Cardiopulmonary Examination Research Articles

Suitability of GPT-4o as an evaluator of cardiopulmonary resuscitation skills examinations

AimTo assess the accuracy and reliability of GPT-4o for scoring examinees’ performance on cardiopulmonary resuscitation (CPR) skills tests. MethodsThis study included six experts certified to supervise the national medical licensing examination (three junior and three senior) who reviewed the CPR skills test videos across 103 examinees. All videos reviewed by the experts were subjected to automated assessment by GPT-4o. Both the experts and GPT-4o scored the videos across four sections: patient assessment, chest compressions, rescue breathing, and repeated operations. The experts subsequently rated GPT-4o’s reliability on a 5-point Likert scale (1, completely unreliable; 5, completely reliable). GPT-4o’s accuracy was evaluated using the intraclass correlation coefficient (for the first three sections) and Fleiss’ Kappa (for the last section) to assess the agreement between its scores vs. those of the experts. ResultsThe mean accuracy scores for the patient assessment, chest compressions, rescue breathing, and repeated operation sections were 0.65, 0.58, 0.60, and 0.31, respectively, when comparing the GPT-4o’s vs. junior experts’ scores and 0.75, 0.65, 0.72, and 0.41, respectively, when comparing the GPT-4o’s vs. senior experts’ scores. For reliability, the median Likert scale scores were 4.00 (interquartile range [IQR] = 3.66–4.33, mean [standard deviation] = 3.95 [0.55]) and 4.33 (4.00–4.67, 4.29 [0.50]) for the junior and senior experts, respectively. ConclusionsGPT-4o demonstrated a level of accuracy that was similar to that of senior experts in examining CPR skills examination videos. The results demonstrate the potential for deploying this large language model in medical examination settings.

Adolescent female reproductive system dysplasia: a clinical study of 356 cases

Objective: To explore the age of onset and consultation, the main clinical manifestations, common types of combined malformations, the relationship of endometriosis, surgical prognosis and different types of proportion of adolescent female reproductive system dysplasia. Methods: The medical records of 356 patients (aged 10-19) with female reproductive system dysplasia in Women's Hospital, School of Medicine, Zhejiang University from January 2003 to August 2018 were collected and retrospectively analyzed. Results: (1) Among the 356 adolescent dysplasia patients, uterine dysplasia (23.6%, 84/356), oblique vaginal septum syndrome (OVSS; 22.5%, 80/356) and vaginal dysplasia (21.6%, 77/356) were the most frequent ones, followed by multi-sectional dysplasia (16.0%, 57/356), other types of developmental abnormalities like external genitaliaand urogenital fistula (13.5%, 48/356) and Mayer-Rokitansky-Küster-Hauser syndrome (MRKH syndrome; 2.8%, 10/356). (2) There were significant differences between the median age of onset and the age of consultation of patients with OVSS and other types of abnormalities except hymen atresia (both P<0.05). In contrast, there were no significant differences between the age of onset and the age of consultation of the patients of uterine dysplasia, vaginal dysplasia, hymen atresia, MRKH syndrome and multi-sectional dysplasia (all P>0.05). (3) The clinical manifestations were lack of specificity, and mainly abnormal finding was lower abdominal pain. (4) After admission, the majority of patients underwent comprehensive cardiopulmonary examination (71.3%, 254/356) and urinary system examination (63.5%, 226/356). Only 18.3% (65/356) of patients had completed abdominal organ examination, and 5.9% (21/356) skeletal system examination. About other systemic malformations, urological malformations were the most common (27.5%, 98/356), followed by anorectal malformation (0.6%, 2/356), heart malformations (0.3%, 1/356), and spinal malformations (0.3%, 1/356). 46.4% (84/181) of the surgical patients were diagnosed with combined endometriosis. Patients with obstructive genital tract malformations were more likely to combine with endometriosis than non-obstructive ones [50.3% (74/147) vs 29.4% (10/34); P<0.05]. However, there was no significant difference between the severity of endometriosis of those two kinds (P>0.05). (5) Totally 308 patients were followed up successfully with a median of 25.0 years old, and 20 cases were treated again; 12.0% (37/308) of them were suffering from menstrual disorder and 33.1% (102/308) of them with dysmenorrhea. Totally 130 patients had sexually active reported no sexual problems. Conclusions: Uterine dysplasia, OVSS and vaginal dysplasia are the most common syndromes in adolescent female reproductive system dysplasia along with frequent cases of coexisting urinary malformations and increasing risks of endometriosis. Meanwhile, the lack of specificity of clinical manifestations might delay the timely diagnosis and treatment after the onset of symptoms. Nonetheless, most patients could achieve good surgical outcomes.

