Severe Deconditioning Research Articles

Reported roles of care partners in a specialized weaning centre—perspectives of patients, care partners, and health care providers

BackgroundCare partners are individuals chosen by a person with an illness to support their care during hospitalization. Patients with persistent critical illness have longer than average critical care admission and often other conditions including dysphagia, communication vulnerability, severe physical deconditioning, the need for an artificial airway, and difficulty weaning from invasive mechanical ventilation. Family presence has been identified as important for patients experiencing persistent critical illness in specialized weaning centers. Despite this, the role of care partners in clinical settings for patients with persistent critical illness has not been fully characterized, particularly from the perspectives of patients, care partners, and health care providers. The aim of this study was to gain insights into the roles of care partners during persistent critical illness from the perspectives of patients, care partners, and health care providers.MethodsWe used qualitative descriptive methodology including semi-structured interviews and content analysis. Interviews were audio recorded and transcribed verbatim. Included participants (n = 30) were patient survivors (n = 7), care partners of patient survivors (n = 9), and professionally diverse health care providers (n = 14) of adult patients with persistent critical illness from two specialized units in one community academic hospital in Toronto, Canada.ResultsParticipants across all groups described care partner roles that included physical, mental health, cognitive, social, and spiritual support of the patient, including the perceived role of safeguarding the multiple dimensions of care for the patient who is experiencing persistent critical care in specialized care settings.DiscussionThe results of this study are being used to co-design, implement, and evaluate a sustainable care partner program that is acceptable, appropriate, and feasible to implement in clinical settings where the care of patients with persistent critical illness occurs.Reporting methodConsolidated criteria for reporting qualitative studies (COREQ).

EP10.01-019 Rowing Against Cancer: From a Support Project to a Research Program. Perspectives and Challenges of Rowing in Metastatic Lung Cancer Patients

Lung cancer symptoms and secondary effects of cancer treatments impact quality of life and induce patients to excessive rest and lack of physical activity resulting in severe deconditioning. Exercise has been shown to increase performance status, strength, endurance and reduce emotional issues in lung cancer patients. Despite these benefit this approach is a poorly utilized strategy and several barriers must be overcome due to limited data, lack of awareness of the benefits of exercise, and limited patient motivation.

Response to Moderate and Vigorous Aerobic/Resistance Exercise in a Woman With Long-COVID

Response to Moderate and Vigorous Aerobic/Resistance Exercise in a Woman With Long-COVID

Comparison of the Degree of Deconditioning in Myalgic Encephalomyelitis/Chronic Fatigue Syndrome (ME/CFS) Patients with and without Orthostatic Intolerance

Background: Orthostatic intolerance (OI) is a core finding in individuals with myalgic encephalomyelitis /chronic fatigue syndrome (ME/CFS). Deconditioning is often proposed as an important determinant for OI. Deconditioning can be objectively classified using the predicted peak oxygen consumption (%VO2 peak) values as derived from cardiopulmonary exercise testing (CPET) and OI can be objectively quantified using cerebral blood flow (CBF) changes during tilt testing. Therefore, if deconditioning contributes to OI, a correlation between peak VO2 and the %CBF reduction is expected. Methods and results: 18 healthy controls (HC) and 122 ME/CFS patients without hypotension or tachycardia on tilt testing were studied. Deconditioning was classified as follows: %VO2 peak ≥85%= no deconditioning, %VO2 peak 65-85%= mild deconditioning, %VO2 peak<65%= severe deconditioning. HC had higher %VO2 peak compared to ME/CFS patients (p<0.0001). ME/CFS patients had significantly larger CBF reduction than HC (p<0.0001). No relation between the degree of deconditioning by the %VO2 peak and the %CBF reduction in ME/CFS patients was found. Moreover, we separately analyzed ME/CFS patients without an abnormal CBF reduction. Despite equal CBF reductions compared to HC and large differences between these patients and the patients with an abnormal CBF reduction, cardiac index (CI) changes (measured by suprasternal Doppler) were significantly less compared to ME/CFS patients with an abnormal CBF reduction (p<0.0001) but larger than in HC (p=0.004). Despite these different hemodynamic findings, %VO2 values were not different between the two patient groups, argumenting again against the causative role of hemodynamic abnormalities in deconditioning. Conclusion: In ME/CFS patients without hypotension or tachycardia there is no relation between the %VO2 peak during CPET and the %CBF and %CI reduction during tilt testing, whether or not patients have an abnormal CBF reduction during tilt testing. It suggests again that deconditioning does not play an important role in OI.

