Vigilant Care Research Articles

Bipolar Disorder: A Comprehensive Analysis of its Etiology, Impact, and Treatment Options

Bipolar disorder (BD) is a disorder significantly impacts individuals worldwide, marked by alternating episodes of mania and depression. The onset and progression of the disease are impact by a interplay of genetic factors, neurobiological differences, environmental stressors, hormonal imbalances, and circadian rhythm disruptions. These factors collectively contribute to the manifestation and exacerbation of the disorder. The disorder profoundly affect both mental and physical health. The pervasive impact on daily life can be overwhelming, resulting in severe emotional distress. This distress is compounded by the high risk of suicide associated with the disorder, underscoring the critical need for vigilant care and comprehensive support to ensure the well-being of affected individuals. Effective treatment requires a holistic approach combining pharmacological interventions, psychotherapy, and lifestyle adjustments. Mood stabilizers, antipsychotics, and antidepressants, alongside Cognitive Behavioral Therapy (CBT), psychoeducation, and family therapy, form the cornerstone of treatment. Lifestyle modifications, including regular exercise, adequate sleep, and balanced nutrition, are crucial for symptom management. Electroconvulsive Therapy (ECT) is considered for severe cases. This review underscores the need for continuous research and innovation in therapeutic strategies and emphasizes bridging global disparities in mental health services to ensure equitable care and improve the well-being of people with bipolar disorder.

Utility of DECAF Score as A Bed Side Tool in Predicting Outcomes in Patient with Acute Exacerbation of Chronic Obstructive Pulmonary Disease

Background Acute exacerbations of chronic obstructive pulmonary disease (AECOPD) can be fatal. It is the third leading cause of death worldwide, causing 3.23 million deaths in 2019. The DECAF (Dyspnea, Eosinopenia, Consolidation, Acidemia, Atrial Fibrillation) score is a widely used system for predicting the survival of patients with AECOPD. It uses Routinely available indices, is quick and can be easily used by clinicians to identify sick patients who need vigilant care. MethodsA cross sectional study was conducted at College of Medical Sciences Teaching Hospital, Bharatpur for 6 months. Patients with COPD meeting inclusion Criteria were selected and the DECAF score at time of admission was calculated. Their duration of hospital stay, use of ventilator and final outcome were noted and its relation to the Decaf score was analysed. ResultsA total of 163 patients (Male-87, Female-76) were included in the study. The mean age of the patients was 70 ±10 years and mean duration of hospital stay was 5.91±2.19 days. There is significant relationship between DECAF score and the mortality (p-value < 0.001) with higher the score higher the chance of not improving. Analysis between the DECAF score and length of Hospital stay by regression equation found the regression coefficient 0.410 to be significant (p-value < 0.001) indicating that if DECAF score increases by one, the length of hospital stay will also increases by 0.41 day.Conclusions Patients with a DECAF score of four or higher have a significant risk of mortality as well as long duration of hospital stay. Thus, DECAF is a simple tool that incorporates routinely available indices to predict adverse outcomes in AECOPD.

Challenges of physiotherapy service on a patient with cystic fibrosis and severe pulmonary exacerbation and put on extracorporeal membrane oxygenation: A case report

A 14-year-old male with cystic fibrosis (CF) and severe pulmonary exacerbation was put on venovenous extracorporeal membrane oxygenation (VV-ECMO) and mechanical ventilator. This case report is to share the challenges and vigilant care on service delivery of physiotherapy services faced and gone through at a pediatric intensive care unit of a quaternary care children’s hospital. Sputum clearance technique was provided in the coexistence of VV-ECMO and mechanical ventilator. Inspiratory muscle training and physical rehabilitation commenced at the phase of progressive weaning from noninvasive ventilation. The total intervention duration was 40 days; the lung sound and chest X-ray were cleared up, and the physical tolerance was improved to walking with light assistance. Airway clearance and physical rehabilitation in CF on VV-ECMO are achievable with alertness and alternatives with careful observance. Although ECMO may hinder the efficacy of sputum clearance, cautious and safe-guarded physiotherapy techniques can influence outcomes.

Fenestration: Integrating Wings Into the Atrial Septal Occluder for Navigating a Challenging Terrain.

