Cutaneous Adverse Drug Reactions of COVID-19 Vaccines: A Cross-Sectional Study of the Largest Healthcare System in Taiwan

Objectives: Potential cutaneous adverse drug reactions (cADRs) associated with COVID-19 vaccinations are well-known. However, comprehensive evaluation including detailed patient characteristics, vaccine types, signs and symptoms, treatments and outcomes from such cADRs are still lacking in Taiwan. Method(s): A cross-sectional study was conducted from December 2019 to October 2022 to analyze spontaneous ADR reporting data from Taiwan's largest multi-institutional healthcare system. Physicians and pharmacists initially ensured the data quality and completeness of the reported ADR records. Subsequently, we applied descriptive statistics to analyze the patient cohort based on demographic characteristics, administered COVID-19 vaccines, clinical manifestations, and patient management. Result(s): We identified 242 cADRs from 759 reported COVID-19 vaccine-related ADRs, 88.3% of which were judged as "possible" using the Naranjo Scale. The mean age of patients with cADRs was 48.1+/-17.5 years, with the majority (44.2%) of cADRs reported in the 40-64yr old age group. cADRs were more common in women (68.2%) and most of the patients had no history of allergy to vaccines (99.6%). Oxford/AstraZeneca (58.6%) accounted for the most reported brand of COVID-19 vaccines. Patients developed cADRs within 1 to 198 days (median = 5.5 days), and mostly after first-dose vaccination (77.8%). The most frequently reported cADR was rash/eruption (18.7%), followed by itchiness/pruritus (11.7%) and urticaria (9.2%), mainly affecting the lower limbs (23.8%) and upper limbs (22.6%). Medications were prescribed for 65.1% of the cADRs, and signs and symptoms were resolved within 1 to 167 days (median = 7 days) after treatment with oral antihistamines (23.0%), topical corticosteroids (14.6%) or oral corticosteroids (14.4%). Conclusion(s): Our findings provide comprehensive details regarding COVID-19 vaccine-related cADRs in Taiwan. Certain groups, especially women and the middle-aged, who reported a relatively higher rate of cADRs, may benefit from pre-vaccination counseling about the risks of cADRs and the use of appropriate medications.Copyright © 2023

Surgical clinical characteristics of acute arterial thrombosis of the extremities in the context of SARS-CoV-2 infection

Objective: To determine the clinical-surgical features of critical limb ischaemia (CLI) within the context of infection by SARS-CoV-2. Method(s): Cross-sectional, retrospective, observational, descriptive study, with clinical data obtained from printed and electronic records of patients with CLI treated by the Angiology and Vascular Surgery Service of the General Hospital of Mexico in the period between January 2020 and July 2021. Result(s): We evaluated the data of 33 patients with critical limb ischaemia of which 15 were positive for SARS-CoV-2 in the period from January 2020 to July 2021, females were the most affected representing the 53.3% of the total, patients under 60 years old accounted for 26.67%. Twenty-six percent of the patients presented critical limb ischaemia without having previous comorbidities, 60% of these presented with an advanced state of the disease and a delay in specialised medical care of more than 6 hours after the onset of symptoms, which warranted a major amputation in 37% of cases, the lower extremities represented 90% of the affected anatomical regions. Conclusion(s): the outcomes in our study show that the incidence of critical limb ischaemia during the SARS-CoV2 pandemic period occurred in an atypical way in a segment of young patients and without known event-generating comorbidities. Thromboembolic events, probably associated with the hypercoagulable state generated by this infection, also evolved rapidly and aggressively from the onset of symptoms despite prompt treatment.Copyright © 2022 Sociedad Medica del Hospital General de Mexico. Published by Permanyer.

The Magnitude of Covid-19 Effect on Melanoma Diagnosis, Histopathologic Features and Stage of the Disease in University Hospital of Split

Introduction: Due to the COVID-19 pandemic, some planned medical activities have been postponed, for both national directives and out of concern of the patients who were afraid to go to hospitals. Skin cancers, especially melanomas, diagnosed during lockdown also differed from pre-lockdown tumors in several notable ways, such as number of newly diagnosed patients and histopathologic features. The primary tumor thickness (mm), ulceration (%), anatomic localization, and regional lymph node involvements are important elements for determining the melanoma staging and prognosis. Aim(s): The aim of this report was to investigate the difference in number of newly diagnosed melanoma patients, histopathological features and melanoma TNM-staging between comparable pre-pandemic (March 2019 until March 2020) and pandemic periods (March 2020 until March 2021). Method(s): We collected the data from hospital clinical and pathohistological databases on the total number of newly diagnosed patients with melanoma in University Hospital of Split. Comparative analyses were performed in a pre-pandemic and a pandemic cohort. Result(s): Comparing the first year of the pandemic (N=57) with the same period one year before (N=69), 17,4% decrease of melanoma cases was observed. Cohort analysis showed no differences in the distribution of age and sex. The median age of the melanoma patients in a pre-pandemic cohort was 66 years (29-86), and in pandemic cohort 68 years (31-88). The male gender predominated among melanoma patients. In a pre-pandemic cohort, 63,8% of melanoma patients were man, and in pandemic cohort 68,4%. Cohort analysis showed differences in the primary localization of skin melanoma. In pre-pandemic cohort, primary localization of melanoma were head and neck in 17 patients (25%), trunk in 26 patients (38%), upper extremities in 13 patients (19,1%), lower extremities in 10 patients (14.7%) and unknown primary site in 2 patients (2,9%). In pandemic cohort, primary localization of melanoma were head and neck in 10 patients (17,5%), trunk in 32 patients (56,1%), upper extremities in 8 patients (14%), lower extremities in 5 patients (8,8%) and unknown primary site in 2 patients (3,5%). Cohort analysis showed no differences in the pathohistological subtypes. The most common pathohistological subtypes in both cohorts were superficial spreading subtype (21,7% vs 25,8%), unclassified (21,7% vs 17,5%) and nodular subtype (14,5% vs 17,5%). In pandemic cohort we diagnosed patients with increased tumor thickness and positive lymph nodes. In pre-pandemic cohorts we had more patients with thickness less than 1 mm (40,6% vs 31,6%). We found more patients with tumor thickness between 1 to 2 mm (17,5% vs 4,3%) and more than 4 mm (25% vs 20%) in pandemic. Accordingly, in pandemic cohort we found more patients with positive lymph nodes then in pre-pandemic (22,9% vs 5,9%), and more patients with initially metastatic disease (22,8% vs 15,9%). We did not observed any differences in presence of ulceration among the studied cohorts (26% vs 28%). Conclusion(s): In the analysis conducted in University Hospital of Split, we observed a marked decrease of newly diagnosed melanoma patients in the first year of the pandemic compared to the same period before the pandemic. We observed increased tumor thickness, more patients with lymph nodes involvements and initially metastatic disease in post-lockdown period. These findings may be the result of delays in diagnosis due to the disruptions in routine dermatologic and oncologic care during Covid-19 pandemic. The further analyses are needed to fully understand the impact of the Covid-19 pandemic on melanoma outcomes.

