Spontaneous Improvement Research Articles

Neurological Manifestations of Glutamic Acid Decarboxylase Autoimmunity in Indian Patients.

To study the neurological manifestations of glutamic acid decarboxylase (GAD 65) autoimmunity in Indian patients. Retrospective study conducted in a tertiary care referral hospital in South India. Patients who tested positive for GAD 65 antibodies from February 2013 to July 2019 were included. We identified 922 patients who underwent GAD 65 testing, of which 81 tested positive (8.78%) [mean age 55.42 years (SD 17.39, range 9-86 years, median age 57 years)]. Males (n = 47) outnumbered the females (n = 34). All the GAD values measured were <5000 IU/ml. There were 34 cases (42%) of atypical parkinsonism (16/34, 47% fulfilled the diagnostic criteria for autoimmune atypical parkinsonism) in our series forming the most common group with GAD 65 positivity, followed by autoimmune encephalitis (8 cases, 9.88%). Men were more affected with atypical parkinsonism (22/34; 64.70%), stiff person syndrome (2/3; 66.66%), and neuropathy (4/7; 57.1%) while women were more with autoimmune encephalitis (6/8; 75%). Eighteen (22.6%) had underlying autoimmunity (three had type 1 diabetes mellitus). Six (7.4%) had underlying neoplasm. Thirty-three out of 43 patients responded to immunotherapy (76.74%). Five had spontaneous improvement. Glutamic acid decarboxylase65 antibody values were much lower in our study population. Male-dominant autoimmunity was seen unlike that in Western literature. The most striking was the high preponderance of atypical parkinsonism in GAD 65-positive patients. We also found that GAD 65 positivity is a useful marker for a positive response to immunotherapy in suspected autoimmune neurological syndromes irrespective of their titers.

High-dose coenzyme Q10 therapy versus placebo in patients with post COVID-19 condition: A randomized, phase 2, crossover trial.

Post COVID-19 condition (PCC) is defined as symptoms lasting more than 12 weeks after developing COVID-19. Evidence of mitochondrial dysfunction has been reported in peripheral blood mononuclear cells obtained from patients with COVID-19. We hypothesized that PCC is caused by prolonged mitochondrial dysfunction. Given that coenzyme Q10 (CoQ10) can improve mitochondrial function, we examined whether high-dose CoQ10 can reduce the number and/or severity of PCC-related symptoms. In this placebo-controlled, double-blind, 2×2 crossover interventional trial, participants were recruited from two centres at Aarhus University Hospital and Gødstrup Hospital, Denmark. They were randomly assigned to receive either oral capsules of CoQ10 in a dose of 500mg/day or placebo for 6 weeks, with crossover treatment after a 4-week washout period. The ED-5Q and a PCC-symptom specific questionnaire were completed by the participants at 5 visits during the 20-week study period. The primary endpoint was the change in the number and/or severity of PCC-related symptoms after the 6-week intervention compared to placebo. Participants who completed the two-dosing period were included in the primary analysis, while all participants receiving one dose were included in safety assessment. From May 25th, 2021, to September 22nd, 2021, 121 participants underwent randomization, and 119completed both dosing periods - 59 and 60 in group A and B, respectively. At baseline, the mean PCC-related symptom score was 43.06 (95% CI: 40.18; 45.94), and the mean EQ-5D health index was 0.66 (95% CI: 0.64; 0.68). The difference between CoQ10 and placebo was not significant with respect to either the change in EQ-5D health index (with a mean difference of 0.01; 95% CI:-0.02; 0.04; p=0.45) or the change in PCC-related symptom score (with a mean difference of-1.18; 95% CI:-3.54; 1.17; p=0.32). Based on self-reported data, CoQ10 treatment does not appear to significantly reduce the number or severity of PCC-related symptoms when compared to placebo. However, we observed a significant spontaneous improvement on both scores regardless of treatment during 20 weeks observation. Placebo and CoQ10 capsules were provided by Pharma Nord, and the trial was supported by grants from the Novo Nordisk Foundation (NNF21OC0066984). This trial is registered with EudraCT, 2020-005961-16 and ClinicalTrials.gov, NCT04960215. The trial is completed.

Disease-Modifying Therapy in Subacute Sclerosing Panencephalitis: An Area of Darkness.

