Drug Repurposing in Oncology: A Systematic Review of Randomized Controlled Clinical Trials.

Quality pharmacological treatment can improve survival in many types of cancer. Drug repurposing offers advantages in comparison with traditional drug development procedures, reducing time and risk. This systematic review identified the most recent randomized controlled clinical trials that focus on drug repurposing in oncology. We found that only a few clinical trials were placebo-controlled or standard-of-care-alone-controlled. Metformin has been studied for potential use in various types of cancer, including prostate, lung, and pancreatic cancer. Other studies assessed the possible use of the antiparasitic agent mebendazole in colorectal cancer and of propranolol in multiple myeloma or, when combined with etodolac, in breast cancer. We were able to identify trials that study the potential use of known antineoplastics in other non-oncological conditions, such as imatinib for severe coronavirus disease in 2019 or a study protocol aiming to assess the possible repurposing of leuprolide for Alzheimer's disease. Major limitations of these clinical trials were the small sample size, the high clinical heterogeneity of the participants regarding the stage of the neoplastic disease, and the lack of accounting for multimorbidity and other baseline clinical characteristics. Drug repurposing possibilities in oncology must be carefully examined with well-designed trials, considering factors that could influence prognosis.

Autonomic Dysfunction after Covid-19 Immunization - Case Report

Background: The infection caused by the SARS-CoV-2 continues affecting millions of people worldwide and vaccines to prevent the coronavirus disease (COVID-19) are considered the most promising approach for curbing the pandemic. Otherwise, cardiovascular and neurological complications associated with the vaccines were speculated and some few case reports were published. Objective(s): We describe a case of postural orthostatic tachycardia syndrome (POTS) after viral vector COVID-19 vaccination and the possible autoimmune process of the syndrome. Method(s): A 35-year-old female, without previous symptoms or comorbidities, developed intermittent palpitation, intense fatigue and dyspnea, compromising her daily activities, triggered by upright position, seven days following the second dose of the Oxford vaccine. Physical examination was normal, except for a heart rate (HR) increase of 33 beats/min from supine to standing position, with no significant change in blood pressure and reproduction of symptoms. Result(s): A 24-hour Holter monitoring revealed episodes of spontaneous sinus tachycardia correlated with palpitation and fatigue. Extensive diagnostic investigations excluded primary cardiac, endocrine, infectious and rheumatologic etiologies. The patient underwent an autonomic function test which demonstrated normal baroreflex sensitivity, as well as normal cardiovagal and adrenergic scores. Head-up tilt test showed persistent orthostatic tachycardia (HR increase from a medium of 84 beats/min in supine position to 126 beats/min during upright tilt), without hypotension, consistent with the diagnostic criteria for POTS. According to the current guidelines, general behavior recommendations, pharmacotherapy with low dose of propranolol associated with the autonomic rehabilitation were oriented. Along three months of follow-up, the patient reported a gradually improvement in her symptoms. Conclusion(s): POTS is a heterogeneous disorder of the autonomic nervous system characterized by orthostatic tachycardia associated with symptoms of orthostatic intolerance. Although the physiopathology of COVID-19 vaccine and autonomic disorders remains speculative, autoimmune response is one of the possible mechanisms. Based on clinic presentation, the time frame of symptom onset is consistent with other well-known post-vaccination syndromes, which may be an indicator of an autoimmune process induced by immunization. Further studies are needed to assess causal relationship between immunization and autonomic dysfunction.Copyright © 2023

Long COVID: Rapid Evidence Review

Postacute sequelae of COVID-19, also known as long COVID, affects approximately 10% to 30% of the hundreds of millions of people who have had acute COVID-19. The Centers for Disease Control and Prevention defines long COVID as the presence of new, returning, or ongoing symptoms associated with acute COVID-19 that persist beyond 28 days. The diagnosis of long COVID can be based on a previous clinical diagnosis of COVID-19 and does not require a prior positive polymerase chain reaction or antigen test result to confirm infection. Patients with long COVID report a broad range of symptoms, including abdominal pain, anosmia, chest pain, cognitive impairment (brain fog), dizziness, dyspnea, fatigue, headache, insomnia, mood changes, palpitations, paresthesias, and postexertional malaise. The presentation is variable, and symptoms can fluctuate or persist and relapse and remit. The diagnostic approach is to differentiate long COVID from acute sequelae of COVID-19, previous comorbidities, unmasking of preexisting health conditions, reinfections, new acute concerns, and complications of prolonged illness, hospitalization, or isolation. Many presenting symptoms of long COVID are commonly seen in a primary care practice, and management can be improved by using established treatment paradigms and supportive care. Although several medications have been suggested for the treatment of fatigue related to long COVID, the evidence for their use is currently lacking. Holistic treatment strategies for long COVID include discussion of pacing and energy conservation;individualized, symptom-guided, phased return to activity programs;maintaining adequate hydration and a healthy diet;and treatment of underlying medical conditions.Copyright © 2022 American Academy of Family Physicians.

