Anca-Associated but Not Vasculitis

Background/Aims A 72-year-old lady presented in primary care with complaints of generalised body aches, bilateral leg weakness and constitutional symptoms following a first dose of COVID-19 vaccine. Blood tests showed slightly raised inflammatory markers. She was initially diagnosed with polymyalgia rheumatica and was started on 40mg prednisolone with minimal improvement. Methods The examination in the rheumatology clinic was unremarkable. Investigations revealed raised white cell count, consistent with high dose steroid treatment, and elevated monocytes. There was mild improvement in inflammatory markers. The working diagnosis was of self-limiting viral illness. Further testing discovered strongly positive MPO ANCA (115 IU/ml), and the patient received three pulses of 500mg methylprednisolone for suspected vasculitis arranged by the medical team. There was no evidence of renal involvement. The diagnosis made at this point was autoimmune inflammatory disorder with unclear aetiology. At the subsequent clinic visit she reported mild shortness of breath, but no other symptoms suggestive of either vasculitis or connective tissue disease. Repeat ANCA showed significant reduction in MPO titre following pulse steroid treatment. CT of chest, abdomen and pelvis demonstrated a localised lobular/ nodular deformity of the liver. Viral hepatitis screen was negative. CA19-9 was raised at 100 U/ml. Liver biopsy was reported as poorly differentiated carcinoma without specific localising immunohistochemical features. Results The patient underwent hemi-hepatectomy for histologically confirmed pT2pNXM0R0 liver cholangiocarcinoma in a tertiary centre followed by adjuvant chemotherapy with capecitabine. With treatment, her MPO ANCA and CA19-9 levels declined. An interval CT scan of chest, abdomen and pelvis performed ten months after the surgery, showed no recurrence of malignancy. Given the fact that the patient's MPO ANCA fell following the treatment of cholangiocarcinoma, it is likely that positive MPO ANCA is associated with underlying malignancy rather than an active vasculitis. Conclusion This unusual case describes an evolution of the diagnostic process guided by non-specific symptoms and ANCA positivity, arriving at an unexpected diagnosis of malignancy. Although ANCA is a sensitive and specific marker of vasculitides, it can be positive in other conditions particularly hepatitis B, inflammatory bowel disease and autoimmune liver disorders. Malignancy can also be associated with ANCA in the absence of vasculitis. In one study, of 118 ANCA positive patients without ANCA-associated vasculitis, four were found to have malignancy. In a study of 1024 patients who had ANCA tested, 61 patients were found to have malignancy, predominantly haematological and lung cancers. However, after adjustment for sex, age and time of blood draw, no association was found between ANCA status and incidence of cancer. Interestingly, paraneoplastic vasculitis such as polyarteritis nodosa (PAN) has been described in the context of underlying cholangiocarcinoma, and is associated with ANCA rise. Moreover, patients with raised ANCA and PAN also have raised CA 19- 9.

Interpersonal violence in a city of Parana: a study about the epidemiological profile of victims and characterization of dental trauma

The socioeconomic context and population vulnerability are directly associated with violence in the country. In Brazil, the Criminal Code provides the illicit act and punishes the aggressor who offends the physical aggression from a person. Interpersonal violence is an illegal act and is associated with the vulnerability of victims. Therefore, the study of the epidemiological profile of victims of interpersonal violence is needed to alert the population about their susceptibility. The present study aimed to design the epidemiological profile of victims of bodily injury from interpersonal violence in the region of Maringa, in the state of Parana, and to study the characterization of dental injuries in terms of permanent weakness and deformity. Four thousand nine hundred sixty-two reports performed between 2018 and 2020 were analyzed using descriptive statistics. Data collected included: sex, age, marital status, the region affected by the bodily injury, type of dental trauma, and responses to "weakness" or/and "permanent deformity". During the period studied, there was a prevalence of female victims (57.8%), white skin color (80.2%), aged between 21 and 30 years (24.9%), single (54.9%), and the most affected region was the upper limbs (32.1%). Regarding bodily injuries with dental involvement, 67 cases were reported, male victims were prevalent (60.3%), and dental fracture was highlighted with 54.4% of examined injuries. The implementation of the Forensic Dentistry Centre took place in August 2019 at the Medico-Legal Institute of Maringa. Also, with the interruption of expert activities in 2020 - due to the COVID-19 pandemic - relevant outcomes regarding permanent weakness were observed. The epidemiological profile of victims is characterized by the female sex, white skin color, the age group from 21 to 30 years old, and singles. Regarding dental trauma, male victims, and dental fractures were prevalent. Furthermore, there was an increase in the classification of "permanent weakness", as well as a slight increase in cases of "further assessment required" for permanent deformity.Copyright © 2023 Faculdade de Medicina de Ribeirao Preto - U.S.P.. All rights reserved.

