Hours Of Symptoms Research Articles

Multimodal Imaging Characteristics and Correlation to Outcomes in Patients with CRAO Presenting to a Large Academic Center

PurposeTo characterize a large modern cohort of patients with central retinal artery occlusion (CRAO) by describing presenting features and outcomes relating to manually segmented optical coherence tomography (OCT) features, angiographic reperfusion, and visual recovery. DesignRetrospective clinical cohort study. MethodsPatients with CRAO (ICD-10: H34.1) initially presenting to a tertiary referral center between January 2017 and December 2021 were included. Demographics, eye exam findings, fundus photographs, OCT, and fluorescein angiography (FA) were analyzed. Main outcome measures included total and inner retinal thickness on macular OCT, reperfusion, visual outcomes, and development of neovascularization. Results145 eyes of 144 patients with mean age at of 69.4±13.6 years were included. The mean time to presentation was 1.6±4.2 days, with 19% examined within 4.5 hours and 26% within 6 hours of vision loss. 19% had cilioretinal artery (CLRA) sparing. Mean initial visual acuity (VA) was 1.68±1.10 LogMAR (CLRA sparing) compared to 2.53±0.58 LogMAR (non-CLRA sparing), P<0.001. 32% had elevated inflammatory makers. Out of 47 eyes with final fluorescein angiography, one-third showed some reperfusion. Final vision was 1.40±1.16 LogMAR (CLRA sparing) compared to 2.46±0.81 (non-CLRA sparing), P<0.001. A third of patients improved in VA in both groups, 27% of patients gained more than 2 lines of vision in the CLRA sparing group and 36% in the non-CLRA sparing group. 17% improved to better than 20/200 in CLRA-sparing and 4% in non-CLRA sparing. 11% developed neovascularization all in non-CLRA sparing. In a multiple linear regression, VA at presentation was associated with regaining vision of 2 lines or more (OR=2.603, P=0.007). OCT showed progressive thinning over time, reaching lowest measurements at 6 months, and stabilizing thereafter. ConclusionsIn this modern cohort of acute CRAO patients, presentation to a tertiary facility within 12 hours of symptoms was seen in almost half of the patients. Final visual acuity improved in almost a third of the patients, however, vision better than the legal blindness limit was rare (∼5%). Interestingly, a third of patients had some mild elevation of systemic inflammatory markers. Better visual acuity at presentation was associated with visual gain, while baseline OCT values had poor correlation with final outcome.

Assessment of Early Laparoscopic Cholecystectomy in Management of Acute Calcular Cholecystitis

Abstract Background Acute cholecystitis is one of the most significant diseases in the Western world and has a high socioeconomic impact. Mainly, patients with gallstones and older adults are affected. The main complication of acute cholecystitis is recurrent biliary colic and cholestasis. The latter may lead to ascending cholangitis, and while this can be managed with antibiotics, other complications cannot be cured conservatively such as gangrenous changes, gall bladder perforation and biliary leakage, and acute necrotic gallstone pancreatitis. Liver abscesses and underlying incidental carcinoma have also been reported in some cases. Aim of the Work The purpose of this study is to focus on success rate of early laparoscopic cholecystectomy as a management of acute calcular cholecystitis along with its operative and post- operative outcomes. Patients and Methods This is a prospective cohort study conducted on forty (40) patients presenting to Ain-Shams University hospitals and authorized hospitals presented with acute calcular cholecystitis starting from January 2021 and December 2021. Results Our study demonstrates that in terms of morbidity and mortality, early laparoscopic cholecystectomy is safe, feasible and cost-effective for cases of acute cholecystitis. The outcome of the patients in our study provides further evidence that early laparoscopic cholecystectomy can be performed within the first 72 hours of symptoms with no significant increase in length of operation. Moreover, there was no significant increase in the rate of major intra operative or post operative complications such as bleeding, bile duct injury, bowel injury, wound infection and conversion to open cholecystectomy. The major advantage of early cholecystectomy was that early laparoscopic cholecystectomy allows significantly shorter total hospital stay and reduction in days away from work. Moreover, it avoids repeated admissions for recurrent symptoms. Conclusion Early laparoscopic cholecystectomy is safe, feasible and cost-effective for cases of acute cholecystitis and its major advantage is that it allows significantly shorter total hospital stay and reduction in days away from work and avoids repeated admissions for recurrent symptoms.

Impact of COVID-19 on acute appendicitis presentation, management and pathology findings in adult and paediatric populations.

