Severe Nausea Research Articles

CEAC (oral semustine, etoposide, cytarabine and cyclophosphamide) vs BEAM (carmustine, etoposide, cytarabine, and melphalan) conditioning regimen of autologous stem cell transplantation for diffuse large B-cell lymphoma: a post-hoc, propensity score-matched, cohort study in Chinese patients.

Autologous stem cell transplantation (ASCT) is a salvage therapy for relapsed or refractory diffuse large B-cell lymphoma (DLBCL). We have developed a novel conditioning regimen called CEAC (oral semustine 250mg/m2 d-6, etoposide 300mg/m2 d-5 ~ d-2, cytarabine 500mg/m2 d-5 ~ d-2, and cyclophosphamide 1200mg/m2 d-5 ~ d-2) In lymphoma patients in China. Here, we conducted a study to compare the conventional BEAM regimen with the CEAC regimen in 110 DLBCL patients. Propensity-score matching was performed in a 1:4 ratio (22 patients received BEAM and 88 received CEAC). Our results showed no significant difference in the overall response rate (95% vs 97%, P = 1.000) and complete response rate (66% vs 73%, P = 0.580) between the two cohorts. The 5-year progression-free survival (PFS), 5-year overall survival (OS), and 5-year cumulative incidence of relapse (CIR) for all patients were 72% (95% CI 62%-82%), 92% (95% CI 86%-97%), and 29% (95% CI 17%-38%), respectively. There was no significant difference in the 5-year PFS (80% vs 70%, P = 0.637), 5-year OS (95% vs 91%, P = 0.496), and 5-year CIR (20% vs 30%, P = 0.733) between cohorts. In terms of safety, the CEAC cohort had a lower incidence rate of grade 1-2 gastrointestinal hemorrhage (P = 0.023) and severe nausea (P = 0.007) compared with the BEAM cohort. In conclusion, the CEAC regimen seems to be a suitable alternative to the BEAM regimen for ASCT in DLBCL patients.

A Randomized Clinical Trial Investigating an Integrated Nursing Educational Program to Mitigate Chemotherapy-Induced Nausea and Vomiting in Cancer Patients: The NIV-EC Trial

Background: In addition to pharmacological prevention, chemotherapy-induced nausea and vomiting (CINV) can be mitigated through patient education; written supporting materials can be beneficial. Methods: This is a randomized, controlled trial which randomly assigned patients undergoing first chemotherapy cycle to receive oral information regarding CINV prevention and management (control arm) or oral information plus an informative booklet (experimental arm). Overall, 384 cancer patients fulfilling the following inclusion criteria were enrolled: age ≥18 years; life expectancy ≥6 months; no cognitive impairment; written informed consent. After the first cycle, CINV occurrence and its impact on daily activities were assessed using the Functional Living Index Emesis (FLIE). Results: Severe nausea was self-reported by 3.0% and 10.8% of patients in the experimental and control group, respectively (difference: 7.8%; 95% confidence interval: 2.3% to 13.1%). Moderate/high impact of nausea on daily activities was lower in patients also receiving the booklet than in the control group (4.2% and 10.1%, respectively; difference: 5.9%; 95% confidence interval: 0.3% to 11.5%). Vomiting was not statistically different between study arms. Conclusions: This integrated nursing approach was effective in aiding cancer patients in CINV self-management. Although the beneficial effect was moderate, this intervention demands minimal resources in terms of costs and time.

Legislative and regulatory barriers to pharmacies dispensing buprenorphine for OUD.

Buprenorphine (BUP) is increasingly recognized and utilized as a valuable medication for the treatment of opioid use disorder. This article focuses on the problem of regulatory restrictions on access to buprenorphine products without naloxone (mono-product), involving patients in one geographic area, but which may represent a more general access problem in the United States. In response to an audit by the Tennessee Board of Pharmacy, a pharmacy in northeast Tennessee designed a questionnaire to survey patient motivation for traveling long distances to fill their prescriptions for BUP, rather than buprenorphine/naloxone (BNx, combo-product), and to document their satisfaction with treatment with the mono-product. Questionnaires were submitted by 194 patients, living in northeast Tennessee, southwest Virginia, and southeast Kentucky. Significant, intolerable, side effects were reported by all patients in the survey prescribed BNx, but because of legislative and regulatory restrictions in their respective states, they were unable to obtain BUP closer to home. Consequently, they were required to drive significant distances from their homes to fill their prescriptions, a median distance of 52 miles, and in some cases as far as 216 miles round trip. Intolerable reactions included severe headaches, nausea and vomiting, allergies, and severe dysphoria. All patients tolerated BUP and were clinically well maintained on the mono-product. Severe, intolerable reactions/side effects from the naloxone component of BNx are not uncommon, but legislative and regulatory restrictions on the mono-product prohibit providers and pharmacies in some states from prescribing and dispensing BUP. The participants in this qualitative study found it necessary to travel significant distances to obtain their prescribed medication, thereby potentially limiting access to this life-saving therapy.