Adolescent-Acquired Flatfeet: The Tip of the Iceberg.

There has been a substantive change in our lifestyle over the last two decades. The widespread availability of entertaining digital devices created an unhealthy culture of a sedentary lifestyle, with our children hooked to their digital devices for countless hours. The mental and social consequences have been well explored in several studies. Leading a sedentary lifestyle has been shown to be associated with obesity, diabetes, cardiovascular diseases, and even early death. The adolescent-acquired flatfeet is another addition to the ever-growing list. The lack of physical activities among children nowadays has led to a pandemic of long muscles tightness in children, particularly during the growth spurt. The mismatch between the long bones and adjacent muscles growth caused relative muscles shortening, particularly the muscles that cross more than one growth center, such as the hamstring muscles and gastrocnemius muscles. As a result, it has become common to see children who cannot touch the floor on forward bending because of hamstring muscles tightness or inability to walk on their heels because of gastrocnemius muscles tightness. While muscles tightness is relatively benign, its consequences, such as adolescent-acquired flatfeet, are not. In this review, we have explored the condition, its prevention, and treatment to raise awareness among the public and professionals.

Percutaneous tracheostomy in head and neck oncology surgery: How Covid-19 changed our practice

Enhanced experience in performing percutaneous tracheostomies during the COVID-19 pandemic resulted in changes to airway management protocol for patients undergoing major head and neck reconstructive surgery within our department. Most patients now receive a percutaneous tracheostomy over the previously favoured surgical tracheostomy. The aim of this study was to review our experience in performing percutaneous tracheostomies, whilst comparing complication rates with surgical tracheostomies performed in similar settings. All consecutive patients undergoing free flap reconstructive surgery for head and neck cancer between June 2020 and November 2021 were included, with 56 patients receiving a percutaneous tracheostomy. Data across a range of variables including age, BMI, comorbidities and complications was compared with 56 surgical tracheostomies performed for the same group of patients before the COVID-19 pandemic and resultant protocol changes. In the percutaneous group, a marginally lower complication rate was observed over the surgical tracheostomy group;28.57% and 30.35% respectively. Analysis of the 16 patients who experienced complications in the percutaneous group led to development of selection criteria to identify appropriate patients to receive a percutaneous tracheostomy in future, based on factors such as BMI, bleeding risk and positioning deformities. The COVID-19 pandemic has offered a multitude of learning experiences for healthcare professionals to change our practice. In our unit, this has involved modifying the routine tracheostomy procedure used for airway management intra- and post-operatively in major head and neck reconstruction surgery.Copyright © 2023 The Authors

Remote monitoring and virtual follow-up ventilation clinics in the age of Covid-19

Background: To review the efficacy of long-term non-invasive ventilation (LTV) with virtual follow-up, using assistive technologies and remote monitoring. Objective(s): Compliance greater than 4 hours, correction of hypercapnia and improvements in sleep and quality of life (QoL) were the objectives in improving patient outcome. Method(s): We conducted a retrospective cohort study including patients established on LTV over an 18 month period from the start of the pandemic. Initiation of LTV was established as an inpatient (n= 17;35%), outpatient (n= 28;57%) or from the patient's home (n= 4;8%) and follow-up was by telephone, video consultation or from the patient's own home. LTV was considered successful if compliance achieved was > 4 hours using remote monitoring, corrected hypercapnia (tCO2 < 6.5Kpa) and patient-reported improvements in sleep and QoL. Result(s): Forty-nine patients were included. LTV was initiated for: neuromuscular disease (n=19;39%), obesity hypoventilation or overlap (n=12;24%), chronic obstructive pulmonary disease (n=11;22%) and chest wall deformity (n=6;14%). Compliance > 4 hours was achieved in 69% with effective correction of hypercapnia (tCO2 < 6.5Kpa) in 67% and reported improved sleep and QoL at 63%. Overall success in all 3 objectives was 61%. Patient preference for future follow-up was 45% requesting face-to-face consultations and 33% to continue remotely. A proportion of the most vulnerable (14%) would prefer to be seen at home. Conclusion(s): Successful LTV can be achieved with remote compliance data and transcutaneous carbon dioxide monitoring to support virtual clinics. Patient preference for face-to-face consultations remains important in overall satisfaction.

