Protracted Course Research Articles

Long-term Outcomes following Operative Management of Pediatric Scapholunate Ligament Injuries.

Background Scapholunate (SL) ligament injuries are rarely diagnosed in children. This study reports the outcomes of surgically treated SL ligament injuries in patients younger than 18 years. Methods A retrospective review was performed on 20 pediatric patients with SL ligament injuries. Records were reviewed for preoperative and postoperative radiographic data, intraoperative findings, classifications of interosseous ligament injury, and postoperative course. Results Thirteen girls and seven boys sustained SL injuries requiring operative intervention and were followed for an average of 26 months. Magnetic resonance imaging (MRI) was performed in 15 patients, which revealed an SL tear in 7 patients. Arthroscopically, SL injuries were classified as Geissler grade III in 12 patients and grade IV in 5 patients. Based on the Mayo Wrist Score, nine patients had excellent or good results, while six demonstrated fair results. The mean wrist flexion-extension arc was 109 degrees, while the mean grip strength was 82% of the unaffected side. Patients treated >1 year following injury had significantly decreased grip strength and Mayo Wrist Score. Conclusion In this study, worse results were seen in children with a protracted course prior to treatment of an SL injury. A high index of suspicion is necessary to detect an SL injury in the younger age group and should be in the differential for those with persistent dorsal wrist pain, tenderness over the dorsal SL joint, and/or positive Watson's test. MRI may assist in diagnosis but is not definitive to rule out injury. Arthroscopy is valuable to determine the extent of injury.

Delayed revascularization of extremities following vascular injuries: Challenges and outcome

PurposeIn developing countries delayed presentation following major vascular injury is common due to limited vascular trauma units; delay in diagnosis and time lost in transit which pose a major challenge for limb salvage. Aim of this study was to assess limb survival and complications after delayed revascularization of extremity following major vascular injury. Method20 patients, (19 males and 1 female, mean age 31.55 years) with major extremity vascular injury who presented >8 h after vascular trauma were included in this study. All patients had road traffic accidents as the cause of extremity injury. These patients were operated by primary vascular repairs, thrombectomy and/or interposition vein graft along with fixation of concomitant skeletal trauma. ResultsThe commonest vessel injured was popliteal artery. The mean time of limb revascularization was 30.8 h. Limb salvage rate was 95% and there was no perioperative mortality. 9 patients developed postoperative complications including sloughing of leg muscles (4), foot drop (3) pseudo aneurysm (1) and reperfusion injury (1). At 6 months follow-up all the patients were able to walk with full weight bearing and there was no chronic ischemia, pain or sinuses. ConclusionLimb salvage can be achieved with good results in patients with delayed revascularization in selected cases. However; delayed revascularization leads to long and protracted postoperative course with high chances of vascular and neurological complications.

Abstract 10437: Venoarterial Extracorporeal Membrane Oxygenation Rescue Therapy in Vasoplegic Shock Due to Calcium Channel Blocker Overdose: 5 Year Single Center Experience

Introduction: Over 15,000 incidences of Calcium Channel Blocker (CCB) overdose were reported by the American Association of Position Control Centers (AAPCC) in 2020, resulting in 45 deaths from pure CCB overdose and 176 deaths from multidrug overdose involving CCBs. We present a single-center experience on the use of VA ECMO in the management of refractory hypotension due to CCB toxicity. Hypothesis: VA ECMO is effective and can be life-saving in vasoplegic shock from drug overdose Methods: We retrospectively reviewed our ECMO registry in the last 5 years to identify patients who were started on ECMO support for refractory hypotension due to drug overdose. Results: We found 5 patients who were started on VA-ECMO for drug overdose, all involving CCBs. Mean age was 60. They had persistent lactic acidosis and hypotension after fluid resuscitation, requiring escalating doses of vasopressors until they were on or near the maximum. All patients were started on hyperinsulinemia euglycemic protocol and 3 patients received methylene blue. The mean time to intubation was 11.2 ± 4.14 hours. An echocardiogram demonstrated intact systolic function in all patients. VA-ECMO was started within 11.2 ± 4.5 hours of admission. Pressor requirements quickly improved on ECMO support. Average time on ECMO was 69 ± 48.6 hours. 4 of 5 patients improved quickly and were extubated within 10 days (mean: 4.88 ± 2.95). In these 4 patients, the length of ICU stay was 8.5 ± 3.87 days, and hospital stay was 11.75 ± 2.06 days. One patient had a protracted course due to renal failure, pneumonia, and concern for North-South Syndrome. Cannulation was switched to subclavian/axillary approach, but that was complicated by left arm ischemia and switch to VV-ECMO after 44 hours of VA-ECMO. She was discharged after a 46-day hospital stay. Conclusions: VA-ECMO support is effective and lifesaving in patients with refractory shock from CCB toxicity. Early referral to ECMO capable center should be considered in these patients.

