Early Evaluation Of Patients Research Articles

Cardiac Arrest-Associated Coagulopathy Could Predict 30-day Mortality: A Retrospective Study from Medical Information Mart for Intensive Care IV Database.

Cardiac arrest (CA) can activate the coagulation system. Some coagulation-related indicators are associated with clinical outcomes. Early evaluation of patients with cardiac arrest-associated coagulopathy (CAAC) not only predicts clinical outcomes, but also allows for timely clinical intervention to prevent disseminated intravascular coagulation. To assess whether CAAC predicts 30-day cumulative mortality. From the Medical Information Mart for Intensive Care IV (MIMIC-IV) database, we conducted a retrospective cohort study from 2008 to 2019. Based on international normalized ratio (INR) value and platelet count, we diagnosed CAAC cases and made the following stratification of severity: mild CAAC was defined as 1.4 > INR≧1.2 and 100,000/µL < platelet count≦150,000/µL; moderate CAAC was defined with either 1.6 > INR≧1.4 or 80,000/µL < platelet count≦100,000/µL; severe CAAC was defined as an INR≧1.6 and platelet count≦80,000/µL. A total of 1485 patients were included. Crude survival analysis showed that patients with CAAC had higher mortality risk than those without CAAC (33.0% vs 52.0%, P < 0.001). Unadjusted survival analysis showed an incremental increase in the risk of mortality as the severity of CAAC increased. After adjusting confounders (prehospital characteristics and hospitalization characteristics), CAAC was independently associated with 30-day mortality (hazard rate [HR] 1.77, 95% confidence interval [CI] 1.41-2.25; P < 0.001); moderate CAAC (HR 1.48, 95% CI 1.09-2.10; P = 0.027) and severe CAAC (HR 2.22, 95% CI 1.64-2.97; P < 0.001) were independently associated with 30-day mortality. The presence of CAAC identifies a group of CA at higher risk for mortality, and there is an incremental increase in risk of mortality as the severity of CAAC increases. However, the results of this study should be further verified by multicenter study.

Diagnostic Value of Pulmonary Ultrasound and Arterial Blood Gas Analysis in Acute Patients with Severe Injuries Complicated by Respiratory Failure-A Retrospective Study.

To investigate the early application of pulmonary ultrasonography and arterial blood gas analysis in critical patients with severe multiple injuries exacerbated by respiratory failure. The retrospectiveselection was performed on 81 patientsadmitted to our critical care unit between January 2020 and January 2021 withsevere multiple injuries rendered worse by respiratory failure. Based on the different examination procedures, the patients were categorised into three groups (n=27): group A; diagnosed with pulmonary ultrasonography, group B; diagnosed with arterial blood gas; and group C; diagnosed with both pulmonary ultrasonography and arterial blood gas analyses. Patients were subsequently divided into a survival group (n = 65) and a death group (n = 16). On an annual basis, patients' prognoses wereexamined in relation tothe predictive value of pulmonary ultrasound. Initial diagnosis, diagnosis, and initial correct treatment times were significantly shorter in groups B and C than group A (P<0.05). In contrast, initial diagnosis time, diagnosis time, and initial correct treatment times werepotentially shorter in group C than in group B (P<0.05). Compared to groups B and C, group A had a considerably lower diagnosis rate for the examination methods (P<0.05). The right diaphragm displacement and left diaphragm displacement in the survival group were potentially higher than the LUS score (P < 0.05). In contrast, thesurvival group'slung ultrasound score (LUS)was considerably lower than the death group's. Statistical analysis showed that the predictive values of right diaphragm displacement, left diaphragm displacement, and mean diaphragm displacement were significant compared with the LUS score. The findings of the receiver operating characteristic curve demonstrated that the right, left, and average diaphragm displacements had high predictive values. In the early evaluation of patients with severe multiple injuries complicated by respiratory failure, pulmonary ultrasonography combined with arterial blood gas analysis is crucial for the rapid diagnosis and prognosis prediction of patients.