A novel approach to low-energy calcaneal tuberosity avulsion fractures in patients with fragile bone quality: A report of two cases

Maintaining reduction of a calcaneal tuberosity avulsion fracture is challenged by the powerful force exerted upon the bone fragment by the Achilles tendon. Low-demand, elderly patients with osteoporotic bone usually undergo a low-energy mechanism when this fracture pattern occurs. Likely attributable to poor bone quality, the rate of early fixation failure has been documented to be as high as 40%. We present the cases of two 65-year-old female patients who each sustained a calcaneal tuberosity avulsion fracture. Both patients underwent a low-energy mechanism of injury and had a medical history of many comorbidities. The first patient underwent a partial calcaneal ostectomy and tenotomy after failing open reduction internal fixation (ORIF). The second patient primarily underwent a partial calcaneal ostectomy and tenotomy. Postoperatively, after the incision site was fairly healed, both patients could bear weight as tolerated. This method of excision and release may allow for decreased risk of skin compromise and return trips to the operating room for failed ORIF. In low-demand patients with low-energy calcaneal avulsion type fractures and osteoporotic bone, this technique may be the preferred surgical option.Copyright © 2022 The Author(s)

Segmental lung anatomy for ultrasound assessment for post-COVID conditions

Introduction: Ultrasound (US) has become a more reliable method for lung parenchyma assessment. Precise detecting localization and effective monitoring treatment is crucial in respiratory medicine patients. The aim was to evaluate the accuracy of the US to detect and monitor lung lesions in compliance with lung segmental anatomy in post-COVID patients with associated comorbid respiratory conditions. Materials: We did an evaluation of 30 consecutive patients (25-74?years), who suffered from various chronic respiratory conditions and underwent COVID-19 during the last 3 months. All patients underwent first line lung ultrasound followed by CT and bronchoscopy where needed. Result(s): US can detect correctly in 28/30 cases to verify lesion and segmental localization as confirmed on CT and/or endoscopy. The US was effective to monitor treatment in 24/30 cases without need for follow up CT, including 5 patients after bronchoscopic lavage. Various specific conditions were detected and monitored on US: segmental atelectasis, pneumonia (22 cases);right middle lobe atelectasis (3);bronchiectatic disease (3);lung cirrhosis, post tuberculosis changes (2). Lung compression / atelectasis due to severe scoliosis and thoracic deformities detected in 2 patients. In some cases US was more effective vs CT due to possibility of real time ventilation observation, detecting tissue movement;dorsal areas ventilation was underdetected on CT due to patients'position. Conclusion(s): US can be used for detecting peripheral lung lesions, precise determination of segmental localization, is important for early diagnosis and monitoring.

Nail ridging in rheumatoid arthritis patients and relation to disease activity: An integrated rheumatology-dermatology multi-centre study

Aim of the work: To evaluate the frequency of nail ridging (NR) in patients with rheumatoid arthritis (RA) and to study its relation to disease activity. Patients and methods: 230 RA patients and 97 matched controls from Helwan, Ain Shams and Mansoura university hospitals were studied. Disease activity score (DAS28) was assessed. NR has been searched for in all patients. The number of affected fingers was recorded. NR was determined by a magnifying lens, seen by naked eye or seen and felt. Dermoscopic photography of the NR using Dermalite DL4 3Gen dermatoscope has been recorded. Results: The median age of patients was 49 years (42–58 years);they were 221 females and 19 males (F:M 11.1:1) with a disease duration 9 years (5–11 years). Their DAS28 was 3.6 (2.9–4.6). NR was significantly increased in RA cases vs. control;73% vs 20%;p < 0.001. In patients, NR was detected by a magnifying lens in 32.6%, seen in 27% and seen and felt in 13.5%. Joint deformities were significantly higher in those with NR. DAS28 was a significant independent predictor of NR;for every one-point increase in DAS28, there was a 153 times higher odds to exhibit NR at a sensitivity of 93.5%, specificity 80.3% and at a diagnostic accuracy of 90%. Conclusion: NR is a frequent finding in RA. An integrated rheumatological- dermatological clinical evaluation may be helpful and further studies are required to prove the importance of this sign for follow up of RA patients.

Incidence, etiology and time course of delays to adult spinal deformity surgery: a single-center experience.

