Recalcitrant Cases Research Articles

S. aureus biofilm metabolic activity correlates positively with patients’ eosinophil frequencies and disease severity in chronic rhinosinusitis

Chronic rhinosinusitis (CRS) is a persistent inflammation of the sinus mucosa. Recalcitrant CRS patients are unresponsive to medical and surgical interventions and often present with nasal polyps, tissue eosinophilia, and Staphylococcus aureus dominant mucosal biofilms. However, S. aureus sinonasal mucosal colonisation occurs in the absence of inflammation, questioning the role of S. aureus in CRS pathogenesis. Here, we aimed to investigate the relationship between S. aureus biofilm metabolic activity and virulence genes, innate immune cells, and disease severity in CRS. Biospecimens, including sinonasal tissue and nasal swabs, and clinical datasets, including disease severity scores, were obtained from CRS patients and non-CRS controls. S. aureus isolates were grown into biofilms in vitro, characterised, and sequenced. The patients’ innate immune response was evaluated using flow cytometry. S. aureus was isolated in 6/19 (31.58%) controls and 23/53 (43.40%) CRS patients of 72 recruited patients. We found increased S. aureus biofilm metabolic activity in relation to increased eosinophil cell frequencies and disease severity in recalcitrant CRS cases. Mast cell frequencies were higher in tissue samples of patients carrying S. aureus harbouring lukF.PV, sea, and fnbB genes. Patients with S. aureus harbouring lukF.PV and sdrE genes had more severe disease. This offers insights into the pathophysiology of CRS and could lead to the development of more targeted therapies.

Use of tofacitinib in recalcitrant cases of chronic pruritus of unknown origin.

Use of tofacitinib in recalcitrant cases of chronic pruritus of unknown origin.

Recent Advances in Temporomandibular Joint Surgery.

Temporomandibular disorders (TMDs) affect a high percentage of children and adults worldwide. Surgery may be indicated in severe or recalcitrant cases. Several recent advancements in TMD and temporomandibular joint (TMJ) surgery have elevated understanding and the ability to treat affected patients. We discuss recent advances in TMD epidemiology, juvenile idiopathic arthritis (JIA) of the TMJ, and surgical techniques and technologies. Technical advancements have been identified in TMJ arthroscopy, the treatment of TMJ subluxation and dislocation, and extended prosthetic total TMJ reconstruction (eTMJR). Overall, this review provides valuable insights into significant recent advancements in TMJ disorders and their surgical management.

To compare the safety and efficacy of intrastromal voriconazole alone and in combination with intracameral voriconazole in intractable cases of fungal keratitis

Background: Mycotic keratitis is a potential sight-threatening infection and a leading cause of ocular morbidity worldwide. It is inherently difficult to treat due to the delayed diagnosis and fungistatic nature of available topical medications. Aims and Objectives: The aim is to compare the safety and efficacy of intrastromal voriconazole alone and in combination with intracameral voriconazole in recalcitrant fungal keratitis cases. Materials and Methods: A prospective, hospital-based, interventional study was conducted in 40 cases of fungal keratitis involving >50% stromal thickness and not showing a good response to conventional antifungal treatment even after 4 weeks. Cases were randomly divided into two groups: group A and group B of 20 each; group A patients received intrastromal voriconazole, while group B patients were given intrastromal+intracameral voriconazole combination in 50 mg/0.1 mL dose. Cases were examined daily for 1 week and then every week for 4 weeks to monitor progression. Results: Out of 20 cases in group A, 14 (70%) patients got improved, while 18 (90%) patients in group B showed significant improvement after 4 weeks, and the difference was statistically significant (P=0.02). In group A, the average number of injections given to the patients was 3.65±1.56 for 15.2±8.79 days, while in group B, the average number of injections given to the patients was 2.65±1.44 for 13.2±7.768 days, with a statistically significant difference (P=0.033). Conclusion: Intrastromal and intracameral voriconazole combination is a cost-effective and highly efficacious modality in managing recalcitrant cases of fungal keratitis. It should be recommended in cases with thick hypopyon and Aspergillus as the causative fungi that do not respond to conventional treatment.