Simulation-Based Cardiopulmonary Examination Skills Checklist: Assessment of Inter-rater Reliability

Purpose: Experiential learning using high-fidelity simulation is a valuable tool for teaching Doctor of Physical Therapy (DPT) students the cardiopulmonary examination. There are currently no standardized assessment tools to evaluate student performance and provide feedback on these skills. The cardiovascular and pulmonary section of the American Physical Therapy Association recently published recommended competency levels for entry-level physical therapists including examination skills. The primary aim of this study was to create and assess inter-rater reliability of a cardiopulmonary examination skills checklist that aligns with these recommendations and can be used in the simulation environment. Methods: A skills checklist with 6 sections was developed to assess student performance on the cardiopulmonary examination within a high-fidelity simulation experience. Training videos on the cardiopulmonary examination and checklist use were created and given to 3 graders. Seventy-three DPT students performed the cardiopulmonary examination within simulation while being recorded. Three graders then assessed the same 25 randomly selected videos using the checklist. Inter-rater reliability, item % agreement and student performance were analyzed. Results: The overall interclass correlation coefficient (ICC) of the checklist was calculated to be 0.858, demonstrating strong agreement between graders. The ICC for individualized checklist sections ranged from 0.659 to 0.960, demonstrating good to near perfect agreement. The average percent correct achieved by students was 80.48 (6.91%), R = 65% to 93.33%. There were &gt;80% agreement for 55/60 items and &gt;90% agreement for 44/60 items. Conclusion: The checklist provided an effective tool to assess student performance on the cardiopulmonary examination and demonstrated consistent scoring between graders.

SAT579 Newly Diagnosed Graves' Disease With Complete Heart Block In Elderly Patient. A Case Report

Abstract Disclosure: M.M. Eid: None. T. Zahra: None. J. Vargas-Jerez: None. Introduction: Hypothyroidism is the most common thyroid disorder in elderly. The prevalence of hyperthyroidism in elderly is 0.5-3% and mainly caused by toxic thyroid nodules. Graves’ disease is an autoimmune disorder mediated by TSH receptor antibody (TSHR AB), presents commonly with hyperthyroidism in middle age female(1). Complete heart block in elderly can be due to conduction system fibrosis, Ischemic/structural heart diseases, medications, electrolyte disturbance and hypothyroidism(2). Case 72yo, Female with history of DM and HTN. Denied smoking, alcohol, drug and allergy. Irrelevant family history. Medications include amlodipine, metformin and atorvastatin. She was referred to endocrinology clinic for low TSH (was normal last year). Review of system was negative, denied tremor, palpitation, anxiety, weight loss, bowel movement/mood/sleep change, vision/swallowing problem. Physical examination: ABP150/80, Heart Rate(HR) 75/min. Mild lid lag, no exophthalmos. No tremor. Thyroid gland: diffusely enlarged non tender, no bruit. Normal cardiopulmonary and abdomen examination. Laboratory work up TSH less than 0.01 normal 0.2 to 4.20 uIU/ml , FT4 3.5 normal 0.9 to1.8 ng/dl, FT3 6 normal 2 to 4.4 pg/ml. Repeat lab confirmed TSH suppression and high FT4 ,FT3. TSHR antibody 7.66 normal less than 1.75 IU/L, Thyroid stimulating immunoglobulin 5.05 normal less than 0.5 IU/L ,HBA1C 6.6, Normal liver and kidney function tests and Complete blood count. She was diagnosed with Graves’ disease, kept on Methimazole 10mg/day. 2 weeks later, she presented to the ED after syncope at home. Initial EKG showed complete heart block HR 35/min and right bundle branch block (RBBB), ABP 110/65. Hours later EKG showed transient first degree heart block HR 75/min, RBBB and left axis deviation, then complete heart block with HR 30/min. Normal Troponin, potassium 4.2 mmol/L, sodium 141 mmol/L, calcium 9.2mg/dl, TSH 0.015 uIU/ml,FT4 3 ng/dl. Negative Anti-Lyme IgG and IgM. Normal Echocardiogram. She underwent uneventful Dual chamber pacemaker implantation with close endocrinology follow up. Conclusion: Graves’ Disease has variable presentations in elderly. Hyperthyroidism causes tachyarrhythmia due to the positive chronotropic effect of thyroid hormones. Bradyarrhythmia in our case is most likely due to conduction system fibrosis and could be related to the inhibitory effect of TSHR AB in elderly in contrary to the simulating effect in young patients. It is still rare to diagnose symptomatic bradyarrhythmia with uncontrolled hyperthyroidism(1).

