Subsequent Symptom Improvement Research Articles

Neural responses to facial emotions and subsequent clinical outcomes in difficult-to-treat depression.

Amygdala and dorsal anterior cingulate cortex responses to facial emotions have shown promise in predicting treatment response in medication-free major depressive disorder (MDD). Here, we examined their role in the pathophysiology of clinical outcomes in more chronic, difficult-to-treat forms of MDD. Forty-five people with current MDD who had not responded to ⩾2 serotonergic antidepressants (n = 42, meeting pre-defined fMRI minimum quality thresholds) were enrolled and followed up over four months of standard primary care. Prior to medication review, subliminal facial emotion fMRI was used to extract blood-oxygen level-dependent effects for sad v. happy faces from two pre-registered a priori defined regions: bilateral amygdala and dorsal/pregenual anterior cingulate cortex. Clinical outcome was the percentage change on the self-reported Quick Inventory of Depressive Symptomatology (16-item). We corroborated our pre-registered hypothesis (NCT04342299) that lower bilateral amygdala activation for sad v. happy faces predicted favorable clinical outcomes (rs[38] = 0.40, p = 0.01). In contrast, there was no effect for dorsal/pregenual anterior cingulate cortex activation (rs[38] = 0.18, p = 0.29), nor when using voxel-based whole-brain analyses (voxel-based Family-Wise Error-corrected p < 0.05). Predictive effects were mainly driven by the right amygdala whose response to happy faces was reduced in patients with higher anxiety levels. We confirmed the prediction that a lower amygdala response to negative v. positive facial expressions might be an adaptive neural signature, which predicts subsequent symptom improvement also in difficult-to-treat MDD. Anxiety reduced adaptive amygdala responses.

THU536 Pseudoglucagonoma Syndrome: A Rare Complication After Partial Pancreatectomy

Abstract Disclosure: E.P. Monsour: None. S. Badour: None. K.M. Tuna: None. J. Leey: None. M. Lamas: None. Introduction/Background: Necrolytic migratory erythema (NME) is a specific cutaneous eruption associated with glucagonoma, an alpha-cell secreting pancreatic neuroendocrine tumor. Glucagonoma syndrome is a paraneoplastic syndrome characterized by NME, diabetes, stomatitis, anemia, weight loss, and gastrointestinal disturbances. Rarely NME can occur in the absence of an alpha-cell tumor of the pancreas, termed pseudoglucagonoma syndrome, seen in other clinical entities such as hepatic disease and intestinal malabsorption. Here, we describe a rare case of pseudoglucagonoma syndrome as a long-term complication following partial pancreatectomy. Clinical Case: A 45-year-old male with a history of benign pancreatic head cyst s/p partial pancreatectomy, pancreatic exocrine insufficiency, and pancreatogenic diabetes reported a 2-week history of a rash on his bilateral upper and lower extremities that was accompanied with blistering and skin peeling. Associated symptoms included tongue pain, diarrhea, and worsening paresthesias. Medications included subcutaneous insulin aspart, pantoprazole, and pancrelipase. Physical examination revealed a patchy rash with hyperpigmented plaques and shellac-like scales, a smooth red tongue, and symmetric hyperreflexia. Preliminary punch biopsy was concerning for NME; thus, the patient was evaluated for possible glucagonoma. Laboratory evaluation revealed normocytic anemia with hemoglobin of 9.8 mg/dL, plasma glucose of 104 mg/dL, and glucagon level of 103 ng/L (RR: &amp;lt;208 ng/L). MRCP was negative for any pancreatic lesions. The patient was further evaluated for nutritional deficiencies and had strinkingly low vitamin A, D, E, K, B6, serum copper, and zinc levels. Plasma amino acids revealed low phenylalanine and tryptophan levels. He was started on a multivitamin (with minerals) and oral nutritional supplements with resolution of rash and subsequent improvement in symptoms. Final pathology of punch biopsy revealed parakeratosis with dermal edema, most compatible with nutritional deficiency. Discussion and conclusion: The pathogenesis and etiology of NME in glucagonoma and pseudoglucagonoma syndromes are not entirely understood. NME is thought to be multifactorial to multiple (essential) nutrient and vitamin deficiencies, as seen in our patient and other nutrient deficiency dermatoses such as zinc deficiency, necrolytic acral erythema, and pellagra. After further investigation, the patient reported poor adherence to pancrelipase supplementation, likely contributing to his clinical presentation and symptoms. Whereas in glucagonoma, excess glucagon levels cause a state of catabolism and exert its effect on the liver to increase gluconeogenesis via amino acid catabolism leading to deficiency. It is essential for clinicians to be aware of this rare and underrecognized phenomenon. Presentation: Thursday, June 15, 2023

Symptom severity, specialty palliative care, and subsequent symptom control among adolescents and young adults with cancer: A population-based study.