We investigated the impact of the COVID-19 pandemic on trends of presentation, management and pathology findings in patients who underwent an appendicectomy for suspected acute appendicitis. The retrospective study reviewed patients (n = 939 adults and n = 329 children) who had an appendicectomy performed for suspected acute appendicitis and histopathology assessment in the Belfast Health and Social Care Trust, Northern Ireland. Pre-COVID-19 (March 2019 to February 2020) and COVID-19 Year 1 (March 2020 to February 2021) data were compared. Chi-squared tests were applied to compare timeframes. 513 adult appendicectomies were performed in the immediate year pre-COVID-19, compared to 426 in COVID-19 Year 1, representing a 17% reduction. No such reduction was seen within the paediatric population, likely related to a change in regional paediatric referral criteria during the pandemic. When comparing COVID-19 Year 1 with pre-pandemic, fewer patients presented with <24 hours of symptoms (45% v 53%, p = 0.005), and there was greater use of pre-operative computed tomography imaging in adults (63.2% v 48.7%, p<0.001). Fewer adult and paediatric cases of simple acute appendicitis and non-diagnostic specimens, with relative increased proportions of perforated acute appendicitis, were observed in COVID-19 Year 1 compared with pre-pandemic. No absolute increase in perforated acute appendicitis cases was observed in adults. Year 1 of the COVID-19 pandemic was associated with delayed presentation of acute appendicitis in adults and children. In adults, an overall reduction in appendicectomy operations, increased use of pre-operative diagnostic imaging, and fewer specimens showing simple acute appendicitis or non-diagnostic features, collectively support appropriate restriction of surgery for those patients with a more certain acute appendicitis diagnosis.

Abstract 89: Portable, Low-Field Magnetic Resonance Imaging: Determining Mismatch Following Acute Ischemic Stroke

Background and Aims: Treatment options for acute ischemic stroke (AIS) are uniquely dependent on the time of stroke onset. Intravenous thrombolysis must be administered within 4.5 hours of symptoms commencing, yet a subset of patients wake-up with symptoms and time of onset is unknown. Mismatch between fluid-attenuated inversion recovery (FLAIR) and diffusion-weighted imaging (DWI) MRI can be used to qualify wake-up strokes for thrombolysis. This has been shown to lead to improved functional outcomes in multicenter trials (WAKE-UP, MR-WITNESS). However, access to MRI is a barrier to differential diagnosis and subsequent treatment. Recent advances in portable, low-field MRI (LF-MRI) offer a solution to increase access to MRI technologies and circumvent the limitations of conventional systems. As such, in this pilot study, we sought to establish the utility of portable LF-MRI to identify DWI-FLAIR mismatch following AIS. Methods: Patients with a diagnosis of AIS presenting to Emergency Department or Intensive Care Unit of the Yale New Haven Hospital or Massachusetts General Hospital from January 2020 to June 2023 underwent DWI and FLAIR acquisition on a 0.064T MRI (Hyperfine Research Inc.) at &lt;4.5 hours ( n =7), 4.5-6 hours ( n =7), and 6-48 hours ( n =110) since last known well (LKW). Conventional high-field (HF) MR images were acquired within 72 hours of LF-MRI. HF-DWI images were co-registered to LF-FLAIR and the hyperintense DWI stroke lesion segmented and superimposed on the FLAIR. The segmentation was mirrored to the contralateral hemisphere of the LF-FLAIR to establish a FLAIR signal intensity ratio (SIR). Results: The FLAIR SIR on images &lt;4.5 hours since LKW was 0.98±0.08. The SIR for cases 4.5-6 hours was 1.34±0.33. Cases 6-48 hours produced a SIR of 1.56±0.36. The SIR at &lt;4.5 hours was significantly less than that observed &gt;6 hours since LKW ( p =0.03). Conclusion: This pilot study demonstrates that a 0.064T portable MRI is capable of distinguishing hyperacute stroke from later stroke onset using FLAIR SIR. Future research is needed in a larger cohort to determine if this imaging technology can be used to guide thrombolysis in the setting of wake-up stroke.

Abstract WP208: Infarction Size Affects Clinical Outcomes in Emergent Carotid Artery Stenting With Mechanical Thrombectomy