Aicardi-Goutières syndrome type 7 in a Chinese child: A case report

IFIH1 is a protein-coding gene. Disorders associated with IFIH1 include Aicardi-Goutières syndrome (AGS) type 7 and Singleton-Merten syndrome type 1. Related pathways include RIG-I/MDA5-mediated induction of the interferon (IFN)-α/β pathway and the innate immune system. AGS type 7 is an autosomal dominant inflammatory disorder characterized by severe neurological impairment. In infancy, most patients present with psychomotor retardation, axial hypotonia, spasticity, and brain imaging changes Laboratory assessments showed increased IFN-α activity with upregulation of IFN signaling and IFN-stimulated gene expression. Some patients develop normally in the early stage, and then have episodic neurological deficits. The 5-year-old girl presented with postpartum height and weight growth retardation, language retardation, brain atrophy, convulsions, and growth hormone deficiency. DNA samples were obtained from peripheral blood from the child and her parents for whole-exome sequencing and test of genome-wide copy number variation. Heterozygous mutations in the IFIH1 gene were found. Physical examination at admission found that language development was delayed, the reaction to name calling was average, there was no communication with people, but there was eye contact, no social smile, and no autonomous language. However, the child had rich gesture language and body language, could understand instructions, had bad temper. When she wants to achieve something, she starts crying or shouting. Cardiopulmonary examination showed no obvious abnormality, and abdominal examination was normal. Bilateral muscle strength and muscle tone were symmetrical and slightly decreased. Physiological reflexes exist, but pathological reflexes were not elicited. We reported the clinical characteristics of a Chinese child with a clinical diagnosis of AGS type 7, which expanded the mutational spectrum of the IFIH1 gene.

The Classical 6-P of Acute Limb Ischemia

Acute limb ischemia (ALI) is a surgical emergency and often threatens limb viability. This is a case of a 45-year-old patient who presented with the classical six Ps of ALI. A 45-year-old lady with underlying hypertension and heart failure presented with acute right leg pain arriving by ambulance at the Emergency Department within 4 hours of the symptom. The patient was clinically obese and seemed very uncomfortable as evidenced by her writhing in pain. She was borderline tachycardic and hypertensive. The cardiopulmonary and abdominal examinations were unremarkable. On extremity examination, she was unable to move her right leg starting from the knee caudally. The leg appeared mottling and cold. On vascular examination, there was no abdominal or femoral bruit but there was a diminished pulsation of the right femoral, dorsalis-pedis and posterior-tibialis arteries as confirmed by Doppler compared to the contralateral side. On the neurological examination, the sensation was absent and no pain upon the passive stretch. Ankle-Brachial-Systolic Index (ABSI) was 0.7. As evidenced by pain, pallor, pulselessness, poikilothermia, paralysis, and paresthesia, clinical diagnosis of acute right leg ischemia was established with most likely vascular occlusion proximal to the left femoral artery. The vascular team was urgently referred. Electrocardiogram showed sinus tachycardia. Bedside ultrasound revealed normal aortic root size and neither aortic dissection nor aneurysm. 2-point compression tests were fully compressible and X-ray films showed no fracture. Creatinine Kinase was 65 units/litre whereas other blood parameters were unremarkable. She was then classified as Rutherford IIB and underwent a right femoral thromboembolectomy. The presentation of ALI requires rapid diagnosis and appropriate management as it is time-sensitive and limb-threatening. Emergency physicians should be aware of advances in endovascular therapies as a recommended option for the treatment of ALI. International Journal of Human and Health Sciences Supplementary Issue: 2023 Page: S23

Association between cardiopulmonary function, health-related quality of life and cognitive impairment among the older nursing home residents in Shanghai, China.

This study aimed to examine the association between cardiopulmonary function, health-related quality of life (HRQOL) and cognitive function among nursing home residents aged 80 years and over. A nursing home-based, cross-sectional study was implemented among 677 aged over 80 years in Shanghai, China. A total of 197 participants underwent effective cardiopulmonary function examinations. Mini-Mental Status Examination (MMSE) and Short Form-36 scales (SF-36) were used to assess cognitive function and HRQOL, respectively. Decline in left ventricular ejection fractions (LVEF) [adjusted odds ratio (AOR), 1.98; 95% confidential interval (CI), 1.03-3.81)] and vital capacity (VC) (AOR, 2.08; 95%CI, 1.07-4.04) was associated with cognitive impairment. After adjusting confounding factors, relationships between cognitive function and physical functioning (PF) (AOR, 0.98; 95%CI, 0.97-0.99) still existed. Healthcare professionals should pay more attention to cardiopulmonary health and HRQOL in the nursing home residents. Actions of public health strategies focus on the improvement of cardiopulmonary function, and PF among older nursing home residents with cognitive impairment is required.