e24127 Background: Adolescents and young adults (AYA) with cancer can suffer from substantial symptom burdens. Specialty palliative care (SPC) is recommended but often uninvolved or involved late. In a population-based AYA cohort, we determined: 1) whether symptom severity measured by routine patient report was associated with subsequent SPC involvement; and 2) whether SPC involvement was associated with subsequent symptom improvement. Methods: All Ontario, Canada AYA diagnosed with cancer aged 15-29 between 2010-2018 were identified and linked to healthcare databases, including one capturing self-reported Edmonton Symptom Assessment System (ESAS) scores at cancer-related visits. SPC was identified through validated algorithms using PC fee codes billed by SPC physicians. ESAS scores were categorized as not measured, mild (0-3), moderate (4-6), or severe (7-9), and could vary over time. For each symptom, the association of ESAS score with subsequent SPC involvement was determined, adjusting for patient and disease characteristics. For objective #2, only AYA who died within 5 years of cancer diagnosis were included and a “difference-in-difference” approach was used. Cases (SPC involvement before death, index date was time of first SPC service) were matched 1:1 to controls (no SPC involvement at equivalent index date, defined by time prior to death) by sex and cancer type. By symptom type, linear regression determined whether the difference between the 90-day post-index and 90-day pre-index mean ESAS scores was itself different between cases and controls through examining interaction terms. Results: 5,435 AYA met inclusion criteria. 5-year cumulative incidence of SPC involvement was 19% [95th confidence interval (95CI) 18-20%]. For all symptoms, moderate and severe scores were associated with increasing likelihood of SPC involvement compared to mild scores; not being ESAS screened was associated with decreased likelihood. The greatest magnitude of association was seen for pain scores [adjusted hazard ratio of SPC involvement for severe vs. mild 7.7, 95CI 5.8-10.2, p &lt; 0.001]. 721 (13.3%) AYA died within 5 years of diagnosis; 612 (84.9%) had at least one SPC visit prior to death. 202 case-control pairs were identified. SPC involvement was associated with improved pain score trajectories (mean pain scores improved from 3.4 to 3.1 in cases vs. worsened from 1.9 to 2.1 in controls; p = 0.003), but did not impact trajectories of other symptoms. Conclusions: AYA reporting moderate or severe symptoms through a provincial screening program were more likely to subsequently receive SPC; systematic screening may increase access. SPC was associated with a subsequent decrease in pain severity, but did not affect other symptoms. New interventions targeting these other symptoms during cancer treatment and particularly at the end-of-life are urgently needed.

Imatinib use in the management of a patient with Doege-Potter syndrome.

Doege-Potter syndromeis a paraneoplastic syndrome characterized by nonislet cell tumor hypoglycemia due to a solitary fibrous tumor, which produces insulin-like growth factor II. In this report, we present the case of a 67-year-old male with recurrent and refractory hypoglycemia due to DPS successfully treated with imatinib. He initially presented with neuroglycopenic symptoms and dyspnea secondary to a giant tumor in the left hemithorax, which was totally resected. During follow-up, 7 years later, he presented with thoracoabdominal tumor recurrence associated with severe hypoglycemia and underwent subtotal tumor resection, with a subsequent improvement of symptoms. The following year, he had a recurrence of his intra-abdominal tumor, which was unresectable, associated with severe hypoglycemia refractory to dextrose infusion and corticosteroids, thus receiving imatinib with a favorable response. The clinical presentation, diagnostic approach, progression of the disease, and response to treatment with imatinib in the management of a patient with large, recurrent, and unresectable mesenchymal tumors with insulin-like growth factor-2 secretion causing hypoglycemiahighlight the importance of this case report. Doege-Potter syndrome (DPS) is a rare cause of tumoral hypoglycemia of non-pancreatic origin. Some malignant or benignant neoplasms have ectopic secretion of insulin-like growth factor-2. Total surgical removal is the principal treatment in patients with DPS. Tyrosine kinase inhibitors management in DPS may contribute to improved tumor control in patients with unresectable tumors and severe hypoglycemia.

Abstract Number ‐ 12: First‐In‐Human Endovascular Treatment of Idiopathic Intracranial Hypertension Using a Miniature Biomimetic Transdural Shunt.