Degloving Injury: Evaluation and Management

Objective: To study the frequency, clinical presentation, management and outcome of degloving soft-tissue injuries.
 Study Design: Case series.
 Place and Duration of Study: Department of Surgery, Federal General Hospital, Islamabad Pakistan, from Jan 2018 to Dec 2019.
 Methodology: This study included 28 consecutive patients with degloving injuries. Patients with degloving injuries of the soft tissue were included. Initial assessments of all patients were done according to advanced trauma life support. Regular clinical examination for abnormalities such as excessive local pain that was out of line with the intensity of the trauma, extensive ecchymosis or hematomas, and especially, local and regional hypermobility of the skin, capillary refill and perfusion of the area.
 Results: Out of 28 patients, there were 25 males (9.28%) and three females (10.72%). The mean age was 33.07±9.04 years with a range of 6-50 years. The thigh was the most frequently involved area by degloving injury (25.00%). The back was involved in 17.85% of patients. Leg (10.71%) and foot (10.71%) were involved in 21.42% of patients. From the management point of view, 42.85% of patients had some form of debridement and healing by secondary intention, 17.85% patients were managed conservatively, and 10.71 % of the patients' primary closure was successful.
 Conclusion: Degloving soft-tissue injury is debilitating and, if not taken care may lead to ischemia necrosis, infection and septicemia of the tissues, which needs extensive debridement, prolonged use of broad-spectrum antibiotics, which result in disability and protracted course of rehabilitation.

Changes in immunological reactivity of patients with pulmonary tuberculosis and allergic and toxic-allergic reactions

BACKGROUND. The spread of tuberculosis in Ukraine forces doctors to use intensive chemotherapy, which leads to adverse reactions and promotes to the spread of drug-resistant tuberculosis. Toxic-allergic reactions take a protracted course and are difficult to respond to corrective therapy, which requires additional research.
 OBJECTIVE. To determine changes in immunological reactivity in patients with pulmonary tuberculosis with allergic and toxic-allergic reactions by cellular immunity research.
 MATERIALS AND METHODS. The results of clinical, laboratory and immunological examination of patients were analyzed depending on the presence/absence of clinical signs of allergic reactions to antituberculosis drugs using the method of flow cytofluorimetry and assessment of phagocytic link of immunity.
 RESULTS AND DISCUSSION. There were detected the activation of all studied subpopulations of T- and B-lymphocytes and an increase in the absolute and percentage number of natural killers in the blood of patients without adverse reactions. It is a positive factor for the destruction of mycobacteria. The development of allergic reactions support the inhibition of the activity of the general pool of T-lymphocytes, their subpopulations, B-lymphocytes, natural killers, the absorption activity of phagocytes. It is an unfavorable factor that can lead to the formation of anergy of immunocytes. Increased activity of the inflammatory process and deepening of the immunological imbalance were detected in patients with clinical and laboratory signs of toxic-allergic reactions. It is not accompanied by an inhibitory effect on blood lymphocytes and phagocytes, is revealed. It indicates a special pathogenesis of toxic-allergic reactions with involvement of disturbed liver functions.
 CONCLUSSION. Identified differences in the immune status will allow to adjust the treatment.

Features of the development and clinical course of pneumothorax in patients with a new coronavirus infection

New coronavirus infection (COVID-19) is a modern global problem that requires the rapid development of diagnostic and treatment methods, as well as the study of pathological effects on body tissues. Due to severe damage to the respiratory organs, special attention is paid to the study of pneumothorax as a manifestation of gas syndrome, one of the complications of COVID-19.The purpose of the study was to assess the incidence of pneumothorax as a complication of COVID-19, the features of the development of the pathological process, and to determine the criteria for treatment tactics.Materials and methods. In total, for the period from April 2020 to May 2022 at the Clinical Infectious Diseases Hospital named after. S.P. Botkin treated 31532 patients with a confirmed diagnosis of COVID-19. As part of this study, the case histories of 316 patients with clinical manifestations of gas syndrome were retrospectively analyzed. All patients were diagnosed with COVID-19, the diagnostic criterion of which was a positive result of the PCR test – the detection of RNA in a swab taken from the nasopharynx and oropharynx.Results. Analysis of case histories showed that severe COVID-19 occurs in all age groups. Collapse of half of the lung was observed in most cases (59 patients). The main treatment method for pneumothorax was Bulau drainage. At the same time, in 47 patients (32%) this method required active aspiration. In 37 patients (26%), drainage was corrected and the pleural cavity was re-drained. In 37 patients, the result of hospitalization was a fatal outcome, the main causes of which were severe pneumonia and/or severe immunodeficiency, 75 patients (52%) were discharged from the hospital in a stable condition.Conclusions. The occurrence of pneumothorax in patients with COVID-19 is characterized by late onset, protracted course, the formation of purulent complications and a high incidence of fatal outcomes, which do not always correlate with the severity of pneumonia.