Cardiopulmonary examinations of athletes returning to high-intensity sport activity following SARS-CoV-2 infection

After SARS-CoV-2 infection, strict recommendations for return-to-sport were published. However, data are insufficient about the long-term effects on athletic performance. After suffering SARS-CoV-2 infection, and returning to maximal-intensity trainings, control examinations were performed with vita-maxima cardiopulmonary exercise testing (CPET). From various sports, 165 asymptomatic elite athletes (male: 122, age: 20y (IQR: 17-24y), training:16 h/w (IQR: 12–20 h/w), follow-up:93.5 days (IQR: 66.8–130.0 days) were examined. During CPET examinations, athletes achieved 94.7 ± 4.3% of maximal heart rate, 50.9 ± 6.0 mL/kg/min maximal oxygen uptake (V̇O2max), and 143.7 ± 30.4L/min maximal ventilation. Exercise induced arrhythmias (n = 7), significant horizontal/descending ST-depression (n = 3), ischemic heart disease (n = 1), hypertension (n = 7), slightly elevated pulmonary pressure (n = 2), and training-related hs-Troponin-T increase (n = 1) were revealed. Self-controlled CPET comparisons were performed in 62 athletes: due to intensive re-building training, exercise time, V̇O2max and ventilation increased compared to pre-COVID-19 results. However, exercise capacity decreased in 6 athletes. Further 18 athletes with ongoing minor long post-COVID symptoms, pathological ECG (ischemic ST-T changes, and arrhythmias) or laboratory findings (hsTroponin-T elevation) were controlled. Previous SARS-CoV-2-related myocarditis (n = 1), ischaemic heart disease (n = 1), anomalous coronary artery origin (n = 1), significant ventricular (n = 2) or atrial (n = 1) arrhythmias were diagnosed. Three months after SARS-CoV-2 infection, most of the athletes had satisfactory fitness levels. Some cases with SARS-CoV-2 related or not related pathologies requiring further examinations, treatment, or follow-up were revealed.

Point-of-care ultrasound needs assessment in a paediatric acute care setting in Malawi.

To describe the use of point-of-care ultrasound (POCUS) in an acute-care paediatric setting in Malawi, including clinical indications, types of examinations and frequency of positive findings. Retrospective, cross-sectional study of a convenience sample of POCUS examinations performed in one tertiary referral hospital in Lilongwe, Malawi over 1 year. POCUS examinations were performed by Paediatric Emergency Medicine physician consultants as part of routine clinical practice and at the request of local clinicians. Images were saved along with the clinical indication and physician interpretation for quality review. Ultrasounds performed by the radiology department and those examinations that were technically faulty, missing clinical application or interpretation were excluded. In total, 225 ultrasounds of 142 patients were analysed. The most common clinical indications for which examinations were completed were respiratory distress (23%), oedema (11.7%) and shock/arrest (6.2%). The most common examinations performed were cardiac (41.8%) and lung (15.1%), focused assessment with sonography in trauma (FAST; 12.9%) and ultrasound-guided procedural examinations (9.8%). Pathology was identified in 68% of non-procedural examinations. Cardiac examinations demonstrated significant pathology, including reduced cardiac function (12.8%), gross cardiac structural abnormality (11.8%) and pericardial effusion (10.3%). POCUS was used for both clinical decision-making and procedural guidance, and a significant number of POCUS examinations yielded positive findings. Thus, we propose that cardiopulmonary, FAST and procedural examinations should be considered in future for the POCUS curriculum in this setting.

Abstract 14124: Acute Mitral Regurgitation With Chronic Endocarditis in Type I Osteogenesis Imperfecta

Case Presentation: A 45-year-old man with history of Type I osteogenesis imperfecta (OI) presented with severe shortness of breath and worsening bilateral lower extremity edema for 6 weeks. Paternal family history was significant for Type I OI with early deaths in affected females. Physical examination revealed a distressed man with blue - gray sclerae and jugular venous distention. Cardiopulmonary examination was remarkable for tachycardia, grade IV holosystolic murmur radiating to the axilla, bilateral lung crackles with decreased air entry on the lower lung fields and pitting pedal edema up to mid thighs. TTE and TEE were significant for severe eccentric posterior MR with multiple vegetations versus ruptured chordae and normal systolic function. He underwent an emergency mitral valve replacement complicated by post-operative severe AR requiring redo sternotomy with aortic valve replacement. Histologically, aortic valve leaflets were suggestive of chronic endocarditis with dual negative sets of blood cultures drawn since admission. He was eventually discharged home after an intense cardiac rehabilitation with appropriate follow ups. Discussion: OI is a rare hereditary connective tissue disorder affecting the production of Type I collagen due to mutations in COL1A1 and COL1A2 genes. Although lesser known, OI valvulopathy is typically limited to the left sided structures, for unknown reasons, with the most common valvular anomaly being AR followed by MR. Despite the dramatic cardiac involvement in our patient and known mortality risk associated with surgical intervention, prompt evaluation and early intervention led to a successful outcome.

