Constitutional Signs Research Articles

Childhood lupus emergency presentation: Is early treatment justified: A case series

Juvenile systemic lupus erythematosus is a multisystem disorder of autoimmune aetiology and is diagnosed on the basis of criteria such as the constitutional symptoms, various symptoms, and signs related to multi-system involvement and supporting laboratory investigations. It is sometimes very challenging when we come across some JSLE cases with an atypical presentation or as a catastrophe. We have discussed a few atypical cases of systemic lupus erythematosus here. Definitive diagnostic tests such as the anti-nuclear antibody with a high negative predictive value and other diagnostic tests would take time and it is worth starting treatment rather than waiting for the investigations in some cases. This case report study is to sensitise the treating paediatrician to use clinical acumen to plan meticulously the management of JSLE cases.

Genre of literary epitaph in Tabasaran poetry

The article is devoted to the study of the genre of literary epitaph in Tabasaran poetry. In the water part, which has a theoretical character, the difference between the cemetery and literary epitaph is shown, the constitutional signs of two genre varieties are revealed, the degree of mastering of the genre in the literatures of the peoples of Dagestan is stated. In the main part of the work, the thematic, structural and compositional analysis, as well as the analysis of the subjective organization of the texts of the Tabasaran literary epitaph were carried out on the material of the poetic texts of poets G. Hajiyev and R. Ramazanov. The author comes to the conclusion that the literary epitaph in Tabasaran poetry has an edifying and satirical character; it condemns the actions and qualities of people who contradict the national ideal of a woman, mother, highlander — adultery, violence against people, selfishness and indifference, depravity and perseverance in committing sins. Also in the epitaphs, the problems of retribution for earthly life, gratitude are raised.

The Burden of Cardiovascular Diseases Due to COVID-19 Pandemic.

The coronavirus disease 2019 (COVID-19) is an infection caused by the severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2) that produces respiratory symptoms and has serious consequences for people's cardiovascular systems (CVS). It is a severe issue and a major task not only for health care experts but also for governments to contain this pandemic. SARS-CoV-2 is the seventh member of the human coronavirus family to be implicated in this zoonotic outbreak. COVID-19's CV interactions are comparable to those of SARS-CoV, Middle East respiratory syndrome (MERS-CoV), and influenza. Those who have COVID-19 and underlying cardiovascular diseases (CVDs) are at a higher risk of serious illness and mortality, and disease has been linked to several direct and indirect CV consequences. COVID-19 causes CVDs such as arrhythmias, cardiac arrest, cardiogenic shock, myocarditis, stress-cardiomyopathy, and acute myocardial damage (AMD) as a consequence of acute coronary syndrome. The provision of CV care may expose health care professionals to risk as they become hosts or vectors of viral transmission. It binds to the angiotensin-converting enzyme receptor, causing constitutional and pulmonary signs in the beginning, and then as the infection advances, it affects other organs such as the gastrointestinal tract, CVS, neurological system, and so on. COVID-19 mortality is increased by underlying CVDs comorbidities.

A Descriptive Case Series Study from 2009 to 2019 and a Brief Review on Takayasu’s Arteritis Patients in Arak

Background: Takayasu is a form of large vessel vasculitis that mainly affects the aorta and its branches. It is a chronic disease, and the long-term prognosis depends on arterial complications and its progressive stage. Objectives: This project is a single-center descriptive study of Takayasu’s arteritis patients in Arak city aimed to determine these demographic patterns, which can help physicians in early diagnosis. Methods: All Takayasu’s arteritis patients referred to the rheumatology center of Amir Al-Momenin subspecialty clinic were studied from 2009 to 2019. Imaging methods were used for diagnosis, and SPSS version 23 was used for statistical analysis. Results: Out of 17 registered patients, information of nine patients was available from the beginning of diagnosis. Constitutional signs and symptoms indicated an inflammatory process in 77.78% of the patients. All patients in this study received a steroid-sparing drug as a part of the treatment, and the most commonly used drug was methotrexate, which was used in all patients at the onset. Conclusions: This study reports the details and the characteristics of patients with Takayasu’s Arteritis in Arak, Iran. Although the number of patients was small, these results can inform the physicians about the signs, symptoms, and complications of delayed diagnosis of this disease. One of the most important points in the diagnosis of Takayasu is the delay between the onset of symptoms and the diagnosis of the disease. This delay may lead to irreversible complications and increased morbidity.