Litigation analysis of medical damage after total knee arthroplasty: a case study based on Chinese legal database in the past ten years

BackgroundThe medical damage litigations after knee arthroplasty are on the rise year by year. However, few studies examined the litigation after knee arthroplasty. This study analyzed the litigation of medical damage after knee replacement in the past ten years based on a Chinese database. It synthesized the focus of the dispute in these cases to provide a reference for doctors to reduce the risk of litigation.MethodsRetrospectively analyzed were medical damage litigations after total knee arthroplasty in the past ten years (June 2011–June 2021) from the "Wolters Kluwer Legal Information Database". The data collected included the characteristics of patients, causes of litigation, the results of litigation and the amount of compensation.ResultsA total of 110 litigation cases were analyzed, including 40 male patients (36.3%) and 70 female patients (63.6%). The top cause of litigation was infection (43.6%). The most common factor leading to the doctor losing the case was "complications caused by operational error" (P < 0.05). Complications, such as amputation, postoperative ischemic stroke and infection, were more likely to result in higher compensation.ConclusionsThe prevention of infection and the avoidance of operational errors are very important in avoiding medical litigations. Moreover, avoiding disabling complications or a protracted course of disease could significantly reduce the amount of compensation. In addition, full and reasonable communication, paying full attention to the reaction of patients, and timely diagnosis could also effectively minimize the risk of litigation and loss.

S2001 Chronic Norovirus Infection in a Double Solid Organ Transplant Patient

Introduction: Infectious diarrhea is a common complication in the postoperative course of a solid organ transplant (SOT) recipient. While self-limiting in immunocompetent patients, transplant patients on long-term immunosuppression can have severe, prolonged disease with significant morbidity. We present a case of chronic diarrhea due to recurrent norovirus infection in a double SOT patient to encourage early recognition. Case Description/Methods: A 61-year-old male presented with 35-pound weight loss despite a good appetite and large-volume watery diarrhea intermittently for 2 years. He had a liver-kidney transplant 14 years prior secondary to cryptogenic cirrhosis and renal cell carcinoma. Immunosuppression consisted of prednisone, tacrolimus, and mycophenolate mofetil (MMF). Stool PCR was positive for norovirus and negative for other viruses, bacteria, and parasites. His MMF dose was reduced with no benefit. He was discharged with supportive care with initial improvement in the diarrhea but returned to the hospital 4 other times with worsening diarrhea and weight loss. Infectious workup was persistently positive for norovirus. Bi-directional endoscopy with biopsies revealed colonic mucosa with rare epithelial apoptosis, chronic duodenitis, and increased intraepithelial lymphocytosis in the duodenum and ileum consistent with chronic norovirus (Figure). The full diagnostic workup is detailed in Table 1. He was managed conservatively during each hospitalization with fluids and antimotility agents and recently discharged home with plans to start nitazoxanide outpatient. Discussion: Norovirus infection among SOT patients can lead to severe and symptomatic chronic infection. Patients can develop dehydration, transplant rejection, and malnutrition making them higher risk for hospitalizations and death. It is unclear why some immunocompromised patients recover spontaneously while others demonstrate a protracted course but supportive care is the mainstay of therapy. Limited case series have shown nitazoxanide to be effective in treating SOT patients with chronic norovirus infection. However, nitazoxanide needs to be continued until stool RNA studies become negative. This case highlights the importance of considering chronic norovirus when a SOT patient presents with chronic diarrhea and weight loss. Early initiation of supportive care and nutrition consultation are imperative in reducing morbidity in these patients. Nitazoxanide can be effective in patients that are refractory to supportive therapy.Figure 1.: Duodenal biopsy (A): Focal intraepithelial lymphocytosis and lamina propria plasma cell infiltrates. Terminal ileum biopsies (B,C): Focal intraepithelial lymphocytosis and lamina propria plasma cell infiltrates (B); popcorn-like epithelial apoptosis (C). Table 1. - Diagnostic Workup Test/Procedure Result Creatinine, serum 2.1 mg/dl (baseline 1 mg/dl) Stool PCR -Positive for norovirus-Negative for Clostridium difficile toxins, Salmonella, Shigella, Yersinia, and Campylobacter Osmolality, feces 420 mOsm/kg Fecal fat Abnormal Duodenal biopsy -Mucosa with intraepithelial lymphocytosis, dense plasma cell infiltrates in the lamina propria, and rare apoptotic bodies-Negative for CMV, EBV, HSV Stomach biopsy -Gastric antral and oxyntic gland mucosa with chronic inactive gastritis-Negative for H. pylori Right colon biopsy Rare epithelial apoptosis Left colon biopsy Rare epithelial apoptosis Terminal ileum biopsy Mucosa with intraepithelial lymphocytosis, dense plasma cell infiltrates in lamina propria, and rare apoptotic bodies

