One-year outcomes following rehabilitation for chronic hip-related groin pain: ancillary analysis of a pilot randomized clinical trial

Purpose: Rehabilitation to address modifiable factors associated with chronic hip-related groin pain (CHRGP) may lead to reduced pain and improved function, yet little is known about its effectiveness. We assessed the preliminary effects of two interventions that target two distinct mechanisms, sensory disturbances and abnormal movement patterns. Sensory disturbances such as peripheral and central sensitization may contribute to pain persistence long after initial injury. Joint mobilization (JtMob) may impart a neurophysiological response within the nervous system that results in pain reduction and improved mobility. Abnormal movement patterns may create altered mechanical stresses on hip joint structures, resulting in pain and activity limitations. Movement pattern training (MoveTrain) may improve movement patterns and thus patient function. Method(s): Patients with CHRGP, 18-40, were enrolled. Assessments included self-report questionnaires, clinical exam, and quantitative sensory testing. Outcomes included the Hip disability and Osteoarthritis Outcome Score (HOOS), a patient-reported outcome;frontal plane kinematics of hip, pelvis, and trunk during single leg squat;and pain pressure threshold (PPT) assessed at the anterior groin of the most bothersome hip and dominant thenar eminence (local and generalized pressure hypersensitivity, respectively). Patients were randomized to JtMob or MoveTrain in a 1:1 ratio stratified by sex and HOOS Symptoms. Treatment for both groups included 10 individualized visits over 12 weeks with a trained physical therapist (PT);assessment of patient goals and education which focused on patient-specific tasks reported by the patient to be symptom-producing;instruction in a home exercise program (HEP);and handouts that provided education, description and benefits of assigned treatment and instructions for HEP. The key element of JtMob was PT-provided manual techniques using specific criteria to determine the joint mobilization techniques and parameters used for each patient. The patient's symptom report to each technique was monitored and if indicated, the technique modified according to our outlined procedures. The HEP included flexibility exercises. The key element of MoveTrain was task-specific instruction to correct abnormal movement patterns displayed during daily and patient-specific tasks. For example, hip adduction was minimized during a step descent. The HEP included repeated practice of modified tasks. Task difficulty was progressed based on each patient's performance. Immediately after treatment completion, patients returned for follow up assessment. To assess treatment sustainability after the active treatment phase, we collected HOOS at 6 and 12 months (extended follow-up), and kinematics and PPT at 12 months. Data from patients who provided any data after baseline were analyzed with a repeated measures analysis of variance (RM-ANOVA) with baseline value as a covariate, patient as a random effect, and an autoregressive covariance structure. After adjusting for baseline, the between-group difference in change from post-treatment to each extended follow-up results from pre-planned statistical contrasts in a RM-ANOVA that includes main effects for treatment group, visit and the group by visit interaction. The within-group treatment effect at each extended follow-up was calculated by subtracting the earlier time point from the later follow-up within each treatment group. Dependent samples t-tests were used to assess the degree of within-group change. Result(s): Demographics and outcome data are provided in Tables 1 and 2, respectively. Thirty-three patients with CHRGP were randomized and 29 (88%) provided post-treatment data. Four patients did not complete treatment or post-treatment testing (3 due to COVID pandemic, 1 lost to follow up);6 patients did not complete 12 month laboratory testing (due to pandemic), but did complete 12 month questionnaires. Previously, we reported that both groups reported clinically important improvements in HOOS subscales and MoveTrain group improved hip and pelvis kinematics immediately after treatment compared to baseline. After adjusting for baseline, there were no between-group differences in change in outcomes between post-treatment and extended follow-up when comparing JtMob and MoveTrain, indicating that treatment effects immediately post-treatment were maintained at 12 months after treatment completion. Conclusion(s): Our preliminary findings suggest that 12 weeks of JtMob or MoveTrain, may result in improvements in patient-reported pain and function and these effects may persist 12 months after treatment completion. A future, larger trial to definitively assess the efficacy of JtMob and MoveTrain and identify factors associated with long-term outcomes will improve our ability to develop treatment strategies for people with CHRGP. [Formula presented] [Formula presented]Copyright © 2023

Mpox in persons living with HIV: Results from an international dermatologic registry

In 2022, mpox virus spread globally with 99% of cases in non-endemic countries. People living with HIV (PLHIV) are disproportionally affected, often with more severe clinical features and outcomes. The AAD/ILDS Dermatology COVID-19, Monkeypox (mpox), and Emerging Infections registry captured mpox cases from 13 non-endemic countries in a de-identified REDCap registry. We aimed to examine cutaneous symptomatology and outcomes in cases of mpox in PLHIV. Of 119 reported cases, 44 were PLHIV (35%). Cases were 98% male, with a median age of 38 years, located in Europe (57%) and the U.S. (39%). Nearly half of PLHIV reported skin lesions as their initial sign (45%), and 43 (98%) reported skin lesions during illness. The primary initial lesion locations were peri-anal (34%) and genito-inguinal (34%). Co-infection with other sexually transmissible infections (STI) was more common in PLHIV, 57% vs. 38% in all-registry cases (p<0.01). The most common co-infections were gonorrhea, syphilis, and chlamydia. Time to resolution was 17 days, 3 days shorter than all-registry cases, which may be due to higher use of Tecovirimat in PLHIV (36% vs. 25% in all-registry cases;p<0.01). There were no differences in the frequency of hospitalization or scarring. One death was reported. Overall, cutaneous lesion count was similar in PLHIV and all-registry cases. Lesion location was more frequently reported in the peri-anal and genito-inguinal regions. Sample size was insufficient to detect differences in length of infection, hospitalization, or scarring in PLHIV. Co-infections were more common in PLHIV, highlighting a need for co-testing for STIs during mpox evaluation.Copyright © 2023

