Chronic Steroid Research Articles

S2355 An Unusual Presentation of a Rare Cause of Lower Gastrointestinal Bleeding: Cecal Dieulafoy’s Lesion Presenting as Melena

Introduction: Dieulafoy’s lesion is characterized as a large tortuous submucosal artery projecting through a small mucosal defect with no evidence of primary mucosal ulceration or erosion. These lesions are uncommonly identified as causes of acute gastrointestinal (GI) bleeding, accounting for only 1-2% of cases. Dieulafoy’s lesions can occur throughout the entire GI tract, most commonly occurring in the stomach (72% of cases) and rarely in the lower GI tract (5% of cases). Typically, lower GI tract Dieulafoy’s lesions present as hematochezia. We report an unusual case of a cecal Dieulafoy’s lesion that presented as melena. Case Description/Methods: A 64-year-old male with a relevant past medical history of hypertension, rheumatoid arthritis (on chronic steroids) and superior vena cava thrombosis (on anticoagulation) presented with melena. The patient denied bright red blood per rectum, or any other gastrointestinal symptoms. His vital signs were stable at the time of presentation. Physical examination was unremarkable except for melenic stool on rectal exam. Labs were significant for a hemoglobin of 7.0 g/dL (prior baseline of 12.0 g/dL), AST 67 U/L, ALT 43 U/L, ALP 219 U/L, INR 1.17, and PTT 55.3 seconds. Due to evidence of persistent bleeding, three units of packed red blood cells were transfused and a pantoprazole drip was initiated with suspicion of an upper GI source of bleed. Endoscopy was performed, which showed esophagitis with no active bleeding and gastritis. A colonoscopy was then performed which revealed a solitary Dieulafoy’s lesion in the cecum. An overlaying adherent clot was dislodged to reveal the lesion. Complete hemostasis was achieved using four hemostatic clips. Post procedural course was uncomplicated and the patient’s hemoglobin remained stable. Discussion: Our case describes a cecal Dieulafoy’s lesion that presented, unusually, as melena. There have been several reports of cecal Dieulafoy’s lesion presenting as hematochezia. To our knowledge, this is the first reported case of a cecal Dieulafoy’s lesion presenting solely as melena. We aim to add to the relatively few cases of cecal Dieulafoy’s reported, and help improve the diagnostic accuracy of these type of lesions. Without timely diagnosis and treatment, Dieulafoy’s lesions have the potential to progress to life-threatening bleeding. Thankfully, with expedient diagnosis and with modern endoscopic tools, hemostasis can be achieved in up to 90% of such cases.Figure 1.: A: Bleeding cecal Dieulafoy’s lesion B: Endoscopic clip removing adherent clot and exposing visible vessel C: Hemostasis achieved with four hemostatic clips.

MALIGNANT HEMISPHERIC INFARCTION AFTER SUBTLE TRACHEAL RUPTURE

TOPIC: Critical Care TYPE: Medical Student/Resident Case Reports INTRODUCTION: Tracheal rupture after endotracheal intubation is a rare but life-threatening complication with an incidence of approximately 0.005%. Predisposing factor can be a weakness of the membranous trachea secondary to chronic illness or steroid use. Herein we present a case of a young woman who developed a distal tracheal rupture after emergent endotracheal intubation with devastating consequences. CASE PRESENTATION: A 48-year-old female with a medical history of hypertension, epilepsy, and panhypopituitarism secondary to a respected craniopharyngioma was admitted to the intensive care unit with a diagnostic impression of obstructive uropathy with septic shock and multiorgan failure. Supportive management with aggressive fluids resuscitation, antibiotics, dual vasopressor therapy, and endotracheal intubation was given. Hours later, the patient became hemodynamically unstable requiring increased vasopressor therapy with increased demand in ventilation parameters. Physical examination was positive for massive subcutaneous emphysema from her chest tracking through facial and neck planes. A chest computerized tomography (CT) scan was performed and showed a distal tracheal rupture as the most likely cause of the massive pneumothorax that progressed to tension subcutaneous emphysema. Upon acute neurological deterioration, a head CT scan was performed, revealing a left pan-hemispheric malignant ischemic stroke involving the left anterior, middle, and posterior cerebral arteries suggestive of a left internal carotid artery (ICA) complete occlusion. The patient had a National Institutes of Health Stroke Scale score above 20, a left hemisphere infarction, and a GCS 3/11, conferring a poor clinical outcome. As poor prognosis and poor quality of life were expected, the family members opted to withdraw life support. DISCUSSION: Malignant hemispheric infarction has a mortality rate as high as 80 percent with catastrophic neurologic sequelae. Its incidence is less than ten percent of all ischemic infarcts and it's generally caused by embolic occlusion of the ICA. CONCLUSIONS: To our knowledge, there are no malignant hemorrhagic strokes provoked by traumatic intubation resulted from tracheal rupture documented to this day. We presume the etiology of this event to be subcutaneous air that exerted enough pressure between the fascial and cervical planes to result in significant vascular compression. Tracheal rupture is one of the most feared immediate complications of intubation as it could result in increased morbidity and mortality. There is no established consensus for the treatment yet, but early surgical repair has been the mainstay of treatment. However, conservative management has been chosen in cases of small ruptures with similar outcomes. REFERENCE #1: JOSEPH, M. M., & LEWIS, S. (2002). Stroke after penetrating trauma of the oropharynx. Pediatric Emergency Care, 18(3), 179–181.doi:10.1097/00006565-200206000-00007 DISCLOSURES: No relevant relationships by Ian Da Silva Lugo, source=Web Response No relevant relationships by Juan Feliciano-FIgueroa, source=Web Response No relevant relationships by Hector Nunez Medina, source=Web Response No relevant relationships by Héctor Oliveras-Cordero, source=Web Response No relevant relationships by Juan Santiago, source=Web Response

