Exploring the Association between Hemochromatosis and Lower-Limb Venous Disease.

OBJECTIVE: Chronic venous disease is a circulatory system dysfunction that has the potential to lead to venous leg ulceration. Although research on the influence of specific gene variants on chronic venous disease has been limited, a few studies have reported an association between hemochromatosis and chronic venous disease. However, no studies have looked at the prevalence of lower-limb venous disease and leg ulcers in people with hemochromatosis. This study aimed to review the existing literature for any association between venous disease and hemochromatosis and investigate the prevalence of venous disease and leg ulcers in people with hemochromatosis. METHODS: Scoping systematic literature review and cross-sectional study surveying people with hemochromatosis. RESULTS: This scoping systematic literature review included nine articles and indicated a link between hemochromatosis and venous disease/leg ulcers, although further studies are needed to support this link. Analysis of survey results from people with hemochromatosis found a 9.2% prevalence of leg ulcers in those with self-reported hemochromatosis, considerably higher than the 1% to 3% expected, suggesting that hemochromatosis gene variants may be associated with the pathogenesis of chronic venous disease and leg ulcers. CONCLUSIONS: This is the first known study to complete a review of the literature regarding hemochromatosis and venous leg ulcers and document the association between hemochromatosis and venous disease/leg ulcers. There is a lack of research in this area and hence limited evidence to guide practice.

Clinical indicators of acute deterioration in persons who reside in residential aged care facilities: A rapid review.

PURPOSE: To identify the clinical indicators of acute deterioration in residents and the factors that influence residential aged care facility staff's identification of these. DESIGN: Rapid review and narrative synthesis. METHODS: The WHO and Cochrane Rapid Review Methods Group recommendations guided the review processes. CINAHL, Medline, PubMed, and the Cochrane Library were searched from 2000 to January 2022. Data related to clinical indicators of deterioration were categorized using the Airway, Breathing, Circulation, Disability, Exposure assessment framework, and factors influencing detection were grouped as consumer (resident and family), aged care workforce, and organization factors. RESULTS: Twenty publications were included of which 14 informed clinical indicators; nine highlighted factors that influence staff's identification of these and three informed both. Included article were collectively below moderate quality. Most clinical indicators were grouped into the 'Disability' category with altered level of consciousness, behavior, and pain identified most frequently. Few studies reported more traditional indicators of deterioration used in the general population - changes in vital signs. The most common factors influencing the detection of acute deterioration were organizational and workforce-related including resource, knowledge, and confidence deficits. CONCLUSION: Findings suggest subtle changes in resident's health status, rather than focusing primarily on physiologic parameters used in early warning tools for acute care settings, should be recognized and considered in the design of early warning tools for residential aged care facilities. CLINICAL RELEVANCE: Early warning tools sensitive to the unique needs of residents and support for aged care facility staff are recommended to improve the capacity of aged care facility care staff to identify and manage acute deterioration early to avoid hospitalization.

Clinical correlates of pain in adults with hard-to-heal leg ulcers: a cross-sectional study.

OBJECTIVE: Pain is a complex symptom associated with hard-to-heal (chronic) leg ulcers that is often poorly managed. The objective of this study was to gain greater understanding by investigating relationships between physical and psychosocial factors, and pain severity in adults with hard-to-heal leg ulcers. METHOD: A secondary analysis of data collected for a longitudinal, observational study of adults with hard-to-heal leg ulcers was undertaken. Data were collected over a 24-week period, including variables relating to sociodemographics, clinical variables, medical status, health, ulcer and vascular histories, and psychosocial measures. Multiple linear regression modelling was used to determine the independent influences of these variables on pain severity, as measured with a Numerical Rating Scale (NRS). RESULTS: Of 142 participants who were recruited, 109 met the inclusion criteria for this study, of whom: 43.1% had venous ulcers; 41.3% had mixed ulcers; 7.3% had arterial ulcers; and 8.3% had ulcers from some other cause. The final model explained 37% (adjusted r2=0.370) of the variation in the pain NRS scores. Controlling for analgesic use, salbutamol use (p=0.005), clinical signs of infection (p=0.027) and ulcer severity (p=0.001) were significantly associated with increased pain, while the presence of diabetes (p=0.007) was significantly associated with a decrease in pain. CONCLUSION: Pain is a highly complex and pervasive symptom associated with hard-to-heal leg ulcers. Novel variables were identified as being associated with pain in this population. The model also included wound type as a variable; however, despite being significantly correlated to pain at the bivariate level of analysis, in the final model, the variable did not reach significance. Of the variables included in the model, salbutamol use was the second most significant. This is a unique finding that, to the authors' knowledge, has not been previously reported or studied. Further research is required to better understand these findings and pain in general.