Acute exantematic pustulosis generalized by meropenem, differential diagnosis with COVID

Case report We present the case of a 63-year- old man with two consecutive admissions, due to COVID19 infection and subsequent bacterial superinfection. Three days after the second admission (04/28), and 43 days from the beginning of the infection an assessment by dermatology and allergology is then requested. The patient had generalized erythematous maculopapular rash in the trunk, back, groin and limbs. On the left side and back, pustular lesions not focused on follicles were also added, with a fever of 37.7degreeC. There were no oral and genital lesions. No psoriasis. The drugs used during the present and previous admissions were reviewed. Previous admission (04/04-22/ 20): Linezolid, ciprofloxacin, meropenem 04/13-22, piperacillin/tazobactam, hydroxychloroquine, azithromycin, ceftriaxone. Upon discharge amoxicillin/acid clavulanic. Present admission (04/25) Cutaneous reaction 04/28. 04/25: meropenem, paracetamol, enoxaparin, insulin, omeprazole, venlafaxine. 04/26: Darbepoetin, furosemide, mycophenolate in single dose. 04/27: Linezolid, macrogol, Clopidogrel, Magnesium, Calcitriol. Medical records: DM type 2, liver transplantation due to HCV cirrhosis, HCV recurrence, uninodular hepatocarcinoma, advanced CKD, secondary hyperparathyroidism, multiple neurological antecedents. We performed a detailed study. We hypothesized with a pharmagological/ drug reaction with several drugs possibly involved and our main suspicion was an allergic reaction to beta-lactams. Biopsy: Subcorneal pustules, basal spongiosis and presence in the superficial dermis of edema and an inflammatory infiltrate with abundant neutrophils. No fungi. Findings compatible with clinical diagnosis of generalized acute exanthematic pustulosis (PEGA). Immunohistochemical study Covid19. (Jimenez Diaz Foundation) Finely granular positivity in endothelium and more coarse in sweaty epithelium. Neutrophilic superficial inflammatory component with presumably spure staining. ACe-2 (positive external control) is not detected. The patient presents a EuroSCAR score of 9, sum of the clinic and the pathological anatomy, and therefore defined diagnosis. Clinical diagnosis: PEGA secondary to meropenem. Conclusion(s): We present the case of a PEGA by meropenem, not very often described in the literature. We highlight the importance of differential diagnosis with viral infections. Skin tests, especially epicutaneous tests, are key to the diagnosis. (Figure Presented).

Paediatric Aps - Children Are Not Just Small Adults

Introduction/Background: Antiphospholipid syndrome (APS) is a rare autoimmune multisystem disease characterised by thrombosis and pregnancy morbidity in the presence of persistently elevated titres of: lupus anticoagulant, anticardiolipin and/or anti-glycoprotein 1. It may be primary (occurring alone) or secondary (in combination with another disease, most commonly systemic lupus erythematosus (SLE)). Recent publications highlighted clinical criteria limitations for children and raised awareness of the burden and prevalence of non-criteria manifestations in this population. This case report adds further weight to the need to raise multi-specialty awareness of non-criteria manifestations to aid recognition and treatment of this rare condition with potentially severe sequelae. Description/Method: 13-year-old female with SLE diagnosed aged 8 in India with bilateral optic neuritis occurring two months later. ANA positive at diagnosis with low complement and thrombocytopenia. Treated with prednisolone and hydroxychloroquine. Patient moved to the UK aged 9;initial abnormal bloods: mildly positive ANA (ENA negative), thrombocytopenia, strong lupus anticoagulant. As serology not strongly suggestive and optic neuritis rare in lupus diagnosis questioned. Ophthalmology review confirmed bilateral optic atrophy without evidence of previous vasculitis. There was debate whether the postretinal demyelination was due to antiphospholipid syndrome or a primary demyelinating condition. Hydroxychloroquine stopped and azathioprine started. Following normal neurology investigations (brain, spine MRI/MRV/MRA) concluded if patient developed new APSrelated symptoms or worsening visual evoked potentials anticoagulation would be discussed. Patient remained stable over four years with chronic thrombocytopenia and ESR persistently elevated. Azathioprine changed to Mycophenolate mofetil (MMF) due to side effects. Routine medication monitoring bloods in 2022 showed ESR 97, CRP 78, Platelets 61. Review identified vasculitic rash on soles of both feet with palpable nodules and normal pulses. Further investigation confirmed antiphospholipid antibody triple positivity. Aspirin commenced, hydroxychloroquine restarted, MMF dose increased and rituximab administered. Left foot rash settled but right progressed with toe discolouration and numbness. Skin biopsy considered but not performed due to skin integrity concerns. Foot pulses remained present and normal. Bilateral lower limb doppler reported as normal;increased symptoms resulted in CT angiogram which revealed bilateral non-occlusive popliteal thrombus and left pulmonary embolus. Subsequent echocardiogram was normal. Patient was anticoagulated with low molecular weight heparin followed by warfarin. Vascular surgical team advocated medical management and patient received seven infusions of Iloprost followed by Sildenafil. She achieved near total resolution of skin changes to toes with only minimal loss of skin over tip of right great toe. Patient will now require long-termanticoagulation. Discussion/Results: APS was considered in initial differential diagnosis but patient did not meet current clinical criteria as no past evidence of thrombosis. Lupus anticoagulant was consistently strongly positive and anticardiolipin repeatedly negative. As anti-B2 glycoprotein 1 antibody is not routinely tested and must be verbally requested, it was only checked once (negative) prior to discovery of triple positivity. ANA reported as strongly positive at time of SLE diagnosis but reviewing original notes from India titre was 1:100 and therefore not highly convincing. ENA negative and complement and white cell count normal on repeat testing since. Therefore, it is probable that this patient has primary APS as opposed to secondary APS in association with SLE. However, it is possible that this patient may develop more symptoms of SLE over time. When this patient presented with foot rash there were high numbers of children presenting with varying severity of painful, itchy toes coined 'covid toes' due to suspected lin to SARS-CoV-2 infection. Patient had exposure history, and COVID antibody serology was difficult to interpret due to recent vaccination. Dermatology found appearance to be consistent with 'covid toes' and advised supportive treatment. The triple APS antibody positivity result provided probable aetiology. Providing evidence of thrombus was problematic with false reassurance from apparently normal lower limb arterial doppler when actually popliteal arteries were not checked in view of the presence of normal flow proximally at the groin and distally in the feet. This case highlights the need to continue to search for thrombus in presence of high titres antiphospholipid antibodies and particularly in the case of triple positivity as although patient presented with colour change to toes, she was entirely asymptomatic from her PE and her left foot improved spontaneously despite a left popliteal thrombus also being present. Key learning points/Conclusion: Non-criteria manifestation of thrombocytopenia (occurs in 25% paediatric APS patients) was present throughout and patient had past history of haematuria (a recognised renal non-criteria manifestation). A paediatric specific APS criteria including these may have resulted in earlier detection of triple antiphospholipid antibody positivity and thus earlier treatment escalation and possible avoidance of thrombus. It has been reported that a high proportion of children with positive antiphospholipid antibodies don't develop a thrombus. However, it is interesting that our patient was entirely asymptomatic from her pulmonary embolus which was an incidental finding on her CT angiogram. This prompts a discussion about how much imaging should be performed in those with high levels of persistent positive antiphospholipid antibodies. Rituximab resulted in normalisation of platelet count and ESR for the first time since initial presentation. Anticardiolipin antibodies normalised, lupus anticoagulant decreased from strong to moderate and anti- B2 glycoprotein levels decreased but remained positive. Rituximab is a recognised treatment for catastrophic antiphospholipid syndrome (CAPS) but not routinely used in APS. The consistently raised ESR in an apparently clinically well patient is a reminder to continue to search for causes of inflammation. As the CRP was largely in normal range, this demonstrates the unique value of the ESR. In view of anti-B2 glycoprotein 1 antibody requiring to be verbally requested, discussions are ongoing with the laboratory department regarding the possibility of electronic request and a comment with recommendation to check other two antiphospholipid antibodies following one positive antibody result. As a result of this case, a plan will be put in place to ensure annual screening of antiphospholipid antibodies in all juvenile SLE patients in our care. It is hoped that this case report promotes discussion amongst the paediatric rheumatology community regarding further research required for development of paediatric specific APS criteria and management.