P60.08 Systemic Immune-Inflammatory Index (SII) as a Biomarker for Metastatic Non-Small Cell Lung Cancer

Inflammation contributes to tumor development and progression. Neutrophils promote tumor metastasis by increasing vascular permeability while platelets interact with tumor cells through TGFB and NF-KB pathways promoting growth. Lymphocytes on the other hand are thought to inhibit tumor-cell division. Systemic immune-inflammatory index (SII) has been developed as a simple biomarker in solid tumors to elucidate role of inflammation in malignancy. SII has not been studied in metastatic NSCLC. This study aimed to evaluate prognostic and predictive role of SII in metastatic NSCLC. Data was obtained retrospectively for 236 patients with metastatic NSCLC between 1/1/2015-12/31/2020, who received systemic therapy. SII was calculated at treatment initiation as Platelet count x Neutrophil count/ Lymphocyte count. Overall survival (OS) and Progression Free survival (PFS) were determined as time from start of first line treatment till death and progression or death respectively. Univariate and multivariate Cox regression and Chi-squared analyses were utilized to determine significance of the findings. An optimal SII cut-off value of 1238.5 was determined using a receiver operator curve (ROC). Tobacco use was associated with higher SII (2028 vs 1399 p =0.01). Higher SII was noted for females (1952 vs 1789 p=0.49), age <70 years (1919 vs 1831 p=0.74), African-Americans vs Caucasians (2030 vs 1875 p=0.76), Chronic obstructive pulmonary disease (1987 vs 1807 p=0.49), steroid (2319 vs 1753 p=0.06) and antibiotic use (2310 vs 1791 p=0.14) within one month prior to treatment, and with coronary artery disease (2122 vs 1808 p=0.33); however these differences were not statistically significant. No statistically significant differences were noted based on histology: adenocarcinoma vs Squamous cell carcinoma vs large cell (1675.5 vs 1833.8 vs 1232.8 p=0.9). A low SII (<1238.5) was associated with improved PFS as compared to a high SII (median: 12.7 vs 7.2 months; HR 1.051, 95%CI 1.025-1.073, p<0.0001). Low SII however was not associated with improved OS (14.5 vs 12.7 months; HR 1.014; 95%CI 0.992-1.033), p=0.17). In low SII group, PFS was 11.3 vs 16.7 vs 5.9 months compared to a PFS of 6.9 vs 10.6 vs 5.9 months in high SII group for patients receiving chemotherapy vs targeted therapy vs immunotherapy respectively. SII may be a potential predictive marker for response to treatment. However, it does not appear to be a prognostic biomarker given lack of statistically significant difference in OS. SII is an easy and inexpensive tool to obtain, which makes it an appealing prediction biomarker. Future studies should evaluate the role of SII and its change following treatment, on response to immune checkpoint inhibitors.

S641 Systematic Review and Meta-Analysis on Gastrointestinal Bleeding in COVID-19: A Lesson From the First 10 Months of the Pandemic

Introduction: Gastrointestinal bleeding (GIB) has been reported in patients infected with Coronavirus disease 2019 (COVID-19). Furthermore, current treatment for COVID-19 infection includes the frequent use of steroids and anticoagulants, both of which predisposes to GIB; hence the risk of GIB in this population should not be overlooked. No literature has reported the actual risk of GIB in COVID-19 patients to date. This meta-analysis investigated whether COVID-19 infection is associated with a higher risk of GIB. Methods: A systematic search of literature databases (Pubmed, Embase, Medline, Scopus, Web of Science, and Cochrane) was conducted from inception to September 2020. Observational studies or clinical trials that reported the occurrence of GIB in COVID-19 patients of age ≥18 years were included. The study protocol was registered in PROSPERO (CRD42020216564).The meta-analyses were performed with random-effect model using STATA software version 15. Meta-regression was used to identify potential moderators. Funnel plot and Egger’s intercept were used to detect potential publication bias. Results: Twelve studies with a total of 9135 participants were included (Table 1). Meta-analysis of proportion estimated the crude occurrence of overall, upper and lower GIB as 3.45 (95% CI 1.83-5.49) %, 2.47 (95% CI 0.60-5.36) % and 1.41 (95% CI 0.84-2.12) % respectively (Figure 1). Meta-regression between the occurrence of GIB and multiple clinical characteristics of the study population found cancer as a potential moderator. Age, gender, comorbidities such as hypertension, diabetes, chronic kidney disease, anticoagulants and steroids use, the mortality of the population were not found to be associated with GIB in COVID-19 patients. Conclusion: The occurrence of overall, upper and lower GIB in hospitalized COVID-19 patients is higher than that of the general population (reported incidence of 0.15%, 0.047%, and 0.033% respectively in the latter group). Our results show that pre-existing cancer increases the risk of GIB in COVID-19 patients. It is postulated that COVID-19 may exacerbate the inflammatory burden of cancer patients, resulting in mucosal breakdown and higher occurrence of GIB. There was no significant association demonstrated between GIB and the use of anticoagulants or steroids in this study.In conclusion, attention should be raised to the elevated risk of GIB in COVID-19 patients, particularly in those with pre-existing cancer.Figure 1.: Meta-analysis of occurrence of GIB in COVID-19 population.Table 1.: Study characteristics of the included studies Abbreviation: No. = number of GIB = gastrointestinal bleeding UGIB = upper gastrointestinal bleeding LGIB = lower gastrointestinal bleeding RT-PCR = reverse transcriptase-polymerase chain reaction ICU = intensive care unit WHO = World Health Organization +ve = positive.

