Complete Panel Research Articles

Abstract 11378: Spontaneous Esophageal Hematoma in Chronically Anticoagulated Atrial Fibrillation

Introduction: Intramural esophageal hematoma is a rare condition presenting with dysphagia, nausea and mid epigastric or retrosternal chest pain. We present a unique case of spontaneous esophageal hematoma in a patient anticoagulated with apixaban for atrial fibrillation. Case presentation: An 88-year-old woman with history of hypertension, hypothyroidism, persistent atrial fibrillation on apixaban presented to emergency department with sudden onset epigastric pain, dysphagia and nausea without vomiting while having dinner. Physical examination was unremarkable except for mild tenderness in the epigastric region. Initial workup including complete blood count, complete metabolic panel, lipase, troponin was unremarkable. EKG showed atrial fibrillation with no ischemic changes. CT chest showed abnormal hyperdense mass-like thickening approximately 4 x 3 x 12 cm involving the mid/distal thoracic esophagus with possible differentials being food bolus, esophageal hematoma or mass. Prothrombin complex concentrate (Kcentra) was given as patient was on apixaban and gastroenterology was consulted for upper endoscopy which showed a large hematoma occupying most of the esophageal lumen at the entire length of esophagus. After family discussion on stroke-versus-bleeding risk with anticoagulation, cardiology recommended holding anticoagulation for at least a month and future evaluation for WATCHMAN device. With stable hemoglobin and gradual advancement to a soft diet, patient was discharged home with repeat endoscopy planned in two weeks. Conclusion: Spontaneous esophageal hematoma, although rare in incidence, should be identified as a differential diagnosis in a patient on anticoagulation presenting with chest pain. Literature shows a higher incidence of this complication in women. Timely diagnosis and management along with discontinuing anticoagulation can significantly lower morbidity and mortality and overall has favorable prognosis.

ODP183 Diabetic Ketoacidosis Precipitated by Ketogenic Diet and SGLT-2 Inhibitor Use in an Individual with T2DM

Abstract Background SGLT-2 inhibitors have been associated with increased risk of ketoacidosis even with normal blood glucose levels. A ketogenic diet is a low-carb, high-fat diet which has recently gained popularity for weight loss by producing a state of ketosis. We present this case to emphasize the risk of ketoacidosis in patients on SGLT-2 inhibitors and a ketogenic diet. Clinical Case A 48-year-old woman with a 16-year history of T2DM presented to the ER with a 3-day history of upper abdominal cramping and headaches, decreased urine output, and progressively worsening nausea and vomiting. Her glycated hemoglobin level was 9.4% (n: 4-6%) and her blood glucose readings were not elevated during this time. Other medical issues include dyslipidemia, transaminitis and hypertension. She does not smoke or drink alcohol. She takes glimepiride 0.5 mg daily and canagliflozin was added approximately 1.5 weeks prior to presentation. She was on a ketogenic diet. A few days prior to these symptoms she was in the process of moving out of her home, spending long days physically exerting herself. On exam she was in mild distress with dry mucous membranes. Vitals showed tachycardia (119BPM) but otherwise were stable. Labs revealed that she was severely acidotic with an anion gap of >27 and pH < 6.9 (n: 7.34-7.43), with urinalysis positive for ketones (2+, n: negative), protein (3+, n: negative), and glucose (3+, n: negative). Complete blood count showed leukocytosis (WBC: 18,000, n: 4. 00-12. 00*10 3 /mcL). Complete metabolic panel showed hyponatremia (130, n: 136-145mmol/L), elevated glucose (305, n: 70-99,g/dL), and low bicarbonate (<5, n: 22-30mmol/L). A chest X-ray, lumbar puncture and CT of head and abdomen were unrevealing. She was admitted to the ICU for treatment of suspected DKA with severe acidosis and hypovolemia. She was hydrated with IV fluids and was started on an insulin drip according to DKA protocol. Her anion gap closed in 22 hours. The patient spent 3 days in the ICU and 1 day on general floor before discharge on home medications and was advised to follow up with endocrinology. At follow up 2 months later her C-peptide was 2.14 (0.78-5.19 ng/mL) and GAD65 antibody assay was 0. 00 (<0. 02 nmol/L), the SGLT-2 inhibitor was discontinued, and she was instead started on a GLP-1 agonist. Conclusion The mechanism behind DKA with SGLT-2 inhibitor use involves glycosuria and volume depletion, lowering the insulin-to-glucagon ratio, while stimulating lipolysis. The addition of a low carbohydrate or ketogenic diet produces a state of ketosis as fat is utilized for energy and ketones are produced, further promoting DKA. With increased use of SGLT-2 inhibitors in patients with and without diabetes mellitus extreme caution should be exercised in prescribing SGLT-2 inhibiters in a patient on a low carbohydrate diet. Presentation: No date and time listed