Mucocutaneous Manifestations of COVID-19 among Iraqi Patients in Al Diwaniyah Province, Iraq: Case Series Study

Background:The relatively wide distribution of ACE2 receptors all over body tissues suggests the possibility of clinical manifestations other than that of the respiratory tract. The usual incubation period is about 14 days which is often followed by the usual respiratory symptoms and constitutional signs. Globally, additional novel manifestations, including dermatological ones have been reported. Aim:To characterise the skin manifestations in patients with COVID-19 in Al Diwaniyah Province, mid-Euphrates region of Iraq.Method: The present case series study included 54 patients with COVID-19 and a variety of skin manifestations. Those patients visited the dermatology unit at Al Diwaniyah teaching hospital, Al Diwaniyah province, Iraq during the period of the study. The study started in July 2020 and ended in June 2021.Results: The most common features were those of morbilliform eruptions accounting for 18.5% of cases followed by urticarial lesions accounting for 13.0% of cases for followed by ecchymotic pruritic lesion (11.1%). Other features such as oral ulceration and vesicular lesions were also seen in 9.3% of cases. All the body was involved in 29.6% followed by tongue and lip involvement. Morbilliform eruption was the most common diagnosis followed by acute urticaria, herpes simplex, leukocytoclastic vasculitis and then by a variety of other skin manifestations. Conclusion: Skin manifestations in association with COVID-19 were highly variable with onset and duration which could be due to infection, drug reaction or immune mechanisms.

Anesthesia management in a post Covid-19 obstetric patient-What we need to know.

The outbreak of the coronavirus disease (COVID)-19 pandemic has led to unprecedented challenges globally. At the outset of the receding second wave and third wave of COVID-19, many patients who have recovered from the severe acute respiratory syndrome coronavirus-2 (SARS-CoV-2) are coming for elective/emergency surgery. This demands a noteworthy emphasis on the post-COVID-19 obstetric patients. The administration of quality and safe obstetric anesthesia are quite challenging in this mentioned subset due to the overlap of signs and symptoms of COVID-19 with the constitutional signs and symptoms of pregnancy. The physiological changes in normal pregnancy and vascular, metabolic alterations in high-risk pregnancy may affect or exacerbate the pathogenesis or clinical presentation of COVID-19, respectively. This article highlights the specific concerns in recovered COVID-19 pregnant patients with associated comorbidity posted for surgery and their repercussions on anesthesia management.

P-BN05 Solitary jejunal diverticulum: a rare unexpected cause of chronic pneumoperitoneum

Abstract Background Jejunal diverticula are rare acquired herniation of the mucosa and submucosa through the muscularis propria. They are asymptomatic in the majority of cases, however, they can present with non-specific abdominal symptoms and rarely complicate leading to acute abdomen. Perforation usually results in symptoms and signs of acute peritonitis and it is not an identifiable aetiology of chronic pneumoperitoneum. Computed tomography scan may identify intestinal wall oedema, air bubbles travelling through the mesentery, free intra-abdominal air and/or fluid . Radiological diagnosis requires high index of suspicion of such pathology. We report a case of an isolated jejunal diverticulum as a cause for aseptic chronic pneumoperitoneum . Methods A 77-year-old female was referred to the ambulatory emergency surgical unit (AESU) with a 4-month history of nonspecific abdominal pain, considerable weight loss, diarrhea, nausea and a few episodes of vomiting.Physical examination revealed no constitutional signs of sepsis and her abdomen was mildly distended but soft and nontender to palpation. Laboratory investigations were unremarkable. CT scan of her abdomen and pelvis on her first visit showed pneumoperitoneum with associated low volume ascites, which raised the possibility of sealed gastrointestinal perforation. In the absence of any clear signs of sepsis, a strategy of ambulatory, conservative management and follow up was chosen. Four months after her initial presentation our patient presented with ongoing vague abdominal symptoms with weight loss and failure to thrive. A CT colonogram described pneumoperitoneum and larger volume of ascites is in comparison to the previous CT scan. There was an unusual pattern of mural gas in some loops of small bowel in the left side of the abdomen that suggested pneumatosis. MDT decided to proceed with diagnostic laparoscopy. Results Laparoscopy exploration revealed odorless pneumoperitoneum, moderate amount of non-turbid bile stained serous ascites and thin fibrinous covering. We identified a jejunal diverticulum associated with mesenteric air bubbles and moderately enlarged reactive feeling lymph nodes in the diverticular segment . A small bowel resection with a primary side-to-side anastomosis, washout of the abdomen and cholecystectomy were done through a Kocher’s subcostal incision. She made an uneventful post-operative recovery and was discharged home well on day 4. Histopathological examination of the resected specimens confirmed the presence of a ruptured isolated jejunal diverticulum with a breach in muscularis propria and chronic cholecystitis in the gallbladder. Conclusions In summary, our case report highlights the importance of being aware of the possibility of perforated jejunal diverticula as a possible source of chronic pneumoperitoneum causing chronic nonspecific abdominal pain, diarrhea and unexplained weight loss. The surgical option of segmental resection and primary anastomosis was beneficial in this patient. However, calculating the risk benefit ratio remains the mainstay of the management plan, which, as ever, should be tailored to each patient’s general condition and fitness with appropriate counselling and consent.