Glucagon-Like Peptide-1 Analogue In The Management Of Rebound Intracranial Hypertension: A Case Report

Background: Rebound intracranial hypertension (RIH) is a possible complication of epidural blood patching used in the management of spontaneous intracranial hypotension (SIH). RIH has been reported to occur in up to 27% of patients after SIH treatment and is characterized by elevated intracranial pressure, resulting in severe headache, nausea, and vomiting. Although it typically resolves spontaneously, treatment may be warranted for symptom control. While acetazolamide is the most commonly used agent for RIH, there are side-effects, and its efficacy remains inconclusive. Recently, novel glucagon-like peptide-1 (GLP-1) analogues have been found to modulate CSF secretion and consequently reduce intracranial pressure. However, there are no studies that have evaluated the use of these agents in the treatment of RIH. We report of a case of a 46 year old female patient with persistent RIH after CSF leak repair that was refractory to pharmacologic and interventional treatments. The patient was treated with Semaglutide, an oral GLP-1 analogue and experienced immediate and sustained benefit of her symptoms. Conclusion: RIH is a common complication after successful patching of a CSF leak, a proportion of patients suffer from persistent and debilitating headaches. Our case report showed that GLP-1 agonist Semaglutide appeared to reduce symptoms in this one patient with refractory RIH symptoms. The use of GLP-1 agonists in the treatment of RIH should be evaluated in controlled studies to establish its safety and efficacy in this population.

Symptoms and impacts of familial chylomicronemia syndrome: a qualitative study of the patient experience

BackgroundFamilial chylomicronemia syndrome (FCS) is a rare, hereditary, metabolic disorder. FCS causes high levels of triglycerides in the blood, which can lead to abdominal pain, xanthomas, and acute pancreatitis (AP). Volanesorsen, along with adherence to a very low-fat diet is used to reduce triglyceride levels in individuals with FCS. We aimed to understand the symptoms of FCS and their impact on health-related quality of life (HRQoL).MethodsInterviews were conducted with individuals with genetically confirmed FCS in the UK and Spain, some of whom had been treated with volanesorsen. Interview guides were developed with input from a patient advocacy group to explore the symptoms, impacts and management of FCS. Interviews were conducted by telephone and were recorded and transcribed. Data were analyzed using thematic analysis and saturation was recorded.ResultsSeventeen interviews were conducted with individuals with FCS (aged 27–68 years), thirteen of whom were currently/previously treated with volanesorsen. Episodes of AP were the most impactful reported symptom, resulting in severe abdominal pain, nausea, vomiting, fever, bloating and appetite loss. Other symptoms and functional issues included abdominal pain, gastrointestinal symptoms, impaired cognitive function and fatigue. These had an impact on work, social activities, relationships and psychological wellbeing. These symptoms and impacts were illustrated in a conceptual model, including management strategies. The challenges of managing a low-fat diet and experience with volanesorsen were discussed.ConclusionIndividuals with FCS experience a range of interrelated symptoms and functional limitations which impact their broader HRQoL. Treatments which alleviate symptoms and reduce the incidence of AP episodes have the potential to improve the HRQoL of these individuals.

Prophylactic norepinephrine combined with 6% hydroxyethyl starch (130/0.4) co-load infusion for preventing postspinal anesthesia hypotension during cesarean section: a randomized, controlled, dose-finding trial.

Colloid and/or co-load may be more effective than crystalloid for preventing postspinal anesthesia hypotension. We tested five different prophylactic norepinephrine dosages combined with colloid co-load infusion in patients receiving cesarean section and spinal anesthesia. Patients were randomly allocated to receive different prophylactic norepinephrine dosages (0 [NE 0 group], 0.025 [NE 25 group], 0.05 [NE 50 group], 0.075 [NE 75 group], or 0.1 [NE 100 group] µg/kg/min) combined with 500mL 6% hydroxyethyl starch (130/0.4) immediately following spinal anesthesia (n = 35 per group). The primary endpoint was the incidence of postspinal anesthesia hypotension (systolic blood pressure [SBP] < 80% of baseline). Secondary endpoints included severe hypotension, bradycardia, nausea or vomiting, hypertension, SBP stability control versus baseline, the 50% (effective dose, ED50) and 90% (ED90) dose effective for preventing postspinal anesthesia hypotension, Apgar scores, and umbilical cord blood gases. The incidence of postspinal anesthesia hypotension was 48.6%, 31.3%, 17.1%, 14.3%, and 5.7% in the respective groups. As the prophylactic norepinephrine dosage increased, the incidence of postspinal anesthesia hypotension declined (p < 0.001), and SBP remained stable relative to baseline (median performance error [MDPE], p < 0.001; median absolute performance error [MDAPE], p = 0.001). The ED50 and ED90 values were -0.006 (95% CI -0.046-0.013) and 0.081 (95% CI 0.063-0.119) µg/kg/min. Other endpoints were comparable across the groups. An initial prophylactic norepinephrine dosage of 0.05µg/kg/min combined with 500mL 6% hydroxyethyl starch (130/0.4) co-load infusion was optimal for preventing postspinal anesthesia hypotension during cesarean section. NCT05133817, registration date: 12 Nov, 2021.

