Women Facing Head and Neck Cancer: Psychosocial Implications and Protective Factors

Background/Purpose: In the United States, 26% of newly diagnosed head and neck cancer (HNC) patients are women (Siegel et al., 2022). New cases have remained steady for 20 years, but the mortality rate has increased 1.9% per year. Currently, oral cavity and pharyngeal cancers have the second highest mortality rate of all cancers in women (www.seer.cancer.gov/report-to-nation/). This is alarming considering overall cancer mortality in women has dropped 1.4% (www.seer.cancer.gov/report-to-nation/). HNC disrupts the social, emotional, and physical lives of patients. The literature highlights such concerns as depression, problems with speech, eating, and body image, and social support needs (Bond et al., 2014;Hodges & Humphris, 2009;Locher et al., 2010;Maguire et al., 2017;Nund et al., 2015). The purpose of this study was to investigate the unique experience of being a woman with HNC. Problem: The psychosocial impact of HNC is documented in the literature;however, studies include few women and do not report results by sex. Method(s): Women were recruited from two academic medical centers in the Midwest. Participants were interviewed twice for 30-60 min each session. Most were interviewed using a virtual platform, with some in person or by phone. Each semi-structured interview was recorded and transcribed. Transcripts were analyzed using grounded theory techniques to identify themes. Result(s): This study included 10 women, with a mean age of 62.9 years. Several themes emerged, including physical and emotional impact of HNC, adjustment to life with cancer, coping and control, and support needs. Most surprisingly, this study found having HNC helped women feel prepared to navigate the Covid-19 pandemic. Topics included mask wearing, social interactions, family implications, societal views about illness, and feeling prepared. Conclusions and Implications: This study offers insights about the non-medical needs of women with head and neck cancer and provides some guidance on care provision.

The CRISIS Approach When Autonomy and Beneficence Are in Conflict (CS358)

Outcomes: 1. Utilizing CRISIS approach, participants can employ a unique strategy to holistically support patients with poor coping in an acute life-threatening situation. 2. Utilizing the CRISIS approach, participants will apply an ethical tool to mitigate the incongruence that sometimes happens between two ethical principles-autonomy versus beneficence. Autonomy is not always in harmony with beneficence. We present a patient with decisional capacity hospitalized with acute reversible neuromuscular paralysis who refused treatment despite expected recovery. Her decision created moral distress for the clinicians. An improvised palliative strategy resolved the above dilemma. Case presentation: 68-year-old female admitted with new-onset unsteady gait, diplopia, and speech impairment on waking up. She was healthy until 3 weeks before admission, when she developed upper extremity numbness progressing to both legs after a COVID-19 infection. She had bulbar and axial muscle weakness and right oculomotor nerve palsy with ptosis. Positive ice pack and pyridostigmine test indicated myasthenia gravis (MG). During hospitalization, she required mechanical ventilation secondary to acute respiratory failure from progressive paralysis. Serum-negative MG diagnosed, given the response to IVIG and pyridostigmine. The patient, amid acute crisis, refused therapies and wanted to transition to DNR-comfort care despite understanding the reversibility of her illness. Her family members supported comfort care option. Neurology was conflicted with the patient's choice because MG was treatable. Palliative care, ethics, and neuropsychology consulted to establish decision-making capacity, goals-of-care, and holistic support. Intervention(s): Palliative team utilized the CRISIS approach to address the impasse between the patient and the clinicians: 1. Continue care, collaborate with the teams 2. Respond empathetically 3. Integrate patient's autonomy 4. Support holistically 5. Improvise a care plan 6. Sustain quality of life We validated patient's autonomy. We recommended allowing time for the patient/family to process her illness. We continued holistic support and symptom management and created an improvised multidisciplinary plan to help her cope with the acute illness. The above approach enabled her to opt for therapies instead of comfort care only, and she gradually recovered. Respecting patients' autonomy and incorporating beneficence via our intervention led to positive outcomes. The CRISIS approach could help other clinicians in the situation when conflict arises between autonomy and beneficence.Copyright © 2023