P041 Systemic Lupus Erythematosus in Algerian Children: clinical, immunological profile and prognosis

Abstract Background Pediatric Systemic Lupus Erythematosus (pSLE) is a chronic mutisystemic autoimmune disease with complex clinical manifestations whose diagnosis is not always easy and the course is generally severe and the treatment is not very well codified and often extrapolated from that of adults. This study aims to describe the clinical, immunological, therapeutic characteristics and short outcome of systemic lupus erythematosus in Algerian children. Methods This was a prospective, multicentre and descriptive study 36 months (January 2015 - December 2018) at the department of Pediatrics of University Hospital Nefissa Hamoud ex Parnet Algiers. Children less than16 years of age fulfilling the American College of Rheumatology SLE criteria were included. Disease activity estimated by Systemic Lupus Erythematosus Disease Activity index (SLEDAI) whose use has been validated in children and damage index based on Systemic Lupus International Collaborating Clinics (SLICC) score were determined. Results Eighty-three (83) patients were studied. Female: male ratio was1:49. Mean ages at lupus onset and diagnosis were respectively: 10, 12 ± 3, 88 and 11, 3 ± 3, 62 years. All patients had skin involvement while constitutional signs including fever and asthenia were observed in (98.8%). Rheumatological, renal, neuropsychiatric, cardiac, hepato-digestive, pleuropulmonary and ocular disorders were observed respectively: 65, 1%, 44, 6%, 41%, 27, 7%, 41%, 19, 3% and 7, 2%. All patients were positive for antinuclear antibodies. Anti-double-stranded DNA (75%) was the most frequently observed autoantibody profile. Antiphospholipid antibody positivity was noted in 52% whereas hypocomplementemia in fractions C3, C4 was observed in 55% and 56% respectively. In our study, the severe forms were more frequent (83%) than the mild ones (17%) with a significant difference (P = < 10–6). Overall, the mean SLEDAI at disease onset was 22.11 ± 11.87 with high activity ≥ 20 in 59% of cases. The mean damage score was 1.8 ± 2.045 (interquartile range 0–8). Among induction drugs, oral corticosteroids were the most frequently used (92%), and in a third of cases intravenously at high doses in combination with immunosuppressive therapy. In induction therapy, cyclophosphamide (CYC) was the most used drug (23%) compared with mycophenolate mofetil (MMF) (14%). Unlike the maintenance phase where MMF observed an increase (28%) vs (8%) CYC. The use of MMF was correlated with severe lupus nephritis with a significantly effective difference in the decrease in SLEDAI (P = 0.0001). The use of hydroxychloroquine (HCQ) was observed in 81% in induction and 89% in maintenance treatment. The correlation of HCQ use with survival was significantly positive (P = 0.04). Indeed, adherence to treatments and essentially HCQ was a protective factor, its odds ratio is < 1 with a significant p-value, [OR 0.016 95% CI (0.001–0.353)]. Mortality was estimated at 11%. Multivariable regression analysis showed that the neurological involvement (odds ratio = 6,093 95% confidence interval ((1,1 8 0 ∼ 31 446)) and macrophage activation syndrome were associated with a high risk of mortality. Conclusion we report a series of pSLE characterized by great clinical and biological heterogeneity. It follows a severe course of the disease with high disease activity at the diagnosis and therefore leads to high morbidity and mortality. However, these results must be confirmed by other pediatric studies which could form the basis of a diagnostic and therapeutic approach more adapted for children. Keywords Algeria, Child, Clinical features, Disease activity, lupus