How Safe are Fluoroquinolones for Diabetic Patients? A Systematic Review of Dysglycemic and Neuropathic Effects of Fluoroquinolones.

IntroductionThe US Food and Drug Administration issued safety warnings about neuropathy in 2013 and dysglycemia in 2018 caused by fluoroquinolone use, mainly based on case reports and case series. We conducted this systematic review to evaluate the safety of fluoroquinolones in diabetic patients by investigating their dysglycemic and neuropathic effects.MethodsPubMed, Scopus, and Google Scholar were searched for randomized controlled trials and observational studies published from inception till September 2019 evaluating the safety of fluoroquinolones. Efficacy studies of fluoroquinolones reporting these adverse effects were also included. Primary outcomes were hypoglycemia, hyperglycemia, and neuropathy among patients with or without diabetes and treated with fluoroquinolones compared with placebo or other antibiotics. The Cochrane Collaboration tool for randomized controlled trials and modified Newcastle–Ottawa quality-assessment scale were used for assessment of the included studies.Results and DiscussionA total of 725 studies were identified in the initial search. After screening of titles and abstracts and full-text review, 16 articles fulfilled the inclusion criteria. The sampled patients were aged 30–78 years. Hyperglycemia was reported in 1,588 patients that received fluoroquinolone among eight studies with 4,663 patients, and hypoglycemia was reported in 2,179 patients that received fluoroquinolones among eleven studies with 6,208 patients. Dysglycemia was not generally associated with diabetes mellitus per se. Nevertheless, patients with more comorbidities, especially those with chronic kidney disease, receiving antidiabetics and/or steroids had more glycemic events when treated with fluoroquinolones.ConclusionMoxifloxacin was found to be associated the most and ciprofloxacin the least with dysglycemia. fluoroquinolones must be used with great caution among diabetic patients who have comorbidities and are receiving antidiabetics and/or steroids. Further evidence is required from studies on neuropathy caused by fluoroquinolones.

Estimations of Laryngotracheal Stenosis After Mechanical Ventilation: A Cross-Sectional Analysis.

To estimate the incidence of laryngotracheal stenosis among adults after intubation. Cross-sectional analysis. We used the Nationwide Readmission Database to examine adult patients readmitted within 45 days after admission for mechanical ventilation. Those with a diagnosis of laryngotracheal stenosis or tracheostomy dependence on their index admission were excluded. Patient demographics, associated comorbidities, and intubation lengths were compared among those with and without a diagnosis of airway stenosis at readmission. An estimated 624,918 patients met inclusion with a mean age of 59 years (standard error=0.2). There were 1,230 patients readmitted within 45 days and diagnosed with laryngeal (N=362) or tracheal stenosis (N=920) estimating an incidence of 1.98 per 1,000 discharges. Compared with those without a diagnosis of airway stenosis, those with stenosis were younger (57 vs. 59 years, P < .001), more often female (62% vs. 45%, P < .001) and frequently intubated for >96 hours (47% vs. 32%, P < .001). Additionally, a history of respiratory failure, pneumonia, obesity, gastroesophageal reflux disease, and chronic steroid use were also more common among patients with stenosis. Multiple logistic regression analysis identified a decreased risk of stenosis with advancing age while an increased risk was associated strongest for females (odds ratio [OR]: 1.96, 95% confidence interval [CI]: 1.58-2.44, P < .001) and those with chronic steroid use (OR: 2.69, 95% CI: 1.80-4.02, P < .001). The incidence of laryngotracheal stenosis after intubation in adults is rare but is associated with female gender and younger age. NA Laryngoscope, 132:1723-1728, 2022.

Risk factors of surgical mortality in patients with Clostridium difficile colitis. A novel scoring system.

The purpose of the study is to identify the risk factors of mortality and develop a risk scoring system in patients who underwent colectomy due to Clostridium difficile colitis (CD-C). Patient information was extracted using the American College of Surgeons National Surgical Quality Improvement Program (NSQIP) data from 2012 to 2016. All adult patients who underwent colectomy for CD-C were included in the study. The data were split into training and testing data sets. A multiple logistic regression model was developed by backward deletion methods for risk assessment. To test the performance of the prediction model for 30-day mortality, a receiver operating characteristic (ROC) curve was generated and an area under the curve (AUC) was created. The training data set consisted of 434 (80%) patients, and the testing data set consisted of 91 (20%) patients. The overall mortality was 35%. No significant differences were found between the training and testing data sets for patient characteristics, comorbidities and mortality. The final model of the logistic regression model revealed a highly significant 30-day mortality for an age of ≥ 75years old, ventilator dependency, Septic shock prior to surgery and a history of steroid use. The AUC value was 0.745 (95% CI 0.660-0.826). The risk of mortality scores range from 0 to 37. The highest score of 37 was related to an 83.9% predicted mortality. Older age, septic shock, ventilator dependency requiring supportive care and a history of chronic steroid use were highly associated with mortality. A nomogram showing the scores and their relationship to mortality may provide guidance to point of care physicians for deciding the goal of care. Level of evidence: IV.

