Functional Hand-Based Splint in the Treatment of Metacarpal Fractures

Background: Post-treatment stiffness remains a significant hurdle following treatment for displaced or minimally displaced metacarpal fractures. Treatment goals should focus on a stable and acceptable reduction, minimal patient morbidity, and optimal mobility. Methods: A retrospective review of all non-operative metacarpal fractures over a five-month period at a tertiary center hand clinic treated with a hand-based splint were reviewed for radiologic and clinical stability. The splint allowed metacarpophalngeal joint, interphalangeal joint, and radiocarpal joint motion. Data collected included age, handedness, type and location of fracture, occupation, and ability to continue working. Radiologic images were reviewed by a radiologist not otherwise involved in patient care. Results: Thirty-three patients were reviewed with a total of 39 fractures of the second, third, fourth, and fifth metacarpals. Nine patients had nondominant hand fractures while 24 were dominant hand injuries. Twenty out of 24 patients employed pre-injury were able to continue working without missing any days. Three patients were lost to the final follow-up. The average splint duration was 24 days. Twenty-seven of 30 patients showed no change in alignment from start of splinting to end, while three showed some change but remained within non-operative criteria. Conclusion: A hand-based functional splint for metacarpal fractures allows for excellent maintenance of fracture reduction, early or immediate return to pre-injury activities, low patient morbidity, and maintains functional motion throughout treatment. It can be applied to any non-operative fracture of the second through the fifth metacarpal.

A variant in the CASR gene (c.368T>C) causing hypocalcemia refractory to standard medical therapy

Summary Hypoparathyroidism is characterized by low or inappropriately normal parathormone production, hypocalcemia and hyperphosphatemia. Autosomal dominant hypocalcemia (ADH) type 1 is one of the genetic etiologies of hypoparathyroidism caused by heterozygous activating mutations in the calcium-sensing receptor (CASR) gene. Current treatments for ADH type 1 include supplementation with calcium and active vitamin D. We report a case of hypoparathyroidism in an adolescent affected by syncope without prodrome. The genetic testing revealed a variant in the CASR gene. Due to standard therapy ineffectiveness, the patient was treated with recombinant human parathyroid hormone (1–34), magnesium aspartate and calcitriol. He remained asymptomatic and without neurological sequelae until adulthood. Early diagnosis and treatment are important to achieve clinical stability. Learning points Autosomal dominant hypocalcemia (ADH) type 1 is one of the genetic etiologies of hypoparathyroidism caused by heterozygous activating mutations in the calcium-sensing receptor (CASR) gene. The variant c.368T>C (p.Leu123Ser) in heterozygosity in the CASR gene is likely pathogenic and suggests the diagnosis of ADH type 1. Teriparatide (recombinant human parathyroid hormone 1–34) may be a valid treatment option to achieve clinical stability for those individuals whose condition is poorly controlled by current standard therapy.

Evaluation and Feasibility of a Head Positioning Intervention in Patients with Intraparenchymal Hemorrhage

Stroke caused by intraparenchymal hemorrhage (IPH) is most commonly the result of hypertension-induced blood vessel rupture in the brain and is associated with devastating disability and high rates of death. To date, no intervention has improved outcomes in IPH stroke patients; however, head elevation may be one of the most important first steps to promote clinical stability in the hyperacute stage of IPH stroke because of the risk of increased intracranial pressure (ICP) in these patients. Nursing research completed in the late 1970s and early 1980s in patients with increased ICP due to traumatic brain injury showed that elevating the head of bed (HOB) increased gravity drainage of venous blood and cerebrospinal fluid, lowering ICP, However, no study has yet been completed in a generalizable sample of hyperacute IPH stroke patients to examine serial changes in clinical stability in relation to HOB positioning. Recently, the Head Position in Stroke Trial (HeadPoST), which enrolled a highly heterogeneous sample of subacute stroke patients, found that head position does not affect 3-month outcome; however, the study was heavily criticized by international stroke experts due to significant internal validity concerns. HeadPoST findings have created significant confusion within the acute stroke practice community about whether there is a role for head positioning in hyperacute IPH stroke management. The focus of our research was to build knowledge of key clinical methods that will support future definitive HOB research in hyperacute IPH stroke patients. We established 1) the clinical knowledge and skill set supporting nurses’ ability to localize stroke disability within vascular territories in the brain and 2) use of the National Institutes of Health Stroke Scale as a valid assessment tool for serial monitoring of clinical change in hyperacute IPH patients. We also 3) examined the degree of acceptance of HeadPoST findings internationally among nurse and physician clinicians caring for IPH stroke patients and 4) evaluated elements tied to the feasibility of conducting hyperacute IPH HOB research at a large, comprehensive stroke center in the Midsouth. Collectively, the chapters in this dissertation create a foundation for future IPH head-positioning research, providing direction for our next steps in understanding the contribution of HOB positioning to hyperacute IPH patient management. Patients with hypertensive IPH stroke suffer significantly higher rates of disability and death compared to other forms of stroke, yet despite a great deal of inquiry into interventions to improve outcomes, none have been successful. Positioning the patient’s HOB at 30-degrees may be one of the most important early interventions that nurses can employ to impart stability in hypertensive IPH patients. Our research and conclusions position nurse scientists to further their examination of the effect of this simple HOB-positioning intervention in this highly vulnerable patient population.