A Large Database Evaluation of Infection and Nonunion Following Ankle Arthrodesis: Does Pain Regimen Matter?

Category: Ankle Arthritis; Ankle Introduction/Purpose: Multimodal therapies are critical for limiting use of opioids for postoperative pain control after orthopaedic procedures. Though NSAIDs and COX-2 inhibitors are effective non-opioid adjuncts for postoperative pain, animal models have demonstrated increased rates of nonunion or delayed union in the presence of NSAIDs. Nonunion or delayed union results in a protracted postoperative course that may warrant longer duration of surveillance or revision procedures. Retrospective studies and meta-analyses investigating NSAID use and bone healing have conflicting findings. Additionally, there are few studies investigating NSAID use and other adverse events such as postoperative infection. Improved understanding of the impact of NSAID use on union rates and infection after ankle arthrodesis will allow practitioners to optimize safe, effective pain control while limiting risk of nonunion. Methods: This large retrospective database study queried a national insurance claims database (PearlDiver Technologies) for patients undergoing ankle arthrodesis from 2015 through 2019 as identified by ICD-10 codes. Patients prescribed NSAIDs or COX-2 inhibitors within six weeks following ankle arthrodesis were identified. Patients with any operation one year prior to or following ankle arthrodesis were excluded from analysis to prevent attributing complications to another operation. Association between NSAID or COX-2 inhibitor use and infection or nonunion following ankle arthrodesis were analyzed using multivariable logistic regression analyses. To adjust for comorbid conditions, multivariable models included age at time of operation, sex, obesity, tobacco use, and diabetes. Results: Our query yielded 2,355 patients in the five-year period who underwent ankle arthrodesis. 257 (11%) patients were prescribed NSAIDs following surgery and 56 (2.4%) patients were prescribed COX-2 inhibitors. Infection risk was similar between patients not prescribed either medication (n=92, 4.5%) and those treated with NSAIDs (n=14, 5.4%; P=0.60) or COX-2 inhibitors (n=2, 3.5%; P=0.99). The nonunion rate between patients not prescribed either medication (n=232, 11%) was similar to those treated with COX-2 inhibitors (n=8, 14%; P=0.64), but increased in patients treated with NSAIDs (n=45, 18%; P=0.006). On multivariable analysis, tobacco use (OR, 1.46; 95% CI, 1.09-1.94), obesity (OR, 2.08; 95% CI, 1.57-2.76), and NSAID use (OR, 1.53; 95% CI, 1.06-2.17) were associated with increased odds of nonunion after ankle arthrodesis (all P&lt;0.02) (Table). Conclusion: Analysis of the PearlDiver database, the largest available administrative claims database, for 2,355 patients undergoing ankle arthrodesis demonstrated an 11% risk of nonunion and 4.5% risk of infection. The risk of nonunion is increased in patients prescribed NSAIDs within six weeks postoperatively (18%). After adjusting for comorbid conditions associated with nonunion, such as tobacco use and obesity, NSAID use increased risk of nonunion whereas COX-2 inhibitor use did not. Prospective investigation is necessary to better understand these relationships, however, our analysis suggests practitioners should judiciously utilize NSAIDs and consider use of COX-2 inhibitors for pain control after ankle arthrodesis surgery.

The Emerging Role of Radiation Therapy in Renal Cell Carcinoma.