Hard bilateral syphilitic testes with vasculitis: a case report and literature review

BackgroundWe report the case of a patient with syphilitic testicular gumma and vasculitis with adrenal failure due to chronic steroid use.Case presentationA 63-year-old male presented with hard right eye swelling and very firm bilateral testes on palpation, which he had for 2 years. Testicular tumor markers were negative; syphilis test was positive. Radiological examination suggested aortitis and bilateral testicular malignancy. The patient received ampicillin for the infection and prednisolone for vasculitis. Left orchidectomy was performed to confirm the presence of testicular tumor; histological examinations revealed granulomatous orchitis. The prednisolone doses were adjusted because of relapses and adverse effects of steroid use. Unfortunately, the patient died in the intensive care unit because of uncontrolled blood pressure and pneumonia.ConclusionsThis is a rare case of syphilis with testicular involvement and vasculitis. This report shows the importance of broadening the differential diagnoses of testicular firmness.

196. Best practice guideline on the assessment and management of osteoporosis in adult patients undergoing elective spinal reconstruction

<h3>BACKGROUND CONTEXT</h3> Poor bone health in patients undergoing reconstructive spine surgery can lead to complications such as vertebral fractures, pseudarthrosis, proximal junctional kyphosis, and instrumentation failure. No guidelines currently exist for the management of osteoporosis and osteopenia in patients undergoing spinal reconstructive surgery. This expert panel was created to establish best practice guidelines to identify and treat patients with poor bone health prior to undergoing elective spinal reconstruction. <h3>PURPOSE</h3> An expert panel to define best practice guidelines for the assessment and management of osteoporosis in patients undergoing elective spinal reconstruction. <h3>STUDY DESIGN/SETTING</h3> Expert panel, consensus study. <h3>OUTCOME MEASURES</h3> Consensus above 70% on final statements. <h3>METHODS</h3> A multidisciplinary panel with 20 experts was assembled including orthopedic and neurological surgeons, endocrinologists, and rheumatologists. Three rounds of surveys and discussions regarding the current literature were held until a final set of guidelines was created with over 70% consensus. <h3>RESULTS</h3> A total of 21 statements were included in the final survey. Bone health should be considered in every patient prior to elective spinal reconstruction. All patients above 65 and those under 65 with particular risk factors (chronic steroid use, high fracture risk or previous fracture, limited mobility, and eight other key factors) should have a formal bone health evaluation prior to undergoing surgery. DEXA scans of the hip are preferable due to their wide availability. Opportunistic CT Hounsfield Units can be useful in identifying poor bone health. Patients with osteoporosis and osteopenia should be appropriately optimized prior to elective surgery. In the absence of contraindications, teriparatide and abaloparatide are considered first-line agents due to their bone building properties as compared to antiresorptive medications such as bisphosphonates. These treatments should be administered preoperatively for at least 2 months and postoperatively for at least 8 months. <h3>CONCLUSIONS</h3> Based on the consensus of a multidisciplinary panel of experts, we propose best practice guidelines for assessment and treatment of poor bone health prior to elective spinal reconstructive surgery. Patients above age 65 and those with particular risk factors under 65 should undergo formal bone health evaluation. We also reached consensus on perioperative optimization, utility of various diagnostic modalities, and the optimal medical management of bone health in this population. We believe that these guidelines will help reduce adverse postoperative outcomes related to bone health <h3>FDA DEVICE/DRUG STATUS</h3> Teriparatide, abaloparatide, bisphosphonates: Approved.

Effect of Steroid Therapy on Growth hormone in Children with Nephrotic Syndrome

Background: Nephrotic syndrome is the most frequent kidney-related condition in the United States today, providing a severe health risk. The cornerstone of therapy is still corticosteroids. Protein deficiency was a major cause of linear growth retardation in nephrotic individuals before steroids were administered. The goal of our research was to see how corticosteroids affected growth hormone in children with nephrotic syndrome. Methodologies: From February to December 2020, a cross-sectional research was conducted on children with nephrotic syndrome who visited the Benha University Nephrology clinic. After receiving written agreement from the patients' parents, the research included 36 patients with nephritic syndrome of both sexes, divided into two groups: corticosteroid response group and corticosteroid plus other immunosuppressive medications group. The following conditions were applied to all of the instances in the study: Growth hormone level in blood was measured after a thorough history, full clinical examination, and laboratory testing. Results: The majority of our NS patients (66.7%) were on corticosteroid medication, while 33.3 percent were on corticosteroid plus immunosuppressive medication, according to our research. Complete remission was 1 (2.8%), steroid dependent was 20 (55.5%), rare recurrence was 3 (8.4%), and corticosteroid resistant was 12 in our research (33.3). According to the findings of the present research, small stature accounted for 15 percent of the cases analysed (41.7 percent ). The G.H distribution in the examined cases was found to vary between 0.04 and 2.80ng/ml, with a mean of 0.76 0.86. The distribution of elicited growth hormone in the examined patients varied from 1.17 to 14.60 (ng/ml), with a mean of 5.28 2.81. According to this research, the distribution of activated growth hormone categories among the analysed patients was as follows: borderline (10.78%), normal (6.17%), and subnormal (20%). (55.6 percent ). There was a statistically significant negative connection between cumulative steroid dosage and mortality in the present trial (growth hormone and provocated Growth hormone). Conclusion: The majority of children with nephrotic syndrome exhibited a height disadvantage. Children with nephrotic syndrome may have growth retardation as a result of chronic steroid therapy. In most instances of NS, growth hormone levels are below normal. Corticosteroid cumulative doses have a negative impact on linear growth.

