Initial Blood Tests Research Articles

Delayed Colonoscopy Following a Positive Fecal Test Result and Cancer Mortality.

BackgroundA fecal test followed by diagnostic colonoscopy for a positive result is a widely endorsed screening strategy for colorectal cancer (CRC). However, the relationship between the time delay from the positive test to the follow-up colonoscopy and CRC mortality has not been established.MethodsFrom a population-based screening program, we identified CRC patients newly diagnosed from 2005 through 2015 by a positive fecal occult test followed by a colonoscopy. The primary outcome measure was CRC-specific mortality according to four categories for the time elapsed between the positive result and the subsequent colonoscopy.ResultsThe 1749 patients underwent colonoscopies within 0–3 months (n = 981, 56.1%), 4–6 months (n = 307, 17.5%), 7–12 months (n = 157, 9.0%), and later than 12 months (n = 304, 17.4%). CRC-specific deaths according to exposure groups were: 13.8% (135 of 981) for 0–3 months, 10.7% (33 of 307) for 4–6 months (crude hazards ratio [HR] = 0.74, 95% confidence interval [CI] = 0.51 to 1.14), 11.5% (18 of 157) for 7–12 months (crude HR = 0.83, 95% CI = 0.51 to 1.42), and 22.7% (69 of 304) for longer than 12 months (crude HR = 1.40, 95% CI = 1.04 to 1.90). The only variable that was associated with mortality risk was the number of positive slides (P = .003). High positivity was twice the value in the 0–3 as the longer-than-12 months group: 51.9% vs 25.0% and similar for the 4–6 and 7–12 months groups (38.1% and 36.5%), respectively. The adjusted HRs for CRC mortality were 0.81 (95% CI = 0.55 to 1.19); 0.83 (95% CI = 0.50 to 1.41), and 1.53 (95% CI = 1.13 to 2.12, P = .006) for the 4–12, 7–12, and longer-than-12-months groups, respectively, compared with the shortest delay group.ConclusionsAmong screen-diagnosed CRC patients, performance of colonoscopy more than 12 months after the initial positive fecal occult blood test was associated with more advanced disease and higher mortality due to CRC.

Determinants of non-participation in colon examination following positive stool sample in colorectal cancer screening.

Social inequalities has been shown for participation in colorectal cancer screening and recently in the initial stool sample blood test. If these differences persist at follow-up colon examination after a positive stool test, it would suggest that social inequality in screening may be greater than the inequality observed in initial stool sample blood test. All data were derived from national registers. Using logistic regression analyses, odds of non-participation for follow-up colon examination were estimated based on age group, educational level, income quartile, immigration status and marital status in men and in women, who had participated in initial stool sample test for blood with a positive result. Among 20 849 men and 16 565 women invited for follow-up colonoscopy in the period 2014-15, 10.63 and 11.37%, respectively, did not attend. In men, odds of non-participation were higher in the eldest, those with lower income and lower educational level, in immigrants and in singles. Odds ratio (OR) in males of highest income quartile was 0.54 [95% confidence interval (CI) 0.46; 0.63] compared with lowest income quartile. In women, the differences were not as large. OR in females of highest income quartile was 0.73 (95% CI 0.61; 0.87) compared with lowest income quartile. Sociodemographic differences in odds of non-participation exist in follow-up colon examination in the Danish colorectal cancer screening. Differences were evident in all subgroups of the male population. The same patterns were seen in women. Social inequalities in participation for follow-up colon examination can increase overall social inequality and consequently, lead to health disparities.

SUN-LB098 Mimic Presentation of Neuromuscular Symptoms in Thyrotoxic Periodic Paralysis in Hispanic Male

Introduction: Thyrotoxic periodic paralysis (TPP) is a rare condition characterized by sudden paralysis with profound hypokalemia. Clinical Case: A 34 year-old obese Hispanic male presented to ED with sudden onset of generalized weakness and numbness of bilateral upper & lower extremities for one day. The patient was not able to get up when he woke up in the morning. He described having blurry vision, more severe on the right side, which was associated with right retroocular pain. He reported over twenty pounds of weight loss within past two months, accompanied with intermittent episodes of watery diarrhea, palpitations, restlessness, mild headache, and dizziness. He denied loss of consciousness, urinary or fecal incontinence, fever, cough or recent respiratory infection. Past medical history included gastritis. He reported no recent trauma, injury or hospitalization. No smoking, alcohol abuse or illicit drug use. On physical examination, the patient was having mild respiratory distress. Right eye exophthalmos and normal cardiopulmonary examination were noted. Neck examination showed no thyroid gland enlargement. Neurological findings revealed cranial nerve and sensory examination intact, but all four limbs were flaccid and motor strength of all extremities was 1/5. Deep tendon reflex was absent. Initial blood test on admission showed Potassium 1.9 mmol/l, Phosphorus 2 mg/dl, Magnesium 1.9 mg/dl, Lactic acid 4.6 mmol/l, TSH 0.005 mIU/l, Free T3: 8.80 pg/ml, Free T4: 2.3 ng/ml, and TBG 14.1 mcg/dl. Thyroid peroxidase was positive. EKG revealed sinus tachycardia. ABG indicated primary respiratory acidosis. Lumbar puncture was normal and ruled out Guillain-Barré syndrome and, viral or bacterial meningitis. Thyroid sonogram showed heterogeneous thyroid with no nodules. CT head without contrast showed no evidence of intracranial hemorrhage. MRI brain revealed no intracranial mass. MRI lumbar & thoracic spine showed a normal finding. After the aggressive replacement of potassium chloride, the muscle weakness improved significantly, and methimazole was initiated. The patient was admitted to ICU for close monitoring and electrolyte management. Conclusion: Thyrotoxicosis periodic paralysis (TPP) is a rare condition that manifests through acute paralysis, and hypokalemia in the presence of hyperthyroidism (1). It is usually found in relatively young Asian population, but also the occurrence has increased in the Hispanic population recently. Early recognition of TPP in a patient with unexplained hypokalemia and painless generalized weakness, is imperative to demand thyroid studies to rule out this condition. Close electrolyte management is important rebound hyperkalemia and life-threatening arrhythmias. Reference: (1) Meseeha M et al. Thyrotoxic periodic paralysis: a case study and review of the literature. J Community Hosp Intern Med Perspect. 2017;7(2):103-106. Unless otherwise noted, all abstracts presented at ENDO are embargoed until the date and time of presentation. For oral presentations, the abstracts are embargoed until the session begins. s presented at a news conference are embargoed until the date and time of the news conference. The Endocrine Society reserves the right to lift the embargo on specific abstracts that are selected for promotion prior to or during ENDO.