ODP470 Compressive Goiter with COVID-19: An Unusual Etiology of Respiratory Distress Requiring Endotracheal Intubation with Surgical Resection

Abstract Introduction Gradual enlargement of multinodular goiter (MNG) may compress surrounding structures which may progressively cause complications of tracheal stenosis and airway compromise. Surgical resection remains the gold standard treatment in MNG patients presenting with respiratory distress. In the current global COVID -19 pandemic, compressive goiter should be a differential diagnosis in patients with stable benign thyroid goiter presenting with dyspnea. We present a case of MNG with life threatening airway obstruction during an active COVID-19 infection. Case presentation A 74-year-old female with a history of hyperthyroidism with multi-nodular goiter and recurrent atrial fibrillation status-post ablation, was transferred to the intensive care unit for treatment after being intubated for respiratory distress at a nearby hospital. She was diagnosed with hyperthyroidism about 40 years ago and managed with methimazole. Over the last two years, thyroid ultrasound and prior imaging showed MNG with patent but moderate tracheal narrowing; fine-needle aspiration (FNA) confirmed benign colloid nodules with cystic degeneration. She was pending cardiac clearance for surgery when symptoms acutely worsened two days before admission. On initial assessment, she was hemodynamically stable, afebrile, with oxygen saturation of 86% on room air. She was alert and able to follow commands. On physical examination, she had stridor and thyromegaly was evident with mild tenderness on palpation. Cardiopulmonary examination was remarkable for coarse breath sounds. Labs showed TSH 4.82 (Normal 0.3 - 4.5 ulU/mL), FT4 0.64 (Normal 0.5- 1.26 ng/dL). Respiratory panel test came back positive for SARS-CoV-2. Racemic epinephrine and albuterol nebulizers were administered to help with her symptoms. CT scan of the neck revealed a severe narrowing and mild rightward shift of the trachea by a large multinodular goiter, prompting the decision to intubate for airway protection. CT scan of the chest with contrast demonstrated the large MNG with tracheal stenosis. Her methimazole dose was adjusted. After cardiac clearance, she underwent thyroidectomy through a transcervical approach. Levothyroxine and calcium supplementation were started post-surgery. She was extubated two days after her thyroidectomy. Pathology results showed no evidence of malignancy. Discussion Acute airway obstruction by large MNG requiring emergent airway protection is rare. Typically airway compromise from large otherwise stable benign goiters results from sudden hemorrhage into a cyst, upper respiratory tract infection leading to tracheal edema, or worseningcomorbid conditions. During the COVID-19 pandemic, acute respiratory failure and shortness of breath is typical of worsening disease course. This case highlights the importance of maintaining wider differentials of respiratory failure even and we need to consider worsening of tracheal narrowing with a large goiter due to tracheal edema from SARS- CoV-2 Infection. Thyroidectomy before SARS-CoV-2 infection may have reduced her need for emergent intubation for acute respiratory failure by improving pre existing airway compression. Presentation: No date and time listed

A palpable depression

Several studies have shown that patients with depression, anxiety and stress have a higher ratio in developing atrial fibrillation (AF), with higher proportion occurring in patients with recurrent episodes of AF which are related to severity of disease and increased mortality ratio. We aim to discuss the case of AF caused by mental disorder to examine its relationship and impact in patient’s clinical outcomes. A 70 years-old-man came to clinic with palpitation five days before admission. He often cries and has not been able to sleep since his wife died three months prior. He admits to have neither hope nor desire to do his usual activities or even start new activities. Vital signs show BP 140/90 mmHg, pulse 150x/m, RR 20x/m, SpO2 98%. Cardiopulmonary examination revealed irregular S1-S2. ECG shows premature atrial contraction which evolved to asinus rhythm with HR 150x/minute, AF and incomplete right bundle branch block a months after the first ECG was examined. Depression-Anxiety-stress scoring-42 (DASS-42) was conducted in this patient. Results shows the patient has very severe depression, intermediate anxiety and severe stress. Mental disorders lead to increased etiology of cardiac remodeling factors due to degeneration and sympathetic stimulation, which then induced the AF. Further research is needed to examine whether psychiatric treatment can prevent AF in improving quality of life, healthy behavior and awareness for managing mental health.