Simple SummaryStereotactic ablative radiation therapy (SAbR) is a safe and effective local therapy for renal cell cancer (RCC) with emerging and evolving indications. In this review we provide an overview of the evidence to support SAbR for RCC in a variety of clinical settings.Advancements in radiation delivery technology have made it feasible to treat tumors with ablative radiation doses via stereotactic ablative radiation therapy (SAbR) at locations that were previously not possible. Renal cell cancer (RCC) was initially thought to be radioresistant, even considered toxic, in the era of conventional protracted course radiation. However, SAbR has been demonstrated to be safe and effective in providing local control to both primary and metastatic RCC by using ablative radiation doses. SAbR can be integrated with other local and systemic therapies to provide optimal management of RCC patients. We will discuss the rationale and available evidence for the integration and sequencing of SAbR with local and systemic therapies for RCC.

Single nucleotide polymorphisms and chromosomal copy number variation may impact the Sporothrix brasiliensis antifungal susceptibility and sporotrichosis clinical outcomes

Feline-transmitted sporotrichosis has garnered attention due to the recent high incidence and the lack of efficient control in the epicenter of the epidemic, Rio de Janeiro, Brazil. Sporothrix brasiliensis is the major pathogen involved in feline-to-human sporotrichosis in Brazil and displays more virulent genotypes than the closely related species S. schenckii. Over the last two decades, several reports of antifungal-resistant strains have emerged. Sequencing and comparison analysis of the outbreak strains allowed us to observe that the azole non-wild-type S. brasiliensis strain CFP 1054 had significant chromosomal variations compared to wild-type strains. One of these variants includes a region of 231 Kb containing 75 duplicated genes, which were overrepresented for lipid and isoprenoid metabolism. We also identified an additional strain (CFP 1055) that was resistant to itraconazole and amphotericin B, which had a single nucleotide polymorphism in the tac1 gene. The patients infected with these two strains showed protracted clinical course and sequelae. Even though our sample size is modest, these results suggest the possibility of identifying specific point mutations and large chromosomal duplications potentially associated with antifungal resistance and clinical outcomes of sporotrichosis.

Traditional Chinese Medicine Regulates Th17/Treg Balance in Treating Inflammatory Bowel Disease.

Inflammatory bowel disease (IBD), also known as chronic nonspecific inflammatory disease of the colon and rectum, is primarily characterized by mucopurulent bloody stools, diarrhea, abdominal pain, and tenesmus. Its cause is uncertain. IBD patients frequently experience a high rate of recurrence, a protracted treatment course, and a high risk of carcinogenesis. Additionally, the difficulty of treatment is significantly increased by these illness characteristics. Currently, the normal treatment for this illness can lessen symptoms to some amount and even meet clinical treatment requirements, but due to serious side effects, unfavorable reactions, and high costs, we need to develop better complementary and alternative medicines. A number of studies have found that the imbalance of T helper cell 17 (Th17)/regulatory T cells (Treg) contributes significantly to the occurrence and progression of IBD and that Th17/Treg balance restoration is frequently useful in the management of IBD. As a result, regulating the Th17/Treg balance has also emerged as a novel approach to treating IBD. Traditional Chinese medicine (TCM) has gained popularity in recent years due to its advantages of low side effects, a variety of targets, and multiple regulatory mechanisms. A number of studies have shown that TCM can successfully intervene in the Th17/Treg imbalance and restore it, and research on the prevention and treatment of IBD by TCM by restoring Th17/Treg has also shown promising results. The characteristics of the Th17/Treg balance and its role in the pathogenesis of IBD, as well as the role of TCM in regulating the Th17/Treg imbalance, are analyzed. The research results are expected to provide a theoretical basis for the clinical treatment and pathology mechanism research of IBD.

Lymphomas mimicking neuroinflammatory diseases – A diagnostic conundrum worth revisiting

Purpose of reviewCentral nervous system (CNS) lymphomas (CNSLs) have varied clinical presentations which can mimic neuroinflammatory disease, leading to a diagnostic dilemma for clinicians. Recent findingsThis report describes two patients who initially received a diagnosis of neuroinflammatory disorders but were refractory to treatment over a protracted time course. In both cases, biopsy revealed diffuse large B cell lymphoma (DLBCL) as the final diagnosis. SummaryThe analysis of these cases provides an opportunity for increased recognition of CNS lymphomas for earlier diagnosis and treatment. It also calls for increased clinical suspicion for CNSLs in such circumstances. And possibly the search for new biomarker development for identifying and tracking CNSLs.

Frozen shoulder.