Subacute sclerosing panencephalitis (SSPE) is a neurodegenerative disorder because of the persistence of mutated measles virus in the central nervous system. Till date, no curative therapy has been established for SSPE. Multiple drugs have been tried to modify the disease process but have shown mild to moderate benefit at best. It is also challenging to attribute the relative success of some strategies described in single case reports because of the known phenomenon of spontaneous improvement in 5% of patients with SSPE. Critical gaps in understanding the pathophysiological processes involved exist. Current therapies such as interferon alfa require invasive strategies for administration by the intraventricular or intrathecal route, with varying dosage regimens. Oral therapies such as isoprinosine and ribavirin are expensive and not readily available in resource-constrained settings. Most of the evidence so far favors the use of combinational regimens. In this viewpoint, we critically summarize the current evidence on disease-modifying strategies in the context of our region.

Clinical Profile and Management Outcomes among Patients with Carotid-Cavernous Fistula.

A carotid-cavernous sinus fistula (CCF) is an abnormal communication between the internal carotid artery and/or the external carotid artery and the cavernous sinus. There is a paucity of information on the ophthalmic outcomes of endovascular treatment for CCF in the Philippines. This study aimed to describe the clinical experience of CCF in our institution in order to further our understanding of the disease. This study described the demographic profile, risk factors, and clinical features of patients with CCF, and compared the data of patients according to the type of CCF. The study discussed the changes in clinical features over time in CCF patients who chose not to undergo endovascular treatment. The study also discussed the clinical outcomes of CCF patients who underwent endovascular treatment and compared the clinical outcomes to CCF patients who did not undergo endovascular treatment. A retrospective cohort study design was performed using a medical record review of patients clinically diagnosed with CCF from January 2011 to June 2019. One hundred twenty medical records of patients diagnosed with CCF were included. Based on angiographic findings, patients were grouped according to type of CCF, with 86 patients in Group 1 or Direct CCF, 23 patients in Group 2 or Indirect CCF, and 11 patients in Group 3 or Mixed type of CCF. The patients were also grouped according to treatment, with 109 patients in Group A, or patients who did not undergo endovascular treatment, and 11 patients in Group B, or patients who underwent endovascular treatment. There was a male predominance in CCF, most occurring in the age range of 26 to 35 years. Risk factors for CCF were trauma and hypertension. Clinical features included the presence of blurring of vision, proptosis, corkscrewing of conjunctival vessels, extraocular movement limitation, diplopia, audible bruit, elevated intraocular pressure, and pulsation. Findings on Computed Tomography scan included dilated superior ophthalmic vein, proptosis, and enlarged extraocular muscles. Direct CCF (Group 1) occurred mostly in males, with mean age of 39.1 years, and with trauma as the major risk factor. Indirect CCF (Group 2) occurred mostly in females, with mean age of 52.1 years, and with hypertension as the major risk factor. Regardless of the type of CCF, patients who did not undergo endovascular treatment can exhibit spontaneous improvement or worsening of clinical features. Patients who underwent endovascular treatment generally had favorable clinical outcomes, manifesting as either improvement or no worsening of features. There were minimal ophthalmic complications associated with treatment. Endovascular treatment is safe and effective in the improvement of visual acuity, corkscrewing of conjunctival vessels, amount of proptosis, extraocular movement limitation, diplopia, and presence of audible bruit.

Retinal veno-venous anastomosis in chronic branch retinal vein occlusion: when natural healing takes place

It was a 63-year-old woman with a positive history of systemic hypertension consulting for a three years history of blurred vision Oculus Dexter (OD). She noticed a slowly progressive spontaneous improvement and denied any previous ophtalmology consultation. Best-corrected visual acuity was 6/18 OD with unremarkabale adnexal and anterior segment examination. Fundus examination showed showing supero-tempral branch retinal vein occlusion with arterio-venous nicking, macular exudates, and numerous retinal venovenous anastomoses bridging the horizontal raphe temporally. The fellow eye was normal. We ordered a fluorescein angiography with color and monochromatic photography that highlighted the previous findings and showed macular diffusion in early and late phases (A,B,C,D). We retained the diagnosis of retinal venovenous anastomosis in chronic branch retinal vein occlusion with chronic macular edema. The patient preferred observation of her condition and refused further investigations or interventions. After two years of follow-up, her visual acuity was stable. We insisted on medical control of her systemic hypertension.