P34 A case of Entamoeba histolytica infection in a patient with polymyalgic-onset inflammatory arthritis

P34 A case of Entamoeba histolytica infection in a patient with polymyalgic-onset inflammatory arthritis

39-Year-Old Woman With Severe Weakness

39-Year-Old Woman With Severe Weakness

Twiddler's Syndrome

A 57-year-old woman with a history of cardiac sarcoidosis, complicated by recent episodes of nonsustained ventricular tachycardia requiring an implantable cardiac defibrillator, presented with 2–3 days of substernal chest wall discomfort and palpitations. Her cardiopulmonary examination was unremarkable, with a regular rhythm and no new murmurs. Initial electrocardiogram (Figure 1) demonstrated a normal sinus rhythm with no ectopic beats, however, supplemental electrical pacing spikes (black arrows) were noted to occur at a regular interval without associated cardiac capture.

Myocardial Bridging, a Neglected Anomaly in Acute Coronary Syndrom

Background: Myocardial Bridging (MB) is an anomaly characterized by an intra-myocardial route of a segment of one of the major coronary arteries. Functional myocardial bridging is less commonly observed on angiography (0.5–16%) and can range from 4 to 80 mm in length. This case report elaborates about a case of a symptomatic MB occurrence in a patient manifesting as an acute coronary syndrome. Case presentation: A 66 years old female presented to ER with a typical angina gradually increasing since 1 week ago. Associated symptoms were episodic syncope, dyspnea, and dyspepsia. physical examination reveals, vital signs are within normal limits. The cardio-pulmonary examination was unremarkable. Electrocardiogram (ECG) showed inverted T waves on V1-V4, cardiac biomarker enzymes were not increased, chest X-ray revealed an enlarged heart, echocardiography showed a left ventricular hypertrophy (LVH) with normal left ventricle ejection fraction (LVEF). Nitrate, aspirin, and P2Y12 inhibitor were then administered in the ER, and the patient was then transferred to catheterization lab. CT-Angiography showed a MB in the middle left anterior descending (LAD), the patient was then treated with bisoprolol as a maintenance therapy. Conclusion: MB, if presenting symptomatically, especially as an acute coronary syndrome (ACS), may become lifeŧhreatening if not recognized and treated appropriately. Flow normalization and symptom management in such circumstances are best achieved through revascularisation via percutaneous coronary intervention (PCI) and drug therapy by using beta-blocker.

A case of ischemic-hypoxic encephalopathy due to oral succinylcholine ingestion.

A case of ischemic-hypoxic encephalopathy due to oral succinylcholine ingestion.

Cardiopulmonary examinations of athletes returning to high-intensity sport activity following SARS-CoV-2 infection

Abstract During the pandemic, several studies were carried out on the short-term effects of acute SARS-CoV-2 infection in athletes. As some cases of young athletes with serious complications like myocarditis or thromboembolism and even sudden death were reported, strict recommendations for return to sport were published. However, we have less data about athletes who have already returned to high-intensity trainings after a SARS-CoV-2 infection. Athletes underwent cardiology screening (personal history, physical examination, 12-lead resting ECG, laboratory tests with necroenzyme levels and echocardiography) 2 to 3 weeks after suffering a SARS-CoV-2 infection. In case of negative results, they were advised to start low intensity trainings and increase training intensity regularly until achieving maximal intensity a minimum of 3 weeks later. A second step of cardiology screening was also carried out after returning to maximal intensity trainings. The above mentioned screening protocol was repeated and was completed with vita maxima cardiopulmonary exercise testing (CPET) on running treadmill. If the previous examinations indicated, 24h Holter ECG recording, 24h ambulatory blood pressure monitoring or cardiac MR imaging were also carried out. Data are presented as mean±SD. Two-step screening after SARS-CoV-2 infection was carried out in 111 athletes (male:74, age:22.4±7.4y, elite athlete:90%, training hours:14.8±5.8 h/w, ice hockey players:31.5%, water polo players:22.5%, wrestlers:18.9%, basketball players:18.0%). Second screenings were carried out 94.5±31.5 days after the first symptoms of the infection. A 5% of the athletes was still complaining of tiredness and decreased exercise capacity. Resting heart rate was 70.3±13.0 b.p.m., During CPET examinations, athletes achieved a maximal heart rate of 187.3±11.6 b.p.m., maximal relative aerobic capacity of 49.2±5.5 ml/kg/min, and maximal ventilation of 138.6±31.2 l/min. The athletes reached their anaerobic threshold at 87.8±6.3% of their maximal aerobic capacity, with a heart rate of 93.3±3.7% of their maximal values. Heart rate recovery was 29.9±9.2/min. During the CPET examinations, short supraventricular runs, repetititve ventricular premature beats + ventricular quadrigeminy and inferior ST depression were found in 1–1 cases. Slightly higher pulmonary pressure was measured on the echocardiography in 4 cases. Hypertension requiring drug treatment was found in 5.4% of the cases. Laboratory examinations revealed decreased vitamin D3 levels in 26 cases, decreased iron storage levels in 18 athletes. No SARS-CoV-2 infection related CMR changes were revealed in our athlete population. Three months after SARS-CoV-2 infection, most of the athletes examined had satisfactory fitness levels. However, some cases of decreased exercise capacity, decreased vitamin D3 or iron storage levels, arrhythmias, hypertension and elevated pulmonary pressure requiring further examinations, treatment or follow-up were revealed. Funding Acknowledgement Type of funding sources: Public grant(s) – National budget only. Main funding source(s): This project was supported by a grant from the National Research, Development and Innovation Office (NKFIH) of Hungary; The research was financed by the Thematic Excellence Programme of the Ministry for Innovation and Technology in Hungary, within the framework of the Therapeutic Development and Bioimaging programmes of the Semmelweis University

