diagnostic decision-making.

Osteopathic Approach to a Patient with Recurring Low Back Pain following OMT results in Diagnosis of Underlying Gynecological Etiology: A Case Report

Abstract This case report describes the occurrence of acute low back pain, and the application of Osteopathic Manipulative Treatment techniques (OMT) initially resulting in resolution of the patient's presenting symptoms. When OMT is successful in resolving the patient's symptoms, this usually supports a musculoskeletal etiology; however, when confronted with recurrence of symptoms despite repeated successful resolution of these symptoms with OMT, the physician should suspect an organic etiology. This case demonstrates the importance of the osteopathic physician understanding viscerosomatic dysfunctions and the efficacy of the osteopathic approach to arriving at correct diagnoses. Of note, the osteopathic approach to a patient with recurring low back pain following OMT resulted in diagnosis of the underlying gynecological organic etiology for this patient's symptoms.

Characteristics and Outcomes of Failure to Thrive in Pediatric Patients Referred to the King Abdulaziz Medical City Pediatric Clinic.

Failure to thrive (FTT) in pediatric populations is a diagnostic challenge with implications for growth and development. Despite its prevalence, detailed epidemiological data, especially concerning organic versus non-organic etiologies, are sparse.This study examines the prevalence, characteristics, and outcomes of organic and non-organic FTT in a pediatric outpatient setting at King Abdulaziz Medical City, Jeddah. This retrospective chart review included pediatric patients aged three months to 14 years diagnosed with FTT at KAMC from 2016 to 2023. FTT was defined by weights below the 3rd percentile or a decline across two major growth percentiles. Patients were stratified into organic and non-organic FTT groups based on predefined criteria. Prevalence rates, clinical characteristics, and outcomes were compared to draw distinctions between the two categories. Out of 349 evaluated patients, organic FTT was present in 160 patients (45.8%), with gastrointestinal conditions and endocrine disorders being the most common etiologies. Non-organic FTT, accounting for 189 (54.2%) of cases, was primarily associated with inadequate nutritional intake and behavioral factors. Notably, the non-organic FTT group exhibited a significantly higher rate of condition resolution (45.0%) compared to their organic counterparts (32.5%). Furthermore, significant laboratory parameter differences were noted, indicating a higher white blood cell count in organic cases, among other findings. Non-organic FTT was more prevalent and demonstrated higher resolution rates, suggesting better outcomes with timely intervention and appropriate care strategies. The study advocates for increased educational efforts for caregivers and healthcare providers and calls for further research to explore effective management protocols for FTT.

(160) Improving Symptoms in Young Men with Erectile Dysfunction: Testosterone Therapy With or Without PDE5 Inhibitors

Abstract Introduction While erectile dysfunction (ED) in young men has traditionally been viewed as primarily psychogenic in etiology, a growing body of evidence supports a higher prevalence of organic etiology. Objective The aim of this study was to further characterize the etiology and treatment outcomes of ED in men under 40 years at a single institution. Methods A retrospective chart review of men presenting with ED from 2010-2022 was undertaken. Men initially presenting under the age of 40 years were included and analyzed for hypogonadism, ED etiology, and treatment outcomes. Results Of our cohort, a total of 74 men under the age of 40 years presented with complaint of ED (mean age 31.6 years). Twenty-three (31.1%) men were eugonadal without organic etiology of ED. Of these men, 22 (95.7%) were started on phosphodiesterase-5 inhibitors (PDE5i) and one (4.3%) reported symptom resolution without treatment. The remaining 51 (68.9%) men presented with ED of likely organic origin. Forty-two (82.4%) of these men were hypogonadal and were started on testosterone, human chorionic gonadotropin, clomid and/or a PDE5i. Of those who followed up, 32 (91.9%) men reported improvement in symptoms after therapy. The organic etiologies of ED in the nine (17.6%) eugonadal men included history of urologic surgery (4), Peyronie’s disease (2), prior genitourinary trauma (1), spinal cord tumor (1), and prolactinoma (1). Within this group, four (44.4%) progressed to intra-cavernosal injection, two (22.2%) improved with PDE5i, and three (33.3%) were lost to follow-up. Conclusions It appears that the majority of young patients who present with ED are hypogonadal. Treating this population of men with medication to raise natural testosterone with or without the addition of a PDE5i has been shown to improve their symptoms. Young eugonadal men with no discernable organic etiology of ED respond well to oral PDE5i alone but tended to not follow-up, suggesting possible ED resolution without a need for prolonged treatment. In all, clinicians should check serum testosterone levels and conduct a thorough urological history to identify potential organic etiologies of ED in younger men before assuming a psychogenic basis. Disclosure Any of the authors act as a consultant, employee or shareholder of an industry for: Consultant for AbbVie, Marius, Tolmar, Endo, Petros, Boston Scientific, Coloplast Investor: Sprout.