Background: Management of large vessel occlusion with extensive ipsilateral internal carotid artery (ICA) occlusion is unknown. We evaluated patients who underwent emergent carotid artery stenting (CAS) of the ICA with mechanical thrombectomy (MT). Methods: We retrospectively collected baseline demographic, clinical, and radiographic data on 27 patients who presented as a stroke alert within 24 hours of symptoms and had extensive (from bifurcation to distal ICA) occlusion by computerized tomography angiography from 2019-2023 at our institution. All patients underwent CAS with MT and received dual antiplatelet therapy. We measured outcomes by: (1) development of symptomatic ICH at 24 hours, (2) mortality, (3) Modified Rankin Scale (mRS) at 90 days, and (4) change in NIHSS at 24 hours. Baseline characteristics were reported by descriptive statistics. Statistical analyses were completed using Fisher’s exact test, Wilcoxon rank sum test, and logistic regression. Differences were statistically significant at p &lt; 0.05. Results: The mean age for our cohort was 64.5 ± 10.62 and nine patients were females (33.3%). Sixteen had M1 (59.3%) while 10 had M2 occlusion (37%), 14 patients received IV tPA (51.9%), and mean NIHSS at presentation was 15.6 ± 5.99. All patients achieved TICI 2b or TICI 3 recanalization. In our cohort, patients with lower ASPECT score 7.4 ± 1.8 compared to those with higher ASPECT score 9.0 ± 1.0 were more likely to have symptomatic ICH ( p = 0.032), and higher odds of mortality OR = 0.496, 95% CI (0.261-0.945). The development of symptomatic ICH at 24 hours following procedure was associated with severe disability (mRS 4-6) at 90 days ( p = 0.032). Administration of intravenous tPA was significantly associated with improvement of 4 or more points on NIHSS at 24 hours ( p = 0.032), but not with symptomatic ICH ( p = 0.419). Age, NIHSS at presentation, systolic blood pressure, and diabetes mellitus were not associated with mortality or symptomatic ICH. Conclusion: The area of infarction at the time of presentation (ASPECT score) is an essential factor in stratifying patient selection for emergent CAS during MT in extensive internal carotid artery occlusion. Further studies are needed to evaluate infarction size for safe interventions.

Wall motion score index and left ventricular ejection fraction as predictors of cardiovascular events after acute myocardial infarction

Background: Left ventricular ejection fraction serves as a vital gauge of left ventricular overall function and plays a crucial role in assessing the severity and prognosis of ischemic heart disease. Another approach for evaluating left ventricular function is through the assessment of regional function using the wall motion score index. In this study, our objective was to assess and compare the predictive value of both WMSI and LVEF in patients with Acute Myocardial Infarction for their ability to predict all-cause mortality and readmission due to heart failure. Methods: This prospective study was conducted on admitted patients in Government Kilpauk Medical College on 70 patients with Acute myocardial infarction between the first 48 hours of symptoms and before hospital discharge. Follow-up with clinic visits was conducted 3, 6 and 12 months after discharge. The primary endpoint was the composite of all-cause mortality and readmission for heart failure. Results: 63% of patients had LVEF of less than 40%, and 55% had WMSI&gt;1.5. After a follow-up of 1 year, 3.7% mortality and 11% readmission for heart failure were observed. WMSI&gt;1.5 and LVEF&lt;40% were associated with poor survival, while the WMSI proved to be a better predictor for rehospitalisation. 81% of STEMI group patients had EF&lt;40%, but only 18% of the NSTEMI group had EF &lt; 40%, which is statistically significant. There is no superiority between WMSI and LVEF in the STEMI and NSTEMI groups. Killip classification proved to be an independent predictor of mortality, but no statistical significance was observed in readmission. Conclusions: Both LVEF and WMSI were predictors of all-cause mortality, while the WMSI was a predictor for readmission for heart failure.

Relation of Monocyte Count to Thrombus Burden in ST-Segment Elevation Myocardial Infarction Patients Undergoing Primary Percutaneous Coronary Intervention

Objective: To determine the association of monocyte count to thrombus burden in ST-segment elevation myocardial infarction (STEMI) patients undergoing primary percutaneous coronary intervention (P-PCI). Method: This analytical, cross-sectional study was done in the Angiography Department of Rawalpindi Institute of Cardiology, Rawalpindi from October 30, 2020 to April 30, 2021. After taking ethical approval, 180 STEMI patients undergoing P-PCI who presented within 24 hours of symptoms were included using nonprobability convenient sampling. Informed written consent of the patients was obtained. Primary PCI with stenting was done and the thrombolysis in myocardial infarction (TIMI) scale was applied to determine intracoronary thrombus burden. The blood samples of patients were taken to estimate monocyte count. The data was analyzed through the Statistical Package for the Social Sciences (SPSS) version 25. Results: The frequency of thrombus burden was high in 71(39.4%) patients and low in 109(60.6%) patients. The monocyte count showed a significant difference in patients with high thrombus versus low thrombus burden. In low thrombus burden patients, the mean monocyte count was 0.49±0.50 and in high thrombus burden patients, the mean monocyte count was 0.64±0.48. The results of stratification of thrombus burden with age group showed significant p-value and with others showed non-significant p-value. Conclusion: The monocyte count is a reliable, inexpensive and simple-to-measure predictor of high thrombus burden in coronary arteries in STEMI patients undergoing primary PCI