Neuromuscular electrical stimulation and exercises effect on functional exercise performance and quality of life in cases of liver cirrhosis

IntroductionPatients with cirrhosis experience severe physical deconditioning, sarcopenia, physical frailty, fatigue, and malnutrition. Exercise capacity is limited owing to inactivity, bed rest, obesity, or cachexia. Limb muscle dysfunction has important consequences for patients with liver cirrhosis because it contributes to exercise limitation and reduces daily activities and social life, leading to a quality of life (QOL) impairment, greater utilization of social and health resources, and a worse prognosis. The study purpose was to compare the effect of neuromuscular electrical stimulation (NMES) and exercises on treatment of patients with liver cirrhosis.MethodsA total of 60 patients (41 males and 19 females) with liver cirrhosis, aged 35–59 years, were randomly assigned to 2 groups: an NMES group (<i>n</i> = 30) and exercises group (<i>n</i> = 30). The intervention was implemented 3 times per week for 3 months. Exercise performance and QOL were measured before and after the intervention.ResultsBefore treatment, there was no significant difference in exercise performance or QOL between the 2 groups; however, after 3 months of intervention, a significant difference in exercise performance was observed between the 2 groups (<i>p</i> = 0.001). Both groups improved their QOL (<i>p</i> = 0.001), but the NMES group improved more than the exercise group.ConclusionsNMES is an important technique to increase exercise performance and QOL in patients with liver cirrhosis.

Short and medium-term impact of a cardiac rehabilitation (CR) program in COVID-19 patients after acute care hospitalization

Abstract Background COVID-19 (C-19) infection can acutely cause organ dysfunctions, especially cardiorespiratory, even with a long recovery period, inducing a significant functional deficit. Aim of the study was to evaluate the impact of a holistic hospital intensive rehabilitation program, based on CR, on C-19 patients (P), after acute care, to improve their fitness, in order to return to their life in the best conditions. Methods In the period april-august 2020, 30 P (mean age 73 years, 60% male) were admitted to the rehabilitation centre at a mean distance of 31±11 days from the onset of C-19; 34% of them had undergone prolonged invasive ventilation, 34% non invasive ventilation and 32% required high flow oxygen. Comorbidities were: hypertension (77%), diabetes (13%) and chronic coronary syndrome (10%); 18 P were unable to stand, and 12 showed impaired trunk control. No P had impaired LVEF or significant valvular disease. Initially, the program focused on training for trunk and sitting control; then on exercises for straightening the upper and lower limbs. From the second week, started a CR training on the cycle ergometer 10–20 minutes a day for 6 days a week, similar protocol to that used in P with heart failure. The aerobic training was of moderate intensity, not exceeding 40–60% of the maximum heart rate, Borg scale 10–12, starting with zero load, gradually increasing by 10–15 watts and up to a minimum target of 25–30 watts. The impact of the protocol on motor functions [MRC Muscle Strenght Scale, Short Physical Performance Battery (SPPB)] on functional capacity [6 Minutes Walking Test (6MWT)] on anxiety (A) and depression (D) [Hamilton Anxiety Rating scale (HAMA) and Hamilton Depression Rating scale (HAMD)] and on basic activities of daily life [Barthel Index (BI)] were evaluated. The assessment was done on the admission (T0), at the discharge (T1, on average after 31 days) and after a follow-up of 55 days (T3). Results The results are shown in the table below. Only 4 P were able to perform the 6MWT at T0. The motor function improves rapidly and then reaches a plateau and its trend is reflected in the BI. Functional capacity, on the other hand, improves significantly even at a distance. A and D decreased rapidly but increased over time. Conclusions A rehabilitation protocol, centered on CR, induces a rapid increase in motor capacity, even in severely compromised subjects such as C-19. The improvement in fitness over time, as demonstrated by the 6MWT, probably is due to the severe muscle deconditioning, for the long stay in acute care. The long-term worsening of A and D may depend on various causes: no longer living in a “protected and safe” place, the fear of relapse, returning home and discovering new deaths and mournings. A program, CR-like, can counteract many of the negative consequences of C-19; however these P deserve an outpatient rehabilitation to maintain and consolidate the positive results over time. Funding Acknowledgement Type of funding sources: None. Table 1

Deconditioning does not explain orthostatic intolerance in ME/CFS (myalgic encephalomyelitis/chronic fatigue syndrome)