Visceral pseudoaneurysms and the role of endovascular treatment – a case report

Introduction: Visceral pseudoaneurysms are pathological dilations of the visceral arteries and/or their branches. They are a rare entity but with devastating consequences given their high potential for rupture and hemorrhage. The evolution of endovascular techniques has changed the paradigm in the treatment of this entity, making it the preferred option for the elective treatment of visceral pseudoaneurysms. Clinical case: The authors described the case of a pancreatic pseudoaneurysm in a young male patient, with past medical history of chronic pancreatitis and pancreatic pseudocyst, marked smoking and alcoholic habits, which presented with an abdominal pain and a drop in hemoglobin. After discussing the case with the Vascular Surgery department, it was decided towards an endovascular treatment given the patient's clinical stability and appropriate anatomical location for the proposed intervention. Coil embolization via humeral artery was performed with immediate angiographic success, and clinical, analytical and imaging improvement in the postoperative period. Conclusion: In addition to open surgical repair and laparoscopic surgery, there are also endovascular procedures for the treatment of visceral pseudoaneurysms, so the vascular surgeon must be aware with the available strategies, taking into account the patient, the characteristics and location of the visceral pseudoaneurysm.

Importance of Variability Pattern Analysis for Malnutrition Information Score to Improve Treatment of Chronic Kidney Disease

Background: Morbidity and mortality envisaged by chronic kidney disease (CKD) remains a health menace throughout the world. Complications, incidence, prevalence, the impact of dietary recommendations, risk factors, outcome, and management strategies have not been rationalized due to several adversities resulting in escalated death rates. The objective of this study was to evaluate and establish a malnutrition information score (MIS) as a means of ease of CKD prevention and progression. MIS underlies the consistencies in findings through MIS show higher values can be corroborated to recommend the augmentation parameters in utilizing MICS techniques and other healthcare types of equipments. Methods: A randomized, non-biased sampling of patients presenting to dialysis unit with their maintenance schedule program in the nephrology department of Medical Unit-3 of PIMS, Islamabad were introspected for inclusions. Personal history, BSF thickness and MAC values were measured, and MAMC was calculated by = MAC – (3.1416 x TSF). The study was conducted in the Department of Nephrology, PIMS, Islamabad for a duration of six months. Results: The study conducted across 59 male patients and 33female patients indicate that males are more susceptible to CKD than females as evidenced by clinical stability of 67%. Appetite loss, degree of severity, Co-morbidity, BMI, MIS range, and clinical stability status of 100 study participants show variable indices indicating the stress on personal and family history of the patients. MIS pose as an indicator for determining the apt Malnutrition-Inflammation Complex Syndrome (MICS) and other types of equipments for treating CKD. Conclusion: CKD patients undergoing maintenance hemodialysis analyzed for dietary balance affirm the utility of MIS in determining the MICS and other types of healthcare equipments indirectly in ensuring reduction in morbidity and mortality.

1228. Outcomes Associated with Empiric Cefepime or Meropenem for Bloodstream Infections Caused by Ceftriaxone-Resistant, Cefepime-Susceptible Escherichia coli and Klebsiella pneumoniae

Background Cefepime is a 4th generation cephalosporin frequently used for empiric sepsis therapy. Dose- and MIC-dependent efficacy of cefepime is supported by the Clinical & Laboratory Standards Institute, however its use in infections due to extended-spectrum beta-lactamase-producing Enterobacterales is controversial. This study aims to compare outcomes in patients given empiric meropenem or cefepime for bloodstream infections (BSI) caused by ceftriaxone-resistant E. coli and K. pneumoniae. Methods This single-center retrospective cohort included adults hospitalized from 2010 - 2020 and received empiric cefepime or meropenem for BSI caused by ceftriaxone-resistant E. coli or K. pneumoniae. In the cefepime group, only organisms with MIC ≤ 2 mg/L were included. Patients who received the empiric agent for < 48 hours, or received an additional active agent within 48 hours were excluded. The primary outcome was 30-day mortality; secondary outcomes were recurrent infection, readmission, and time to clinical stability. Chi-squared or Fisher’s exact was used for categorical variables and Mann-Whitney-U for continuous variables. Inverse probability treatment weighing was used to determine the impact of empirical therapy on clinical stability at 48 hours. Results Fifty-four patients were included: 36 received empiric meropenem, 18 received cefepime. There were no significant differences in baseline severity of illness or comorbid conditions. Urinary source was less common in the meropenem group compared to cefepime (52.8 vs 83.8%, p=0.028) (Table 1). There was no difference in 30-day mortality between meropenem and cefepime (2.8 vs 11.1%, p = 0.255). More patients achieved clinical stability at 48 hours on empiric meropenem compared to cefepime (75 vs 44.4%, p = 0.027), and time to clinical stability was significantly shorter (median 21.3 vs 38.5 hours, p = 0.016). Most patients in the meropenem and cefepime groups completed definitive treatment with a carbapenem (88.9 vs 72.2%, p=0.142). Table 1: Results Summary of primary and secondary outcomes Conclusion There was no difference in mortality between patients receiving empiric cefepime for BSI due to ceftriaxone-resistant Enterobacterales, with cefepime MIC ≤ 2 mg/L, compared to meropenem; however, time to clinical stability was significantly delayed. Disclosures James Kirby, MD, D(ABMM), First Light Biosciences (Board Member)TECAN, Inc. (Research Grant or Support)