Frozen shoulder is a common debilitating disorder characterized by shoulder pain and progressive loss of shoulder movement. Frozen shoulder is frequently associated with other systemic conditions or occurs following periods of immobilization, and has a protracted clinical course, which can be frustrating for patients as well as health-care professionals. Frozen shoulder is characterized by fibroproliferative tissue fibrosis, whereby fibroblasts, producing predominantly type I and type III collagen, transform into myofibroblasts (a smooth muscle phenotype), which is accompanied by inflammation, neoangiogenesis and neoinnervation, resulting in shoulder capsular fibrotic contractures and the associated clinical stiffness. Diagnosis is heavily based on physical examination and can be difficult depending on the stage of disease or if concomitant shoulder pathology is present. Management consists of physiotherapy, therapeutic modalities such as steroid injections, anti-inflammatory medications, hydrodilation and surgical interventions; however, their effectiveness remains unclear. Facilitating translational science should aid in development of novel therapies to improve outcomes among individuals with this debilitating condition.

Багаторічна динаміка стійкості до професійного вигорання у педагогічних працівників закладів освіти різного типу

Objective: The aim of the study was to assess the level of professional burnout among teachers of educational institutions of various types in the long-term dynamics, taking into account the forms of work organization. Materials and methods: During 2008 - 2021 the level of occupational burnout was monitored in 852 pedagogical workers of the Sumy region. The study was carried out according to the method of V. V. Boyko «Diagnostics of the level of occupational burnout». The study included three stages. In 2008, 420 teachers of secondary education institutions were surveyed. In 2020, 342 teachers of preschool and primary schools were examined. In 2021, 85 teachers of secondary education institutions were examined. In 2021, the organization of the educational process was taken into account. It included an online format in the context of the COVID-19 pandemic caused by the SARS-CoV-2 coronavirus, taking into account a history of coronavirus disease. Results: During the entire observation period, a low level of occupational burnout prevailed among teaching staff. Over the years, there has been a steady trend in the spread of the average level of occupational burnout, which has a negative sign of a protracted course with regular symptoms. The dependence of the development of the general syndrome of occupational burnout on age was established (r=-0,87, p&lt;0,01). In 2008, occupational burnout was formed at the expense of teachers aged 31-40 years old. In recent years of observation, all levels of occupational burnout were formed at the expense of teachers aged 51 years old and more. Thus, the teachers retained the features of the psycho-emotional state with manifestations of occupational burnout after twelve years of observation and formed groups with high occupational burnout at the time of the re-examination. As of February 2021, 63,53% of teaching staff in the observation group had a history of coronavirus disease. Regardless of this, there was a general tendency among pedagogical workers for the advantage of low and medium levels of occupational burnout over high. A high level of professional burnout among teachers who underwent COVID-19 (9,26±0,95 %) was recorded in 3,64%, which is less than the same group of teachers (with a high level of professional burnout) without a history of COVID-19 (12,90±1,34 %, t=2,21, p&lt;0,05). It has been established that the development of professional burnout is not associated with the psycho-emotional state of the coronavirus disease, since the main factors in the formation of professional burnout are the organizational factors of the labor process. Conclusions: During 2008-2021, teachers experienced an increase in the rate of development of occupational burnout. The dependence of occupational burnout on age has been established.