A STUDY OF ENVIRONMENTAL IMPACT OF AIR POLLUTION ON HUMAN HEALTH: PM DEPOSITION MODELLING

&lt;p&gt;Earth is consisting of land, air and water. Air contains oxygen, nitrogen, carbon dioxide, water vapor, other gases are present above the permissible limit, and it creates effects on human health. It is one of the most important public health issues due to development of urbanization, industrialization and globalization in large cities. Air pollution levels in developed countries have been increased in recent years. In developing countries air pollution levels are still high. In recent years, the health studies have become visible showing harmful health effects in lungs and respirable system. Air pollution is responsible for 7million deaths annually. It affects the health of humans and other living beings in our world. The government has developed the guidelines for air quality and rule to restrict emissions in effort to control air pollution. These updated AQGs provide exact guidelines for PM 10 and pm 2.5. The primary objective of this paper is to study the ambient air quality and its impact on lungs. Particulate matters are the particles suspended in air/atmosphere. Mainly PM10and PM 2.5Ultra fine particles (&amp;lt;1µm) are mainly responsible for causing interruption for human health.PM10 and PM2.5 are characterized by their presence only within the upper respiratory tract. Some PM 2.5 and Ultra fine particles are characterized by their presence deeper regions of alveoli. Ultrafine particles (PM0.1), which are present in the air in large numbers, pose a health risk. They generally enter the body through the lungs but translocation to essential organs. Compared to fine particles (PM2.5) ,they cause more pulmonary inflammation and are retained longer in the lung. Their toxicity is increased with smaller size, larger surface area, adsorbed surface material, and the physical characteristics of the particles. Exposure to PM0.1 induces cough and worsens asthma. Metal fume fever is a systemic disease of lung inflammation most likely caused by PM0.1. The disease is manifested by systemic symptoms hours after severe exposure to PM0.1 could cause systemic inflammation, endothelial dysfunction, and coagulation changes that predispose individuals to cardiovascular disease and hypertension.&lt;/p&gt;&#x0D;

Abstract TP26: System-wide Implementation Of Computed Tomography Perfusion (CTP) Imaging

Background: Mechanical thrombectomy (MT) is effective for reducing morbidity in patients presenting within 24 hours of symptom onset with large vessel occlusion (LVO). Perfusion imaging is helpful in selecting patients in this extended time window. We report our experience of implementing CTP imaging in all our spokes and its impact on quality metrics and outcomes. Methods: Acute Stroke Imaging Protocol was updated to include CTP in addition to CT and CTA for all suspected stroke patients presenting within 24 hours of symptoms in April 2021 processed by RAPID AI (iSchema View inc, Menlo Park, CA, USA). Consecutive patients aged ≥18 years with suspected stroke presenting to regional spokes between Jan 2021 to Dec 2021 were included in the analysis. Demographics, NIHSS, quality metrics at regional facility (Door-to-thrombolysis, door-in-door-out times) and Comprehensive Stroke Center-CSC (door-to-arterial access, reperfusion rates (TICI IIb/III), hemorrhagic transformation) and functional outcomes (modified Rankin Scale, mRS) at 90 days were compared between the groups. Results: CTP studies were performed on 1113 patients between April 2021 and December 2021. RAPID AI processing identified LVO in 203 (18.7%) patients, of which 29 (14%) patients were included in this analysis; 14 patients were transferred to CSC for possible MT without CTP at regional facility and 15 were transferred with CTP at regional. Age (p=0.44), NIHSS (p=0.08) and onset-arrival time (p=0.54) were similar in both groups at the regional facility. Door to thrombolysis (p=0.13) and door-in-door-out (p=0.17) times were similar in both groups at the regional facility. CSC metrics of door-to-arterial access times (p=0.84), reperfusion (TICI IIB/III) (p=0.83) and hemorrhagic transformation (p=0.49) rates were similar between groups. 90 day good functional outcomes (mRS 0-2) were similar in patients undergoing thrombectomy (p=0.86). Conclusion: Our study suggests that AI supported perfusion imaging is feasible in a large stroke network and does not appear to have a significant impact on process times, quality metrics and outcomes. A larger study would need to be conducted to validate the observed results.

Implementation of a Regional STEMI Network in North Cairo (Egypt): Impact on The Management and Outcome of STEMI Patients.

