Diet and Lifestyle Modifications for Fibromyalgia

Fibromyalgia (FM) is a complex, widespread pain disorder characterized by symptoms such as fatigue, sleep deprivation, mental fog, mood swings, and headaches. Currently, there are only three FDA-approved medications for FM patients: duloxetine, milnacipran, and pregabalin, with outcomes frequently being inadequate. This research team aims to investigate the effects of diet and lifestyle modifications on FM, with emphasis on anti-inflammatory diet, antioxidants, and gluten-free diets, as well as supplementation with Magnesium, CQ10, and Vitamin D, microbiome, sleep, exercise, and cognitive behavioral therapy. We reviewed the pathophysiology of certain foods that can be proinflammatory with the release of cytokines leading to activation of pain, fatigue and aggravation of the majority of Fibromyalgia symptoms. A literature review was performed by identifying FM articles published between 1994 and 2022 via PubMed and EMBASE databases, with particular emphasis on randomized controlled trials, meta-analysis, and evidence-based treatment guidelines. This review article was completed by a comprehensive narrative review process, in which our team systematically examined relevant scientific literature to provide a comprehensive overview of the significant role that diet and other lifestyle modifications play in mediating symptoms of Fibromyalgia. We propose that diet modifications and lifestyle changes, such as sleep, exercise, and weight loss, can be important steps in managing FM.

Appropriateness of Levothyroxine Prescription: A Multicenter Retrospective Study

CONTEXT

Levothyroxine is one of the most prescribed medications in the United States.

OBJECTIVE

This study explores the appropriateness of levothyroxine prescriptions.

METHODS

A retrospective multicenter study was conducted on adult patients who were prescribed levothyroxine for the first time between 2017 and 2020 at three academic centers in the United States. We classified each case of levothyroxine initiation into one of three mutually exclusive categories: appropriate (clinically supported), indeterminate (clinically unclear), or nonevidence based (NEB, not clinically supported).

RESULTS

A total of 977 participants were included. The mean age was 55 years (SD 19), there was female (69%) and White race predominance (84%), and 44% had possible hypothyroid symptoms. Nearly half of the levothyroxine prescriptions were considered NEB (528, 54%), followed by appropriate (307, 31%) and indeterminate (118, 12%). The most common reason for NEB prescription was an index thyrotropin (TSH) value of less than 10 mIU/L without previous TSH or thyroxine values (131/528, 25%), for appropriate prescription, was overt hypothyroidism (163/307, 53%), and for an indeterminate prescription was a nonconfirmed subclinical hypothyroidism with TSH greater than or equal to 10 mIU/L (no confirmatory testing) (51/118, 43%). In multivariable analysis, being female (odds ratio [OR]: 1.3; 95% CI, 1.0-1.7) and prescription by a primary care provider (OR: 1.5; 95% CI, 1.2-2.0) were associated with NEB prescriptions.

CONCLUSION

There is a considerable proportion of NEB levothyroxine prescriptions. These results call for additional research to replicate these findings and to explore the perspective of those prescribing and receiving levothyroxine.

Comprehensive metabolic investigation of dopamine reuptake inhibitor HDMP-28 in equine liver microsomes and Cunninghamella elegans for doping control

A dopamine reuptake inhibitor is a type of medication or substance that works by blocking the reuptake of dopamine in the brain. Dopamine reuptake inhibitors offer multiple effects, including increased alertness, improved mood, and therapeutic potential for conditions like depression, ADHD, and Parkinson's disease. HDMP-28, or methylnaphthidate, is a potent synthetic stimulant from the phenyltropane class. It surpasses methylphenidate in both dopamine reuptake inhibition and half-life. As a dopamine reuptake inhibitor, it boosts dopamine levels by hindering reuptake into nerve cells, resulting in heightened stimulation and increased energy. In order to comprehensively address both the tangible and potential repercussions of the unauthorized utilization of the aforementioned substance in sports, it is imperative to establish analytical methodologies for the identification of the parent drug and its primary metabolites. Additionally, a comprehensive analysis of the metabolic characteristics of HDMP-28 in both human and animal subjects has yet to be published. This study explores the metabolic conversion of HDMP-28 mediated by equine liver microsomes and Cunninghamella elegans. An extraction and detection method was developed, optimized, and validated for doping assessment in equine urine and plasma. Liquid chromatography-high-resolution mass spectrometry was employed to determine metabolite structures. The study identified 31 (22 phase I and 9 phase II) metabolites of HDMP-28, including hydroxylated, hydrogenated, and hydrolyzed analogs. Glucuronic acid-conjugated metabolites were also detected. This manuscript describes metabolites based on the in vitro studies, which might not be the same in vivo. These findings aid in the detection and understanding of the illicit use of HDMP-28 in equestrian sports.