BackgroundOrthostatic intolerance (OI) is a frequent finding in individuals with myalgic encephalomyelitis /chronic fatigue syndrome (ME/CFS). Published studies have proposed that deconditioning is an important pathophysiological mechanism in various forms of OI, including postural orthostatic tachycardia syndrome (POTS), however conflicting opinions exist. Deconditioning can be classified objectively using the predicted peak oxygen consumption (VO2) values from cardiopulmonary exercise testing (CPET). Therefore, if deconditioning is an important contributor to OI symptomatology, one would expect a relation between the degree of reduction in peak VO2during CPET and the degree of reduction in CBF during head-up tilt testing (HUT).Methods and resultsIn 22 healthy controls and 199 ME/CFS patients were included. Deconditioning was classified by the CPET response as follows: %peak VO2 ≥ 85% = no deconditioning, %peak VO2 65–85% = mild deconditioning, and %peak VO2 < 65% = severe deconditioning. HC had higher oxygen consumption at the ventilatory threshold and at peak exercise as compared to ME/CFS patients (p ranging between 0.001 and < 0.0001). Although ME/CFS patients had significantly greater CBF reduction than HC (p < 0.0001), there were no differences in CBF reduction among ME/CFS patients with no, mild, or severe deconditioning. We classified the hemodynamic response to HUT into three categories: those with a normal heart rate and blood pressure response, postural orthostatic tachycardia syndrome, or orthostatic hypotension. No difference in the degree of CBF reduction was shown in those three groups.ConclusionThis study shows that in ME/CFS patients orthostatic intolerance is not caused by deconditioning as defined on cardiopulmonary exercise testing. An abnormal high decline in cerebral blood flow during orthostatic stress was present in all ME/CFS patients regardless of their %peak VO2 results on cardiopulmonary exercise testing.

The addition of respiratory muscle strength training to facilitate swallow and pulmonary rehabilitation following massive tissue loss and severe deconditioning: A case series

IntroductionImpaired respiratory and swallow function in patients with intensive care unit–acquired deconditioning, such as associated with massive tissue loss, is not uncommon and can require prolonged rehabilitation. AimThe aim of the study was to examine the effect of combined inspiratory and expiratory respiratory muscle strength training (RMST) on respiratory and swallow function in two critical care patients with marked deconditioning after massive tissue loss. MethodsCase 1 was a 19-year-old male patient with 80% body surface area burns; case 2 was a 45-year-old man with group A streptococcus myositis necessitating quadruple amputation. Both required prolonged intensive care and mechanical ventilation. Both received routine intensive pulmonary and swallow rehabilitation before the trial; however, chronic aspiration and poor secretion clearance remained. At 25 and 26 weeks after initial injury, RMST was performed using EMST150 (expiratory) and Threshold IMT (inspiratory) devices, respectively. At baseline and throughout treatment, data collected included peak expiratory flow (PEF), anthropometry measures, aspiration risk (Penetration-Aspiration Scale [PAS]), pharyngeal clearance (Yale Pharyngeal Residue Scale), secretions (New Zealand Secretion Scale [NZSS]), and functional diet (Functional Oral Intake Scale [FOIS]) via endoscopy. Results/discussionAt baseline, the PEF score of case 1 was 41% (predicted age–height norm) and the PEF score of case 2 was 14%, indicating severe expiratory compromise. Both had extreme energy requirements (3300 kcal/day; 3500 kcal/day). The baseline swallowing scores of case 1 and 2 were as follows: PAS, 8 and 8; Yale, 9 and 10; NZSS, 4 and 7; and FOIS, 1 and 1, respectively, indicating profound dysphagia. At week 3 of 7 of RMST, swallow function improved to allow both to commence oral intake, followed by tracheostomy decannulation. At weeks 10 and 11, full dysphagia resolution was achieved (FOIS = 7; PAS = 1, Yale = 2, NZSS = 0), with PEF at 70% and 48% predicted respectively. Both patients continued RMST, and at discharge from the acute facility, PEF was 84% and 80% predicted respectively. ConclusionThe addition of RMST assisted swallow and pulmonary rehabilitation in both cases and was clinically viable to deliver. Controlled validation trials are now required.