Tofacitinib in the treatment of recalcitrant cases of psoriasis vulgaris

Treatment of recalcitrant cases of psoriasis vulgaris can pose a major challenge to dermatologists. Despite the availability of various drugs and treatment modalities, these cases often either show unsatisfactory response to these treatments or may have to be discontinued due to development of adverse effects or may be contraindicated due to underlying morbidities. After exhausting the conventional modalities such as methotrexate, cyclosporine, acitretin, apremilast, and phototherapy, the next line of management involves usage of biologicals. Biologicals, although efficacious in most cases, come with their own set of drawbacks including cost, availability, and risk of development of anti-drug antibodies, rendering them ineffective. Furthermore, some patients have found to relapse within a few months of stopping them. We present a case series of five patients of refractory psoriasis vulgaris who had exhausted all conventional modalities (including biologicals in three of the patients) who were successfully treated with tofacitinib, a small molecule inhibiting Janus kinase 1/3 enzyme. Our patients have reported no side effects with tofacitinib till date and are continuing to maintain the results. From this series, we conclude that tofacitinib may be an effective therapy for the management of recalcitrant psoriasis.

The Pressure Is Rising: Evaluation and Treatment of Chronic Exertional Compartment Syndrome.

Chronic exertional compartment syndrome is a condition that typically affects athletic/active individuals. Chronic exertional compartment syndrome predominantly affects the lower leg; however, there are cases involving the hand, forearm, foot, and thigh. The signs and symptoms of chronic exertional compartment syndrome are severe pain, tightness, cramping, muscle weakness, and paresthesias during participation in exercise. Dynamic intramuscular compartmental pressure (preexertion and postexertion) is the standard diagnostic test. Although other imaging modalities, such as radiography, ultrasound, and magnetic resonance imaging are typically incorporated to rule out other pathologies. In addition, these modalities are being utilized to limit invasiveness of the diagnostic experience. Initial care commonly involves conservative treatment, such as physical therapy, modifications of patient's exercise technique, foot orthoses, and various procedures over a period of 3 to 6 months. Recalcitrant cases may be referred for surgical intervention (fasciotomy), which has inconclusive head-to-head data with conservative management with regard to return to prior sport and specific activity level.

Recurrent Respiratory Papilloma of the Larynx

Recurrent respiratory papilloma (RRP) is a common benign neoplasm that most commonly affects the larynx. Caused primarily by human papilloma virus (HPV) types 6 and 11, RRP affects both children and adults; juvenile-onset RRP is thought to be related to HPV exposure during childbirth, whereas adult-onset disease has been hypothesized to be related to sexual contact.1Aaltonen L.M. Rihkanen H. Vaheri A. Human papillomavirus in larynx.Laryngoscope. 2002; 112: 700-707https://doi.org/10.1097/00005537-200204000-00020Crossref PubMed Scopus (83) Google Scholar Symptoms of RRP are typically voice or airway related. Adults tend to experience voice changes, primarily because of impairment of vocal fold vibration in the setting of papilloma along the membranous vocal folds. In children, in whom lesions tend to grow more quickly, airway narrowing may present with stridor in addition to voice changes. Direct or indirect laryngoscopy is standard work-up. Flexible fiberoptic or distal chip scopes may reveal heaped, irregular lesions of the glottis (Figure 1A) or supraglottis, and filters (eg, narrow-band imaging) (Figure 1B) may help to reveal intraepithelial capillary loops. Biopsy remains the criterion standard for diagnosis. Figure 2 illustrates typical findings, including a higher-power image of a cellular papillary frond with viral cytopathic effects and corresponding chromogenic in situ hybridization for low-risk HPV type 6/11.2Venkatesan N.N. Pine H.S. Underbrink M.P. Recurrent respiratory papillomatosis.Otolaryngol Clin North Am. 2012; 45 (671-94, viii-ix. https://doi.org/10.1016/j.otc.2012.03.006)Abstract Full Text Full Text PDF Scopus (89) Google Scholar Treatment includes excision or ablation with cold technique, photoangiolytic lasers, or microdebriders, with maximal conservation of the subepithelial vocal fold tissue. Recurrent respiratory papilloma routinely recurs, and so adjunct treatments with cidofovir and bevacizumab are advocated for recalcitrant cases.3Pogoda L. Ziylan F. Smeeing D.P.J. Dikkers F.G. Rinkel R.N.P.M. Bevacizumab as treatment option for recurrent respiratory papillomatosis: a systematic review.Eur Arch Otorhinolaryngol. 2022; 279: 4229-4240https://doi.org/10.1007/s00405-022-07388-6Crossref Scopus (3) Google Scholar Emerging evidence suggests that HPV vaccination, even in those already affected, may be beneficial in reducing the severity of disease.4Ponduri A, Azmy MC, Axler E, et al. The efficacy of human papillomavirus vaccination as an adjuvant therapy in recurrent respiratory papillomatosis. Laryngoscope. Published online January 18, 2023. https://doi.org/10.1002/lary.30560.Google Scholar The authors report no competing interests.