Effects of empagliflozin on progression of chronic kidney disease: a prespecified secondary analysis from the empa-kidney trial

BACKGROUND

Sodium-glucose co-transporter-2 (SGLT2) inhibitors reduce progression of chronic kidney disease and the risk of cardiovascular morbidity and mortality in a wide range of patients. However, their effects on kidney disease progression in some patients with chronic kidney disease are unclear because few clinical kidney outcomes occurred among such patients in the completed trials. In particular, some guidelines stratify their level of recommendation about who should be treated with SGLT2 inhibitors based on diabetes status and albuminuria. We aimed to assess the effects of empagliflozin on progression of chronic kidney disease both overall and among specific types of participants in the EMPA-KIDNEY trial.

METHODS

EMPA-KIDNEY, a randomised, controlled, phase 3 trial, was conducted at 241 centres in eight countries (Canada, China, Germany, Italy, Japan, Malaysia, the UK, and the USA), and included individuals aged 18 years or older with an estimated glomerular filtration rate (eGFR) of 20 to less than 45 mL/min per 1·73 m2, or with an eGFR of 45 to less than 90 mL/min per 1·73 m2 with a urinary albumin-to-creatinine ratio (uACR) of 200 mg/g or higher. We explored the effects of 10 mg oral empagliflozin once daily versus placebo on the annualised rate of change in estimated glomerular filtration rate (eGFR slope), a tertiary outcome. We studied the acute slope (from randomisation to 2 months) and chronic slope (from 2 months onwards) separately, using shared parameter models to estimate the latter. Analyses were done in all randomly assigned participants by intention to treat. EMPA-KIDNEY is registered at ClinicalTrials.gov, NCT03594110.

FINDINGS

Between May 15, 2019, and April 16, 2021, 6609 participants were randomly assigned and then followed up for a median of 2·0 years (IQR 1·5-2·4). Prespecified subgroups of eGFR included 2282 (34·5%) participants with an eGFR of less than 30 mL/min per 1·73 m2, 2928 (44·3%) with an eGFR of 30 to less than 45 mL/min per 1·73 m2, and 1399 (21·2%) with an eGFR 45 mL/min per 1·73 m2 or higher. Prespecified subgroups of uACR included 1328 (20·1%) with a uACR of less than 30 mg/g, 1864 (28·2%) with a uACR of 30 to 300 mg/g, and 3417 (51·7%) with a uACR of more than 300 mg/g. Overall, allocation to empagliflozin caused an acute 2·12 mL/min per 1·73 m2 (95% CI 1·83-2·41) reduction in eGFR, equivalent to a 6% (5-6) dip in the first 2 months. After this, it halved the chronic slope from -2·75 to -1·37 mL/min per 1·73 m2 per year (relative difference 50%, 95% CI 42-58). The absolute and relative benefits of empagliflozin on the magnitude of the chronic slope varied significantly depending on diabetes status and baseline levels of eGFR and uACR. In particular, the absolute difference in chronic slopes was lower in patients with lower baseline uACR, but because this group progressed more slowly than those with higher uACR, this translated to a larger relative difference in chronic slopes in this group (86% [36-136] reduction in the chronic slope among those with baseline uACR <30 mg/g compared with a 29% [19-38] reduction for those with baseline uACR ≥2000 mg/g; ptrend<0·0001).

INTERPRETATION

Empagliflozin slowed the rate of progression of chronic kidney disease among all types of participant in the EMPA-KIDNEY trial, including those with little albuminuria. Albuminuria alone should not be used to determine whether to treat with an SGLT2 inhibitor.

FUNDING

Boehringer Ingelheim and Eli Lilly.

Impact of primary kidney disease on the effects of empagliflozin in patients with chronic kidney disease: secondary analyses of the EMPA-KIDNEY trial

BACKGROUND

The EMPA-KIDNEY trial showed that empagliflozin reduced the risk of the primary composite outcome of kidney disease progression or cardiovascular death in patients with chronic kidney disease mainly through slowing progression. We aimed to assess how effects of empagliflozin might differ by primary kidney disease across its broad population.

METHODS

EMPA-KIDNEY, a randomised, controlled, phase 3 trial, was conducted at 241 centres in eight countries (Canada, China, Germany, Italy, Japan, Malaysia, the UK, and the USA). Patients were eligible if their estimated glomerular filtration rate (eGFR) was 20 to less than 45 mL/min per 1·73 m2, or 45 to less than 90 mL/min per 1·73 m2 with a urinary albumin-to-creatinine ratio (uACR) of 200 mg/g or higher at screening. They were randomly assigned (1:1) to 10 mg oral empagliflozin once daily or matching placebo. Effects on kidney disease progression (defined as a sustained ≥40% eGFR decline from randomisation, end-stage kidney disease, a sustained eGFR below 10 mL/min per 1·73 m2, or death from kidney failure) were assessed using prespecified Cox models, and eGFR slope analyses used shared parameter models. Subgroup comparisons were performed by including relevant interaction terms in models. EMPA-KIDNEY is registered with ClinicalTrials.gov, NCT03594110.