A Case Report on Mucormycosis in Non-Diabetic, Non-Covid Recovered Patient with no History of Steroid use

Rhino cerebral orbital mucormycosis is an aggressively spreading fungal infection caused by filamentous fungi of the Mucoraceae family and is found to be more prone in patients with comorbidities that include: uncontrolled diabetes mellitus, immune-suppressed patients, iron and aluminum overload, chronic steroid therapy, severe trauma, and protein-energy malnutrition.&#x0D; A 51year old male patient was admitted to the hospital with a complaint of headache and intermittent fever. The patient had no history of diabetes or denovo hypertension. Based on the analysis of histopathological and radiological investigations, the patient was diagnosed with mucormycosis. The patient furthermore underwent an endoscopic surgical debridement followed by standard treatment including antifungal antibiotic(amphotericin-B) and azole antifungals (posaconazole) along with symptomatic treatment. Though the patient was given all possible therapy available, no improvement was seen in the patient's condition (poor prognosis).

Immunotherapy in Special and Rare Situations: A Brief Review.

Immunotherapy has established itself as an important component of the treatment armamentarium against various solid as well as hematologic cancers. Immune checkpoint inhibitors (ICI) provide for a very well-tolerated and efficacious treatment option that has improved survival in several cancers. The approved ICIs mainly consist of antibodies targeting cytotoxic T lymphocyte–associated antigen 4 (CTLA-4) and programmed cell death protein 1 (PD-1) or its ligand, programmed cell death ligand 1 (PD-L1). However, most clinical trials of ICI have excluded patients from high-risk populations, such as those with autoimmune diseases, patients on chronic steroid intake for various reasons or preexisting HIV infections. The older adults are also an underrepresented section of the population enrolled into such trials, most probably due to the higher prevalence of comorbidities and frailty affecting their Eastern Co-Operative Oncology Group performance status, and thus the eligibility for clinical trial enrollment. This paper aimed to briefly review the available evidence and thus guide the decision-making process for use of ICI in such rare and special situations.

Tracheoinnominate Artery Fistula.

This simulation provides training for emergency medicine residents in the stepwise management of a patient who presents with bleeding from a tracheoinnominate artery fistula. Additional learners who might benefit from this simulation are otolaryngology and general surgery residents as well as critical care fellows. Hemorrhage from a tracheoinnominate artery fistula (TIAF) is a rare but life-threatening complication in a patient with a recent tracheostomy. This complication occurs in 0.7% of tracheostomy patients with a mortality of 50-70%.1 Seventy-five percent of patients with a TIAF will present within the first three weeks of surgery and 50% of patients will present with a sentinel bleed that briefly resolves.1 Key elements of a history and exam that should raise a provider's concern for this diagnosis include a recent tracheostomy (within the last 4 weeks), a percutaneous tracheostomy, prior radiation, chronic steroid use, a neck or chest deformity or a sentinel bleed.2 Survival from a TIAF hinges upon emergent, operative repair by an otolaryngologist and cardiothoracic surgeon. Cuff hyperinflation and the Utley Maneuver are critical bedside interventions to temporize this massive bleed and stabilize the patient for definitive, operative repair. By the end of this simulation, learners will be able to: 1) perform a focused history and physical exam on any patient who presents with bleeding from the tracheostomy site, 2) describe the differential diagnosis of bleeding from a tracheostomy site, including a TIAF, 3) demonstrate the stepwise management of bleeding from a suspected TIAF, including cuff hyperinflation and the Utley Maneuver, 4) verify that definitive airway control via endotracheal intubation is only feasible in the tracheostomy patient when it is clear, upon history and exam, that the patient can be intubated from above, 5) demonstrate additional critical actions in the management of a patient with a TIAF, including early consultation with otolaryngology and cardiothoracic surgery as well as emergent blood transfusion and activation of a massive transfusion protocol. This case was written with a modified, low-fidelity manikin, traditionally used for training in nasogastric tube placement and tracheostomy care. We modified this manikin to simulate a hemorrhage from the tracheostomy site.3 The patient in our case had a history of laryngeal cancer, and thus we occluded his larynx for this simulation. As a result of this obstruction, he was unable to be intubated from above. We provided confederates, a bedside nurse and family member, to assist the learners throughout the case. We also utilized a simulation technician to operate dynamic vital signs on a simulated cardiac monitor. It would be technically challenging to adapt this case to a high-fidelity simulator due to potential for damage of the internal electrical elements by the large amount of artificial blood from the tracheostomy tube. However, a mechanical pump provided a useful means of active bleeding in this low-fidelity manikin. We provided a pre- and post-simulation questionnaire for the 33 emergency medicine residents who participated in this simulation. There were 11 residents from each of the PGY-1, PGY-2 and PGY-3 year-groups. Thirty-two residents (97%) completed the pre-survey and 33 residents (100%) completed the post-survey. For our questions, we used a 5-point Likert Scale to assess a resident's knowledge of the learning objectives within this simulation. Responses from our pre- and post- survey indicated a significant improvement in knowledge about a tracheoinnominate artery fistula as well as the general management of tracheostomy complications in the emergency department. This simulation is a useful educational tool for instructing emergency medicine residents on optimal management of tracheostomy emergencies such as a TIAF. The interprofessional teaching by an emergency medicine attending and mid-level (PGY-3) otolaryngology resident allowed for a richer and more detailed discussion during the debriefing. Throughout the case, the emergency medicine attending played the role of a bedside nurse and offered supportive, clinical cues when bleeding recurred. The otolaryngology resident played the role of a family member and offered helpful cues during the history and exam portion of the case. Following the case, both content experts provided useful clinical insight during the debriefing. If staffing availability permits, it might be advantageous to use additional simulation-trained personnel to play the roles of the nurse and family member, thus allowing the emergency medicine attending and otolaryngology content experts to simply view the case from the control room and perform the debriefing. Tracheostomy, surgical airway, tracheoinnominate artery fistula, bleeding from tracheostomy site, complications with tracheostomies, hemorrhagic shock.