Background Atrial septal defect (ASD) closure with significant left-to-right shunt and concurrent comorbidities poses challenges for intervention. A fenestrated atrial septal defect (FASD) device is a viable option for patients who cannot undergo complete occlusion due to hemodynamic and medical reasons. This study explores the use of FASD occluders in patients with secundum ASD and associated comorbidities where complete occlusion is difficult. Methodology This retrospective study collected the details of patients recommended for FASD closure diagnosed with significant secundum ASD and who had additional comorbidities between July 2015 and July 2023 in a tertiary cardiac center in eastern India. Among this cohort, patients who underwent FASD device placement were subjected to a comprehensive analysis. Results In total, 16 patients diagnosed with secundum ASD, characterized by significant left-to-right shunt and concurrent comorbidities, were considered for FASD closure during the study period. Ultimately, 13 patients (first group) underwent fenestrated atrial septal occluder implantation. The average age was 45.07 years, with the majority being females (n = 9). Comorbidities among this cohort included substantial left ventricular diastolic dysfunction (n = 7), left ventricular diastolic dysfunction coupled with moderate pulmonary hypertension (n = 1), severe pulmonary hypertension (n = 1), severe pulmonary valvular stenosis with right ventricular diastolic dysfunction (n = 2), and systemic lupus erythematosus (SLE) (n = 2). From this cohort, three patients did not undergo the intervention. The second group consisted of an elderly patient with severe left ventricular diastolic dysfunction, a young adult with a history of left atrial arrhythmia, and achild with Duchenne muscular dystrophy (DMD). The average ASD size among patients who underwent the intervention was 26.38 mm, with a thick-to-thick dimension measuring 31.15 mm. The procedure was successful in all 13 patients, with the most frequently used device being a 34 mm occluder (range = 28-40 mm). All devices, excluding the initial one, were custom-made atrial septal occluders (Lifetech Scientific). Among the patients, 12 exhibited left-to-right fenestration flow, while one patient experienced fenestration constriction, likely due to occluder overcrowding. The first patient hada handmade 5 mm fenestration in a 40 mm Amplatzer septal occluder, which got closed off at the one-year follow-up. The procedure was well-tolerated hemodynamically in all patients, with no major complications during the peri-procedural period. Short-term follow-up indicated favorable patient progress. Conclusions FASD closure emerges as a pivotal alternative for intricate scenarios involving secundum ASD coupled with concurrent comorbidities, offeringindividualized tailored solutions. Alongside the conventional associated comorbidities, such as left ventricular diastolic dysfunction and pulmonary hypertension, FASD devices hold the potential to extend their benefits to patients grappling with other complexities, including severe pulmonary valvular stenosis, SLE, predisposition to left atrial arrhythmia, and conditions like DMD. Ensuring meticulous evaluation of patient suitability and providing ongoing vigilant care becomes paramount for achieving optimal outcomes. The validation of these findings and the broadening of the comprehension of this approach necessitate further comprehensive investigations.

Prevalence and Cardiovascular Risk Factors Associated with Obesity/ Overweight in Adult Patients Living with HIV/AIDS: Case of the Makokou Outpatient Treatment Center, Ogooué-Ivindo, North-Eastern Gabon

Background: Designed to fight HIV/AIDS, antiretroviral drugs (ARVs) may be responsible for certain cardiometabolic abnormalities in people living with HIV (PLWHIV). To this end, the present study evaluates the prevalence and impact of obesity/overweight on the development of cardiovascular risk factors in patients at the outpatient treatment center (CTA) of Makokou, in the Ogooué-Ivindo region, North-eastern Gabon.
 Materials and Methods: This is a cross-sectional and descriptive study, based on a retrospective analysis of the records of patients followed at the HIV/AIDS outpatient treatment center of Makokou from December 2015 to December 2020. A structured questionnaire was used to collect data such as age, gender, socio-economic level, daily habits such as alcohol consumption, tobacco consumption, and physical exercise. Other epidemiological parameters such as body mass index (BMI), and CD4 count were measured.
 Results: A total of 165 people living with HIV (PLHIV), the majority of whom were between 41 and 60 years of age (60.60%). treated with antiretrovirals from December 2016 to December 2021 were collected for this study. With a sex ratio (F/M) of 3.58, women (78.2%) were in the majority compared to men. The mean age was 51 ± 13 years. While 95.8% of the patients were from the different departments of the province of Ogooué-Ivindo, the remaining patients (4.8%) were from other provinces such as Estuaire, Haut-Ogooué or Ogooué-Lolo. Civil servants represented 21%. The self-employed represented 29%, and the unemployed represented 50%. Only 34% of the participants in the study, the majority of whom were women, engaged in regular physical activity. 5.4% of the patients, mostly men, were active smokers. 34%, especially women, consumed alcohol. 20% of the PLWHIV had a medical history of type 2 diabetes mellitus or hypertension (HTA), and the majority were female. 5.4% of the declared hypertensives were on treatment. 7.8% of the hypertensive patients were discovered in consultation. The remainder were normotensive (86.8%). A significant difference in hypertension was observed in patients aged between 41 and 60 years ( p= 0.0029*). The data revealed a positive correlation index (r=0.19) between BMI and hypertension. All the therapeutic combinations with which the patients were treated contained NRTIs, of which the most used were tenofovir disoproxil (TDF) 66.67% and lamivudine (3TC) 33.33% and finally the most used NRTI was Efavirenz (EFV) 76.36%. After 5 years of treatment, 89 PLWHIV ( 53.93%), had CD4 count ≥ 500 cells/mm3. 53 PLWHIV (32%) had CD4 count ranging from 200 - 499 mm3 and thus moderate immune deficiency and with CD4 count < 200 cell /mm3, 23 PLWHIV (14%) had severe immune deficiency. HIV-infected patients under 40 years of age had a mean CD4 count of 412 cell/mm3, which was lower than that of patients 40 years of age and older, which was 556 cell/mm3. It was noted that after 5 years, treatment with ARVs was significantly associated with an increase in BMI among PLHIV, (P=0.0210). It was indicated that the increase or decrease of CD4 count in PLWHIV, depended on BMI, after 5 years of ARV treatment.
 Conclusion: This study confirms the existence of an increase in overweight and obesity in people living with HIV/AIDS under antiretroviral treatment. It also shows that obesity had an impact on the development of certain cardiovascular risk factors in these people, which require careful vigilance of the health personnel on their weight gain, due to lipidic parameters such as cholesterol, HDL, Triglycerides.