All in the Marrow - a Case of Primary Bone Marrow Oedema

Introduction/Background: Primary bone marrow oedema syndrome is an elusive and less well-defined entity. Whether Rheumatologists should consider it as a stand alone diagnosis, is debatable. It possibly would be best described as an MRI feature which could be a finding in a number of diseases which would include the initial phases of Osteonecrosis of the bone, Rheumatoid Arthritis, Spondyloarthritis, Enthesitis related, Post traumatic, OA, Infections and Cancers. The treatment options become constricted due to the paucity of evidence. Rheumatologists need to consider this as an area of unmet need with development of consensus classification criteria and treatment approaches. Description/Method: 27-year-old male, Height 174 cms Weight 90 Kgs BMI 29 Kg/m2, became symptomatic in Jan 2022 with complains of pain in the both hip joints & groin regions, pain became excruciating and he became bed-bound, with early morning stiffness lasting approximately 45 mins. Had received steroids for COVID infection in August 2020. Investigations Hb 13.5gm/dl TLC 7000/mm3 Platelet 400 x 103/mm3 Sr Bil 0.8mg/dl AST 16 IU/L. ALT 24 IU/L Sr Creatininine 1.1mg/dl Blood Sugar Levels, Fasting 89 mg/dl Post Prandial 102 mg/dl ESR 10mm in 1st hour by Wintrobes method CRP Quantitative 29.38mg/L HLA B27 by PCR Negative, RF Negative, ACCP Negative Serum, IgG, Beta2 Glycoprotein 1.44 SGU Serum, IgM, Beta2 Glycoprotein 3.44 SGU Serum, IgG, Cardiolipin antibody 8.4 GPL Serum, IgG, Cardiolipin antibody 17.45 GPL Lupus anticoagulant by DRVVT Negative Sr Cholesterol 211mg/dl HDL 29 mg/dl LDL 156mg/dl TGs 130 mg/dl MRI Hips & SI joints Transient bone marrow oedema/osteopenia of bilateral hip. PET CT Increased metabolic activity in both hip joints Bone Scan (99mTcMDP) Increased vascularity in perfusion phase, increased accumulation in soft tissue in blood pool phase and increased uptake in bilateral Hip joints in skeletal phase scan, suggestive of CRPS Type-I. Management Was initially managed with Tab Etoricoxib 90mg BD, also started on Tab Sulphaslazine and Tab Methotrexate. However, when he had no symptomatic relief he was administered Inj Infliximab on 12 May 2022 and a second dose on 9 June 2022. He had excellent pain relief after the 1st dose, however after 10 days of the administration, he again began experiencing pain especially after walking. He also had pain in the knees on this occasion. He was also administered Inj Zoledronic 4mg on 23 May 2022. He is at present not requiring any NSAIDs over the last 1 month. Discussion/Results: The patient having presented with excruciating and debilitating pain was worked up and evaluation revealed features of bone marrow oedema on MRI which was corroborated with bone scan and PET CT imaging. The acute phase reactant CRP was also significantly elevated. The patient also gave history of early morning stiffness lasting approximately 45 mins. Hence an underlying Inflammatory process such as Spondyloarthritis(Peripheral) with enthesitis was considered. The confounding factors were the pain which worsened on mobilization, HLA B27 negative status, Rheumatoid Factor and ACCP negative status and past history of having received IV Corticosteroids for COVID infection in August 2020. In view of the debilitating pain and aworking diagnosis of Spondyloarthritis, hewas started onNSAIDs alongwith rest, initially, followed by conventional synthetic disease modifying agents in Rheumatic disease followed by biologic synthetic diseasemodifying agent - Inj Infliximab. The thought process was to avoid prolonged NSAID use to prevent the associated side effects. However, since Avascular Necrosis of the Femoral head is a very likely possibility, the patient is planned to be kept under close follow up. Key learning points/Conclusion: Collaborative efforts between the Departments of Nuclear Medicine, Radiology, Orthopaedics and Rheumatology are crucial in the early detection and approach to cases of Bone Marrow oedema. Avascular necrosis of head of Femur is a far more common entity and must be kept in ind even when a diagnosis of Bone Marrow oedema syndrome is being entertained. Diagnosis of Bone Marrow oedema syndrome must be entertained only as a diagnosis of exclusion. Continued follow up and regular imaging must be pursued rigorously in patients diagnosed with Bone Marrow oedema syndromes. There is a requirement to document acute phase reactants such as CRP and ESR in patients diagnosed with Avascular necrosis of bone as this data could help us differentiate AVN from Primary Bone marrow oedema in the early stages.