Introduction Successful percutaneous transvenous deployment of a miniature valved biomimetic transdural endovascular shunt (CereVasc eShunt, Auburndale, MA, USA) via an inferior petrosal sinus approach was recently described for treatment of post‐subarachnoid hemorrhage communicating hydrocephalus.The endovascular shunt replicates the function of the arachnoid granulation by draining cerebrospinal fluid (CSF) from the cerebello‐pontine angle cistern to the ipsilateral internal jugular vein. Idiopathic intracranial hypertension (IIH), usually resulting from venous transverse sinus stenosis, can be treated with pharmacological inhibition of CSF production, surgical ventriculoperitoneal shunting, or using venous stent angioplasty. In IIH, elevated CSF pressure can act to exacerbate venous sinus stenosis, resulting in worsening CSF reabsorption, thereby perpetuating a vicious cycle. The authors sought to evaluate the role of the minimally invasive eShunt approach in IIH management. Methods A 50‐year‐old male patient with history of dyslipidemia and IIH initially presented 6 years ago with diplopia initially treated with poorly tolerated acetazolamide and periodic lumbar punctures with subsequent symptom improvement. The patient was admitted following rapid evolution of sudden onset horizontal diplopia and headache. Brain magnetic resonance revealed flattening of the posterior sclera, partially empty Sella Turcica, enhancement of the prelaminar optic nerves and enlarged Meckel´s cave. Lumbar puncture was performed with opening pressure of 28 cmH2O. Cerebral angiography with 3D venography confirmed bilateral transverse sinus stenosis, though without a significant pressure gradient. Results The patient declined surgical ventriculoperitoneal shunting and was approved for compassionate use of eShunt by regulatory and bioethics committees.He underwent successful endovascular transdural deployment of the eShunt, which he tolerated well and was discharged at 48 hours post‐procedure with rapid symptomatic headache relief. Upon 30‐day follow‐up repeat brain MRI showed improvement of the prominent subarachnoid space around both optic nerves and sustained improvement of his pre‐procedural headache and diplopia.A repeat lumbar puncture revealed a lowed opening pressure of 20 cmH2O and MRI cisternography confirmed maintained patency of the biomimetic valve with accumulation of Gadolinium‐enhanced CSF drainage through the eShunt into the jugular bulb. Conclusions The current report describes the first‐in‐human use of the eShunt device for treatment of IIH resulting in sustained symptomatic relief along with decrease in CSF pressure and pre‐laminar optic nerve edema. The current results, which require confirmation in a larger cohort with longer follow‐up, are encouraging and suggest a possible role for minimally invasive endovascular transdural eshunt placement in the management of IIH.

Changes in trauma-related cognitions predict subsequent symptom improvement during prolonged exposure in patients with childhood abuse-related PTSD

Change in negative posttraumatic cognitions is a proposed mechanism through which Prolonged Exposure (PE) leads to symptom reduction of posttraumatic stress disorder (PTSD). A strong case for posttraumatic cognitions as a change mechanism in PTSD treatment can be made by establishing temporal precedence of change in cognitions. The current study examines the temporal relationship between change in posttraumatic cognitions and PTSD symptoms during PE, using the Posttraumatic Cognitions Inventory. Patients with DSM-5 defined PTSD following childhood abuse (N = 83) received a maximum of 14–16 sessions of PE. Clinician-rated PTSD symptom severity and posttraumatic cognitions were assessed at baseline, week 4, 8, and 16 (post-treatment). Using time-lagged mixed effect regression models, we found that posttraumatic cognitions predicted subsequent PTSD symptom improvement. Notably, when using the items of an abbreviated version of the PTCI (PTCI-9), we found a mutual relationship between posttraumatic cognitions and PTSD symptom improvement. Crucially, the effect of change in cognitions on PTSD symptom change was greater than the reverse effect. The current findings corroborate change in posttraumatic cognitions as a change process during PE, but cognitions and symptoms cannot be completely separated. The PTCI-9 is a short instrument that appears suitable to track cognitive change over time.

ODP333 Mucosal-Associated Lymphoid Tissue Lymphoma: a Rare Condition in the Differential Diagnosis of a Parasellar Mass