Abdominal Aortic Occlusion in Setting of Covid-19

Introduction: The incidence of arterial thrombosis among critically ill patients with COVID-19 is 4.4%, acute aortic obstruction alone having a mortality rate of 31%. We present a review of the literature regarding isolated abdominal aortic thrombosis (IAAT) in the setting of COVID-19 infection, as well as a case presentation. Method(s): A literature review was performed using Pubmed with the keywords, aorta, aortic, thrombus, and Covid-19. Within these articles, the scope was narrowed to articles that related to IAAT in the setting of Covid-19 infection. Result(s): Our literature review found 9 articles detailing a total of 11 cases of IAAT in the setting of COVID-19 infection. IAAT had a mortality 22% (2 out of 9 patients). Approximately, 55% (6 out of 11) of the patients were treated with surgery and 27% (3 out of 11) received anticoagulation. 73%, (8 out of 11) of the patients in our literature review presented with symptoms of acute limb ischemia. Ages ranged from neonate to 85 years old, though 82% (9 out of 11) were over the age of 50. Conclusion(s): Our literature review suggests that IAAT is a serious complication of COVID-19 infection. IAAT is more common in males and people over the age of 50, which aligns with the 52 year- old male patient who presented to our clinic with lower extremity claudication and bilateral 1st & 5th toe cyanosis after COVID-19 infection. To prevent devastating limb ischemia, we emphasize early evaluation of claudication symptoms in patients with COVID-19 or recent COVID-19 infection.

The incidence of deep vein thrombosis following COVID-19 vaccination in an Australian population

Introduction: After the COVID-19 vaccination roll out in March 2021 patients began presenting to a Victorian Emergency Department with lower limb pain following their vaccination. As a result, requests for ultrasound examinations, to exclude post vaccination deep vein thrombosis (DVT) began appearing. Method(s): A retrospective study of ultrasound examinations and their result over a 1-year period was undertaken. Patients were identified who had a clinical indication of having been referred following COVID-19 vaccination. Bivariate analysis was conducted, using logistic regression, to determine the strength of association between independent variables. Result(s): The study found 1689 patients had a lower limb DVT ultrasound examination. Ultrasound was positive for DVT in 244/1689 patients (14.4%). 104/1689 (6.1%) patients presented for ultrasound following COVID-19 vaccination. Six of these were found to have DVT detected. The association between post vaccination and DVT was an odds ratio (OR) of 0.347 (95% CI 0.150 to 0.799, p = 0.013). All patients had recently received AstraZeneca (AZ) vaccine. Four patients were diagnosed with superficial vein thrombosis (SVT) post vaccination. Nineteen patients were identified as COVID-19 positive. Three of these had DVT detected. Conclusion(s): This study found 6 patients out of 1689 (0.35%) of lower limb ultrasound examinations over a one-year period, were positive for DVT after COVID-19 vaccination. Take home message: The results showed post vaccination patients were less likely to be diagnosed with a DVT than the population referred who had not had recent vaccination.

ID: 215433 The History of Spinal Cord Stimulation to Treat Painful Diabetic Peripheral Neuropathy