SAT318 Autoimmune Polyglandular Syndrome II In A Young Female With Severe Weight Loss, DKA, And Psychiatric Features

Abstract Disclosure: G. Wintermyer: None. C. Arcilla: None. E. Villanueva: None. Autoimmune polyglandular syndrome type II (APS II) is a rare combination of multiple endocrine diseases. The most common associated diseases are diabetes type I, Hashimoto thyroiditis, and Addison’s disease. Most patients present with nonspecific symptoms, typically in adulthood. Here we describe a 19-year-old female with APS II:A 19-year-old female with history of depression presented to hospital with severe nausea, vomiting and chest pain. She was diagnosed with pneumomediastinum secondary to hyperemesis. The symptoms were assumed secondary to ziprasidone that she was then taking.Patient experienced 20-pound weight loss in a very short period. Patient went to ED again for excessive weight loss. She was diagnosed with DKA for the first time and was admitted to ICU (Glucose level above 500 mg/dL and A1C 7.1%). After discharge, patient came to the endocrinology clinic for management of type 1 diabetes. Her BMI was 17 kg/m2. Vital signs were normal. Since the start of insulin therapy, patient gained weight and her BMI increased to 18.5 kg/m2.Patient was clinically well for about 1 year. She had periodic complete blood tests, including TSH, A1C and CMP, all of which remained normal with A1C’s of 6.3% and 6.8%. Approximately 1 year later, her TSH was 8.230 uIU/mL and free T4 was 0.92 ng/dL with subsequent TPO of 27 IU/mL. Diagnosis of Hashimoto’s hypothyroidism was made, and she was started on levothyroxine.Even though patient was on treatment for hypothyroidism, she complained of fatigue. CMP showed sodium 133 mEq/l and bicarbonate 17 mEq/l. Celiac antibodies presented negative. Cortisol AM and ANA were ordered. Before patient had the lab tests done, she was admitted to psychiatric hospital due to psychosis and bizarre behavior. Shortly after, patient was transferred to medical hospital for nausea and vomiting. Her labs were as follow: Sodium 100 mEq/l, Potassium 6.5 mEq/l, Bicarbonate 12 mEq/l, anion gap 19, Glucose 157 mg/dl. Stat cortisol and ACTH were 1.3 mg/dL and 332 pg/mL, respectively.Patient was admitted to ICU with adrenal crisis. She was started on Fludrocortisone and IV Hydrocortisone and IV fluid for hyponatremia. She was discharged from hospital with resolution of her psychiatric features. Her final diagnosis was APS II. She was started on Fludrocortisone 0.1, Hydrocortisone 20 mg in the morning and 10 mg at night.Clinicians should keep this disease in mind when assessing a patient who has presented with other autoimmune endocrinologic diseases, especially diabetes type I or adrenal insufficiency. Frequent visits, vital checks, CMP, and antibody screening tests including GAD antibodies, anti-adrenal antibodies, and TPO antibodies help in diagnosing this syndrome earlier.Clinicians also should be mindful of psychiatric features in a patient. They should try to rule out medical causes before diagnosing a patient with psychiatric disease as profound hyponatremia can cause acute psychosis. Presentation: Saturday, June 17, 2023

THU099 The Challenging Management Of Silent Corticotroph PitNET—From Very Aggressive To Mild Course Of Disease During Long Follow Up