Detection of Risk Predictors of COVID-19 Mortality with Classifier Machine Learning Models Operated with Routine Laboratory Biomarkers

Early evaluation of patients who require special care and who have high death-expectancy in COVID-19, and the effective determination of relevant biomarkers on large sample-groups are important to reduce mortality. This study aimed to reveal the routine blood-value predictors of COVID-19 mortality and to determine the lethal-risk levels of these predictors during the disease process. The dataset of the study consists of 38 routine blood-values of 2597 patients who died (n = 233) and those who recovered (n = 2364) from COVID-19 in August–December, 2021. In this study, the histogram-based gradient-boosting (HGB) model was the most successful machine-learning classifier in detecting living and deceased COVID-19 patients (with squared F1 metrics F12 = 1). The most efficient binary combinations with procalcitonin were obtained with D-dimer, ESR, D-Bil and ferritin. The HGB model operated with these feature pairs correctly detected almost all of the patients who survived and those who died (precision &gt; 0.98, recall &gt; 0.98, F12 &gt; 0.98). Furthermore, in the HGB model operated with a single feature, the most efficient features were procalcitonin (F12 = 0.96) and ferritin (F12 = 0.91). In addition, according to the two-threshold approach, ferritin values between 376.2 μg/L and 396.0 μg/L (F12 = 0.91) and procalcitonin values between 0.2 μg/L and 5.2 μg/L (F12 = 0.95) were found to be fatal risk levels for COVID-19. Considering all the results, we suggest that many features combined with these features, especially procalcitonin and ferritin, operated with the HGB model, can be used to achieve very successful results in the classification of those who live, and those who die from COVID-19. Moreover, we strongly recommend that clinicians consider the critical levels we have found for procalcitonin and ferritin properties, to reduce the lethality of the COVID-19 disease.

Intracranial cysts: incidental or neurodevelopmental?

Intracranial cysts are fluid-filled sacs within the brain. There is a diversity of intracranial cysts with different incidences in addition to the growing awareness about comorbidities and the consequences. The present study aimed to evaluate cystic findings in children who were admitted to the department of pediatric neurology. Children who were admitted to the Clinic of Pediatric Neurology and who had an MRI between 2016 and 2021 were evaluated. The MRI examination was performed with the pediatric epilepsy protocol. Children with primary intracranial cysts were enrolled in the study. Demographic and clinical findings were evaluated from the hospital's database and patients' files. Among the 78 patients, 36 (46.2%) were male and 42 (53.8%) were female. The mean age was 7 ± 5.4years. The most frequent presenting complaint was a seizure (47.4%). Approximately one-quarter (28.2%) had mental and/or motor retardation. Nine (11.5%) of the children had a neuropsychiatric diagnosis. Most of the cysts were located at the midline (41%) with the majority located extra-axial (71.8%) and supratentorial (78.2%). Arachnoid cysts were observed most frequently with a percentage of 64.1%, followed by pineal cysts (15.4%). The history of seizure, epilepsy, presence of mental retardation, and neuropsychiatric problems were evaluated according to the population ratios based on z approximation in which significantly higher rates were observed among cases with intracranial cysts. Intracranial cysts should be taken into consideration for comorbid pathologies, especially in the childhood period. Early evaluation in patients with intracranial cysts for developmental delay and neuropsychiatric problems is important.

Diagnostic Accuracy of a Near-Infrared Spectroscopy Device for Detecting Intracranial Hemorrhage in Mild Closed Traumatic Brain Injury at a Philippine Trauma Center

Objective: This study aimed to evaluate the sensitivity, specificity, positive predictive value, negative predictive value, positive likelihood ratio, and negative likelihood ratio of a handheld Near Infrared Spectroscopy (NIRS) device (Infrascanner 2000®) in detecting intracranial hemorrhage in mild, closed traumatic brain injury patients in the emergency room setting. Methods: This prospective study evaluated the diagnostic validity of a NIRS device in hemodynamically stable patients with mild, closed traumatic brain injury. The authors included patients aged 15 to 65 years who were consecutively admitted to the Emergency Department of the Philippine General Hospital from June 2017 to September 2017. Patients were scanned by a trained research assistant with the NIRS device in the frontal, temporal, parietal, and occipital areas of the brain bilaterally. A cranial computed tomography scan was used as a reference standard for comparison. Results: A total of 83 participants with mild, close traumatic brain injury were included in the final analysis. There were 68 (82%) males, and the mean age was 29.52 years old. Of the 83 participants, 41 had intracranial hemorrhages (23 subdural, 13 epidural, 5 intraprenchymal). The NIRS device exhibited a sensitivity, 85.37% [55-96.19%]; specificity, 92.86% [85.07-100.00%]; PPV, 92.12% [83.53-100.00%]; NPV, 86.67% [76.74-96.60%]; PLR, 11.96 [3.99- 35.82]; and NLR, 0.16 [0.07-0.33]. Conclusion: The NIRS device can reliably screen for hemorrhages in patients with mild, closed traumatic brain injury using CT scan results as the gold standard. These diagnostic values suggest the potential role of the NIRS device in the early evaluation of patients with traumatic brain injury requiring urgent care. Key words: near-infrared spectroscopy, intracranial hemorrhage, mild traumatic brain injury

The Digital Rectal Examination: Appropriate Techniques for the Evaluation of Constipation and Fecal Incontinence.