Abstract The differential diagnosis for sellar and parasellar masses is broad and includes pituitary tumors, inflammatory lesions, meningioma, and lymphoma. In rare cases, the latter can manifest as extranodal marginal zone lymphoma of mucosa-associated lymphoid tissue (MALT)-subtype. We report a case of MALT-lymphoma presenting as a parasellar mass. A 68-year-old woman presented with several months of diplopia, cognitive slowing, and progressive balance issues. Brain MRI revealed a 4.6×2.3×1. 0 cm dural skull-based lesion extending from the left tentorium cerebelli to the left cavernous sinus and sella with mass effect on the optic chiasm and pituitary gland. Hormonal assessment revealed elevated prolactin at 93 ng/mL (NR 2.8-29.2) thought to be due to stalk effect. There were no abnormalities in other axes. CSF analysis demonstrated elevated protein (211 mg/dL, NR 15-45) and was negative for malignant cells. Due to the degree of cavernous sinus involvement, the mass was deemed surgically unresectable. Her PCP started dexamethasone 10mg daily for her neurologic symptoms, resulting in subsequent symptomatic improvement, reduction in mass size, and normalization of prolactin. However, she experienced weight gain, glucose intolerance, and fatigue, so dexamethasone was tapered and stopped after a 5-month course. Nine months later, she re-presented with symptoms of a sixth cranial nerve palsy. MRI demonstrated interval increase in mass size, protrusion into the left sella, and possible upward displacement of the pituitary. No pituitary hormone deficiencies were noted. Tumor biopsy and debulking revealed MALT-lymphoma. She received external beam radiation (200 cGy/fraction for 12 fractions) with improvement in symptoms and size of the mass. A PET-CT showed no evidence of other FDG-avid lesions. Follow-up MRI showed resolution of the mass with only minimal thickening along the left cavernous sinus. She continues to follow with Endocrinology post-radiation therapy for hormonal monitoring. Her pituitary axes have remained intact for 7 years. Steroid-responsive sellar and parasellar masses often invoke associations with inflammatory conditions such as sarcoidosis and idiopathic hypertrophic pachymeningitis. Lymphoma, and in particular MALT-lymphoma, also need to be considered in the differential diagnosis for these lesions. MALT-lymphomas of the central nervous system (CNS) tend to occur in women and arise from the dura. In one retrospective analysis, about 50% of cases occurred as primary lymphoma in the CNS while the remaining had systemic disease. Ten out of 13 subjects (77%) in a case series of primary CNS MALT-lymphoma had a complete response to surgery, chemotherapy, and/or radiation therapy. In a separate retrospective analysis, 3 out of 70 subjects (4.3%) experienced a recurrence over a median follow-up of 23 months after treatment. Given the importance of radiation therapy to the management of these tumors, Endocrinologic follow-up is essential given the increased risk of hypopituitarism after intracranial radiation. Presentation: No date and time listed

S2362 Paraneoplastic Mucous Membrane Pemphigoid: Not Your Typical Cause of Odynophagia

Introduction: Paraneoplastic Mucous Membrane Pemphigoid (MMP) is a rare inflammatory autoimmune disorder that primarily affects the oral, ocular and aerodigestive mucous membranes and is associated with an underlying malignancy. IgG, IgA, and C3 autoantibodies target basal membrane zones causing subepithelial blisters with erosive lesions in the mucosa. It is rarely seen in the clinical setting, with an incidence of 2-10 cases in 100,000 individuals. High clinical suspicion is needed in order to diagnose Paraneoplastic MMP presenting as odynophagia and dysphagia. Case Description/Methods: A 88 year old female presented with a 5 month history of worsening odynophagia, dysphagia to solids and liquids and a fifty pound weight loss. Physical examination was remarkable for diffuse erosive lesions of the oral mucosa, tense bullae on the soft palate, and bilateral temporal symblepharon along with inflammation of upper and lower eyelids. Laboratory workup demonstrated elevated Cancer Antigen-125 (574.20 U/mL). Immunofluorescence study of biopsies taken from esophageal mucosa, right lateral tongue lesions and the left inferior conjunctiva were remarkable for IgG, IgM, IgA interkeratinocytic deposits at lower level of the epidermis and C3 linear deposits at the dermoepidermal junction consistent with Paraneoplastic Mucous Membrane Pemphigoid. Chest-abdominal-pelvic computed tomography scan demonstrated an irregular enhancing right adnexal mass, intra-abdominal lymphadenopathy, left hemiabdomen omental metastatic deposits and bilateral pulmonary nodules. Computed tomography guided core biopsy of a left omentum deposit was remarkable for primary ovarian metastatic high grade serous carcinoma. Due to refractory odynophagia and dysphagia, intravenous Solumedrol was initiated with subsequent improvement of symptoms. Patient was discharged with multidisciplinary team follow up for chemotherapy initiation and Rituxan induction. Discussion: Paraneoplastic MMP is an uncommon autoimmune mucocutaneous disease diagnosed when there is presence of stomatitis, histologic features of acantholysis or interface dermatitis, demonstration of anti-plakin autoantibodies on biopsy, with an underlying neoplasm. Less than 500 cases have been reported where clinical features, presentation, and autoantibodies profiles have varied widely between patients highlighting the challenge of diagnosis. Early recognition of Paraneoplastic MMP presenting as odynophagia is difficult due to the overlap of symptoms in more prevalent conditions.

S2264 A Case of Progressive Untreated Eosinophilic Gastrointestinal Disorder Complicated by Eosinophilic Myocarditis