Abstract CT208: Phase I Dose Escalation Study of Radiotherapy and Durvalumab (MEDI4736) in Relapsed or Refractory Diffuse Large B-cell Lymphoma (DLBCL): The RaDD Study

Abstract Background: Most DLBCL &amp; FL responds well to first line treatment, yet relapsed disease outcomes are poor. Immune checkpoint inhibition (ICI) with PD/PD1 inhibitors (PD1i) yield high response rates in some lymphomas; though single agent PD1i yields a disappointing ORR of 10% in heavily pre-treated DLBCL, some responses are durable. RT stimulates anti-tumour immunity through several mechanisms and may enhance response to ICI. Concurrent ICI &amp; RT is synergistic in preclinical studies &amp; solid tumours, improving local &amp; distant (abscopal) response. RT to multiple disease sites may broaden the spectrum of tumour antigen release and overcome clonal variation between disease sites to further augment the immune response. A dose-response relationship between RT and antigen release has yet to be established. This phase I dose escalation study aims to determine the safety profile of RT in combination with durvalumab, an anti-PD-L1 monoclonal antibody, in relapsed/refractory DLBCL and FL. Study Design and Methods: RaDD (NCT03610061) is a phase I dose escalation study to determine the safety profile of escalating dose and number of sites of RT in combination with durvalumab in relapsed/refractory (RR) DLBCL &amp; FL. Eligible patients (pts) have received ≥ 1 prior line of therapy and are ineligible for or relapsed after autologous stem cell transplant (auto-SCT). Pts with active autoimmune disease, CNS involvement, prior allogeneic-SCT or chronic steroid use are excluded. RT dose and site escalation proceeds according to a 3+3 design with 6 dose levels (cohorts 1-6). Treatment comprises external beam RT to target site(s) daily for 5 days (Cohorts 1-5); Cohort 6 receives a further 5 daily fractions (max 30Gy). Durvalumab 1500mg IV commences day 2 of RT and continues 4-weekly until disease progression. Pts can continue until a second radiological progression if clinical benefit is ongoing. The dose limiting toxicity period is 28 days from start of RT. The primary endpoint is the toxicity, drug pharmacokinetics, maximum tolerated dose (MTD) and recommended phase two dose (RP2D) of simultaneous RT and durvalumab. Secondary endpoints include response rates, progression-free survival and overall survival. Correlative studies will examine the tumour-immune system interaction; an exploratory PET substudy with novel tracers for durvalumab (89Zr-Durvalumab) &amp; CD8+ T cells (89Zr -Df-IAB22M2C) will also be performed. Projected enrolment for determination of the MTD and RP2D is 6-30 pts pending toxicity. Recruitment will continue to 36 pts for secondary endpoint analysis. 22 pts are enrolled to date in the main study, with 2 patients enrolled in the PET-substudy. Acknowledgements: Victorian Cancer Agency (grant funding - TRP16006), Astra Zeneca (durvalumab and funding), Celgene (funding), Imaginab (89Zr -Df-IAB22M2C). Citation Format: Kate Manos, Richard Khor, Geoffrey Chong, Jodie Palmer, Michael MacManus, Colm Keane, Andrew M. Scott, Jake Shortt, David Ritchie, Leonid Churilov, Laura Johnston, Tom Witkowski, Allison Barraclough, Sze Ting Lee, Wendi Lin, Rachel Koldej, Eliza Hawkes. Phase I Dose Escalation Study of Radiotherapy and Durvalumab (MEDI4736) in Relapsed or Refractory Diffuse Large B-cell Lymphoma (DLBCL): The RaDD Study [abstract]. In: Proceedings of the American Association for Cancer Research Annual Meeting 2021; 2021 Apr 10-15 and May 17-21. Philadelphia (PA): AACR; Cancer Res 2021;81(13_Suppl):Abstract nr CT208.