Design of the inverter in high accuracy and development of work therein by using compound ligation

A ligation (CL) system with a very high frequency in an inverter was used, it is a novelty in this study. We also employed a three-phase dynamic load (positive sequence voltage) to correct the power factor and account for active and reactive power in the output system this work is a novelty. The technique through compound ligation (CL) can improve inverter output waveform by reducing losses caused by ingrained agents in voltage source inverters (VSI), such as dead time caused by overload or voltage drop in an inverter's output, or abnormal load current conditions such as a short circuit current occur in the output stage of the inverter, and so on. The invention relates to the conversion of D.C. to A.C. power inverters, it is preferable to use compound ligation to achieve high efficiency, the device is lightweight, and has low losses and good precision. In addition, the present invention relates to improving an inverter load request sensation circuit, smoothing operational current, inverter response, and inverter spontaneous power factor improvement, as well as correction of the reactive power of passive components. In addition, an inverter with high active power (P) equal to (2.6×106 Watt), reactive power (Q) (5.4×107 VAR), was designed, and used positive sequence voltage (1.6×108 Watt ), as well as the switching period (10µs), The system's total harmonic distortion (THD) in voltage and current was 0.11 percent, while the system's accuracy was 99 percent. This is developed by using FPGA and oscillator circuit and programmable peripheral interface 8255 A as well as, ultrasonic PWM with a high-frequency range of (20–500 kHz) as demonstrated evidenced by the results obtained

Natural History of Chiari 1 Deformity.

Chiari type 1 deformity (Ch1) is associated with bony deformity of the skull base and herniation of cerebellar tonsils more than 5 mm below the foramen magnum. Magnetic resonance imaging (MRI) is used for diagnosis and surgery is advised for symptomatic children. We present a case series using MRI including cerebrospinal fluid (CSF) flow, in children with Ch1 to demonstrate a variety of outcomes, both surgical and spontaneous: spontaneous resolution, spontaneous worsening, postsurgical improvement, and postsurgical deterioration. A 2-week-old female newborn underwent brain MRI demonstrating an ectopic neurohypophysis, under opercularization suggesting brain immaturity and a normal craniocervical junction (CCJ). Follow-up (F/U) MRI at 6 years of age showed interval spontaneous development of Ch1 with decreased CSF spaces at CCJ. A 6-year-old girl referred for imaging with short stature and growth hormone deficiency demonstrated incidental findings of Ch1 without syringomyelia. There was 15-mm protrusion of pointed cerebellar tonsils through the foramen magnum and a reduced CSF space at the craniocervical junction. No surgery was performed, and F/U MRI at the age of 7 years demonstrated spontaneous resolution of the tonsillar ectopia (cerebellar tonsils now 3 mm right and 6 mm left) and expansion of the CSF spaces at CCJ. A 7-year-old boy with headaches and staring spells underwent an MRI demonstrating 6-mm protrusion of pointed cerebellar tonsils and CSF space reduction at CCJ. No surgery was performed, and F/U imaging at the age of 9 years demonstrated spontaneous improvement in cerebellar tonsillar position and increased bidirectional CSF flow at CCJ. A 17-month-old boy underwent brain MRI for unsteady gait and poor vestibular response, which showed Ch1 and narrow CSF spaces at the foramen magnum and with reduced CSF flow. At the age of 3 years, after posterior fossa decompression, F/U MRI showed postsurgical improvement of the position of the cerebellar tonsils and increased CSF space at CCJ. A 4-month-old male infant with a history of 34-week prematurity, prior germinal matrix hemorrhage, and neonatal subdural hemorrhage was referred for MRI of the cervical and thoracic spine for evaluation of developmental delay and hypotonia with torticollis. Magnetic resonance imaging of the spine demonstrated mild protrusion of inferiorly pointed cerebellar tonsils up to the foramen magnum, with visible CSF and without retroflexion of the dens. Follow-up MRI scans demonstrated progressive worsening of the Chiari 1 deformity, even after multiple surgeries. It is important to be aware of a variety of different outcomes with Ch1, including spontaneous resolution, spontaneous worsening, improvement with surgery, and even deterioration after surgery. More research is required to determine objective criteria for predicting outcome, which include both anatomic measures and physiologic measures of CSF flow, so that better surgical decisions can be made and for evaluating patients who have undergone surgery.

Prepared and Unprepared Techniques of Improvisation in Foreign Jazz Instrumental Music of the Second Half of the XX Century