A new case of myasthenia gravis following COVID-19 Vaccination

Background: Myasthenia gravis (MG) is an autoimmune disease of unknown etiology. Infections are known as a major cause of MG exacerbations. A few studies have shown an association between new onset MG and SARS-CoV-2 infection. Case presentation: We have reported a case of new onset myasthenia gravis in a 68-year-old man presented with bulbar symptoms a few days after receiving COVID-19 vaccine (Sinopharm vaccine). The disease was confirmed by high titer of antibody against acetylcholine receptor and electrophysiological examinations. Conclusion(s): Among the adverse effects reported with the COVID-19 vaccine, new onset myasthenia gravis is very rare. The underlying mechanism is unknown but the immune response after vaccination and molecular mimicry theory has been proposed.Copyright © 2022

ICT usage in aphasia rehabilitation-beliefs, biases, and influencing factors from the perspectives of speech and language therapists

Background: The use of digital technology is promoted as an efficient route for the delivery of intensive speech and language therapy in aphasia rehabilitation. Research has begun to explore the views of people with aphasia (PwA) in relation to Information and Communication Technology (ICT) usage in the management of aphasia but there is less consideration of the prescribers' views, i.e., speech and language therapists (SLTs). Aim(s): We aimed to explore SLTs' views of ICT use in aphasia management and identify factors that influence their decisions to accept and integrate ICT in aphasia rehabilitation. In addition, we considered the findings in the context of the Unified Theory of Acceptance and Use of Technology (Venkatesh, Morris, Davis & Davis, 2003). Methods & Procedures: Speech and language therapists (n = 15) from a range of clinical and geographical settings in the Republic of Ireland were invited to participate in one of four focus groups. Focus group discussions were facilitated by an SLT researcher and were audio-recorded and transcribed. Analysis was completed following Braun and Clarke's six phases of thematic analysis (Braun and Clarke, 2006). Outcomes & Results: Four key themes were identified;i. Infrastructure, Resources, and Support, ii. SLT beliefs, biases and influencers, iii. Function & Fit, and iv. ICT and Living Successfully with Aphasia. The SLTs discussed a wide range of factors that influence their decisions to introduce ICT in aphasia rehabilitation, which related to the person with aphasia, the SLT, the broad rehabilitation environment, and the ICT programme features. In addition, several barriers and facilitators associated with ICT-delivered aphasia rehabilitation were highlighted. Conclusion(s): This research highlights a range of issues for SLTs in relation to the use of ICT in aphasia rehabilitation within an Irish context. The potential benefits of using ICT devices in rehabilitation and in functional everyday communication were discussed. However, SLTs also identified many barriers that prevent easy implementation of this mode of rehabilitation.Copyright © 2022 The Author(s). Published by Informa UK Limited, trading as Taylor & Francis Group.

Patient Satisfaction With Telemedicine Versus In-Person Speech-Language Therapy: A Systematic Review

Introduction: Telemedicine has become a popular option to provide speech-language pathology (SLP) services during the COVID-19 global pandemic. We sought to systematically review the literature to evaluate patient satisfaction with telemedicine vs in-person visits for SLP services. Method(s): A systematic review was performed in Embase, MEDLINE, AMED, and Scopus databases. Search terms included variations of speech-language pathology, telemedicine, and video. The initial search yielded 549 studies. Of these studies, 37 met criteria for full-text screening. Inclusion criteria included (1) age >18 years and (2) patient satisfaction as an outcome measure. Case reports were excluded. Result(s): Twenty-nine studies met inclusion criteria;8 studies used validated satisfaction questionnaires, 17 used nonvalidated questionnaires, and 4 used qualitative interviews. Of the 29 studies, 3 were randomized controlled trials (RCT). Of the 26 non-RCTs, 24 reported >50% overall satisfaction with televisits. Six studies evaluated patient preference for inperson vs televisits;all studies reported >50% of patients having no preference. Eleven studies evaluated willingness to reengage in telemedicine, and all reported that >50% of patients were willing to reengage with telemedicine. Of the RCTs, 2 used the same validated survey, the Functional Assessment of Chronic Illness Therapy-Treatment Satisfaction- General (FACIT-TS-G), for patients undergoing posttreatment laryngectomy and swallow rehabilitation therapy. Both studies revealed that patients rated televisits with significantly higher satisfaction for the overall results of therapy (P<.02). A third of the RCTs, which focused on patients with chronic stuttering, found telemedicine was more frequently described as extremely convenient (P=.018). Conclusion(s): Although most studies evaluating patient satisfaction with SLP interventions via telemedicine reported greater than 50% overall satisfaction, there was frequent use of nonvalidated measures of patient satisfaction (17 of 29). Use of validated measures is warranted for evaluating patient satisfaction.