FINDINGS

Between May 15, 2019, and April 16, 2021, 6609 participants were randomly assigned and followed up for a median of 2·0 years (IQR 1·5-2·4). Prespecified subgroupings by primary kidney disease included 2057 (31·1%) participants with diabetic kidney disease, 1669 (25·3%) with glomerular disease, 1445 (21·9%) with hypertensive or renovascular disease, and 1438 (21·8%) with other or unknown causes. Kidney disease progression occurred in 384 (11·6%) of 3304 patients in the empagliflozin group and 504 (15·2%) of 3305 patients in the placebo group (hazard ratio 0·71 [95% CI 0·62-0·81]), with no evidence that the relative effect size varied significantly by primary kidney disease (pheterogeneity=0·62). The between-group difference in chronic eGFR slopes (ie, from 2 months to final follow-up) was 1·37 mL/min per 1·73 m2 per year (95% CI 1·16-1·59), representing a 50% (42-58) reduction in the rate of chronic eGFR decline. This relative effect of empagliflozin on chronic eGFR slope was similar in analyses by different primary kidney diseases, including in explorations by type of glomerular disease and diabetes (p values for heterogeneity all >0·1).

INTERPRETATION

In a broad range of patients with chronic kidney disease at risk of progression, including a wide range of non-diabetic causes of chronic kidney disease, empagliflozin reduced risk of kidney disease progression. Relative effect sizes were broadly similar irrespective of the cause of primary kidney disease, suggesting that SGLT2 inhibitors should be part of a standard of care to minimise risk of kidney failure in chronic kidney disease.

FUNDING

Boehringer Ingelheim, Eli Lilly, and UK Medical Research Council.

Comparative investigations into the growth details of Histoplasma capsulatum var farciminosum on four different agar media

Epizootic equine lymphangitis (EEL) is a chronic fungal disease that affects equids. The causative agent is a dimorphic fungus called Histoplasma capsulatum var farciminosum. Histoplasmacapsulatum var farciminosum field strain 7 (D 2878/2023) isolated from the eye socket of an EEL Ethiopian horse was sub-cultured on four different solid media and incubated at 26°C and 37°C for 6 weeks. Details of growth morphology were recorded and shown in images during 6 weeks of incubation. Histoplasmacapsulatum var farciminosum grew best at 26°C on all four agars, but only on sheep blood agar at 37°C as small, white dry colonies.

Indicators for the evaluation of musculoskeletal trauma systems: A scoping review and Delphi study

BACKGROUND

Trauma is a leading cause of mortality and morbidity, disproportionately affecting low- and middle-income countries. Musculoskeletal trauma results in the majority of post-traumatic morbidity and disability globally. The literature has reported many performance indicators relating to trauma care, but few specific to musculoskeletal injuries.

STUDY OBJECTIVES

The purpose of this study was to establish a practical list of performance indicators to evaluate and monitor the quality and equity of musculoskeletal trauma care delivery in health systems worldwide.

METHODS

A scoping review was performed that identified performance indicators related to musculoskeletal trauma care. Indicators were organized by phase of care (general, prevention, pre-hospital, hospital, post-hospital) within a modified Donabedian model (structure, process, outcome, equity). A panel of 21 experts representing 45 countries was assembled to identify priority indicators utilizing a modified Delphi approach.

RESULTS

The scoping review identified 1,206 articles and 114 underwent full text review. We included 95 articles which reported 498 unique performance indicators. Most indicators related to the hospital phase of care (n = 303, 60%) and structural characteristics (n = 221, 44%). Mortality (n = 50 articles) and presence of trauma registries (n = 16 articles) were the most frequently reported indicators. After 3 rounds of surveys our panel reached consensus on a parsimonious list of priority performance indicators. These focused on access to trauma care; processes and key resources for polytrauma triage, patient stabilization, and hemorrhage control; reduction and immobilization of fractures and dislocations; and management of compartment syndrome and open fractures.

CONCLUSIONS

The literature has reported many performance indicators relating to trauma care, but few specific to musculoskeletal injuries. To create quality and equitable trauma systems, musculoskeletal care must be incorporated into development plans with continuous monitoring and improvement. The performance indicators identified by our expert panel and organized in a modified Donabedian model can serve as a method for evaluating musculoskeletal trauma care.

Reducing donor-site complications in DIEP flap breast reconstruction with closed incisional negative pressure therapy: A cost-benefit analysis

INTRODUCTION

Deep inferior epigastric perforator (DIEP) flaps are considered the gold standard for autologous breast reconstruction but create large abdominal incisions that risk donor-site morbidity during harvest. Closed incision negative pressure therapy (ciNPT) is emerging as an effective alternative to standard postoperative dressings, but there is a paucity of data in DIEP flap donor sites.

METHODS

We conducted a retrospective case-control study investigating the use of ciNPT in DIEP flap donor sites at a single institution between March 2017 and September 2021. Patients who underwent microsurgical autologous breast reconstruction with DIEP flaps were included. Patients were divided into those with donor incision sites managed with ciNPT (n = 24) and those with conventional postoperative wound dressings (n = 20). We compared patient demographics, wound drainage volumes and postoperative outcomes between the two groups. A cost-benefit analysis was employed to compare the overall costs associated with each complication and differences in length of stay between the two groups.