The purpose of the work is to analyse the prepared and unprepared techniques of improvisation in foreign jazz instrumental music of the second half of the XX century, as well as to determine the trends and features of their development. The research methodology involves the use of historical, analytical, and comparative methods, which allows revealing the peculiarities of the development of creative techniques in jazz instrumental music of the stated period. The scientific novelty of the work lies in the fact that prepared and unprepared improvisation techniques in foreign jazz instrumental music of the second half of the XX century are investigated for the first time, the analysis of which makes it possible to find out how these techniques and jazz instrumental music of the specified period developed as a whole. Conclusions. In the second half of the ХХ century, prepared and unprepared improvisations developed dynamically. Prepared improvisation is a fairly common creative technique in jazz music, which has its roots in academic music. The main principle of prepared improvisation is that it is planned in advance by the performer. It becomes widespread in jazz in the first half of the ХХ century during the swing era, during the heyday of big jazz orchestras and big bands. In the second half of the ХХ century the prepared improvisation technique develops freely, interacts with other improvisation techniques (collective, solo, choral, and modal). However, at the same time, jazz music has been associated precisely with unprepared improvisation since its inception. This technique does not require prior preparation, the birth of music occurs directly at the moment of making music. If prepared improvisation can be positioned as a phenomenon of limited improvisation, then unprepared improvisation gives complete creative freedom to the musician. In addition, it should be noted that the principles of unprepared improvisation are quite close, similar and related to the techniques of free and spontaneous improvisation. To a large extent, these techniques are used in avant-garde trends and free jazz. In the development of unprepared improvisation in jazz instrumental music of the second half of the ХХ century it is difficult to single out specific periods that are marked by certain characteristic and innovative tendencies of formation.&#x0D; Key words: prepared improvisation, unprepared improvisation, creative and performance techniques, jazz instrumental music.

The Eye as a Window to the Brain: Prominent Retinal Vasculopathy Points to Neuro-Behcet Diagnosis for an Undifferentiated Solitary Brain Lesion

Objective To report a perplexing case of Behcet disease (BD) presenting as a focal parenchymal lesion that reached a diagnosis after noting a prominent retinal vasculopathy, highlighting the importance of ophthalmologic evaluation in undifferentiated CNS disease. Background BD can have variable systemic manifestations driven by a vasculitis, including oral or genital ulcers, pulmonary aneurysms, and uveitis. Neurologic involvement is present in less than 10% of patients, most commonly as a meningoencephalitis. Design/Methods We present the case of a woman who developed asymmetric sub-acute sensorineural hearing loss at age 31 followed by transient right facial weakness at age 40, and most recently presented with right facial numbness and arm weakness at age 47. Brain MRI revealed a left frontal enhancing lesion with associated T2/FLAIR hyperintensity extending from the periventricular to the juxtacortical area with a thin rim of a reduced diffusion. CSF and serum studies were negative for inflammation, infection and malignancy except for elevated ESR and CRP. Brain biopsy revealed non-specific gliosis. Persistent enhancement on MRI was noted over 3 months, with spontaneous clinical improvement. Patient endorsed insidious vision changes over recent years, and visual testing was performed. Results Dilated ophthalmic examination demonstrated striking peripheral attenuation and sclerosis of retinal vasculature, with evidence of nonperfusion and skip lesions on retinal fluorescein angiography (FA). Findings of occlusive retinal peripheral vasculopathy suggested an underlying vasculitis as the etiology of the brain lesion and prior deficits, raising the likelihood of BD. Patient was homozygous for HLA-B*51, further supporting this diagnosis even with lack of mucosal ulcers and negative history of pathergy. Conclusions Neurologic manifestations of BD can be diverse including retinal occlusive vasculopathy; ulcers are not universally present. Ophthalmologic examination, even when minimally symptomatic, can inform the diagnosis of CNS lesions. Patient was started on Prednisone, Infliximab and Methotrexate, achieving disease remission.

Obstructive sleep apnea in young infants: Sleep position dependence and spontaneous improvement.

The natural evolution of obstructive sleep apnea (OSA) in young infants is not established. We re-evaluated 10-year pediatric sleep center infant polysomnography (PSG) data, excluding infants with syndromes, genetic defects, structural anomalies or periodic breathing > 5% of sleep time. Obstructive events > 1 h-1 were evident in 255 infants, of which 91 were eligible for the study. Of the 38 infants in a follow-up study, 30 (79%) were male, 15 (40%) were born prematurely, 25 (66%) had observed apneas, and 13 (33%) had experienced a brief, unexplained event or had a sibling of the infant died suddenly. The first PSG was performed at a median corrected age of 4 weeks (interquartile range [IQR] 2-7) and the second at 11 weeks (IQR 9-14). The obstructive apnea and hypopnea index (OAHI) was greater in the supine compared to side-sleeping position in both recordings (p < 0.001), whereas OAHI dropped from 10 h-1 (IQR 6-24) in the first PSG to 3 h-1 (IQR 1-9) in the second PSG (p < 0.001). OSA alleviation was also observable as a decrease in the number of oxygen desaturations (p < 0.001), as a decrease in transcutaneous (p = 0.001) and end-tidal carbon dioxide (p = 0.01) 95th percentile levels, and work of breathing (p = 0.002). Seven infants had a third PSG to verify a satisfactory improvement of OSA. OSA in young infants without a clear syndrome or structural anomaly is sleep position dependent and shows improvement during the following few months.