IRIS CHANGES AT PATIENTS WITH TEMPORОMANDIBULAR JOINT DISEASES AND URINARY SYSTEM PATHOLOGY

Relevance. In recent years, many have been devoted to the problem of the temporomandibular joint (TMJ) diseases, in which the attention is paid to the widespread pathology of TMJ in young people, which develops against the background of the genetically-determined weakness of connective tissue (CTs), which is also the present occurrence of various concomitant diseases of polygenic-multifactorial nature, including the organs of the urinary system (US).
 The study of the state of the iris is used as a screening technique that allows you to quickly, simply, harmlessly, informatively, painlessly, non-invasively diagnose the genetically determined structural and functional state and quality of the CTs.
 Objective. To investigate the iris changes in patients with TMJ and US diseases, to reveal the dependence of the occurrence of degenerative-dystrophic and destructive-inflammatory changes in the joints and US on the structural and functional state of the CTs, to supplement the known traditional methods of diagnosing genetically determined CTs weakness.
 Materials and methods. The study involved 54 patients (men – 14, women – 40), whose average age was 37.3±7.6 years, who were treated at the Dental Medical Center of the Bogomolets NMU. Control group – 22 patients (men – 10, women – 12) without general somatic pathology, with a physiological bite, without signs of TMJ diseases, whose average age was 25.7±6.8 years. Main group – 22 patients (men – 4, women – 28) with TMJ diseases and US pathology, whose average age was 31.6±7.7 years.
 Iridobiomicroscopy was performed in patients of both groups. Iridogenetic constitutional signs were determined: the color of eyes, constitutional type after E.S. Velkhover, type with the connective tissue weakness after I. Deck, the density of iris stoma.
 The obtained laboratory data were referenced in the International System of Units and processed by variational statistics using MedStat and EZR v.1.35 (Saitama Medical Center, Jichi Medical University, Saitama, Japan, 2017), which is a graphical interface to RFSC (The R Foundation for Statistical Computing, Vienna, Austria).
 Results. Among the examined patients with TMJ diseases and MVS pathology, 75% showed predominantly light eye color and V degree (46.9%) of iris stroma density, in the control group: dark iris color (54.5%) and II degree (68.2%) of iris density.
 Iridogenetic constitutional signs of the CT weakness in the patients with TMJ diseases have been determined: the light color of eyes, radial-lacunar constitutional type after E.S. Velkhover (75%), lymphatic constitutional type with the connective tissue weakness after I. Deck (57,9%).
 Structural local or chromatic changes of the iris stroma in the projection region of the kidney (75%) and bladder (43.6%) in young patients with TMJ diseases showed a congenital weakness of the CTs of these organs and a tendency to develop pathology of the US.
 Conclusions. Patients with degenerative-dystrophic and destructive-inflammatory diseases of the TMJ and concomitant US pathology are characterized by iridogenetic constitutional signs of the CTs weakness in the patients with TMJ diseases have been determined: the light color of eyes, radial-lacunar constitutional type after E.S. Velkhover, low degree of iris stroma density, lymphatic constitutional type with the connective tissue weakness after I. Deck.
 Structural local or chromatic changes of the iris stroma in the projection region of the kidney and bladder in young patients with TMJ diseases showed a congenital weakness of the CTs of these organs and a tendency to develop pathology of the US.
 It can be assumed that the development of TMJ diseases in young patients is based on dysplastic changes in the CTs system, which is additionally manifested in the examined patients by pathological changes in the US.
 Iridobiomicroscopy, as a screening technique for determining the structural and functional state of CTs, makes it possible to increase the accuracy of diagnostics when examining patients with TMJ diseases who have concomitant pathology of internal organs, including US.

