Disclosures: Raymond Cheng: I Have No Relevant Financial Relation- ships To Disclose
Objective: To test the hypothesis that factors indicative of chronic disease, infection risk, or poor wound healing, present at the time of admission, will be associated with 1) a higher incidence of acute transfers to inpatient medical and surgical services and 2) fewer gains in function during a course of acute inpatient rehabilitation.
Design: Cross-sectional retrospective study.
Setting: Acute inpatient rehabilitation service at a large university hospital.
Participants: 71 dysvascular amputee patients over the age of 18, admitted to the acute inpatient rehabilitation unit at the University of Michigan from 1/2011 to 4/2015.
Interventions: Not applicable.
Main Outcome Measures: Occurrence of transfer to acute service and Functional Independence Measure (FIM) total score.
Results: Logistic regression analysis and general linear regression analysis were used to test a predictive model of age, creatinine, hemoglobin, white blood cell (WBC) count, hemodialysis use, wound vac use, IV antibiotic use, and presence of a prior amputation at the time of hospital admission. No predictors were significantly associated with study outcomes.
Conclusions: These comorbidities were not significantly associated with the rate of transfer back to acute service or functional gains during inpatient rehabilitation. Future analysis should factor in the presence of diabetes and determine if a combination of these comorbidities con- tributes to medical complications and functional gains.
Level of Evidence: Level II
Poster 26 A Randomized Trial of Cardiac Rehabilitation for Adolescents and Adults with Congenital Heart Disease
Ana Ubeda Tikkanen, MD, PHD (Spaulding Rehabilitation Hospital, Boston, MA, United States), Jonathan Rhodes, MD, Micheal Landzberg, Ami Bhatt, MD, MPH, David M. Systrom, MD, Aaron Waxman, MD, Lilamarie Moko, BA, Robin Bradley, BS, Scott Crouter, PhD, Alexander Opotowsky, MD, MPH
Disclosures: Ana Ubeda Tikkanen: I Have No Relevant Financial Relationships To Disclose
Objective: To describe the effects of Cardiac rehabilitation (CR) programs on exercise capacity and quality of life in adolescents and adult with Congenital Heart Disease (CHD).
Design: We performed a prospective, randomized, controlled trial (NCT01822769).
Setting: Tertiary care hospitals.
Participants: Patients with moderately or severely complex CHD ≥ 15 year-old, with resting O2 saturation ≥ 91% and peak O2 consumption (VO2pk) ≤ 80% predicted were randomized to cardiac rehabilitation or standard of care (SOC).
Interventions: 12 week, twice a week, standardized clinical CR pro- gram including exercise training and education.
Main Outcome Measures: We assessed exercise capacity, inert gas rebreathing cardiac output, quality of life, self reported health status, and other variables at baseline and after 3 months.
Results: We enrolled 28 subjects (mean age 41.1±12.1 y, 50% male), with 13 randomized to CR and 15 to SOC. BMI averaged 28.0±3.8kg/m2 with VO2pk=16.8±3.8 ml/kg/min, peak work rate=95±28W and median Minnesota Living with Heart Failure Questionnaire (MLHFQ) score =27 [IQR 11-44]. CR subjects were older (48±9 v 36±12 y, P =. 01) but there were no significant between group differences in sex, height, weight, VO2pk, peak work rate, cardiac output, MLHFQ score or other variables. There were no adverse events related to CR. Those assigned to CR lost weight over the intervention relative to SOC (-2.3kg, P <. 03). VO2pk increased in the CR group compared with SOC (+2.2 mL/kg/min, 95%CI 0.7-3.7, P = . 002, age adjusted +2.7 mL/kg/min, P = . 004; absolute in- crease 119 mL/min, P =. 01); there was also a nonsignificant improvement in work rate (+8.1W, P = . 13) and MLHFQ score (-6.5, P =. 13). Among
n=25 with baseline MLHFQ >5, there was a clinically important >5 point decrease in 72.7% of CR subjects compared with 28.6% of SOC subjects, P =. 047). Patients in the CR group also had greater improvement in a visual analogue scale self-assessment of overall health (P <. 04)
Conclusions: CR is safe in adults with CHD and is associated with improvement in aerobic capacity and self-reported health status compared with SOC. Further studies should evaluate the longer term effects of CR in adults with CHD.