Hypoglossal nerve palsy after SARS-CoV-2 vaccination – report of two cases

BackgroundSARS-CoV-2 vaccination is associated with an increased risk for Bell’s palsy and some other neurological disorders assumed to be of autoimmune origin. While facial nerve palsy is frequent and usually idiopathic, hypoglossal nerve palsy is rare, and a specific cause is almost always found. We firstly report two patients who developed isolated hypoglossal nerve palsy shortly after SARS-CoV-2 vaccination.Case presentationTwo otherwise healthy patients, a 49-year-old man and a 39-year-old woman, developed unilateral hypoglossal nerve palsy 10 and 7 days after the second SARS-CoV-2-vaccination (AstraZeneca and BioNTech/Pfizer), respectively. In both subjects, needle electromyography showed denervation and rarefication of motor units. CT, MRI, examination of blood and CSF as well as ENT exam were unremarkable. In both subjects symptoms gradually improved.ConclusionDue to close temporal relationship, the absence of other etiologies, and spontaneous improvement we suspect the vaccination as the cause for hypoglossal nerve palsy in both patients. This is further supported by the rarity of isolated hypoglossal nerve palsies, especially in idiopathic cases. We suggest the addition of hypoglossal nerve palsy to the list of neurological injuries potentially caused by SARS-CoV-2 vaccination.

Follicular Keratosis in Adolescents: Diagnostic Features and Cosmetological Aspects of Therapy

Follicular keratosis (FK) is one of the most common dermatological diseases in children. FK manifests usually in early childhood and worsen frequently, thus, symptoms are more prominent during puberty. The skin of proximal extensors of upper and lower limbs is mainly affected, while skin of cheeks, back and buttocks is affected more rarely. FK is just a cosmetic defect which significantly affects adolescents’ self-esteem and emotional state up to the development of severe depressive syndrome and obsessive conditions accompanied by pathomimia. FK can be associated with other nosologies such as: atopic dermatitis, vulgar ichthyosis, obesity, diabetes mellitus, and even aggravate Down and Noonan syndromes. Spontaneous improvement is still possible with age. We can use topical therapy with emollient, keratolytic, anti-inflammatory drugs, as well as various types of laser and phototherapy to alleviate the disease symptoms. This article provides basic information on etiology, pathogenesis, and treatment of FK with clinical case description.

PMON117 IGF-1 Testing: Diagnostic Pitfalls

Abstract Introduction Acromegaly is a rare endocrine disorder, with an incidence of 5.3/million/year, that results from persistent hypersecretion of growth hormone (GH), which stimulates hepatic secretion of insulin-like growth factor-1 (IGF-1). The best single test for the diagnosis of acromegaly is measurement of serum IGF-1; however, the result must be interpreted with caution, with understanding of potential pitfalls. Here we present a case of falsely elevated IGF-1 levels. Case Description A 43-year-old female with medical history of prediabetes, sleep apnea, and headaches was referred to endocrine clinic for evaluation of possible acromegaly. Patient had been evaluated by her primary care physician for frequent headaches, unintentional weight gain, and bilateral leg and hand swelling. Patient endorsed being unable to wear her wedding ring for a few years. Initial laboratory evaluation by primary care physician 3 months prior revealed normal thyroid function, prolactin, FSH, LH, random cortisol, but elevated IGF-1 of 310 ng/mL (normal 71-258 ng/mL), with negative pregnancy test. Brain MRI at that time revealed a pineal gland cyst but no pituitary abnormality. During her initial endocrine visit, IGF-1 was repeated, which was again elevated but improved to 283 ng/mL (normal 71-258 ng/mL). Other pertinent labs included a normal random ACTH of 18 pg/mL (normal &amp;lt;47 pg/mL), and pm cortisol of 2.4 mcg/dL (normal 2.9-17.3 mcg/dL). Physical examination was notable for a few light purple striae on abdomen, acanthosis nigricans, and mild limb edema, but no macrognathia, enlarged hands or feet. Given patient's lack of typical features of acromegaly, normal pituitary imaging, and spontaneous IGF-1 improvement, it was decided to postpone GH measurements with oral glucose tolerance test but repeat IGF-1 in 6 months. Patient was able to follow up 11 months after initial visit at which patient denied any worsening symptoms. At that time, repeat laboratory study showed normal IGF-1 of 231. Given spontaneous normalization of IGF-1 levels, no further laboratory testing or imaging studies were recommended, and patient was instructed to follow up in 11-12 months. Discussion Prompt diagnosis of acromegaly is crucial. However, it is important to note IGF-1 could be falsely elevated. A retrospective review by Erickson et. al of 2747 unique patients with IGF-1 elevation, 117 (4%) were found to have false-positive results following a review of the clinical data. In addition to acromegaly, other causes of elevated IGF-1 levels include high protein and high glycemic-index diet, pregnancy, hyperthyroidism, IGF-1 assay problems, and some rare tumors (carcinoids) secreting IGF-1. Discovery of "falsely" elevated IGF-1 may lead to unnecessary testing and physician visits. Therefore, clinicians should consider retesting patients after some time interval if spurious IGF-1 is suspected, before aggressively pursuing more extensive investigations. Presentation: No date and time listed