International validation of a venous leg ulcer risk assessment tool.

OBJECTIVE: To internationally validate a tool for predicting the risk of delayed healing of venous leg ulcers (VLUs). METHOD: A 10-item tool including sociodemographic factors, venous history, ulcer and lower limb characteristics, compression and mobility items to determine the risk of delayed healing of VLUs has previously been developed and validated in Australia. This study prospectively validated this tool using receiver operating characteristic (ROC) methods; using the area under the curve (AUC) to quantify the discriminatory capability of the tool to analyse the international populations of the UK, Austria and New Zealand. RESULTS: The validation of the tool in the UK, Austria and New Zealand has indicated that the model has moderate discrimination and goodness-of-fit with an AUC of 0.74 (95% CI: 0.66-0.82) for the total risk assessment score. CONCLUSION: The international validation of a risk assessment tool for delayed healing of VLUs will allow clinicians globally to be able to determine realistic outcomes from an early assessment and to be able to guide early tailored interventions to address the specific modifiable risk factors and thus promote timely healing.

Promoting Person-Centered Care for Health Baccalaureate Students: Piloting an Interprofessional Education Approach to Wound Management.

OBJECTIVE: To describe and analyze the implementation of a wound management interprofessional education experience for nursing, podiatry, pharmacy, and exercise and nutrition science health baccalaureate students. The disciplines outside of nursing were invited to join the classes of a wound care elective unit in nursing. METHODS: This study included the development and implementation of a wound care program and observation of all students enrolled in the health disciplines where wound management education was relevant. RESULTS: Results indicated an increase in students' recognition of their roles and the roles of others within an interprofessional healthcare team. Facilitators reported that students learned to share information and work collaboratively to plan care for people with wounds. CONCLUSIONS: The outcomes confirm that the structured wound management program of interprofessional education within a Faculty of Health course promoted student recognition of wound management and the essential shared approach to person-centered care.

Risk factors for the recurrence of venous leg ulcers in adults: A systematic review protocol.

BACKGROUND: Venous leg ulcers are slow to heal, and recurrence is frequent. Living with venous leg ulcers can affect physical and psychological health, and result in financial burden for individuals. Physiological and psychosocial factors are associated with venous leg ulcer recurrence. As over 50% of venous leg ulcers will recur within 12 months of healing, a comprehensive knowledge of holistic risk factors associated with recurrence is required by health professionals involved in the care of the person with venous leg ulcers. AIM: To develop a systematic review protocol to determine the risk factors for recurrence of venous leg ulcers in adults. METHOD AND ANALYSIS: This protocol was developed according to the Preferred Reporting Items Form Systematic Review and Meta-Analysis Protocols (PRISMA-P). The inclusion criteria will be based on the PICOS mnemonic-adults with a history of venous leg ulcer/s (participants), risk factor/s under physiological (general/medical), clinical, demographics, psychosocial categories (I (intervention) or E (exposure), venous leg ulcer non-recurrence (comparison group), venous leg ulcer recurrence (outcomes to be measured) and will include study designs of original qualitative, quantitative and mixed method studies (study designs to be included). Methodological quality will be assessed using the Mixed Methods Appraisal Tool. This Systematic Review Protocol was registered in PROSPERO [CRD42021279792]. RESULTS: If meta-analysis is not possible, a narrative review of results will be presented. CONCLUSIONS: This systematic review on recurrence of venous leg ulcers can provide evidence-based information for preventive strategies for recurrence of a healed venous leg ulcer. The standardised approach outlined in this systematic review protocol offers a rigorous and transparent method to conduct the review.