Bilateral Lung Transplantation for End-Stage Respiratory Failure from COVID-19 Pneumonia

IntroductionThe SARS-CoV-2 virus is causing severe end-stage fibrosis and respiratory failure in otherwise healthy individuals. Lung transplant (LTX) has been performed internationally in select patients for this indication, but there is limited evidence on its role in COVID-19. We describe a patient who received a bilateral LTX 12 weeks after an initial diagnosis of COVID-19 pneumonia.Case ReportA 51-year-old male with hypertension and presented to an outlying hospital with dyspnea, fever and exposure to SARS-CoV-2. He was hypoxic and a diagnosis of COVID-19 pneumonia was made by nasopharyngeal swab. He was treated with dexamethasone, remdesivir, and convalescent plasma, mechanical ventilation and eventually femoral VV-ECMO cannulation to maintain oxygenation. He was extubated and was transitioned to a left subclavian dual-limb 30 Fr VV-ECMO cannula for improved rehabilitation. He was then transferred to our center for LTX consideration given refractory ARDS. Evaluation for LTX revealed pulmonary hypertension, negative SARS-CoV-2 PCR and deconditioning but no absolute contraindications. He participated in intensive rehabilitation and progressed to assisted steps despite severe deconditioning and hypoxia. He was listed for a bilateral lung transplant with a lung allocation score of 90 and received a donor offer 7 days after listing and after 82 days on ECMO. He underwent bilateral LTX via clamshell exposure with central VA ECMO support. Intraoperatively, the lungs were densely consolidated with severe hilar adenopathy without peripheral adhesions. Post-operatively, he was transitioned back to his original VV ECMO circuit and then decannulated on post-op day 3. Standard induction with basiliximab and immunosuppression with IV methylprednisolone, mycophenolate and tacrolimus was administered. He had a transient elevation of liver enzymes on post-operative day 1 and an early planned tracheostomy was performed due to deconditioning. He has since, been progressing well on oxygen via tracheostomy collar and is able to speak with a one-way valve and participate in rehabilitation.SummaryFor patients with irreversible end-stage lung disease after COVID-19 pneumonia, LTX is a viable option. Timely transfer to a lung transplant center and intensive rehabilitation are essential. Standard established immunosuppression and post-transplant protocols should be followed.

Authors' Reply: Open tracheostomy for COVID-19-positive patients: A method to minimize aerosolization and reduce risk of exposure.

BACKGROUND: The COVID-19 virus is highly contagious, and thus there is a potential of infecting operating staff when operating on these patients. This case series describes a method of performing open tracheostomy for COVID-19 patients while minimizing potential aerosolization of the virus using typically available equipment and supplies. METHODS: This is a case series of 18 patients who were COVID-19-positive and underwent open tracheostomy in the operating room under a negative pressure plastic hood created using readily available equipment and supplies. Patients had to be intubated for at least 14 days, be convalescing from their cytokine storm, and deemed to survive for at least 14 more days. Other indications for tracheostomy were altered mental status, severe deconditioning, respiratory failure and failed extubation attempts. RESULTS: There were 14 men and 4 women with severe SARS-CoV2 infection requiring long-term intubation since March 23 or later. The mean age was 61.7 years, body mass index was 32.6, and the pretracheostomy ventilator day was 20.4 days. The indications for tracheostomy were altered mental status, severe deconditioning and continued respiratory with hypoxia. Failed extubation attempt rate was 16.7% and hemodialysis rate was 38.9%. All patients were hemodynamically stable, without any evidence of accelerating cytokine storm. To date there was one minor bleeding due to postoperative therapeutic anticoagulation. CONCLUSION: This report describes a method of performing open tracheostomy with minimal aerosolization using readily available equipment and supplies in most hospitals. LEVEL OF EVIDENCE: Therapeutic/care management, Level V.

Open tracheostomy for COVID-19-positive patients: A method to minimize aerosolization and reduce risk of exposure.

IntroductionThe COVID-19 virus is highly contagious and thus there is a potential of infecting operating staff when operating on these patients. This case series describes a method of performing open tracheostomy for COVID-19 patients while minimizing potential aerosolization of the virus using typically available equipment and supplies.MethodsThis is a case series of 18 patients who were COVID-19 positive and underwent open tracheostomy in the operating room under a negative pressure plastic hood created using readily available equipment and supplies. Patients had to be intubated for at least 14 days, be convalescing from their cytokine storm, and deemed to survive for at least 14 more days. Other indications for tracheostomy were altered mental status, severe deconditioning, respiratory failure and failed extubation attempts.ResultsThere were 14 men and 4 women with severe SARS-CoV2 infection requiring long-term intubation since March 23 or later. The mean age was 61.7, BMI was 32.6, and the pre-tracheostomy ventilator day was 20.4. The indications for tracheostomy were altered mental status, severe deconditioning and continued respiratory with hypoxia. Failed extubation attempt rate was 16.7% and hemodialysis rate was 38.9%. All patients were hemodynamically stable, without any evidence of accelerating cytokine storm. To date there was one minor bleeding due to postoperative therapeutic anticoagulation.ConclusionThis report describes a method of performing open tracheostomy with minimal aerosolization using readily available equipment and supplies in most hospitals.