POSTSURGICAL ACUTE GENERALIZED EXANTHEMATOUS PUSTULOSIS: TIMING IS EVERYTHING

<h3>Introduction</h3> Acute generalized exanthematous pustulosis (AGEP) is a severe cutaneous adverse reaction commonly caused by antibiotics. <h3>Case Description</h3> A 62-year-old male was evaluated for a painful and burning pustular eruption three days after a hip arthroplasty. Medication timeline was notable for intraoperative (3 days prior) receipt of cefazolin, dexamethasone, hydromorphone, ropivacaine, and tranexamic acid. Two days prior, he received oxycodone, ondansetron, omeprazole, sennosides, and dexamethasone. One day prior to presentation he received meloxicam and aspirin. Physical examination revealed confluent erythema studded with pinhead-sized sterile pustules on the bilateral thighs, under arms (Figure 1A), and trunk. Complete blood count with differential showed mild neutrophilia (7.59; ref 1.56-6.45 × 10⁻⁹/L) and a complete metabolic panel was within normal limits. Histopathology of a punch biopsy from the right thigh revealed subcorneal pustules with epidermal spongiosis, mild papillary dermal edema and a mixed perivascular infiltrate (Figure 1B) consistent with AGEP. He was instructed to avoid all beta-lactams, non-steroidal antiinflammatory agents (NSAIDs), and steroids. The eruption completely resolved within 10 days of avoidance measures and antihistamines. There were plans to perform patch testing to cefazolin, prednisone, and dexamethasone. Unfortunately, the patient was lost to follow-up. <h3>Discussion</h3> AGEP is diagnosed clinically and confirmed by a skin biopsy. Patch testing may be utilized to evaluate for the culprit agent; but when this is not available, the timeline between medication exposure and index reaction may aid in causal agent identification. The median time from exposure to onset of AGEP is 1 day for antibiotics versus 11 days for all other medications.

35. The development, testing, and validation of an automatic LIMS import method for NGS myeloid panel results

For oncology genetic testing, there is a critical need for patient results to be readily available and accessible for the ordering pathologist's review. After an initial genetic testing workup, emergency treatment or follow-up testing may be required, thus accessibility of results is a key feature in providing patient-focused laboratory testing. Ideally, genetic testing results would be incorporated into a LIMS data management system in order to have a permanent record of testing and to allow for the results to be easily accessible, searchable, and transferable by the clinical or pathology team working on behalf of the patient. For maximum impact, Next Generation Sequencing (NGS) reports should be electronically integrated into the patient's electronic health record. NGS reports uploaded as PDF attachments constrain health record searches. Additionally, data in PDF reports often are not able to be transferred to a comprehensive pathology report and may require cumbersome manual entry. Our team has recently completed a project to create an automatic import method for our Myeloid Complete NGS Panel report into our electronic patient data management system. Our data management system is interfaced with our client's LIMS platform enabling the direct and automatic transfer of orders coming in as well as delivery of the resultant NGS report into the patients' health records. We will present the steps taken to create, test, troubleshoot, and validate the automatic upload system. We will also detail critical components of the NGS LIMS report and challenges that were addressed during this project.