A COMPARATIVE STUDY ON EFFICACY OF PLATELET RICH PLASMA VS CORTICOSTROID INJECTION IN TREATMENT OF CHRONIC PLANTER FASCIITIS

Background- Plantar fasciitis is a common cause of heel pain. It is a disabling disease in its chronic form[1]. Various treatment options are available including Nonsteroidal anti-inammatory drugs, physiotherapy, orthosis, corticosteroid injection and lately autologous platelet-rich plasma (PRP) has been used. Purpose: To compare the efcacy of platelet rich plasma and corticosteroid injections in reducing pain and improving functional outcome in patients with chronic plantar fasciitis. Materials and Methods: To compare the efcacy a non-randomized comparative prospective clinical trial conducted in the Department of Orthopaedics, Adichunchanagiri institute of Medical Sciences, B.G NAGARA after obtaining ethical clearance. This study consisted of 80 patients diagnosed with the chronic planter fasciitis. Patients fullling inclusion criteria was included in the study for a period of 18 months (November 2020 to May 2022). Visual analogue scale for pain scores were used as outcome variables. Results: In the present study, pain was assessed using a 10- point VAS. Pre-injection, mean VAS score was 8.23 ± 1.12 and 8.53 ± 1.09 in the corticosteroid and PRP group respectively, with no signicant difference between them (p value = 0.22). At 3 weeks, mean VAS score was 8.38 ± 1.39 and 6.88 ± 1.19 in the corticosteroid and PRP group respectively. Though the mean VAS score was lower in the PRP group, there was no signicant difference between them (p value = 0.31). At 6 weeks, we observed that mean VAS score was lower in the PRP group (5.2 ± 0.94) as compared to corticosteroid group (5.5 ± 0.88), though the difference was not statistically different. At 3 months, we observed that mean VAS score was signicantly lower in the PRP group (3.58 ± 0.81) as compared to corticosteroid group (4.03 ± 0.83), p value < 0.05. The trend continued at the next follow up as well. At 6 months, we observed that mean VAS score was signicantly lower in the PRP group (1.78 ± 0.66) as compared to corticosteroid group (2.15 ± 0.58), p value < 0.01. Conclusion: PRP was more effective and durable than steroid injection for the treatment of chronic recalcitrant cases of planter fasciitis

Surgery in the Era of Immunotherapy for Advanced Head and Neck Non-melanoma Skin Cancer.

Surgery remains the mainstay of treatment for non-melanoma skin cancer (NMSC). Immunotherapy (IO) has emerged as an alternative option. This review provides a contemporary summary of how to incorporate IO into the management of advanced NMSC. Evidence-based outcomes and recent clinical trials are provided with emphasis on the three most common NMSC diagnoses: cutaneous squamous cell carcinoma (cSCC), basal cell carcinoma (BCC), and merkel cell carcinoma (MCC). Surgical resection while preserving form and function remains the standard of care for the majority of NMSCs. In recalcitrant cases failing traditional surgery and/or primary radiation, patient ineligible for such treatments, or unresectable disease, IO has emerged as a promising alternative. In the majority of cases, it is a supplanting primary chemotherapy. Surgery remains the standard of care for NMSC. Immunotherapy has emerged as an alternative option for non-surgical candidates and as a neoadjuvant means to minimize morbidity.