Regional ST-segment-elevation myocardial infarction (STEMI) networks facilitate timely performance of primary percutaneous coronary intervention (PPCI), reduce mortality and improve outcomes. Few data exist on the feasibility and impact of regional STEMI networks in developing countries. The aim of this study was to examine the feasibility and impact of establishing a regional STEMI network on the management and outcomes of STEMI patients in north Cairo. A prospective observational study conducted on 352 patients presenting in North Cairo with confirmed diagnosis of STEMI within 48 hours of symptoms. Patients were divided into group I (n = 140) before and group II (n = 212) after establishment of the STEMI network. Both groups were compared as regards patients' demographics, presentation, management and short-term outcomes. The north Cairo regional STEMI network was established among four governmental hospitals and the governmental ambulance was used for interhospital transfer. WhatsApp® was used for trans-network team communication. Mean age of the study population was 55.4 ± 11.02 years and 286 (81.3%) were males. Mean time from chest pain to first medical contact did not change between the two groups (240 minutes; P = 0.36) while door to balloon mean time was reduced (from 54.3 to 44.1 minutes: P = 0.01). Use of thrombolytic therapy declined from 51 (36.4%) to 16 (7.5%) (P < 0.001) while primary PCI increased from 59.8% to 77.1% (p < 0.001). Left ventricular ejection fraction improved from 51.3 ± 10.7 to 55.4 ± 9.1 (P < 0.001), the mean time of CCU stay was reduced from a mean of 3.0 to 2.0 days (P < 0.001) and in-hospital mortality improved from 6.4% to 2.8% (P = 0.10). The establishment of the STEMI network in north Cairo was feasible and improved patients' outcomes. Use of primary PCI increased and in-hospital mortality improved from after establishment of STEMI network.

Simple and Swift Acute Ischemic Stroke Therapy based on Cases and Evidence: Possibilities of Cost Reduction and Improving Global Access

There have been significant improvement in the care of acute ischemic stroke (AIS) resulting in reducing death and improving outcomes. Numerous groundbreaking positive randomized controlled trials have demonstrated that strokes with large vessel occlusion (LVO) treated with endovascular mechanical thrombectomy (EVMT) with standard treatment are associated with much better outcomes compared to those treated only with standard therapy. Additional evidence also revealed that the positive outcomes continue to persists for stroke patients with large vessels occlusion if they are treated with 24 hours of symptoms including those with wake-up stroke. The evidence suggests that for every two-patient treated with EVMT, one patient can be saved, which is the highest evidence in the medicine surpassing acute myocardial infarction and other acute lifesaving therapies. Based on these evidence, the local, National and International organizations have updated the guidelines in the treatment of AIS which have remarkably strengthen the process, pathways and standards for acute ischemic stroke management in the developed countries. However, not much progresses have made in the developing and third-world countries for stroke therapies, because of cost, affordability and there are no third-party payers. Most recent trials have further discovered that stroke patient with LVO and a large core volume treated with endovascular perfusion therapy in conjunction with standard treatment do significantly better comparted to standard treatment alone. New trials have also demonstrated that stroke patients undergoing EVMT with or without thrombolytic have equal functional outcome. Additional evidence suggests that non-disabling stroke patients treated with dual antiplatelet have equal functional outcome with less bleeding risk compared to intravenous thrombolysis. These evolving evidences have provided us with the opportunities to simplify the algorithm and treatment of acute ischemic stroke, which not only will cutdown time by eliminating unnecessary steps and redundant therapies, but also will reduce the healthcare cost and improving global access, specially, countries where patients bear the costs. In this review, author presents real life stroke patients treated based on recent evidence and provides with a simple and swift algorithm, that will reduce time to perfusion therapy and will make treatment affordable globally.

Pregnancy-Associated Ovarian Torsion - a Single-Center Case-Control Study.

The etiology of OT is largely unknown. Any predisposition to rotation of the infundibulopelvic ligament and utero-ovarian ligament should be considered a possible etiology. Information with respect to ovarian torsion (OT) among pregnant is underreported and based on small studies. We aim to compare characteristics of confirmed OT to laparoscopies performed for the indication of suspected OT, in which no OT was found among pregnant women. This is a retrospective case-control study. We included pregnant women who underwent laparoscopy for a suspected OT between March 2011 and August 2020. Pregnant women with confirmed OT (torsion group) were compared to those without (no torsion group). There were 169 women with suspected OT. OT was confirmed in 140 (82.8%) women. There was higher proportion of assisted reproductive technology (ART) gestation in the torsion group [76 (54.3%) vs. 5 (17.2%), p < 0.001]. The rate of pregnant approaching evaluation within 8h of symptoms onset was higher in the torsion group [57 (40.7%) vs. 2 (6.9%), p < 0.001]. The mean visual analogue score (VAS) was higher in the torsion group (8.5 vs. 7.1, p = 0.002). The mean pulse was lower in the torsion group (79 vs. 88bpm, p < 0.001). From sonographic characteristics examined, the following was higher in the torsion group; mean maximal size of the ovary (70mm in the torsion group vs. 54mm in the no torsion group, p = 0.011). In a multivariable logistic regression analysis, number of hours of symptoms was negatively associated with AT [aOR, 95% CI 0.95 (0.91-0.98)] and pulse was negatively associated with OT [aOR, 95% CI 0.78 (0.63-0.95)]. Among the 29 cases in which no OT was found during laparoscopy, the following findings were noted: 16 (55.2%) no abnormality at all, 5 (17.2%) functional ovarian cyst, 2 (6.9%) mature teratoma and 6 cases of peritoneal adhesions (20.7%). The time from pain onset to approaching evaluation and women's pulse should be considered and acknowledged in the evaluation of OT during pregnancy.