TB MASQUERADING AS LUNG MALIGNANCY

TOPIC: Chest Infections TYPE: Medical Student/Resident Case Reports INTRODUCTION: Radiological manifestations of pulmonary tuberculosis (TB) tend to be heterogeneous. [1] In this report, we highlight one such atypical manifestation that posed a diagnostic dilemma and necessitated a biopsy. CASE PRESENTATION: A 67 year old male with no known medical illness presented with a 3 month history of dry cough to a hospital in southern India. The cough was associated with night sweats, appetite loss, fatigue and intermittent fever. He reported no episodes of breathlessness or hemoptysis. He denied any sick contacts, was a non smoker and had no family history of malignancy. On examination, his vital signs were stable and he was not in respiratory distress. There were no palpable lymph nodes Cardiopulmonary examination revealed no abnormal findings. Blood examination showed hemoglobin of 11.9 g/dL and ESR of 54 mm/hr, with normal blood cell counts. Chest radiograph revealed opacities in the right middle zone. A high resolution computed tomography (HRCT) of the thorax was done, and findings raised suspicion of neoplastic changes.HRCT revealed a patchy consolidation with necrotic areas and irregular margins in the superior segment of the right lower lobe, extending up to the costal pleura. Multiple ground glass opacities with nodular thickening of the oblique fissure were noted in the right lower lobe as well. Due to their typical appearance, these features were attributed to a neoplastic etiology. Interestingly, a homogenously enhancing lobulated mass was noted in the prevascular compartment of the superior mediastinum. It was also seen abutting the SVC posteriorly, where it caused a focal compression on the left brachiocephalic vein. This was thought to be a lymph nodal mass. Computed Tomography (CT) guided biopsy of the right lower lobe lesion was conducted. Histopathology revealed granulomatous inflammation with epitheloid and giant cells surrounding areas of caseous necrosis. The patient was started on Anti Tuberculous Treatment and responded well. Follow up imaging six months later revealed fibrotic changes with calcified granulomas. DISCUSSION: Clinical and radiological manifestations of TB are heterogeneous and include a variety of benign and malignant diseases. [1] Diagnostic dilemmas can delay appropriate treatment, favoring Mycobacterium tuberculosis transmission. Up to one third of TB cases have an atypical appearance on radiograph or CT imaging. [2] Thus, despite demographic features and symptoms typical of TB, our patient's HRCT posed a diagnostic dilemma. The consolidation with necrotic areas and superior mediastinal mass raised suspicion for lung malignancy. CONCLUSIONS: An extensive workup is required to differentiate TB from lung malignancy. HRCT and biopsy can be critical. Comprehensive awareness and knowledge of atypical TB manifestations can help in early diagnosis and start of therapy, increasing the probability of clinical and microbiological cure. REFERENCE #1: Collu C, Fois A, Crivelli P, Tidore G, Fozza C, Sotgiu G, Pirina P. A case-report of a pulmonary tuberculosis with lymphadenopathy mimicking a lymphoma. Int J Infect Dis. 2018 May;70:38-41. doi: 10.1016/j.ijid.2018.02.011. Epub 2018 Mar 1. PMID: 29477363. REFERENCE #2: Jeon KN, Bae K, Park MJ. Atypical radiologic appearances of pulmonarytuberculosis in non-HIV adult patients. In Proceedings: The RoyalAustralian and New Zealand College of Radiologists (RANZCR) 63rdAnnual Scientific Meeting, and Asian Oceanian Congress of Radiology(AOCR), 30 August–2 September 2012, Sydney, Australia;http://dx.doi.org/10.1594/ranzcraocr2012/R-0200 DISCLOSURES: No relevant relationships by Arup Ganguly, source=Web Response No relevant relationships by Vinayak Jain, source=Web Response No relevant relationships by Adithya Shetty, source=Web Response