Disorders of defecation, including constipation and fecal incontinence, are very common. The digital rectal examination (DRE) is a key component in the early evaluation of patients with these complaints. Confident performance of a DRE requires dedicated training for the clinician and hands-on experience with the technique. DRE can yield a diagnostic accuracy comparable to specialized physiologic tests, including anorectal manometry. This review will describe in detail the steps required to perform a thorough DRE evaluation, as well as the proper interpretation of observations. Thereafter, the current evidence-based findings supporting the value of DRE in defecatory disorders will be summarized.

Factors Associated With Subdural Hygroma Following Mild Traumatic Brain Injury.

Subdural hygroma (SDG) is a complication of traumatic brain injury (TBI). In particular, the outcome and outpatient treatment period may vary depending on the occurrence of SDG. However, the pathogenesis of SDG has not been fully elucidated. Therefore, this study aimed to identify the risk factors associated with the occurrence of SDG after mild TBI. We retrospectively analyzed 250 patients with mild TBI admitted to a single institution between January 2021 and December 2021. The SDG occurrence and control groups were analyzed according to the risk factors of SDG, such as age, history, initial computed tomography (CT) findings, and initial laboratory findings. The overall occurrence rate of SDG was 31.6% (n=79). A statistically significant association was found between preoperative diagnoses and the occurrence of SDG, such as subarachnoid hemorrhage (odds ratio [OR], 2.36; 95% confidence interval [CI], 1.26-4.39) and basal skull fracture (OR, 0.32; 95% CI, 0.12-0.83). Additionally, age ≥70 years (OR, 3.20; 95% CI, 1.74-5.87) and the use of tranexamic acid (OR, 2.12; 95% CI, 1.05-4.54) were statistically significant factors. The prognostic evaluation of patients using the Glasgow Outcome Scale (GOS) did not show any statistical differences between patients with and without SDG. SDG was not associated with the prognosis of patients assessed using the GOS. However, depending on the occurrence of SDG, differences in patient symptoms may occur after mild TBI. Therefore, the early evaluation of patients with mild TBI and determination of the probability of developing SDG are important.

The Efficacy of Bronchoscopy versus Computerised Tomography in Initial Identification of Patients with Hemoptysis.

The effects of bronchoscopy and chest CT on early evaluation of patients with hemoptysis are still controversial. PubMed, EMBASE, and the Cochrane Library databases were systematically searched. Odds ratio (OR) was applied to assess the utility of bronchoscopy for hemoptysis etiology and site in comparison with CT in the various clinical processes. A total of 23 studies were included (N=4635). The results showed that bronchoscopy implied a lower overall diagnostic accuracy, especially in identifying the etiology of hemoptysis, compared with CT (OR= 0.34, 95% CI: [0.23, 0.51], OR=0.21, 95% CI: [0.14, 0.31], respectively). When the results of radiograph were normal, the effectiveness of bronchoscopy was significantly weaker than that of CT (OR=0.32, 95% CI: [0.22, 0.45]). In the cases of massive hemoptysis, bronchoscopy and CT had no statistical significance for identifying bleeding (OR=0.27, 95% CI: [0.02, 3.18]). The study suggested that bronchoscopy did not show superior diagnostic accuracy than CT for patients with hemoptysis at the first visit. Key Words: Hemoptysis, Bronchoscopy, CT, Meta-analysis.