COXSACKIE B2 VIRUS: FROM A SOCCER GAME TO FULMINANT MYOCARDITIS

SESSION TITLE: Wednesday Medical Student/Resident Case Report Posters SESSION TYPE: Med Student/Res Case Rep Postr PRESENTED ON: 10/23/2019 09:45 AM - 10:45 AM INTRODUCTION: The presentation of viral myocarditis ranges from no symptoms to devastating illness.1 This is an unfortunate case of Coxsackie B2 virus induced Fulminant Myocarditis (FM); which despite aggressive medical and mechanical circulatory support progressed to fatality. CASE PRESENTATION: A 20-year-old male patient was transferred to our hospital with respiratory failure and shock. He presented to his local hospital with dyspnea, fever, myalgias and arthralgias that started after an indoor soccer game two weeks earlier. Prior to admission he was treated with inhalers, steroids and antibiotics without improvement. The TTE showed an LVEF 30% and Chest CT Scan showed bilateral consolidations and multiple nodules surrounded by ground glass opacities. Mechanical ventilation, vasopressors and inotropes were initiated prior to transferring him to our hospital. Upon arrival he required paralysis and pronation to improve his hypoxia. He was started on broad spectrum antimicrobials. However, the initial infectious workup was negative. Further workup obtained due to persistent fever revealed portal vein thrombosis which was treated with heparin. Hypercoagulability, malignancy and rheumatology tests were unrevealing. Expanded infectious workup was most notable for positive Coxsackie B2 serology with titers that increased 4-fold during hospitalization to 1:320, consistent with viral myocarditis. TEE showed persistent LV dysfunction, global LV wall motion abnormalities, increased septal wall thickness, severe mitral regurgitation and moderate tricuspid regurgitation. After receiving diuretics, vasopressors and inotropes he improved and was extubated. He subsequently decompensated requiring reintubation and resumption of inotropes. ECMO was initiated with biventricular assist device support. Heart transplant was considered but his hospital course was complicated by severe deconditioning and went on to develop GI bleeds, acute renal failure, fungemia, pulmonary abscess status post decortication and contained pulmonary artery rupture. On ICU day #97, his illness was deemed not survivable and his family withdrew care. DISCUSSION: Coxsackie B serotypes are among the more common causes of viral myocarditis, which may evolve into FM.2 FM is defined as 2-4 weeks of acute illness, followed by cardiogenic shock, needing hemodynamic support; and myocardial inflammatory infiltrates on histology. FM has a dramatic and progressive clinical course, with a severely impaired LVEF.3 It often requires prolonged hemodynamic support and referral for heart transplant.4 In general, in-hospital outcomes are poor; with increased morbidity and up to 32% reported mortality.5 CONCLUSIONS: Coxsackie B induced Fulminant Myocarditis portends increased morbidity and mortality, even after aggressive medical and mechanical circulatory support. Reference #1: Kindermann et al. J Am Coll Cardiol. 2012;59:779–92. Reference #2: Mehta et al. Case Reports in Infectious Diseases. 2018;ID 4258296:1-4. Reference #3: Ammirati et al. Circulation. 2017;136:529-45. DISCLOSURES: No relevant relationships by Stefanie DiGiandomenico, source=Web Response No relevant relationships by Tirsa Ferrer Marrero, source=Web Response No relevant relationships by Javeria Haque, source=Web Response No relevant relationships by Christopher Roberts, source=Web Response No relevant relationships by Gabriel Ryan, source=Web Response no disclosure on file for Jonathon Truwit; No relevant relationships by Krista Tuomela, source=Web Response No relevant relationships by Jane Wainaina, source=Web Response