A discrete de Rham method for the Reissner–Mindlin plate bending problem on polygonal meshes

In this work we propose a discretisation method for the Reissner–Mindlin plate bending problem in primitive variables that supports general polygonal meshes and arbitrary order. The method is inspired by a two-dimensional discrete de Rham complex for which key commutation properties hold that enable the cancellation of the contribution to the error linked to the enforcement of the Kirchhoff constraint. Denoting by k≥0 the polynomial degree for the discrete spaces and by h the meshsize, we derive for the proposed method an error estimate in hk+1 for general k, as well as a locking-free error estimate for the lowest-order case k=0. The theoretical results are validated on a complete panel of numerical tests.

Those who need it the most get it the least: Age specific reciprocal effects between social support and mental strain

Socioemotional selectivity theory and models of lifespan development of resources suggest that older workers may particularly benefit from social resources so as to maintain their well-being throughout their work-life span. However, the age-differential effects of social support at work have been rarely investigated. We hypothesised that age moderates the effects of colleagues' and supervisors' social support on mental strain, with strongest effects for older workers. A two-wave complete panel design (six months' time lag) was used. Self-reports from N = 334 nurses (age: 21–63 years) were gathered with established questionnaires: strain was measured by means of the irritation scale; social support from colleagues and supervisors by using a German adaptation of the social support scales. We proved factorial validity and measurement invariance across time points (CFA) and computed path models (SEM). As expected, age moderated the negative longitudinal effects of colleagues' social support on mental strain. Older nurses (≥45 years) benefited the most from colleagues' social support. However, mental strain in older nurses was associated with reduced social support from colleagues. Surprisingly with middle-aged nurses (35–44 years) an increase in colleagues' social support resulted in higher mental strain. No effects for supervisor support were observed. Results indicate that social support by colleagues is an important resource for older workers, but older workers are less likely to receive social support when mental strain is present. Moreover, the timing of social support across the work lifespan seems to be critical, as it might have detrimental effects in middle-aged workers.

Inflation Forecasts and European Asset Returns: A Regime-Switching Approach

Considering market-based inflation expectations, we show that investors’ forecasts are non-linear. We capture this non-linear behavior with a Markov-switching model that allows us to identify a regime of high uncertainty, and a regime of low uncertainty and low concern about inflation. Using a complete cross-asset panel of equity sectors, bonds, and commodities, we perform regressions in both regimes including several control variables, and show that the exposure of European assets returns to implied inflation is regime-dependent. We show that inflation-indexed government bonds and oil are the best way to get exposure to slow upward revisions of future inflation that correspond to periods of rallying inflation. We thus identify alternatives to hedge oneself against revisions in inflation forecasts when inflation is considered as a variable of interest by market participants, which, in fact, corresponds to periods of breaks in the trend of realized inflation. In particular, we provide empirical evidence that some equity sectors exhibit good inflation-hedging properties.

Gastrointestinal Neuroendocrine Tumours: A Single-Centre Experience

Abstract Objectives Gastrointestinal neuroendocrine tumours (GI-NETs) are actually malignant tumours, and their most common location of metastasis is the liver. In this study, we define the epidemiologic features of NETs and investigate the demographic factors, clinicopathologic features, survival, and the oncologic results related to GI-NETs. Materials and Methods In this 10-year study (2009–2019), all GI and liver NETs were taken out from the pathology records. When classification based on the WHO classification criteria, patients were categorized based on their location, sex, age, and proliferative index. After studying clinical charts of GI-NET cases, a complete panel of IHC markers such as Chromogranin A, ‘Ki67’ and synaptophysin were used. Results: Based on published data, the liver is not a common primary site for NETs; most liver lesions are most likely to have been metastases. The mean age of patients at diagnosis was 52.72 years. In this research, 27.78% of patients had colon NETs and 27.78 liver. Two (11.11%) patients were classified as stage II, seven (38.89%) as stage III, and one (5.56%) as stage IV. After a 120-month follow-up, 13 (72.22%) patients with colorectal NETs were alive, and 5 (27.78%) of the patients had died. Conclusion Treatment of colon and rectal NETs is difficult because it affects the patient's initial site of involvement, and this often makes treatment difficult for the patient. With suitable management, the prognosis can be positive with long survival, but it is related to the tumour variation grade, the efficiency of the selected treatment, and also to the patient's adherence to the follow-up.