The role of speckle tracking echocardiography in the identification of culprit lesion in patients with non ST-segment elevation acute coronary syndrome

Abstract INTRODUCTION An early evaluation of patients with non-ST elevation acute coronary syndrome patients (NSTE-ACS) is important to choose the appropriate treatment strategy. In this setting of patients, conventional echocardiographic assessment may reveal normal myocardial kinesis in 25 to 76% of cases. Global and territorial longitudinal strain (GLS and TLS, respectively) may be an early and accurate non-invasive tool for prediction of multivessel CAD in patients with NSTE-ACS. AIM To evaluate the ability of TLS to predict culprit lesions in patients with NSTE-ACS. Material and method We studied 183 patients diagnosed with NSTE-ACS, in our Institution over 2 years of time. Conventional echocardiography and 2D speckle tracking echocardiography (STE) imaging were performed by two experienced echocardiographers, who were blinded to patient characteristics. The TLS was identified as the mean value of the segments'strain as respect to each vessel territory.Coronary angiography was performed in all patients. Significant CAD (luminal stenosis more than 70% in a major epicardial coronary vessel) and culprit lesion were identified and threated by PTCA when appropriate. Results A significant difference between mono- and tri-vessel CAD in the variation of WMSI has been demonstrated. There was a statistically significant difference between both 3-vessels vs 1-vessel disease and 2-vessels vs 1-vessel disease in changing of TLS-LAD, TLS-RCA and TLS-Cx values (p-value &amp;lt;0.001). There was a significant difference between 3-vessels vs 2-vessels disease for TLS-RCA values. There was a statistically significant difference for WMSI-LAD, WMSI-CX and WMSI-RCA values whether the respective artery was involved or not. Variations of TLS were statistically significant both when the territorial tributary artery was involved and also if the artery represented the culprit lesion (p-value TLS-LAD &amp;lt;0.001, TLS-LAD culprit &amp;lt;0.001, TLS-CX&amp;lt;0.001, TLS-cx culprit &amp;lt;0.001, TLS-RCA &amp;lt;0.001, p-value TLS-RCA culprit 0.022). A regression model was performed comparing the variation of WMSI as respect to the variation of WMSI+TLS in the territory of culprit lesions. For WMSI- LAD the OR was 0.94 and for TLS-LAD the OR was 1.19 and the p-value of the addition was 0.001. The OR of WMSI-CX was 1.76 and for TLS-CX the OR was 1.40 and the p- value of the addition was 0.001. The OR of WMSI- RCA was 0.71 and for TLS- RCA the OR was 1.17, the p- value of the addition was 0.019. Conclusion TLS allows an accurate identification of the culprit lesion in patients presenting with NSTE-ACS. TLS can be considered as part of routine echocardiography on top of WMSI in early evaluation for a better clinical assessment in this subset of patients. Funding Acknowledgement Type of funding sources: Public hospital(s). Main funding source(s): Policlinico di Bari

3D-Speckle Tracking Echocardiography for Assessment of Coronary Artery Disease Severity in Stable Angina Pectoris

Background: Stable angina pectoris is a common disease that may cause disability. Echocardiography is the leading and feasible cardiac imaging in patients with cardiac disease. An early evaluation of patients with complex coronary lesions plays an important role in the prognosis and selection of treatment strategy. Objective: To evaluate the feasibility and accuracy of 3D-speckle tracking echocardiography in assessment of coronary artery disease severity in stable angina pectoris. Patients and methods: The study was across sectional study include 90 patients with chronic coronary syndrome(stable angina) come to Islamic cardiac center at Al-Azhar University for coronary angiography on clinical basis indications between period from April 2019 to May 2020.The patients were classified into two groups after according to the results of coronary angiography. Group (I): Case group include 60 patients with different coronary lesions in angiography, and Group (II): control group include 30 patients with normal coronary angiography. The group (I) subsequently divided into two subclasses after coronary angiography according to the Gensini score. Group (IA) non-critical stenosis ( 0-19) , group (IB) critical stenosis (≥ 20). Results: There was no statistically significant difference between patients and control groups as regard demographic data and risk factors( age , gender, diabetes mellitus, hypertension, smoking ,family history and dyslipidemia) .There was no statistically significant difference between group (I) &group(II) as regard their Echo parameters left atrial diameter ( LAD) , left ventricular end diastolic diameter (LV EDD), left ventricular end systolic diameter (LV ESD) , left ventricular end systolic volume (LV ESV )and left ventricular ejection fraction (LV EF%) . There was statistically significant decrease in group(I) compared to group(II) as regard their 3D speckle parameters global longitudinal strain ( GLS%)( -12.35% ± 2.7% versus -20.2% ±1.19%) , global circumferential strain( GCS%)(-19.23% ± 4.18% versus -26.57% ± 1.3%), global radial strain (GRS% )(23.48 ± 3.32% versus 53.67% ± 2.99%) and global area strain (GAS%)(-23.98% ± 4.14% versus -31.93 ± 1.28%) . Also there was significant decrease in critical stenosis group (IB) as regard 3D speckle parameters in comparison with non-critical stenosis group (IA). Conclusion: 3D-STE is a noninvasive and handy parameter that has the potential to improve the value of echocardiography in the detection of the coronary artery disease (CAD) and to provide more information for clinical physicians. It could be expected to identify severe coronary stenosis in chronic coronary syndrome (CCS) patients even when resting wall motion and left ventricular ejection fraction were normal. It shows good sensitivity and specificity with best values for global area strain (GAS).