Same-Day Discharge Following Atrial Fibrillation Ablation Procedure

Background: Complications following atrial fibrillation (AF) ablation have steadily decreased over the past decade. Following the global COVID-19 pandemic, significant pressure was put on electrophysiology labs to reduce their use of hospital beds. We sought to determine the feasibility as well as safety of same-day discharge following AF ablation procedure. Methods and Results: Between April 2020 and April 2022, 134 patients underwent an AF ablation in our institution and were scheduled to be discharged the same day. Among them, 86.6% (116) went home an average of 8.1 hours after the sheaths were pulled. As for the remaining 18 patients, the majority stayed because the procedure finished too late for the monitoring period to be complete and had no complications requiring an overnight stay. Of the remaining 5 patients, 3 stayed for groin bleed, 1 for minor pericardial effusion and 1 for pulmonary edema. All except the pulmonary edema patient went home the next day. As for the 116 patients who went home the same day, 9.5% (11) came back in the following week to the ER with either pericardial pain (7), shortness of breath (1), recurrent arrhythmia (1) or minor groin discomfort (3). All of them were safely discharged from the ER the same day. Conclusion(s): Our data confirms that same-day discharge following AF ablation procedures is both safe and feasible as confirmed by the absence of any major complications in our single center experience. Some patients came back to the emergency room for expected post ablation discomfort, but none required an overnight stay. Copyright © 2022

Direct Admission Versus Secondary Transfer for Patients Treated with Mechanical Thrombectomy in Our Comprehensive Stroke Centre - Has Our Relocation Been Justified?

Background and Aims: Mechanical thrombectomy can only be performed in comprehensive stroke centres (CSC) which provide onsite interventional radiology and neurosurgical services. The benefits of direct admission to a CSC versus secondary transfer following initial admission to a stroke unit without MT service are heavily contested. Nottingham University Hospitals provides the East Midlands' Mechanical Thrombectomy (MT) service in the United Kingdom. With an aim to reduce the number of transfers for patients eligible for MT within the region, we relocated our stroke services from Nottingham City Hospital (NCH) to Queens' Medical Centre (QMC), a major trauma centre with on-site interventional services in July 2020. Method(s): We compared timings of stroke assessment and outcomes for consecutive patients transferred from NCH to those who were directly admitted to QMC after the change in our service model. Result(s): 101 patients admitted from Nottingham underwent MT between January 2019 and January 2022. For patients transferred (n=48) and patients directly admitted (n=53) respectively: average time from CT scan to groin puncture were 163 and 151 minutes;reperfusion rates (TICI>2a) were 100% and 96%. The median modified Rankin Score on discharge were 3.5 and 3.6 respectively. Conclusion(s): Although shorter imaging-to-groin puncture time was demonstrated post-relocation, comparable functional outcomes were seen between patients transferred and directly admitted to our CSC. This could be attributed to an increased time window of MT eligibility from 6 to 24 hours post symptom onset after our relocation. Further studies are required to establish its effects and explore the impacts of the COVID-19 pandemic on our stroke service.