RESULTS

There was no statistically significant difference in age, body mass index (BMI), comorbidity burden or smoking status between the two groups. Both groups had similar lengths of stay and wound drainage volumes with no readmissions or reoperations in either group. There was a statistically significant reduction in donor-site complications (p = 0.018), surgical site infections (p = 0.014) and seroma formation (p = 0.016) in those with ciNPT. Upon cost-benefit analysis, the ciNPT group had a mean reduction in cost-per-patient associated with postoperative complications of £420.77 (p = 0.031) and £446.47 (p = 0.049) when also accounting for postoperative length of stay CONCLUSION: ciNPT appears to be an effective alternative incision management system with the potential to improve complication rates and postoperative morbidity in DIEP flap donor sites. Our analysis demonstrates improved cost-benefit outweighing the increase in costs associated with ciNPT. We recommend a multicentre prospective trial with formal cost-utility analysis to strengthen these findings.

PSUN260 Diabetic Myconecrosis: a Rare Complication of Uncontrolled Diabetes Mellitus

Introduction

Spontaneous diabetic myonecrosis is a rare and underdiagnosed microvascular complication of long standing and poorly controlled diabetes mellitus. The pathogenesis of this infarction of the skeletal muscle appears to be related to vasculopathic changes without an atheroembolic event or occlusion of major arteries. The factors responsible for the acute onset of symptoms are unknown. Since the initial description in 1965, only 170 cases have been described, including 126 initial episodes and 44 episodes of recurrence, with a mean age at presentation of 45 years (range 20 to 67 years). Most of the patients have other microvascular complications. Characteristic symptoms at presentation include acute onset unilateral lower limb pain and swelling, most often in the thigh, without a history of trauma. Bilateral involvement is present in approximately 30% of the cases. Fever has been reported only in about 10% of cases.

Case Report

A 23-year-old female presented with ten days history of fever, left groin pain and inability to walk. Other than chronic fatigue, her review of symptoms was mostly negative. She denied any trauma. She had a history of poorly controlled type 1 diabetes mellitus (HbA1c 10.5%) with diabetic nephropathy (proteinuria),but no evidence of retinopathy or neuropathy. On examination, her left groin and proximal thigh were warm and tender to palpation without noticeable erythema or swelling. Labs showed elevated inflammatory markers. CT scan showed inguinal and retroperitoneal lymphadenopathy with subcutaneous edema of the visualized left lower extremity. Fevers persisted despite appropriate administration of antibiotics for cellulitis. Infectious workup was negative. A biopsy of her inguinal lymph node showed reactive changes. MRI of her left thigh showed large, confluent areas of intramuscular hypo enhancement compatible with diabetic myonecrosis. Her symptoms improved over the next 3-4 weeks with supportive care.

Discussion

Spontaneous diabetic myonecrosis is a very rare complication of uncontrolled diabetes. Knowledge about his condition is required to make the correct diagnosis and avoid the use of unnecessary laboratory tests and treatments. The presence of the characteristic clinical features such as pain and swelling in typically affected areas such as the thigh, will frequently suggest the diagnosis. MRI with intravenous contrast enhancement is the diagnostic imaging of choice and shows increased signal on T2-weighted images from muscle edema and areas of non-enhancement from myonecrosis. Treatment involves symptomatic management with rest, optimal glycemic control, analgesia, and low-dose aspirin, although the optimal treatment approach is uncertain. The short-term prognosis is good, but the recurrence rate remains high and long-term prognosis is poor given underlying poorly controlled diabetes.

Presentation: Sunday, June 12, 2022 12:30 p.m. - 2:30 p.m.

Subcategories of Fibromyalgia: A New Concept

Fibromyalgia has previously been categorized as primary, secondary, and juvenile fibromyalgia. However, these definitions do not adequately explain the etiopathology of disease, nor do they help direct new specific therapies. Herein, we review the previously known categorizations of fibromyalgia. Based on common patient characteristics and previously studied pathophysiologies, we propose new subcategorizations of fibromyalgia that we have self-narrated, including hormonal fibromyalgia, neuroendocrine fibromyalgia, psychologic fibromyalgia, inflammatory fibromyalgia, and lastly, neuropathic fibromyalgia. Future research needs to be done to verify, add to, and fully describe these self-narrated categories of fibromyalgia that we have proposed.