Acute invasive fungal rhinosinusitis in pediatric patients with oncohematological diseases

IntroductionInvasive fungal diseases represent important causes of morbidity and mortality among pediatric oncohematological patients. Acute invasive fungal rhinosinusitis is a rare and aggressive disease that occurs mainly in immunocompromised patients. The mortality rate is high and therefore, accurate and early diagnosis is essential. ObjectivesThe aim of this study was to describe the frequency of acute invasive fungal rhinosinusitis among pediatric oncohematological patients and characterize them with confirmed diagnoses. MethodsThis was a retrospective study that analyzed the medical records of pediatric patients diagnosed with oncohematological diseases and suspected fungal infections, who were included after obtaining informed consent, from January to December 2017, in the pediatric unit of a tertiary university hospital. Data collected from medical record analysis included the following: underlying diagnosis, absolute neutrophil count, clinical presentation, culture and biopsy results, surgical procedures performed, survival and mortality. ResultsA total of 27 patients were evaluated, with three suspected cases of acute invasive fungal rhinosinusitis. Histopathological and microbiological analyses confirmed two cases. In both cases, the pathogen isolated in the culture was Fusarium sp. The two confirmed cases were female, aged 12 and 14 years, both with an absolute neutrophil count of 10cells/μL. The underlying disease of the first patient was acute myeloid leukemia (subtype M5), whereas the second patient presented idiopathic bone marrow aplasia. ConclusionBoth confirmed cases of acute invasive fungal rhinosinusitis presented with constitutional symptoms and signs of nasal and sinusital inflammation. This demonstrates the importance of fever as a symptom in immunocompromised patients and it should prompt otorhinolaryngological investigation.

Development of an Electronic Tool to Measure Daily Appropriateness of Inpatient Antibacterial Use

Background: Assessing antimicrobial use (AU) appropriateness isa cornerstone of antimicrobial stewardship, largely accomplished through time-intensive manual chart review of specific agents or diagnoses. Efforts to evaluate appropriateness have focused on assessing the appropriateness of an entire treatment course. An electronic measure was developed to assess the appropriateness of each day of inpatient AU leveraging electronic health record data. Methods: We extracted contextual data, including risk factors for resistant organisms, allergies, constitutional signs and symptoms from diagnostic and procedural codes, and microbiological findings, from the electronic health records of patients in Veterans’ Health Administration inpatient wards reporting data to the National Healthcare Safety Network (NHSN) AU option from 2017–2018. Only the antibacterial categories shown in Figure 1 were included. Respiratory, urinary tract, skin and soft-tissue, and other infection categories were defined and applied to each hospital day. Algorithm rules were constructed to evaluate AU based on the clinical context (eg, in the ICU, during empiric therapy, drug–pathogen match, recommended drugs, and duration). Rules were drawn from available literature, were discussed with experts, and were then refined empirically. Generally, the rules allowed for use of first-line agents unless risk factors or contraindications were identified. AU was categorized as appropriate, inappropriate, or indeterminate for each day, then aggregated into an overall measure of facility-level AU appropriateness. A validation set of 20 charts were randomly selected for manual review. Results: Facility distribution of appropriateness, inappropriateness, and indeterminate AU by 4 of the adult, 2017 baseline NHSN Standardized Antimicrobial Administration Ratio (SAAR) categories are shown in Figure 1. The median facility-level inappropriateness across all SAAR categories was 37.2% (IQR, 29.4%–52.5%). The median facility-level indeterminate AU across all SAAR categories was 14.4% (IQR, 9.1%–21.2%). Chart review of 20 admissions showed agreement with algorithm appropriateness and inappropriateness in 95.4% of 240 antibacterial days.Conclusions: We developed a comprehensive, flexible electronic tool to evaluate AU appropriateness for combinations of setting, antibacterial agent, syndrome, or time frame of interest (eg, empiric, definitive, or excess duration). Application of our algorithm in 2 years of VA acute-care data suggest substantial interfacility variability; the highest rates of inappropriateness were for anti-MRSA therapy. Our preliminary chart review demonstrated agreement between electronic and manual review in >95% of antimicrobial days. This approach may be useful to identify potential stewardship targets, in the development of decision support systems, and in conjunction with other metrics to track AU over time.Funding: NoneDisclosures: None

Diagnosis and Acute Management of E-Cigarette or Vaping Product Use–Associated Lung Injury in the Pediatric Population: A Systematic Review