Understanding Skin Failure: A Scoping Review.

OBJECTIVE: To map the use of the term "skin failure" in the literature over time and enhance understanding of this term as it is used in clinical practice. DATA SOURCES: The databases searched for published literature included PubMed, Embase, the Cumulative Index for Nursing and Allied Health Literature, and Google Scholar. The search for unpublished literature encompassed two databases, Open Gray and ProQuest Dissertation and Theses. STUDY SELECTION: Search terms included "skin failure," "acute skin failure," "chronic skin failure," and "end stage skin." All qualitative and quantitative research designs, editorial, opinion pieces, and case studies were included, as well as relevant gray literature. DATA EXTRACTION: Data collected included author, title, year of publication, journal name, whether the term "skin failure" was mentioned in the publication and/or in conjunction with other skin injury, study design, study setting, study population, sample size, main focus of the publication, what causes skin failure, skin failure definition, primary study aim, and primary outcome. DATA SYNTHESIS: Two main themes of skin failure were identified through this scoping review: the etiology of skin failure and the interchangeable use of definitions. CONCLUSIONS: Use of the term "skin failure" has increased significantly over the past 30 years. However, there remains a significant lack of empirical evidence related to skin failure across all healthcare settings. The lack of quality research has resulted in multiple lines of thinking on the cause of skin failure, as well as divergent definitions of the concept. These results illustrate substantial gaps in the current literature and an urgent need to develop a globally agreed-upon definition of skin failure, as well as a better understanding of skin failure etiology.

Treatment de-escalation for HPV-associated oropharyngeal squamous cell carcinoma with radiotherapy vs. trans-oral surgery (ORATOR2): study protocol for a randomized phase II trial.

BACKGROUND: Patients with human papillomavirus-positive (HPV+) oropharyngeal squamous cell carcinoma (OPC) have substantially better treatment response and overall survival (OS) than patients with HPV-negative disease. Treatment options for HPV+ OPC can involve either a primary radiotherapy (RT) approach (± concomitant chemotherapy) or a primary surgical approach (± adjuvant radiation) with transoral surgery (TOS). These two treatment paradigms have different spectrums of toxicity. The goals of this study are to assess the OS of two de-escalation approaches (primary radiotherapy and primary TOS) compared to historical control, and to compare survival, toxicity and quality of life (QOL) profiles between the two approaches. METHODS: This is a multicenter phase II study randomizing one hundred and forty patients with T1-2 N0-2 HPV+ OPC in a 1:1 ratio between de-escalated primary radiotherapy (60 Gy) ± concomitant chemotherapy and TOS ± de-escalated adjuvant radiotherapy (50-60 Gy based on risk factors). Patients will be stratified based on smoking status (< 10 vs. ≥ 10 pack-years). The primary endpoint is OS of each arm compared to historical control; we hypothesize that a 2-year OS of 85% or greater will be achieved. Secondary endpoints include progression free survival, QOL and toxicity. DISCUSSION: This study will provide an assessment of two de-escalation approaches to the treatment of HPV+ OPC on oncologic outcomes, QOL and toxicity. Results will inform the design of future definitive phase III trials. TRIAL REGISTRATION: Clinicaltrials.gov identifier: NCT03210103. Date of registration: July 6, 2017, Current version: 1.3 on March 15, 2019.

Stigmatization and knowledge of anorexia nervosa.

PURPOSE: To further understand the stigma, attitudes towards, and recognition of Anorexia Nervosa (AN), the current study utilized both stigma and mental health literacy methodology. This study also included another psychological disorder, major depressive disorder (MDD) and a normal, lonely female (C) as comparison conditions. METHODS: Male (291) and female (576) undergraduate students read a vignette describing one of the conditions. Participants then rated the vignettes on general personality characteristics, condition recognition, perceived seriousness and need for treatment. RESULTS: Many of the participants could not correctly identify AN. However, both AN and MDD were stigmatized. Although AN was rated as being very driven and disciplined, there was recognition that treatment was warranted. Familiarity with the conditions did not impact ratings. CONCLUSIONS: Continued efforts to reduce the stigma of AN and subsequent treatment seeking are warranted. The normal, lonely condition also being rated somewhat negatively highlights the need to include comparison conditions in stigma studies. LEVEL OF EVIDENCE: Level II, comparative study.