Early Recognition of Pediatric Strokes in the Emergency Department: Epidemiology, Clinical Presentation, and Factors Impeding Stroke Diagnosis in Children

Purpose: Strokes are challenging to diagnose in pediatric emergency departments (EDs) as level of suspicion is low and atypical presentations are common. We analyzed clinical features, epidemiology and factors of delayed identification in arterial ischemic strokes (AIS) and hemorrhagic strokes (HS). Methods: Single-centre retrospective cohort study of children aged between 29 days and 18 years old diagnosed with stroke between July 2016 to June 2021. Results: Among 36 children, 11 (30.5%) had AIS, 25 (69.4%) had HS. Median age for AIS was 9 years (interquartile range [IQR], 2 to 9) and HS 9 years (IQR, 1 to 11.5) (P=0.715). Focal neurological deficit was seen in 72.7% of AIS and 20% of HS (P=0.006). Only 18.2% of AIS and 52.0% of HS presented within 6 hours of symptoms. Median time from symptom onset to ED presentation was 24 hours (IQR, 12 to 28) for AIS and 7 hours (IQR, 1.8 to 48) for HS (P=0.595). Most (85.6%) arrived by own transport. Median time from presentation to neuroimaging was 7 hours (IQR, 0.9 to 7) for AIS and 4.8 (IQR, 1.3 to 16.8) hours for HS (P=0.376). Eleven patients, 9/25 (36.0%) HS and 2/11 (18.2%) AIS, did not have stroke as differential diagnosis at ED (P=0.714). Common initial diagnoses were viral illness or headaches. On univariate analysis, age &lt;1 (odds ratio [OR], 17.5; 95% confidence interval [CI], 1.2 to 250.4; P=0.035) and absence of focal neurological deficit (OR, 13.091; 95% CI, 1.5 to 117.9; P=0.022) were significant factors for delayed identification. Conclusion: Index of suspicion for pediatric strokes among caregivers and clinicians should be increased. Public awareness campaigns are recommended.

When the ECG Tells the Story, But It is Not Heard

A 42-year-old woman was awoken by chest pain and dyspnea around 3 AM. She called EMS after approximately 1 hour of symptoms. An ECG was recorded, and the EMS team consulted an interventional cardiac center.

Outcomes of Patients Receiving Thrombolysis in a Mobile Stroke Unit: A 4-Year Retrospective, Observational, Single-Center Study

Background and Purpose Patients with acute ischemic stroke (AIS) eligible for thrombolysis benefit when thrombolysis is administered quickly, and mobile stroke units (MSU) can facilitate timely thrombolysis. We sought to compare time metrics and clinical outcomes of AIS patients receiving thrombolysis in an MSU compared with patients arriving via local emergency medical services (EMS). Methods We performed a retrospective, non-randomized, cohort study comparing MSU-arriving to EMS-arriving AIS patients from January 20, 2017 through November 30, 2020. The primary outcome was rate of return to baseline functional status as measured by the modified Rankin Score (mRS) 90 days after thrombolysis. Secondary outcomes included evaluation and treatment intervals from last known well, treatment rate in the first hour of symptoms, hospital length of stay, and mortality. Chi square and Student’s t-test were used to compare groups. Results Of 1752 total patients with prehospital suspected stroke, 975 (55.7%) were transported via MSU, of whom 431 (44.2%) were diagnosed with stroke, including 368 (85.4%) with AIS, and 69 AIS patients (18.8%) received thrombolysis. Of 777 (44.3%) EMS-arriving patients, 373 (48%) were diagnosed with stroke, including 305 (81.8%) with AIS, and 74 (24.3%) received thrombolysis. Though not statistically significant, point estimates of the proportion of AIS patients treated with thrombolysis returning to baseline functional status were more commonly observed for MSU than for EMS transports when the baseline mRS was 0-2 (45.8% vs 33.3%), 0-3 (41.9% vs 33.3%), and 4-5 (71.4% vs 20.0%). MSU patients were more likely to receive thrombolysis in the first 60 minutes of symptom onset (31.9% vs 12.2%, p = 0.006). Overall mortality rates regardless of baseline mRS were similar between groups. Conclusions AIS patients received thrombolysis faster in the MSU compared with EMS and more frequently within 60 minutes of stroke onset. Point estimates for 90-day clinical outcomes of AIS patients treated with thrombolysis favored MSU without a statistically significant difference.