Facilitators and barriers to post-discharge pain assessment and triage: a qualitative study of nurses\u2019 and patients\u2019 perspectives

BackgroundAfter hospital discharge, patients can experience symptoms prompting them to seek acute medical attention. Early evaluation of patients’ post-discharge symptoms by healthcare providers may improve appropriate healthcare utilization and patient safety. Post-discharge follow-up phone calls, which are used for routine transitional care in U.S. hospitals, serve as an important channel for provider-patient communication about symptoms. This study aimed to assess the facilitators and barriers to evaluating and triaging pain symptoms in cardiovascular patients through follow-up phone calls after their discharge from a large healthcare system in Central Massachusetts. We also discuss strategies that may help address the identified barriers.MethodsGuided by the Practical, Robust, Implementation and Sustainability Model (PRISM), we completed semi-structured interviews with 7 nurses and 16 patients in 2020. Selected nurses conducted (or supervised) post-discharge follow-up calls on behalf of 5 clinical teams (2 primary care; 3 cardiology). We used thematic analysis to identify themes from interviews and mapped them to the domains of the PRISM model.ResultsParticipants described common facilitators and barriers related to the four domains of PRISM: Intervention (I), Recipients (R), Implementation and Sustainability Infrastructure (ISI), and External Environment (EE). Facilitators include: (1) patients being willing to receive provider follow-up (R); (2) nurses experienced in symptom assessment (R); (3) good care coordination within individual clinical teams (R); (4) electronic health record system and call templates to support follow-up calls (ISI); and (5) national and institutional policies to support post-discharge follow-up (EE). Barriers include: (1) limitations of conducting symptom assessment by provider-initiated follow-up calls (I); (2) difficulty connecting patients and providers in a timely manner (R); (3) suboptimal coordination for transitional care among primary care and cardiology providers (R); and (4) lack of emphasis on post-discharge follow-up call reimbursement among cardiology clinics (EE). Specific barriers for pain assessment include: (1) concerns with pain medication misuse (R); and (2) no standardized pain assessment and triage protocol (ISI).ConclusionsStrategies to empower patients, facilitate timely patient-provider communication, and support care coordination regarding pain evaluation and treatment may reduce the barriers and improve processes and outcomes of pain assessment and triage.

Cardiotoxicity Associated with Chemotherapy Used in Gastrointestinal Tumours.

Cardiotoxicity is a well-recognised side effect of cancer-related therapies with a great impact on outcomes and quality of life in the cancer survivor population. The pathogenesis of chemotherapy-induced cardiotoxicity in patients with gastrointestinal cancers involves various molecular mechanisms, and the combined use of various chemotherapies augments the risk of each drug used alone. In terms of cardiotoxicity diagnosis, novel biomarkers, such as troponins, brain natriuretic peptide (BNP), myeloperoxidases and miRNAs have been recently assessed. Echocardiography is a noninvasive imaging method of choice for the primary assessment of chemotherapy-treated patients to generally evaluate the cardiovascular impact of these drugs. Novel echocardiography techniques, like three-dimensional and stress echocardiography, will improve diagnosis efficacy. Cardiac magnetic resonance (CMR) can evaluate cardiac morphology, function and wall structure. Corroborated data have shown the importance of CMR in the early evaluation of patients with gastrointestinal cancers, treated with anticancer drugs, but further studies are required to improve risk stratification in these patients. In this article, we review some important aspects concerning the cardiotoxicity of antineoplastic drugs used in gastrointestinal cancers. We also discuss the mechanism of cardiotoxicity, the role of biomarkers and the imaging methods used in its detection.

A Clinical Analysis of Extrapulmonary Complications in Novel Coronavirus Pneumonia Patients.