Exploring the prevalence and management of wounds for people with dementia in long-term care.

The prevalence of wounds and comorbidities such as dementia increase with age. With an ageing population, the likelihood of overlap of these conditions is strong. This study aimed to determine the prevalence of wound types and current management strategies of wound care for people with dementia in long-term care (LTC). A scoping literature review, a cross-sectional observational and chart audit study of residents in dementia specific facilities in LTC were conducted. The scoping review indicated that people with dementia/cognitive impairment are often excluded from wound related studies andof the nine studies included in this review, none looked at the prevalence of types of wounds other then pressure injuries. In the skin audit, skin tears were noted as the most common wound type with some evidence-based practice strategies in place for residents. However, documentation of current wound occurred in less than a third of residents with wounds. This is the first study to note the prevalence of different wound types in people with dementia and current management strategies being used across two dementia-specific facilities and a lack of research in this area limits evidence in guiding practice.

Radiotherapy versus transoral robotic surgery and neck dissection for oropharyngeal squamous cell carcinoma (ORATOR): an open-label, phase 2, randomised trial.

BACKGROUND: Transoral robotic surgery (TORS) with concurrent neck dissection has supplanted radiotherapy in the USA as the most common treatment for oropharyngeal squamous cell carcinoma (OPSCC), yet no randomised trials have compared these modalities. We aimed to evaluate differences in quality of life (QOL) 1 year after treatment. METHODS: The ORATOR trial was an investigator-initiated, multicentre, international, open-label, parallel-group, phase 2, randomised study. Patients were enrolled at six hospitals in Canada and Australia. We randomly assigned (1:1) patients aged 18 years or older, with Eastern Cooperative Oncology Group scores of 0-2, and with T1-T2, N0-2 (≤4 cm) OPSCC tumour types to radiotherapy (70 Gy, with chemotherapy if N1-2) or TORS plus neck dissection (with or without adjuvant chemoradiotherapy, based on pathology). Following stratification by p16 status, patients were randomly assigned using a computer-generated randomisation list with permuted blocks of four. The primary endpoint was swallowing-related QOL at 1 year as established using the MD Anderson Dysphagia Inventory (MDADI) score, powered to detect a 10-point improvement (a clinically meaningful change) in the TORS plus neck dissection group. All analyses were done by intention to treat. This study is registered with ClinicalTrials.gov (NCT01590355) and is active, but not currently recruiting. FINDINGS: 68 patients were randomly assigned (34 per group) between Aug 10, 2012, and June 9, 2017. Median follow-up was 25 months (IQR 20-33) for the radiotherapy group and 29 months (23-43) for the TORS plus neck dissection group. MDADI total scores at 1 year were mean 86·9 (SD 11·4) in the radiotherapy group versus 80·1 (13·0) in the TORS plus neck dissection group (p=0·042). There were more cases of neutropenia (six [18%] of 34 patients vs none of 34), hearing loss (13 [38%] vs five [15%]), and tinnitus (12 [35%] vs two [6%]) reported in the radiotherapy group than in the TORS plus neck dissection group, and more cases of trismus in the TORS plus neck dissection group (nine [26%] vs one [3%]). The most common adverse events in the radiotherapy group were dysphagia (n=6), hearing loss (n=6), and mucositis (n=4), all grade 3, and in the TORS plus neck dissection group, dysphagia (n=9, all grade 3) and there was one death caused by bleeding after TORS. INTERPRETATION: Patients treated with radiotherapy showed superior swallowing-related QOL scores 1 year after treatment, although the difference did not represent a clinically meaningful change. Toxicity patterns differed between the groups. Patients with OPSCC should be informed about both treatment options. FUNDING: Canadian Cancer Society Research Institute Grant (#701842), Ontario Institute for Cancer Research Clinician-Scientist research grant, and the Wolfe Surgical Research Professorship in the Biology of Head and Neck Cancers grant.