Introduction: Diabetic peripheral neuropathy (DPN) is the most common neuropathic syndrome seen in patients with diabetes. Roughly 30% of the diabetes patient population1 experience painful DPN symptoms including bilateral stabbing or burning pain in addition to numbness in the feet and lower legs. Traditionally painful DPN symptoms have been treated with conventional medical management (CMM) including glycemic control, general risk factor management, as well as pharmaceutical agents. These treatment approaches are often unsuccessful in the long-term1. Spinal cord stimulation (SCS) has been demonstrated as an effective treatment for painful DPN of the lower extremities with multiple publications dating back to 1996 showing benefits of SCS for pain relief and improved Quality of Life (QoL) in DPN patients (Figure 1)2-18. Method(s): A systematic literature review of the robust body of evidence for SCS in the treatment of painful DPN was conducted. Publications were selected for inclusion by two independent reviewers using defined selection criteria. Additional relevant publications from outside the search dates were included. Result(s): SCS was first documented as an effective treatment for DPN in three single-arm studies published between 1996 and 20122,4,5, one of which was followed-up to thirty-six months18, and another to seven-years3. These studies paved the way for two RCTs published in 20146,7, one of which was followed-up to five-years in two publications8,10, and another7 was followed-up with analyses on QoL9 and an evaluation of the effects of burst SCS17. Two meta-analyses were published in 2020 and 202111,12. A post-hoc analysis of a multi-center single-arm study on high frequency (10kHz) SCS to treat DPN was published in 202013 and followed by an RCT published in 202114 with additional 1-year follow-up15,16. Collectively these studies demonstrate that SCS is an effective therapy for patients with painful DPN by reducing pain and increasing QoL for DPN patients (Figure 1). Conclusion(s): This review of a large body of evidence shows a decades-long history of the effectiveness of SCS for symptom relief in patients suffering from painful DPN. Future research on the effectiveness of new waveforms and novel methods of energy delivery to the spinal cord are needed. The study of outcomes in addition to pain relief is also needed, which may better illustrate the breadth of effects of SCS therapy on the underlying disease factors. Increasing awareness of the current evidence is essential to increasing therapy adoption by expanding payer support and influencing referring health care provider behavior. Disclosure: Eric Grigsby, MD: AE Mann Foundation: Consulting Fee: Self, Bioness Inc.: Consulting Fee: Self, Medallion Therapeutics: Consulting Fee: Self, Medtronic: Consulting Fee: Self, SPR Therapeutics: Consultant: Self, Tenex Health: Consultant: Self, Voyager Therapeutics: Consultant: Self, Xalud: Consulting Fee: Self, AE Mann Foundation: Consulting Fee: Self, Medallion Therapeutics: Consulting Fee: Self, Bioness Inc.: N/A: Self, Medallion Therapeutics: N/A: Self, SPR Therapeutics: N/A: Self, Abbott / St. Jude Medical: N/A: Self, Tenex: N/A: Self, Vertos: N/A: Self, Xalud: N/A: Self, AE Mann Foundation: Consulting Fee: Self, Bioness Inc.: Consulting Fee: Self, Medtronic, Inc.: N/A: Self, Collegium Pharmaceutical, Inc.: Trustee: Self, Flowonix Medical: Served on speakers' bureau: Self, Jazz Pharmaceuticals: Served on speakers' bureau: Self, Jazz Pharmaceuticals: Trustee: Self, Spinal Restoration, Inc.: Trustee: Self, Jazz Pharmaceuticals: N/A: Self, Alfred Mann Foundation: N/A: Self, Boston Scientific: N/A: Self, CNS Therapeutics: N/A: Self, Collegium Pharmaceutical, Inc.: N/A: Self, Flowonix Medical: N/A: Self, Jazz Pharmaceuticals: N/A: Self, Medtronic, Inc.: N/A: Self, Myoscience: N/A: Self, NeurAxon Inc.: N/A: Self, Spinal Restoration, Inc.: N/A: Self, St. Jude Medical, Inc.: N/A: Self, Abbott Laboratories: Consultant: Self, Alfred Mann Foundation: Consulting Fee: Self, Cervel Neurotech, Inc.: Consultant: Self, CNS Therapeutics: Consultant: Self, Covidien: Consultant: Self, Cumberland Pharmaceuticals, Inc.: Consultant: Self, Flowonix Medical: Consultant: Self, Jazz Pharmaceuticals: Consultant: Self, Mainstay Medical: Consultant: Self, Medtronic, Inc.: Consultant: Self, Myoscience: Consultant: Self, NeuroPhage Pharmaceuticals: Consultant: Self, Nevro Corp: Consultant: Self, Palyon: Consultant: Self, Spinal Modulation: Consultant: Self, SPR Therapeutics: Consultant: Self, St. Jude Medical, Inc.: Consultant: Self, Tenex Health, Inc.: Consultant: Self, VertiFlex Inc.: Consultant: Self, Vertos Medical, Inc.: Consultant: Self, Xalud Therapeutics, Inc.: Contracted Research: Self, Medtronic, Inc.: Served on speakers' bureau: Self, Flowonix Medical: Served on advisory board: Self, Medtronic, Inc.: N/A: Self, Jazz Pharmaceuticals: N/A: Self, Medtronic, Inc.: Ownership Interest: Own Stock, Stock Options, Future Stock Options: Self, Nevro Corp: Ownership Interest: Own Stock, Stock Options, Future Stock Options: Self, Rachel Slangen, PhD: None, Lisa Johanek, PhD: Medtronic: Salary/Employee: Self, Maddie LaRue, PHD: Medtronic: Employee:, Cecile de Vos, PhD: None, Melissa Murphy: Medtronic: Consulting Fee:, Relievant: Consulting Fee:Copyright © 2023