R-Propranolol Has Broad-Spectrum Anti-Coronavirus Activity and Suppresses Factors Involved in Pathogenic Angiogenesis.

The SARS-CoV-2 pandemic highlighted the need for broad-spectrum antivirals to increase our preparedness. Patients often require treatment by the time that blocking virus replication is less effective. Therefore, therapy should not only aim to inhibit the virus, but also to suppress pathogenic host responses, e.g., leading to microvascular changes and pulmonary damage. Clinical studies have previously linked SARS-CoV-2 infection to pathogenic intussusceptive angiogenesis in the lungs, involving the upregulation of angiogenic factors such as ANGPTL4. The ß-blocker propranolol is used to suppress aberrant ANGPTL4 expression in the treatment of hemangiomas. Therefore, we investigated the effect of propranolol on SARS-CoV-2 infection and the expression of ANGPTL4. SARS-CoV-2 upregulated ANGPTL4 in endothelial and other cells, which could be suppressed with R-propranolol. The compound also inhibited the replication of SARS-CoV-2 in Vero-E6 cells and reduced the viral load by up to ~2 logs in various cell lines and primary human airway epithelial cultures. R-propranolol was as effective as S-propranolol but lacks the latter's undesired ß-blocker activity. R-propranolol also inhibited SARS-CoV and MERS-CoV. It inhibited a post-entry step of the replication cycle, likely via host factors. The broad-spectrum antiviral effect and suppression of factors involved in pathogenic angiogenesis make R-propranolol an interesting molecule to further explore for the treatment of coronavirus infections.

Practicing Telemedicines in India

The great use of telecommunication technology propels new healthcare system of telemedicine through which diagnosis as well as treatment can be done in the remote areas. The ancient Greek language explain the terminology of telemedicine in the phrase of distance healing. As per WHO, Telemedicine is the delivery of health-care services, where distance is a critical factor, by all health-care professionals using information and communications technologies for the exchange of valid information for diagnosis, treatment and prevention of disease and injuries, research and evaluation, and the continuing education of health-care workers, with the aim of advancing the health of individuals and communities. Historically the concept of teleconsultation was evolved in the first half of twentieth century when the data of ECG was communicated through telephone lines, this can be traced as first evidence of this unique healthcare system. Further the introduction of electrical system of telegraph as well as evolution of telephone revolutionized this system of healthcare. when the Technology of telemedicine help both patients as well as service providers in multiple ways involving physicians, surgeons, pharmacists, paramedical staff, IT and electronics engineers, government, hospitals and end user public Location is now a days no problem and therefore there is no limitation of the availability of healthcare facilities to such location or remote location. The biggest role in such development is played by the communication technology which may provide healthcare services to every nook and corner of the location. It can decrease the health staff pressure because in India WHO guidelines ask to maintain the ratio 1:1000 of doctor and Indian public compared to present 0.62:1000 ratio of doctor and public. The great advantage of this system is that in case of epidemic or pandemic like COVID 19 Telemedicine can keep the health staff are well general public free from contagious infection (COVID-19). There are a number of networking communication modes that can be applied, which may improve the patient compliance,dosage regimen can be managed in better fashion thus increase the longevity of person life. Disasters management during pandemics present unique challenges which can be addressed effectively as happened during the lockdown. This technology-based practice can break the infectivity chain of the transmission of communicable diseases This chapter incorporates basic concept of telemedicine, its origin and types, communication technologies, services by telemedicine, types of telemedicine, tools of telemedicine, telemedicine software's and guidelines related to practicingtelemedicine in reference to Indian context. Copyright © RJPT All right reserved.

Beta-blockers in cardiac arrhythmias-Clinical pharmacologist's point of view.

