Post-stroke Anxiety Among Patients in Jordan: A Multihospital Study

This study aimed to assess the prevalence, correlates, and significant associated factors of anxiety among patients with stroke. A cross-sectional, correlation design was utilized. The Hospital Anxiety and Depression scale was used to detect and assess the severity of anxiety and depression among mentally well patients at general hospital settings. Among the 226 patients with stroke, 45.6% had clinically significant levels of anxiety to be considered as a definite case. Having a short duration since the stroke onset, being a definite case of depression, being unable to perform self-care activities, having an insufficient monthly income, and having visual problems due to stroke were the significantly associated factors. The high prevalence of anxiety among patients with stroke highlights the need for interventions of early detection and management to enhance recovery. Patients who have any of the significant traits predicted post-stroke anxiety required special attention.

Drug Reaction with Eosinophilia and Systemic Symptoms (DRESS) Syndrome Associated with Enoxaparin Therapy in a Pediatric Patient

Introduction: Drug Reaction with Eosinophilia and Systemic Symptoms (DRESS) syndrome is a rare drug hypersensitivity reaction characterized by diffuse skin eruption with systemic symptoms (fever, lymphadenopathy, elevated transaminases, leukocytosis with eosinophilia and atypical lymphocytes) which develops 2-6 weeks after exposure to inciting medications. Clinical presentation is variable and nonspecific. DRESS syndrome is more common in adults, can be life threatening, and is most commonly seen with antibiotics, antiepileptic drugs, and allopurinol. An inciting drug is identified in the majority of cases. DRESS syndrome has been described rarely in association with Vitamin K antagonists and direct oral anticoagulants. In an in-depth examination of existing literature, there are only two reported cases of DRESS syndrome associated with enoxaparin therapy, both in adult patients and no reports of pediatric DRESS syndrome secondary to anticoagulants. We present a case of a pediatric patient with DRESS syndrome associated with enoxaparin therapy. Case Report: A previously healthy 11-year-old female was admitted with sepsis secondary to osteomyelitis and periosteal abscess of the left lower extremity, as well as MRSA bacteremia. The patient was initiated on clindamycin and vancomycin for treatment of underlying infections. A left lower extremity ultrasound with doppler was obtained due to lower extremity swelling and demonstrated an acute deep venous thrombus of the left popliteal vein. She was initiated on a heparin drip and subsequently transitioned to enoxaparin one week later. Several weeks into her hospital course (two weeks after initiation of enoxaparin), she developed facial swelling, a generalized morbilliform rash, and diffuse lymphadenopathy both on exam and abdominal imaging. She continued to have persistent fevers despite multiple washouts of the extremity, appropriate antimicrobial coverage, and negative blood cultures. Liver enzymes concurrently increased (AST 362 IU/L (normal 5-60 IU/L), ALT 371IU/L (normal <35 IU/L) at peak) with development of clinical symptoms. Eosinophilia was not present on initial CBC, though she subsequently developed mild eosinophilia (1.1 K/ul at peak). HHV6, CMV, and EBV serologies were all negative. Skin biopsy was performed and was consistent with a drug eruption. Using the RegiSCAR criteria for DRESS syndrome, this constellation of labs and symptoms indicate a definite case of DRESS syndrome with a score of 6 (final score >5 is needed for a definite case). The patient was started on treatment with high-dose steroids. Clindamycin and vancomycin were both discontinued due to their known association with DRESS syndrome. She was transitioned to doxycycline, however, no improvement in rash, fevers, or liver enzymes was seen over the course of five days. Given this, enoxaparin was transitioned to apixaban. The patient improved with resolution of rash, fevers, and improvement of liver enzymes and eosinophilia within a few days of the discontinuation of enoxaparin. Conclusion: The diagnosis of DRESS syndrome can be challenging due to its nonspecific presentation, particularly in pediatric patients where symptoms can overlap with common viral syndromes and Kawasaki disease, and therefore requires a high index of suspicion. Though children with DRESS syndrome have a better prognosis than adults, prompt recognition and treatment is required to limit morbidity and mortality. In pediatric patients receiving treatment with enoxaparin, DRESS syndrome should be included on the differential for those who develop persistent fevers, lymphadenopathy, rash, transaminitis and/or eosinophilia, and discontinuation of enoxaparin should be considered. Disclosures Weyand: Takeda: Consultancy; Genentech: Consultancy; Novo Nordisk: Research Funding; Sanofi: Consultancy, Research Funding.