Factors Affecting Adherence to Early Mobilization in an Intensive Care Unit: An Analysis of Data Collected Prospectively Over a Three-Year Period by Clinical Information System

Background: Early mobilization benefits critically ill patients. Scant information is available about adherence to early mobilization protocols in intensive care units (ICU). With the aim of optimizing the application of our early mobilization protocol in mechanically ventilated patients in routine daily practice, this study analyzed adherence to the protocol, impediments to adherence, and adverse eventsin our ICU. Methods: This observational study analyzed data collected prospectively at a 24-bed polyvalent ICU over a three-year period (2017–2019). Data from adult patients on mechanical ventilation > 48 hours who met the inclusion criteria for the early mobilization protocol were included. We analyzed demographics, adherence to the protocol, total number of mobilizations, impediments to early mobilization, artificial airway/ventilatory support at each mobilization level, and adverse events during mobilization. All data was automatically obtained from the clinical information system by extract, transform, and load processes using Python 3.0. The unit of analysis was ICU stay-day. Results: We analyzed 3269 stay-days from 388 patients with median age of 63 (51–72) years, median APACHE II 23 (18–29) and median ICU stay of 10.1 (6.2–16.5) days. Adherence to the protocol was 56.6% (1850 stay-days), but patients were mobilized in only 32.2% (1472) of all stay-days. The most common reasons for not mobilizing patients were failure to meeting the criteria for clinical stability in 241 (42%) stay-days and unavailability of physiotherapists in 190 (33%) stay-days. Adverse events occurred in only 6 (0.4%) stay-days mobilizations. Conclusions: Although adherence to the protocol was high, patients were mobilized in only one-third of all stay-days. This study points to ways we can improve early mobilization in our ICU, including assessing the suitability of the criteria for clinical stability and increasing the presence of physiotherapists.

2-Alkyl-4-quinolone quorum sensing molecules are biomarkers for culture-independent Pseudomonas aeruginosa burden in adults with cystic fibrosis

Introduction. Pseudomonas aeruginosa produces quorum sensing signalling molecules including 2-alkyl-4-quinolones (AQs), which regulate virulence factor production in the cystic fibrosis (CF) airways. Hypothesis/Gap statement. Culture can lead to condition-dependent artefacts which may limit the potential insights and applications of AQs as minimally-invasive biomarkers of bacterial load. Aim. We aimed to use culture-independent methods to explore the correlations between AQ levels and live P. aeruginosa load in adults with CF. Methodology. Seventy-five sputum samples at clinical stability and 48 paired sputum samples obtained at the beginning and end of IV antibiotics for a pulmonary exacerbation in adults with CF were processed using a viable cell separation technique followed by quantitative P. aeruginosa polymerase chain reaction (qPCR). Live P. aeruginosa qPCR load was compared with the concentrations of three AQs (HHQ, NHQ and HQNO) detected in sputum, plasma and urine. Results. At clinical stability and the beginning of IV antibiotics for pulmonary exacerbation, HHQ, NHQ and HQNO measured in sputum, plasma and urine were consistently positively correlated with live P. aeruginosa qPCR load in sputum, compared to culture. Following systemic antibiotics live P. aeruginosa qPCR load decreased significantly (P<0.001) and was correlated with a reduction in plasma NHQ (plasma: r=0.463, P=0.003). Conclusion. In adults with CF, AQ concentrations correlated more strongly with live P. aeruginosa bacterial load measured by qPCR compared to traditional culture. Prospective studies are required to assess the potential of systemic AQs as biomarkers of P. aeruginosa bacterial burden.

Acrometastasis: A Rare Entity. A Proximal Radius Case

Bone metastases under de knee and elbow (acrometastasis) are rare. We present the case of a patient diagnosed with lung adenocarcinoma, with a lesion in the right proximal radius. Radiological imaging through CT and MR suggested metastatic lesion, which anatomopathological results confirmed. As the presence of these markers provides a poor outlook, radiotherapy was initially considered. However, given the clinical stability of the patient and the limited amelioration observed, surgical treatment was finally conducted.