1794 Esophageal Adenocarcinoma in a Patient With Inclusion Body Myositis

INTRODUCTION: Inflammatory myopathies are rare autoimmune diseases characterized by chronic muscle inflammation and weakness. Dysphagia is often an early onset symptom in inflammatory myopathies. Here we present a case of esophageal adenocarcinoma diagnosed in a patient with inclusion body myositis (IBM) and chronic progressive dysphagia. CASE DESCRIPTION/METHODS: A 59 year old woman with an 8 year history of gradually progressive IBM presented to the ER with worsening dysphagia; she has had progressive dysphagia over the preceding 10 days to the point she is unable to tolerate solids. Despite longstanding, progressive symptoms, referral to a gastroenterologist was never made as it was assumed her symptoms were from her underlying IBM. On exam, she is a functional quadriplegic from her underlying IBM and is largely bedbound as a result. Her labs were notable for a macrocytic anemia with negative inflammatory myopathy antibody panel. Barium esophagram revealed a large filling defect in the mid to distal esophagus measuring approximately 3.6 × 2.4 cm and subsequent upper endoscopy revealed an 8cm nearly obstructive distal esophageal mass which appeared to arise in the setting of suspected Barrett’s esophagus. Biopsies demonstrated esophageal adenocarcinoma with signet cell features. Subsequent staging was consistent with cT3N0 disease though she was deemed not to be a surgical candidate due to her quadriplegia and severe deconditioning. An endoscopic esophageal bare metal stent was placed for symptom palliation and she was referred to hospice. DISCUSSION: The inflammatory myopathies are a group of autoimmune diseases characterized by chronic muscle inflammation accompanied by weakness. IBM, in contrast to polymyositis and dermatomyositis, has normal or minimally elevated creatine kinase, insidious progression, and is poorly responsive to immunosuppressive therapy. While IBM is generally not thought to be a paraneoplastic syndrome, there are case reports of them being paraneoplastic with a negative antibody panel (as seen in this case). Bulbar symptoms are common in IBM, and &gt;50% of patients will develop oropharyngeal dysphagia usually due to cricoarytenoid weakness. In this case, the patient’s dysphagia was prematurely attributed to IBM, precluding a timely diagnosis of esophageal adenocarcinoma. In patients with inflammatory myopathy and dysphagia, endoscopy is still of utmost importance and symptoms should not be solely attributed to underlying IBM.

3121 Spontaneous Breakage and Antegrade Enteral Migration of Jejunal Extension Tubing

INTRODUCTION: Gastroenteric tube feeding can provide essential nutrition for patients with neurologic or mechanical dysphagia. Many patients undergo pre-pyloric feeding; however, some patients require post-pyloric feeding through jejunal access. These present additional challenges in placement with potential for complications. Here we discuss a rare complication of a jejunal extension portion of a gastrojejunostomy (G-J) tube separating and becoming a foreign body. CASE DESCRIPTION/METHODS: A 77-year old woman with a past medical history of rheumatic heart disease with mitral stenosis and pulmonary hypertension (pHTN) was admitted for acute decompensated pHTN. Three months prior the patient had underwent radiologic percutaneous placement of a pull-type gastric-tube (G-tube) for dysphagia due to severe deconditioning. One week later she developed gastroparesis and the tube was exchanged under fluoroscopy with a 9-french G-J tube extension. Upon admission patient was tolerating tube feeds without complication and underwent intravenous diuresis for her pHTN exacerbation. On hospital day seven she reported onset of abdominal pain and bloating. Physical exam noted new right-upper quadrant tenderness and mild distention, G-J tube insertion site appeared normal without leakage or skin breakdown. Abdominal x-ray showed the jejunal extension tubing had separated from the G-tube balloon insertion and was visualized projecting coiled over right lower quadrant (Figure 1). Tube feeds were held and the gastroenterology service was consulted. At time of re-examination abdominal symptoms had resolved. Given the positioning of the tubing, serial abdominal imaging and supportive measures of daily suppositories to facilitate spontaneous passage by rectum were recommended. The patient was restarted on tube feeds through the remaining G-tube without complication. Ultimately the jejunal extender proceeded through the colon (Figure 2) and passed by rectum 5 days later without complication (Figure 3). DISCUSSION: The placement of jejunal extensions through existing gastrostomy tubes is typically a well-tolerated procedure and antegrade migration of jejunal tubing is rare. In this case the jejunal tubing somehow separated from its gastrostomy tube anchor. In the event of this rare complication it is reasonable to monitor for spontaneous passage with serial imaging as demonstrated in this case, with consideration for surgical exploration or endoscopic retrieval if there is non-progression of the tube or an associated complication.

MON-342 Calcitriol-Mediated Hypercalcemia in Adrenal Diffuse Large B-Cell Lymphoma