Results of treatment of the post-COVID-19 infection femur head aseptic necrosis

Objective: To study the clinical signs and methods of treatment of patients with COVID-19-related femoral head aseptic necrosis. Method(s): There were 80 patients (65 men and 15 women) with COVID-19-related femoral head aseptic necrosis. In the first days of the disease, pain was noted in the groin area and hip joint, which increased after 2-3 days. Because of the pain, the physical activity of patients was sharply reduced, some patients could not walk. A characteristic early clinical sign of femoral head aseptic necrosis after COVID-19 infection in 60% was observed limitation of internal rotational movements of the thigh in the area of the hip joint, limitation of external rotational movements of the thigh was noted in 40% of patients with stages 1-2 of the disease. Both internal and external rotational movements of the thigh in the area of the hip joint 100%. All patients had 3-4 stages of the disease. Depending on the stage of the disease, various methods of treatment were carried out. Result(s): In the early stage 1-2 of the disease, patients were prescribed anti-inflammatory drugs (Dexalgin), therapeutic blockades and injections, physiotherapy, manual and underwater massage, exercise therapy, plasma therapy. If conservative treatment was ineffective, surgical treatment was performed. Patients underwent our proposed method, a minimally invasive decompressive, revascularization surgery in the head of the femur using stromal vascular fraction, bone marrow concentrate, and using bioceramics. In stage 3-4, hip arthroplasty is used. Conclusion(s): Clinical signs of COVID-19-related femoral head aseptic necrosis make it possible to determine the degenerative-destructive changes and the choice of treatment method. In stages 1-2 decompressive, revascularization operations were performed in the area of the femoral head using stromal vascular fraction, bone marrow concentrate, and with the use of bioceramics. In stages 3-4 of the disease, we perform arthroplasty.

Case report: post-Covid-19 arthritis and peri arthritis

We present the case of a 63 years old male patient known for type 2 diabetes and sleep apnoea. He was admitted as inpatient for a nontraumatic severe and disabling left hip pain. The pain started progressively one month ago. The medical history was otherwise irrelevant, with no general symptoms nor other symptoms suggestive of an inflammatory disease. To mention a history of an asymptomatic SARS-COV2 infection, diagnosed by a naso-pharyngial PCR, approximately 10 days before the onset of the pain. On physical examination, the patient was afebrile. The palpation of the inguinal region was tender on palpation with marked limitation of the hip range of motion. The spine and other peripheral joints were painless without inflammatory sign. Moreover, there was no skin lesion nor inguinal lymph nods enlargement. Due to the importance of pain with marked functional limitation, the patient is hospitalized for investigations and pain-management. On blood sample there was a mild increase of inflammatory markers (CRP 25mg/l, VS 20mm/h) with normal cell count. Standard X-rays of the pelvis and hip were normal. The MRI of the hip showed a mild coxo-femoral arthritis with marked inflammation of the surrounding musculature. An arthrocentesis was performed and 2ml of serous fluid was aspirated. There were no crystals. The cellularity could not be tested due to small amounts of fluid. The synovial culture showed a polymicrobious growth compatible with contamination. In summary, we were facing a patient with an acute and very painful hip monoarthritis. There was no history of gastrointestinal or urinary tract infection, the search for C. trachomatis and N. gonorrhoea in urines was negative. An extensive serologic testing (HIV, HBV, HCV, HBV, HCV, HIV, Lyme, Syphilis, Coxiella, Bartonella, Brucella & Quantiferon) and the search for T. whipplei were negative as well. There was no HLA-B27 and rheumatoid factor, ACPA, ANA, ANCA and specific antibodies related to polymyositis were negative. The chest-abdomen-pelvis scan showed no sign of neoplasia. To rule out a vasculitis we proceeded to a PET-CT, which showed no sign of vasculitis or myositis. Considering the timing of the onset of the symptoms and the absence of any other diagnosis, the patient was diagnosed with reactive arthritis caused by SARS-COV2. The patient was treated with Diclofenac 150 mg/day and opioids. The clinical evaluation one month after discharge showed a spontaneous significant improvement.

Critical leg ischemia related to COVID 19 in doubly vaccinated patients

Background: COVID and venous thromboembolism in unvaccinated population is now a well-established entity but this case is unique as the 1) patient had both COVID vaccines and then tested positive for COVID and 2) presented with vague symptoms and had minimum oxygen requirement 3) developed arterial thromboembolism and acute leg ischemia after 4 days of admission leading to limb amputation ultimately. Data on COVID and COVID vaccine's association with Arterial thromboembolismstill needs to be explored. In our case it was challenging to establish whether the thromboembolism was a complication of vaccine, COVID or was that the result of synergistic interaction of both. Case Presentation: 61 Years old gentleman presented to Emergency Department with vague history of lethargy ongoing for 3-4 weeks and no significant prior co-morbid except sickle cell trait. He had received both doses of COVID vaccine 2 months before presentation and denied any shortness of breath, cough, fever or pain. On presentation he was de-saturating to 77% on Room air and had bilateral crepitations in his chest with PO2 of 7.4 kPa on ABG and raised inflammatory markers on bloods. His CXR showed changes consistent with COVID and he was started on Dexamethasone. His COVID test came back as positive. Throughout his staymaximumamount of oxygen required by him was 36% day1 which improved to 28-32% later, he had not been tachypneic or tachycardiac. His d-dimer was raised at 3000 which was thought to be COVID related, and the decision was taken to perform CTPA to rule out Pulmonary embolism if oxygen requirement worsens. His oxygen requirement continued to remain static with a little improvement or worsening. His inflammatory markers also got better. On Day 4 Patient complained of Right Leg pain. On further enquiry he revealed pain has been ongoing for last 2-3 weeks. His legs were bilaterally ice cold to touch and had hair loss in bilateral legs, pulses in both legs down the femoral artery were not palpable bilaterally. His blood gas Lactate was 2.6 with worsening inflammatory markers but no fever spikes or worsening in oxygen requirement or any other symptoms apart from leg pain. He was immediately seen by vascular Surgery team and was started on therapeutic anticoagulation suspecting acute leg ischemia. CT Angio report showed: Occlusion of Right iliac system, common femoral artery part of the SFA and all the popliteal artery and tibial vessels and unstable thrombus in the left common iliac artery causing severe stenosis and occluded left TP trunk. He was continued on therapeutic anticoagulation and then underwent Right iliofemoral embolectomy, on table angiogram, left common iliac angioplasty via left groin approach and right above knee amputation. Postoperatively he remained well and was tested COVID negative later. He was then discharged to Rehab from hospital for further care. Discussion and conclusion: We suggest that COVID patients with significantly raised d-dimers should be investigated for hidden thromboembolic focus in same way in non COVID patients and not just in lungs but in other organ systems as well. There should be some guidelines regarding increased dose prophylaxis or a flowchart to investigate for these thromboembolic association in COVID.