Level of Evidence: Level I
Poster 27 Acupuncture Treatment for Levator Ani Syndrome: A Case Report
Hamad T. Saleemi, DO (Stony Brook University Hospital, Port Jefferson, NY, United States), Henna Farooque, DO, Sunia Choudhury, Jun Zhang, MD
Disclosures: Hamad Saleemi: I Have No Relevant Financial Relation- ships To Disclose
Case/Program Description: Levator ani syndrome is a painful condition due to spasm of the levator ani muscle. The etiology is unknown and diagnosis is by exclusion of other more serious conditions such as diver- ticulitis, bleeding, abscess, or cancer. Treatment typically consists of muscle relaxants, warm baths, therapeutic ultrasound and in extreme cases, botox injections. Acupuncture treatment has not been studied in patients with levator ani syndrome. In our case, a 64-year-old male pre- sented after left intraparenchymal hemorrhage status post apollo pro- cedure and then transferred to inpatient rehabilitation. During patient’s stay, he began to complain of “deep rectal pain” that was unrelieved by hemorrhoidal suppository and prevented him from participating in rehabilitation sessions. A complete work up including, CAT scan, sigmoidoscopy, and MRI were completed but without any significant findings. Patient was diagnosed with levator ani syndrome. He was started on valium suppositories which did not relieve his pain. A strict bowel regimen somewhat alleviated his symptoms. Patient reported pain that was an average of 7/10 in severity and on some days it was severe enough to prevent him from participating in therapy. Patient was treated with acupuncture: Du 21, HN 3, RN16, RN 12, RN10, RN7, Bilateral LI4, LI11, SP6, ST 36 X 60 minutes for a total of 3 treatment sessions.
Setting: Community hospital inpatient rehabilitation unit.
Results: After his first session of acupuncture, the patient reported immense relief. He had two more acupuncture sessions thereafter. His pain rating was down to a 2/10. His pain was relieved and he was able to continue acute rehabilitation.
Discussion: Although levator ani syndrome is a benign condition, the pain and discomfort it causes can become unbearable. In our case, it affected the patient’s ability to participate in rehabilitation. Medi- cation management along with botox injections have been the main- stay of treatment but with unreliable effect.
Conclusions: This case showed that acupuncture treatment success- fully relieved symptoms of levator ani syndrome. However, additional research with better design and sample size is needed to identify the best treatment options for levator ani syndrome.
Level of Evidence: Level V
Poster 28 Steroid-Induced Myopathy from Endogenous Hypercortisolism Secondary to Adrenocortical Carcinoma: A Case Report
Rajiv D. Reddy, MD (Rehabilitation Institute of Chicago/Northwestern University, Chicago, IL, United States), Gayle R. Spill, MD
Disclosures: Rajiv Reddy: I Have No Relevant Financial Relationships To Disclose
Case/Program Description: A 56-year-old female presented to the emergency department with tremulousness and muscle twitching. She had a history of newly diagnosed diabetes mellitus (DM), rapid weight
gain, hirsutism, and progressive proximal muscle weakness. Electromy- ography and nerve conduction studies prior to admission were normal - consistent with glucocorticoid-induced myopathy. Laboratory work-up revealed low adrenocorticotropic hormone levels and markedly elevated 24-hour cortisol. Biopsy of a left adrenal mass seen on MRI confirmed the diagnosis of adrenocortical carcinoma. Mifeprostinone was initiated, with satisfactory control of endogenous steroid production.
Setting: Inpatient Rehabilitation Hospital/Academic Rehabilitation Hospital.
Results: The patient was transferred to an inpatient rehabilitation hospital for continued medical treatment and rehabilitation with a focus on strength and endurance. On admission, motor strength was 3/ 5 in bilateral hip flexors, 4/5 in other proximal muscles with relative sparing of distal muscles. She was dependent to maximal assist with all mobility and ADLs except wheelchair use. On discharge she required minimum to moderate assistance; however, she remained non-ambu- latory and did not have significant return of strength despite continued control of her DM and cortisol levels.
Discussion: Glucocorticoid-induced myopathy is a well-known complication of Cushing Syndrome resulting from iatrogenic steroid exposure. However, its incidence and relation to endogenous cortisol production has not been reported. While the mechanisms underlying myopathy are likely the same, details regarding the associated severity, prognosis, and outcome remain unclear. This patient’s lack of early recovery, despite eliminating endogenous cortisol production, possibly prognosticates a course with minimal strength return. This is in contrast to iatrogenic steroid-induced myopathy.
Conclusions: Iatrogenic steroid-induced myopathy is not uncommonly seen in both inpatient and outpatient physiatry. We present a case of glucocorticoid-induced myopathy from endogenous steroid produc- tion, which previously has not been reported. It is important for physiatrists to be aware of this syndrome to promote early diagnosis and intervention, and to set appropriate rehabilitation goals.
Level of Evidence: Level V
Poster 29
The Over Utilization of PPIs in an Acute Rehabilitation Hospital and How to Fix it!