ObjectiveThis study aimed to investigate the clinical manifestation and treatment effects of extrapulmonary complications in cases of novel coronavirus pneumonia.MethodsThe clinical data of patients with novel coronavirus pneumonia who were admitted to Hanchuan People’s Hospital between January and March 2020 were retrospectively analyzed, and the clinical characteristics, laboratory test results, and treatment pathways of patients with extrapulmonary complications were analyzed and summarized.ResultsOf the 500 patients in this study, 97 patients with a history of chronic diseases were excluded, and 152 patients had extrapulmonary complications. Common extrapulmonary syndromes: 98 patients (64.47%) suffered from digestive system involvement; 43 patients (28.29%) suffered from cardiovascular system damage; 32 patients (21.05%) had urinary system damage; 25 patients (16.45%) had nervous system damage; and 30 patients (19.74%) had more than two kinds of system damage. In all cases, these patients were treated with comprehensive measures, and effective outcomes were achieved.ConclusionAccording to the clinical characteristics and laboratory test results of this sample group, early evaluation of patients with extrapulmonary complications and timely symptomatic treatment can effectively improve outcomes of pneumonia treatment, accelerate the alleviation of symptoms, and improve patients’ condition.

Early Evaluation of Patients on Axial Flow Pump Support for Refractory Cardiogenic Shock is Associated with Left Ventricular Recovery.

We investigated prognostic factors associated with refractory left ventricle (LV) failure leading to LV assist device (LVAD), heart transplant or death in patients on an axial flow pump support for cardiogenic shock (CS). Sixty-two CS patients with an Impella® CP or 5.0 implant were retrospectively enrolled, and clinical, biological, echocardiographic, coronarographic and management data were collected. They were compared according to the 30-day outcome. Patients were mainly male (n = 55, 89%), 58 ± 11 years old and most had no history of heart failure or coronary artery disease (70%). The main etiology of CS was acute coronary syndrome (n = 57, 92%). They presented with severe LV failure (LV ejection fraction (LVEF) 22 ± 9%), organ malperfusion (lactate 3.1 ± 2.1 mmol/L), and frequent use of inotropes, vasopressors, and mechanical ventilation (59, 66 and 30%, respectively). At 24 h, non-recovery was associated with higher total bilirubin (odds ratios (OR) 1.07 (1.00–1.14); p = 0.039), lower LVEF (OR 0.89 (0.81–0.96); p = 0.006) and the number of administrated amines (OR 4.31 (1.30–14.30); p = 0.016). Early evaluation in patients with CS with an axial flow pump implant may enable the identification of factors associated with an unlikely recovery and would call for early screening for LVAD or heart transplant.

The Value of 3-dimensional Speckle Tracking Echocardiography in the Diagnosis and Evaluation of Coronary Lesions in Stable Angina Pectoris Patients

Background: Echocardiography is the leading and feasible cardiac imaging in patients with cardiac disease. An early evaluation of patients with complex coronary lesions plays an important role in the prognosis and selection of treatment strategy. Objectives: To compare and determine the value of 3D speckle tracking echocardiography (3D SE) at rest in diagnosis of coronary artery disease (CAD) in stable angina pectoris patients using SYNTAX score as a reference. Patients and methods: A total of 90 patients with stable angina underwent invasive coronary angiography (CAG) enrolled into study from Islamic Cardiac Center at Al-Azhar University during the period from April 2017 to December 2019 and classified to case and control groups based on CAG results. Subjects underwent CAG and 3D-STE examination and SYNTAX score calculation, and then the patients were sub grouped according to SYNTAX score. Results: There was a significant difference in strain measurement (Global longitudinal, circumferential and radial strain) between SYNTAX score sub-groups. The absolute value of different strain measurements decreased from low SYNTAX score to intermediate or high SYNTAX scores. For GLS was -14.8±1.9%,-11.08±1.7 and -7.4 ±1.2, respectively, and for GAS was -39.5±1.08,-25.95±7.09 and -14.6±1.86, respectively, and for GCS was -24.47±3.89,-14.96±2.41 and -8.73± 2.53, respectively, using ROC curve analysis the cut off value of GLS that differentiate between high SYNTAX score (≥33) and non-high score (≤32) was -7.7 and -17.1 for GAS and -12.5 for GCS. The cut off value of GLS that differentiate between low SYNTAX score (≤22) and non-low score (≥23) was-12.5. Conclusion: Three-dimensional -STE is a noninvasive, reproducible, and efficient tool that has a potential clinical practice to evaluate the coronary lesion in chronic coronary syndrome patients. The absolute values of stain parameters were significantly associated with the complexity of coronary artery lesions.