238 THE IMPACT OF COVID-19 ON ACUTE STROKE TREATMENT

Abstract Background Acute stroke management is time critical. Treatment options are dictated by time of symptom onset. 2019 Irish National Audit of Stroke (INAS) showed less than 50% stroke cases arrived in hospital within three hours of symptoms and national average rate of thrombolysis was 11%. The median time Door-To-Needle time (DTN) was 56 minutes, and to thrombectomy 93 and 240 minutes ‘direct to mothership’ / ‘drip and ship’ transfer to thrombectomy centre respectively. Methods Retrospective review of all stroke FAST calls on our acute stroke database in TUH from July 2019 -2021. Data was analysed pre (up until March 2020) and during COVID-19 pandemic. Results FAST protocol imaging was obtained in 78% of cases (464/594). Documented time of symptom onset to CT was 1:50:00 pre-Covid-19 and 2:26:00 during Covid (p&amp;lt;0.001). ED registration to CT was 28mins pre-Covid-19 and 30mins during Covid (p&amp;lt;0.001). The median DTN time was 41mins pre-Covid-19 (n=21), and 54mins during Covid-19 (n=37). Conclusion In contrast to INAS COVID-19 report, median DTN times and thrombolysis rates dis-improved at TUH. Trends observed probably reflect multiple factors; patient hesitation to attend ED; patient isolation from family; busier ambulance service; Infection control protocols. We observed small but significant change in door-to-CT time but a more significant increase in DTN. This may reflect time taken donning Personal Protective Equipment (PPE) or general increased ED activity. Understanding the impact of COVID-19 on acute stroke treatment metrics in addition to differences at sites may identify targets for national quality improvement in service delivery.

Sensitivity and Diagnostic Yield of the First SARS-CoV-2 Nucleic Acid Amplification Test Performed for Patients Presenting to the Hospital

Early and accurate diagnostic testing for SARS-CoV-2 is essential to initiate appropriate treatment and infection control and prevention measures among patients presenting to the hospital. To evaluate the diagnostic sensitivity of the SARS-CoV-2 nucleic acid amplification test (NAAT) performed within 24 hours of arrival to the emergency department among a nationally representative sample of patients. This diagnostic study was conducted at 47 hospitals across 7 provinces in Canada participating in the Canadian COVID-19 Rapid Response Emergency Department Network among consecutive eligible patients presenting to a participating emergency department who were tested for SARS-CoV-2 from March 1, 2020, to December 31, 2021. Patients not tested within 24 hours of arrival and those presenting with a positive result from a test performed in the community were excluded. The primary outcome was a positive result from the SARS-CoV-2 NAAT. Outcome measures were the diagnostic sensitivity and yield of the SARS-CoV-2 NAAT. Of 132 760 eligible patients (66 433 women [50.0%]; median age, 57 years [IQR, 37-74 years]), 17 174 (12.9%) tested positive for SARS-CoV-2 within 14 days of their first NAAT. The diagnostic sensitivity of the SARS-CoV-2 NAAT was 96.2% (17 070 of 17 740 [95% CI, 95.9%-96.4%]) among all of the tests performed. Estimates ranged from a high of 97.7% (1710 of 1751 [95% CI, 96.8%-98.3%]) on day 2 of symptoms to a low of 90.4% (170 of 188 [95% CI, 85.3%-94.2%]) on day 11 of symptoms among patients presenting with COVID-19 symptoms. Among patients reporting COVID-19 symptoms, the sensitivity of the SARS-CoV-2 NAAT was 97.1% (11 870 of 12 225 [95% CI, 96.7%-97.3%]) compared with 87.6% (812 of 927 [95% CI, 85.2%-89.6%]) among patients without COVID-19 symptoms. The diagnostic yield of the SARS-CoV-2 NAAT was 12.0% (18 985 of 158 004 [95% CI, 11.8%-12.2%]) and varied from a high of 20.0% (445 of 2229 [95% CI, 18.3%-21.6%]) among patients tested on day 10 after symptom onset to a low of 8.1% (1686 of 20 719 [95% CI, 7.7%-8.5%]) among patients presenting within the first 24 hours of symptom onset. This study suggests that the diagnostic sensitivity was high for the first SARS-CoV-2 NAAT performed in the hospital and did not vary significantly by symptom duration. Repeated testing of patients with negative test results should be avoided unless their pretest probability of disease is high.