ISOLATED RETINAL VASCULITIS: Prognostic Factors and Expanding the Role of Immunosuppressive Treatment in Retinal Vasculitis Associated With Positive QuantiFERON-TB Gold Test.

To identify prognostic factors for poor visual outcomes in patients with isolated retinal vasculitis and to elucidate the outcome of immunosuppressive treatment without the use of antituberculosis drugs for patients with retinal vasculitis associated with a positive QuantiFERON-TB Gold In-Tube (QFT) test. A retrospective chart review was performed of patients presenting with retinal vasculitis. After the diagnosis of active retinal vasculitis had been confirmed by fluorescein angiography and other possible causes of retinal vasculitis had been excluded, patients were categorized into two groups by their QFT result. Potential associated factors between the poor and good visual outcome groups were statistically analyzed by the chi-square test and logistic regression model with generalized estimating equations. Seventy-three eyes (48 patients) were enrolled in this study. After univariate analysis, multivariate logistic regression analysis was performed and revealed that logMAR visual acuity at the initial visit ( P = 0.01) and outer retinal disruption ( P = 0.03) were the two factors significantly associated with poor visual outcomes. Systemic corticosteroids were administered without the use of antituberculosis drugs to all 16 cases of presumed tuberculous retinal vasculitis associated with positive QFT (26 eyes), 10 (63%) of whom were given nonsteroidal immunosuppressive drugs and achieved inflammatory control and treatment success. Risk factors leading to poor visual outcome in patients with isolated retinal vasculitis have been identified. Immunosuppressive treatment without antituberculosis drugs seems to be a promising regimen for selected patients with presumed tuberculous retinal vasculitis under vigilant care.

INCREASING TRENDS AND UNFAVORABLE OUTCOMES OF ACUTE KIDNEY INJURY AMONG PATIENTS WITH PULMONARY HYPERTENSION: A NATIONWIDE ANALYSIS