Differences between national and international guidelines for the management of diabetic foot disease.

AIM: No studies have investigated if national guidelines to manage diabetic foot disease differ from international guidelines. This study aimed to compare guidelines of Western Pacific nations with the International Working Group on the Diabetic Foot (IWGDF) guidance documents. METHODS: The 77 recommendations in five chapters of the 2015 IWGDF guidance documents were used as the international gold standard reference. The IWGDF national representative(s) from 12 Western Pacific nations were invited to submit their nation's diabetic foot guideline(s). Four investigators rated information in the national guidelines as "similar," "partially similar," "not similar," or "different" when compared with IWGDF recommendations. National representative(s) reviewed findings. Disagreements in ratings were discussed until consensus agreement achieved. RESULTS: Eight of 12 nations (67%) responded: Australia, China, New Zealand, Taiwan, and Thailand provided national guidelines; Singapore provided the Association of Southeast Asian Nations guidelines; and Hong Kong and the Philippines advised no formal national diabetic foot guidelines existed. The six national guidelines included were 39% similar/partially similar, 58% not similar, and 2% different compared with the IWGDF recommendations. Within individual IWGDF chapters, the six national guidelines were similar/partially similar with 53% of recommendations for the IWGDF prevention chapter, 42% for wound healing, 40% for infection, 40% for peripheral artery disease, and 20% for offloading. CONCLUSIONS: National diabetic foot disease guidelines from a large and diverse region of the world showed limited similarity to recommendations made by international guidelines. Differences between recommendations may contribute to differences in national diabetic foot disease outcomes and burdens.

Pretargeted delivery of PEG-coated drug carriers to breast tumors using multivalent, bispecific antibody against polyethylene glycol and HER2.

Pretargeting is an increasingly explored strategy to improve nanoparticle targeting, in which pretargeting molecules that bind both selected epitopes on target cells and nanocarriers are first administered, followed by the drug-loaded nanocarriers. Bispecific antibodies (bsAb) represent a promising class of pretargeting molecules, but how different bsAb formats may impact the efficiency of pretargeting remains poorly understood, in particular Fab valency and Fc receptor (FcR)-binding of bsAb. We found the tetravalent bsAb markedly enhanced PEGylated nanoparticle binding to target HER2+ cells relative to the bivalent bsAb in vitro. Pretargeting with tetravalent bsAb with abrogated FcR binding increased tumor accumulation of PEGylated liposomal doxorubicin (PLD) 3-fold compared to passively targeted PLD alone, and 5-fold vs pretargeting with tetravalent bsAb with normal FcR binding in vivo. Our work demonstrates that multivalency and elimination of FcRn recycling are both important features of pretargeting molecules, and further supports pretargeting as a promising nanoparticle delivery strategy.

Effects and safety of atmospheric low-temperature plasma on bacterial reduction in chronic wounds and wound size reduction: A systematic review and meta-analysis.

The use of atmospheric low-temperature plasma (AP) on chronic wounds and its effect on microbial bioburden in open wounds has not been explored with a systematic review and meta-analysis. PRISMA guidelines were followed and PubMed, Embase, CENTRAL, and CINAHL databases searched for randomised controlled trials (RCTs), which compared AP with no AP for the management of open, chronic wounds. The primary outcomes of reduction of bioburden or wound size were included. Meta-analyses were performed; odds ratio (OR) and 95% confidence intervals (CIs) were extracted and pooled in a random effects model. Four RCTs investigated the effect of AP on chronic wound healing. Chronic wounds treated with AP did not show a significant improvement in healing (AP vs control: OR = 1.46; 95% CI = 0.89-2.38; P = 0.13). Five further RCTs investigated the reduction of bioburden in wounds, but AP demonstrated no significant reduction of bioburden (AP vs control: OR = 0.85; 95% CI = 0.45-1.62; P = 0.63). All nine RCTs recorded the presence of any severe adverse events (SAEs) in the 268 patients studied, with only one unrelated SAE identified in each group (AP vs control: OR = 1.00; 95% CI = 0.05-19.96; P = 1.00). Use of AP in wound care is safe, but the retrieved evidence and meta-analysis show that there is no clinical benefit of AP in chronic open wounds using currently available AP device settings.