ß-blockers is a vast group of antiarrhythmic drugs which differ in their pharmacokinetic and chemical properties. Some of them block ß-adrenergic receptors selectively while the others work non-selectively. Consequently, they reduce the influence of the sympathetic nervous system on the heart, acting negatively inotropic, chronotropic, bathmotropic and dromotropic. Although they have been present in medicine since the beginning of the 1960s, they still play a crucial role in the treatment of cardiac arrhythmias. They are also first-line group of drugs used to control the ventricular rate in patients with the most common arrhythmia-atrial fibrillation. Previous reports indicate that infection with SARS-CoV-2 virus may constitute an additional risk factor for arrhythmia. Due to the aging of the population in developed countries and the increase in the number of patients with cardiac burden, the number of people suffering from cardiac arrhythmias will increase in the upcoming years. As a result the role of above-mentioned beta-blockers will remain significant. Particularly noteworthy is propranolol-the oldest beta adrenergic antagonist, which in recent years has found additional applications due to its unique properties. In this article, we reviewed the accessible literature and summarized the current guidelines on the use of beta-blockers in the treatment of cardiac arrhythmias.

BOOZE, BETAS, AND A FATTY SOLUTION TO SPARE PANDEMIC WOES

SESSION TITLE: Cases of Overdose, OTC, and Illegal Drug Critical Cases Posters SESSION TYPE: Case Report Posters PRESENTED ON: 10/17/2022 12:15 pm - 01:15 pm INTRODUCTION: The COVID-19 pandemic raised economic strife, social isolation, fear from contagion, and anxiety to a level where 45% of surveyed U.S. adults report a detriment to their mental health. With U.S. suicide rates up from 10 to 14 cases per 100,000 over the past 20 years, the health and safety of a vulnerable mental health population becomes more of a concern. We report a case of an individual with depression who was resuscitated after severe toxicity from alcohol and beta-blocker ingestions. CASE PRESENTATION: A 58-year-old woman with prior suicide attempts was found in an obtunded state after finishing a 20-pack of beer and swallowing a propranolol 20 mg pill bottle. On admission, she presented with bradycardia, hypotension, and alteration to a Glasgow Coma Scale of 9 with emesis residue on her face. Her blood gas revealed an anion-gap metabolic acidosis with a pH of 7.26, lactate of 2.53, normal potassium and calcium, and glucose of 134 mg/dL. Toxicity labs were notable for an alcohol of 199 mg/dL. Her EKG demonstrated a junctional bradycardia with a p-wave complex after the QRS consistent with retrograde depolarization of the atrium (Image 1). She was intubated to protect her airway. She subsequently developed cardiac arrest secondary to pulseless electrical activity. She underwent CPR for 33 minutes with boluses of intravenous epinephrine, glucagon, insulin, calcium gluconate, and sodium bicarbonate prior to return of spontaneous circulation. Due to failure of transcutaneous pacing, a transvenous pacer was placed. In concert with Poison Control, she was started on an a euglycemic insulin drip and an intralipid infusion. Her hemodynamics improved, and she was weaned off pacing and ICU interventions within 24 hours. She was discharged a week after admission with no residual morbidities. DISCUSSION: Overdose from nonselective beta-blockers can result in bradycardia, hypotension, seizures, QRS widening, QTc prolongation with ventricular tachy-arrhythmias, hyperkalemia, and hypoglycemia. Understanding the pharmacodynamics of beta-blocker toxicity enables targeted interventions to improve: chronotropy with epinephrine, glucagon, and pacing;inotropy with insulin, calcium, glucagon, and phosphodiesterase inhibitors;QRS widening with sodium bicarbonate;and QTc prolongation with magnesium or lidocaine. The high lipid solubility of propanol allows for intravenous lipid infusions to aid in drug elimination for patients in refractory cardiogenic shock. CONCLUSIONS: Despite a lack of labs for monitoring beta blocker toxicity, our case demonstrates successful resuscitation in a severe overdose. Perhaps an absence of hyperkalemia, hypoglycemia, QRS and QTc changes, and tachy-arrhythmias in this incident portended to a decreased morbidity and mortality. Ultimately, we reaffirmed the role of intralipid infusions as a critical treatment adjunct for recovery from cardiogenic shock secondary to beta blockade. Reference #1: Sher L. The impact of the COVID-19 pandemic on suicide rates. QJM. 2020;113(10):707-712. Reference #2: Kerns W 2nd. Management of beta-adrenergic blocker and calcium channel antagonist toxicity. Emerg Med Clin North Am. 2007;25(2):309-viii. Reference #3: Anderson AC. Management of beta-adrenergic blocker poisoning. Clin Pediatr Emerg Med. 2008;9(1):4–16. DISCLOSURES: No relevant relationships by Jackie Hayes No relevant relationships by Andrew Salomon