PREVOTELLA BIVIA BACTEREMIA POST TOCILIZUMAB IN A PATIENT WITH SEVERE COVID-19 PNEUMONIA

TOPIC: Chest Infections TYPE: Medical Student/Resident Case Reports INTRODUCTION: Anaerobes generally constitute a major component of the gut microbiome. They play a significant role in the pathogenesis of infections following disruption of mucosal integrity. Anaerobic organisms are usually difficult to grow and identify and hence may often be overlooked. We present a patient with severe COVID-19 pneumonia who developed de-novo Prevotella bivia bacteremia, following tocilizumab. CASE PRESENTATION: A 38 year old Caucasian male with morbid obesity and no other past medical history presented to the emergency department with complaints of cough, fever, chills and poor appetite for the past 10 days. Upon arrival, he was profoundly hypoxic with Spo2 70% on ambient air. He tested positive for COVID-19. On physical examination, his BMI was 62 kg/m2, he was febrile, in moderate respiratory distress, cardiopulmonary examination revealed coarse bilateral breath sounds. His physical examination was otherwise unremarkable. His chest radiograph demonstrated hazy opacification in both mid lungs and left lung base suggestive of multifocal pneumonia. CT chest did not reveal evidence of pulmonary embolism. Lower extremity ultrasound was however negative for a DVT. Laboratory findings was significant for elevated C-reactive protein 12.4 mg/dl. Patient was placed on heated high flow nasal cannula and received dexamethasone and tocilizumab. His respiratory status continued to worsen and he was subsequently intubated. Lower respiratory culture was positive for MSSA and patient was started cefepime and vancomycin was added as he clinically continued to decompensate. Within the next week, blood culture was positive for Prevotella bivia and his antibiotic regimen was changed to pipericillin-tazobactam. Repeat blood culture continued to be positive and this time, for Enterococcus faecalis. The antibiotic regimen was further changed to meropenem. Interestingly, on his physical examination, there was no abnormalities on his abdomen or pelvic area. CT abdomen pelvis did not shows any acute abnormalities. Following meropenem initiation, his subsequent blood cultures have been negative for any growth. Patient remains intubated with a guarded prognosis. DISCUSSION: Prevotella bivia is one of several species of bacteria in the genus Prevotella. It is an anaerobic gram negative organism that is found in the oral, vaginal, and gut microbiome. Some of the infections caused by this organism include aspiration pneumonia, lung abscess, otitis media, and sinusitis. Various species of Prevotella have been isolated from abscesses and burns close of the mouth, bite, paronychia, urinary tract infection, brain abscess, osteomyelitis, and bacteremia when there is an associated respiratory tract infections. Prevotella bivia bacteremia is highly uncommon. CONCLUSIONS: As we continue to learn more about COVID-19 infection and its treatment modalities, we may come across such unusual scenarios. REFERENCE #1: 27.Curtis JR, Perez-Gutthann S, Suissa S, et al. Tocilizumab in rheumatoid arthritis: a case study of safety evaluations of a large postmarketing data set from multiple data sources. Semin Arthritis Rheum 2015;44:381. REFERENCE #2: Yanagisawa M, Kuriyama T, Williams DW, Nakagawa K, Karasawa T. Proteinase activity of prevotella species associated with oral purulent infection. Curr Microbiol. 2006;14(5):375–378. doi: 10.1007/s00284-005-0261-1 REFERENCE #3: Metronidazole Resistance in Prevotella spp. and Description of a New nim Gene in Prevotella baroniaeC. Alauzet, F. Mory, C. Teyssier, H. Hallage, J. P. Carlier, G. Grollier, A. Lozniewski DISCLOSURES: No relevant relationships by Alfred Aiyanyor, source=Web Response No relevant relationships by Navitha Ramesh, source=Web Response No relevant relationships by Q. Kamran Uddin, source=Web Response