Abstract Disclosure: A. Bogusławska: None. &amp;. Kluczyński: None. A. Hubalewska-Dydejczyk: None. A. Gilis-Januszewska: None. We present a case series of silent corticotroph PitNETs with various clinical outcomes. Case 1. A 33-year-old male admitted to Emergency Department (ED) due to severe headaches and vomiting- giant PitNET (39x33x55 mm) was visualized-debulking transsphenoidal surgery (TSS) was performed. Histopathology results showed silent adenoma subtype 1 (densely granulated), Ki67&amp;lt;1%. Due to rapid progression of PitNET- patient underwent two emergency TSS and stereotactic fractionated radiotherapy. Treatment with temozolomide, pasireotide, cabergoline, radiotherapy was introduced. After 18 months of combined therapy stable disease was observed. Implementation of pasireotide resulted in spectacular decrease of headaches (initially 9-10 to none /10 using NRS). Case 2. A 31-year-old male presented in our clinic due to headaches and bitemporal hemianopsia. In MRI PitNET was found (22x19x23mm) and active Cushing disease (CD) was diagnosed. TSS was performed in 2013. Histopathology results showed corticotroph PitNET with Crook cells. Postoperatively, PitNET progression (17x26x13mm) was observed with no overt CD. In 2022, due to worsening of headaches and vision loss, second TSS was performed. Histopathologists described corticotroph tumor with Crook cells with ATRX mutation of uncertain significance. Pasireotide implementation is planned. Case 3. A 47-yeard-old female was admitted to ED due to severe headache and nausea. In MRI pituitary tumor (20x17x20mm) with local invasion was found. The patient was operated and histopathology showed densely granulated corticotroph PitNET; ACTH(+), GH(+), Ki-67% was 3%, p53&amp;lt;5%, with single Crook cells. In follow-up, progression of PitNET was noted (31x32x30 mm) and the patient underwent proton therapy. Case 4. A 56-yeard old female after three TSS (2012,2017,2018) and craniotomy (2020) due to aggressive corticotroph PitNET with Ki67 &amp;lt;1%. In 2009 a pituitary tumour (9x10x13 mm) was found. Before last craniotomy, the tumour was 24x24x28mm. After neurosurgery, paresis of right III nerve and left hemiparesis occurred. Pasireotide implementation is planned. Case 5. A 70-year old female presented in 2015 with severe headaches/nausea. In MR PitNET (32x24x31mm) was found. The patient underwent TSS and histopathology showed corticotroph PitNET with Ki67&amp;lt;1%. Due to PitNET progression, second TSS and fractionated radiotherapy was performed (2017) however in last MRI (2022), tumor relapse was noted. Case 6/7: A 46-year-old and 50 year-old females were operated due to local symptoms of PitNET. Histopathology revealed silent corticotroph PitNET. In follow-up MRI after one year showed no progression of pituitary tumor. The management of silent corticotroph PitNETs is very challenging and individualized approach is required. Further multicenter studies to understand the pathophysiology and the course of silent corticotroph PitNETs are needed. Presentation: Thursday, June 15, 2023

FRI223 Ectopic ACTH Syndrome

Abstract Disclosure: S. Mallesara Sudhakar: None. E.S. Story: None. Introduction: Ectopic ACTH Syndrome (EAS) is caused by hypercortisolism from extra-hypophysial tumors. EAS accounts for 10-15 % of Cushing’s Syndrome. Case 1: A 36 year old male with recently diagnosed stage IV well differentiated grade 2 neuroendocrine tumor (NET) of the pancreas with liver metastases developed new hypertension, hyperglycemia, hypokalemia, metabolic alkalosis, fatigue and muscle weakness. There were no obvious signs of Cushing’s Syndrome. ACTH was 679 pg/ml, cortisol 120 ug/ml. MRI pituitary was normal. He required 4 antihypertensives, insulin, and metyrapone was initiated for hypercortisolism. Due to difficulty obtaining medications during the COVID pandemic, intolerance to therapies and lack of improvement in clinical symptoms, decision was made to perform laparoscopic bilateral adrenalectomy. He was started on hydrocortisone and fludrocortisone. Pathology revealed diffuse adrenal hyperplasia. Post-surgery he improved dramatically and was able to discontinue antihypertensives and insulin. Chemotherapy for the underlying tumor was discontinued due to cytopenias. His cancer progressed and he succumbed to disease 10 months from initial diagnosis. Case 2: A 60 year old female presented with severe hypokalemia, metabolic alkalosis, hypercalcemia, cytopenias, HTN, weight loss, muscle weakness, nausea and mental status changes. CT abdomen showed bilateral adrenal hyperplasia. ACTH was 489 pg/ml, cortisol 81 ug/ml. MRI pituitary was unremarkable. PET-CT additionally showed hypermetabolic mediastinal lymph nodes and right upper lobe nodular opacity, and widespread osseous lesions. She was started on ketoconazole and antihypertensives. Bilateral adrenalectomy was considered but could not be performed due to rapid clinical deterioration. Etomidate was initiated. Fine needle aspiration of a mediastinal lymph node showed small cell carcinoma. Patient became too frail to receive systemic chemotherapy and succumbed within 2 weeks of hospitalization. Discussion: Most Ectopic ACTH Syndrome cases are caused by NET of the lung, pancreas and thymus. In children, Ewing’s sarcoma has been reported. Small cell carcinoma of lung, malignant pancreatic NETs, and medullary carcinoma of thyroid often present with metastasis and carry an ominous prognosis. Not all patients have clinical features of classic Cushing's syndrome. The outcome of EAS correlates with tumor type. Optimum treatment is surgical resection of the tumor, often not possible with metastatic disease. Hypercortisolism may be controlled with adrenal enzyme inhibitors and receptor blockers. Bilateral surgical adrenalectomy may be needed when symptoms are not controlled by medical management. Early and rapid control of Cushing’s Syndrome is important to facilitate antineoplastic treatment of the underlying tumor. Presentation: Friday, June 16, 2023