Thyroid storm in pregnancy: A case study

Introduction: Inadequately treated maternal hyperthyroidism increases the risk of severe preeclampsia, heart failure, and thyroid storm. Thyroid storm is a life-threatening endocrine emergency characterized by multiple organ failure due to severe thyrotoxicosis. A storm can be triggered by precipitating events such as trauma, surgery, infection, delivery;even pregnancy itself. Case Description: A 35-year-old lady presented to the emergency department with complete miscarriage. She had underlying hyperthyroidism for six years but defaulted her follow-ups and medications since the beginning of the Covid-19 pandemic. She complained of palpitations despite minimal vaginal blood loss. ECG showed sinus tachycardia with a heart rate of 190 beats per minute. Her hemoglobin level was stable, but thyroid function test showed hyperthyroidism with raised free T4 (60 pmol/L) and low TSH (< 0.01 mIU/L). Her Burch-Wartofsky score was 35, implying an impending thyroid storm. IV Verapamil was given immediately and her heart rate improved to 140-150 bpm. She was transferred to a high dependency ward for close monitoring and started on oral Propylthiouracil and Propranolol. Regrettably, when she began to improve, she requested for discharge against medical advice. Discussion: The diagnosis of thyroid storm is clinical, with laboratory tests consistent with overt hyperthyroidism. Clinical scoring systems such as the Burch-Wartofsky Score helps to confirm diagnosis and triage disease severity. Treatment is multimodal using medications (thioamides, iodide, beta-blockers, corticosteroids, antipyretics), oxygen, volume resuscitation, and correction of electrolyte imbalance. A high index of suspicion, rapid recognition, prompt treatment and intensive monitoring are key elements of management.

Diagnosis of infantile subglottic hemangioma and the effect of oral propranolol.

OBJECTIVES: To investigate the clinical characteristics of infantile subglottic hemangioma (SGH), and to observe the safety and efficacy of propranolol in the treatment of SGH. METHODS: The data of 21 children diagnosed with SGH and treated with propranolol in our hospital from March 2013 to January 2021 were retrospectively analyzed and followed up. RESULTS: Among the 21 cases, there were 7 males and 14 females. SGH was found 11 left-sided, 9 right-sided and 1 bilateral-sided. The clinical manifestations included stridor (13/21), respiratory distress (6/21), barking cough (5/21), feeding difficulty (4/21), three concave sign (4/21), cyanosis (2/21) and hoarseness (1/21). 8 patients had multiple cutaneous hemangiomas. The age of presentation ranged from 1 to 8 months, with a median of 1.1 months. 18 cases (85.7 %) had a history of misdiagnosis, 14 bronchitis/pneumonia, 5 laryngomalacia, 2 laryngeal obstruction and 1 asthma. The median ages at diagnosis were 3 months, with a range of 1.2-28 months. The treatment duration ranged from 6 to 25.6 months, with an average of (14.3 ± 4.9) months. Age at termination of treatment ranged from 9 to 38 months, with a median of 18.6 months, and only 2 cases were beyond 2 years old at that time. No adverse side effects from propranolol therapy occurred and all 21 cases were cured. CONCLUSIONS: We advocate a strong index of suspicion for SGH presenting with respiratory symptoms under 2 years old who has poor effect or repeated condition after routine treatment. Laryngoscopy combined with contrast-enhanced CT can confirm the diagnosis of SGH. Oral propranolol is safe and effective, and that early diagnosis and intervention of propranolol without further delay are crucial to the successful management. We advocate continue propranolol treatment beyond 18 months of age, furthermore, 2 years old may be the best time for therapy termination.

NEW ONSET GRAVES' DISEASE AFTER SARS-CoV-2 VACCINATION

Introduction There is an increasing number of reports of thyroid dysfunction after severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2) vaccination. We would like to report a case of new onset Graves' disease following vaccination with the adenovirus-vectored Vaxzevria (Oxford-AstraZeneca). METHODOLOGY A 29-year-old female with no prior history of endocrine or autoimmune diseases, presented with a week of palpitations, heat intolerance and excessive sweating three days after her second dose of Vaxzevria. She did not experience these symptoms after her first dose which she received two months earlier. Her father and sister have Graves' disease. She had a diffuse goiter with no orbitopathy. Thyroid Stimulating Hormone (TSH) was <0.01 mIU/L (normal range: 0.27-4.2) with a markedly elevated free T4 of >100 pmol/L (normal range: 12-22). TSH receptor antibody was positive at >40.00 IU/L (Normal range: <1.75). Ultrasonography revealed a hypervascular, diffusely enlarged goiter. She was started on oral carbimazole and propranolol. Five months later, her free T4 had normalized at 18 pmol/L though her TSH was still undetectable. To date, she remains hesitant for her booster dose. Results SARS-CoV-2 infection and vaccination have been associated with subacute thyroiditis and autoimmune thyroid disease. While there are reports of new onset Graves' disease after mRNA and adenovirus-vectored vaccines, it has not been associated with inactivated virus vaccines. The current prevailing theory is that the adjuvants in the vaccines can trigger an autoimmune event, also called 'autoimmune/ inflammatory syndrome induced by adjuvants' (ASIA). Conclusion Physicians need to be aware of thyroid dysfunction after SARS-CoV-2 vaccination, especially in those with a strong family history of autoimmune disease. Nevertheless, it is also important to note that the benefit of vaccination far outweighs this uncommon potential risk. More studies are required to establish a causal relationship.