Introduction: Eosinophilic gastrointestinal diseases (EGID) are immune-mediated conditions characterized by GI dysfunction and histological evidence of eosinophilic infiltration. While usually confined to the GI tract, severe inflammation can involve multiple organ systems, typically under the umbrella term of hypereosinophilic syndrome (HES). Patients can present with cardiac involvement such as eosinophilic myocarditis which results in an uncommon, but potentially lethal complication. We present a case of a patient with prior history of eosinophilic esophagitis (EoE) subsequently presenting with diffuse EGID complicated by eosinophilic myocarditis. Case Description/Methods: A 63-year-old female with a history of EoE and breast cancer post mastectomy presented with acute epigastric and chest pain. The patient had biopsy-proven EoE which was managed with PPI in the past. On physical examination, she had diffuse abdominal tenderness. Labs were remarkable for peripheral eosinophilia peaking at 57%. Initial high sensitivity troponin I was 300 ng/L without EKG changes, and ultimately peaked at 7821 ng/L. CT of the abdomen and pelvis showed thickening of the stomach, duodenum, and jejunum. Left heart catheterization revealed LAD disease without obstructive disease. EGD demonstrated severe inflammation, erythema, and eosinophilic infiltration in the gastric body, antrum, and throughout the duodenum. High dose steroids were initiated with subsequent improvement in symptoms, serum troponin, and complete resolution of peripheral eosinophilia. Patient followed up as an outpatient, where cardiac MRI confirmed eosinophilic myocarditis, and she was started on Mepolizumab for maintenance therapy and prevention of relapse. Discussion: EGID are increasingly prevalent disorders that can result in significant morbidity and mortality without prompt diagnosis. This patient had a history of EoE and developed diffuse GI involvement and subsequent eosinophilic myocarditis. Her presentation as atypical chest pain suggestive of NSTEMI resulted in delay of initiation of steroids until after heart catheterization. Our case suggests that without glucocorticoid suppression, eosinophilia can cause widespread tissue infiltration and damage. The majority of these patients have chronic disease that require long term maintenance therapy. Mepolizumab has been demonstrated to be an effective agent for hypereosinophilic disorders. When managing EGID, it is pertinent to recognize early involvement of systemic eosinophilic infiltration.Figure 1.: EGD.

Delayed HSV-1 Encephalitis Relapse After Epilepsy Surgery: A Case Report

BACKGROUND AND IMPORTANCE: Herpes simplex virus 1 encephalitis (HSVE) can be a rare postoperative complication after neurosurgery. We present the case of a patient with postoperative, twice recurrent HSVE after 20 years, the longest latency period reported after neurosurgery. CLINICAL PRESENTATION: A 21-year-old man with a history of HSVE at 13 months and intractable epilepsy presented for surgical resection of seizure focus. The patient underwent left temporal craniotomy and resection of left temporal encephalomalacia. Five days after discharge, the patient presented with fever and headache and was found to have herpes simplex virus 1 (HSV-1)–positive cerebral spinal fluid. The infection was treated with acyclovir, with subsequent symptomatic improvement. Six weeks later the patient represented with recurrent symptoms and HSV-1–positive cerebral spinal fluid. This recurrence was treated with a prolonged course of acyclovir, followed by suppressive valacyclovir therapy, resulting in symptomatic improvement. CONCLUSION: HSV-1 encephalitis is a rare but previously reported complication after neurosurgery procedures. In patients with relapse of HSVE, the latency period can range from weeks to years after primary infection, and multiple relapses are rare. We present the case of a patient with twice recurrent, postoperative HSV-1 encephalitis 20 years after initial infection. We aim to emphasize that HSV status should be considered during treatment planning in patients with a history of HSVE being treated for HSV-related illnesses, and HSVE should remain on the differential in these patients when presenting with fever and neurological symptoms after surgery, regardless of time since initial infection.

Factors associated with treatment uptake, completion, and subsequent symptom improvement in a national digital mental health service

Digital mental health services (DMHS) have proven effectiveness and play an important role within the broader mental health system by reducing barriers to evidence-based care. However, improved understanding of the factors associated with successful treatment uptake, treatment completion and positive clinical outcomes will facilitate efforts to maximise outcomes. Previous studies have demonstrated that patient age is positively associated, and initial symptom severity negatively associated with treatment uptake and treatment completion rates in both DMHS and other mental health services. The current study sought to extend these findings by examining the effect of other patient characteristics, in particular, self-reported psychosocial difficulties, using data from a large-scale national DMHS. Using a prospective uncontrolled observational cohort study design, we collected self-reported demographic, psychosocial and clinical data from 15,882 patients who accessed the MindSpot Clinic, Australia, between 1 January and 31 December 2019. Using a series of univariate regression models and multivariate classification algorithms we found that older age, higher educational attainment, and being in a relationship were all positively associated with uptake, completion and significant symptom improvement, while higher initial symptom severity was negatively associated with those outcomes. In addition, self-reported psychosocial difficulties had a significant negative impact on uptake, completion, and symptom improvement. Consistent with previous literature, the presence of these characteristics in isolation or in combination have a significant impact on treatment uptake, completion, and symptomatic improvement. Individual and multiple psychosocial difficulties are associated with reduced capacity to participate in treatment and hence an increased treatment burden. Identifying patients with lower capacity to complete treatment, modifications to treatments and the provision of supports to reduce treatment burden may promote greater engagement and completion of treatments offered by digital mental health services.

Acute Hemiballismus as the Initial Manifestation of Ischemic Stroke: A Case Report.