SESSION TITLE: PAH with ComplicationsSESSION TYPE: Rapid Fire Original InvPRESENTED ON: 10/17/2022 12:15 pm - 1:15 pmPURPOSE: Cardiorenal syndrome is an established risk factor for acute kidney injury (AKI). No contemporary data is available for assessing pulmonary hypertension as an independent risk factor for AKI. We aimed to identify the burden, trends, and outcomes of AKI in pulmonary hypertension hospitalized patients.METHOD: Using National Inpatient Sample (2016-2019, ICD10 codes), we identified hospitalizations with pulmonary heart disease and diseases of pulmonary circulation (PHDPC, 18-90 years) and divided them into AKI and non-AKI. Odds and yearly trend of AKI in PHDPC, demographics, comorbidities, and outcomes for hospitalization between 2 cohorts were analyzed.RESULTS: PHDPC (6,000,000) hospitalizations had 28.3% AKI. Odds of AKI for PDHPC were significantly higher on univariate (OR 2.46, 95CI 2.44-2.48) and multivariate (OR 1.15, 95CI 1.14-1.16) analysis. AKI increased from 23% in 2016 to 27.2% in 2019 in PDHPC (ptrend<0.001). AKI patients were significantly older (mean, 71.3 vs 68.1 years), had higher proportion of males (47.7 vs 42.5%), blacks (20.8 vs 18.4%), Medicare-enrollees (75.1 vs 69.6%), large, urban-teaching, Midwest and West region hospitalizations, non-electively admissions than non-AKI. AKI cohort had significantly higher hyperlipidemia, obesity, prior CABG/MI/PCI, CHF, arrhythmia, valvular disease, PVD, complicated hypertension, neurological disorders, complicated diabetes, hypothyroidism, renal failure, liver disease, peptic ulcer disease, lymphoma, coagulopathy, weight loss, fluid/electrolyte disorders, blood loss anemia, deficiency anemia, and alcohol abuse. All-cause mortality (10.2 vs 3.3%), LOS (mean, 9.2 vs 5.8 days), adjusted charges (median, 64158 vs 41910 USD) were significantly higher in AKI than non-AKI. Univariate (OR 3.38, 95CI 3.32-3.45) and multivariate (OR 2.53, 95CI 2.48-2.58) analysis revealed significantly higher odds of mortality in AKI than in non-AKI in PDHPC (ptrend<0.001).CONCLUSIONS: Nearly one-fourth PDHPC present with concurrent AKI and worsening renal function.CLINICAL IMPLICATIONS: Increased risk of AKI in PDHPC, with poor outcomes, warrants extra vigilant care for patients having concomitant risk factors for AKI.DISCLOSURES: No relevant relationships by Thomas Alukalno disclosure on file for Shilp Arora;no disclosure on file for Behnam Bozorgnia;No relevant relationships by Rupak DesaiNo relevant relationships by Sohiel DeshpandeNo relevant relationships by Akhil JainNo relevant relationships by VIRALKUMAR PATEL SESSION TITLE: PAH with Complications SESSION TYPE: Rapid Fire Original Inv PRESENTED ON: 10/17/2022 12:15 pm - 1:15 pm PURPOSE: Cardiorenal syndrome is an established risk factor for acute kidney injury (AKI). No contemporary data is available for assessing pulmonary hypertension as an independent risk factor for AKI. We aimed to identify the burden, trends, and outcomes of AKI in pulmonary hypertension hospitalized patients. METHOD: Using National Inpatient Sample (2016-2019, ICD10 codes), we identified hospitalizations with pulmonary heart disease and diseases of pulmonary circulation (PHDPC, 18-90 years) and divided them into AKI and non-AKI. Odds and yearly trend of AKI in PHDPC, demographics, comorbidities, and outcomes for hospitalization between 2 cohorts were analyzed. RESULTS: PHDPC (6,000,000) hospitalizations had 28.3% AKI. Odds of AKI for PDHPC were significantly higher on univariate (OR 2.46, 95CI 2.44-2.48) and multivariate (OR 1.15, 95CI 1.14-1.16) analysis. AKI increased from 23% in 2016 to 27.2% in 2019 in PDHPC (ptrend<0.001). AKI patients were significantly older (mean, 71.3 vs 68.1 years), had higher proportion of males (47.7 vs 42.5%), blacks (20.8 vs 18.4%), Medicare-enrollees (75.1 vs 69.6%), large, urban-teaching, Midwest and West region hospitalizations, non-electively admissions than non-AKI. AKI cohort had significantly higher hyperlipidemia, obesity, prior CABG/MI/PCI, CHF, arrhythmia, valvular disease, PVD, complicated hypertension, neurological disorders, complicated diabetes, hypothyroidism, renal failure, liver disease, peptic ulcer disease, lymphoma, coagulopathy, weight loss, fluid/electrolyte disorders, blood loss anemia, deficiency anemia, and alcohol abuse. All-cause mortality (10.2 vs 3.3%), LOS (mean, 9.2 vs 5.8 days), adjusted charges (median, 64158 vs 41910 USD) were significantly higher in AKI than non-AKI. Univariate (OR 3.38, 95CI 3.32-3.45) and multivariate (OR 2.53, 95CI 2.48-2.58) analysis revealed significantly higher odds of mortality in AKI than in non-AKI in PDHPC (ptrend<0.001). CONCLUSIONS: Nearly one-fourth PDHPC present with concurrent AKI and worsening renal function. CLINICAL IMPLICATIONS: Increased risk of AKI in PDHPC, with poor outcomes, warrants extra vigilant care for patients having concomitant risk factors for AKI. DISCLOSURES: No relevant relationships by Thomas Alukal no disclosure on file for Shilp Arora; no disclosure on file for Behnam Bozorgnia; No relevant relationships by Rupak Desai No relevant relationships by Sohiel Deshpande No relevant relationships by Akhil Jain No relevant relationships by VIRALKUMAR PATEL

Sodium–Glucose Cotransporter-2 Inhibitor–associated Euglycemic Diabetic Ketoacidosis: Lessons From a Case Series of 4 Patients Undergoing Coronary Artery Bypass Grafting Surgery

BackgroundEuglycemic diabetic ketoacidosis (DKA) is a potentially life-threatening adverse condition associated with use of sodium–glucose cotransporter-2 inhibitors (SGLT2i). This risk is further pronounced in the perioperative period. There is no consensus for when SGLT2i should be held preoperatively, and recommendations from various organizations have evolved from 1 day to 3 to 4 days in the latest American Diabetes Association guidelines. Further study of patients with perioperative euglycemic DKA is required to help clarify the optimal timing of preoperative discontinuation of SGLT2i agents. MethodsIn this retrospective, single-centre case series we examined 4 patients who developed postoperative euglycemic DKA after coronary artery bypass grafting, 3 of whom underwent semiurgent surgery. We characterized their clinical course, predisposing factors and treatment characteristics. ResultsThe SGLT2i were held for 1 to 5 days preoperatively, with times since last dose before surgery being 54, 79, 80 and 151 hours. Surgery was semiurgent for 3 patients, and elective for 1 patient. Three patients were diagnosed with euglycemic DKA within 24 hours after surgery. The fourth patient developed euglycemic DKA on postoperative day 3 in the context of significant hypovolemia and exhibited potential signs of protracted SGLT2i action at 7 days since the last dose. ConclusionsThe duration of SGLT2i action and risk for DKA is variable and complex. Providers should hold SGLT2i at least 3 days before elective major surgery, with potentially longer times in high-risk patients. Careful vigilance should be used for perioperative DKA development in all patients recently exposed to SGLT2i.

