Lebanon VA Medical Center

Idiopathic normal pressure hydrocephalus (iNPH) is characterized by the classic clinical triad of gait, cognitive, and urinary dysfunction, albeit incomplete in a relevant proportion of patients. The clinical findings and evolution of these symptoms have been variably defined in the literature. To evaluate how the phenomenology has been defined, assessed, and reported, we performed a critical review of the existing literature discussing the phenomenology of iNPH. The review also identified the instrumental tests most frequently used and the evolution of clinical and radiologic findings. The review was divided into 3 sections based on gait, cognitive, and urinary dysfunction. Each section performed a literature search using the terms "idiopathic normal pressure hydrocephalus" (iNPH), with additional search terms used by each section separately. The number of articles screened, duplicates, those meeting the inclusion criteria, and the number of articles excluded were recorded. Findings were subsequently tallied and analyzed. A total of 1716 articles with the aforementioned search criteria were identified by the 3 groups. A total of 81 full-text articles were reviewed after the elimination of duplicates, articles that did not discuss phenomenological findings or instrumental testing of participants with iNPH prior to surgery, and articles with fewer than 10 participants. "Wide-based gait" was the most common gait dysfunction identified. Cognitive testing varied significantly across articles, and ultimately a specific cognitive profile was not identified. Urodynamic testing found detrusor overactivity and "overactive bladder" as the most common symptom of urinary dysfunction.

Palliative care has the potential to improve care for patients and families undergoing high-risk surgery. To characterize the use of perioperative palliative care and its association with family-reported end-of-life experiences of patients who died within 90 days of a high-risk surgical operation. This secondary analysis of administrative data from a retrospective cross-sectional patient cohort was conducted in the Department of Veterans Affairs (VA) Healthcare System. Patients who underwent any of 227 high-risk operations between January 1, 2012, and December 31, 2015, were included. Palliative-care consultation within 30 days before or 90 days after surgery. The outcomes were family-reported ratings of overall care, communication, and support in the patient's last month of life. The VA surveyed all families of inpatient decedents using the Bereaved Family Survey, a valid and reliable tool that measures patient and family-centered end-of-life outcomes. A total of 95 204 patients underwent high-risk operations in 129 inpatient VA Medical Centers. Most patients were 65 years or older (69 278 [72.8%]), and the most common procedures were cardiothoracic (31 157 [32.7%]) or vascular (23 517 [24.7%]). The 90-day mortality rate was 6.0% (5740 patients) and varied by surgical subspecialty (ranging from 278 of 7226 [3.8%] in urologic surgery to 875 of 6223 patients [14.1%] in neurosurgery). A multivariate mixed model revealed that families of decedents who received palliative care were 47% more likely to rate overall care in the last month of life as excellent than those who did not (odds ratio [OR], 1.47 [95% CI, 1.14-1.88]; P = .007), after adjusting for patient's characteristics, surgical subspecialty of the high-risk operation, and survey nonresponse. Similarly, families of decedents who received palliative care were more likely to rate end-of-life communication (OR, 1.43 [95% CI, 1.09-1.87]; P = .004) and support (OR, 1.31 [95% CI, 1.01-1.71]; P = .05) components of medical care as excellent. Of the entire cohort, 3374 patients (3.75%) had a palliative care consultation, and 770 patients (0.8%) received it before surgery. Of all decedents, 1632 (29.9%) had a palliative care consultation, with 319 (5.6%) receiving it before surgery. Receipt of a palliative consultation was associated with better ratings of overall end-of-life care, communication, and support, as reported by families of patients who died within 90 days of high-risk surgery. Yet only one-third of decedents was exposed to palliative care. Expanding integration of perioperative palliative care may benefit patients undergoing high-risk operations and their families.