IntroductionCerebrovascular disease often presents with “negative” symptoms such as weakness with reduced movement of body parts or sensory loss. Rarely do “positive” symptoms such as abnormal movements manifest in acute stroke, with hemichorea being a very rare manifestation.Case ReportThis is a case report of a 62-year-old chronic smoker with no known past medical history who presented with choreatic movements of his arm and leg. Magnetic resonance imaging of the brain showed changes consistent with an infarct in the right centrum semiovale. He was treated with dual antiplatelets and was noted to have subsequent improvement in symptoms.ConclusionRecognition and awareness of stroke presenting as movement disorders in the emergency department can help prevent delays in diagnosis and treatment.

Nivolumab Induced Multiple Endocrinopathies; Adrenal Insufficiency and Primary Hypothyroidism in a Patient With Stage IV Gastric Cancer - A Case Report

Introduction: Nivolumab is a revolutionary immune check point inhibitor (ICI) that changed the world of oncology. It prevents interaction of Program Death Receptor-1 (PD-1) and Program Death Ligand-1 (PD-L1) releasing a cascade of anti-tumor response. However, it has been associated with wide range of autoimmune side effects including gastrointestinal, hepatic, and endocrine side effects. The incidence of nivolumab induced endocrinopathies is relatively rare but increasingly reported. Adrenal insufficiency occurring in <1% of patients, hyperthyroidism in 15.3% and subclinical hypothyroidism in 4.2%. Case Presentations: 81 year old male with stage IV stomach cancer treated with Nivolumab. Prior to immunotherapy initiation, a set of baseline hormones was obtained and was within normal range. 6 months after, routine monitoring showed elevated thyroid stimulating hormone 6.33 mU/L and low FT4 0.59 ng/dL and FT3 0.1 ng/dL. Patient was started on thyroid replacement therapy. After 1 year of Nivolumab therapy, he presented with dizziness and orthostatic hypotension. Laboratory testing was remarkable for low sodium 130 mEq/L, which raised concerns for adrenal insufficiency. Subsequently, ACTH stimulation test showed low cortisol level 15 mcg/dL. Morning cortisol was also low 1.3 mcg/dL. Other pituitary hormones were normal. Patient was started on hydrocortisone with subsequent improvement of symptoms. Discussion: Nivolumab is a human monoclonal antibody that blocks PD-1 and turns off the tumor mediated immune system inhibition. In the meanwhile, ICI also disrupt normal immune signaling mechanisms that lead to decrease immune tolerance and autoimmune diseases. The mechanism of thyroid dysfunction due to ICI remains unclear. PD-1/PD-L1 blockade could induce thyroiditis by diminishing regulatory T cells function. Disruption of interaction between PD-1-expressing lymphocytes and PD-L-expressing thyrocytes –which protects the thyroid gland from autoimmunity– leads to infiltration of the thyroid with autoreactive T and B lymphocytes. Nivolumab induced Adrenal insufficiency is an extremely rare and unclear event, currently, there is no clear evidence that pituitary cells express PD-1. Recently, it was found that the PD-L1 and PD-L2 are expressed in mouse anterior and intermediate pituitary gland, but not the posterior pituitary. This suggests the possibility that specific injury can take place affecting only certain anterior pituitary cells, such as those producing ACTH. Awareness of such endocrinopathies is crucial. Patients should have certain baseline of laboratory data prior to therapy initiation and over the course of treatment. The risk of endocrinopathies is greater at the start of treatment, justifying closer monitoring every visit over the first 6 months, followed by regular monitoring every second visit over the next 6 months and less frequently thereafter.

Agency and alliance as change factors in psychotherapy.

This study examined the reciprocal effects between therapeutic agency, working alliance, and symptoms during psychotherapy. We aimed to predict symptom improvement by previous changes in either agency or alliance. In addition, we examined whether alliance development was predicted by previous changes in agency. A sample of 386 patients in psychodynamic outpatient psychotherapy answered the Therapeutic Agency Inventory (TAI), the Working Alliance Inventory-SR (WAI-SR), and the Symptom Checklist-K11 (SCL-K11) after Sessions 1, 5, 10, 15, and 20. Dynamic panel models were estimated using structural equation modeling. Associations were tested while controlling for autoregressive effects and differentiating within-person changes over time from between-person differences. Increases in agency predicted subsequent symptom improvement. Similarly, increases in alliance predicted subsequent symptom improvement. For agency and alliance, we found a more complex pattern with varying reciprocal effects over time. Findings show evidence for agency and alliance as curative change factors in psychodynamic psychotherapy. The study supports the importance of both agency and alliance and further suggests that both mechanisms may need to be balanced in successful psychotherapies. (PsycInfo Database Record (c) 2021 APA, all rights reserved).