MEDB-04. Young children with metastatic medulloblastoma: frequent requirement for radiotherapy in children with non-WNT/non-SHH medulloblastoma despite highly intensified chemotherapy – Results of the MET-HIT2000-BIS4 trial

PURPOSE: To assess outcomes and biological parameters of children younger than 4 years with metastatic medulloblastoma treated within the MET-HIT2000-BIS4 trial or outside the protocol. PATIENTS AND METHODS: 48 trial participants received either carboplatin/etoposide (years 2001 to 2005, n=18) or an intensified Head-Start-based induction (years 2006 to 2011, n=30), both groups with intraventricular methotrexate, followed by high-dose chemotherapy (HDCT) and/or craniospinal radiotherapy (CSI). In an extended cohort, data of 58 additional were grouped with trial participant data. RESULTS: Trial participants (n=48): After intensified induction, both response (26/27 vs. 10/17 eligible patients, p=0.003), and progression-free survival (PFS, 5-year-PFS (5y-PFS): 57% vs 28%, p=0.014) was higher after intensified induction. However, CSI- /progression-free survival (CSIfPFS) was low (5-year CSIfPFS 17%). Biological subtype influenced 5y-CSIfPFS with 3% in non-WNT/non-SHH medulloblastoma vs. 58% in SHH-medulloblastoma (p<0.001), independent of induction regimens. Extended cohort (n=48 on trial and n=58 off trial): Non-WNT/non-SHH medulloblastoma (n=74, all treated in analogy to the MET-HIT2000-BIS4 protocol): Most frequent subtypes were II (5y-PFS 0%, 5y-OS 7%, n=21) and IV (5y-PFS 55%, 5y-OS 57%, n=16). 5y-CSIfPFS was only 8% [n=5]. Among patients in CR (n=13) or PR (n=10), who received HDCT but not CSI in primary therapy, only 5 were CSI-free survivors (CR: n=4/PR: n=1; Subtype III: n=1, Subtype IV: n=2, non-WNT/non-SHH by histology: n=2). SHH-medulloblastoma (n=32, treated with MET-HIT2000-BIS4 [n=16] or HIT2000-BIS4/HIT-SKK chemotherapy [with intrventricular methotrexate, without HDCT; n=16]): 5y-PFS (72%) and 5y-CSIfPFS (69%) did not differ according to therapy or SHH-subgroups. Two therapy-related deaths occurred on MET-HIT2000-BIS4 therapy. Relapses were more frequent after HIT-SKK (p=0.083). CONCLUSIONS: Despite maximally intensified chemotherapy, patients with metastatic non-WNT/non-SHH medulloblastoma almost always require craniospinal radiotherapy to survive their disease. In SHH-activated medulloblastoma, HDCT might better control the disease but careful vigilance of toxicity is important.

Recurrence of tubercular choroiditis following anti-SARS-CoV-2 vaccination.

PurposeTo report recurrence of tubercular choroiditis following anti-SARS-CoV-2 vaccination in two patients with quiescent disease activity for more than a year.MethodsRetrospective observational case reports.ResultsTwo patients (one female and one male) under follow-up for posterior uveitis having stable course with absence of ocular inflammation for more than a year presented with recurrence of choroiditis lesions 2–6 weeks following anti-SARS-CoV-2 vaccination. Both the patients were managed with intravitreal dexamethasone implant (Ozurdex®, Allergan, Inc., Irvine, CA, USA) and showed resolution of choroiditis lesions upon follow-up.ConclusionsAcute onset recurrence of inflammation, in absence of any change in health status or treatment suggests the potential role of vaccination being the trigger of this reactivation. Given large-scale vaccination against novel coronavirus- SARS-CoV-2, careful vigilance is warranted to pick up the disease recurrence in patients with posterior uveitis.

Health-Related Quality of Life in 91 Patients with X-Linked Agammaglobulinemia.

X-linked agammaglobulinemia (XLA) is a primary immunodeficiency (PID) caused by a defect in the gene encoding for Bruton tyrosine kinase (BTK). In the absence of a functional BTK, patients have low or absent circulating B cells and low or absent serum immunoglobulin. Despite gammaglobulin replacement and prompt use of antimicrobial agents, patients with XLA continue to experience infectious and non-infectious complications throughout their lifetime. The purpose of this study was to understand self-perceived health status of US-based patients with XLA, and examine the associations amongst clinical characteristics, treatment experience, and quality of life (QoL). A 46 and 68 question survey, developed by the Immune Deficiency Foundation (IDF) and a Short Form-12item v2® (SF-12v2®) for adults and SF-10™ for children to assess QoL, were mailed by IDF to patients in 2017 and 2018. Those that self-identified as having XLA or males with agammaglobulinemia were selected for analysis. Mean physical and mental composite scores (PCS and MCS) from SF-12v2® and mean physical health component (PHS) and psychological health summary (PSS) from SF-10™ scores were compared to the US normative data. Ninety-one patients completed the surveys: 58 (63.7%) adults and 33 (36.3%) children. For the combined surveys, the overall median age at time of the survey was 28.5years (yrs); Inter-Quartile-Range (IQR) 13-49.5 yrs; the median age at diagnosis was 2 yrs(IQR = 0-4yrs) and the median number of years with XLA diagnosis was 23 (IQR 10.75-40yrs). Amongst adult patients, physical scores were noted to be below the general adult population but did not reach statistical significance. In contrast, 2 or more chronic conditions impacted both physical and mental QoL (p < .001) and hospitalization was associated with significantly decreased physical health QoL (p < .001); three or more infections in the past 12months exhibited impact on physical health although was not found to be statistically significant. Adult patients with public insurance fared worse in mental health domains compared to those with combined public and private or those with private alone (p = 0.001). Employment status did not impact QoL. None of these variables met statistical significance nor demonstrated impact within the pediatric population in either physical or mental domains of health. Our study provides further insight into what factors impact both physical and mental domains of health amongst patients with XLA. Early detection to prevent the development of associated morbidity, as well as vigilant care to prevent hospitalizations and infections, can limit the impact this disease may have on the overall well-being of XLA patients.