THU255 Tirzepatide-induced Weight Loss In A Type 2 Diabetic Taking Oral Contraceptives

Abstract Disclosure: A. Arunachalam: None. A. Nguyen: None. N.L. Shah: None. Obesity is a global health challenge which can lead to type 2 diabetes, hypertension, cardiovascular disease, and decreased life expectancy. In addition to lifestyle intervention, pharmacotherapy to sustain weight loss has remained limited due to effectiveness, cost, and adverse effects. Tirzepatide is a dual glucose-dependent insulinotropic polypeptide and glucagon-like-peptide-1 receptor agonist currently approved for type 2 diabetes treatment. Tirzepatide-induced weight loss may provide new options for treatment of obesity. We report a 32-year-old female with a history of T2DM and PCOS originally on metformin who was started on semaglutide 0.25 mg, which was uptitrated to 0.5mg weekly for 6 months. She lost 25 lbs with no side effects. Semaglutide and OCPs were discontinued due to fertility with her weight and hemoglobin A1C rebounding off medication. She was started on tirzepatide 2.5mg weekly. At that time, she weighed 223 lbs with a hemoglobin A1C 8.2%. She was counseled to resume OCPs and improve glucose control and weight reduction prior to attempting to conceive. Once increased tirzepatide dosing to 5mg weekly, she endorsed severe nausea and intermittent epigastric abdominal pain on day of injection. She attempted to increase dose to 7.5mg weekly, but dose was reduced due to complaints of constipation and worsened abdominal pain requiring bowel regimen. She remained on tirzepatide for a total of 4 months prior to becoming pregnant while on oral contraceptives. Her weight decreased from 223 to 212 lbs with reduction in hemoglobin A1C from 8.2% to 6.1%. While initially studied for use in type 2 diabetes, tirzepatide was found to induce clinically significant weight reduction. The recent SURMOUNT-1 trial, which studied the effects of tirzepatide in non-diabetics, demonstrated that once-weekly tirzepatide at three different doses demonstrated substantial and sustained weight reduction in patients with obesity. In trials involving patients with once-weekly injectable semaglutide, the mean reduction in hemoglobin A1C was 1.8 percentage points and reduction in mean body weight was 6.5 kg. In the SURPASS-2 trial, reductions in body weight were greater with tirzepatide when compared to semaglutide with mean estimated treatment difference −1.9kg, -3.6kg, and -5.5 kg respectively based on dosing of 5mg, 10mg, and 15mg. The adverse events most commonly reported in patients on tirzepatide include nausea, vomiting, and diarrhea, which occurred most commonly during dose-escalation. Mounjaro is known to reduce the efficacy of oral contraceptive pills due to delayed gastric emptying. This delay is largest after the first dose so recommended to switch from oral to non-oral contraceptives for the first four weeks when tirzepatide is initiated. It is important to counsel patients on the decreased efficacy of oral contraceptives while on tirzepatide. &amp;lt;!--EndFragment--&amp;gt; Presentation: Thursday, June 15, 2023

Design Of aesthetic acoustic metamaterials window panel based on Sierpiński triangle for sound-silencing with free airflow

Design of high-efficiency, low frequency (&amp;lt;1000Hz) soundproof window or wall absorber which is transparent to airflow is presented. Due to the massive rise in human population and modernization, environmental noise has significantly risen globally. Prolonged noise exposure can cause severe physiological and psychological symptoms like nausea, headaches, fatigue, and insomnia. There has been continuous growth in building construction and infrastructure like offices, bus stops, and airports due to urban population. Generally, a ventilated window is used for getting fresh air into the room, but at the same time, unwanted noise comes along. Researchers used traditional approaches like noise barrier mats in front of the window or designed the entire window using sound-absorbing materials. However, this solution is not aesthetically pleasing, and at the same time, it is heavy and not adequate for low-frequency noise shielding. To address this challenge, we design a transparent hexagonal panel based on Sierpiński fractal triangle which is aesthetically pleasing, demonstrates normal incident sound absorption coefficient more than 0.96 around 700 Hz and transmission loss around 23 dB, while maintaining air circulation through triangular cutout. Next, we present a concept of fabrication of large acoustic panel for large-scale applications which lead to suppressing the urban noise pollution