Using the Electronic Medical Record to Increase Laboratory Test Monitoring in Ocular Inflammation Patients: A Quality Improvement Study.

Treatment of chronic, noninfectious ocular inflammation includes corticosteroids, disease-modifying antirheumatic medications, and biologics. To mitigate adverse effects associated with the use of these medications, routine laboratory test monitoring is recommended throughout treatment. We evaluated the effectiveness of an alert added to the electronic medical record (EMR) to aid in laboratory test monitoring for patients prescribed these high-risk medications. A prospective, interventional study assessed the effect of the alert within the EMR on laboratory test ordering at the Division of Ocular Immunology at the Wilmer Eye Institute. The primary outcome measure was the change in number of ordered laboratory tests at 3, 6, and 12 months after the alert activation compared with pre-intervention levels and overall through the study period. The laboratory tests that were monitored included complete blood count, comprehensive metabolic panel, dual-energy x-ray absorptiometry (DXA) scanning, fasting lipid panel, and interferon gamma release assays. The laboratory test orders for 153 patients on high risk medications were analyzed. Only the frequency of ordering the DXA and interferon gamma release assays increased significantly, compared with baseline, throughout the study. Conversely, there was a significant decrease in the frequency of ordering of fasting lipid profiles and hemoglobin A 1c at each time point and for complete blood count and comprehensive metabolic panel at the 6-month time point. An EMR alert results in increased laboratory test ordering initially for tests drawn on a yearly basis, but the effect on more frequently ordered tests wanes with time if the alert can be silenced by the provider. Nonetheless, it provides a novel mechanism to increase laboratory ordering in patients on high-risk medications that can be adapted for use in other EMR software. Future studies are needed to assess whether physician laboratory test ordering behavior is altered throughout the study period with the use of a non-silencable alert.

Cardiometabolic predictors of quantitative high-risk plaque features in a diverse patient population