Genetic diversity and spatial distribution of Burkholderia mallei by core genome-based multilocus sequence typing analysis

Burkholderia mallei is the etiological agent of glanders, a highly contagious and often fatal disease in equids. Due to the high genetic clonality of B. mallei, high-resolution typing assays are necessary to differentiate between individual strains. Here we report on the development and validation of a robust and reproducible core genome-based Multi Locus Sequence Typing Assay (cgMLST) for B. mallei, which is based on 3328 gene targets and enables high-resolution typing at the strain level. The assay was validated using a set of 120 B. mallei genomes from public databases and 23 newly sequenced outbreak strains from in-house strain collections. In this cgMLST analysis, strains from different geographic regions were clearly distinguished by at least 70 allele differences, allowing spatial clustering while closely related and epidemiologically related strains were separated by only zero to three alleles. Neither the different sequencing technologies nor the assembly strategies had an influence on the cgMLST results. The developed cgMLST is highly robust, reproducible and can be used for outbreak investigations, source tracking and molecular characterization of new B. mallei isolates.

[Clinical, diagnostic and evolutionary profile of peritoneal tuberculosis at the national reference general hospital of Ndjamena about 69 cases]

INTRODUCTION

Peritoneal tuberculosis is not uncommon in Chad. Its diagnosis of certainty is difficult and is based on the analysis of ascites fluid and abdominal ultrasound. Our aim was to contribute to the study of the various clinical, diagnostic and progressive aspects of peritoneal tuberculosis in the internal medicine department of the HGRN.

METHODOLOGY

This is a retrospective and prospective study spread over 39 months covering the period from January 2014 to March 2017 including all patients hospitalized for peritoneal tuberculosis in the internal medicine department of the HGRN. The diagnosis was made, on a bundle of anamnestic, clinical, ultrasound, cytological and evolutionary arguments.

RESULTS

During the study period, 69 patients were included, or 9.77% of all hospital admissions. The average age was 42 years (range 18 to 83 years). The female sex represented 52.2% of the cases. The main reasons for hospitalization were ascites (87% of cases), associated with fever (92.5% of cases). The clinical signs were dominated by abdominal pain, deterioration of general condition and transit disorders. The ascites fluid was citrus yellow, rich in lymphocytes (81.6% of cases) and protein (94.2% of cases). Abdominal ultrasound, performed in all patients, demonstrated ascites with deep, mesenteric lymphadenopathy, portal in 62.3% of cases and compartmentalized in 37.7% of cases. Tuberculosis treatment was started in all patients and the outcome was favorable in 65.2% of cases. We deplored 20.3% mortality; all were patients who were severely immunosuppressed with HIV.

CONCLUSION

Peritoneal involvement in tuberculosis is common in Chad. The diagnosis is not always easy, but the clinic associated with the exudative and lymphocytic characters of the ascites fluid as well as the abdominal ultrasound are elements which can direct towards a peritoneal localization of tuberculosis. The course is generally favorable under early treatment and well conducted.

Development of a sensitive competitive enzyme-linked immunosorbent assay for serodiagnosis of Burkholderia mallei, a Tier 1 select agent

Glanders is a highly contagious and potentially serious disease caused by Burkholderia mallei, a Tier 1 select agent. In this study, we raised a monoclonal antibody (mAb) against the lipopolysaccharide (LPS) of B. mallei and developed a competitive enzyme-linked immunosorbent assay (cELISA) for B. mallei infection. Using the titrated optimal conditions of B. mallei-LPS (2 ng) for microtiter plate coating, sample serum dilution at 1:20 and 3.5 ng/μL anti-LPS mAb B5, the cutoff value of the cELISA was determined using serum samples from 136 glanders-free seronegative horses in Hong Kong. All calculated percentage inhibition (PI) values from these seronegative samples were below 39.6% inhibition (1.5 standard deviations above mean PI) and was used as the cutoff value. The diagnostic sensitivity of the developed LPS-based cELISA was first evaluated using sera from donkeys and mice inoculated with B. mallei. An increasing trend of PI values above the defined cELISA cutoff observed in the donkey and mouse sera suggested positive detection of anti-LPS antibodies. The sensitivity and specificity of the LPS-based cELISA was further evaluated using 31 serologically positive horse sera from glanders outbreaks in Bahrain and Kuwait, of which 30 were tested positive by the cELISA; and 21 seronegative horse sera and 20 seronegative donkey sera from Dubai, of which all were tested negative by the cELISA. A cELISA with high sensitivity (97.2%) and specificity (100%) for the detection of B. mallei antibodies in different animals was developed.

Glanders is a highly contagious and life-threatening disease caused by Burkholderia mallei, a Tier 1 select agent, with no available vaccine. The disease is endemic in the Middle East, Asia, Africa and South America with sporadic outbreaks and mainly occurs in horses, donkeys and mules, although it has also been reported in camels, tigers, lions, and even humans. As the bacterium is not easily isolated from clinical specimens and correct identification based on clinical signs is difficult, it is thus important to develop serological tests which can quickly diagnose B. mallei infection. In this study, we generated a monoclonal antibody against B. mallei lipopolysaccharide and used it to develop a competitive enzyme-linked immunosorbent assay (cELISA) for the serodiagnosis of B. mallei infection. The developed cELISA was optimized and evaluated using glanders-free and glanders-positive horses, donkeys and mice from Hong Kong and the Middle East, and was shown to be highly sensitive and specific for the detection of glanders in different animals. A simple and inexpensive test to allow for the early detection and diagnosis of suspected clinical cases as well as the screening of apparently asymptomatic animals will be helpful in controlling the spread and elimination of the disease.