Engineering Polymer-Binding Bispecific Antibodies for Enhanced Pretargeted Delivery of Nanoparticles to Mucus-Covered Epithelium.

Mucus represents a major barrier to sustained and targeted drug delivery to mucosal epithelium. Ideal drug carriers should not only rapidly diffuse across mucus, but also bind the epithelium. Unfortunately, ligand-conjugated particles often exhibit poor penetration across mucus. In this work, we explored a two-step "pretargeting" approach through engineering a bispecific antibody that binds both cell-surface ICAM-1 and polyethylene glycol (PEG) on the surface of nanoparticles, thereby effectively decoupling cell targeting from particle design and formulation. When tested in a mucus-coated Caco-2 culture model that mimics the physiological process of mucus clearance, pretargeting increased the amount of PEGylated particles binding to cells by around 2-fold or more compared to either non-targeted or actively targeted PEGylated particles. Pretargeting also markedly enhanced particle retention in mouse intestinal tissues. Our work underscores pretargeting as a promising strategy to improve the delivery of therapeutics to mucosal surfaces.

Predicting delayed healing: The diagnostic accuracy of a venous leg ulcer risk assessment tool.

The aim of this study was to validate a newly developed tool that can predict the risk of failure to heal of a venous leg ulcer in 24 weeks. The risk assessment tool was validated, and performance of the tool was assessed using Area Under the Receiver Operating Characteristic Curve (AUC) analysis. Retrospective and prospective validation was conducted through multi-site, longitudinal studies. In the retrospective study (n = 318), 30% of ulcers did not heal within 24 weeks, with the tool demonstrating an AUC of 0.80 (95% CI, 0.68-0.93, P < .001) for the total score. In the prospective study across 10 clinical sites (n = 225), 31% (n = 68) of ulcers did not heal within 24 weeks. Participants were classified with the RAT at enrolment as being at low risk (27%), moderate risk (53%) or high risk (20%) of delayed healing; the proportion of wounds unhealed at 24 weeks was 6%, 29% and 59%, respectively. Validation results of the total score indicated good discrimination and goodness of fit with an AUC of 0.78 (95% CI, 0.71-0.85, P < .001). Validation of this risk assessment tool offers assurance that realistic outcomes can be predicted for patients, and scores can guide early decisions on interventions to address specific risk factors for failing to heal, thus promoting timely healing.

Predicting the likelihood of venous leg ulcer recurrence: The diagnostic accuracy of a newly developed risk assessment tool.

The aim of this study was to validate a newly developed tool for predicting the risk of recurrence within 12 months of a venous leg ulcer healing. Performance of the tool to predict recurrence within a 12-month period was assessed using Area Under the Receiver Operating Characteristic Curve (AUC) analysis. Multi-site retrospective and prospective longitudinal studies were undertaken to validate a risk assessment tool for the recurrence of venous leg ulcers within 12 months. In the retrospective study (n = 250), 55% of venous leg ulcers recurred within 12 months, and the risk assessment total score had excellent discrimination and goodness of fit with an AUC of 0.83 (95% CI, 0.76-0.90, P < .001). The prospective study (n = 143) observed that 50.4% (n = 63) of venous leg ulcers recurred within 12 months of healing. Participants were classified using the risk assessment tool as being at low risk (28%), moderate risk (59%), and high risk (13%); the proportion of wounds recurring at 12 months was 15%, 61%, and 67% for each group, respectively. Validation results indicated good discrimination and goodness of fit, with an AUC of 0.73 (95% CI, 0.64-0.82, P < .001). Validation of this risk assessment tool for the recurrence of venous leg ulcers provides clinicians with a resource to identify high-risk patients and to guide decisions on adjunctive, tailored interventions to address the specific risk factors to decrease the risk of recurrence.