Treatment recalcitrant cases of tinea corporis/cruris causedby T. mentagrophytes - interdigitale complex with mutations in ERG11 ERG 3, ERG4, MDR1 MFS genes & SQLE and their potential implications.

Recalcitrant dermatophyte infections are being reported from various parts of the world due to varied causes including strain variation, steroid misuse, SQLE mutations, and variable quality of itraconazole pellet formulations. The oral drug preferred in endemic areas is itraconazole, to which MIC levels remain low, and clinical failures to itraconazole reported defy a sound scientific explanation. The objective of the study was to conduct a proteomic and genomic analysis on isolates from therapeutically recalcitrant case with isolation of gene mutations and enzymatic abnormalities to explain azole failures. Trichophyton mentagrophyte interdigitale complex strains were isolated from seven clinically non-responding tinea corporis/cruris patients, who had failed a sequential course of 6 weeks of terbinafine 250 mg QD and itraconazole 100 mg BID. After AFST 1 strain, KA01 with high MIC to most drugs was characterized using whole genome sequencing, comparative proteomic profiling, and total sterol quantification. Sterol quantification showed that the standard strain of Trichophyton mentagrophytes (MTCC-7687) had half the ergosterol content than the resistant KA01 strain. Genomic analysis revealed mutations in SQLE, ERG4, ERG11, MDR1, MFS genes, and a novel ERG3 mutation. Proteomic analysis established the aberrant expression of acetyl Co-A transferase in the resistant strain and upregulation of thioredoxin reductase and peroxiredoxin. Our findings demonstrate possible reasons for multidrug resistance in the prevalent strain with mutations in genes that predict terbinafine (SQLE) and azole actions (ERG4, ERG11, ERG3) apart from efflux pumps (MDR1, MFS) that can explain multidrug clinical failures.

Impacts of Ultrasonogram-Guided, Intra-fascial, Autologous, Activated Platelet-Rich Plasma Injection in Chronic Plantar Fasciitis: A Quasi-experimental Study.

Background Plantar fasciitis is the most common cause of foot pain. Patients with plantar fasciitis typically present with 'first step pain,'which tends to decrease with activity and worse with heavy use. This study determines the effect of ultrasound-guided, single-dose, platelet-rich plasma (PRP) injection in patients with chronic plantar fasciitis. Materials and methods It was a quasi-experimental trial carried out in the Department of Physical Medicine and Rehabilitation, Bangabandhu Sheikh Mujib Medical University (BSMMU), Dhaka, Bangladesh, from March 2019 to March 2022. A total of 148 patients diagnosed with chronic plantar fasciitis were selected as samples. A total of 75 patients were allocated to group A (intra-lesional injection of autologous PRP with conservative management) and 73 patients to Group B (only conservative management). Both groups of patients were allocated to conservative management with exercises, shoe modification, activities ofdaily living (ADLs) instruction, and oral paracetamol. Results This study shows that in group A, the mean visual analog scale(VAS) score significantly reduced to 1.47±0.51 after six months of single-dose PRP injection (p<0.001). In group B, the VASscorealso decreased substantially after conservative treatment. Though in groups A and B, pain reduction was significant, in group A, the pain was decreased more compared to group B and statistically significant differences were found between the two groups at the 12th week and 24th week. The foot function index (FFI) scores decreased significantly in group A after a single dose PRP injection, compared with group B treated with conventional therapy. In group A, FFI scores decreased from 49.09±5.72 to 7.67±3.41. The study revealed a significant difference between study groupsin the 12th week and 24th week regarding FFI scores. Conclusion Ultrasound-guided intra-lesional autologous PRP Injection is safe and effective and recommended in patients with chronic plantar fasciitis, especially in recalcitrant cases after the failure of conservative treatment and corticosteroid injection.