449. Performance of the Brighton Case Definition for Multisystem Inflammatory Syndrome in Children (MIS-C) Among a Large Single Center Cohort

Background Multisystem Inflammatory Syndrome in Children (MIS-C) is a rare, life-threatening, hyperinflammatory condition presumed to follow SARS-CoV-2 infection. Whether MIS-C can also follow SARS-CoV-2 vaccination is not clear, making MIS-C an adverse event of special interest following immunization. Monitoring for post-vaccine MIS-C is complicated by the clinical overlap of MIS-C with numerous other inflammatory conditions including Kawasaki Disease, toxic shock syndrome, and viral myocarditis. A case definition for MIS-C was recently created with the Brighton Collaboration (BC). We aimed to determine the performance of the BC MIS-C case definition among a large, single-center MIS-C cohort. Methods Retrospective review was performed for the first 100 MIS-C cases at our institution (May 2020-February 2021). All cases met the Centers for Disease Control and Prevention (CDC) case definition. Data on age, presentation, laboratory results and cardiac studies were collected and used to determine cases that fulfilled the BC case definition for MIS-C (see figure). Case Definition: Definite Case Results Of 100 children (age < 21 years) diagnosed with MIS-C using the CDC case definition, 93 patients also fulfilled the BC definition. All 100 patients had elevated laboratory markers of inflammation and positive SARS-CoV-2 antibodies. However, 1 patient was excluded for significant respiratory symptoms (pulmonary hemorrhage), 5 were excluded due to only 1 clinical feature, and an additional patient was excluded for having none of the measures of disease activity. Among the 93 patients fulfilling the revised case definition, 88 (95%) met criteria for a definite case. Five of the 93 patients (5%) were considered probable cases, 1 reported only 1 day of fever and 4 had only 1 measure of disease activity. Conclusion The original case definitions for MIS-C were created rapidly following the first emerging reports of this hyperinflammatory state. Knowledge of the varied clinical presentations of this disorder has grown substantially. Modification of the case definition to include features truly representative of MIS-C will allow for more precise diagnosis in the face of conditions which mimic MIS-C, and for accurate and reliable monitoring for adverse events following immunization. Disclosures Flor M. Munoz, MD, Biocryst (Scientific Research Study Investigator)Gilead (Scientific Research Study Investigator)Meissa (Other Financial or Material Support, DSMB)Moderna (Scientific Research Study Investigator, Other Financial or Material Support, DSMB)Pfizer (Scientific Research Study Investigator, Other Financial or Material Support, DSMB)Virometix (Other Financial or Material Support, DSMB)

The Epistemic Conception of Vagueness

This chapter challenges Epistemicism. It rebuts Williamson’s arguments for unrestricted Bivalence, based on the Disquotational Scheme for the truth predicate, and Sorensen’s arguments that the idea of a predicate’s being of limited sensitivity is itself incoherent. The chapter nevertheless proposes a broadly epistemic conception of what a definite case of a vague predicate is—namely, a case where at least one of two conflicting verdicts about a vague predication must involve some kind of cognitive shortcoming, and proposes a corresponding notion of a borderline case—one where each of a pair of conflicting verdicts can be unexceptionable—and sides with Epistemicism in rejecting the idea of such cases as truth-value gaps. It is contended that Williamson’s explanation of why we cannot know where the putative sharp cut-offs in Sorites series come at best explains too little, since it has nothing plausible to say about our ignorance throughout a borderline area, nor about vagueness induced by deliberate approximation—‘roughly six feet tall’, ‘about a metre long’.

CONTRA-RIEMANNIAN, NEGATIVE MODULI FOR A LINE

Let V be a modulus. We wish to extend the results of[19] to conditionally intrinsic equations. We show that T is not bounded by v. Thus the workin[19] did not consider the positive definite case. Next, unfortunately,

A Classification of Symmetric (1, 1)-Coherent Pairs of Linear Functionals

In this paper, we study a classification of symmetric ( 1 , 1 ) -coherent pairs by using a symmetrization process. In particular, the positive-definite case is carefully described.