346 Accuracy of Tympanic Versus Digital Infra-Red Thermometers for Measuring Core Body Temperature in Critical Care Department - a Quality Improvement Project During Covid-19 Redeployment at a District General Hospital in Surrey, England

Abstract Aim Accurate determination of core body temperature in critically ill patients is required for initiating diagnosis and management. (1) Ideally, temperature measurement should be non-invasive, hygienic, convenient, and affordable. Infrared thermometers are convenient and non-invasive but sensitive to environmental factors. Alternatively, tympanic thermometers are cost effective but invasive. Various observational studies have concluded that tympanic thermometers have high specificity/sensitivity compared to infrared thermometers (2,3). We aimed to demonstrate accuracy of tympanic over infrared thermometers. Method In this observational prospective study, eighty patients (forty each) admitted in intensive care from February 2021 – July 2021 were included. Temperature measurements with were conducted - measuring differences between digital and tympanic thermometers. A Plan Do Study Act cycle was used to facilitate change. Excel and SPSS software were used for data analysis. Results Our study concluded a statistically significant (p&amp;lt;0.01) difference in readings with mean difference of 1.18°C (highest -6°C, lowest- 0.5°C). Pyrexia was undetected in 4 of 40 patients with digital thermometers. Additionally, two patients undergoing hypothermia correction were not adequately measured. Therefore, infrared thermometers were significantly less sensitive and were replaced with tympanic thermometers. A second cycle conducted again demonstrated significant (p&amp;lt;0.01) difference with mean difference of 1.92°C. (highest -6.5°C, lowest -1°C). Conclusions Tympanic thermometers have higher accuracy and precision over digital thermometers. We managed to establish change during our audit with concluding evidence showing infrared thermometers procure false observations affecting patient care, hence, unsafe. In conclusion, tympanic thermometers should be encouraged in critical care settings for vigilant care.

Antimicrobial Resistance in Nosocomial Isolates of Gram-Negative Bacteria: Public Health Implications in the Latvian Context.

Antimicrobial resistance (AMR) is one of the most serious threats in modern medicine which requires the constant monitoring of emerging trends amongst clinical isolates. However, very limited surveillance data is available in the Latvian context. In the present study, we conducted a retrospective analysis of microbiological data from one of the largest public multispecialty hospitals in Latvia from 2017 to 2020. AMR trends for 19 gram-negative bacterial (GNB) genera were investigated. During the study period, 11,437 isolates were analyzed with Escherichia spp. (34.71%), Klebsiella spp. (19.22%) and Acinetobacter spp. (10.05%) being the most isolated. Carbapenems like Meropenem and Ertapenem were the most effective against GNBs (3% and 5.4% resistance rates, respectively) while high resistance rates (>50%) were noted against both Ampicillin and Amoxicillin/Clavulanic acid. Enterobacter spp. and Klebsiella spp. showed a significant increase in resistance rate against Ertapenem (p = 0.000) and Trimethoprim-Sulfamethoxazole (p = 0.000), respectively. A decrease in the prevalence of Extended-Spectrum Beta-Lactamase positive (ESBL+) Enterobacterales was noted. Despite the lower prescription levels of the penicillin group antimicrobials than the European average (as reported in ESAC-Net Surveillance reports), GNBs showed high average resistant rates, indicating the role of ESBL+ isolates in driving the resistance rates. Constant and careful vigilance along with proper infection control measures are required to track the emerging trends in AMR in GNBs.

Long-term effect of tocilizumab in patients with giant cell arteritis: open-label extension phase of the Giant Cell Arteritis Actemra (GiACTA) trial.