An Evidence-Based Approach to Orthobiologics for Tendon Disorders.

Tendinopathy is a chronic injury that affects both the athletic and general population. Recalcitrant tendinopathy is both frustrating for patients and providers once typical conservative treatments have been exhausted. Current research in orthobiologics shows that they are safe and could improve pain and function in recalcitrant cases. Unfortunately, many studies show inconsistency in the content of the orthobiologic injectate and approach in treatment protocols. There are robust data to support the use of platelet-rich plasma for the treatment of recalcitrant common extensor tendinopathy and plantar fasciopathy, but high-quality random control trials are needed before drawing definitive conclusions for other tendinopathies.

Good functional outcomes after endoscopic treatment for greater trochanteric pain syndrome

PurposeGreater trochanteric pain syndrome (GTPS) is a term covering different conditions generating lateral hip pain. Recalcitrant cases may require surgery but there are only a few studies evaluating endoscopic treatment. This study aimed to evaluate the outcome of endoscopically treated GTPS at minimum two years postoperatively using patient-reported outcome measures (PROMs), and to assess the complication rate associated with endoscopic surgery.MethodsA total of 33 patients, mean age 43.2 years, 88% women, with a mean symptom duration of 3.5 years, were included in the study. A total of 36 operated hips were included. Pre- and at minimum two years postoperatively the patients completed questionnaires consisting of the International Hip Outcome Tool (iHOT-12) and the Hip Sports Activity scale (HSAS), the Visual analogue scale for overall hip function (VAS-OHF), the Copenhagen Hip and Groin Outcome Score (HAGOS), the EuroQoL-5 Dimension Questionnaire (EQ-5D) and the EQ-VAS. Complications were assessed using the Clavien-Dindo classification.ResultsMedian follow-up time was 24.5 months postoperatively. Statistically significant improvements were seen for the following PROMs (p < 0.05); iHOT-12 (36.3 vs 54.0), HAGOS different subscores (40.8 vs 59.0, 46.5 vs 62.6, 29.9 vs 53.1, 33.5 vs 51.4, 20.7 vs 41.4, 23.4 vs 43.3), EQ-VAS (55.9 vs 63.3) and EQ-5D (0.392 vs 0.648). VAS-OHF and HSAS did not reach significance. There was a 71% satisfaction rate with the surgery. Three Clavien-Dindo grade 1 and one grade 2 complications were registered postoperatively, with 41% of patients achieving PASS for iHOT-12 at two years follow-up.ConclusionEndoscopic surgery for greater trochanteric pain syndrome improved patient-reported outcomes and the procedure was associated with low risk of complications.Level of evidenceLevel IV.

Comparison between Ultrasound-guided Pulsed Radiofrequency Ablation of the Medial Calcaneal Nerve and Extracorporeal Shockwave Therapy in Managing Recalcitrant Plantar Fasciitis: A Randomised Controlled Trial