INTRODUCTION: Ogilvie syndrome is common in hospitalized patients and can be contributed by medications such as opioids and anti-cholinergics. We present a case of a 70 year-old male with Ogilvie syndrome associated with chronic baclofen use. CASE DESCRIPTION/METHODS: A 70 year-old male with chronic obstructive pulmonary disease (COPD), peripheral neuropathy and spastic hemiplegia treated with baclofen for four years presented to the emergency room with a four-day history of progressively worsening abdominal distension, constipation, poor oral intake, and reduced urine output. He was hospitalized for a COPD exacerbation managed with steroids and breathing treatments. Physical examination demonstrated a significantly distended abdomen without bowel sounds and mild tenderness to palpation without peritoneal signs. Blood tests did not note any electrolyte disturbances. CT imaging without contrast showed gaseous distension of the colon with scattered stool and compression deformities of the T8, T9, T11, L1 and L5 vertebrae. Concerning for an ileus or colonic obstruction, patient was made nil per os (NPO) and had nasogastric and rectal tubes inserted. Despite an aggressive bowel regimen including polyethylene glycol, senna, and rectal enemas, patient's gastrointestinal symptoms did not resolve. Repeat exams demonstrated progressive distension and tenderness to palpation. Abdominal x-ray (AXR) showed persistently dilated large bowel loops and a possible transition point in the distal sigmoid colon. He then underwent a flexible sigmoidoscopy for further evaluation and stool disimpaction; no physical obstruction was encountered, but the colonoscope did not pass beyond the sigmoid colon due to a considerable solid stool burden. He was continued on a bowel regimen with trials of lubiprostone and neostigmine; however, these interventions only led to modest liquid stool output. Finally, baclofen was discontinued, and in the next day, the patient passed solid bowel movements with progressive improvement in his exams. Post-discharge, repeat AXR showed decreased gaseous distension of the transverse and descending colon. Patient was advised to discontinue baclofen. DISCUSSION: Medications can lead to colonic pseudo-obstruction - Ogilvie syndrome - particularly in people with severe comorbidities or acute illnesses. Baclofen has previously been associated with Ogilvie syndrome. When prescribing baclofen, providers must warn patients to monitor stool output and strongly consider administering a bowel regimen.

ABSTRACTThis study was designed to investigate the validation of a Farsi version of the Multidimensional Inventory for Religious Spiritual Well-being (MI RSWB 48) in a convenience sample of 442 Iranian people. Respondents completed a series of demographic questions and the MI RSWB 48. The Cronbach's α coefficient was .82. The MI RSWB 48 items identified two factors, but these factors did not match the two dimensions for which the scale was devised. The Hope Immanent (HI), and Experiences of Sense and Meaning (SM) subscales loaded on Factor 1, but General Religiosity (GR) was loaded on this factor rather than Forgiveness (FO). The Factor 2 had loadings from the FO and Hope Transcendent (HT) subscales. Furthermore, the FO subscale scores had weak associations with the scores for Transcendent dimension. This study suggests that the subscale scores on the MI RSWB 48 may have different implications for Christian and Muslim respondents.

4131 Background: We previously reported the prognostic and predictive utility of pretreatment serum PD-L1 in the CCTG MA.31 serum bank (SABCS 2018, abstr PD3-10). IL-8 (CXCL8) is a pro-inflammatory cytokine that binds to CXCR1 and CXCR2 and promotes tumor immune escape and progression. High serum IL-8 levels are associated with poor prognosis in many cancers, and have recently been reported to predict for reduced OS to nivolumab in lung cancer and melanoma (ASCO 2018, abstr #3025). In this study, we retrospectively evaluated combined pretreatment serum IL-8 and PD-L1 on overall survival (OS) from a phase III randomized pancreatic cancer trial of first-line therapy (octreotide + 5-FU vs. 5-FU) that had reported no significant OS difference between treatment arms. Methods: This study had 147 patients with serum available for this retrospective biomarker analysis from an advanced pancreatic cancer phase III clinical trial.TheELLA immunoassay platform (ProteinSimple, San Jose, CA) was utilized to quantitate serum levels of IL-8 and PD-L1. Kaplan-Meier life table analysis was used to correlate serum biomarkers with overall survival (OS). Results: In univariate analysis, pretreatment serum IL-8 was a significant biomarker as a continuous variable (HR = 1.004; p = 0.012) and trended significant at the median cutpoint (HR = 1.379; p = 0.098) for OS, however serum PD-L1 was not significant at any cutpoint. When serum PD-L1 and IL-8 levels were analyzed as combined biomarkers (median cutpoints), the serum IL-8 high / PD-L1 high cohort had a significantly shorter OS vs the serum IL-8 low / PD-L1 low cohort (HR = 1.816; p = 0.017). Conclusions: In this phase III randomized clinical trial in advanced pancreatic cancer, pretreatment serum IL-8 was a significant biomarker for OS, but serum PD-L1 was not. Higher combined pretreatment serum levels of PD-L1 and IL-8 (both biomarkers high vs. both low) were prognostic for reduced OS in this phase III pancreatic cancer trial. Further study of circulating IL-8 and PD-L1 is warranted in pancreatic cancer for evaluation of targeted and investigational therapies, including the immune checkpoint inhibitors and anti-IL8 therapy.

DHMC, Lebanon, NH. Address correspondence and reprint requests to Kevin F. Spratt, PhD, DHMC, Lebanon, NH; E-mail: [email protected] The manuscript submitted does not contain information about medical device(s)/drug(s). No funds were received in support of this work. No relevant financial activities outside the submitted work.