MACROGLOSSIA IN THE SETTING OF COVID-19

SESSION TITLE: COVID-19 Case Report Posters 1 SESSION TYPE: Case Report Posters PRESENTED ON: 10/17/2022 12:15 pm - 01:15 pm INTRODUCTION: Macroglossia is a rare but life-threatening symptom that disrupts a person's ability to talk, swallow, and can also compromise their airway. Although not very well studied, there are several case reports describing a possible association between COVID-19 infection and macroglossia in people with African ancestry. We present an African American man who developed significant macroglossia several days after testing positive for COVID-19. CASE PRESENTATION: A 59 y/o African American male with a history of chronic bronchitis and tobacco use presented with 4 days of dyspnea. Sars-Cov-2 PCR was positive. Chest x-ray revealed bilateral, diffuse lung infiltrates. He had an elevated CRP of 295 and a d-dimer of 265. He became lethargic and hypercapnic requiring intubation which was nontraumatic. He was sedated, paralyzed, and proned. He received steroid therapy, broad spectrum antibiotics and a dose of Sarilumab. About a week later, he developed macroglossia that worsened over the course of days. Side effect profiles of each of his medications did not reveal any increased likelihood of macroglossia. C1Q complement cascade was mildly elevated and C1 esterase inhibitor level was normal. Diagnosis and treatment was necessary at this point as concerns for tongue central necrosis were raised and baseline tongue size would be required for proper evaluation and surgical intervention if necessary. He was given 4 units of FFP for possible angioedema with no improvement. CT Neck W/ contrast revealed edema and protrusion of the tongue without a discrete mass. Workup for acromegaly, sarcoidosis, amyloidosis, and hypothyroidism were negative. A pressure ulcer developed on his tongue due to the endotracheal tube and so he underwent tracheostomy. His tongue was draped in Chlorhexidine soaked gauze as well as Vashe wound solution. As he recovered from COVID-19 pneumonia, his respiratory status improved as well as his macroglossia. His tracheostomy was decannulated and his tongue returned to its baseline size. DISCUSSION: Macroglossia can lead to complications including airway compromise, dysphagia, or speech difficulties. It has been heavily proposed in the literature that COVID-19 infection can lead to postinfectious inflammatory peripheral nerve injury secondary to immune driven mechanisms. It was also previously proposed in literature based on immune-histochemical analysis of a tongue tissue sample taken from a COVID-19 patient that tongue muscle atrophy occurs as well as macrophage infiltration similar to that of nerve injury repair which can eventually lead to macroglossia. CONCLUSIONS: As the effects of COVID-19 are becoming better studied overtime, macroglossia, especially in those with African ancestry, is increasingly coming under the radar. This case report seeks to educate clinicians on this possible sequela and encourage supportive treatment in hopes that the tongue will recover. Reference #1: McCrossan S, Martin S, Hill C. Tongue Reduction for Macroglossia. J Craniofac Surg. 2021;32(5):1856-1859. doi:10.1097/SCS.0000000000007276 Reference #2: Colombo D, Del Nonno F, Nardacci R, Falasca L. May macroglossia in COVID-19 be related not only to angioedema?. J Infect Public Health. 2022;15(1):112-115. doi:10.1016/j.jiph.2021.10.026 Reference #3: Fernandez CE, Franz CK, Ko JH, et al. Imaging Review of Peripheral Nerve Injuries in Patients with COVID-19. Radiology. 2020;298 (3). https://doi.org/10.1148/radiol.2020203116 DISCLOSURES: No relevant relationships by Megan Devine No relevant relationships by Devin Haney No relevant relationships by Es-Haq Hassanin No relevant relationships by Nadim Islam No relevant relationships by Alyssa Weyer