PSAT324 Altered Mental Status, Hypercalcemia, and Atrial Fibrillation Induced by Post-Parathyroidectomy Thyroiditis

Abstract Background Parathyroidectomy-induced thyroiditis is a rare but possibly underreported phenomenon. It has been reported in primary, secondary, and tertiary hyperparathyroidism, and typically presents with transient thyrotoxicosis in the days to weeks following surgery. Clinical Case A 66-year-old man with end stage renal disease complicated by tertiary hyperparathyroidism and no prior history of thyroid disease or cardiac dysrhythmia was admitted for parathyroidectomy. A multinodular goiter and four enlarged parathyroid glands were identified intraoperatively. With significant thyroid retraction, removal of the inferior parathyroid glands, left superior parathyroid gland, and one-half of the right superior parathyroid gland was successfully performed without complication. Despite normalization of the parathyroid hormone level after surgery, the patient's preoperative hypercalcemia was noted to paradoxically worsen, rising from a corrected total calcium of 10.9 mg/dL (ref. 8.5-10.4 mg/dL) to 12.2 mg/dL. This was observed concurrently with the development of worsening mental status and new onset atrial fibrillation with rapid ventricular rate, prompting beta blockade initiation. Administration of intravenous crystalloid and subcutaneous calcitonin rapidly normalized his serum calcium but did not resolve the altered mentation or cardiac arrhythmia. Thyroid function tests revealed thyroid stimulating hormone 0.05 mIU/L (ref. 0.49-4.67 mIU/L), free thyroxine (T4) 3.8 ng/dL (ref. 0.7-1.9 ng/dL), and total triiodothyronine 144 ng/dL (ref. 60-181 ng/dL). Thyroid stimulating immunoglobulin was negative, and a thyroid ultrasound demonstrated multiple bilateral thyroid nodules with no evidence of increased vascularity of the gland. Serial thyroid function tests over several days revealed spontaneous biochemical improvement in the patient's T4-thyrotoxicosis that correlated with improved mentation. An exhaustive metabolic, infectious, and radiologic work-up yielded no alternative explanation for his initial change in mental status. By postoperative day 6, his cardiac dysrhythmia and altered mentation completely resolved, and the free T4 improved to 2.1 ng/dL, allowing for hospital discharge. His free T4 normalized a week later. Conclusion Our patient's postoperative course appears to have been driven by surgically induced thyroiditis. There are no current recommendations for routine postoperative screening for parathyroidectomy-induced thyroiditis, but biochemical testing should be considered if signs or symptoms of thyrotoxicosis such as unexplained altered mentation, cardiac dysrhythmias, and/or worsening hypercalcemia emerge. Doing so may allow for a rapid and cost-effective approach towards a unifying diagnosis. Bilateral cervical exploration is a known risk factor. Other possible risk factors include the presence of a multinodular goiter and significant intraoperative thyroid retraction, though further characterization of these is needed. Treatment is supportive, as cases typically self-resolve. Presentation: Saturday, June 11, 2022 1:00 p.m. - 3:00 p.m.