The combination of tocilizumab plus a glucocorticoid taper is effective in maintaining clinical remission without requiring additional glucocorticoid therapy in patients with giant cell arteritis, as shown in part one of the Giant Cell Arteritis Actemra (GiACTA) trial. However, the duration of the tocilizumab effect after discontinuation is unknown. Here, we explored the maintenance of efficacy 1 year after discontinuation of tocilizumab treatment, the effectiveness of retreatment with tocilizumab after relapse, and the long-term glucocorticoid-sparing effect of tocilizumab. In part one of the GiACTA trial, 251 patients were randomly assigned (2:1:1:1) to receive subcutaneous tocilizumab (162 mg) once a week or every other week, combined with a 26-week prednisone taper, or placebo combined with a prednisone taper over a period of either 26 weeks or 52 weeks. Patients in clinical remission stopped masked injections at 1 year (the conclusion of part one). In part two, treatment was at the investigators' discretion and could consist of no treatment, tocilizumab, glucocorticoids, methotrexate, or combinations of these, for two years. Maintenance of efficacy as assessed by clinical remission (defined as absence of relapse determined by the investigator), cumulative glucocorticoid dose, and long-term safety were exploratory objectives in part two of the trial. This trial is registered at ClinicalTrials.gov, NCT01791153. 215 patients participated in part two of the trial; 81 patients who were randomly assigned to tocilizumab once a week in part one were in clinical remission after 1 year, of whom 59 started part two on no treatment. 25 of these 59 patients (42%) maintained tocilizumab-free and glucocorticoid-free clinical remission throughout part two. Median (95% CI) cumulative glucocorticoid doses over 3 years were 2647 mg (1987-3507) for tocilizumab once a week, 3948 mg (2352-5186) for tocilizumab-every-other-week, 5277 mg (3944-6685) for placebo with a 26-week prednisone taper, and 5323 mg (3900-6951) for placebo with a 52-week prednisone taper (van Elteren p≤0·001, tocilizumab once a week vs placebo groups; p<0·05, tocilizumab-every-other-week vs placebo groups). Tocilizumab-based regimens restored clinical remission among patients who experienced relapse in part two and were treated (median time to remission: 15 days for tocilizumab alone [n=17]; 16 days for tocilizumab plus glucocorticoids [n=36]; and 54 days for glucocorticoids alone [n=27]). No new or unexpected safety findings were reported over the full 3 years of the study. Giant cell arteritis remains a chronic disease that entails ongoing management and careful vigilance for disease relapse, but continuous indefinite treatment with immunosuppressive drugs is not required for all patients. A substantial proportion of patients treated with tocilizumab for one year maintain drug-free remission during the two years after tocilizumab cessation. For patients who experience relapse, tocilizumab can be used to manage relapses, but it remains prudent to include prednisone for patients who experience relapse because of the risk for vision loss. F Hoffmann-La Roche.

Anesthesia in a patient with multiple-system atrophy using a combination of rocuronium and sugammadex.

Multiple-system atrophy is an adult-onset progressive neurodegenerative disease affecting the central nervous system, including the spinal cord. There has been no perioperative guideline of the muscle relaxants used in multiple-system atrophy, although a recent article recommends anesthesiologists to use shorter-acting drugs at the lowest possible doses in the patients. Here, we document the first case with multiple-system atrophy undergoing surgery managed with a combination of rocuronium and sugammadex. The recovery time to the train-of-four count 2 after intravenous rocuronium 0.6 mg / kg, or the time from the start of sugammadex 2 mg / kg intravenously to the train-of-four ratio over 0.9 was prolonged in our case more than 20 and 2 minutes compared with those in healthy subjects, respectively. Neuromuscular monitoring, in addition to the careful vigilance in the perioperative period, seems mandatory in the patients. J. Med. Invest. 68 : 381-382, August, 2021.

Vigilant care: constructive dialogues and relational responsibility in violent contexts

This is a qualitative exploratory study by the “Assistance and Vigilance Research Program on Violence”, focusing on a group of seven sexual abuse survivors and their mothers. The study’s objective is to develop a caretaker protocol for Parent Vigilant Care. Observers register protocol sessions by themes evolving within the action group. The information is organized into categories: 1) Hidden pain, 2) Caring is protecting, and 3) Breaking through isolation. Observation and conclusions focus on the following: 1) The disconnect revealed by mothers and daughters on the role of mothers in their daughters’ lives, 2) The potential for recovery of affective relationships, 3) Respect development for a horizontal or equalization of power, 4) The return or rescue of a mother’s competency and authority.

Severe penile hair tourniquet syndrome with near amputation of the glans

Penile hair tourniquet syndrome is a rare phenomenon that classically affects boys during their first few years of life. We report a late presentation of an 8-year old nonverbal, severely autistic male with a several-month-long history of a progressing penile hair tourniquet. The persistence of this constricting band led to severe anatomic defects, including near amputation of the glans, with transection of the urethra creating a distal fistula, and erosion through the majority of the cavernosal bodies. Our case highlights the critical importance of vigilant care and high index of suspicion, particularly in vulnerable patient populations such as young boys with autism spectrum disorder. Urgent evaluation and removal of the offending foreign body is required, with use of sedation or anesthesia if necessary.

Type III ABO discrepancy aiding in diagnosis of multiple myeloma

Plasma cell myeloma is characterized by monoclonal proliferation of plasma cells, causing destructive bone lesions and other systemic manifestations. The disease spans a clinical spectrum from asymptomatic to highly aggressive disease. M protein caused by myeloma cells results in type III ABO discrepancy, in which rouleaux formation can be misinterpreted as agglutination. We present a case of a 54year old male admitted in our hospital with breathlessness, severe pallor and fever. Blood transfusions were advised as the haemoglobin was low. Initially there was a discrepancy between forward and reverse grouping which resolved with saline washes. On further investigations like peripheral smear and bone marrow examination, the patient was diagnosed as a case of plasma cell myeloma. In our case the blood grouping revealed type III ABO discrepancy which upon further investigation was found to be a case of plasma cell myeloma. Key Messages: Plasma cell myeloma has varied presentations. In our case, the patient presented with severe anaemia, plasma cells in peripheral blood and type III ABO discrepancy. Rouleaux formation should not be interpreted as agglutination. Careful vigilance by technicians in blood bank and thorough knowledge regarding various discrepancies will help in the management of the patient. Keywords: ABO discrepancy, Agglutination, Anaemia, Plasma cell myeloma, Rouleaux.