Quadriparesis after COVID-19 Vaccination: Two Cases with Different Diagnosis

Aim and objective: During the recent COVID-19 pandemic various vaccines have been developed and approved for emergency use, including adenovirus vector-based ChAdOx1 nCov-19. There are few reports of serious adverse events following immunization (AEFI). Materials and methods: Here, we report two cases of serious AEFI who required ICU admission. Results: Case 1: A 55-y-m hospitalized with complaints of giddiness for 4 days and onset of weakness of all four limbs with altered sensorium for 1 day. He had no history of any comorbidity, non-smoker and non-alcoholic, and no previous episodes of transient ischemic attacks. He was vaccinated with a second dose of adenoviral vector-based ChAdOx1 nCov-19 vaccine (8 days before the onset of first symptoms). After hospitalization, immediate intubation was done for airway protection. His neurological examination revealed blinking of eyes spontaneously, motor power of 0/5 in all four limbs, deep tendon reflex of +2, and mute plantar. MRI Brain was done on the next day (day of illness, DOI-4), which revealed acute infarct in the pons and bilateral cerebellar hemisphere. He was referred to our ICU on DOI-12. Repeat MRI Brain on DOI-16 showed subacute infarcts in the pons, bilateral middle cerebellar peduncles, and left cerebral hemisphere with thrombosed basilar artery. Lipid profile, homocysteine levels, auto-immune work-up were normal. Echocardiography showed normal LV function with no evidence of LA clot. Carotid Doppler showed normal carotid vessels. In view of ischemic stroke and basilar artery thrombosis anti-platelet agent and therapeutic anticoagulation continued. Over the next 3 weeks, he showed gradual improvement in motor power (3/5 in upper limbs and 2/5 in lower limbs) and weaned off from mechanical ventilation. Case 2: A 19-y-m hospitalized with complaints of acute onset paraesthesia and progressive weakness in both lower limbs for 4 days and difficulty in speech and swallowing for 1 day. He had no history of any comorbidity, and no history of preceding viral/bacterial infection except that he had received the first dose of the adenoviral vector-based ChAdOx1 nCov-19 vaccine (16 days before the onset of first symptoms). After hospitalization, he required intubation in view of pooling of oral secretions and respiratory distress. Clinical examination revealed bifacial weakness, severe neck muscle weakness, and flaccid areflexic quadriparesis with prominent proximal upper and lower limb weakness. Pin-prick sensation was distally reduced in both lower limbs with associated autonomic instability in the form of tachycardia and hypertension. MRI Brain was normal in the study. In further work, Guillain-Barré syndrome (GBS) was diagnosed. CSF showed albumin-cytologic dissociation (protein 1.14 g/L and nil cell), and bilateral motor nerve axonal neuropathy on nerve conduction study. Immunoglobulin (IVIG) therapy was started on DOI-6. He did not show significant improvement and was referred to our ICU for further management. During the 5th week of illness, the IVIG dose was repeated without any improvement and continuing requirement of mechanical ventilation. Conclusion: Though vaccination is one of the important public health interventions implemented to tackle the COVID-19 pandemic, there are known and unknown serious AEFI being reported. Both cases presented quadriparesis with different diagnoses, who received vaccination for COVID-19.

Neurological symptoms associated with COVID-19 based on a nation-wide online survey

Aim: There are no broad-scale data available on the presence of neurological symptoms in persons afflicted by COVID-19 in the Czech Republic. Therefore, our goal was to establish the incidence, frequency and duration of new neurological symptoms present in the adult population in the Czech Republic in connection with the COVID-19 disease. Methods: For this purpose, an online questionnaire Neurocovid was developed. The data presented were collected during the period of June 6–August 30, 2021. Results: The questionnaire was filled in by 1,012 individuals aged between 18–79 years (average age 45.6 ±12.88 years, median age 45 years, 65% female). Regional coverage of the Czech Republic mostly corresponded with the demographic distribution of the population. The most common new neurological symptoms that occurred in connection with COVID-19 were cognitive changes such as “slow thinking”, memory difficulties, lack of concentration, speech disorders and disorientation. About 70% of the participants reported at least one of these symptoms. Similar frequency was noted for sleep disorders which were present in more than 70% of the participants. Both groups of symptoms also had a higher tendency to persist long-term. Cognitive changes persisted for over 3 months in 46%, whereas sleep disorders in 72%. Another frequent neurological symptom was olfactory/gustatory dysfunction, which was observed by 67% of the participants. Other symptoms included vertigo (32%), tingling in the body/ limbs (27%), clumsiness/loss of stability while walking (20%), tinnitus (15%), issues with eyesight (14%), and tremor (13%). We did not find a correlation between the severity of the acute phase of the COVID-19 disease and the number or type of new neurological symptoms. Conclusion: This nation-wide online survey of a representative group of the Czech population confirmed a variety of neurological symptoms that occur in connection with COVID-19. The Neurocovid questionnaire should be distributed further to increase data quality and provide an insight into the long-term development of these symptoms.