S3158 Supplement Gone Wrong: Drug-Induced Liver Injury Caused by Artemisinin

Introduction: Drug-induced liver injury (DILI) is defined as hepatic dysfunction caused by prescription medications, supplements, or xenobiotics after alternative causes have been excluded. As one of the leading causes of acute liver failure, DILI should be considered when patients present with hepatic dysfunction. We present a case of symptomatic DILI secondary to artemisinin use. Case Description/Methods: A 78-year-old Chinese man with no medical history presented to the hepatology clinic with 10 weeks of jaundice, weakness, and pruritis. He started taking Artemisinin/ Bioperine 12 weeks ago to prevent COVID-19 but stopped 3 weeks ago. He denied abdominal pain, a family history of liver disease, substance/alcohol use, and taking other concomitant drugs. Physical examination revealed scleral icterus and no other signs of chronic liver disease. Laboratory studies showed total bilirubin 11 mg/dL, alkaline phosphatase 293 U/L, aspartate transaminase 170 U/L, and alanine transaminase 196 U/L with negative workup for hepatitis A, B, and C. CT abdomen and MRCP were unremarkable for liver or biliary pathology. Further serological workup was negative and follow-up labs revealed normalization of liver enzymes and bilirubin. Given the patient’s improvement, liver biopsy was not pursued. The patient was instructed to avoid supplements unless prescribed by a physician. Discussion: DILI is a global issue with an estimated annual incidence rate of 13.9 to 24.0 per 100,000 persons. Diagnosing DILI is important as it can cause acute liver injury and liver failure in certain cases. Since COVID-19 emerged, supplement use has increased given claims of boosting the immune system. Artemisinin is an herb used in traditional Chinese medicine with antimalarial activity investigated to be a possible COVID-19 treatment, but no current evidence exists to support it being effective against COVID-193. Our patient’s supplement also contained Bioperine, a black pepper extract, which is likely benign. Contrarily, artemisinin is a well-described cause of idiosyncratic acute liver injury and hepatotoxicity, causing self-limited mild to moderate transaminitis but also severe cases requiring emergent liver transplantation. Our patient’s unrevealing workup, his spontaneous improvement correlating with supplement discontinuation, and RUCAM score of 7 led to high suspicion of DILI secondary to artemisinin. Providers should always ask patients about supplement use and consider DILI when patients present with liver injury. Table 1. - The patient’s laboratory values, including total bilirubin, alkaline phosphatase (ALP), aspartate transaminase (AST), and alanine transaminase (ALT) improved after stopping Artemisinin/Bioperine Total bilirubin (mg/dL) ALP (U/L) AST (U/L) ALT (U/L) Initial labs with PCP 11 293 170 196 Repeat labs with PCP 5.6 143 75 98 3 weeks after stopping supplement 2.4 85 34 41

Biological therapy for young children with atopic dermatitis

Atopic dermatitis is a common inflammatory skin disease that might lead to severe and persistent disease during infancy. Atopic dermatitis is associated with poor school performance, psychiatric disease, and allergic comorbidities.1–3 If atopic dermatitis is inadequately controlled with emollient use and topical anti-inflammatory therapies, systemic medications including ciclosporin, azathioprine, and methotrexate can be used to treat children with moderate-to-severe disease. However, systemic therapies are rarely used in children because the natural disease course often leads to spontaneous improvement, and because their use requires continuous blood monitoring and is associated with tolerance issues and modest efficacy.

Case report: Eosinophilic pneumonia associated with vedolizumab therapy in a patient with ulcerative colitis

Extraintestinal manifestations are common in patients with inflammatory bowel disease, while respiratory involvement is less common. Vedolizumab is a new class of anti-integrin biological agents approved for treating inflammatory bowel disease. In this report, we present the case of a 38-year-old patient with ulcerative colitis for 7 years who developed cough, fever, and pulmonary infiltrates after taking vedolizumab. There was a spontaneous improvement in clinical symptoms and radiological abnormalities after discontinuing vedolizumab and introducing steroids. Despite the rarity of vedolizumab-induced eosinophilic pneumonia, the case reports indicate that patients with unexplained respiratory symptoms that are taking vedolizumab should be fully contemplated.

How Does Big Data Capability Drive Firm Innovation?

As a key prerequisite for data-driven innovation, big data capability is crucial for firms to gain a competitive advantage. However, the role of big data capability on innovation is still in its infancy. Using the data from 228 Chinese firms, we investigated how and under what conditions big data capability affects radical innovation and incremental innovation. Our results show that big data capability is positively associated with radical/incremental innovation. Further, spontaneous improvisation plays a partial mediating role between big data capability and radical innovation, and creative improvisation plays a partial mediating role between big data capability and radical/incremental innovation. Additionally, data-driven culture strengthens the positive impact of big data capability on creative improvisation. These findings highlight novel pathways and contingencies through which improvisation may prove to be a potential means for big data capability to drive firm innovation.

O-024 Does a vaginal lactobacilli probiotic treatment improve an unfavourable vaginal microbiome before fertility treatment? A randomised, double-blinded, placebo-controlled trial