POS-133 CASE REPORT OF DISSEMINATED KLEBSIELLA INFECTION IN T2DM LEADING TO CKD

K. pneumoniae can present as two forms of community-acquired pneumonia, acute and chronic. Although acute pneumonia may turn into necrotizing pneumonia, which results in a prolonged clinical course, it often has a rapidly progressive clinical course. In contrast, chronic Klebsiella pneumonia runs a protracted indolent course that mimics other chronic pulmonary infections and malignancies. The Klebsiella pneumoniae bacteria usually affects the right upper lung lobe and results in the creation of a cavity, as well as pus-producing tissue death.K. pneumoniae is an aggressive microorganism, accounting for 0.5 to 5% of pneumonia cases. It can lead to cavitation (30-50% of cases) and necrotising pneumonia (NP) within a short period of time (days). Case : 40 year old male with a history of diabetes mellitus (DM) was admitted 20 days back patient was admitted and treated for DKA and LRTI discharged after treatment. Patient readmitted 20 days later with complaints of right sided loin pain, high grade fever of 8 days, cough with expectoration for one month, pyuria for 5 days and anuria for one day. Patient readmitted On admission – P-96/min, BP-140/90 mmhg, RR-26/min, Spo2-96% with O2. On evaluation patient was found to have raised creat (8mg/dl) initiated on hemodialysis. Patient ultrasound showed of left sided bulky kidney with acute pyelonephritis. CXR showed cavitatory lesion in middle lobe of right side lung. 5days Later patient complaint of increased left loin pain repeat USG showed left sided psoas abscess so CT showed no any evidence of communication of pyelonephritis with abscess. Pigtail drain was placed for psoas abscess, culture which was positive for klebsiella. Sputum culture was positive for klebsiella, A diagnosis of dissiminated klebsiella infection was made. In spite of all necessary investigations and treatment patient was dialysis dependent, patient deteriorated over time and could not be saved. Investigations :Tabled 1ParametersValuesHemoglobin9.8 gm/dlTotal leukocyte counts25,500/cummPlatelets2.4 lac/cummUrea104 mg/dlCreatenine4.2 mg/dlSerum Na136 mmol/lSerum K4.5 mmol/lBilirubin1.5 mg/dlSGOT/SGPT45/32Calcium7.6 mg/dlPhosphorus5.8 mg/dlUric acid6.2 mg/dlHbA1c10.5%Urine examinationAlb ++ Sug + Epi cells 1-2/min Pus cells - plenty RBC - 1-2/hpf24 hr urinary protein1.5 gm/day Open table in a new tab Sputum culture & Pus culture – klebsiella Sputum for MTB - negative Fundus – moderate NPDR CXR – Cavitatory lesion in right lung middle zone USG – RK – 12.5*5.9cm, LK – 13.6*6.2cm mod dilation of pelvicalyceal system bilateral bulky kidneys with left acute pyelonephritis. CT abd – left psoas bulky with evidence of 8*2.5 cm well defined hypodense collection within. CT chest – Thick walled cavitatory lesions with surrounding consolidation noted in medial segment of right middle lobe, postero-basal segment of right lower lobe, superior segment of left lower lobe We conclude that patients with immunocompromised state like Diabetes mellitus are more prone to disseminated infections which can lead to high morbidity and mortality. Good glycemic control, early diagnosis and effective management with could be key role in managing a diabetic patient.

NUTM1 -rearranged Carcinoma of the Thyroid : A Distinct Subset of NUT Carcinoma Characterized by Frequent NSD3 - NUTM1 Fusions.

NUT carcinoma (NC) is a rare subtype of squamous cell carcinoma defined by NUTM1 rearrangements encoding NUT fusion oncoproteins (the most frequent fusion partner being BRD4 ) that carries a very poor prognosis, with most patients dying in under 1 year. Only rare primary thyroid NCs have been reported. Here, we evaluated a series of 14 cases. The median patient age at diagnosis was 38 years (range: 17 to 72y). Eight of 13 cases with slides available for review (62%) showed a morphology typical of NC, whereas 5 (38%) had a non-NC-like morphology, some of which had areas of cribriform or fused follicular architecture resembling a follicular cell-derived thyroid carcinoma. For cases with immunohistochemistry results, 85% (11/13) were positive for NUT on biopsy or resection, though staining was significantly decreased on resection specimens due to fixation; 55% (6/11) were positive for PAX8, and 54% (7/13) for TTF-1. Tumors with a non-NC-like morphology were all positive for PAX8 and TTF-1. The fusion partner was known in 12 cases: 9 (75%) cases had a NSD3-NUTM1 fusion, and 3 (25%) had a BRD4-NUTM1 fusion. For our cohort, the 2-year overall survival (OS) was 69%, and the 5-year OS was 58%. Patients with NC-like tumors had a significantly worse OS compared with that of patients with tumors with a non-NC-like morphology ( P =0.0462). Our study shows that NC of the thyroid can mimic other thyroid primaries, has a high rate of NSD3 - NUTM1 fusions, and an overall more protracted clinical course compared with nonthyroid primary NC.

Clinical triad with multi-biopsy histopathology as a reliable diagnostic marker of mycetomas: a retrospective review from a tertiary care center.

Mycetoma is a neglected tropical infectious disease which runs a prolonged and protracted course. Microbiological confirmation is diagnostic yet unreliable due to poor sensitivity and variable availability of culture facilities in resource poor settings. A retrospective review was performed on electronic records (histopathology, microbiology, and radiology) of all patients who underwent skin biopsies with mycetoma as one of the clinical differential diagnoses from year 2016 to 2020. Out of 73 patients biopsied with a differential of mycetoma, 42 fit the clinical triad of swelling-sinuses-granules. After clinical, microbiological, pathological, and radiological correlation, 31 cases were of eumycetoma and seven were of actinomycetoma. Mean patient age was 37.58 ± 13.8 years with a male to female ratio 2.45 : 1 and mean disease duration of 11.31 ± 10.9 years. Histopathological findings revealed fungal hyphae in 18 cases and gram-positive bacteria in six cases. Fungal culture was positive in 13 cases with the three commonest organisms being Madurella mycetomatis in five cases, Fusarium and Aspergillus nidulans in two cases each. X-ray changes of soft tissue, bones, and joints were seen in 25 cases, and "dot-in-circle" sign was seen in eight of nine MRIs. Eumycetoma was more common than actinomycetoma in our setup, ratio being 4.43 : 1. A clinical triad of swelling, multiple sinuses and grainy discharge with any one diagnostic support (histopathology/radiology) is sufficient to make a definitive diagnosis of mycetoma in the absence of microbiological identification.