Characteristics of Functional Hyperthermia Detected in an Outpatient Clinic for Fever of Unknown Origin

Background: Functional hyperthermia (FH) is characterized by hyperthermia resulting from sympathetic hyperactivity rather than inflammation, and it is frequently overlooked by medical practitioners due to the absence of abnormalities in a medical examination. Although FH is an important differential diagnosis for fever of unknown origin (FUO), the literature on FUO cases in Japan lacks information on FH. In this study, we aimed to uncover the population of FH patients hidden in FUO cases. Methods: An outpatient clinic for FUO was established at Okayama University Hospital, and 132 patients were examined during the period from May 2019 to February 2022. Results: A diagnosis of FH was made in 31.1% of the FUO cases, and FH predominantly affected individuals in their third and fourth decades of life with a higher incidence in females (68.3%). The frequency of a history of psychiatric illness was higher in patients with FH than in patients with other febrile illnesses. Although the C-reactive protein (CRP) is generally negative in FH cases, some obese patients, with a body mass index ≥ 25 had slightly elevated levels of CRP but were diagnosed with FH. Conclusions: The results showed the importance of identifying FH when encountering patients with FUO without any organic etiology.

Psychophysiologic symptom relief therapy for chronic back pain: hypothesis and trial rationale.

Chronic pain syndromes affect over one-third of the US adult population and often lead to significant disability and a reduced quality of life. Despite their high prevalence, causal links between chronic pain syndromes and anatomic abnormalities are often not apparent. Most current chronic pain treatments provide modest, if any, relief. Thus, there is a pressing need to understand the causal mechanisms implicated in chronic pain as a means to develop more targeted interventions for improvement in clinical outcomes and reduction in morbidity and financial burden. In the present manuscript, we summarize the current literature on treatment for chronic pain, and hypothesize that non-specific chronic back pain (without a clear organic etiology, such as tumors, infections or fractures) is of psychophysiologic origin. Based on this hypothesis, we developed Psychophysiologic Symptom Relief Therapy (PSRT), a novel pain reduction intervention for understanding and treating chronic pain. In this manuscript, we provide the rationale for PSRT, which we have tested in a pilot trial with a subsequent larger randomized trial underway. In the proposed trial, we will evaluate whether non-specific chronic back pain can be treated by addressing the underlying stressors and psychological underpinnings without specific physical interventions.

Clinical Manifestations.

Memory complaints are common in elderly and have various etiologies, including functional cognitive disorder (FCD). Diagnosis of FCD is supported by clinical evidence of incongruity with a neurodegenerative disorder and/or evidence of internal inconsistency - the ability to perform a task well at certain times, but with impaired ability at other times. The prevalence of features suggesting FCD in organic disorders is unclear. We assessed the presence of clinical features of internal inconsistency and other possible discriminators of FCD from organic causes in patients with mild cognitive impairment (MCI) and subjective cognitive impairment (SCI). Patients attending our tertiary memory clinic in a period of one year with SCI or MCI were included. Exclusion criteria were toxic or metabolic causes of cognitive decline, major psychiatric disorders, co-morbid neurological conditions that could affect cognition, and uncertainty of diagnosis of organic disorder or FCD. Medical records were reviewed for evidence of internal inconsistency and other suggested discriminators between functional and organic etiology. Demographic, cognitive and clinical data were compared between groups. We evaluated 39 patients with FCD and 57 with organic disorders. MCI was more common in patients with organic disorders. However, most patients with FCD also had MCI. Patients with FCD were younger and performed better on cognitive assessments, but with significant overlap between groups (Table 1). While patients with FCD more commonly attended the appointment alone and reported greater concern about their symptoms than their supporters, these features were unspecific (Table 2). Patients with FCD reported symptoms that could represent normal experiences and provided detailed descriptions of memory lapses more commonly. While less sensitive, memory perfectionism and symptoms occurring only in specific situations were highly specific for FCD. Differentiation between functional and organic cognitive disorders based on history and examination can be challenging. Features suggesting internal inconsistency and incongruity with neurodegeneration may also appear in organic causes of SCI and MCI. Their varying specificity and sensitivity for FCD need to be taken into account when considering the diagnosis. Improving the identification of FCD could in turn improve identification of patients with prodromal neurodegeneration.