Acute Pancreatitis Following a Lower Extremity Angioplasty

Introduction: Acute pancreatitis affects a significant population globally. Usual etiologies are gallstones, alcohol, hypertriglyceridemia, medications;less frequent are trauma, hypercalcemia, infections, toxins, ischemia, anatomic anomalies, vasculitis, and idiopathic. Pancreatitis post coronary intervention is an uncommon cause with only 19 published cases in the last two decades. Being cognizant of this etiology is important given the increasing number of patients undergoing angiography. Case Description/Methods: An 81-year-old female with hypertension, diabetes, peripheral arterial disease, prior cholecystectomy underwent left lower extremity angioplasty at an outside center. Within a few hours, she started having severe epigastric pain radiating to her back, nausea, vomiting and loose bloody stool. She presented to the emergency department 24 hours after symptom onset. Epigastric tenderness was present on exam. Labs revealed leukocytosis (24,450/muL), elevated lipase (1410 U/L), elevated creatinine (1.3 mg/dL), lactate (3.1 mmol/L), calcium 9.4 mg/dL and triglycerides 161 mg/dL. Incidentally, found to be positive for COVID-19. Normal common bile duct diameter seen on sonogram. CT angiogram of the abdomen/pelvis showed acute pancreatitis, duodenal and central small bowel enteritis (Figure). She was not on any medications known to cause pancreatitis and denied alcohol use. Patient improved with analgesics and intravenous fluids. She had no recurrence of bloody stools and hemoglobin remained stable. On day 4, she was able to tolerate a regular diet, and leukocyte count and creatinine normalized. Patient did not have any COVID respiratory symptoms, and was discharged. Discussion(s): Given the temporal association to angioplasty and no other identifiable cause, acute pancreatitis was presumed to be due to the contrast used during angioplasty. Other possibilities included cholesterol embolism but no peripheral signs of cholesterol embolism were seen. Patient was an asymptomatic COVID-19 case. Although, there are case series of pancreatitis due to COVID, those were found in very sick symptomatic patients. On review of literature, cholesterol embolism was identified as a definite cause only on autopsy or laparotomy (Table). Other possible mechanisms are: high viscosity of the contrast media leading to ischemia and necrosis, contrast causing NF-kB activation followed by epithelial damage, and vasospasm. Pancreatitis after coronary angiography is rare, nonetheless, an important differential especially if there is a temporal relationship.

A Thorn in his Side

History: A 20 year old D1 men's basketball player with a history of COVID the month prior presented with worsening low back pain. He denied any injury, but reported the pain started as low back discomfort after a basketball game the week prior. He noted a progression and radiation of pain down his right lower extremity to his toes. He had tried physical therapy and dry needling, as well as cyclobenzaprine and naproxen from team physicians with mild improvement. The pain worsened and he went to the ED for evaluation. He was afebrile and had a lumbar radiograph with no acute fracture, grade 1 anterolisthesis of L5 on S1. He was discharged home with norco. Over the next 2 days, he developed chills and in the context of his worsening back pain, his team physicians ordered an MRI. Physical Exam: BMI 26.9 Temp 97.9degree Heart rate: 73 Respiratory rate 14 BP: 124/64 MSK: Spine- Intact skin with generalized pain over lumbar area, worse over the right paraspinal musculature. 5/5 strength of bilateral lower extremity flexion and extension of his hips, knees, and plantar and dorsiflexion of ankles and toes. Bilateral intact sensibility in the sciatic, femoral, superficial, and deep peroneal, sural, and saphenous nerve distributions. Slightly diminished sensibility over the right deep peroneal nerve distribution compared to left. 2/4 patellar and achilles DTRs. No clonus, downgoing Babinski sign. Positive straight leg raise at 45 degrees with the right lower extremity. Differential Diagnosis: 141. Sciatica 142. Lumbar Muscle Strain 143. Disk Herniation 144. Spondylolisthesis 145. Vertebral Osteomyelitis Test Results: CBC:WBC10, HGB13.2, neutrophils 75.7% (red 45%-74%). Unremarkable CMP. CRP =7.31, ESR 23 Blood culture negative, throat culture negative. TB test negative. COVID test negative. Flu test negative. Urine culture and UDS negative. HIV test negative. Procalcitonin of 0.07. IR guided aspiration and bacterial Culture yielded MSSA. MRI w/contrast: showing L1-L4 facet edema concerning for infectious spondylitis, intramuscular, and epidural abscess. Final Diagnosis: Acute intramuscular abscess, vertebral osteomyelitis, with epidural abscess. Discussion(s): Vertebral osteomyelitis is a serious but quite rare disease in the immunocompetent, elite athlete population. Staphylococcus Aureus is the culprit a majority of the time, with only 50% of cases showing neurologic symptoms. This case was unique given the proximity to a dry needling treatment which is the only explainable vector of infection, normal blood cultures in this disease which hematogenously spreads, negativeHIV and other infectious disease testing, and otherwise benign history. Early recognition of this disease yields better outcomes and reduces incidence of severe debility. 5% to 10%of patients experience recurrence of back pain or osteomyelitis later on in life. Outcome(s): Patient was hospitalized and started on Cefepime and Vancomycin. Had an echocardiogram revealing changes consistent with athlete's heart without signs of vegetation on his cardiac valves. Neurosurgery declined to treat surgically. He continued to improve until he was ultimately discharged on hospital day 4 with a picc line and Nafcillin and was later changed to oral augmentin per ID. Follow-Up: By his 6 week follow-up visit with infectious disease and the team physicians, his back pain had completely resolved and was cleared to start a return to play protocol. There was no progression of disease since starting antibiotics, and no recurrence of back pain since treatment.

2022 CAS Virtual Annual Meeting

The proceedings contain 63 papers. The topics discussed include: a retrospective study to optimize post-anesthetic recovery time after ambulatory lower limb orthopedic procedures at a tertiary care hospital in Canada;a virtual airway evaluation as good as the real thing?;airway management during in hospital cardiac arrest by a consultant led airway management team during the COVID-19 pandemic: a prospective and retrospective quality assurance project;prevention of cautery induced airway fire using saline filled endotracheal tube cuffs: a study in a trachea airway fire model;smart phone assisted retrograde illumination versus conventional laryngoscope illumination for orotracheal intubation: a prospective comparative trial;time to single lung isolation in massive pulmonary hemorrhage simulation using a novel bronchial blocker and traditional techniques;cannabinoid type 2 receptor activation ameliorates acute lung injury induced systemic inflammation;bleeding in patients with end-stage liver disease undergoing liver transplantation and fibrinogen level: a cohort study;endovascular Vena Cavae occlusion in right anterior mini-thoracoscopic approach for tricuspid valve in patients with previous cardiac surgery;and mesenchymal stem cell extracellular vesicles as a novel, regenerative nanotherapeutic for myocardial infarction: a preclinical systematic review.