A Case Study on the Utility of Transcranial Doppler Ultrasound in Acute Stroke Evaluation

The use of transcranial Doppler (TCD) ultrasound in the acute stage of large vessel occlusion diagnosis has, for a number of reasons, not seen widespread adoption. The high temporal fidelity of TCD provides information about the neurovasculature that neurological tests and standard computed tomography (CT) imaging cannot. This presents an opportunity in the early evaluation of patients that can help clinicians make informed decisions. The case study presented here illustrates the complementary information that TCD can provide in a situation where other available tests failed to fully elucidate the underlying pathology.

695 Time to Flexible Sigmoidoscopy or Colonoscopy in Patients Admitted With Ulcerative Colitis Has Decreased in the Past 5 Years

INTRODUCTION: Early evaluation of patients with ulcerative colitis (UC) with flexible sigmoidoscopy (FS) or colonoscopy (C) enables assessment of disease activity, exclusion of infectious pathogens, or other conditions that may present similarly to UC. Early FS is also associated with improved outcomes of patients with active UC. The aim of this study was to determine the temporal trends in timing of FS/C in relation to day of admission in patients with UC in the past 5 years. METHODS: Retrospective cohort study using the NIS 2012-2016. Patients with an ICD9-10 principal diagnosis code for UC were included. Elective admissions were excluded. FS/C were identified using ICD9-10 procedural codes. Early FS/C was defined as performed within 48 hours of admission. Primary outcome was to determine the trends in timing of FS/C in patients admitted for UC. Secondary outcomes were determining the odds of early FS/C, inpatient mortality, morbidity, hospitalization length (LOS), total hospitalization charges and costs in patients undergoing early vs. non-early FS/C. Logistic regression was used to adjust for gender, age, Charlson Comorbidity Index, median zip code income, hospital region, location, size and teaching status. RESULTS: 156,720 patients with UC and were included. 3,845 (2.5%) underwent FS and 18,835 (12.0%) underwent C. The mean age was 45.4 years and 53.4% were female. The mean time to FS decreased from 3.2 to 3.0 days, while the mean time to C decreased from 2.8 to 2.5 days in the study period (P = 0.05). The total FS/C increased from 1,155 (3.9%) to 11,727 (35.5%) from 2012 to 2016. 13.3% of patients underwent C at teaching vs. 9.8% at non-teaching centers, while 2.6% underwent FS at teaching vs. 2.1% at non-teaching centers (P = 0.05). Early FS/C was associated with decreased odds of shock and multiorgan failure, as well as decreased resource utilization and LOS (Tables 1 and 2). CONCLUSION: For this dataset, FS/C rates were low in hospitalized patients with UC but are performed more frequently and earlier in the course of an admission. The total number and proportional use of inpatient FS/C increased from 2012-2016. This may reflect an increasing awareness of improved outcomes from earlier disease staging and/or earlier diagnosis of alternate disease processes that can be treated in a timely manner. Early FS/C was also associated with decreased costs, charges and length of hospitalization. These findings further highlight the importance of early endoscopic intervention in patients admitted with UC.

Immediate Postnatal Ventricular Performance Is Associated with Mortality in Hypoplastic Left Heart Syndrome.