HYPEREOSINOPHILIC SYNDROME FOLLOWING the BNT162B2 (BIONTECH/PFIZER) VACCINATION

Background: Some reports of small vessel vasculitis following nSARS-CoV2 vaccination are reported in the literature (1, 2). Objectives: We purpose to report the case of small-medium vessel vasculitis after BNT162b2 (BioNTech/Pfzer) vaccination. Methods: We present the case of a 48 years old man with an unremarkable history who underwent BNT162b2 vaccination. Results: Five days after the frst shot of BNT162b2 vaccine, the patient refer the onset of left inguinal adenopathy, and erythematous dermatitis of the trunk. Ultrasound of the groin found increase bilateral inguinal lymph nodes with reactive characters. Contextually, erythematous, itchy and painful nodular lesions appear in the lower and upper limbs as well as acrocyanosis and paresthesia in the right hand and foot. The tests performed showed thrombocytopenia and eosinophilia. While, CRP, search for fecal parasites, pANCA, cANCA, ANA, RAST test, serum tryptase were all absent. Haematological evaluation, bone marrow biopsy, karyotype and molecular biology (FIP1L1/PDGFRa), were performed, all results negative. The patient was admitted in Internal Medicine ward for worsening of skin lesions and of acrocyanosis with gangrenous lesions at the tips of the fourth fnger of the right hand. An angio-CT showed an occlusion of the right ulnar artery. At electromyography an axonal sensory neuropathy was found. The skin biopsy showed fbrinoid necrosis of venules of the superfcial vascular plexus associated with numerous eosinophils, lymphocytes and karyorrhetic debris (Figure 1). High-resolution CT scan described diffuse minimal accentuation of the interstitial texture with micronodular aspects and some ground glass appearance. The diagnosis of hypereosinophilic syndrome was made. Therapy with Methylprednisolone 500 mg/daily for 3 days then Prednisone 1 mg/kg daily in association with IL-5 inhibitor (mepolizumab) with good clinical response, in addition to anticoagulation with warfarin was started. Conclusion: To our knowledge this might be the frst case of (HES) following COVID vaccine. As our experience, due to the short commercialization of anti-nSARs-CoV2 vaccines, is limited further studies are needed to explore the possible effect on small-medium vessels.

MIDDLE MENINGEAL ARTERY EMBOLIZATION AS A SAME-DAY DISCHARGE PROCEDURE

Introduction Middle meningeal artery embolization (MMAE) is a fundamental piece in the management of Chronic Subdural Hematoma (cSDH) that prevents recurrence and can serve as primary treatment for nonoperative candidates. MMAE offers time-effectiveness, since it may be performed in less than one hour under minimal sedation. As the COVID-19 pandemic makes inpatient beds scarce, MMAE could potentially become a same-day procedure which poses a potential economic benefit for both patients and health institutions alike. We reviewed MMAEs performed at our institution and measured the complication rates in an effort to determine if hospital admission after the procedure is necessary. Methods A retrospective analysis of patients who underwent MMAE for cSDH at the University of California, San Diego was performed. Data collected included post-procedural complications such as focal neurologic deficit, cognitive decline, and groin access-point hemorrhage identified within the first 4 hours, 24 hours, and delayed manner respectively. Success of treatment was defined as patient stability and return to baseline following the post-procedure assessment protocol performed routinely at our institution. We further characterized patients with the Charlson Comorbidity Index (CCI) to identify higher risk populations that would require increased observation. The CCI was also used to determine a cut-off point for same-day discharge eligibility. Results We analyzed data from 95 patients that had 143 subdural hematomas treated at our institution. Of the 95 patients, 93 patients (98%) had no complications following our institution's standardized assessments after MMAE or at discharge the following day. Average SDH size was 12.9mm. Twenty-one patients underwent surgical drainage after MMAE. Following MMAE, two patients presented complications;one patient, an 83-year-old female, developed transient headache and blurry vision one day after MMAE and was discharged uneventfully;this patient had a CCI of 4 points. The other patient was a 77-year-old male with metastatic prostate carcinoma and had an SDH volume expansion one day after the procedure which required operative intervention with burr-hole craniotomy and drainage;this patient had a CCI of 9 points (0% estimated 10-year survival). The remaining 93 patients suffered no complications after MMAE. Conclusion Time-effectiveness and low complication rates make MMAE an ideal same-day procedure for patients with cSDH and a low CCI score. The grand majority of patients had no complications following MMAE, suggesting a large patient population that may benefit from the same-day procedure aspect of intervention. Although some patients underwent planned surgical drainage, the embolization component of management was uneventful. Our analysis provides evidence that MMAE could develop into an ambulatory procedure in patients with cSDH and a low comorbidity profile;this could have economic benefits for both the patients requiring and the institutions offering the procedure. Further prospective studies are needed to strengthen these findings.