Comparative Laparoscopic Cholecystectomy in Acute Cholecystitis in DHQ Abbottabad, KP-Pakistan

Background: Early laparoscopic cholecystectomy before 72 hours is ideal for the treatment of acute cholecystitis after 72 hours, acute or ongoing fibrosis presents careful issues. Aim: To compare the results of an acute cholecystitis blood pressure monitoring center and a specialist acute surgical service 72 hours after symptoms. Study design: Cross-sectional study. Place and duration of study: Department of General Surgery Benazir Bhutto Shaheed Hospital, (DHQ) Abbottabad from 1st October 2021 to 30th March 2022. Methodology: One hundred and eighty acute cholecystectomy patients who went through CEL were enrolled. Record was gathered which included postoperative confusions, length of medical clinic stay, and season of a medical procedure. To get comparable outcomes, subgroup examination of older patients was performed. Results: Eighty operations were performed within 72 hours of symptoms and 100 operations were performed after 72 hours, Patients who received early laparoscopic cholecystectomy for more than 72 hours had longer complication-free time” (125.4 vs. 116 minutes, P=0.035) and hospital stay (4.59 vs. 3.09 days, P=0.001). Postoperative sampling was higher in patients older than 75 years (P &lt; 0.001). Conclusion: Acute cholecystitis patients going through CLE in a careful unit might accomplish improved results even following 72 hours of side effects. In a subset of older patients, extensive hemostasis ought to be performed. Keywords: Acute cholecystitis, early laparoscopic cholecystectomy (ELC)

Influence of pre-endoscopic duration of esophageal food impaction on endoscopy time and postprocedure adverse events

ObjectivesEsophageal food bolus impaction is a medical emergency and 10-20% of impacted food boluses will require endoscopic removal. Emergent and prolonged procedures are associated with increased adverse events. We are interested in the relationship between the pre-endoscopic duration of esophageal food impaction and the duration of esophagogastroduodenoscopy (EGD) performed to remove the impacted food bolus.MethodsBetween 2010 and 2021, we examined EGD procedures performed for esophageal food impaction. Subjects were classified according to pre-endoscopic duration of food impaction.ResultsWe found a positive correlation between pre-endoscopic duration of food impaction and procedure length (r=0.18). Esophageal impactions with mixed foods resulted in the longest procedure duration (p&amp;lt;0.05). Increasing age, male gender, and duration of impaction greater than 42 hours were significantly associated with increased procedure duration (p&amp;lt;0.05). Esophageal perforations, prolonged intubations, admissions following EGD, and readmissions were associated with EGD duration greater than 25.5 minutes. No adverse events occurred in patients who underwent EGD within 6 hours of symptom onset.ConclusionsIn the case of an esophageal food impaction, the time between symptom onset and endoscopy is positively correlated with procedure length and risk of adverse outcomes. We suggest that food impaction should remain an indication for emergent endoscopy. Prospective studies evaluating the safety and outcomes of prolonged time to endoscopy will further clarify the management of esophageal food impactions.

Predictors of No-Reflow in Patients undergoing Primary Percutaneous Coronary Intervention for Acute ST Elevation Myocardial Infarction at Tabba Heart Institute Karachi

Aim: To determine the predictors of no-reflow in patients undergoing Primary Percutaneous Coronary Intervention (PPCI) for acute ST elevation myocardial infarction (STEMI) at Tabba Heart Institute Karachi. Study duration: The study was carried out from September 2020 to September 2021. Methods: An observational study that was conducted at Tabba heart Institute Karachi. All patients with acute ST elevation myocardial infarction (STEMI) presenting within 12 hours of symptoms who undergoing primary PCI were included in the study. The patients were categorized Angiographically as no –reflow (with Thrombolysis in Myocardial Infarction (TIMI) &lt;3 and reflow (TIMI-3) flow groups. The data regarding age and gender, type of MI, time from symptoms onset, co-morbid conditions like diabetes mellitus, hypertension, smoking, baseline Thrombolysis In Myocardial Infarction Trials (TIMI flow), infarct related artery (IRA), diameter of stent used, and the TIMI flow in IRA after the completion of procedure but before the use of intracoronary adenosine if needed, was recorded on a pre-designed proforma. The data was analyzed using SPSS 20.0. Results: Total 296 patients who underwent primary PCI after acute MI were enrolled in the study. Mean age of the study population was 57±11 years. No reflow was present in 31.4% of patients. No reflow was more common in patients with age more than 60 years, females, symptom onset to primary PCI time of more than 6 hours, LAD infarct, and baseline TIMI flow &lt; 2. Conclusion: During primary PCI, no reflow occurs in a significant percentage of patients and is predictable by a number of factors which should be kept in mind to minimize the incidence of no reflow. Key words: No reflow, acute myocardial infarction, primary PCI