A Multidimensional Strategy: Ways to Combat Cyclic Vomiting Syndrome with Hiatus Hernia and Gastroesophageal Reflux Disease in A Young Adult Female

Cyclical vomiting syndrome (CVS) is a chronic idiopathic functional gastrointestinal disorder characterised by intermittent episodes of severe nausea and vomiting with symptoms-free intervals in between. CVS is seen in various age groups with a prevalence of 1.9%. Numerous psychosocial, physical and infectious stressors have been attributed as a trigger of CVS. Often, a co-existing organic and psychiatric comorbidities mask the disorder, and an absence of diagnostic investigation causes a delay in diagnosis and makes it challenging to treat.

B-313 Aberrant Lithium Results After HDL Assay on Roche Cobas c503 Instrument

Abstract Background Lithium is prescribed clinically to manage mania in patients with bipolar disorder. However, blood levels higher than 1.5 mmol/L (12 h post administration) indicate toxicity accompanied by severe nausea and vomiting, severe hand tremors, confusion, and vision changes. If neglected, lithium toxicity can lead to coma, brain damage, or even death. Diligent monitoring of blood lithium levels periodically is critical to preventing lithium toxicity. Case Presentation: A 37 y/o female with schizophrenia and bipolar disorder on lithium since 2019 visited the outpatient clinic for her routing biannual lithium check. The patient’s plasma lithium levels were detected at 3.9 mmol/L (previously 0.4 mmol/L; Therapeutic range: 0.60–1.20 mmol/L; Toxic: &amp;gt;2.00 mmol/L). The cause for elevated lithium level was unclear; EKG and vital sign were unremarkable and patient was asymptomatic for toxicity. Nevertheless, patient was then managed with IV infusions and admitted to emergency room for follow up. A redrawn lithium sample ∼22 h later was 0.3 mmol/L, suggesting no toxicity. We then investigated the discrepancy in lithium levels reported by the laboratory. Retesting of the original sample detected lithium at 0.5 mmol/L, a value significantly less than the previously reported 3.9 mmol/L. Our laboratory had recently introduced the Roche Cobas® pro integrated solutions into the lab and chemistry testing (including Lithium) are performed on the Roche Cobas c503 analyzers (an arm of the Roche pro integrated solutions). Our goal was to investigate the observed phenomenon and find potential solutions, especially as it had significant implications to patient care. Method We reviewed all high lithium levels recently tested our new instrument within a week of this incident. Seven samples (lithium values &amp;gt;1.2 mmol/L) were identified and lithium measurements repeated. We also investigated and ruled out the possibility of carry over contamination by rerunning a low lithium sample before and after a high lithium sample. Results Retesting all seven samples resulted in lower lithium level with an average % change of 365%. Further investigations and discussions with manufacturers alluded to interference after HDL testing on the same instrument. To investigate this hypothesis, we reran two previously reported low samples (0.3 and 0.6 mmol/L) immediately after running the HDL cholesterol assay on the Roche Cobas c503 analyzer. Retesting resulted in lithium levels of 7.32 and 1.36 mmol/L (2313.3% and 126.7% change) respectively. Conclusion Our investigation suggests that running the HDL cholesterol assay prior to the lithium assay on the Roche Cobas c503 analyzer results in positive interference. As oppose to other Roche chemistry analyzers (such as the Roche c501), the Roche Cobas c503 analyzer has no wash step between the HDL cholesterol and the lithium assays. Detergents in buffers and reactive byproducts (like peroxide) of the HDL cholesterol assay, may leave behind salts in the instrument probe that can interfere with the lithium assay. We are currently working on adding a wash step between the HDL cholesterol and lithium assays. In the interim, we are repeating lithium testing on high lithium samples.

Impact of Sleep Disturbance on Fatigue, Nausea, and Pain: Mediating Role of Depressive Symptoms Among Youth With Disorders of Gut-Brain Interaction.