Abstract Background/Introduction Little is known about the prevalence of high-risk plaque features or cardiometabolic predictors in diverse patient populations with underrepresented minorities, in the setting of stable chest pain. Purpose The goals of our study are to 1) describe plaque characteristics in a diverse patient population with underrepresented minorities and 2) characterize cardiometabolic risk factors associated with high prevalence of high-risk quantitative low attenuation noncalcified plaque (LDNCP) burden. Methods Our study included patients with chest pain undergoing CCTA between June 2016 and October 2021 for stable chest pain, who had a complete cardiometabolic panel including lipoprotein(a) and lipid panel, and at least one blood pressure recording before CCTA. Patients with prior PCI or CABG where excluded. CACS was performed before CCTA as per Agatston method and quantified in Agatston Units (AU). Stenosis was graded as per SCCT guidelines by cardiologists and radiologists with level 3 cardiac CT expertise. Plaque measurements were performed using previously validated semiautomated software (AutoPlaque version 2.5) in all patients with CAD-RADS &amp;gt;0 by expert readers blinded from patients' characteristics. Coronary atherosclerotic plaque volumes were measured. Independent predictors for plaque on CCTA among patients were examined using Wilcox multivariate logistic regression. Results A total of 227 consecutive patients were included in our study (see table; age 55.00 [47.50–62.00] years, 63% female, 16% diabetes, 44% hypertension, 40% hyperlipidemia and 32% with current or previous smoking history). Majority of patients were Hispanic (64%) and the rest were Black (27%), White (6%) and Asian (3%). Patients with LDNCP burden &amp;gt;4% were older (60.00 [52.00–66.50] vs 53.00 [43.75–61.00]; p&amp;lt;0.001), more likely to be diabetic (27.7 vs 11.5%; p=0.005), hypertensive (67.7 vs 33.8%; p&amp;lt;0.001), hyperlipidemic (64.6 vs 29.9%; p&amp;lt;0.001) and present smokers (31.3 vs 13.9%; p=0.003). Almost all patients (63/67) with LDNCP burden &amp;gt;4% had non-obstructive disease (CAD-RADS&amp;lt;4). Patient with LDNCP burden &amp;gt;4% were more likely to be on statin therapy (46.0 vs 30.4%; p=0.041). There was no differences in ethnicity, hemoglobin A1C, TC, LDL-C, HLD-C, TGs, lipoprotein(a), SBP or DBP. By logistic regression analysis, age (OR [CI]: 1.06 [1.01–1.08]), hypertension (2.20, [1.06–4.63]) and hyperlipidemia (2.73 [1.37–5.47]) increased the likelihood of LDNCP burden &amp;gt;4%, but not Lipoprotein (a)&amp;gt;175 nmol/L (OR [CI]: 1.07 [0.48–2.31]. Conclusions In our cohort of patients with high number of unrepresented minorities presenting with stable chest pain, almost all patients (94%) with LDNCP burden &amp;gt;4% had non-obstructive CAD (CAD-RADS&amp;lt;4). There were no differences in prevalence of LDNCP or CAD-RADS among different ethnic groups. Age, hypertension and hyperlipidemia, were the cardiometabolic factors related to LDNCP burden &amp;gt;4%. Funding Acknowledgement Type of funding sources: None.

SEVERE COVID-19 COMPLICATED WITH HEMOPHAGOCYTIC LYMPHOHISTIOCYTOSIS: A CASE REPORT

SEVERE COVID-19 COMPLICATED WITH HEMOPHAGOCYTIC LYMPHOHISTIOCYTOSIS: A CASE REPORT

DASATINIB-INDUCED CHYLOTHORAX: A RARE CASE REPORT OF A 50-YEAR-OLD MAN WITH CHRONIC MYELOID LEUKEMIA

DASATINIB-INDUCED CHYLOTHORAX: A RARE CASE REPORT OF A 50-YEAR-OLD MAN WITH CHRONIC MYELOID LEUKEMIA

Extra-Kidney Mass

A 64-year-old man with hypertension (156/76 mm Hg) without associated tachycardia was admitted to our hospital for a 1-week history of left-sided loin pain. Routine blood work indicated that hemoglobin was 10.3 g/dL and the ratio of neutrophil-to-lymphocyte (NLR) was 4.9. Complete metabolic panel and serum catecholamines were normal. Computed tomography (CT) revealed a round soft tissue mass measuring 55 × 45 × 35 mm located beside the left renal hilum and 10 mm away from the celiac trunk. 2 renal hilum lymph nodes were visible.

S3673 Successful Non-Surgical Management of Emphysematous Gastritis: A Rare Diagnosis