PURPOSE: We sought to determine the incidence, origin, and timeframe of delays to adult spinal deformity surgery so that institutions using preoperative multidisciplinary patient assessment teams might better anticipate and address these potential delays. METHODS: Complex spine procedures for treatment of adult spinal deformity from 1/1/18 to 8/31/21 were identified. Procedures for infection, tumor, and urgent/emergent cases were excluded. Operations delayed due to COVID or those that were performed outside of our established perioperative care pathway were also excluded. The electronic health record was used to identify the etiology and timeline of all pre- and peri-operative delays. RESULTS: Of 235 patients scheduled for complex spine surgery, 193 met criteria for inclusion. Of these patients, 35 patients experienced a surgical delay (18.1%) with a total of 41 delays recorded. Reasons for delay include medically unoptimized (25.6%), intraoperative complication (17.9%), patient directed delay (17.9%), patient illness/injury (15.4%), scheduling complication (10.3%), insurance delay/denial (5.1%), and unknown (2.6%). Twenty-four delays experienced by 22 individuals occurred within 7 days of their scheduled surgery date. CONCLUSION: At a single multidisciplinary center, most delays to adult spinal deformity surgery occur before a patient is admitted to the hospital, and for recommendations of additional medical workup/clearance. We suspect that the preoperative protocol might increase pre-admission delays for unoptimized patients, as the protocol is intended to ensure patients receive surgery only when they are medically ready. Further research is needed to determine the economic and system impact of delays related to a preoperative optimization protocol weighed against the reduction in adverse events these protocols can provide.

Superior mesenteric vein thrombosis and osteoporotic vertebral fractures.

Superior mesenteric vein (SMV) thrombosis is relatively rare disease with unspecific symptoms. Thrombus formation within the SMV eventually leads to congestive intestinal necrosis. In most cases, the lack of specific symptoms makes early diagnosis difficult. Therefore, it is important to suspect the disease and actively investigate it, given a causative factor. Here, we report a case of SMV thrombosis with a novel predisposing factor, compression of SMV by deformed spine, found on contrast medium-enhanced computed tomography. Treatment with intravenous heparin followed by oral anticoagulants resulted in favorable outcome. This is the first picture showing the novel mechanism of SMV thrombus formation relating to spinal deformity. Treating osteoporosis before spinal deformity could prevent SMV thrombosis with such a mechanism.

P132. Lumbar fusion during the COVID-19 pandemic: greater rates of morbidity and longer procedures

BACKGROUND CONTEXT: The coronavirus-19 (COVID-19) pandemic has altered the standard of care for spine surgery in many ways. However, there is a lack of literature evaluating the potential changes in surgical outcomes and perioperative factors for spine procedures performed during the pandemic. In particular, no large database study evaluating the impact of the COVID-19 pandemic on spine surgery outcomes has been published. PURPOSE: To evaluate the impact of the COVID-19 pandemic on perioperative factors and postoperative outcomes of lumbar fusion procedures. STUDY DESIGN/SETTING: Retrospective cohort study. PATIENT SAMPLE: Patients who underwent primary, elective lumbar fusionbetween 2019 and 2020. OUTCOME MEASURES: Thirty-day readmission, reoperation, morbidity, complications, operative time, non-home discharge disposition, length of hospital stay, total RVUs and RVUs per minute. METHOD(S): The ACS-NSQIP database was queried for all patients who underwent primary lumbar fusion in 2019 and 2020. Exclusion criteria included cervical or thoracic fusion, arthroplasty, non-elective, emergency cases, deformity procedures, malignancy, preoperative sepsis, wound infection and missing perioperative variables. Patients were grouped into cohorts based on 2019 or 2020 operation year. Multivariate logistic and Poisson regression models were utilized to evaluate the impact of 2020 operative year on postoperative outcomes. RESULT(S): A total of 27,446 patients were included in the analysis (12,473 cases in 2020). For the 2020 cohort, non-white race (24.9% vs 23.4%, p=0.004), functional dependence (1.8% vs 1.4%, p=0.022), congestive heart failure (0.5% vs 0.3%, p=0.015), and ASA class =3 (53.5% vs 52.2%, p=0.037) were more common. Lumbar fusions performed in 2020 were also associated with longer mean operative time (209.3+/-99.3 vs. 205.9+/-98.6 minutes, p=0.005) and higher mean fusion levels (1.45+/-0.69 vs 1.41+/-0.65, p 0.05). However, operation year 2020 independently predicted morbidity (OR 1.087 [95% CI 1.007-1.172], p=0.032), pneumonia (1.407 [1.039-1.906], p=0.027), DVT (1.508 [1.106-2.056], p=0.009) and sepsis (1.537 [1.101-2.146], p=0.012). In terms of perioperative variables, operation year 2020 predicted greater operative time (1.012 [1.001-1.013], p=0.046), non-home discharge (0.690 [0.642-0.743], p<0.001), and total RVUs (1.044 [1.004-1.083], p=0.033). CONCLUSION(S): Lumbar fusion procedures performed amidst the COVID-19 pandemic were associated with poorer outcomes, including higher rates of morbidity, pneumonia, DVT and sepsis. In addition, surgeries performed in 2020 were associated with longer operative times and less frequent non-home discharge disposition. FDA DEVICE/DRUG STATUS: This does not discuss or include any applicable devices or drugs. Copyright © 2022