Introduction: Plantar Fasciitis (PF) is one of the most common causes of heel pain, with a prevalence ranging from 3.6-7% in the general population. Approximately 90% of patients with PF respond well to conservative therapy, including rest, stretching, analgesics, physical therapy, shoe modifications, or steroid injections. However, around 10% of patients have recalcitrant cases that require invasive or surgical interventions. Pulsed Radiofrequency Ablation (PRFA) is a non neurodestructive method that provides non surgical pain relief in such cases. Aim: To compare the effectiveness of ultrasound-guided PRFA of the Medial Calcaneal Nerve (MCN) and Extracorporeal Shockwave Therapy (ESWT) in managing recalcitrant PF. Materials and Methods: This randomised controlled trial was conducted at the Department of Physical Medicine and Rehabilitation, Regional Institute of Medical Sciences, Imphal, Manipur, India over a two-year period from September 2018 to August 2020. A total of 78 patients with PF were included in the study, divided equally into two groups: a study group and a control group, each consisting of 39 participants. The study group received PRFA of the MCN, while the control group received ESWT of the plantar fascia. The Visual Analog Scale (VAS), Plantar Fascia Thickness (PFT), and American Orthopaedic Foot and Ankle Society (AOFAS) hindfoot score were measured at 1, 4, 12, and 24 weeks as outcome variables. Data analysis was performed using Statistical Package for the Social Sciences (SPSS) version 21.0, and statistical tests like Chi-square test, t-test, and repeated measures Analysis of Variance (ANOVA) were used. A p-value of &lt;0.05 was considered significant. Results: Of the 78 patients included in the study, 42 (53.8%) were females and 36 (46.2%) were males, with a mean age of 41.08±10.09 years. The VAS score in the study group improved from 5.51±0.82 at baseline to 1.92±0.80 at 24 weeks, while in the control group, the VAS score improved from 5.36±0.97 at baseline to 2.33±0.66 at 24 weeks. PFT in the study group improved from 4.45±0.374 at baseline to 2.26±0.231 at 24 weeks, while in the control group, PFT improved from 4.42±0.366 at baseline to 2.49±0.357 at 24 weeks. The AOFAS score also improved from 50.49±13.13 at baseline to 74.03±11.53 in the study group, and in the control group, the AOFAS score improved from 49.74±12.26 at baseline to 71.36±10.72 at 24 weeks (p-value &lt;0.05). Conclusion: Significant improvements were observed in all outcome measures in both the study and control groups, with a p-value &lt;0.05. However, the improvements were more pronounced in the study group, with minimal to no sideeffects. Hence, ultrasound-guided PRFA of the MCN can be considered an effective minimally invasive treatment modality for recalcitrant PF.

Comparative study of functional outcomes of open versus arthroscopic surgery of lateral epicondylitis in a tertiary care hospital

Background: Lateral epicondylitis, a degenerative tendinopathy due to microtears in extensor tendons caused by repeated pronation-supination is commonly managed by NSAIDS, physiotherapy, local steroid injections and braces. Although most are self limited, some recalcitrant cases lead to chronic pain and reduction in quality of life. Surgical management by open or arthroscopic means is a viable option but there is a gap of knowledge in current literature regarding superiority of one over the other.Methods: A total of 32 patients with recalcitrant lateral epicondylitis admitted from March 2019 to August 2020 were enrolled and randomized into two groups, receiving either open or arthroscopic debridement of diseased tendons of extensor carpi radialis longus, brevis and communis. Patients were assessed for pain, functional outcome and complications with a 6 month follow-up.Results: VAS score for pain and DASH score for functional outcome improved in all patients after surgery and there was no difference between the two groups. Although mean duration of surgery was significantly longer by arthroscopy, time to return to work was significantly shorter in this group (p&lt;0.001). Difference in complication rate was not statistically significant.Conclusions: Based on this study, surgical management both open and arthroscopic are equally effective for recalcitrant lateral epicondylitis in terms of pain, functional score and patient satisfaction; arthroscopy however shows an earlier return to work. Either can be chosen depending on available skill, equipment and patient demands.

Umbilical Cord Graft for Refractory Neurotrophic Keratopathy.

The purpose of this study was to evaluate whether an umbilical cord tissue graft (UCG) could promote reepithelialization in refractory cases of neurotrophic keratopathy, which failed traditional treatment modalities including amniotic membrane grafts. This retrospective case series included 3 eyes of 3 patients who underwent UCG placement for refractory stage 3 neurotrophic keratopathy. Records were reviewed to evaluate the clinical course including previous treatments, time to UCG dissolution, time to corneal epithelialization, and recurrence of epithelial defects. The time of a nonhealing epithelial defect before UCG placement ranged from 7.7 to 30 weeks (mean 21.0). UCG dissolution time ranged from 1.7 to 8.1 weeks (mean 5.0) compared with the previous failed amniotic membrane dissolution time of 0.3 to 1.6 weeks (mean 0.95). The time to complete epithelialization after UCG placement was 7.7 and 8.1 weeks, respectively, for the first 2 cases, whereas the third case did not fully epithelialize. Only 1 eye did not have recurrence of an epithelial defect. The maximum time of maintained epithelialization without recurrence ranged from 5 to 86 weeks (mean 42.7). Follow-up time was 37 to 108.1 weeks (mean 62.2) after first UCG placement. UCG may allow for longer retention time of tissue grafts, provide a mechanical barrier for protection, and aid in regeneration of the ocular surface. UCG may be an option for re-epithelialization in recalcitrant cases of neurotrophic keratopathy, after conventional treatments such as amniotic membrane grafts have failed.