Background: Hypercalcemia of malignancy can present with a suppressed intact PTH level in response to various etiologies including elevated PTH-rP, increased calcitriol production via activation of the enzyme 1-alpha hydroxylase, or osteolytic bone lesions. PTH-independent hypercalcemia with elevated 1,25-dihydroxyvitamin D (calcitriol) levels should prompt evaluation for granulomatous disorders including sarcoidosis, tuberculosis, and lymphoma. Here we present a case of calcitriol-mediated hypercalcemia secondary to a rare, adrenal diffuse large B-cell lymphoma. Clinical Case: A 61-year-old female presented with fatigue, myalgias, and generalized weakness. On admission, calcium was 14.1 mg/dL (8.9-10.3), phosphorus 2.4 mg/dL (2.3-4) and iPTH was suppressed to 3.6 pg/mL (8.5-75). CT scan revealed a 30-35 Houndsfield unit, 14 x 9 x 13 cm left adrenal mass. Workup included PTH-rP 0.3 pmol/L (<2.0) and calcitriol 109 pg/mL (18-78). Serum and urine electrophoresis were negative for monoclonal protein spikes. Further hormonal evaluation revealed normal serum and urine metanephrines, 24-hour urine cortisol 64 mcg/24h (3.5-45), 8 AM cortisol 1.9 ug/dL following 1 mg dexamethasone suppression (<1.8), midnight salivary cortisol 87 ng/dL (<100), DHEA-S 16.2 mcg/dL (<15-157), and 11-deoxycortisol 24 ng/dL (10-79). Angiotensin-converting enzyme level was normal at 10 U/L (8-53). Her hypercalcemia improved with intravenous fluids and calcitonin. She was not a surgical candidate as PET/CT revealed multiple para-aortic and mesenteric hypermetabolic lymphadenopathy, left breast soft tissue density, and a lesion in the right posterior pelvis likely indicative of metastatic disease. Nuclear bone scan ruled out bone metastases. Para-aortic biopsy was considered technically difficult in this patient so she underwent CT-guided core needle biopsy of the adrenal mass which confirmed high-grade CD5-positive diffuse large B-cell lymphoma. Immunohistochemical staining was positive for CD20, BCL2, BCL6, MUM-1, and Ki-67 90%. She completed 6 cycles of chemotherapy with rituximab, cyclophosphamide, vincristine, doxorubicin, and prednisone (R-CHOP). Repeat PET/CT following completion of chemotherapy showed no residual disease however one month later, she presented with acute encephalopathy with MRI brain showing a large frontal lobe tumor concerning for relapse. She received 1 cycle of intrathecal methotrexate and cytarabine however these were discontinued due to severe deconditioning. She now remains on oral ibrutinib. Conclusions: Primary adrenal lymphomas are a rare cause of non-Hodgkin lymphomas with less than 150 cases noted in the literature. Lymphoma should be included in the differential of patients presenting with PTH-independent hypercalcemia given the aggressive nature of the disease and associated high mortality.

Cardiac Rehabilitation in Patients With Lymphoma Undergoing Autologous Hematopoietic Stem Cell Transplantation: A Cardio-oncology Pilot Project

BackgroundWorldwide > 50,000 hematopoietic stem cell transplants (HSCTs) are performed annually. HSCT patients receive multiple cardiotoxic therapies (chemotherapy and radiation therapy) in addition to severe physical deconditioning during hospital admission. We hypothesized that guided exercise in a cardiac rehabilitation (CR) program following autologous HSCT is a safe and feasible intervention. MethodsPilot project to assess for safety, feasibility and impact of 8 weeks of CR in HSCT patients following transplant. Consecutive patients with lymphoma underwent standard activity protocol testing before HSCT, at 6 weeks following HSCT (prior to CR), and at 14 weeks following HSCT (at completion of CR), consisting of grip strength (GS), gait speed (GtS), timed up-and-go (TUG), and 6-minute walk test (6MWT). CR consisted of 8 weekly visits for guided exercise. ResultsActivity tolerance protocol data of 30 patients (24 male, 6 female) from December 2014 to December 2016 were analyzed using repeated measures (analysis of variance [ANOVA]) to observe for changes in GS, GtS, TUG, and 6MWT. Statistically significant improvements were found in GS (P < 0.005), GtS (P = 0.02), and 6MWT (P = 0.001). These improvements show that guided CR-based exercise may assist HSCT survivors to meet or even surpass baseline exercise levels and improve physical functioning. There were no adverse events (ie, death or injury) during the study period. Fifty-seven percent of referred patients participated in CR, exceeding documented CR adherence in cardiac populations. ConclusionsThe addition of CR-based exercise programming in HSCT survivorship care of patients with lymphoma is a safe and feasible intervention to assist in recovery following transplant.

Phase I study of the safety and activity of formulated IL-12 plasmid administered intraperitoneally in combination with neoadjuvant chemotherapy in patients with newly diagnosed advanced stage ovarian cancer.