To assess quantitative data on the presentation, investigative findings, patterns of lung injury, and interventions of pediatric cases of e-cigarette or vaping-associated lung injury (EVALI) in the acute care setting. A literature search using keywords was performed on April 17, 2020, in accordance with PRISMA guidelines. Three thousand five hundred fifty-eight articles were retrieved from MEDLINE via PubMed, Embase via OVID, CINAHL via EBSCO, Web of Science, and the Cochrane Library. Studies were evaluated for inclusion based on predetermined inclusion and exclusion criteria by 2 independent reviewers. The search yielded a total of 3558 individual results, 145 of which were evaluated by full text review, resulting in 23 articles included in this systematic review. Two of these articles were identified by manual search of article references. A total of 61 cases of EVALI were described, and 10 major patterns of lung injury were identified for which presenting symptoms, diagnostic and laboratory investigations, interventions, and outcomes were synthesized. Cases of EVALI in the pediatric population have been reported in patients as young as 13years and often present with respiratory, constitutional, abdominal, and cardiovascular signs and symptoms. Diagnostic findings vary based on the underlying lung injury pattern. However, typical patterns of common findings were identified, including the presence of ground-glass opacities on computed tomography scan and leukocytosis. Mainstays of treatment include the use of corticosteroids, antibiotics, and ventilatory support, including extracorporeal membrane oxygenation. Outcomes range from complete or near complete recovery of lung function to death.

Syndrome de Cogan

“Typical” Cogan's syndrome is defined as a non-syphilitic interstitial keratitis associated with audio-vestibular resembling Ménière's disease with a 2-year maximum delay between these 2 organ impairment. Cogan syndrome is classified as “atypical” in the absence of interstitial keratitis and the presence of other inflammatory eye manifestations, an audio-vestibular impairment different from typical Menière-like disease, or a delay longer than 2 years between eye and audio-vestibular manifestations. Constitutional signs and large-vessel vasculitis is also possible, mostly affecting the thoracic aorta. The presence of acute-phase reactants is common, but no specific laboratory tests are available. The prognosis is dominated by the audio-vestibular impairment and in particular the risk of deafness, while other complications especially vascular complications being rare. Treatment with glucocorticoids is usually necessary and the combination to other immunosuppressive therapies or biological-targeted drugs needs to be determined.

Tuberculous pyomyositis of upper and lower limb muscles-A prospective study

Objective: Evaluation and management of Tuberculous Pyomyositis, a rare manifestation of Mycobacterium tuberculae. Materials and Methods: All the patients who had visited the orthopaedic OPD at Mahamaya Rajkiya Allopathic Medical College Ambedkar Nagar during the period from March 2012 to March 2019 and diagnosis supported by radiological evaluation by MRI/USG and established by acid fast staining/histopathological evaluation of aspirate/biopsy of involved muscle. Results: Depends upon their clinical presentation initially 28 cases were suspected among which 16 cases (57.10%) found positive for tuberculous pyomyositis. Two patients were lost during follow up so finally there were 14 cases (50%) included in this study. Among 14 cases, 7 cases (50%) were female and 7 cases (50%) male. The age of patients varied from 9 year to 68 year and the duration of illness on presentation from 2 months to 12 months. The routes of infection were hematogenous in 11 cases (78.57%) and penetrating injury in 3 cases (21.42%). All cases were managed with anti tubercular drugs as per guideline, and surgery also needed in 8 cases (72.72%). Conclusion: Isolated presentation of tuberculosis as pyomyositis is rare and not widely reported in the literature. Tuberculous pyomyositis should be considered in long standing vague swelling of the upper and lower limb without constitutional symptoms and signs of inflammations. Thus it is our recommendation is to establish the diagnosis of tubercular pyomyositis followed by anti tubercular treatment; and in selected cases surgical drainage and debridement along with ATT. Keywords: Pyomyositis, Tubercular, Muscle, Infection.

Repere de identitate constituțională în România pre- și post-comunistă

The Romanian Constitution, in art. 1 parag. 3, states that fundamental constitutional values such as human dignity, citizen rights and liberties, the free development of human personality, justice and political pluralism are to be understood through the spirit of the Romanian democratic traditions. Thus, working with traditions, we have to seek constitutional identity signs in the past, in order to see, in a wider analytical and institutional background, what defines the political identity of the Romanian people as a whole and as individuals (citizenship can be discussed in paradox terms). Such an academic endeavor can successfully turn into a book subject, considering its complexity and its inter, intra and pluri scientific field connections. In the limits of a research article, we will briefly explore the constitutional history of pre- and modern Romania (which is mainly a history of constitutional transplant). One of the aimed purposes of the paper is to discover the Romanian individual that constitutes the soul or matrix of the national state or to see if a Constitution really constitute constitutional identity.