To Study the Prevalence of Osteopenia and Osteoporosis in Patients with COPD and to Correlate Severity of COPD with Prevalence of Osteopenia and Osteoporosis

Chronic Obstructive Pulmonary Disease (COPD) is a chronic respiratory airway disease characterized by both pulmonary and systemic inflammatory response and associated extra-pulmonary complications. Female gender, age and smoking are common pathogenic risk factors for both COPD and osteoporosis. Many other factors like low daily physical activity, chronic malnutrition, hypogonadism, vitamin D deficiency and chronic steroid therapy are risk factors for osteoporosis. Objectives: The study was done to evaluate the prevalence of osteopenia and osteoporosis in patients of COPD and to correlate the severity of COPD with osteopenia/ osteoporosis. Material &amp; Method: The study was conducted at a tertiary care hospital in Delhi after ethical clearance from institutional review board. Total of 76 patients of both genders were taken. COPD diagnosis and staging was done as per Global Initiative for Chronic Obstructive Lung Disease (GOLD) criteria. Bone mineral density (BMD) was evaluated by DEXA scan in all patients. All data was entered in preformed data sheets. Statistical analysis for association of COPD with osteoporosis was done by chi-square test. Result: Mostly patients were having either osteopenia or osteoporosis, only 6% patients were having normal BMD. COPD stage III-IV were having significant bone mass loss. Those having long smoking history were more osteoporotic as compared to others. Conclusion: There is a very high prevalence of osteopenia and osteoporosis in COPD patients especially those with prolonged smoking history, GOLD stage III-IV. 35.5% of COPD patients had osteopenia and 57.9 % had osteoporosis.

FREQUENCY OF STRESS HYPERGLYCEMIA AND MORTALITY IN PATIENTS WITH HYPERGLYCEMIA IN MEDICAL INTENSIVE CARE UNIT

Objective: To assess the frequency of stress hyperglycemia and mortality in patients with hyperglycemia admitted in medical Intensive Care Unit.&#x0D; Study Design: Cross-sectional study.&#x0D; Place and Duration of Study: Medical Intensive Care Unit, Combined Military Hospital Quetta, from Nov 2018 to Jun 2019.&#x0D; Methodology: A total of 150 adult patients of age between 18-80 years, of both genders, with Intensive Care Unit stay &gt;24 hours, who were treated in medical Intensive Care Unit during study period, were included in the study. Those patients with duration of stay &lt;24 hours, paediatric patients, surgical and pregnant patients and those who were on chronic steroid therapy and those who were given TPN and dextrose infusions were excluded. The blood sugar fasting was measured daily and blood sugar random was measured on admission and twice daily. The patients were segregated into three groups: Normoglycemia, Diabetes mellitus and Stress hyperglycaemia. The frequency of patients and outcome of patients in terms of death was observed in all groups.&#x0D; Results: The mean age of study population was 55.02 ± 18.14 years, with 99 (66%) were males while 51 (34%) were females. Among study population 77 (51.3%) had normoglycemia, 46 (30.7%) had Diabetes Mellitus while 27 (18%) had stress hyperglycaemia. Out of 77 patients with normoglycemia 10 (12.9%) died, while number of deaths in patients with diabetes mellitus and stress hyperglycaemia was 21 (45.6%) and 15 (55.5%) respectively. The mean maximum blood glucose in those who survived and died was 214.39 ± 100.69 mg/dl and 295.26 ± 122.60................

Inflammatory Bowel Disease and Thrombosis: A National Inpatient Sample (NIS) Study