The Percutaneous Tracheostomy in Head and Neck Oncology Surgery

Introduction/Aims: Enhanced experience in performing percutaneous dilatational tracheostomies (PDT) during the COVID-19 pandemic resulted in changes to airway management for patients undergoing head and neck reconstructive surgery at Queen Elizabeth Hospital Birmingham. All patients now receive a percutaneous tracheostomy over the previously favoured surgical tracheostomy (ST), unless contraindicated. This ambispective case series aimed to review experiences in performing percutaneous tracheostomies, whilst comparing complication rates with surgical tracheostomies performed in similar settings. In addition, we propose a selection criteria for identifying patients suitable for PDT. Material(s) and Method(s): All patients undergoing free flap reconstruction for head and neck cancer treatment between June 2020-November 2021 were included, with 56 patients receiving PDT. This was compared with data of 56 ST performed before the COVID-19 pandemic. Results/Statistics: In the percutaneous group, a marginally lower complication rate was observed over the surgical tracheostomy group;28.57% and 30.35% respectively. Although not statistically significant, time to decannulation was slightly lower in PDT group (5.8 days) compared to ST group (7.3 days). An additional observed advantage included quicker tracheostomy wound healing with PDT. Analysis of the 16 patients who experienced complications with PDT aided development of the selection criteria for identifying patients for percutaneous tracheostomy. This selection criteria considers BMI, ASA, bleeding risk and positioning deformities. Conclusions/Clinical Relevance: This study has demonstrated PDT to be an equally safe and successful technique with a similar complication rate to ST in head and neck cancer reconstruction surgery. Moving forward, further studies with larger sample sizes would be recommended to draw conclusions. Copyright © 2022

Effectiveness of Needle Tenotomy for Correction of Equinus in Clubfoot.

INTRODUCTION: During the COVID-19 surge, due to a lack of operating room availability, we performed Achilles tendon tenotomy in clubfoot patients using a 16/18 gauge needle to avoid delay in their management. The procedures were performed on an outpatient basis. The current retrospective study aims to investigate the effectiveness of needle tenotomy for the correction of equinus in clubfoot at a minimum of one year of follow-up. METHODS: Clinical records of all clubfoot patients that underwent needle tenotomy of Achilles tendon from March 2020 onwards with at least one year of follow-up were reviewed. We recorded Pirani scores and the equinus deformity at the initial presentation, after Achilles tendon tenotomy, and at the final follow-up. We also recorded any procedure-related complications following the Achilles tendon tenotomy. We compared dorsiflexion after final cast removal and after one year of follow-up. RESULTS: A total of 26 clubfeet in 14 patients underwent needle tenotomy of the Achilles tendon and completed one year of follow-up. Ankle dorsiflexion was achievable in all patients and the mean dorsiflexion of 27.4 degrees. The average Pirani score after tenotomy at final cast removal was 0.16, while the mean dorsiflexion at final cast removal was 24.2 degrees (p = .00084). No tenotomy procedure-related complications were noted. CONCLUSION: Percutaneous needle tenotomy of the Achilles tendon is a simple, safe, and effective technique for equinus correction in clubfoot. Considering the less invasive nature of the procedure, it can be done as a short procedure on an outpatient basis and has a limited risk of hemorrhage and other wound-related complications.

COVID-Associated Mucormycosis in Case of Fibrous Dysplasia of Maxilla: Freeing 2 Birds With 1 Key

Introduction: India is one of the countries most affected by COVID-19. COVID-19-associated mucormycosis (CAM) has added to the woes of the already devastating effects of the virus. About 97.6% of cases in India presented with rhino-orbito-cerebral disease. Fibrous dysplasia (FD) is characterized by abnormal mixtures of fibrous and osseous elements leading to bony deformities and pathological fractures. Monostotic and polyostotic varieties have been described, with the latter being more common in children. The monostotic type of FD accounts for about 70% to 80% of FD, affecting the second and third decade. Method(s): We present a case of 44-year-old man with fibrous dysplasia of left maxilla with CAM, an angioinvasive fungal disease associated with high morbidity and mortality. As India and the entire world is struck by the COVID-19 pandemic, the use of corticosteroids has proven somewhat helpful in managing severe COVID infection. Evidence shows it has also led to CAM. Our patient was treated with radical surgical treatment of lesion with gross removal of all necrotic tissues from the sinuses along with antifungal treatment with amphotericin B. FD is a benign disorder characterized by replacement of normal bone with cellular fibrous connective tissue. Result(s): Our case presented with CAM of maxilla with palatal involvement requiring urgent surgical intervention and antifungal therapy. It incidentally happened to be a case of FD. Maxillectomy took care of the patient's FD as well. Conclusion(s): FD is a disorder characterized by dystrophy and bony metaplasia, and treatment depends on the zone of involvement. Early diagnosis and surgical intervention, with good antifungal therapy with strict glycemic control, are critical features to prevent its onslaught. Sometimes treatment of one condition can cure the others as well.