Midterm Outcomes of Endoscopic Plantar Fascia Debridement in 125 Patients: A 5-Year Follow-Up

Plantar fasciitis is one of the most common pathologies addressed by foot and ankle surgeons. Despite advances and overall success rates for conservative therapy, many of the recalcitrant cases proceed to require surgical correction. Partial to complete release of the fascia is often performed altering foot biomechanics and severing the windlass mechanism. Endoscopic debridement of the plantar fascia allows for direct visualization and removal of the inflammatory tissue while leaving the fascia and its function intact. A total of 125 feet were evaluated with a minimum follow-up time of 5 years. Gender, body mass index, and duration of symptoms were all evaluated and documented. Visual analog scale scores (VAS), American Orthopedic Foot and Ankle Score (AOFAS), and Foot Function Index (FFI) were collected both pre- and postoperatively. AOFAS, FFI, and VAS scores improved from a pre-operative mean of 57.6, 89.4%, and 8.6-89.1, 13.4%, and 0.7 respectively (p < .05) at final follow-up. Of the 125 patients, 98% stated they were satisfied with the operative outcome and would undergo the procedure again. At final follow-up, no patient suffered rupture of the fascia or recurrence. Patients were able to bear weight immediately following the surgery in a walking boot and on average patients were able to return to work at 3.4 days following surgery. This is a novel technique that does not compromise the plantar fascia or alter foot biomechanics with promising 5-year outcomes.

LBODP069 Parathyroid Crisis And Recalcitrant Hypercalcemia From Double Parathyroid Adenomas

Abstract Parathyroid crisis is a rare and life-threatening manifestation of hyperparathyroidism. Patients present with severe hypercalcemia and associated symptoms of bone disease, nephrolithiasis, abdominal pain, and fatigue. Multi-organ dysfunction in the form of encephalopathy, cardiac dysrhythmias, and renal failure is often present. There have also been reports of bleeding duodenal ulcers secondary to marked elevated parathyroid hormone. The most common etiology is a single parathyroid adenoma (85%) followed by hyperplasia (10%), double adenomas (4%), and carcinoma (1%). Parathyroid crisis requires immediate medical management of hypercalcemia and in recalcitrant cases, urgent parathyroidectomy. A 67-year-old female presented to the hospital with weakness and intermittent hematochezia. She was found to have acute renal failure, new onset anemia, and profound hypercalcemia of 17.1 mg/dl. On exam, she was slow to respond and exhibited diffuse muscle weakness. EKG showed sinus tachycardia, a right bundle branch block, and normal QTc. She received aggressive intravenous fluids and calcitonin. Bisphosphonate was not given due to renal failure. Due to refractory hypercalcemia, she was initiated on cinacalcet. She ultimately required hemodialysis due to failure of medical therapy. Further work-up showed a PTH of 2627 pg/ml. Vitamin D levels, TSH, and serum and urine protein electrophoresis were unremarkable. Renal ultrasound did not show nephrolithiasis. Given hematochezia and anemia in the setting of parathyroid crisis, endoscopy was done and was unrevealing of ulcers. A parathyroid ultrasound and nuclear medicine CT scan showed bilateral parathyroid adenomas. She underwent left superior and right inferior parathyroidectomy with biopsies revealing hypercellular parathyroid tissue with no features of malignancy. Following surgery, calcium levels gradually normalized. However, she remained dialysis dependent. This case exhibits a rare presentation of parathyroid crisis from double adenomas, requiring urgent double parathyroidectomy due to refractory hypercalcemia. This patient had an astoundingly elevated PTH level of 2627 pg/dl, one of the highest values documented in literature, which may attribute to the recalcitrant nature of hypercalcemia. Prompt diagnosis and treatment of parathyroid crisis is critical in preventing life-threatening complications. Presentation: No date and time listed

A large case series on the use of diphencyprone immunotherapy in the clearance of palmoplantar warts.