A high degree of sleep disturbance is reported among youth with disorders of gut-brain interaction (DGBIs). Given that sleep quality impacts a range of pediatric health outcomes including somatic sensations (eg, pain) and depressive mood occurs relatively frequently among youth with DGBIs, there is a dire need to disentangle the unique contributions of sleep and depressive mood on the somatic sensations experienced by youth with DGBIs. We aimed to examine whether depressive mood mediates the relations among sleep disturbance and pain intensity, nausea, and fatigue among youth with DGBIs. One hundred eighteen patients aged 8-17 years ( Mage = 14.05, SD = 2.88; 70.34% female), 83.05% White/non-Hispanic recruited at a pediatric neurogastroenterology clinic completed measures of sleep disturbance, nausea, fatigue, pain intensity, and depressive mood. Three mediation models examined the effect of sleep disturbance on nausea, fatigue, and pain, with depressive mood as a mediator. Participants reported moderate sleep disturbance. Depressive mood partially mediated the significant, respective relations between greater sleep disturbance and more severe nausea and fatigue. Sleep disturbance was significantly associated with higher pain intensity; however, depressive mood was not a significant mediator of this relation. Sleep quality is a major concern among youth with DGBIs. Low sleep quality may worsen nausea and fatigue via co-occurring increases in depressive mood symptoms. In contrast, sleep disturbance may directly increase pain, regardless of youths' depressive mood symptoms. Future research should explore these relations through prospective studies leveraging a combination of subjective and objective assessment approaches.

A Case Report on the Toxicological Evaluation of Pyridaben from a Human Cadaver

Suicidal poisoning with pesticides in humans is common in India. Despite the interdiction or regulation of several pesticides, there are reported considerate poisoning cases in India. Pyridaben is a potentially fatal insecticide with extreme neurotoxicity in humans. Pyridaben toxicity reports in humans are uncommon. Here we describe a case of acute poisoning with Pyridaben in a minor girl who presented with severe nausea, vomiting, altered consciousness, body weakness, abdomen pain, and congestion of visceral organs. Soon after the poisoning, the patient was treated with life-saving mechanical ventilation. Forensic examination of the viscera of a minor victim enlightened that the death was assignable to Pyridaben intoxication. GC-MS analysis of viscera showed significant results in concern to the identification of Pyridaben. The present case study emphasized the misuse of readily accessible pesticides and identified a new pesticide that can exert a deleterious impact on human health deliberately (suicide) and unintentionally (accidental) exposure. The same needs to be communicated to the scientific community to explore this lethal pesticide for its all-possible detrimental impacts consequently gathering scientific evidence in this regard will abet to regulate it by legislative.

Effects of aprepitant on post-operative nausea and vomiting in patients with congenital heart disease undergoing cardiac surgery or catheterization procedures: a retrospective study with subjects as their own historical control

IntroductionFor patients undergoing cardiac surgery and catheterization procedures, severe post-operative nausea and vomiting (PONV) can occur despite standard anti-emetic interventions. Aprepitant, a neurokinin-1 (NK-1) receptor blocker, is safe and effective at preventing PONV resistant to standard therapies.MethodsPatients with a history of severe PONV presenting for cardiac surgery or catheterization procedures from January 1, 2018 to January 6, 2021 were identified. After pharmacist approval, patients received aprepitant pre-operatively (Dose: 80 mg for weight &amp;gt;50 kg, 40 mg for weight 30–50 kg). A retrospective chart review was performed. Primary outcomes of the incidence of PONV and PONV-related complications were evaluated.ResultsSeventeen patients were included with a mean age of 16.0 years at the time of their initial procedure, which acted as the “control” procedure, and 17.5 years when they received aprepitant. After the control procedure 64.7% of patients required rescue anti-emetics. When this group of patients received aprepitant pre-operatively at their subsequent procedure, only 17.6% required rescue medication (p = 0.005). Similarly, 64.7% of patients suffered at least one PONV-related complication after the control procedure. With aprepitant use pre-operatively, 5.9% of the same patients experienced a PONV-complication (p = 0.0003). Specifically, unplanned ICU admission due to severe PONV after catheterization procedures decreased from 55.6% (5/9) in the control group to 0 after these patients were treated pre-emptively with aprepitant (p = 0.01). For surgical patients, there were significant decreases in PONV-related complications including delayed oral intake and delayed ambulation (p = 0.04) in the aprepitant group compared to the control group.DiscussionThis small, retrospective study supports the conclusion that preoperative aprepitant administration in patients undergoing cardiac catheterization or cardiac surgery with a history of congenital heart disease and severe PONV significantly reduces the incidence of PONV and PONV-related complications. Decreasing these complications will likely improve the surgical experience for patients and families while also decreasing hospital costs and improving efficiency.