Health Education In The Self Care Process Of The Chronic Wounds Healing Of The Diabetic Foot

Purpose/Objectives: The increase in life expectancy in recent years is closely related to scientific advances in health area. Thus, longevity led to a greater emergence of chronic diseases, such as diabetes mellitus (DM). In this scenario, chronic wounds represent a serious public health problem. It is estimated that 85% of lower extremity amputations in individuals with DM are related to the presence of foot ulcers. The perception of changes in the skin, such as deformities, superficial traumas and cracks, is impaired in diabetics due to loss of sensitivity, predisposing the appearance of wounds. Ulcers and other injuries can be prevented through simple measures, such as regular skin inspection, specialized care and the use of adequate footwear;as the greater understanding of self-care, the greater the benefits of treatment. In this sense, Primary Care is an effective mean of assisting such individuals, as health education actions can be carried out for this population, their families and caregivers, with a view of promoting health. In addition, the health education process must take place in parallel with medication and dressings, which are essential, especially the latter, given the specificity of the product and the level of tissue regeneration. The primary objective of this study is to present the educational activities developed by the Extension Project Physiotherapy in the Community of the State University of Paraíba in partnership with the research project Tissue Engineering in Epithelial Repair: Biodegradable Scaffold for Tissue Regeneration, which is developing chitosan/Jatropha mollissima scaffolds, in the Laboratory of Evaluation and Development of Biomaterials from the Northeast of the Federal University of Campina Grande. Methodology: The participants consisted of users of Basic Health Units (BHU) in the city of Campina Grande/Paraiba/Brazil. The educational material on Diabetes and Diabetic Foot Wound Care was produced from documents such as articles, guidelines and booklets. The CANVA application was used to create the images and infographics, to facilitate the understanding of the participants, and it was sent along with an explanatory audio. The disclosure took place on the public profile on Instagram @fisionacomunidadeuepb and also through the WhatsApp application for the diabetic elderly who participate in the project, in addition to face-to-face meetings at BHU, to clarify doubts at previously scheduled times and with a limited number of people due to the covid 19 pandemic. Results: The results included a greater understanding of the process of illness and wound development, as well as awareness of the importance of adherence to treatment and care in the use of dressings, especially. According to the records, the participation in the means used was intense, which suggests that these people will also be multipliers in the health education process. Conclusion/Significance: It is concluded that health education strategies, even at the time of a pandemic, are useful in the process of correct information dissemination, helping the most vulnerable population to understand their disease and, at the same time, help them in self care and responsibility, thus facilitating the intervention used by the health and engineering team.