A CASE OF POSTURAL ORTHOSTATIC TACHYCARDIA SYNDROME AFTER MRNA COVID-19 VACCINE

CASE: Ms.X is a 31-year-old female with an unremarkable medical history who presented to the general medicine clinic with palpitations that started 3 days after taking her second dose of Pfizer Covid vaccine. The palpitations ocurred exclusively when standing, with no associated chest pain, dizziness, or presyncope. History is negative for tobacco smoking, drug or alcohol use, and consumption of energy or caffeinated beverages. The physical examination was notable for moist mucous membranes and normal volume examination. Orthostatic vitals were remarkable for an increase in HR by 30 beats with minimal change in BP. EKG showed a normal sinus rhythm, and lab workup inclusive of a CBC, CMP, and TSH was unremarkable. As such, the patient was referred for tilt-table testing. Within 8 minutes of upright tilting, HR was137 from a baseline of 77, and BP was 144/108 from 125/71. A looprecorder was inserted which revealed presence of patient triggered episodes of sinus tachycardia upon standing. The patient was started on propranolol 10 mg every 4-6 hours while awake with almost complete resolution of palpitations. IMPACT/DISCUSSION: The incidence of POTS is 0.2-1% in developed countries, with a 5:1 female-male ratio. It presents with orthostatic symptoms like light-headedness, presyncope, and palpitations. It can occasionally present with non-orthostatic symptoms like nausea, bloating, and diarrhea. The pathophysiology is not well-understood but is postulated to be due to an autoimmune disorder, abnormally increased sympathetic activity, and/or sympathetic denervation leading to central hypovolemia and reflex tachycardia. It is a diagnosis of exclusion, but table-tilt test is used to help confirm it. The onset is typically precipitated by immunological stressors like viral infections, vaccination, and pregnancy. Recently, several case reports have been published describing POTS following infection with COVID-19 infection. This was described as long-COVID postural tachycardia syndrome by the American Autonomic Society. However, the association of POTS with COVID-19 vaccine is unclear. Only one case report was published describing the development of POTS after COVID-19 mRNA vaccine. Information relating to this remain limited, and approach to diagnosis and treatment is variable. Our understanding of this condition in relation to vaccination is mostly extrapolated from previously published reports describing it in relation to HPV vaccine. As more people continue to take the vaccine, physicians should be alert to the diagnosis. CONCLUSION: POTS is a frequently underdiagnosed or misdiagnosed disorder. It is characterized by an increase in HR by 30 within 10 minutes of standing . In rare instances, it has been described as a postvaccination adverse immune phenomena, and more recently related to mRNA COVID-19 vaccination. Increased recognition, diagnosis, and reporting will contribute to better understanding and treatment.