Development of gait rehabilitation devices: a review of the literature

A "Stroke" is a neurological disease due to poor blood flowing to the brain, resulting in body cell death. It is ranked second as the most common cause of death globally. The "World Health Organization" estimates that about 15 million people suffer a stroke annually. Most stroke survivors have gait disorders, and most patients cannot walk without assistance. Physiotherapy is crucial for stroke patients to recover and maintain their mobility, functionality, and well-being. In the last 20 years, the replacement of physiotherapists with wearable robotics has become essential due to the developing technology, the need for economic growth, and the challenging health circumstances around the world, such as the COVID-19 pandemic recently. Lower Limb Exoskeleton (LLE) represents the solution for stroke patients under such circumstances, though its performance is a critical challenge paid attention to in the industry. This challenge has motivated the researchers to investigate the application of gait rehabilitation. This review presents and discusses the developments in the control system of LLE over the last decade. It also explores the limitations, new directions, and recommendations in LLE development according to the literature.

IgM Multiple Myeloma Presenting With Diarrhea

Introduction: IgM Multiple Myeloma (MM) is a rare subtype of MM consisting of <1% cases of MM. It is distinguished from Waldenstrom Macroglobinemia, which also produces IgM, by the absence of somatic mutation MYD88. We present a patient with a chief complaint of diarrhea which unknowingly led to his hematological diagnosis Case Description/Methods: A 64 year old male with RA-SLE overlap syndrome on steroids, and recent COVID19 pneumonia, had presented with 5 episodes of watery diarrhea every day and 40 Ib weight loss within 2 months. CT revealed small bowel enteritis and stool studies, including C. diff, cultures, ova and parasites were negative. Diarrhea persisted despite antibiotics, therefore an EGD and Colonoscopy were performed which showed duodenal lymphangiectasia and a normal colon. Duodenal biopsy revealed eosinophilic deposits in the villous lamina propria which stained for IgM and stained negative under congo red ruling out amyloidosis. SPEP and a bone marrow biopsy revealed monoclonal IgMspikes and plasma cells in the bone marrow suggesting MMalong with a co-existing population of CLL. Next-generation sequencing was negative forMYD88, supporting IgM MM instead of Waldenstrom. He developed a protein-losing enteropathy with dramatic hypoalbuminemia (albumin 0.9) and lower extremity edema and DVTs. He was started on chemotherapy and frequent albumin infusions. His diarrhea completely resolved, however not in time, as his other medical comorbidities lagged behind and he developed anasarca and continued to deteriorate. Discussion(s): Plasma cell dyscrasias such as IgM MM or more commonly Waldenstrom have rarely been reported to cause GI symptoms. GI involvement can include direct GI infiltration of plasma cells, IgM deposition, or the finding of a plasmacytoma. It has been speculated that IgM deposits can lead to interstitial viscosity and obstructive lymphangiectasia leading to diarrhea and a protein-losing enteropathy as in our patient. Protein loss has led him to have hypoalbuminemia and possibly loss of antithrombotic proteins that have caused DVTs. Few case reports have suggested that treating the underlying cause with chemotherapy stops diarrhea entirely. Although our patient's diarrhea ceased, we believe that it was not in time for him to entirely recover from the later complications of the disease. We hope that this case can help clinicians to attempt prompt treatment of patients when they find GI specimens showing IgM deposits and they suspect a plasma cell dyscrasia.

A Rare Cause of Enteritis in an Adult Male

Introduction: IgA vasculitis is more commonly seen in the pediatric population than in adults. Rarely IgA vasculitis is associated with malignancy, most commonly solid tumor malignancies, although there are case reports of association with hematologic malignancies. We report a case of large B-cell lymphoma mimicking IgA vasculitis in a 33-year-old immunosuppressed male with a prior history of IgA vasculitis. Case Description/Methods: A 33-year-old Caucasian male post renal transplant from reflux nephropathy on chronic immunosuppression was hospitalized for postprandial epigastric abdominal pain, nausea, vomiting and diarrhea. Two years prior, he was admitted for the same symptoms, palpable purpura of the lower extremities and elevated serum IgA. Enteroscopy had shown duodenal and jejunal ulceration with biopsies staining positive for IgA, confirming IgA vasculitis. He had complete resolution with a steroid taper. His current presentation had resulted in multiple hospital admissions, but empiric trial of steroids failed to alleviate symptoms. Vitals were normal and exam was notable for epigastric tenderness. Labs were notable for WBC 19.00 x103/cmm with normal differential, hemoglobin 9.2 gm/dL (prior 11.0 gm/dL), CRP 20.7 mg/L, serum creatinine 2.7 mg/dL (prior 1.5 mg/dL), and urinalysis with proteinuria, sterile pyuria, and hematuria. CTA abdomen/pelvis revealed thickening of the duodenum with shotty mesenteric lymph nodes without ischemia. Enteroscopy revealed an erythematous duodenum and jejunum (figure A). Jejunal biopsy (figure B) revealed CD20 positive cells consistent with DLCBL (figure C). He was seen by oncology and treated with R-CHOP but later unfortunately expired due to COVID-19 complications. Discussion(s): Non small cell lung cancer and renal cell carcinoma are most commonly associated with IgA vasculitis. It may also be seen in both Hodgkin and Non-Hodgkin lymphomas in adult patients. If IgA vasculitis occurs after a malignancy is diagnosed, it may indicate that metastasis has occurred. Malignancy associated IgA vasculitis is more likely to have an incomplete response to steroids and requires treatment of the underlying malignancy to achieve remission. Our case illustrates posterior probability error and premature closure cognitive biases. We should consider alternative diagnoses rather than anchor on prior diagnoses even when presentations are similar. Our case also highlights the importance of considering occult malignancy in adults with diagnosis of IgA vasculitis.