Background: Inflammatory bowel disease (IBD) is a chronic inflammatory disease of the gastrointestinal mucosa, including two disorders, regional enteritis and ulcerative colitis. These disorders are characterized by defective immune regulation, in which T cells in the gastrointestinal mucosa secrete inflammatory cytokines and an inflammatory response that increases venous thromboembolism (VTE) risk, 2-3 times greater than in the general population. The mechanism by which thrombosis occurs and how to identify those at risk remain unclear.Methods: We conducted a cross-sectional analysis of discharge data from the National Inpatient Sample (NIS) between January 1, 2009 and December 31, 2014. The NIS is an all-payer database that approximates a 20% stratified sample of discharges from U.S. hospitals participating in the Healthcare Cost and Utilization Project. Discharges among individuals with and without IBD were evaluated by age, race, gender, primary and secondary diagnoses, demographics, and length of stay. De-identified discharge data were classified by the International Classification of Diseases, Ninth Revision (ICD-9) diagnostic codes for thrombosis, including deep venous thrombosis (DVT), pulmonary embolism (PE); arterial thrombosis and arterial embolism; intra-abdominal thromboses, including portal vein thrombosis, splenic/other vein thrombosis, and mesenteric vein thrombosis; and other thrombosis, including cerebral artery embolism/ thrombosis, intracranial venous sinus thrombosis, retinal vein occlusion; and hepatic vein thrombosis. Discharge-level weights from the NIS database were used to produce estimates representative of all community hospitals in the U.S. Thrombosis prevalence was compared between patients with and without IBD, as were demographics (age, race, gender), length of stay, inpatient mortality, and risk factors for thrombosis (dehydration, malnutrition, ports/catheters, chronic steroid use, malignancy, surgery, trauma, and immobilization). Medical conditions i.e. hypertension, renal failure. Continuous data (e.g. age) were compared by weighted simple linear regression. Categorical data (e.g. gender and risk factors) were compared across groups by the Rao-Scott Χ2 test. Weighted multivariable logistic regression models for thrombosis were fitted to estimate odds ratios and 95% confidence intervals.Results: During the 5-year period 2009-2014, the prevalence of thrombosis in patients with IBD (unweighted N= 374,315) was 7.5%, significantly higher than in non-IBD patients (unweighted N=44,748,771), 4.5%, p<0.001. Individuals with IBD and thrombosis were older than IBD without thrombosis, 57.5 years vs. 50.4 years, p<0.001. The most common types of thrombosis were mesenteric vein thrombosis, 7.4%, PE, 6.5%, DVT 6.2%, and portal vein thrombosis, 2.5%. The most common risk factors for thrombosis included surgery, 53.7%, ports/catheters, 13.2%, malignancy, 13.1%, dehydration, 12.4%, malnutrition, 8.9%, and chronic steroid use, 8.2%, which, except dehydration, were all more common than in IBD without thrombosis, p<0.001. Hypertension, 45.2%, hyperlipidemia, 21.5%, cardiac disease, 16.6%, diabetes, 14.9% and renal failure, 13.6%, each p<0.001, were also more common in those with thrombosis. Severity of illness was higher, 1.42 vs. 0.96, length of stay longer, 7.7 vs.5.5 days, and inpatient mortality higher, 3.8% vs. 1.5%, each p<0.001. After adjusting for age and comorbidity index, risk factors remaining significant for thrombosis included port/catheters, OR=1.73 (CI 1.66,1.81), chronic steroids, OR=1.61 (1.54,1.69), malnutrition, OR=1.34 (1.28,1.41), and malignancy, OR=1.13 (1.08,1.18), each p<0.001, while dehydration, OR=0.86 (0.83,0.90), and Asian race, OR=0.61 (0.52,0.72), each p<0,001, appeared protective against thrombosis.Conclusion: This NIS analysis indicates the prevalence of thrombosis in IBD is 1.7-fold greater than in those without IBD. Even after adjusting for age and severity of illness, the odds of thrombosis in IBD are 73% higher with ports, 61% higher with chronic steroids, 34% higher with malnutrition, and 13% higher with malignancy. These findings suggest the importance of anticoagulation, particularly in IBD patients admitted with ports/catheters, steroids, malnutrition, and/or malignancy and suggest potential benefit if continued long-term in the outpatient setting. DisclosuresRagni:Shire: Consultancy, Honoraria, Research Funding; Sangamo: Research Funding; Alnylam: Consultancy, Honoraria, Research Funding; MOGAM: Consultancy, Honoraria; Bayer: Consultancy, Honoraria, Research Funding; SPARK: Research Funding; NovoNordisk: Honoraria; Bioverativ: Consultancy, Honoraria, Research Funding; Biomarin: Consultancy, Honoraria, Research Funding; Genentech/Roche: Research Funding.

Occurrence and Management of Cataracts in Adult Patients (pts) with Chronic Immune Thrombocytopenia (cITP) during Long-Term Treatment with Eltrombopag (EPAG): Results from the Extend Study

Occurrence and Management of Cataracts in Adult Patients (pts) with Chronic Immune Thrombocytopenia (cITP) during Long-Term Treatment with Eltrombopag (EPAG): Results from the Extend Study

Reduction of Chronic Steroid Use in Patients Discharged for Inflammatory Bowel Disease Flares: A 28-Month Quality Improvement Study

Patients hospitalized with inflammatory bowel disease (IBD) flares are at risk of chronic steroid use when they are discharged without a clear prednisone tapering plan (and steroid-sparing treatment strategy) or gastroenterology follow-up. Our quality improvement (QI) project examines the impact of a new hospital-wide 6-week standardized oral prednisone taper electronic order set.

Factors Associated With Unanticipated Admission After Outpatient Endoscopic Sinonasal Surgery.

To identify factors that may increase the risk of unplanned admission following elective outpatient endoscopic sinonasal surgery (ESS). Retrospective analysis of the National Surgical Quality Improvement Program (NSQIP). All cases of ESS were extracted from the 2010 to 2018 NSQIP database using Current Procedural Terminology codes. Only cases coded as outpatient, elective, and nonemergent procedures were included. Unplanned admissions were defined as cases with a total hospital stay of 1 day or more. Univariate and multivariate analyses were performed to identify variables that independently predicted unanticipated admission. A total of 971 cases met inclusion criteria, of which 274 (28.2%) were unanticipated admissions. Patients in the unplanned admission group were more likely to be older (46.8 vs. 41.1 years, P < .001), male (57.7% vs. 48.4%, P=.009), obese (54.8% vs. 43.8%, P=.003), and have hypertension (35.0% vs. 25.0%, P=.002). Unplanned admitted patients were also more likely to be included under American Society of Anesthesiologists (ASA) classification III-IV (43.1% vs. 27.2%, P < .001). There were no significant differences in race, smoking, diabetes, or chronic steroid use. Unplanned admitted patients had a higher rate of surgical complications (2.9% vs. 1.0%, P=.041). Upon multivariate analysis, independent preoperative risk factors for unplanned admission included age (OR: 1.018, P=.002), male gender (OR: 1.415, P=.025), obesity (OR: 1.527, P=.008), and ASA III-IV (OR 1.501, P=.018). Factors independently associated with unplanned admission following outpatient ESS were older age, male gender, obesity, and higher ASA. Identification of patients at risk may reduce unanticipated hospital admission after ESS. 4 Laryngoscope, 132:518-522, 2022.