The effect of digital acupressure on chemotherapy-induced nausea in Indonesian patients with stages III-IV breast cancer

Patients with breast cancer are reported to experience nausea and vomiting during neoadjuvant chemotherapy. Both remain the most troubling side effects of chemotherapy, even in the era of new antiemetic agents. Hence, our study aims to investigate the clinical outcome of acupressure in the prevention of acute chemotherapy-induced nausea (CIN) by evaluating the frequency and severity of nausea. This study was a randomized controlled trial consisting of 42 breast cancer patients, divided equally into two groups (experimental (acupressure) and control groups). Digital acupressure was performed at pericardium 6 (P6 or Neiguan) and stomach 36 (ST36 or Zusanli) points. Assessment of nausea was conducted by examining the frequency of nausea and measuring nausea-related subscores from the simulator sickness questionnaire (SSQ) and visual analog scale (VAS) within one hour after chemotherapy. Our study indicated that patients in the experimental group had significantly lower frequency and less severe nausea than those in the control group. In conclusion, acupressure effectively decreased the frequency and severity of nausea in breast cancer patients undergoing neoadjuvant chemotherapy. Acupressure could be implemented as an adjunct intervention in addition to antiemetic therapy for the prevention of CIN in breast cancer patients.

Peppermint Terhadap Mual Muntah Pada Ibu Hamil Trimester I Di Wilayah Kerja Puskesmas Salam Babaris

Nausea and vomiting occur in pregnant women in the first and second trimesters and can last up to 4 months. The impact can be experiencing disruption in work, household activities, psychological disturbance. Interventions can be carried out non-pharmacologically by using peppermint which can overcome digestive problems because it has a very high fragrance level, a cold, refreshing, strong aroma. The purpose of the study was to determine the effectiveness of giving peppermint to reduce nausea and vomiting in first trimester pregnant women in the working area of the Salam Babaris Health Center, Tapin Regency. The research method uses quasi-experimental types type with one sample test. It was carried out from January to February 2023. The sample consisted of 15 pregnant women. Bivariate analysis using the t test. The results of the study before being given peppermint, 9 people (60%) category of severe nausea vomiting and after being given pappermint became the category of mild nausea vomiting as many as 6 people (40%). The results of the t test obtained a p-value of 0.003, there is an effect of peppermint administration on reducing nausea vomiting in pregnant women trimester I. Giving peppermint in the form of candy is able to overcome nausea vomiting in pregnant women trimester I.

Pneumocephalous: Radiological Presentation of Intra-cranial Hypotension after Spinal Anaesthesia

Pneumocephalus is a commonly encountered entity in patients of head trauma and post-op cases of neurosurgery, however it is rarely observed after spinal anaesthesia.&#x0D; It commonly presents orthostatic hypotension associated with severe headache, nausea and vomiting. We report a case of pneumocephalus following spinal anaesthesia administered for open hernia repair.&#x0D; The proposed mechanisms of pneumocephalus secondary to spinal tapping are the ball-valve mechanism (1) and the inverted soda-bottle effect (2).

Efficacy of an enhanced recovery after surgery pathway to manage pain, nausea and vomiting after head and neck surgeries with free tissue transfer reconstruction.

Pain and post-operative nausea and vomiting are the main factors that impair the quality of recovery after surgery. Very few reports have analyzed patient-reported outcomes to investigate the efficacy of an enhanced recovery after surgery protocol to alleviate these symptoms after head and neck surgeries with free tissue transfer reconstruction. We investigated post-operative pain and post-operative nausea and vomiting in 47 patients who underwent head and neck surgeries with free tissue transfer reconstruction with enhanced recovery after surgery support between February 2021 and August 2022. Patient-reported outcomes were assessed using the visual analog scale and Japanese version of the Quality of Recovery-40. Significant increases in the mean visual analog scale scores for pain and post-operative nausea and vomiting were observed only on post-operative Day 1 compared with preoperative values (pain: 3.19±2.78 vs. 1.96±2.42, P=0.0408; post-operative nausea and vomiting: 1.52±2.09 vs. 0.54±1.37, P=0.0194). From post-operative Day 2, there were no significant differences between the pre- and post-operative visual analog scale scores, and no significant increases in the incidences of moderate or severe pain and post-operative nausea and vomiting compared with preoperatively. The Japanese version of the Quality of Recovery-40 score for post-operative pain showed no significant deterioration compared with preoperatively, while the Japanese version of the Quality of Recovery-40 score for post-operative nausea and vomiting showed significant deterioration compared with the preoperative value on post-operative Days 2, 4 and 7. The visual analog scale and Japanese version of the Quality of Recovery-40 scores for post-operative pain and visual analog scale score for post-operative nausea and vomiting suggested that the enhanced recovery after surgery strategy favorably controlled pain and post-operative nausea and vomiting after head and neck surgeries with free tissue transfer reconstruction. However, as the post-operative Japanese version of the Quality of Recovery-40 score for post-operative nausea and vomiting was lower than the preoperative value, there is still a need for further improvement of the enhanced recovery after surgery pathway.