Abstract Study question Does treatment with lactobacilli-loaded vaginal capsules improve an unfavourable vaginal microbiome associated with a lower implantation chance before fertility treatment? Summary answer Probiotic treatment did not improve the vaginal microbiome compared with placebo. However, spontaneous improvement of the vaginal microbiome was observed in 34.2% of all participants. What is known already Studies have shown that the vaginal microbiota composition is predictive of IVF treatment outcome and suggest that dysbiosis in the reproductive tract negatively affects the chance of pregnancy through as yet unclear mechanisms. Tests designed to assess different components of endometrial function are entering clinical practice and with microbiota being shown to modulate organ function throughout the body, interest is growing in assessing the vaginal microbiome as a potentially treatable marker of endometrial receptivity and predictor of treatment outcome. Study design, size, duration This randomised, double-blinded, placebo-controlled study was conducted at a single University fertility clinic between April 2019 and February 2021. The vaginal microbiome composition of eligible patients referred for IVF treatment was determined using a validated PCR based IS-pro technique dividing samples into three overall profiles: low, medium, and high quality. Seventy-four women with an unfavourable vaginal microbiome (low or medium profile) were included and randomly assigned 1:1 to receive either vaginal probiotic capsules or placebo. Participants/materials, setting, methods Following screening and inclusion, participants completed a 10-day treatment with vaginal probiotic capsules (containing &amp;gt;108 CFU of Lactobacillus gasseri and &amp;gt;108 CFU Lactobacillus rhamnosus) or placebo. Samples to determine the effect on the vaginal microbiome were taken following completion of treatment (primary outcome) and again in the subsequent menstrual cycle (secondary outcome). Improvement in the microbiome was defined as a shift from low to medium, low to high, or medium to high profiles. Main results and the role of chance Seventy-seven women were randomised, 74 women completed the intervention and follow-up. Randomisation yielded 38 women in the lactobacilli group and 36 women in the placebo group. The demographic and baseline characteristics were similar in the two groups. Primary outcome: the vaginal microbiome improved after intervention in 34.2% of all participants with no significant difference between the two groups (lactobacilli group 28.9%, placebo group 40.0%), RR = 0.72 (95% CI 0.38–1.38), P = 0.32. Similarly, in the cycle after intervention (secondary outcome), the vaginal microbiome composition was improved relative to baseline samples in 31.9% of all participants with no significant difference between the groups (lactobacilli group 30.6%, placebo group 33.3%), RR = 0.92 (95% CI 0.47–1.80), P = 0.80. Limitations, reasons for caution The intervention did not include all strains of lactobacilli implicated in influencing fertility outcomes. The broad categorisation of the vaginal microbiome profile as either low, medium or high may mask more subtle changes. Wider implications of the findings This study indicates that administering vaginal lactobacilli probiotics may not improve a suboptimal vaginal microbiome. However, a spontaneous improvement rate of 34.2% over a period of one to three months may provide the basis for an alternative therapeutic strategy of postponing fertility treatment until spontaneous improvement occurs. Trial registration number ClinicalTrials.gov identifier NCT03843112. EU Clinical Trials Register (EudraCT number: 2018 002376-41).

Subjective Outcome after Discontinuation of Botulinum Toxin-A Detrusor Injection for Lower Urinary Tract Disorders: The Majority Suffers!

Introduction: According to the EAU guidelines, botulinum toxin type A (BoNT-A) detrusor injections are one of the last options in the management of overactive bladder before opting for invasive surgery. So far, there have been no studies dedicated exclusively to such patients who have undergone this treatment and in whom this treatment has presumably failed. From the patient’s point of view, there are questions regarding what reasons led to discontinuation, how patients perceive their BoNT-A treatment in hindsight, what further treatment do these patients receive, and how satisfied such patients are with their current situation. Methods: A database of clinical and inpatient records was searched, and 695 records from 406 patients were identified in a 6-year period, who had received BoNT-A detrusor injections. There were 255 cases that were treated with BoNT-A injections into the detrusor muscle where the therapy was not repeated for at least 12 months (= suspected treatment failures). Interviews with these patients were conducted by mail and phone, and 115 questionnaires could be included in the analysis. Results: From the subjective and prospective points of view of the patients, the most common reason for stopping the therapy was a lack of efficacy of BoNT-A injections (39.1%). For 26.1% of all patients, side effects were a reason for dissatisfaction but never a reason for discontinuation. For 10.4%, the reason for stopping the therapy was spontaneous improvement. 35.6% of the respondents had no follow-up therapy. Those with a follow-up therapy mostly returned to anticholinergic treatment (33%). Operations were carried out on 13%, of which about half were highly invasive. For 71.3% of those patients, who were under any current therapy, this therapy led to no improvement or only some improvement of the symptoms. Surprisingly, 50.4% of the respondents would choose to undergo BoNT-A injection therapy again. Discussion/Conclusion: The majority of patients who did not continue BoNT-A therapy are still suffering from lower urinary tract symptoms. The lack of efficacy was the reason for stopping the BoNT-A injection therapy for less than half of the patients. From the patient’s point of view, reasons other than the effectiveness also seem to be relevant in the choice of the treatment. When changing therapy, most returned to drug treatment. However, for the majority of patients with any follow-up therapy, this therapy could not improve the symptoms.