Evaluation of Factors Causing a Delay in Management and Hospital Stay in Diabetic Foot Amputation Patients: A Prospective Cohort Study

OBJECTIVE: To determine the rate of different amputation levels in diabetic foot patients and the incidence of repetitive foot surgeries and evaluate the factors causing a delay in hospital stay and amputation of patients. METHODOLOGY: This prospective cohort study was conducted in Dr. Ruth K.M. Pfau, Civil Hospital Karachi, Pakistan. The study selected 375 participants from the clinic's daily patient inflow from October 2021 to March 2022 using a non-probability consecutive sampling technique. Those who had a delay in hospital stay and amputation were further followed up from May-October 2022. The chi-square test and Kruskal Wallis test (p-value <0.05) were used to correlate the effect of the level of lower limb amputation and the cause of delay in amputation using SPSS version 24.0. RESULT(S): Total 246(65.60%) were males and 129(34.40%) were females. Toe amputation was the most commonly seen amputation in 173(46.1%) participants. About 168(44.8%) patients had some in-hospital delay stay during their treatment. Preoperative hurdles (Uncontrolled RBS, Osteomyelitis, etc.) were the most common factor causing an in-hospital delay in 92(24.5%) patients. The level of amputation performed was found to be statistically significant with factors causing a delay in hospital stay through chi-square (p=0.003*) and Kruskal Wallis test H (2) statistic= 13.3, df = 3, H (2), P=0.004*). CONCLUSION(S): Diabetic foot is a frequent cause of amputation globally, majorly in developing countries like Pakistan. On-time provision of treatment to these patients can decline the global amputation rate due to diabetic foot ulcers.Copyright © 2023 Syeda Anjala Tahir.

Covid-19 Booster Vaccine Related Dermatitis: A Case Study

Case Report: A 28 year old male with a past medical history of hypothyroidism and positive ANA presented to an outpatient dermatology clinic with a diffuse pruritic rash two weeks after the administration of his first Moderna COVID booster vaccine. He denied any other accompanying symptoms such as fever or chills as well as any similar rashes to prior doses of the Moderna COVID vaccine. The rash consisted of pink erythematous minimally scaly papules, thin plaques and patches involving the left and right dorsal hands, forearms, wrists, face, neck and left shoulder. The remainder of the patient's skin including the bilateral lower extremities, the eyelids, conjunctiva and oral mucosa was clear. The patient denied any similar rashes in the past. The patient denied any allergies to medications, or food or environmental allergies. He denied any notable contact allergen exposures, including to soaps, lotions, and cosmetic products. The patient also denied any significant family history or past surgical history. The patient was on Armour Thyroid for hypothyroidism and testosterone for low levels since age eighteen. The patient was started on cetirizine 10 mg once daily for the rash with minimal improvement. Autoimmune workup for the rash was notable for an elevated anti-RNP and as the patient's past medical history included Raynaud's phenomenon and ANA positivity for ten years, the patient was diagnosed with mixed connective tissue disease (MCTD). Autoimmune conditions can often have an indolent course, where symptoms progressively develop and worsen. MCTD is an autoimmune overlap syndrome that can consist of the following three connective tissue diseases: systemic lupus erythematosus, scleroderma, and polymyositis. Millions of individuals across the world are receiving COVID vaccines to protect themselves and members of their community, and it is of utmost importance that we continue to investigate adverse events. Although of low incidence, these rare effects have the ability to impact large numbers of people within both healthy and immunocompromised populations. It is critical that we examine and document them in a rigorous manner, to ensure safe vaccine delivery and reassure the public about vaccine safety overall.

Post-COVID-19 vaccination Guillain-Barre syndrome with sensory ataxia, gaze-evoked nystagmus, mental-status change and positive pathological reflex

Background: Various neurological disorders have been reported after vaccination against coronavirus disease 2019, one of which is Guillain-Barre Syndrome (GBS). Case Presentation: We report a case of a 73-year-old woman who developed GBS and extra-GBS manifestations 19 days after the second dose of BNT162b2 mRNA vaccine. She presented lower limb predominant muscle weakness and loss of tendon reflexes. Nerve conduction study showed acute motor and sensory axonal neuropathy. In addition, she developed notable deep sensory ataxia, and showed positive pathological reflex, gaze-evoked nystagmus and altered consciousness, which suggested brainstem involvement. Conclusion(s): This is the first coronavirus disease 2019 vaccine-related GBS complicated with such central nervous system manifestations.Copyright © 2023 Japanese Society for Neuroimmunology.