Comparison of five basal compositions of selective chocolate agar media for isolation of Taylorella equigenitalis

The gold standard method to isolate and identify Taylorella equigenitalis, the contagious agent of equine metritis, is the culture method according to the World Organisation for Animal Health Terrestrial Manual. No selective T. equigenitalis chocolate agar medium has been developed since the 1980s and the existing media show limited performances due to the fastidious nature of T. equigenitalis and the presence of interfering bacteria in the genital tract of equines. Here, the growth rates of 6 T. equigenitalis strains and 7 non-T. equigenitalis strains were compared on Timoney's selective medium formulated with 5 different basal agars (Columbia, Eugon, Blood, Mueller-Hinton and Tryptose Blood) provided by 2 to 4 suppliers per basal agar. The impact of glucose and/or Vitox supplementation was also investigated. Overall, the performance of selective T. equigenitalis media could be improved by substituting Eugon or Columbia agar with Blood, Mueller-Hinton or Tryptose Blood agar. It is nevertheless essential to validate the basal agar/supplier pair using a panel of T. equigenitalis strains. Furthermore, our findings confirm the need to supplement the selective media with a mixture of amino acids, nucleotides, and organic, mineral and vitamin compounds, translated here by Vitox supplementation.

Analysis of Facial Electromyography Signals Using Linear and Non-Linear Features for Human-Machine Interface

In this work, an attempt has been made to analyze the facial electromyography (facial EMG) signals using linear and non-linear features for the human-machine interface. Facial EMG signals are obtained from the publicly available, widely used DEAP dataset. Thirty-two healthy subjects volunteered for the establishment of this dataset. The signals of one positive emotion (joy) and one negative emotion (sadness) obtained from the dataset are used for this study. The signals are segmented into 12 epochs of 5 seconds each. Features such as sample entropy and root mean square (RMS) are extracted from each epoch for analysis. The results indicate that facial EMG signals exhibit distinct variations in each emotional stimulus. The statistical test performed indicates statistical significance (p<0.05) in various epochs. It appears that this method of analysis could be used for developing human-machine interfaces, especially for patients with severe motor disabilities such as people with tetraplegia.

455 A Case of An Unusual Penetrating Brain Injury

Introduction

Penetrating brain injuries (PBI) are less common than closed head traumas. Interest in frontal lobe injuries dates back to 1848’s famous Phineas Gage incident. Here, we report a case of a construction worker, who showed a remarkable neuropsychiatric outcome following a workplace accident.

Case Presentation

45year old gentleman came with complaint of a foreign body accidentally lodged in his forehead. He had no neurological deficits or CSF leak. X-ray revealed that a 5.5cm metallic screw was penetrating his skull, headfirst; CT revealed that approximately 3cm of the screw was in the frontal sinus. He was given antiepileptics and antibiotics prophylactically. Surgically the screw was removed by raising a bone flap and mobilizing the screw carefully by cutting the dura and adequate irrigation, causing minimal damage to the brain parenchyma. The dural deficits were repaired and the frontal sinus was canalized, then a drain was placed, and the patient was shifted to ICU for postoperative monitoring.

Discussion

It is important to prognosticate PBI as they can have neurological deficits that may be lifelong. Understanding the mechanism of injury, aggressive medical management and immediate surgical intervention may lead to improved outcomes. A foreign object of the size of 5.5cm, completely penetrating the skull would have otherwise resulted in extensive parenchymal damage. Literature suggests that no two people have an identical frontal sinus. In our patient the size the frontal sinus has served the purpose of protection against PBI and has resulted in minimal parenchymal injury (of only about 1cm).

426 PREVALENCE OF, AND RISK FACTORS FOR, DEMENTIA IN ADULT OUTPATIENT REFERRALS TO A REGIONAL REFERRAL HOSPITAL IN ARUSHA, TANZANIA

Introduction

The global burden of dementia is increasing, with the greatest increase predicted to occur in sub-Saharan Africa (SSA). Despite this there are limited previous data on the prevalence of, and risk factors for, dementia in SSA. This study aimed to estimate the prevalence of dementia, and investigate its associations, in those aged 60 years and older attending the outpatient department of Mount Meru Hospital in northern Tanzania. This is the first hospital-based outpatient dementia prevalence and risk factors study to be conducted in an east African population.

Methods

This was a one-phase cross-sectional study. Adults aged 60 years and over attending medical outpatients were screened for dementia using The Identification and Intervention for Dementia in Elderly Africans cognitive screening tool. Those who scored ≤9 were clinically assessed using the DSM-IV criteria. Demographic, medical comorbidity and lifestyle information were collected during a clinical assessment.