P234 Giant right atrial myxoma presenting as right heart failure

Abstract Introduction Myxomas are the most frequent primary cardiac neoplasms. It is currently believed that myxomas are derived from multipotent mesenchymal cells capable of both neural and epithelial differentiation Histologically, these tumors are composed of dispersed cells within a stroma of mucopolysaccharides Myxomas produce vascular endothelial growth factor, which probably contributes to the growth induction at the initial stages of tumor growth. Tumors vary widely in size, ranging from 1 to 15 cm in diameter and weighing between 15 and 180 g. About 35 percent of myxomas are friable, and they tend to present emboli. The clinical characteristics of these tumors are closely related to their location, size, and mobility; there are no specific signs and symptoms that suggest the presence of a myxoma. There are several mechanisms by which cardiac tumors can cause symptoms. The blockage of circulation through the heart or heart valves produces symptoms of heart failure. Atrial myxoma can interfere with the valves of the heart and cause regurgitation. They can also produce systemic embolisms and constitutional signs. Clinical Case We present a 29-year-old female patient who started with fatigue, weight loss, increased abdominal perimeter and dyspnea of one month"s effort that progressed to dyspnea at rest in the last week associated with syncope, so she decided to go to the emergency department of our institution. Upon arrival at the emergency room, the patient was found with vital signs within normal parameters, however with dyspnea at rest, jugular plethora and important lower limb edema. On auscultation, a systolic-diastolic murmur was found with an increase in the Rivero Carvallo maneuver, with reinforcement of the pulmonary component of the second noise and parasternal high-left rise. In clinical analysis, NT-proBNP 5698pg/mL, AST 34, INR 1.65 and serum lactate of 4.2 was found. A Transthoracic Echocardiogram (TTE) was performed, where a 10cm mass effusion was documented that occupied the entire right atrium and protruded into the right ventricular outflow tract. With these findings, medical treatment was started for right heart failure and it was to cardiac surgery for resection of the right atrium where it had been performed, however during the immediate postoperative state, presented biventricular failure and later asystole without achieving a return of spontaneous circulation despite resuscitation maneuvers. Conclusion In this case, it is an unusual presentation of a rare cardiac pathology that started with symptoms of right heart failure due to the obstruction of the right ventricular outflow tract. We consider that it is an interesting clinical case and with important educational aspects to take into consideration the differential clinical diagnoses of a patient presenting to the emergency department with right heart failure. Abstract P234 Figure. Giant Myxoma

COVID-19: Considerations for obstetric anesthesia and analgesia

Peripartum services are indispensable notwithstanding the COVID-19 pandemic. Providing safe and quality obstetric anesthesia is quite demanding as most signs and symptoms of COVID-19 are non-specific and overlap with the constitutional signs of pregnancy. Overloaded viral testing facilities, urgency of caesarean delivery, limited resources, capricious evidence-base, and potential exposure risk to healthcare providers further add to the challenge imposed by COVID-19. In this discourse we attempt to provide a summary of the current evidence and recommendations concerning the practice of obstetric anesthesia and analgesia.

Paraneoplastic disorders associated with miscellaneous neoplasms with focus on selected soft tissue and Undifferentiated/ rhabdoid malignancies.

A variety of soft tissue and visceral neoplasms have been associated with constitutional symptoms and signs including fever, fatigue, arthritis and laboratory abnormalities such as elevated erythrocyte sedimentation rate, leukocytosis with marked neutrophilia, anemia, thrombocytosis and others. This review addresses three main neoplastic categories that are associated with specific paraneoplastic phenomena: (1) neoplasms having in common the presence of diffuse mixed inflammatory infiltration (closely simulating an inflammatory pseudotumor) and frequently associated with constitutional symptoms; (2) neoplasms with undifferentiated, anaplastic or rhabdoid cell morphology (frequently SWI/SNF-deficient) associated with diverse paraneoplastic manifestations; and (3) paraneoplasia associated with neoplasms carrying specific gene fusions such as solitary fibrous tumor (STAT6-NAB2 gene fusions), infantile fibrosarcoma and congenital mesoblastic nephroma (ETV6-NTRK3 gene fusions), and angiomatoid fibrous histiocytoma (EWSR1-CREB1 & EWSR1-ATF1 fusions).