P69. Older people living with degenerative spine disease and undergoing spine surgery: just trying to get back to a normal life

<h3>BACKGROUND CONTEXT</h3> Lumbar degenerative spine disease is a consequence of aging. Globally, 266 million people are diagnosed with this debilitating condition annually. As the population ages, the number of spinal surgeries to address the symptoms of this condition will increase. However little information is available about the experiences of older people living with degenerative spine disease and who undergo spine surgery. <h3>PURPOSE</h3> The purpose of this study was to investigate older peoples' understandings of living with and having surgery for degenerative spine disease and the process they engage in to try to get back to their normal life. <h3>STUDY DESIGN/SETTING</h3> A qualitative approach, grounded theory (GT), in a Midwestern quaternary care hospital. <h3>PATIENT SAMPLE</h3> Participants were = 65yrs of age, hospitalized following spine surgery for degenerative spine disease. <h3>OUTCOME MEASURES</h3> Interviews lasted from 30-60 minutes. Early interviews were open and non-directional, to obtain the meanings that participants assigned to having spine surgery for degenerative spine conditions. As analysis progressed, interviews became more focused to add category depth. <h3>METHODS</h3> A total of 28 interviews with 14 individuals who were recruited for 2 in-depth interviews at 2-time points: T1 during hospitalization and T2, 1-3 months post discharge. All 14 participants were interviewed at T1; 10 at T2-one month; 2 at T2- two months and 2 at T2-3 months postdischarge (N=28 interviews). Interviews lasted 30-60 minutes. All interviews were audio recorded and transcribed verbatim. Consistent with GT, purposive and theoretical sampling was used. Data analysis included open, axial, and selective coding and was conducted by an interdisciplinary team. <h3>RESULTS</h3> Based on analysis of the data, a conceptual model was developed which illustrates the phases older persons with degenerative spine disease go through in their trajectory of trying to get back to their normal life. Three key categories identified were (1) losing me (2) fixing me and (3) recovering me. Multiple dimensions within each category were identified. All participants described a prolonged process of losing who they were in terms of functional independence and being able to socialize. Fixing me consisted of having to prove the need for surgery and preparing for surgery. Recovering me involved constant monitoring for success and progress with rehabilitation. For most, recovering me was ongoing- none identified they had returned to their normal. Several conditions, including setbacks and delays, slowed participants recovery trajectory. Throughout this process, participants had to continually adjust their expectations of what was returning to normal. Additionally, participants described complications as ongoing symptoms of their degenerative spine disease after surgery, and a long, protracted course in trying to get back to normal life. <h3>CONCLUSIONS</h3> The conceptual model, based on real-world patient experiences, details how older people engage in living with and undergoing surgery for degenerative spine disease. Our model can serve as the foundation for developing interventions to guide patient education programs for preparing for surgery, improve transitions of care and develop patient-centered approaches for treating and managing older people with degenerative spine disease and spine surgery. <h3>FDA DEVICE/DRUG STATUS</h3> This abstract does not discuss or include any applicable devices or drugs.

MULTI-DISCIPLINARY INTERVENTION FOR LABIAL FUSION IN A CASE OF VULVAL LICHEN PLANUS.

Vulvo-vaginal lichen planus is a very distressing and rare forms of non-venereal genital dermatoses. Erosive variants of Lichen planus often have a protracted course and has a higher risk of malignant transformation. This case was a 53-year- old woman, previously diagnosed with lichen planus on conservative treatment, who now presented with symptomatic labial adhesions and urinary complaints like urgency, frequency and poor urine stream. Clinical examination revealed normally developed labia majora, partially but extensively fused labia minora including the clitoral hood. Urethral opening was not visualised, while a small vaginal orifice was seen with no ulcerations. A multi-disciplinary team consisting of urologist and plastic and cosmetic surgeon dissected out the labial adhesions with the electrocautery and reconstructed the vaginal and urethral openings. Cystoscopy followed by urethral dilatation was done for urethral narrowing. Postoperatively, on following up the patient the adhesions were completely separated, and the area healed well. No recurrences were noted. Though aggressive management with topical steroids and other measures often improves symptoms on short term basis, few patients may require long term management by multi-disciplinary team to optimize the outcomes.