Right ventricular (RV) function as assessed by deformation has been evaluated prenatally and after palliation in hypoplastic left heart syndrome (HLHS). However, limited data exist about the immediate postnatal cardiac adaptation and RV function in HLHS. We compared echocardiographic measures of cardiac performance in HLHS versus controls in their first week of life. As a secondary objective, we evaluated if markers at the first echocardiogram were associated with mid- and long-term outcomes. Clinical and echocardiographic data of patients with HLHS between 2013 and 2016 were reviewed. The study population was matched with controls whose echocardiograms were obtained due to murmur or rule out coarctation. Speckle-tracking echocardiography was used to assess deformation. Thirty-four patients with HLHS and 28 controls were analyzed. Age at echocardiogram was similar between HLHS and controls. The RV of HLHS was compared to both RV and left ventricle (LV) of controls. HLHS deformation parameters [RV peak global longitudinal strain (GLS), global longitudinal strain rate (GLSR)] and tricuspid annular plane systolic excursion (TAPSE) were decreased compared to RV of controls. The LV-fractional area change, peak GLS, GLSR, circumferential strain, and strain rate of controls were higher than the RV of HLHS. Calculated cardiac output (CO) was higher in the HLHS group (592 vs. 183mL/kg/min, p = 0.0001) but similar to the combined LV and RV output of controls. Later mortality or cardiac transplantation was associated with the RV CO and RV stroke distance at initial echocardiogram. Cox proportional hazard regression determined that restriction at atrial septum, decreased initial RV stroke distance and decreased TAPSE had a higher risk of death or cardiac transplantation. TAPSE and RV stroke distance by velocity time integral had adequate inter-reader variability by Bland-Altman plot and Pearson's correlation. Our study found that the HLHS RV deformation is decreased in the early postnatal period when compared to both LV and RV of controls, but deformation was not associated with mid- and long-term outcomes. Later mortality or cardiac transplantation was associated with decreased initial stroke distance and cardiac output. Early evaluation of patients with HLHS should include an assessment of stroke distance and future research should evaluate its implication in management strategies.

Triage of the indeterminate thyroid aspirate: What are the options for the practicing cytopathologist?

Fine-needle aspiration (FNA) plays a key role in the early evaluation of patients with thyroid nodules; however, from 15% to 30% of FNA specimens are cytologically indeterminate. Molecular testing has proven useful when applied to indeterminate thyroid FNAs, and its use has been endorsed in the American Thyroid Association guidelines. In addition to the noncommercial ("in-house") application of v-Raf murine sarcoma viral oncogene homolog B1 (BRAF), rat sarcoma (RAS), rearranged in transformation/papillary thyroid carcinoma (RET/PTC), and peroxisome proliferator-activated receptor γ/paired box gene 8 (PPARγ/PAX8) testing, there are currently 3 commercially available molecular panels that vary in their relative reported performances, strengths, and limitations. Here, we discuss the role of molecular testing for indeterminate thyroid aspirates, taking into consideration the recent reclassification of the encapsulated follicular variant of papillary thyroid carcinoma (PTC) as "noninvasive follicular neoplasm with papillary-like nuclear features (NIFTP)." Cancer Cytopathol 2017;125(6 suppl):477-85. © 2017 American Cancer Society.

(18)F-Fluorocholine PET/CT for early response assessment in patients with metastatic castration-resistant prostate cancer treated with enzalutamide.

We investigated the role of (18)F-methylcholine (FCH) PET/CT in the early evaluation of patients with metastatic castration-resistant prostate cancer (mCRPC) treated with enzalutamide. The study group comprised 36 patients with a median age of 72 years (range 48-90 years) who were treated with enzalutamide 160 mg once daily after at least one chemotherapeutic regimen with docetaxel. Patients were evaluated monthly for serological prostate-specific antigen (PSA) response. FCH PET/CT was performed at baseline and repeated after 3-6 weeks. Univariate and multivariate Cox regression models addressed potential predictors of progression-free survival (PFS) and overall survival (OS). At a median follow-up of 24.2 months (range 1.8-27.3 months), 34 patients were evaluable for early FCH PET/CT evaluation of response, and of these 17 showed progressive disease (PD) and 17 had stable disease or a partial response. A decrease in PSA level of more than 50% was observed in 21 patients. Early FCH PET/CT PD predicted radiological PD 3 months in advance of CT in 12 of 18 patients (66%) and was discordant with the decrease in PSA level in 13 patients. In 6 of these, biochemical PD was confirmed in 2 months. In multivariate analysis, only decrease in PSA level and FCH PET/CT were significant predictors of PFS (p = 0.0005 and p = 0.029, respectively), whereas decrease in PSA level alone was predictive of OS (p = 0.007). This is one of the first studies to evaluate the role of FCH PET/CT as an early predictor of outcome in mCRPC patients treated with enzalutamide. Our preliminary results suggest that the combination of FCH PET/CT and decrease in PSA level could be a valid tool to predict PFS in mCRPC patients. PSA remains the single most important prognostic factor, while FCH PET/CT does not add more information on OS beyond that obtained from PSA. Further studies in larger populations are needed to confirm these data and to clarify the role of FCH PET/CT in predicting response to enzalutamide in mCRPC patients.