Joseph Rabi, MD (Schwab Rehab Hospital, Chicago, IL, United States), Vovanti Jones, MD, Hasan Abad, MSIII, Zainab A. Naji, MD, Zahra Khudeira, PharmD, BCPS, CPPS, Michelle S. Gittler, MD
Disclosures: Joseph Rabi: I Have No Relevant Financial Relationships To Disclose
Objective: The overutilization of proton pump inhibitors (PPIs) is well documented and exposes patients to an increasing number of potential risks. It is likely that there is overutilization of PPIs in acute rehabil- itation hospitals due to inappropriate use of ulcer prophylaxis and the physiatrists not knowing the reason the patient is on it due to lack of documentation they receive from outside hospitals. PPIs increase the risk of C diff, pneumonia, osteoporosis, electrolyte abnormalities and interaction with Plavix.
Design: Retrospective/Observational Study.
Setting: Acute Rehabilitation Hospital.
Participants: Inpatient Rehabilitation Patients.
Interventions: Formal educational lecture.
Main Outcome Measures: A retrospective study at an outpatient rehabilitation hospital reviewed all patients on PPIs. We retrospec- tively analyzed the usage of PPIs in the month of October 2015 with indication per documentation why patient was on it, whether pa- tients were discharged on it, if they were on Plavix, and if they were on it prior to hospitalization. After this data was collected, a formal lecture and email of PowerPoint educational slides on FDA approval of PPIs indications were sent out to attending and resident physi- cians. We performed an observational study at this point and collected data in the month of January 2016 to see if there were any changes.
Results: Preeducation PPI use included 45 patients. Per documenta- tion, 28 (62%) patients were on PPIs for GI prophylaxis or unknown indication, 23 (51) were discharged on PPIs, 4 (9%) were on plavix and 17 (38%) were on it prior to hospitalization. Post education PPI use included 23 patients. Per documentation, 8 (35%) were on PPIs for unknown indication, 14 (61%) were discharged on PPIs, 2 (9%) were on plavix and 15 (65%) were on it prior to hospitalization.
Conclusions: The intervention of education with a formal lecture and emails to attending and resident physicians helped limit the over- utilization of PPIs in an acute rehabilitation hospital. By limiting the use of PPIs, it can lead to fewer known risks of PPIs and potentially fewer transfer although the latter needs to be studied further.
Level of Evidence: Level III
Poster 30 Use of Delirium Triggering Medications Among Patients with Delirium at Admission to Inpatient Rehabilitation Facility
Laurie Dabaghian, MD (Rutgers New Jersey Medical School, Woodcliff Lake, New Jersey, United States), Peter P. Yonclas, MD,
Benjamin Seidel, DO, Neil N. Jasey, MD, Mooyeon Oh-Park, MD
Disclosures: Laurie Dabaghian: I Have No Relevant Financial Relationships To Disclose
Objective: Delirium, an acute change in attention and cognition, is a common complication among hospitalized patients, particularly among older adults. The occurrence of delirium is associated with worse rehabilitation and functional outcomes. Drugs with risk of trig- gering delirium are known as deliriants. We intended to investigate the use of deliriants among patients with delirium at admission to inpa- tient rehabilitation facility (IRF).
Design: Cross-sectional study.
Setting: a large freestanding IRF.
Participants: Patients who were recorded as positive for delirium on the 3D-CAM (3 minute diagnostic interview for confusion assessment method) upon admission to the IRF during October to December 2015. Only the first admission was included in the analysis if there were multiple admissions for one patient.
Interventions: Not applicable.
Main Outcome Measures: The number of total deliriants and High Risk Deliriants (HRD) per patient and proportion of patients on deliriants. The HRD and Moderate Risk Deliriants (MRD) were defined based on the sys- tematic reviews. HRD included narcotics, central acting agents (eg, benzodiazepines, tricyclic antidepressants) and metoclopramide. Mod- erate Risk Deliriants (MRD) included antihistamines, H2-blockers, fluo- roquinolones, and miscellaneous medications (eg, steroids, digitalis).
Results: 41 out of total 413 patients admitted had delirium at admission. Mean age of delirious patients was 78.2±14.8 (yrs) with 60% being female. Forty out of 41 (97.5%) were taking one or more delir- iants with median value of 3 medications per patient. 75.5% (31/41) taking at least one HRD with 51.2% (21/41) on >2 HRD, 22% (9/41) on ≥3 HRD, and 10% (4/41) on ≥4 HRD.
Conclusions: The majority of delirious patients on admission to our IRF were on multiple delirium triggering medications. Although the causes of delirium are not clearly defined in these patients, medica- tion review and reconciliation should be an important part of delirium work-up in the acute inpatient rehabilitation setting. Level of Evidence: Level IV
Poster 31
Taxane-Induced Myositis: A Case Report
John Ho, MD (Wayne State University School of Medicine, Dearborn, MI, United States)
Disclosures: John Ho: I Have No Relevant Financial Relationships To Disclose