Preliminary Data Show Heterogenous Patterns of 18f-FDG PET/CT When Assessing the Inflammatory Component of Primary or Secondary Myelofibrosis

Abstract Background. Recent studies have highlighted the interest of non-invasive procedures to assess extramedullary hematopoiesis in patients with overt myelofibrosis, primary (PMF) or secondary (sMF) to essential thrombocytemia (ET) or to polycythemia vera (PV) (1-4). Several nuclear medicine imaging techniques have been employed without clear consensus about the predominant value of one over other in these mostly preliminary works (2-4). Population and objectives. Because the pathophysiology of PMF or sMF involves some inflammatory pathways we studied the interest of 18F-FDG (18F-fluorodeoxyglucose) PET/CT in patients with PMF (5). The main objective was to know whether the inflammatory component of PMF could be well detected by this technique. Secondly, we looked for some kind of correlation between the FDG uptake on medullary and extramedullary sites of hematopoiesis and the severity of the disease. Five patients with diagnosis of MF (3 PMF and 2 sMF) were assessed (see Table 1 for baseline characteristics and results) Methods.18F-FDG PET/CT imaging was performed following a 60 min. uptake after intravenous injection of a weight-adapted FDG activity (2,5 MBq/kg) on a Siemens Biograph mCT. Images were reviewed by board certified nuclear medicine physicians. Spleen size was measured on axial slices. SUVmax were assessed in a 5 mm diameter spheric volume of interest in homogenous parts of liver and spleen, and in the L2 vertebral body for axial skeleton assessment. Spleen uptake was considered as abnormal in case of a diffuse uptake exceeding hepatic baseline uptake. Skeleton uptake was considered as abnormal in case of diffuse increased uptake. Results. UPN01LP: slight higher metabolic activity in the axial skeleton and diffuse spleen uptake ; UPN02AP: no hypermetabolic activity in the spleen and slightly higher uptake in the axial skeleton ; UPN03AA: diffuse bone hypermetabolic activity and high metabolic activity in the spleen ; UPN05HL: diffuse bone hypermetabolic activity and higher metabolic activity in the spleen ; UPN06DF: no diffuse hypermetabolic activity in the spleen, slight higher uptake in the axial skeleton. In summary, those patients with overt myelofibrosis and constitutional signs tend to show a diffuse higher activity both in the axial skeleton and the spleen whereas those without overt myelofibrosis and without constitutional signs tend to present a normal metabolic activity in the axial skeleton and in the spleen. These patterns are in accordance with the progression and severity of the disease. The higher uptake of 18FDG in the axial skeleton in patients with overt MF contrasts with what is observed with some hybrid imaging techniques that show a lower radionuclide (111In/SPECT/CT) uptake at this level translating a lower hematopoietic activity (3). Conclusions. Based on these preliminary results we consider 18FDG-PET/CT procedures are able to detect the inflammatory component of PMF or sMF and the intensity of FDG uptake appears to be correlated to the severity of the disease. Those patients with a high metabolic activity in the axial skeleton and the spleen might be candidates for specific therapies, although these statements need to be confirmed in a larger series of patients. Bibliography. 1 Derlin T et al. Assessment of bone marrow inflammation in patients with myelofibrosis: an 18F-fluorodeoxyglucose PET/CT study. Eur J. of Nucl Med Mol Imaging 2015 2 Agool A et al. Radionuclide imaging of bone marrow disorders. Eur J Nucl Med Mol Imaging. 2011. 3 Ojeda-Uribe M et al. Assessment of sites of marrow and extramedullary hematopoiesis by hybrid imaging in primary myelofibrosis patients. Cancer Medicine 2016. 4 Vercellino L et al. Assessing bone marrow activity in patients with myelofibrosis: results of a pilot study of 18F-FLT PET. J. of Nucl Med 2017. 5 Desterke C et al. Inflammation as a Keystone of Bone Marrow Stroma Alterations in Primary Myelofibrosis. Mediators Inflamm. 2015 Download : Download high-res image (107KB) Download : Download full-size image Table 1 . Disclosures No relevant conflicts of interest to declare.

Tuberculosis of patella: Nonspecific presentation, treated conservatively

Skeletal tuberculosis (TB) accounts for 8% of extrapulmonary TB, and patella accounts for 0.1% of all skeletal TB. Patella TB in early stages is very difficult to diagnose because of no constitutional signs and symptoms. It may be found in immunocompromised states, endemic areas, and in chronic debilitated patients. Isolated TB of patella is very rare, so early diagnosis and management is quite difficult without clinical and histopathological examination. There is a significant improvement in clinical outcome after taking antitubercular multidrug therapy and surgery is rarely required.