Feasibility of a pain informed movement program for people with symptomatic knee osteoarthritis

Purpose: Disability in knee osteoarthritis (KOA) is known to be largely due to pain, the mechanism of which is complex and multidimensional with alterations in nociceptive processing in the peripheral and central nervous system (CNS) leading to persistent pain. Current clinical practice guidelines for KOA provide strong recommendations for education and exercise including land-based or mind-body approaches. However, individually these strategies are only moderately effective. One potential reason for this is a lack of understanding of their underlying mechanisms and how their combination might impact nervous system modulation. Neuromuscular exercise is known to improve lower extremity strength. Mind-body approaches as well as pain neuroscience education (PNE) are uniquely positioned to potentially reverse CNS adaptations by inducing positive neuroplastic changes and improving descending modulation of pain resulting in decreased pain. To our knowledge, neuromuscular exercise, mind-body techniques, and PNE have not been studied in combination. We therefore aimed to establish the feasibility of an intervention consisting of these three elements referred to as Pain Informed Movement (PIM). The results of this study will inform necessary modifications for a two-arm pilot randomized controlled trial (RCT). Method(s): This study was a single-arm feasibility trial with a nested qualitative component and the primary feasibility outcome of complete follow up. Inclusion criteria: age >= 40 years, KOA clinical diagnosis or people fulfilling the NICE diagnostic criteria, and average pain intensity >=3/10 on the numeric pain rating scale. PIM consisted of twice weekly in-person exercise sessions and a third home exercise session for 8 weeks. In addition, PNE, provided as online videos, covered the following topics: purpose of pain, neurophysiological changes associated with pain, movement guidelines when pain persists, mind-body techniques to impact neurophysiology and support moving with ease that included breath awareness and regulation, muscle tension regulation, awareness of pain related thoughts and emotions, and relaxation. The mind-body techniques and the PNE topics were implemented during the group exercise sessions that included evidence-based neuromuscular exercises aimed at improving sensorimotor control and functionality of the knee joint. Participants completed questionnaires and in-person assessments at baseline and at program completion. Assessments included weight and height, chair stands as a measure of functional leg strength, and conditioned pain modulation to assess efficiency of the descending modulatory pathways. Participants also had their blood drawn to monitor changes in brain derived neurotrophic factor (BDNF), a marker of neuroplasticity. Questionnaires included the Pain Catastrophizing Scale, Hospital Anxiety and Depression Scale, the Knee Injury and Osteoarthritis Outcome Score - function and pain subscales, Chronic Pain Self Efficacy scale, pain intensity rated in the past 24 hours, the past week, and worst pain in the past 24 hours. Secondary feasibility outcomes included acceptability of the intervention, burden of assessments, recruitment rate, compliance rate, adherence rate, and self-reported adverse events. Feasibility findings were evaluated against a-priori success criteria. In the qualitative component, participants were invited to an online focus group and were asked about their experience and perceptions of the program. Interview recordings were analyzed using thematic content analysis to identify suggestions for program modification. Result(s): In total, 19 participants (mean age 63.3 years (SD 10.5), 73% female) were enrolled, with a complete follow up rate of 74% (n=14) for our primary objective, indicating that modifications would be needed to proceed. Of the 5 dropouts, only one was study related. We will be adding additional inclusion criteria of: ability to get up and down from the floor independently, and no use of mobility aids. Adherence to in-person treatment sessions was 91%, hich indicates proceeding with the protocol for the next phase (i.e., pilot RCT). Some absences were due to unmodifiable factors (e.g., COVID-19). We will make protocol amendments for the purpose of improving the adherence rate to include 'no planned absences'. All other success criteria were met: recruitment rate, compliance to exercise sessions, program acceptability, duration, frequency, and delivery, likelihood of recommending the program to others and taking the program again, burden, and adverse events (Table 1). Analysis of the focus groups revealed that the video content pertaining to the mind-body techniques would benefit from on screen demonstrations by the instructor to assist with participants' execution of breath and muscle tension regulation. The majority of participants improved in most of the physical assessment outcomes and questionnaires (Table 2). Conclusion(s): The PIM program is feasible, acceptable, not burdensome, does not cause adverse events, and had an excellent compliance rate. Minor modifications are needed to optimize enrolment and adherence rates. Although improvements in pain, function, and psychological measures were observed, the feasibility nature of this study precludes any conclusions regarding efficacy. A pilot two-arm RCT will be conducted to establish the feasibility and explore potential effects of PIM when compared to conventional neuromuscular exercise and standard OA education. [Formula presented] [Formula presented]Copyright © 2023

Telemedicine technologies in improving the effectiveness of followup monitoring of patients with lower extremity peripheral artery disease during the COVID19 pandemic.

Aim. To evaluate the effectiveness of a novel approach to followup monitoring of patients with lower extremity peripheral artery disease (PAD) using telemedicine technologies. Material and methods. The study included 175 patients (mean age, 68, 1+/-7, 7 years). Two following groups of patients were formed: the main group (n=86), which used an optimized monitoring program using telemedicine techniques, and the control group (n=89), which assumed traditional monitoring by a cardiologist and a vascular surgeon. The mean followup period was 11, 77+/-1, 5 months. The optimized monitoring program included the implementation of audio communication with patients by an employee with a secondary medical education with an assessment of the current health status according to original unified questionnaire, with the definition of personalized management tactics. At the primary and final stages, the patient underwent an assessment of clinical and anamnestic data, mental and cognitive status, and compliance. Results. At the final stage, uncompensated hypertension was revealed in 36, 0% and 49, 4% (p=0, 0001), smoking - in 30, 6% and 42, 9% (p=0, 05) in the main and control group, respectively. In the main group, a greater painfree walking distance was revealed - 625, 8+/-395, 3 m (control group - 443+/-417 m (p=0, 013)). The average systolic blood pressure was 125, 2+/-10, 2 mm Hg and 138, 8+/-15, 8 mm Hg (p=0, 0001) in the main and control group, respectively. In the control group, a greater number of patients with a high level of personal and situational anxiety were revealed (p=0, 05). In the main group, a higher level of adherence to therapy was established at the final study stage (p=0, 001). Conclusion. The optimized monitoring program for patients with limited mobility is effective and can be implemented in practical healthcare for patients with lower extremity PAD.Copyright © 2023 Vserossiiskoe Obshchestvo Kardiologov. All rights reserved.