Introduction: Emphysematous gastritis (EG) is a rare condition characterized by the presence of gas within the gastric wall in association with clinical sepsis. This uncommon entity has a high mortality rate, and early diagnosis and treatment are essential to prevent progression of this potentially fatal condition. Here we describe a rare case of EG in a middle-aged female presenting with diffuse abdominal pain and vomiting. By providing the clinical course and presentation of this rare disease, we can help guide future clinician understanding and management of EG. Case Description/Methods: A 64-year-old female with no pertinent gastrointestinal history presented to the emergency department with a one-week history of generalized abdominal pain and non-bloody emesis. On arrival, she was tachycardic with a heart rate of 112 beats per minute but was otherwise hemodynamically stable and afebrile. Physical examination was significant for diffuse tenderness to palpation in all four abdominal quadrants. Initial complete blood count revealed a white blood cell count of 14,100 per microliter of blood and complete metabolic panel revealed no abnormal values. Abdominal and pelvic computed tomography showed air within the wall of the gastric body and gastric fundus with findings most consistent with emphysematous gastritis. The patient underwent treatment with bowel rest, intravenous fluid resuscitation, a proton-pump inhibitor, and broad-spectrum antibiotic therapy. Her symptoms gradually improved, her diet was advanced, and she was discharged without complaints (Figure 1). Discussion: Emphysematous gastritis is a rare, but potentially fatal condition caused by gas-forming microorganisms with a mortality rate of 55-61%. Due to its rarity, no guidelines have been established for the management of EG. However, early diagnosis and initiation of conservative medical management has been shown to reduce mortality and the need for surgical intervention. Surgical exploration is reserved for patients who demonstrate signs of clinical deterioration, perforations, peritonitis, uncontrolled disseminated sepsis or who have failed optimal medical management. Here we describe a case of EG in a female presenting with manifestations of sepsis that was treated successfully with conservative medical management. This case report adds to the limited literature on the clinical course and treatment of this rare disease by supporting the notion that surgical intervention may be foregone if the patient is stabilized and medical management is successful.Figure 1.: Abdominal and pelvic computed tomography without contrast showing air within the wall of the gastric body and gastric fundus representative of emphysematous gastritis.

S1993 Chilaiditi’s Sign

Introduction: Chilaiditi’s sign refers to the incidental radiographic finding of large bowel interposed between the diaphragm and the liver. This finding can frequently be mistaken as pneumoperitoneum, a finding that is often thought of as a surgical emergency. In the following case, we describe a patient who was found to have Chilaiditi’s sign on computed tomography (CT) imaging. Case Description/Methods: A 75-year-old male with history of bladder cancer status post resection 6 days prior presented to the emergency room for lower abdominal pain and hematuria. He denied having any nausea, vomiting, or changes in bowel habits. Except for a hemoglobin of 12.6 g/dL, basic laboratory testing including a complete blood count and comprehensive metabolic panel was within normal ranges. Physical examination revealed suprapubic tenderness but was otherwise unremarkable. To further evaluate his symptoms, a CT of the abdomen and pelvis was performed, revealing a hematoma in the bladder wall and the appearance of free air under the diaphragm. However, upon further inspection, the air was noted to be within the lumen of a segment of colon which was interposed between the liver and the diaphragm (Figure), consistent with Chilaiditi’s sign. This was thought to be an incidental finding, and the patient was referred to urology for further management of his bladder cancer. Discussion: Chilaiditi’s sign, or hepatodiaphragmatic interposition of the colon, is a rare radiological finding with a reported incidence of 0.025% to 0.28%. Due to air frequently found in the colon, patients with this condition can appear to have pneumoperitoneum due to the colon being near the diaphragm in an abnormal location. The finding is more common in males, older patients, and patients with dolichocolon, chronic lung disease, liver disease, or ascites. Although the cause of this condition is not clearly understood, absence or laxity of the ligament supporting the transverse colon or the falciform ligament is thought to contribute to this condition. Patients with this finding are generally asymptomatic and do not require any treatment. In rare cases, the finding is associated with clinical symptoms, such as abdominal pain, nausea, vomiting, and constipation; in these circumstances, the condition is termed Chilaiditi’s syndrome.Figure 1.: Interposition of a stool-filled transverse colon between the liver and right hemidiaphragm.