Effects of Integrated Telehealth-Delivered Cognitive-Behavioral Therapy for Depression and Insomnia in Rural Older Adults.

BACKGROUND: We examined the effects of integrated cognitive-behavioral therapy for depression and insomnia (CBT-D + CBT-I) delivered via videoconferening in rural, middle aged and older adults with depressive and insomnia symptoms. METHOD: Forty patients with depressive and insomnia symptoms were randomized to receive either 10 sessions of CBT-D + CBT-I or usual care (UC). Patients in the integrated CBT condition were engaged in telehealth treatment through Skype at their primary care clinic. Assessments were conducted at baseline, post-treatment, and 3-month follow-up. RESULTS: CBT-D +CBT-I participants had significantly greater improvements in sleep at post-treatment and 3-month follow-up as compared to the UC participants. The time by group interaction for depression was not significant; both the CBT-D + CBT-I and UC conditions had a decrease in depressive symptoms over time. CONCLUSION: While integrated CBT benefits both depression and insomnia symptoms, its effects on depression are more equivocal. Further research should consider expanding the depression treatment component of integrated CBT to enhance effectiveness.

Timing of Diagnosis: Understanding Resilience Narratives of HIV Positive Older Adults Diagnosed Pre- and Post-HAART.

BACKGROUND: Despite the growing population of older adults living with human immunodeficiency virus/ acquired immune deficiency syndrome (HIV/AIDS), few studies have examined this population in terms of timing of HIV diagnosis. This study explores resilience and protective factors among HIV-positive older adults, 17 of whom were diagnosed prior to the development of highly active antiretroviral therapy (HAART), and 13 of whom were diagnosed after the development of HAART. METHODS: We explored the concepts of resilience and protective factors in 30 older adults living with HIV in Ontario, Canada. A qualitative approach was used to conduct in-depth interviews and grounded theory techniques were used to analyze the interview transcripts. RESULTS: Having lived with HIV for nearly 30 years, the pre-HAART group had developed more personal strategies for enhancing resilience, including self-care behaviors. They were more regimented and dedicated to their daily health, and were more engaged in their medical care as opposed to the post-HAART group who viewed self-care as staying adherent and refraining from risky health behaviors. IMPLICATIONS: Although HAART has radically changed the prognosis of HIV, we have limited information about the differences between those who were diagnosed before and after the development of HAART. We will present recommendations for addressing previous trauma and improving self-care.

Euglycemic Diabetic Ketoacidosis with Elevated Acetone in a Patient Taking a Sodium-Glucose Cotransporter-2 (SGLT2) Inhibitor.

BACKGROUND: Sodium-glucose cotransporter-2 (SGLT2) inhibitor medications are a class of antihyperglycemic agents that increase urinary glucose excretion by interfering with the reabsorption of glucose in the proximal renal tubules. In May of 2015, the U.S. Food and Drug Administration released a warning concerning a potential increased risk of ketoacidosis and ketosis in patients taking these medications. CASE REPORT: We present a case of a 57-year-old woman with type 2 diabetes mellitus taking a combination of canagliflozin and metformin who presented with progressive altered mental status over the previous 2 days. Her work-up demonstrated a metabolic acidosis with an anion gap of 38 and a venous serum pH of 7.08. The serum glucose was 168 mg/dL. The urinalysis showed glucose > 500 mg/dL and ketones of 80 mg/dL. Further evaluation demonstrated an elevated serum osmolality of 319 mOsm/kg and an acetone concentration of 93 mg/dL. She was treated with intravenous insulin and fluids, and the metabolic abnormalities and her altered mental status resolved within 36 h. This was the first episode of diabetic ketoacidosis (DKA) for this patient. WHY SHOULD AN EMERGENCY PHYSICIAN BE AWARE OF THIS?: Diabetic patients on SGLT2 inhibitor medications are at risk for ketoacidosis. Due to the renal glucose-wasting properties of these drugs, they may present with ketoacidosis with only mild elevations in serum glucose, potentially complicating the diagnosis. Acetone is one of the three main ketone bodies formed during DKA and it may be present at considerable concentrations, contributing to the serum osmolality.