Outside The Box But All Squeezed In: A 23- year-old Man With Progressive Dyspnea After Overseas Travel

Case Presentation: A 23-year-old previously healthy man presented with progressive dyspnea. Physical examination revealed jugular venous distension and lower extremity edema. Laboratory testing demonstrated elevated B-type natriuretic peptide (193 pg/mL) and normal high sensitivity troponin. Echocardiogram revealed small pericardial effusion, respiratory variation in diastolic flow across the mitral valve, diastolic septal bounce, and annulus reversus (Figure). The differential diagnosis for constrictive pericarditis was broadly considered in the context of a recent febrile illness and frequent travel to Hawaii and Vietnam;we included infectious, autoimmune, and malignant etiologies. Cardiac magnetic resonance imaging revealed thickening and diffuse enhancement in the pericardium as well as ventricular interdependence. Chest CT identified hilar and anterior mediastinal lymphadenopathy. Laboratory testing was positive for QuantiFERON gold and negative for COVID-19, HIV, and ANA. Transbronchial biopsy demonstrated non-necrotizing granulomas with negative acid-fast bacilli smear, culture, and polymerase chain reaction for mycobacterial DNA. Reexamination identified a red-brown plaque on the patient's thigh;biopsy showed granulomatous inflammation and rod-shaped organism with positive FITE staining. A presumed unifying diagnosis was made of extrapulmonary tuberculosis (TB) complicated by constrictive pericarditis. Discussion(s): Despite being a primarily pulmonary disease, systemic involvement can occur with TB with the heart being one of the most common extrapulmonary sites. This case highlights 1) the utility of extra-cardiac diagnostic testing (e.g., dermatologic biopsy) in the diagnosis of constrictive pericarditis, and 2) the diagnostic challenge associated with extrapulmonary TB, particularly paucibacillary disease that requires a detailed social history with "out-of-the-box" thinking.

Impact of COVID-19 pandemic on burden of dog bite cases at a Tertiary Care Hospital in Kashmir

Background: Dog bite is a public health problem in Kashmir incurring huge cost of treatment. Objective(s): To see the impact of COVID-19 pandemic on the burden of dog bite cases and the profile of patients, comparing with that of the years before the three peak waves of COVID-19 and after that at Shri Maharaja Hari Singh Hospital. Methodology: This is a retrospective record review of the dog bite cases in the year 2018 to 2022 in Anti Rabies Clinic, SMHS Hospital Srinagar. The target population of the study were people living in Srinagar city. Proportion of dog bite according to demographic and clinical variables were calculated. Univariate and multivariate analysis were done to look for risk factors responsible for dog bite in COVID infection waves compared to pre and post pandemic times. Results and Conclusion(s): The dog bite cases in the prepandemic time period and during the three waves of COVID 19 infection were recorded at 3.3% and 2.4% respectively. There was male predominance and highest incidence of the dog bite was in age group of 20-59 years. The commonest site of bite were lower limbs and stray dog bites were highest risk exposure. Less dog bite cases reported in 2020, 2021 which may be due to the impact of pandemic. Majority of the cases were stray dog bites and high incidence of dog bites can be a major concern for health, social and economic wellbeing of the nation which needs urgent intervention.

Racial Disparities in Elective Total Knee and Hip Replacement Surgeries during the Covid-19 Pandemic: A Retrospective Study of a Diverse Population in Washington State

Purpose of Study: Total knee (TKA) and hip (THA) arthroplasty procedures are recognized as effective treatments for osteoarthritis of the knee and hip joints which are the leading causes of lower extremity disability among older adults. Previous studies have demonstrated a variance in patients electing to undergo these interventions with non-White patients having significantly lower utilization rates. Our study examined if these disparities continued to exist during the COVID-19 pandemic period. Methods Used: This retrospective cohort study included 580 patients who underwent TKA or THA in 2020 and 2021 in a racially diverse region in Washington State. Demographic data, comorbidities, and post-surgical outcomes were recorded. Patients were stratified as those identifying as White (n=490, 84.5%) or Hispanic/ Latino (n=65, 11.2%). Patients identifying with other races (n=25, 4.3%) were excluded from the study due to small sample sizes. Differences between our two groups were examined using a chi-square test for categorical variables and an independent t-test for continuous variables. The level of significance was set at P < 0.05. Summary of Results: Compared to the White patients, Hispanic/ Latino identifying patients were younger (61.9+/-12.79 years versus 68.58+/-9.00 years;P <0.001), had lower Charlson Comorbidity Index scores (P=0.019), and were more likely to use non-Medicare or Medicaid insurance (P <0.001). No differences were observed in postoperative complication (P=0.632) and COVID-19 infection (P=0.465) rates between the groups. Conclusion(s): Although Hispanic/ Latino identifying patients in this region constitute 45.8% of our study population according to the most recent census tabulation, they accounted for only 11.2% of the patients in our study. These patients were also younger, had fewer comorbidities, and tended to use non-Medicare or Medicaid insurance suggesting an exclusive Hispanic/ Latino patient population electing to undergo TKA or THA procedures during the COVID-19 pandemic. Future studies controlling for osteoarthritis risk factors and patients' election of treatment options may explain these disparities we have observed.