Results

Prevalence of dementia was 5.0% (95% confidence interval: 3.7–6.3). Binary logistic regression found female sex (odds ratio (OR) = 2.778), having no formal education (OR = 6.088), quantity of alcohol consumption (units/week) (OR = 1.080), uncorrected visual impairment (OR = 4.260), body mass index &lt;18.5 kg/m2 (OR = 6.588) and stroke (OR = 15.790 with wide 95% confidence interval (3.48–74.475)) to be significantly, independently associated with dementia.

Conclusions

The prevalence of dementia in this population is lower than previously reported community-based rates in Tanzania, and similar to those in high-income countries. This is the first time the association between uncorrected visual impairment and dementia has been reported in SSA. Other associations identified are in keeping with previous literature. Further research on the management of dementia and its risk factors, and the support and education of carers and patients in east African populations is required.

Globetrotting strangles: the unbridled national and international transmission of Streptococcus equi between horses

The equine disease strangles, which is characterized by the formation of abscesses in the lymph nodes of the head and neck, is one of the most frequently diagnosed infectious diseases of horses around the world. The causal agent, Streptococcus equi subspecies equi, establishes a persistent infection in approximately 10 % of animals that recover from the acute disease. Such 'carrier' animals appear healthy and are rarely identified during routine veterinary examinations pre-purchase or transit, but can transmit S. equi to naïve animals initiating new episodes of disease. Here, we report the analysis and visualization of phylogenomic and epidemiological data for 670 isolates of S. equi recovered from 19 different countries using a new core-genome multilocus sequence typing (cgMLST) web bioresource. Genetic relationships among all 670 S. equi isolates were determined at high resolution, revealing national and international transmission events that drive this endemic disease in horse populations throughout the world. Our data argue for the recognition of the international importance of strangles by the Office International des Épizooties to highlight the health, welfare and economic cost of this disease. The Pathogenwatch cgMLST web bioresource described herein is available for tailored genomic analysis of populations of S. equi and its close relative S. equi subspecies zooepidemicus that are recovered from horses and other animals, including humans, throughout the world. This article contains data hosted by Microreact.

A new strain of Taylorella asinigenitalis shows differing pathogenicity in mares and Jenny donkeys

BACKGROUND

Three horse mares inadvertently inseminated with semen from a Tayorella asinigenitalis-positive Jack donkey developed severe, purulent endometritis whereas two Jenny donkeys mated naturally to the same Jack donkey did not develop clinical signs of infection.

OBJECTIVES

To isolate and identify the causative agent.

STUDY DESIGN

Case report.

METHODS

Endometrial swabs from the infected mares were cultured on selective and non-selective media under aerobic and microaerophilic conditions. Isolates were subjected to Gram staining, oxidase and catalase tests, the Monotayl Latex Agglutination test and PCR to test for both T. equigenitalis and T. asinigenitalis. In vitro antimicrobial susceptibility testing was performed and the bacterial isolate was genotyped using MLST.

RESULTS

A new sequence type of T. asinigenitalis was confirmed.

MAIN LIMITATIONS

A limited numbers of mares and donkeys are described.

CONCLUSIONS

This strain of T. asinigenitalis causes a severe venereal infection in mares but not in Jenny donkeys.

SAT-686 Type 1 Diabetes Diagnosed in an 83 Year Old Man After Nivolumab Therapy

BACKGROUND

Immune checkpoint inhibitors are increasingly being used for a variety of cancers and are a promising treatment option. Immune related adverse effects are their major side effects, most common being hypophysitis and hypothyroidism. While diabetes and adrenalitis have only been rarely reported, these too are becoming more common. We present a case of type 1 diabetes associated with Nivolumab therapy diagnosed in an 83-year-old man.

CASE

An 83 year old male with past medical history of emphysema, coronary artery disease, hypertension, non-small cell lung cancer treated with lobectomy, hepatitis C cirrhosis with hepatocellular carcinoma with metastasis to lungs, who completed 10 cycles of Nivolumab presented to oncology clinic with complains of polyuria, polydipsia and a weight loss of 10 pounds over the last one week. Lab work showed a blood glucose of 743 with an anion gap of 18 and bicarb of 18. B-hydroxy butyrate was 3.19. He was admitted to our ICU for diabetic ketoacidosis. He did not have a history of diabetes mellitus. No family history of diabetes was reported. His Hemoglobin A1c was found to be 10.1. He had normal blood sugars before starting Nivolumab therapy. His C-peptide was found to be low at 0.61. Insulin antibody, Islet cell antibody, Zinc transporter antibody and GAD antibodies were negative. He was discharged on basal bolus Insulin regimen. He is being followed in our endocrinology clinic and continues to be insulin dependent.

CONCLUSION

Nivolumab is PD-1 (programmed cell death) inhibitor, which is used as cancer immunotherapy in multiple advanced cancers including hepatocellular carcinoma. Clinically significant endocrinopathies are documented in <5% of patients treated with PD-1 inhibitors. The cause of Diabetes by PD-1 inhibitors is not well defined but believed to be caused by destruction of pancreatic beta cells due to inhibition of autoimmunity by autoreactive T cells. Literature review showed only 42 published cases of PD-1 inhibitor induced type 1 diabetes. Average age at presentation was 62 years and about 69% patients were in DKA at diagnosis. In a recently published study involving 1163 patients who received PD-1 inhibitors, only 21 cases of diabetes were identified, 12 of those were with new onset DM and only 1 case was due to Nivolumab use.