5568 Background: This study evaluated weekly intraperitoneal (IP) GEN-1, an IL-12 plasmid formulated with polyethyleneglycol-polyethyleneimine cholesterol lipopolymer, with intravenous (IV) weekly taxane (T) and carboplatinum (C) every 3 weeks in epithelial ovarian, fallopian tube or primary peritoneal cancer (EOC) patients undergoing neoadjuvant therapy (NAC). The primary objective was to evaluate the tolerability and safety of GEN-1 with NAC. Secondary objectives included objective clinical response and pathological response at interval debulking surgery (IDB). Methods: Newly diagnosed advanced stage EOC patients being treated with NAC were eligible. The trial utilized a 3+3 design with GEN-1 IP dose levels of 36 mg/m2, 47 mg/m2, 61 mg/m2, and 79 mg/m2 weekly for 8 treatments with concurrent IV T/C. Dose-limiting toxicity (DLT) was based on the first 4 doses of GEN-1 administered. Results: To date, 13 patients have been treated on-study with 12 patients receiving all 8 treatments of IP GEN-1 with no DLTs. The most common related toxicities were Gr 1 nausea, vomiting, abdominal pain and fatigue. One patient experienced Gr 2 fevers associated with GEN-1 but responded to acetaminophen and fluids. One patient did not undergo IDB while on-study due to a cancer related pulmonary embolism and severe deconditioning. This patient has since improved and will have IDB. Conclusions: Adding GEN-1 to neoadjuvant T/C is safe and appears to be active in EOC patients. We are reporting the interim findings; final results with translational data to be presented. Clinical trial information: NCT02480374. [Table: see text]

After critical care: Challenges in the transition to inpatient rehabilitation.

The aftermath of treatment for critical illness and/or critical injury in the intensive care unit (ICU) often includes persisting cognitive and emotional morbidities as well as severe physical deconditioning (a constellation termed post-intensive care syndrome, or PICS), but most patients do not receive psychological services before they enter the inpatient rehabilitation facility (IRF). Although a burgeoning literature guides the efforts of critical care providers to reduce risk factors for PICS - for example, reducing the use of sedatives and enacting early mobilization, there is need for a corresponding awareness among IRF psychologists and other providers that the post-ICU patient often arrives in a state of significantly reduced capacity, with persisting cognitive impairments and acute psychological distress. Many are at risk for long-term complications of posttraumatic stress disorder, general anxiety and/or clinical depression, and assuredly all have experienced a profound life disruption. This paper offers a multilevel perspective on the adaptation of post-ICU patients during inpatient rehabilitation, with discussion of the psychologist's role in education and intervention. Clinical review paper. NA. To optimize response to rehabilitation, it is important to understand the behavior of post-ICU patients within a full biopsychosocial context including debility, cognitive and emotional impairment, disruption of role identities, and environmental factors. The psychologist can provide education about predictable barriers to participation for the post-ICU patient, and guide individual, family and team interventions to ameliorate those barriers. (PsycINFO Database Record

Epidemiology of Chronic Obstructive Pulmonary Disease (COPD) in Aging Populations

Current epidemiologic practice evaluates COPD based on self-reported symptoms of chronic bronchitis, self-reported physician-diagnosed COPD, spirometry confirmed airflow obstruction, or emphysema diagnosed by volumetric computed chest tomography (CT). Because the highest risk population for having COPD includes a predominance of middle-aged or older persons, aging related changes must also be considered, including: 1) increased multimorbidity, polypharmacy, and severe deconditioning, as these identify mechanisms that underlie respiratory symptoms and can impart a complex differential diagnosis; 2) increased airflow limitation, as this impacts the interpretation of spirometry confirmed airflow obstruction; and 3) “senile” emphysema, as this impacts the specificity of CT-diagnosed emphysema. Accordingly, in an era of rapidly aging populations worldwide, the use of epidemiologic criteria that do not rigorously consider aging related changes will result in increased misidentification of COPD and may, in turn, misinform public health policy and patient care.

Physical Rehabilitation in the ICU

Intensive care unit (ICU) based rehabilitation has become an important evidence-based component in the management of patients with critical illness. In addition to critical illness, prolonged bed rest and immobility may lead to severe physical deconditioning and loss of muscle mass and muscle weakness. Intensive care unit acquired weakness is associated with increased duration of mechanical ventilation and weaning, longer ICU and hospital stay, and increased mortality. These physical impairments may last for years after ICU discharge. Early Physical Medicine and Rehabilitation (PM&amp;R) interventions in the ICU may attenuate or prevent the weakness and physical impairments occurring during critical illness. This article reviews the effects of prolong bed rest and inactivity, early PM&amp;R interventions, their safety, feasibility, benefits and future directions for early PM&amp;R in the ICU.Bangladesh Crit Care J September 2015; 3 (2): 63-66