NCOG-33. GLIOBLASTOMA AND PARKINSONISM, IS DEPLETED DOPAMINE A PROTECTIVE SURVIVAL FACTOR? A CASE SERIES OF 3 GBM PATIENTS

Abstract Glioblastoma multiforme (GBM) is the most common malignant brain tumor, and carries a grave prognosis with a median survival of 15 months. The pathophysiologic hallmark of Parkinson’s disease is neuronal loss of dopamine producing cells in the substantia nigra. Dopamine has been shown to modify cell-cycle status in neural progenitor cells. Dopamine agonism is adequate to increase progenitor proliferation in the subventricular zone (SVZ). Dopamine receptor antagonists have antiproliferative effects. A few clinical trials use selective dopamine receptor D2 (DRD2) inhibitors. Parkinsonism can have organic etiologies like stroke or neoplasm, while idiopathic Parkinsonism is known as Parkinson’s disease. While uncommon to have dual diagnoses, we identified three patients with both GBM and Parkinsonism, all were IDH wildtype, 2 patients were MGMT methylated, mean age was 67 years. Our 3 patients have a combined median PFS of 23.4 months, mean PFS of 25.4 months, which compares favorably to historical control median PFS of 6.9 months. Our 3 patients with dual diagnosis have a median OS of 47.3 months, and mean OS of 43.7 months, which compares favorably to historical median OS of 14.6 months. One might expect a patient with a neurodegenerative disease like Parkinson’s disease and a highly malignant tumor like GBM to have an extremely poor prognosis, yet our patient cohort reveals the opposite. The improved overall survival in GBM patients with Parkinsonism supports further clinical research into selective dopamine receptor inhibitors.

Sex influence in the etiology and long-term prognosis of significant tricuspid regurgitation

Abstract Introduction It is widely recognized that significant tricuspid regurgitation is more frequent in women, but there is practically no information on the prognostic differences according to sex in the different etiological groups. Our objective was to analyze the impact of sex on the frequency and prognosis according to the etiological group. Methods Retrospective multicenter study that included consecutive patients with significant tricuspid regurgitation (moderate-severe degree or greater) diagnosed between 2002 and 2017 in 3 referral hospitals. We retrospectively classified the patients according to sex and type of tricuspid regurgitation based on clinical and echocardiographic data. The type of tricuspid regurgitation was defined in the first step that met the established criteria, differentiating between congenital and organic etiology (structural tricuspid disease), left valve disease (mild mitral stenosis or another at least moderate valve disease), ventricular dysfunction, associated with pulmonary hypertension, or atrial (by not fulfilling any of the above and presenting atrial dilatation). Subsequently, we compared prevalence and mortality from all causes according to sex for each etiology. Results A total of 778 patients were included, 71% women. The median follow-up was 40.2 months (interquartile range 11.2-80.9). When comparing the frequency of each etiological group according to sex, we only found significant differences in tricuspid regurgitation associated with ventricular dysfunction (9.7% men vs 3.1% women, p &amp;lt;0.001). In terms of survival, we found significant differences with higher survival in women with organic etiologies (92.4 months in women vs 54.1 in men, p=0.021), secondary to valve disease (79.6 months in women vs 54.1 in men, p&amp;lt;0.001) or pulmonary hypertension (58.9 months in women vs 28.7 in men, p=0.01). In the rest of the etiological groups, differences were not statistically significant. Figure shows Kaplan-Meier survival curves based on each etiology for each gender. Conclusions Significant tricuspid regurgitation was observed in a higher percentage of women (71%). Regarding the frequency for each type of tricuspid regurgitation, only significant differences were found in the etiology secondary to ventricular dysfunction, being more frequent in men. Regarding the survival curves, significant differences were found with greater survival in the group of women in organic tricuspid regurgitation, secondary to valve disease and secondary to pulmonary hypertension.Kaplan Meier survival curves

Etiological Profile of Dyspepsia in Difficult-to-reach Tribal Population of Himachal Pradesh