ATYPICAL PRESENTATION OF MUCORMYCOSIS IN A NONSEVERE COVID-19 PATIENT

SESSION TITLE: COVID-19 Case Report Posters 2 SESSION TYPE: Case Report Posters PRESENTED ON: 10/19/2022 12:45 pm - 01:45 pm INTRODUCTION: Coronavirus Disease 2019 (COVID-19) infection ranges from asymptomatic to severe disease as defined by WHO. Emerging fungal infections such as mucormycosis and aspergillosis have been described in critically ill patients, most notably in India, when treated with steroids due to severe COVID-19 [1]. We present a unique case of an atypical presentation of mucormycosis in a non-severe COVID-19 patient not treated with corticosteroids. CASE PRESENTATION: A 19-year-old male with type 1 diabetes mellitus presented to the emergency room for evaluation of shortness of breath, nausea and fatigue. History was significant for insulin noncompliance with home blood glucose in the 300s and a positive COVID-19 test one day prior to arrival. Initial vitals positive for tachycardia, tachypnea and hypertension while on room air. Labs showed leukocytosis 14,000 cells/uL, bicarbonate 7.2 mmol/L, anion gap 24.8, glucose 428 mg/dL, beta-hydroxybutyrate 58 mg/dL and nucleic acid amplification COVID-19 positive. Physical exam showed left eyelid and facial swelling, nasal congestion without sinus tenderness or other deformity, and kussmaul breathing pattern. CT face confirmed left periorbital cellulitis. Transfer to tertiary center for Ophthalmology evaluation was attempted but refused due to capacity. He was started on diabetic ketoacidosis treatment as well as broad spectrum antibiotics with the assistance of Infectious Disease, however COVID-19 treatments were held due to mild illness. Despite these interventions, he became stuporous and amphotericin was started. MR Brain showed findings suggestive of cavernous sinus thrombosis, acute ischemia and local mass effect. ENT then performed an endoscopic antrostomy with ethmoidectomy and biopsies were taken. Pathology resulted as invasive fungal sinusitis with 90° branching hyphae confirming mucormycosis and a lumbar drain was placed with intrathecal amphotericin started for concern of mucormycosis meningitis. The patient was ultimately transferred to a tertiary care center where he expired. DISCUSSION: Mucormycosis, an angioinvasive fungal infection affecting the immunocompromised and diabetics, is rare but deadly. The estimated prevalence in the United States is 0.16 per 10,000 hospital discharges [2] and bears a mortality rate of 46%. Recent systematic reviews report 275 cases of COVID associated mucormycosis with 233 in India [1] with 76.3% receiving corticosteroids prior to diagnosis [3], likely contributing to an immunocompromised state. Our case demonstrates that despite not receiving corticosteroids, even those with mild COVID-19 are at risk for this disease. CONCLUSIONS: Patients with diabetes, immunocompromised states, and now COVID-19, presenting with orbital symptoms warrant consideration of mucormycosis. Prompt management of the underlying condition, IV amphotericin, and possible debridement may increase survival. Reference #1: John TM, Jacob CN, Kontoyiannis DP. When Uncontrolled Diabetes Mellitus and Severe COVID-19 Converge: The Perfect Storm for Mucormycosis. J Fungi (Basel). 2021 Apr 15;7(4):298. doi: 10.3390/jof7040298. PMID: 33920755;PMCID: PMC8071133. Reference #2: Kontoyiannis DP, Yang H, Song J, et al. Prevalence, clinical and economic burden of mucormycosis-related hospitalizations in the United States: a retrospective study. BMC Infect Dis. 2016;16(1):730. Published 2016 Dec 1. doi:10.1186/s12879-016-2023-z Reference #3: Singh AK, Singh R, Joshi SR, Misra A. Mucormycosis in COVID-19: A systematic review of cases reported worldwide and in India. Diabetes Metab Syndr. 2021 Jul-Aug;15(4):102146. doi: 10.1016/j.dsx.2021.05.019. Epub 2021 May 21. PMID: 34192610;PMCID: PMC8137376 DISCLOSURES: No relevant relationships by james abraham No relevant relationships by christian ALMANZAR ZORRILLA No relevant relationships by Grace Johnson No relevant relationships by Thanuja Neerukonda No relevant relationships by Blake Spain No relevant re ationships by Michael Su No relevant relationships by Steven Tran No relevant relationships by Margarita Vanegas No relevant relationships by Alexandra Witt

Analysis of Ponseti Method in Congenital Talipes Equinovarus (CTEV)

Introduction: Congenital talipes equinovarus (CTEV) is the most common congenital foot disorder, commonly known as congenital clubfoot. Ponseti method of manipulation and serial plaster casting is the gold standard treatment for idiopathic congenital clubfoot. The purpose of this study is to analyse the efficacy of correction of Congenital Talipes Equinovarus deformity (CTEV) using ponseti method. Materials and Methods: This analysis was carried out at the Jhalawar Medical College Hospital's Orthopaedics Department, including 30 children with idiopathic CTEV of age less than 2 years, among which 13 unilateral and 17 bilateral CTEV, total 47 feet, willing for treatment. Patients were followed up weekly for corrective casting till tenotomy and corrective cast was applied for three weeks after final correction or percutaneous tendo-achilles tenotomy. Results: Assessment of results using Pirani severity scoring6,7 at the end of treatment and on regular follow-ups. The most common age group was 0-1 months with 24(80%) cases.Among 30 cases,there were 22 males(73.30%) & 8 females(26.70%). 17 cases were bilateral(56.67%) and 13 cases(43.33%) were unilateral. Post casting treatment, percutaneous tenotomy was done in 14 cases (46.67%) in which 12 cases(54%) were male and 2 cases(16%) were female. No patient has undergone extensive surgery like postero-medial soft tissue release or bony procedures to correct the deformity. Only two recurrence were recorded which was due to non compliance due to occurrence of pandemic COVID-19 Lockdown. They were treated with manipulation and pop cast followed D-B splint. Conclusion: Ponseti method is an excellent conservative method of treatment of Congenital Talipes Equino varus. Treatment must start at the earliest possible for better outcome. Long term follow up till 4 years age would be better to assess the relapse rate.