A Pandemic Care Partner Summit: Online Program Helps Parkinson's Care Partners Take Positive Actions

Objective: The Parkinson's Foundation Care Partner Summit ;Cumbre Para Cuidadores was held virtually on May 16, 2020 in the height of the COVID-19 Pandemic. For the first time, this event was offered without an in-person element, redesigning it's format over the course of eight weeks. Six months after the event, a survey was sent to all registrants of the program to assess the lasting impact of the program on the lives of participating care partners. Background: Respondents were asked when they watched the Summit (Live vs. recorded), what positive actions they have taken since watching (based on responses to the post-event evaluation question After attending today's summit, what are your plans to change and implement lessons learned?), and which of their loved one's PD symptoms has been most challenging for them (the care partner). Methods: 1136 participants joined live while an additional 1692 preregistered but did not attend day of. The combined 3190 registrants were sent a short survey via email in November. Results: 47 participants responded, 36 of whom watched the summit live and did not review any of the recordings. 7 participants reported watching both live and recorded content and 4 reported only watching the recorded content. An additional 9 responses were excluded because respondents reported that they did not watch the summit live or recorded or did not report when they watched the summit. 94% reported at least one positive action, 79% reported at least two, and 53% reported at least three. More than half of respondents reported talking to the PD doctor about cognition or mental health (67%), practicing more patience and compassion with their loved one (57%), and scheduling time for selfcare (53%). When asked about the most challenging symptom for the care partner, 17% reported cognitive changes, followed by Speech and Swallowing Problems at 16%. However, by grouping apathy, anxiety, and depression into mental health this becomes the third most challenging at 14%. Conclusion: While the survey response was small, we are encouraged by the impact reported by participants. Further investigation is required into the long term impact of online psychoeducational programs directed towards those caring for loved ones with Parkinson's disease, and we hope to continue to assess how these types of programs can make life better for people with Parkinson's disease and their loved ones.

18fluorodeoxyglucose (FDG) brain PET/CT as the only diagnostic tool able to identify early cognitive impairment in a covid-19 patient: a case-report

Background-Aim: Cognitive impairment may represent a long lasting symptom after COVID-19 resolution and FDG brain PET is useful to evaluate if brain metabolic changes are transient or long lasting. Hypometabolism was shown in many brain areas, i.e. cingulate cortex, bilateral gyrus rectus, prefrontal and orbitofrontal cortex and cerebellar vermis. Methods: We report the case of a 62 years old man with type 2 diabetes, affected by COVID-19 infection in October 2020. After resolution, the patient had short-term memory loss and speech deficit affecting daily living and working activities and referred to the Gerontology and Geriatrics Institute (Univ. of Perugia). Neurological examination and neuropsychological tests were carried out and no alterations were found. In October 2021, the neurological examination was still normal, as well as neuropsychological tests. Brain MRI showed only two small chronic ischemic foci without bi-hemispheric white matter clinically significant abnormalities. In November 2021, the patient underwent FDG brain PET/CT (discovery ST, G.E.) according to standard protocols and images were evaluated both qualitatively and semiquantitatively. Results: An area of moderate significant hypometabolism was identified in the precuneus (predominant on the right side) and others multiple small and mild hypometabolic regions were localized in bilateral pre-frontal cortex, sensorimotor and parietal cortex both on left hemisphere. PET and MRI fusion images (Syngo.via VB10B image processing software, Siemens) showed that hypometabolic areas corresponded to structurally intact parenchyma at MRI. In January 2022 clinical and neuropsychological follow up did not evidence cognitive impairment, although the patient still felt depressed and impaired in memory, attention and daily living activities. Conclusions: In this case, FDG brain PET/CT was the only diagnostic procedure showing findings consistent with patient symptoms. In particular, precuneus hypometabolism may represent in this patient an early hallmark of dementia (i.e. Alzheimer's disease-AD), although other characteristic brain areas are not significantly impaired (i.e. cingulate cortex). In this case, FDG brain PET use, during follow up, could be crucial to evaluate if the metabolic changes may evolve into a chronic state, thus supporting mild cognitive impairment clinical suspect due to AD or confirming a stable COVID related neuronal damage. Furthermore, a second normal FDG brain PET/CT scan may suggest a post-acute infection transient phase, preluding to normal functional status. In conclusion, FDG brain PET/CT may represent an important diagnostic tool in modifying subsequent diagnostic assessment suggesting or routinely clinical follow up or other investigations for dementia (i.e. amyloid PET, amyloid and Tau protein liquor measurement). In our study, fused PET and MRI images were used, although hybrid PET/MRI system could be the choice option if available.