Upskirt exposure: The effectiveness of lead skirts to protect the urologist during seated endoscopic stone surgery

Introduction & Objectives: The use of intra-operative image intensifier (II) has increased in urological practice as the mainstay of stone surgery is performed endoscopically. Here we examine the radiation exposure to the groin of the urologist performed endoscopic stone surgery. Our primary aim was to assess whether urologists are exposed to potentially avoidable radiation exposure in the seated position when using vest and skirt lead protection. We hypothesize that the level of exposure is negligible and should not influence surgeon decision on seated versus standing or on lead apron versus skirt and vest combination protective wear. Methods: We conducted a prospective, multicentre study across all public hospitals in the Hunter New England Area Health Network offering Holmium:YAG laser lithotripsy. Routinely, servicing a very large population base, the number of laser lithotripsy cases are quite high however during our research period the coronavirus pandemic diminished the number of elective cases performed. Because of this, we included a total of 50 cases in this study. Small multidimensional-reading dosimeters were worn on the medial aspect of both upper thighs of the urologist under the lead skirt as well as a third dosimeter worn on the outside of the lead protective skirt. All cases were performed with the II in an under-couch position and all cases included were either ureteroscopy or pyeloscopy with laser destruction of urinary stones. In one centre, all surgery was performed by a consultant urologist whilst in another it was all performed by a registrar. Screening time and total dose delivered were prospectively collected using the local network picture archiving and communication system (PACS). This data was analysed by an onsite physicist and collated. After calculating mean and median radiation dose exposures for each dosimeter and grouping those worn under the skirt, comparison was made between dosimeters worn under skirt versus over skirt and Results: Lead gowns reduced radiation dose exposure by 87% (p = <0.01);99% on the side opposite the II and by 76% on the same side of the II (p = 0.2). Mean total dose area product was 88.9 GyCm2 with a mean screening time of 80 seconds per case (range 12-311 seconds). Conclusions: These results support the hypothesis that there is no significant exposure risk in a seated position with vest and skirt combination lead protective wear. An unexpected result was the difference in exposure between the side closest versus furthest away from the image intensifier.

Two cases of a pityriasis rubra pilaris (PRP)-like skin eruption following administration of the Pfizer-BioNTech mRNA and AstraZeneca COVID-19 vaccines

Since the approval of vaccines for SARS-CoV-2, dermatologists have sought to characterize the adverse cutaneous effects associated with those vaccines. We describe two cases of pityriasis rubra pilaris (PRP) following vaccination against COVID-19. A 51-year-old man initially developed an erythematous scaly rash in his groin and over his knees 3 days following the first dose of the Pfizer COVID-19 vaccine. He presented after the second dose, as the rash worsened, affecting 60% body surface area (BSA). On examination there was an erythematous skin eruption extending from his scalp to both arms and the proximal thighs with sparing of the periumbilical area. There was no evidence of palmoplantar hyperkeratosis. The second case is a 51-year-old man presented with an itchy, erythematous rash affecting >80% BSA, 2 days after his first dose of the AstraZeneca COVID-19 vaccine. On examination there were multiple erythematous annular plaques, some of which were becoming more confluent, with islands of sparing. There was no evidence of palmoplantar hyperkeratosis. Differential diagnosis in both included drug-induced psoriasis and PRP. Histopathological diagnosis was consistent with PRP. Management of both cases included ruling out occult malignancy and infectious causes. Both patients were treated with acitretin and topical steroids. It is important to recognize this serious adverse event early so appropriate treatment can be initiated. When the culprit is the COVID-19 vaccine, typical features like palmoplantar hyperkeratosis may not be present. If PRP occurs after the first dose then discussion with the patient, weighing the risks and benefits including worsening of disease compared with the possibility of severe disease/death from COVID-19, is needed.

STROKE CARE IN CROATIA DURING COVID-19 PANDEMIC THROUGH RES-Q aREGISTRY DATA

Background and aims: The Registry of Stroke Care Quality (RES-Q) is a tool for monitoring the quality of stroke care in hospitals throughout Europe. The COVID-19 pandemic was associated with a global decline in the volume of stroke hospitalizations and revascularization procedures. The aim was to compare results captured from RES-Q registry in Croatia in March 2019 and March 2020 and March 2021, before, during the first wave, and third wave of the COVID-19 pandemic in Croatia Patients and methods: Data on demographics, stroke care pathway, specific acute treatment, and prevention issues, in all acute stroke admissions in Croatia during March 2019 and March 2020, and March 2021 through the RES-Q registry were analyzed. Results: The study included 1 comprehensive stroke center and 7 primary stroke centers in Croatia, which captured data in all three periods. We have noted a reduction of stroke patients' admissions during the COVID-19 pandemic for 26.6% during the first wave and for 16.7% during the third wave. (Figure Presented) Conclusion: Our results showed a reduction of stroke patients' admissions in both periods;reduced numbers of female patients and patients with subarachnoid hemorrhage, and transfers among hospitals with prolonged door-to-needle time and door-to-groin time during the first wave of COVID-19 pandemic. The usage of revascularization therapies has shown a slight increase in the evaluated period.