RESTING TREMOR AFTER COVID-19 INFECTION

CASE: The patient is a 66 year-old woman with history of hypertension and recovered COVID-19 presenting to the outpatient clinic for eight months of persistent resting tremor of her left arm. The tremor started shortly after she developed headache, fatigue, and epistaxis found to have COVID-19. The tremor is mild, occurs multiple times throughout the day, and usually resolves spontaneously after several seconds. The patient denies any paresthesias, muscle weakness, motor slowing, or ataxia. She has no family history of Parkinson's disease or essential tremor. On physical exam, vital signs are normal. Motor strength is 5/5 and sensation is intact throughout. Brachioradialis deep tendon reflex is 1/4 bilaterally though slightly increased on the right side. Cranial nerves II through XII are intact. Gait is normal with no evidence of shuffling. No pronator drift is evident. No cogwheel rigidity is noted. Finger-to-nose motion is normal. Throughout the appointment, the patient is noted to have an intermittent mild resting tremor in her left arm that lasts several seconds and resolves spontaneously. Laboratory results including a basic metabolic panel and thyroid stimulating hormone level are normal. Incidentally, the patient underwent a recent brain MRI for chronic sensorineural hearing loss that showed normal appearance of the internal auditory canals/ middle ear structures and no evidence of intracranial pathology. The patient was subsequently started on daily propranolol. A subsequent telemedicine visit one month later revealed that her resting tremor had nearly resolved. IMPACT/DISCUSSION: The outpatient presentation of resting tremor warrants consideration of a broad differential that includes Parkinson's disease and other causes of parkinsonism, including neurodegenerative diseases and essential tremor, among others. Furthermore, previous studies have demonstrated new onset movement disorders associated with COVID-19 including myoclonus, ataxia, action/postural tremor, catatonia, dystonia, chorea, and functional movement disorders. The exact pathophysiology of COVID-19 related movement disorders is not well understood. Of note, these prior studies did not specifically address evaluation of COVID-19 related movement disorders in the outpatient setting. CONCLUSION: The patient described above likely developed new onset left arm tremor secondary to COVID-19. Her reassuring physical exam findings, laboratory results, and head MRI suggest against other etiologies. The patient was successfully treated with propranolol. This case demonstrates the importance of neurologic assessment in the outpatient setting, particular in patients with a history of COVID-19 diagnosis. Though limited data exists on outpatient evaluation and management of movement disorders secondary to COVID-19, it is important to recognize this phenomenon as a potential diagnosis.

ECT Resolving Catatonia in a Huntington's Disease Patient: A Case Report and Review of Literature

Background: Psychiatric symptoms, particularly depression, are common in Huntington’s Disease (HD) patients. Catatonia is relatively rare in this population, and there is no current standardized treatment for catatonic HD patients (Merida-Puga et al., 2011). ECT is not generally used for treatment of psychiatric disorders in HD patients;however, there is evidence that it should be considered for some catatonic HD patients (Mowafi and Millard, 2021). Here, we present the case of a HD patient with catatonia rapidly responsive to ECT and conduct a literature review, adding further evidence of its efficacy in this population. Case: Mr. S is a 60-year-old male with a history of HD, MDD, and anxiety who presented to the ED with suicidal ideation and a plan to overdose due to his disease progression, significant anxiety, and paranoia surrounding the COVID-19 pandemic. He was previously admitted to another psychiatric hospital without clinical benefit. His psychotropic regimen at admission included buspirone, citalopram, deutetrabenazine, paliperidone, propranolol, and tiagabine. Four days into his admission, he was nonresponsive on interview. Given concern for catatonia (Bush-Francis Rating Scale, BFRS, 24), a successful lorazepam challenge was administered. Paliperidone was held and lorazepam was scheduled. In the subsequent days, multiple medication changes were made, including discontinuation of deutetrabenazine given concern for depression exacerbation. ECT was started due to continuation of catatonia symptoms despite scheduled lorazepam (BFRS fluctuating from 1 to 23). Following his first two treatments, he resumed oral intake, and his BFRS reduced to 0. By ECT #3, he was speaking fluently with improvement in his mood and suicidal ideation. Following an initial series of eight ECT, treatments were tapered with maintained improvement. Discussion: Our patient had complete resolution of his catatonia and remission of depression with a short course of ECT, experiencing profound improvement even two treatments into the course. Prior case reports indicated the need for longer ECT courses before resolution with the minimum being five treatments and the maximum being 42 (Mowafi and Millard, 2021). However, our patient has had sustained improvement in mood and catatonia symptoms allowing for minimization of polypharmacy. Implications: Given the neuropsychiatric burden in HD patients, it is important for C-L psychiatrists to be aware of ECT's efficacy for both depression and catatonia in this population. References: 1. Merida-Puga, J., Ramirez-Bermudez, J., Aguilar-Venegas, L. C., Fricchione, G. L., & Espinola-Nadurille, M. (2011). Westphal variant Huntington disease and refractory catatonia: a case report. Cognitive and behavioral neurology: official journal of the Society for Behavioral and Cognitive Neurology, 24(4), 204–208. 2. Mowafi, W., & Millard, J. (2021). Electroconvulsive therapy for severe depression, psychosis and chorea in a patient with Huntington's disease: case report and review of the literature. BJPsych bulletin, 45(2), 97–104.