Safety and tolerance of androgen receptor antagonists in nonmetastatic, castration-resistant prostate cancer.

e17607 Background: Metastatic castration resistant prostate cancer (mCRPC) is a fatal disease. Nonmetastatic, castration-resistant prostate cancer (nmCRPC) often predates mCRPC. Recently, three androgen receptor (AR) antagonists i.e. apalutamide, enzalutamide, and darolutamide have been approved for nmCRPC. Nonetheless, any new therapeutic approach poses new safety concerns. We conducted a systematic review and meta-analysis of the published phase 3 randomized controlled trials (RCTs) to determine the safety and tolerance of AR-antagonists in nmCRPC patients. Methods: We conducted a systematic search at PUBMED, MEDLINE, EMBASE, and meeting abstracts as per PRISMA guidelines from inception until November 2019. Published phase 3 RCTs using AR-antagonists in the study arm for nmCRPC were included in the analyses. We used Mantel-Haenszel (MH) method and random effects model to calculate the estimated pooled risk ratio (RR) with 95% confidence interval (CI). Heterogeneity was tested with I2 value and Cochran’s Q-test. Results: Three phase 3 RCTs (ARAMIS, PROSPER, and SPARTAN) comprising 2687 patients in the AR-antagonist arm and 1417 patients in the control arm were included in the final analysis. AR-antagonists used in the study arms were following— ARAMIS: darolutamide, PROSPER: enzalutamide, and SPARTAN: apalutamide. Placebo was used in the control arms. All patients continued androgen deprivation therapy (ADT). Randomization was 2:1 in all studies. No publication bias was appreciated all three studies. The pooled RR of any-grade adverse events (AEs) is 1.08 (95% CI: 1.02 – 1.14, p = 0.01, I2 = 79%) which was statistically significant. The pooled RR of grade ≥ 3 AEs was also significant at 1.32 (95% CI: 1.19 – 1.46, p &lt; 0.00001, I2 = 0%). The pooled RR of grade 5 event is 2.67 (95% CI: 0.79 – 9.02, p = 0.11, I2 = 70%) which was not statistically significant. The pooled RR for discontinuation of treatment regimen was also statistically significant at 1.31 (95% CI: 1.00 – 1.72, p = 0.05, I2 = 35%). Conclusions: In nmCRPC patients, AR-antagonists in combination with ADT is associated with a mild increase risk of any-grade AEs, grade ≥3 AEs, and treatment discontinuation secondary AEs. However, AR-antagonists were not associated with a significantly increased risk of death due to AEs. Careful clinical vigilance and timely intervention with appropriate supportive care are critical to prevent AEs related morbidities and prevent treatment discontinuation.

Management and Outcomes of Button Batteries in the Aerodigestive Tract: A Multi-institutional Study.

To describe the clinical presentation, management, and complications associated with button battery impaction in the aerodigestive tract in children. Retrospective case series. This multi-institutional study, endorsed by the American Society of Pediatric Otolaryngology research consortium, is a retrospective medical record review, including all children at five tertiary-care institutions presenting with button batteries impacted in the aerodigestive tract between January 2002 and December 2014. Battery type/size, duration and location of impaction, presenting symptoms, treatment, complications, and outcomes were examined. Eighty-one patients were included (64.2% male), with ingestion witnessed in 20 (24.7%). Median age at presentation was 3 years (range, 1 week-14 years). Median time from diagnosis to removal was 2.5 hours (range, 0.4-72 hours). Locations included the esophagus (n = 48), hypopharynx (n = 1), stomach (n = 6), nasal cavity (n = 22), and ear canal (n = 4). Most common symptoms for esophageal/hypopharyngeal impactions included dysphagia (26.5%), nausea/vomiting (26.5%), drooling (24.5%), cough (18.4%), and fever (18.4%). Most common symptoms for nasal impactions included epistaxis (54.6%), rhinorrhea (40.9%), nasal pain (27.3%), and fever (22.7%). Almost all esophageal impactions were from 3-V (89.5%), 20-mm (81.8%) lithium batteries. Severe esophageal complications included stricture (28.6%), perforation (24.5%), tracheoesophageal fistula formation (8.2%), pneumothorax (4.1%), and bilateral true vocal fold paresis (4.1%). Nasal complications included necrosis (59.1%), septal perforation (27.3%), and saddle nose deformity (4.5%). Duration of impaction correlated with an increased likelihood of persistent symptoms only for nasal batteries (P = .049). Button batteries in the upper pediatric aerodigestive tract or ear canal should be considered a surgical emergency, requiring urgent removal and careful vigilance for complications. 4 Laryngoscope, 131:E298-E306, 2021.