SHOULDER INJURY RELATED TO VACCINE ADMINISTRATION (SIRVA)

CASE: A 62-year-old woman presented with 4 months of sharp progressive left shoulder pain, radiating down her arm with associated weakness, numbness and tingling most pronounced at the 4th and 5th digit. Her symptoms began within hours of receiving the influenza vaccine to her left shoulder. She denied prior left shoulder or neck pain, headaches, changes in vision, other neurologic symptoms, or trauma. Exam: Left upper extremity without skin changes or deformity, normal muscle bulk, tone and DTRs, lateral upper arm tenderness to light and deep palpation, reduced sensation to light touch at the 4th and 5th left digit with loss of two-point discrimination, reduced active and passive ROM of the glenohumeral joint to flexion/extension/abduction, and restricted internal and external rotation. Cervical x-rays showed spondylosis at C5-6, C5-6 neural foramen narrowing. Normal left shoulder x-ray. Left shoulder MRI showed high grade bursal surface, full-thickness tear of the distal supraspinatus tendon at its insertion, mild subscapularis tendinosis, and small subacromial subdeltoid bursitis. She was treated with a topical NSAIDs, tramadol and cyclobenzaprine as needed and referred to physiotherapy and PM&R. Despite maximum therapy, there was only marginal improvement of left shoulder pain and function at 9 months, she is still unable to perform her ADLs or return to work, and currently receiving home care through her daughter as a caregiver. IMPACT/DISCUSSION: The MRI findings and the temporal relationship between vaccine administration and onset of symptoms, suggest Shoulder Injury Related to Vaccine Administration (SIRVA) as the most likely diagnosis. SIRVA is defined as shoulder pain with limited ROM that commences within 48 hours after vaccine receipt in individuals without prior history of pain, inflammation, or dysfunction of the affected shoulder. SIRVA occurs when a vaccine is delivered into the sub-deltoid bursa or joint space, leading to a robust inflammatory response. The single most important factor in SIRVA diagnosis is the temporal association between vaccine administration and symptom onset. Commonly reported symptoms include shoulder pain, decreased limb mobility, numbness/tingling and muscle tightness. SIRVA complications include bursitis, tendonitis, rotator cuff tear, and adhesive capsulitis. Approximately 65% of patients with SIRVA will have pain lasting more than 3 months. SIRVA is challenging to treat, but there has been some success with early corticosteroid injection within 5 days of symptom onset. Given the current increase in vaccine administration with COVID-19, this case highlights SIRVA as a diagnostic consideration for patients who present with shoulder pain post-vaccination. CONCLUSION: SIRVA should be considered in any patient with new-onset shoulder pain that began within 48 hours of vaccine administration. SIRVA is a post-vaccination complication resulting in shoulder injury that can be prevented with proper vaccine administration technique.

Online Instruction to Measure Axial Alignment with the Bonesetter App.

Background and objectives: Alignment of the lower extremity is important when treating congenital deformities, fractures, and joint replacement. During the COVID-19 pandemic, AO North America offered an online course on deformity measurement and planning. The Bonesetter app is a deformity planning tool that is freely available online. The purpose of this study was to see how effective an online course was in teaching axial alignment measurement and to assess that skill using an online digital planning tool, the Bonesetter app. Materials and Methods: An online module on axial alignment was provided during the AONA osteotomy course as well as a tutorial on how to use an online digital planning tool (Bonesetter app). The tools within the Bonesetter app allow users to draw digital lines directly on the CT images and measure the exact angle between two planes. Participants in this study were directed to perform these measurements in four different cases that tested different variations of deformity. Results: The measurements were completed correctly in case 1 = 56%, case 2 = 61%, case 3 = 84%, and case 4 = 76%. The standard deviation of angular digital measurements between individuals was ±4.26 degrees. Measuring the angle directly vs. drawing angles to a horizontal line had smaller standard deviations per case (p < 0.005) and less incidents outside 1 standard deviation for each measurement. Errors in adding and subtracting were the most common errors, particularly in relation to femoral anteversion or retroversion. Conclusions: The online course successfully instructed a group of orthopedic surgeons to measure alignment and malalignment of lower limb axial deformities. The Bonesetter app helped participants to learn this skill and identify errors in measurement. The inability to differentiate between anteversion and retroversion of the femur is a common source of error when it occurs and should be a focus of instruction.