Not Every Wheeze is Asthmatic: An Aspiration Pneumonia Case Report

Introduction: Wheezing in infants is an extremely common complaint, being markedly frequent in emergency services. Nonetheless, such a complaint is part of a wide spectrum of pathologies thus, demanding deeper investigation over the differential diagnosis must be addressed in an appropriate manner, in order to implement the necessary therapy as early as possible, and excessive intervention avoided, as much as possible Therefore, this case-report seeks to serve as a reminder of the importance of keeping a high suspicion on aspiration pneumonia even in previously healthy patients. The Case: HPDJ, male, date of birth (Dec, 30th of 2019), then 10 months and 10 days old, enters the medical emergency service of the pediatric hospital on November, 10th of 2020, with a report of flu-like symptoms that persisted for 10 days. The possibilities of bronchiolitis, pneumonia and SARS-COV 2 are questioned given the pandemic context, therefore being approached with salbutamol and prednisolone, chest x-ray and complementary exams. The patient is hospitalized, under regimen of ceftriaxone, salbutamol and general symptomatic medication. The patient is discharged 6 days after the first hospitalization with recovered general condition and without adventitious sounds or pathological findings on auscultation, being referred to the pulmonology outpatient clinic of the pediatric hospital. During outpatient follow-up, the patient complains of a feverish respiratory condition, and then the possibility of aspiration by a foreign body was questioned. On Dec, 09th, foreign body is removed, with subsequent improvement of symptoms in 48 hours. Conclusion: The maintenance of high clinical suspicion and attention to anamnesis are extremely important factors for the early diagnosis of less common causes of common complaints, such as aspiration of a foreign body in the face of a wheezing complaint, thus avoiding prolonged and not fully effective treatments, which can put the child at risk for more severe complications and worse prognosis.

Transcatheter Device Closure of Secundum Atrial Septal Defect in Adult Patient

Background:Atrial septal abnormalities are common congenital lesions remaining asymptomatic until adulthood in a great number of patients. The most frequent atrial septal defects in adults are ostium secundum atrial septal defect (ASD). Complications from untreated, hemodynamically significant ASD are atrial arrhythmia, paradoxical embolization, Eisenmenger’s syndrome, pulmonary hypertension, and right ventricular failure.Objective:We present a case report of secundum ASD in adult female patient who underwent transcatheter device closure with Amplatzer occluder.Methods and Results:The case of female Bosnian patient 50 years old who lives in Belgium for 20 years ago and during her visit to Bosnia she came to our polyclinic for cardiological exam. Echocardiographic exam showed enlargement of left atrium (LAD 51mm), right atrium and ventricle (RAD 46mm, RVd 33mm), atrial septal defect 9mm with left right shunt Qp:Qs 2,3:1. Several months later transcatheter device closure with Amplatzer occluder was performed and subsequent symptomatic improvement reported after closure.Conclusion:Echocardiography has superior role for precise evaluation of ASD type secundum who are suitable for transcatheter device closure as primary treatment option. Transcatheter techniques has now become preferable to surgical repair and provide valid option of treatment for this type of CHD.

UNMASKING CHRONIC COUGH AND ASTHMA: THE SILENT BODY

SESSION TITLE: Fellows Allergy and Airway Case Report Posters SESSION TYPE: Fellow Case Report Posters PRESENTED ON: October 18-21, 2020 INTRODUCTION: Foreign body aspiration is an emergency situation which requires early bronchoscopy. Most of the patients will recall the event, however it could be a surprising finding in bronchoscopy procedures. Symptoms include shortness of breath, fever, and hemoptysis. In this case, it presents as chronic cough with uncontrolled asthma for several years despite optimized therapy. CASE PRESENTATION: Case of a 52-year-old man with past medical history of GERD, partly controlled severe asthma and chronic persistent cough who presented with bloody sputum without shortness of breath, chest pain or palpitation. Initial evaluation at ER with evidence of right lower lobe infiltrate and was admitted for treatment of pneumonia. He also recognized recurrent episodes of bronchitis, and fever episodes in the last 48 hours. He presented 3 months prior to admission to the emergency department with cough and subjective fever, by which had a chest x ray showing linear and patchy densities at the right lung base, azithromycin was prescribed and discharge home respectively. On examination, vital signs were stable. Chest auscultation revealed mildly decreased breath sounds and rhonchi in the right lower lung field. Chest transverse axial computer tomography with a right basilar lung consolidation with air bronchograms and hyperdense filling defect in the right lower lobe bronchus. Chest computer tomography 3 year prior to admission had evidence of right sided infiltrate believe to be secondary to pneumonia that was treated at that time. In view of hemoptysis and persistent right lower lobe infiltrate a flexible bronchoscopy was performed that revealed significant erythema with a foreign body visualized in the right lower lobe with associated granulation tissue . Subsequent evaluation visits with improved chronic cough and asthma respectively after the successful retrieval. DISCUSSION: Foreign bodies may result in serious complications if left unrecognized. This complication includes recurrent pneumonia, lung abscess, bronchopleuralcutaneus fistulas, atelectasis, and bronchiectasis with mucus impaction . However, in the case of chronic aspiration, bronchoscopy may show features of tissue reaction to the foreign body, by which object could be found incarcerated and difficult to be seen. Granulation reactions could eventually lead to airway strictures, and subsequently airway distortion, by which could present with unilateral wheezes in physical examination. Its important to note that bronchoscopy is present in chronic cough management algorithm. CONCLUSIONS: Chronic cough and persistent asthma that does not respond to standard therapy is the key to suggest a foreign body aspiration. Chronic cough is the most common symptom and is present in two-thirds of patients with foreign body aspiration. For that purpose, it’s important an early suspicion for a successful detection and a subsequent improvement of symptoms. Reference #1: Irwin RS, Madison JM. The diagnosis and treatment of cough. N Engl J Med. 2000;343:1715–21. Reference #2: Irwin RS, Boulet LP, Cloutier MM, Fuller R, Gold PM, Hoffstein, et al. Managing cough as a defense mechanism and as a symptom. A consensus panel report to the American College of Chest Physicians. Chest. 1998;114(2 suppl):133–81S. Reference #3: Al-Majed SA, Ashour M, Al-Mobeireek AF, Al-Hajjaj MS, Alzeer AH, Al-Kattan K. Overlooked inhaled foreign bodies: late sequelae and the likelihood of recovery. Respiratory Medicine. 1997;91(5):293–296. DISCLOSURES: No relevant relationships by Christian Castillo Latorre, source=Web Response No relevant relationships by Ilean Lamboy, source=Web Response No relevant relationships by Mariana Mercader-Pérez, source=Web Response No relevant relationships by William Rodriguez-Cintron, source=Web Response No relevant relationships by Jose Torres-Palacios, source=Web Response