Pre-Pandemic Sentinel Lymph Node Biopsy In Vulvar Cancer: 4-Year Single Centre Audit

Introduction and aims of the study: In early vulvar cancer, lymph node status is the most important prognostic factor. Sentinel lymph node biopsy (SLNB) is the minimally invasive procedure that lead to the most significant reduction in the classical high morbidity associated with the sistematic inguinal-femoral lymphadenectomy. Besides quality control, the aim of this study is to document the overall experience around SLNB at this referral Centre before the Covid pandemic, in order to monitor and possibly prevent future related changes. Methods: Retrospective analysis of patient files in cases where SLNB was performed as part of the treatment for vulvar cancer at the authors’ Department, from January, 2016 to December, 2019. A single surgeon performed the SLNB with the combined technique (technetium and patent blue). Data collected included demographics, pathology, accuracy, surgery and perioperative results, feasibility and survival. Results: 18 patients with vulvar squamous cell cancer were enrolled in the study. Median age was 68 years, average BMI 27.5kg/m2, 61.1% were married and Charlson score ≥5 was 55.6%. Primary site was labia majora in 44.4% and mid-line was affected in 27.8%. FIGO stage IB in 72.2% of cases, mean tumour diameter was 20.2 (7-39)mm. SLNB was bilateral in 27.8%, 1 out of 38 nodes removed was positive and average number of nodes per patient was 2.1. Mean hospital stay was 13.2 days, blood loss 72ml and no surgical complications. There was a single case of groin recurrence in 45.1 months mean follow-up time and 2 cases of non-related deaths. 33.3% and 5.6% patients had short and long-term postoperative complications, respectively, mostly infectious. Conclusions: SLNB is a reliable and safe minimally invasive technique that should be performed by experienced gynaecological oncologists in well-equipped and multidisciplinary Centres. The Covid pandemic is believed to be causing severe difficulties in the management of patients with vulvar cancer, from diagnosis to follow-up and treatment of recurrences. This study allows a future comparison with positive results at this Centre, possibly reflecting other similar scenarios in Europe.

BMS e-CON 2021 Conference Proceedings on “Exploring the Newer Modalities in Teaching - Learning and Research in Basic Medical Sciences during COVID-19 Era”

The proceedings contain 194 papers. The topics discussed include: regional variation of human pancreatic islets dimension and its impact on beta cells in Indian population;cytogenetic effects of formalin exposure on buccal mucosa: a cross-sectional observational study;association of sperm DNA fragmentation with serum lipid profile among males with abnormal semen parameters;embryological and clinico-anatomical perspective of ilioinguinal nerve variations in inguinal region;student involved fun activities- a novel strategy to teach functional correlation of brain in anatomy lectures;anti-hyperglycemic activity of ethonalic extract of stem of cissus quadrangularis in streptozotocin induced experimental diabetic rats-blood parameters;attitude and response of first year medical students towards cadaveric dissection in medical colleges of south Karnataka;and unilateral ectopic pelvic kidney - a rare case.

Neuromuscular electrical stimulation prevents the skeletal muscle weakness in patients with severe COVID-19 associated with sepsis and septic shock: a case series

Introduction: Neuromuscular electrical stimulation (NMES) results on muscle strength and functionality in patients with severe coronavirus disease 2019 (COVID-19) associated with sepsis and septic shock are unknown. Methods: Patients with severe COVID-19 associated with sepsis or septic shock were selected. The NMES intervention was performed on 7 consecutive days in a daily session of 40 min (frequency of 100 Hz and a pulse of 350 μs). Electrodes were positioned in the vastus medialis and vastus lateralis muscles, and inguinal region. The outcome measures were the femoris cross-sectional area (RF-CSA), thickness of the anterior compartment of the quadriceps muscle, rectus femoris echogenicity, International Classification of Functioning, Disability, and Health (ICF)-muscle strength, Physical Function ICU Test-scored (PFIT-s), Morton Mobility Index (DEMMI), and the Surgical Intensive Care Unit Optimal Mobilization Score (SOMS). The patients were evaluated on days 1, 5, and 8. Results: The RF-CSA area decreased significantly (- 16.9%;p < 0.05) from days 1 to 8, but showed maintenance of the thickness of the anterior compartment of the quadriceps muscle (- 3.20%;p = 0.3) from days 1 to 8. These patients showed a reduction of 2.1% per day in the rectus femoris cross-sectional area and 0.3% per day in the thickness of the anterior compartment of the quadriceps muscle during 8 days. Patients showed maintenance of the echogenicity (1.3%;p = 0.8) from days 1 to 8 with an increase of 0.16% per day. All patients showed an increase in the MRC score and reduction of the ICF-muscle strength, meaning improved muscle strength from days 1 to 8 (p < 0.05). The PFIT-s increased from days 1 to 5 and improved until day 8 compared to day 5 (p < 0.05). DEMMI and SOMS scores increased on day 8 compared to days 1 and 5 (p < 0.05). Conclusions: NMES showed a protective effect on muscle strength and improve the functionality of patients with several COVID-19 associated with sepsis and septic shock.

Scrotal ultrasound in young men with acute scrotal pain: A retrospective consecutive case series audit

Introduction: Although not recommended by EAU guidelines, many men with acute scrotal pain undergo ultrasound (US) to screen for occult tumours. This has low diagnostic yield and must be weighed against the increased risks of coronavirus due to additional hospital attendances, inconvenience for the patient, and demand on NHS resources. We evaluated our case series to determine current practice and diagnostic yield. Method: 141 consecutive cases of scrotal pain and/or swelling were identified from our Trust's Surgical Assessment Unit (September- December 2020). Clinical diagnosis, and where performed, timing, indication and outcome of scrotal US was recorded. Results: 109/141 patients underwent scrotal US;the only urgent clinical indications were suspected collection/abscess (5 cases) or testicular mass (4). Relative indications included uncertain diagnosis (27 cases), suspected missed testicular torsion (6) and suspected hernia (1). 66/ 109 US performed were for 'soft' indications, however one occult testicular tumour, one acute testicular torsion and two inguinal herniae were unexpectedly found. Conclusions: Scrotal US changed immediate patient management in 1/ 109 cases (acute testicular torsion). Early outpatient US would be sufficient to diagnose occult testicular tumour, missed testicular torsions and groin herniae. There is too much reliance on US;more focus on history and examination is needed.