Infantile hemangioma referral delays persist despite 2019 American Academy of Pediatrics Clinical Practice Guideline: Experience at a single quaternary pediatric institution

Infantile hemangiomas (IH) are vascular tumors that often require timely treatment to reduce morbidity.1,2 The 2019 American Academy of Pediatrics (AAP) Clinical Practice Guidelines (CPG) for the Management of IH recommend referral to dermatology prior to 4 weeks of age, enabling timely treatment initiation.1 This study examines adherence to national guidelines and aims to identify barriers to appropriate referral timing & treatment. This retrospective cohort study examined IH patients, ages 0 to 24 months, referred to Phoenix Children’s Hospital (PCH) Dermatology from 1/1/2019 to 12/31/2020, following release of AAP CPG. Patients were categorized into age appropriate (≤4wks) or late (>4wks) referral groups. Associations of referral age w/ demographics/treatments were examined. Among 791 patients identified, 46 (6%) were appropriately referred at ≤4 weeks of age, 680 (86%) were referred late at >4 weeks of age, and 65 (8%) had missing referral dates. For the group of 343 patients who were referred and treated w/ propranolol, mean age at referral, initial dermatology visit, and propranolol initiation was 3.2, 3.8, & 4.2 months, respectively. No statistical differences (p≤0.05) were detected in gender, race, insurance, language, or rates of propranolol/timolol treatment between referral groups. Despite AAP recommendations, the vast majority of infants with IH are referred to PCH Dermatology after 4 weeks of age. Late referral has led to treatment initiation after the rapid growth phase in most patients, which is problematic for those w/ high-risk hemangiomas. Patient demographics were not correlated w/ referral category suggesting that other factors, such as primary care provider referral practices and the COVID-19 pandemic, may have contributed to delayed referrals. Based on mean age at referral and treatment initiation, patients may have already experienced complications from their hemangiomas, which could result in increased healthcare utilization, costs, & morbidity. References: 1) Krowchuk DP et al. Clinical Practice Guideline for the Management of Infantile Hemangiomas: American Academy of Pediatrics. Pediatrics, Jan 2019;143(1). 2) Tollefson MM and IJ Frieden. Early growth of infantile hemangiomas: what parents;photographs tell us. Pediatrics, Aug 2012;130(2): e314-20.

Supplement-Induced Thyrotoxicosis Presenting as New Onset Tachycardia

INTRODUCTION: Dietary and herbal supplements can contain clinically significant amounts of exogenous thyroid stimulants and hormones, including T3 and T4, thus placing consumers at increased risk of thyrotoxicosis and other metabolic-related adverse effects. We present a case of thyrotoxicosis in a young man with no history of thyroid disease, who was found to be consuming an extensive variety of supplements. DESCRIPTION: A 31 year old man with hypertension presented with 1 week of intermittent palpitations. He was in his usual state of health until 1 week prior to admission, when he noticed intermittent, self-resolving episodes of tachycardia as high as the 160s on his smart watch, associated with palpitations, dyspnea, low grade fevers, and intermittent dry cough. He came to the ED for persistence of symptoms. In the ED: T 98.8 F, HR 129, BP 152/77, RR 18, SpO2 98% on RA. CBC, BMP, UA, UTox, blood alcohol content, troponin and COVID tests were unremarkable. TSH was < .007 [0.358-3.740 ulU/mL], with a free thyroxine of 0.54 [0.70-1.48 ng/dL];other thyroid studies later returned with TSI < 0.10 [0.00-0.55 IU/L], free T3 32.50 [1.80-4.60 pg/mL], and an unremarkable thyroid ultrasound. CXR showed no acute infiltrates. EKG revealed sinus tachycardia, no Wolff-Parkinson-White syndrome, and no Brugada waveforms. He was given 2L NS, ceftriaxone 1g IV, aspirin 81mg PO, and tylenol 650mg PO, and admitted to the telemetry unit. Exam revealed an anxious appearing man with tachycardia. On ROS, patient admitted to drinking 6-8 cups of coffee daily, and to taking at least a dozen different supplements. He was started on propranolol 30 mg every 6 hours with improvement in his heart rate, and was counseled to stop the supplements and wean his caffeine intake. He was discharged the following day with plan for endocrinology and primary care follow-up. DISCUSSION: Thyrotoxicosis in this young patient with no history of thyroid disease posed a diagnostic quandary. This prompted further investigation into a more detailed social history, which revealed the extensive variety of supplements he was taking, consistent with thyrotoxicosis factitia. In patients presenting with newonset tachycardia, our case highlights the importance of collecting a thorough social history and maintaining early suspicion for thyroid disease and thyrotoxicosis.