Palmoplantar viral warts are common, often affecting the quality of life of patients and present a major therapeutic challenge. Immunotherapy using diphencyprone (DCP) can be beneficial especially if first-line treatments fail. To determine the effectiveness of DCP in clearing viral warts, and to provide detail on the number of treatments required and any adverse effects (AEs). This was a retrospective case series of 124 patients who had received DCP treatment in a UK private practice setting from 1991 to 2008, carried out by a dermatologist experienced in the procedure. All patients had been referred by other clinicians after failure of standard treatments. The study data were extracted from clinical records, with follow-up until wart clearance or treatment discontinuation. There was an equal distribution in sexes (63 females, 61 males), with 37% of patients having warts present for greater than 5 years. The majority (93%) of patients had already tried cryotherapy, which was unsuccessful in clearing warts completely in all cases. Following DCP treatment, 77% of patients achieved full eradication of their warts, including three patients who were immunosuppressed. The mean number of DCP treatments required to achieve full clearance was 4·7, and the mean concentration of DCP required was 4%. Only 12% of patients experienced AEs, which were mild, and included urticaria and blistering. We suggest that DCP immunotherapy is a safe and effective treatment for eradicating viral warts, especially in recalcitrant cases.

A multicenter, retrospective study to evaluate the effectiveness, safety, and utilization patterns of super bioavailable itraconazole 50 mg in superficial dermatophytic infections

&lt;p class="abstract"&gt;&lt;strong&gt;Background:&lt;/strong&gt; Objectives of the study were to assess the clinical characteristics of patients with superficial dermatophytic infections, and to evaluate the safety and effectiveness of super bioavailable (SB) itraconazole 50 mg.&lt;/p&gt;&lt;p class="abstract"&gt;&lt;strong&gt;Methods:&lt;/strong&gt; In this cross-sectional observational study, data of patients with superficial dermatophytic infections treated as per physician’s discretion was collected retrospectively from 71 centers across India between April 2021 and March 2022. Patient’s demographics, prescribing patterns of SB-itraconazole, and clinician-rated effectiveness and safety were evaluated.&lt;strong&gt;&lt;/strong&gt;&lt;/p&gt;&lt;p class="abstract"&gt;&lt;strong&gt;Results:&lt;/strong&gt; Of 432 analyzed patients, 72.22% (n=312) had new infections, 27.77% (n=120) had recalcitrant/recurrent infections. Majority of the patients were males (66%) and aged 21-40 years (72.45%). &lt;em&gt;Tinea corporis&lt;/em&gt; (27.08%) was the most common fungal infection followed by &lt;em&gt;Tinea cruris&lt;/em&gt; (20.60%). SB-itraconazole was most commonly prescribed with water (63.88%; n=276); majority (55.8%) of the patients received SB-itraconazole post-meals. Majority of the patients achieved clinical (naïve: 71.47%; recalcitrant: 79.17%) cures within 4 weeks. The efficacy was excellent/good in 71.95% of patients who received SB-itraconazole as the first choice over conventional itraconazole for overall benefits as per the clinician’s global assessment; and in 87.22% of patients who received concomitant acid-lowering drugs. Most (83.33%) patients reported excellent/good compliance with SB-itraconazole. The clinicians’ rated this newer formulation of itraconazole (SB-itraconazole) as excellent/good in efficacy (83.33%) and safety (79.17%) for most patients.&lt;/p&gt;&lt;p class="abstract"&gt;&lt;strong&gt;Conclusions:&lt;/strong&gt; SB-itraconazole was effective and safe in patients with superficial dermatophytic infections. The effectiveness of SB-itraconazole was similar with high response rates for naïve and recalcitrant cases. Further, the efficacy was excellent/good in most patients receiving SB-itraconazole as the first choice over conventional itraconazole, or who received concomitant acid-lowering drugs.&lt;/p&gt;