Rare Cause of Arrhythmia and Seizures in a Late-Preterm Newborn

Rare Cause of Arrhythmia and Seizures in a Late-Preterm Newborn

S2078 Multicentric, Synchronous Colon Cancer in the Rectum, Sigmoid and Cecum in an Elderly Female

Introduction: Multicentric tumors are more common in genetically-linked cancers. In most instances, tumor occurrence in a different location is due to recurrence of the malignancy. Our case illustrates a rare endoscopic finding of 3 distinct and synchronous adenocarcinomas of the rectum, sigmoid colon, and cecum in an otherwise healthy elderly female at an average risk for colorectal cancer. Case Description/Methods: An 81-year-old female with no medical history presented to the hospital with constipation and diffuse intermittent abdominal pain for 4 months. She had been self-medicating at home with over-the-counter laxatives but recently reported that she was not experiencing relief. She denied any prior endoscopy or family history of colorectal cancer. On admission, her vital signs were normal and her physical exam was significant for diffuse abdominal tenderness to palpation. Digital rectal examination revealed a non-tender, hard mass in the left lateral wall of the rectum. Her complete blood count and comprehensive metabolic panels were normal. Iron studies were also unremarkable. A computed tomography (CT) scan of the abdomen and pelvis showed thickening in the sigmoid colon and the rectum with scattered subcentimeter lymph nodes. On colonoscopy, she was found to have 3 partially-obstructing, malignant-appearing lesions located in the rectum, proximal sigmoid, and cecum. Biopsies of all 3 sites revealed adenocarcinoma. Immunohistochemistry for DNA mismatch repair proteins (MMR) showed intact MLH1, MSH2, MSH6, PMS2 genes. She underwent a laparoscopic total colectomy with end ileostomy, with pathological staging revealing pT3 N0 for the sigmoid tumor and pT4a N2b for the cecal tumor. She was planned for neoadjuvant chemoradiation therapy in anticipation for future robotic proctectomy for treatment of the rectal tumor (Figure 1). Discussion: Synchronous colorectal cancers pose a distinct challenge in terms of management and treatment. The extent of surgical resection and the use of chemoradiation depends on the location, number of lesions, and lymph node involvement. Our patient was an interesting case as she presented later in life and her only symptom was constipation. She was an average risk patient, had otherwise normal labs, and HNPCC/lynch syndrome-related cancers were excluded on the basis of normal immunohistochemistry testing.Figure 1.: Partially-obstructing malignant lesions in the (A) rectum, (B) proximal sigmoid, and (C) cecum.

S3242 A Case of Isolated Hepatic Tuberculosis in an Immunocompromised Patient

Introduction: Primary hepatic tuberculosis is a rare clinical entity with non-specific clinical and imaging features that can mimic other liver diseases, presenting a diagnostic challenge. We present a case of a patient with human immunodeficiency virus/acquired immunodeficiency syndrome (HIV/AIDS) who developed fevers of unknown origin and elevated liver enzymes. Liver biopsy was key to diagnosis as it revealed necrotizing granulomas consistent with tuberculous hepatitis. Case Description/Methods: The patient is a 54-year-old female with uncontrolled HIV/AIDS (CD4 6/1%) who presented with fever, encephalopathy, and abdominal pain. She was febrile to 38, tachycardic to 103, blood pressure 144/115, 96% on room air. She was ill-appearing, altered, nonverbal, with epigastric and lower abdominal tenderness on exam. Complete metabolic panel, complete blood count, lipase, and lactic acid were all within normal limits on presentation. CT of the abdomen and pelvis was unrevealing. On admission, she was found to have community acquired pneumonia, a urinary tract infection, a pulmonary embolism, and HIV-associated neurocognitive disorder. She was started on antiretrovirals and improved until she developed fevers of unknown origin and newly elevated liver enzymes (aspartate transaminase 400s, alanine aminotransferase 300s, alkaline phosphatase 1200s, total bilirubin 12.4, direct bilirubin 7.1) over the course of her prolonged hospitalization. A hepatic workup was largely unrevealing for etiology. Hepatitis panel, drug panel, cytomegalovirus, and Epstein-Barr virus were all negative. Autoimmune workup was weakly positive for anti-nuclear and anti-smooth muscle antibodies, but these were felt to be clinically insignificant due to low titers. The patient was also trialed on intravenous steroids with little improvement, further arguing against the diagnosis of autoimmune hepatitis. Liver biopsy revealed lobular necrotizing granulomas with scattered histiocytes and lymphocytes, consistent with tuberculous granulomatous hepatitis. She started tuberculosis therapy and tolerated it well. Discussion: Primary hepatic tuberculosis with no clinical extrahepatic manifestations is a rare presentation and sporadically reported in the literature. This clinical case highlights the diagnostic difficulty of hepatic tuberculosis, which should be considered in immunocompromised patients with elevated liver enzymes and unrevealing initial workup. Liver biopsy is essential for diagnosis.Figure 1.: a) Lobular necrotizing granuloma; b) Center of necrotizing granuloma with histiocytes (black arrow) and lymphocytes (blue arrow).