A case of Mis-categorization of different psychopathological domain

Background: Social anxiety disorder (SAD) is characterized by excessive fear of embarrassment, humiliation, or rejection when exposed to possible negative evaluation by others when engaged in a public performance or social interactions. Often, the diagnosis of SAD is missed due to lack of awareness and sometimes misclassified into other psychopathological domains. Case report: A 30-year-old male presented with c/c of fearfulness and suspiciousness in the form that whenever he sees any two individuals talking, he thinks that they are talking about him which were followed by panic like episodes and social avoidance. He consulted a psychiatrist and was prescribed Tab. Amisulpride 400mg/day, Tab. Aripiprazole 20mg/day, Tab. Olanzapine 10mg/day, Tab. Clozapine 100mg/day, Tab. Trifluoperazine 10mg/day+ Tab. Trihexyphenidyl 4mg/day, Tab. Alprazolam 1.5mg/day, Tab. Lorazepam 2mg/day, Tab. Clonazepam 0.5 mg/day and Tab. Propranolol 40mg/day. He didn't improve on these medications but took them for 5-6 years because he was able to sleep throughout the day and avoid social interactions. He visited us and detailed evaluation was done. During history taking, it was noted that his symptoms were actually fear of going in public as he used to think that people are talking that he is inferior to them and that people might misjudge or underestimate him. On detailed Mental Status Examination, it was noted that he suffered from social anxiety with avoidant behavior. Conclusion: It is important to categorize the symptoms into clinically relevant domain by detail history taking and MSE. © IBM Results 152 participants 49.3% Males and 50.7% Females Mean age-29.6 years (SD 4.5) 35.5% reported significant stress Average Stress score on DASS-12.9 (SD 11.1) Mean Professional fulfilment (PF) score-2.0 (SD 1.0) Mean Burnout score-1.3 (SD 0.9) 20.4% residents felt professionally fulfilled 41.4% residents had burnout Stress negatively correlated with Agreeableness Stress positively correlated with Neuroticism Stress positively correlated with Burnout (ñ 0.67;p 0.00) Stress negatively correlated with Professional fulfillment (ñ-0.41;p 0.00) Only Conscientiousness moderated the effect of stress on Burnout and Professional fulfillment Conclusion COVID pandemic generated significant stress among resident doctors Stress is associated with Burnout and Professional fulfilment Higher Conscientiousness reduced burnout due to stress Residents with higher Conscientiousness would experience more negative effect of stress on their professional fulfillment.

21st ESPD Annual Meeting

The proceedings contain 169 papers. The topics discussed include: GNAQ/11 mosaicism causes aberrant calcium signaling and drives systemic hypocalcemia;pediatric obesity and skin disease (PicoSkin-study): cutaneous findings and associated quality of life in 86 children and adolescents with obesity;what gives them the shivers? two new cases of infantile transient smooth muscle contraction of the skin;dermatologic manifestations of multisystem inflammatory syndrome in children during the COVID-19 pandemic;clinical characteristics and management of cutaneous lymphangioma circumscriptum;different shades of grey! infantile black hairy tongue- a case series and review of the literature;descriptive series of cases of pediatric linear morphea in a tertiary hospital in Barcelona;the prevalence of itch in German schoolchildren: a population-based study;neurocognitive functioning, physical health, and mental health of school-aged children treated with propranolol or atenolol for infantile hemangioma;and efficacy and safety of tralokinumab in adolescents with moderate-to-severe atopic dermatitis: results of the phase 3 ECZTRA 6 trial.

A case of Post-COVID-19 thyrotoxicosis and a cavalcade of complications

Thyroid dysfunction has been reported following COVID-19 infection in the recent past. A 50 year old hypertensive female with no previous thyroid illness, developed features of thyrotoxicosis two weeks after a COVID-19 infection. There was no thyromegaly, neck pain or fever and her ESR was 15 mm/hour. She was initiated on propranolol and methimazole in an outside hospital. Ten days later, she presented to our hospital with fever, sore throat, cough and breathing difficulty. On evaluation she was found to be in neutropenic sepsis (WBC -820 cells/mm3, ANC-6 cells/mm3). Evaluation of thyroid functions showed: TSH- <0.00025 IU/ml, free T3 - 4.17 pg/ml, free T4- 3.59 ng/ml and Thyroid Receptor Antibody Levels (TRAb)- 2.53 IU/L. Following treatment with colony stimulating factors and antibiotics she recovered. The patient was commenced on lithium bicarbonate and cholestyramine, along with propranolol. On follow up in the OPD she is euthyroid with free T4 1.43 ng/ml (normal) levels. Post COVID-19 thyrotoxicosis in this case is likely due to Graves' disease. Thyrotoxicosis following COVID-19 is now being recognised and is possibly due to infection induced molecular mimicry with activation of immune pathways causing autoimmune disorders.