Abstract Background: Dyspepsia exhibits a diverse range of underlying causes, with functional dyspepsia (FD) surpassing organic etiologies in prevalence. However, there exists a noticeable absence of prior research delineating the etiological spectrum of dyspepsia among the tribal regions of Himachal Pradesh (HP). The present study was carried out to determine the etiological profile of dyspepsia within this specific population. Materials and Methods: Conducted as a cross-sectional observational study centered around an endoscopy health camp, this investigation took place at the community health center in Kaza – a pivotal administrative hub in the remote Spiti Valley of the Lahaul and Spiti tribal district in HP. The study encompassed consecutive patients above 18 years of age presenting with gastrointestinal complaints. Those predominantly reporting dyspepsia were selected and subsequently underwent thorough endoscopic examination. Data analysis incorporated factors such as age, gender, history of smoking, alcohol consumption, nonsteroidal anti-inflammatory drug usage, and endoscopic findings. Results: Encompassing a total of 187 patients with an average age of 48.5 ± 13.4, the study found that endoscopy yielded normal results in 59.9% of cases (categorized as FD), whereas 40.1% displayed abnormal findings (categorized as organic dyspepsia). Among the latter, the most prevalent organic lesions were peptic ulcer disease (PUD) (62.7%) and erosive esophagitis (22.7%). Furthermore, gastric malignancy was detected in 4% of the cases. Conclusion: The primary organic causes of dyspepsia within the tribal areas of HP appear to be dominated by PUDs, closely followed by erosive esophagitis. Gastric malignancy, although less frequent, was identified in approximately 4% of the dyspeptic cases studied.

C7 (Clinical Case) ACTH-dependent Cushing’s in an 8-Year-Old: A Diagnostic Challenge

Abstract Introduction/Background Cushing’s syndrome (CS) is rare, with 2-5 cases per million annually, and only 10% of these occurring in children. Cushing’s disease (CD) (excessive adrenocorticotropic hormone [ACTH] secretion by a pituitary source leading to hypercortisolism) is the most common organic etiology of CS in children (75-90%). Ectopic ACTH syndrome (EAS), in contrast, accounts for less than 1%. Case Description An 8-year-old male presented with extensive vertebral compression fractures, rapid weight gain, and headaches. He was found to have hypertensive urgency (blood pressure 170/110 mmHg, &amp;gt; 99.9 percentile) and Cushingoid features. Investigations revealed hypokalemia (2.0 mmol/L), elevated serum cortisol (1654 nmol/L, ref 85-620) and elevated 24-hour urine cortisol (27244 nmol/day, ref &amp;lt; 25). An elevated ACTH (35pmol/L, ref 1.6-13.9) confirmed ACTH-dependent CS. Although non-invasive dynamic testing (high dose dexamethasone suppression and desmopressin stimulation tests) suggested an ectopic source, inferior petrosal sinus sampling (IPSS) suggested a pituitary source. Unfortunately, anatomical (3T MRI Sella) and functional imaging (18 F-DOPA and Gallium-68 dotatate PET/CT scans) have not identified a causative lesion to date. On 18 F-DOPA PET/CT imaging, a 1cm focus of avidity was found in the small bowel, concerning for neuroendocrine tumour. However, excisional biopsy identified the mass as a Meckel’s diverticulum with cortisol and ACTH persistently elevated post-operatively. As such, he has been started on ketoconazole to control the hypercortisolemia and reduce morbidity. This has been mainly effective, with 24-hour urine cortisol reduced to 70 nmol/day. He will undergo serial imaging and continue medical therapy as long as tolerated. Exploratory pituitary surgery may be considered if medical therapy proves ineffective or overly burdensome over time. Discussion We present a diagnostically challenging case of ACTH-dependent Cushing’s syndrome, suspected Cushing’s disease. Non-invasive dynamic tests have limited sensitivity and specificity when used in isolation. As a result, source localization in ACTH-dependent Cushing’s can be challenging. Ultimately, IPSS was suggestive of a pituitary source. However, a causative lesion has not been identified despite multiple modalities of anatomic and functional imaging. Medical therapy can be a useful temporizing measure while pursuing further workup, but can have problematic side effects and requires frequent laboratory monitoring. This patient’s story highlights the difficulty in diagnosis and in choosing a management strategy for a patient without an identified source of excess ACTH, as all options carry risk of morbidity. Conclusion CS is rare in paediatrics but should be considered in a patient with suggestive exam findings and refractory hypertension. Diagnostic workup should proceed in sequential order to confirm hypercortisolemia, distinguish between central vs peripheral origin, and localize the responsible lesion. In cases with inconclusive investigations, IPSS remains necessary for localization.