Outcomes of Gene Panel Testing for Sensorineural Hearing Loss in a Diverse Patient Cohort

A genetic diagnosis can help elucidate the prognosis of hearing loss, thus significantly affecting management. Previous studies on diagnostic yield of hearing loss genetic tests have been based on largely homogenous study populations. To examine the diagnostic yield of genetic testing in a diverse population of children, accounting for sociodemographic and patient characteristics, and assess whether these diagnoses are associated with subsequent changes in clinical management. This retrospective cohort study included 2075 patients seen at the Children's Communications Clinic, of whom 517 completed hearing loss gene panel testing between January 1, 2015, and November 1, 2021, at the University of California, San Francisco Benioff Children's Hospital system. From those 517 patients, 426 children with at least 2 audiograms were identified and analyzed. Data were gathered from November 2021 to January 2022 and analyzed from January to February 2022. The measures of interest were sociodemographic characteristics (age at testing, gender, race and ethnicity, primary language, and insurance type), hearing loss characteristics, and medical variables. The outcome was genetic testing results. Variables were compared with univariate and multivariable logistic regression. Of the 2075 patients seen at the Children's Communications Clinic, 517 (median [range] age, 8 [0-31] years; 264 [51.1%] male; 351 [67.9%] from an underrepresented minority [URM] group) underwent a hearing loss panel genetic test between January 1, 2015, and November 1, 2021. Among those 517 patients, 426 children (median [range] age, 8 [0-18] years; 221 [51.9%] male; 304 [71.4%] from an URM group) with 2 or more audiograms were included in a subsequent analysis. On multivariable logistic regression, age at testing (odds ratio [OR], 0.87; 95% CI, 0.78-0.97), URM group status (OR, 0.29; 95% CI, 0.13-0.66), comorbidities (OR, 0.27; 95% CI, 0.14-0.53), late-identified hearing loss (passed newborn hearing screen; OR, 0.27; 95% CI, 0.08-0.86), and unilateral hearing loss (OR, 0.04; 95% CI, 0.005-0.33) were the only factors associated with genetic diagnosis. No association was found between genetic diagnosis yield and other sociodemographic variables or hearing loss characteristics. Patients in URM and non-URM groups had statistically similar clinical features. A total of 32 of 109 children (29.4%) who received a genetic diagnosis received diagnoses that significantly affected prognosis because of identification of syndromic or progressive sensorineural hearing loss or auditory neuropathy spectrum disorder relating to otoferlin. This cohort study's findings suggest that genetic testing may be broadly useful in improving clinical management of children with hearing loss. More research is warranted to discover and characterize diagnostic genes for those who have been historically underrepresented in research and medicine.

Multiscale warpage behaviour in a Fan-Out Panel during thermal cycles

In this work, the warpage of a panel in the context of fan-out packaging is analysed. On a panel size of 300 × 300 mm2 a die layout is molded and debonded from the temporary carrier. The resulting warpage is characterised temperature dependent using the Projection Moiré technique globally across the complete panel and locally on the scale of few dies. Globally, results are analysed with respect to the shape change of the warpage and residual warpage after thermal cycling. Locally the curvature of single dies is compared to the global curvature of the tunnel shaped warpage. This work is part of the investigations with the aim to describe and control the warpage effects in Fan-Out Panel Level Packaging.