Since this type of endocrinopathy is mainly reported in case reports, we will need more research for further understanding of the pathology so that we can keep a watch out for this adverse effect and prevent life- threatening complications.

P2866Automated ultrasound ablation parameters predict lesion depth in a perfused thigh model

Background

The accuracy and safety of lesions created during catheter ablation of cardiac tissue rely on the user's ability to predict the size of lesions that form under variable conditions during treatment. A user-directed robotic system was developed that uses Low-Intensity Collimated Ultrasound (LICU) for cardiac imaging and to produce linear lesions without tissue contact. Molecular absorption of mechanical energy induced in the tissue by LICU causes a temperature rise resulting in thermal tissue necrosis.

Purpose

By varying the speed of the LICU beam as it traces the desired lesion path, while considering the beam intensity, distance from catheter tip to tissue, and relative motion of the target tissue, we demonstrate the capability to deposit lesions of known depth according to a predictive model.

Methods

The LICU catheter was mounted in a servo-controlled, 3 axis stage suspended above a perfused porcine thigh that simulates the thermodynamic properties of the myocardium such as acoustic attenuation, thermal conduction, and specific heat capacity. Therapy was delivered along a linear path while varying the distance to tissue, speed of the beam, and motion of the catheter relative to the tissue in 3 dimensions. Programmed relative motion was representative of typical and extreme motion in humans. Pathological analysis after necropsy was used to quantify lesion depth which was then compared to lesion depth as predicted by a mathematical model from approx. 4–12 mm.

Results

Data from 66 samples were categorized according to typical and extreme motion at 4 different distances (3, 8, 9 and 13 mm). Measured vs predicted lesion depth was well correlated (R = 0.898) with 98.5% of the samples within ±2 mm.

Assessment of LICU lesion depth

Conclusion

Lesion depth using LICU is well controlled in an animal model for the range of distances and relative motion typically encountered in a human subject. The range of acoustic beam speeds and acoustic power density with LICU predictably produces lesions up to 12 mm deep. The LICU thermal model may be useful to create lesions of known depth thus ensuring transmurality of lesions while potentially avoiding unintended extra-cardiac injury.

Evaluation of serological responses in horses challenged with Burkholderia pseudomallei using current diagnostic tests for glanders

Six horses were challenged experimentally with a strain of Burkholderia pseudomallei isolated from a fatal case of the infection in a dromedary camel years earlier in the Emirate of Dubai. Three horses were inoculated subcutaneously and in 3 the bacterium was administered by the oral route. Four of the horses became serologically positive based on reactions to one or more of the OIE described tests for glanders. B. pseudomallei was re-isolated from the 4 serological positive horses. Only one of the subcutaneously infected horses, developed fever for 3 days. The white blood cell values and the neutrophil counts were also elevated. The study confirmed that existing serological test for diagnosing glanders cannot differentiate between glanders and melioidosis in horses.

Health Outcomes of Youth in Clinical Pediatric Weight Management Programs in POWER

OBJECTIVE

To describe treatment outcomes of children and adolescents enrolled in the Pediatric Obesity Weight Evaluation Registry, a consortium of multicomponent pediatric weight management programs in the US.

STUDY DESIGN

This multicenter prospective observational cohort study, established in 2013, includes youth (2-18 years of age) with obesity enrolled from 31 Pediatric Obesity Weight Evaluation Registry (POWER) sites over a 2-year period and followed up to 12 months. Weight status was evaluated by the percentage of the 95th percentile for body mass index (%BMIp95). Associations of weight status outcomes with patient characteristics and program exposure were analyzed with multivariable mixed effects modeling.

RESULTS

We included 6454 children and adolescents (median age, 11 years; IQR, 9-14 years; 53% white, 32% Hispanic; 73% with severe obesity) who were enrolled in POWER. Median changes in %BMIp95 for this cohort were -1.88 (IQR, -5.8 to 1.4), -2.50 (IQR, -7.4 to 1.8), -2.86 (IQR, -8.7 to 1.9), at 4-6, 7-9, and 10-12 of months follow-up, respectively (all P < .05). Older age (≥12 years), greater severity of obesity, and Hispanic race/ethnicity were associated with better improvement in %BMIp95. A 5-percentage point decrease in %BMIp95 was associated with improvement in cardiometabolic risk factors.

CONCLUSIONS

Overall, treatment in pediatric weight management programs is associated with a modest median decrease in BMI as measured by change in %BMIp95. Further studies are needed to confirm these findings, as well as to identify additional strategies to enhance the effectiveness of these multicomponent interventions for youth with severe obesity.

TRIAL REGISTRATION

ClinicalTrials.gov: NCT02121132.