Orbital complications in sickle cell disease: a case report presentation

Our report describes a child with sickle-cell anemia presenting with left-sidedperiorbital swelling, headache, elevated leukocytes and inflammatory markers, discovered to have orbital bone infarction. Initial treatment included antibiotics for presumed infection. As MRI orbit suggested infarction of the orbital bone, exchange transfusion and steroid course was administered with subsequent improvement of symptoms. This case demonstrates that although infectionisa more common etiology of periorbital edema in sickle-cell disease, maintaining the differential of orbital bone infarction is crucial as patient out comes depend on prompt intervention. Caution is advised when treating these patients with steroids given risk of rebound pain.

T-Cell Lymphoma Misdiagnosed as Crohn’s Disease: Case Report

Abstract For many years, there has been a concern that inflammatory bowel disease carries an increased lymphoma risk. At the same time, patients with intestinal lymphomas are occasionally misdiag-nosed as having Crohn’s disease. We report a case of T-cell lymphoma of the bowel misdiag-nosed as Crohn’s disease, which illustrates the diagnostic challenges posed by peripheral extranodal lymphomas. A 68-year old female presented with clinical symptoms (diarrhoea, abdominal pain, poor appetite and significant weight loss), and colonoscopic and initial histological findings that were similar to inflammatory bowel disease. She was diagnosed with Crohn’s disease and received treatment with sulfasalazine with subsequent improvement of symptoms. Eight months after the initial diagnosis the patient experienced sudden abdominal pain. Laparotomy revealed necrosis in the small and large intestine and ileostomy was performed. On day 10 of a complicated postoperative period the patient died. Post-mortem histopathological examination of small and large intestine revealed highly malignant peripheral T-cell lymphoma, not otherwise specified. Differentiation of intestinal T-cell lymphoma from Crohn’s disease continues to be a challenge, because clinical, colonoscopic, radiological and histopathological findings can mimic Crohn’s disease. Careful multi-disciplinary assessment and knowledge of this rare disorder is crucial for timely diagnosis.

Investigating the Role of Interpretation Bias in Mindfulness-Based Treatment of Adults With Generalized Anxiety Disorder.

Although mindfulness-based interventions (MBIs) have garnered empirical support for a wide range of psychological conditions, the psychological processes that mediate the relationship between MBIs and subsequent symptomatic improvement are less well-understood. In the present study we sought to examine, for the first time, the relationship between mindfulness, negative interpretation bias as measured by the homophone task, and anxiety among adults with Generalized Anxiety Disorder (GAD). Forty-two individuals with GAD completed measures of mindfulness, interpretation bias, and anxiety before and after treatment with Mindfulness-based Stress Reduction (MBSR). Contrary to prior research, we did not find evidence of an indirect relationship between baseline levels of mindfulness and anxiety via negative interpretation bias. MBSR did result in significant reductions in negative interpretation bias from baseline to post-treatment; however, we did not find evidence of an indirect relationship between changes in mindfulness and changes in anxiety via changes in interpretation bias. Taken together, these results provide minimal support for the hypothesized relationship between mindfulness, negative interpretation bias, and anxiety among adults with GAD. Limitations and specific suggestions for further inquiry are discussed.