SUN-278 Neonatal Diabetes in an Infant with Heterozygous Mutation in KCNJ11 Gene

Background: Neonatal Diabetes is a rare form of monogenic diabetes that usually presents with hyperglycemia within the first 6 months of life. These infants usually are small for gestational age at birth. Unlike autoimmune diabetes, development of diabetic ketoacidosis (DKA) is extremely rare in this age group. We present a case of neonatal diabetes in a 3 month old, who presented in DKA. Genetic testing confirmed Kir6.2 subunit mutation. Clinical Case: A 3 month old African American male born to non-consanguineous parents presented with respiratory distress and poor weight gain. Initial blood testing showed serum glucose of 810 mg/dl and pH of 6.9 on an arterial blood gas analysis. Septic workup excluded infectious etiology. Antenatal history was significant for oligohydramnios. Birth history was unremarkable. He was born full term with birth weight of 2,579 grams. Physical examination was normal except for signs of severe dehydration. Both height and weight were below the 3rd percentile. Patient was started on DKA protocol. At the time of discharge, good glycemic control was obtained with a combination of short acting and long acting insulin. Genetic testing on our patient showed missense mutation c.601C>T on KCNJ11 gene on the Kir6.2 subunit encoding for beta cell ATP-sensitive potassium channel. Tight glycemic control was maintained with Lantus and Humalog for few months. He was then transitioned to oral Glyburide (0.2 mg/kg/day). He maintained good glycemic control and continued to develop age appropriate milestones. Conclusion: Neonatal diabetes is rare condition that usually presents with poor weight gain with in first few months of life. If remain undetected, these babies can present with DKA. Autoimmune markers are negative and genetic testing can help differentiate between temporary and permanent types. This particular mutation in our patient usually causes permanent diabetes and has a higher incidence of DEND (Developmental Delay, Epilepsy, and neonatal Diabetes). Unlike Type 1 DM, patients with KCNJ11 mutation are responsive to sulphonylureas and can be weaned off insulin. These infants need close neurological monitoring as well.

SAT-594 A Metabolic Muddle : Thyrotoxicosis Causing Diabetic Ketoacidosis

INTRODUCTION: Diabetic Ketoacidosis (DKA) is a metabolic state developing in diabetic patients whenever a stressor shifts the metabolism towards ketogenesis with resultant metabolic acidosis. Common stressors for DKA are infections and medication non-compliance. We present a peculiar case of DKA which was precipitated by thyrotoxicosis. CASE DESCRIPTION: 32-year-old female with past medical history of Type 1 Diabetes Mellitus presented for evaluation of nausea, vomiting and chest pain. She reported as being compliant with her insulin regimen. Physical examination showed rapid breathing and acetone breath. Initial blood tests revealed elevated blood sugars at 745 MG/DL with a high anion gap metabolic acidosis. Beta hydroxybutyrate levels were elevated suggesting diabetic ketoacidosis. Rest of the workup to identify the precipitating cause, including urinalysis, EKG, Chest X ray had been negative. Another striking feature noted on patient's examination was bilateral exophthalmos. No thyroid enlargement was appreciated. A thyroid function panel was ordered which demonstrated elevated free T4 at 3.42 NG/DL (normal range 0.7-1.9 NG/DL), T3 at 26.01 PG/ML (normal range 1.7-3.71 PG/ML) and a depressed TSH level <0.01 mcIU/mL (normal range 0.35-.5 mcIU/ml) suggesting primary hyperthyroidism. Our patient improved upon administration of IV fluids and insulin with resultant closure of anion gap and resolution of DKA. Tachycardia persisted despite the resolution of DKA. Treatment was begun with propylthiouracil and propranolol to control thyrotoxicosis with remarkable improvement at the time of discharge. DISCUSSION: Treatment of Diabetic Ketoacidosis requires a thorough investigation of the precipitating event. In clinical practice, the most common triggers are noted to be infections like pneumonia and urinary tract infections, missed or inadequate insulin dose and myocardial infarction. Hyperthyroidism is rarely considered as a culprit for the same. In literature, there is only mention of few cases of hyperthyroidism causing DKA. Hyperthyroidism affects glucose and insulin metabolism in multiple ways. In untreated hyperthyroidism, proinsulin processing becomes abnormal resulting in a reduced C peptide to pro insulin ratio. Hyperthyroidism also leads to increased glucose absorption in the intestinal tract. Lastly, excessive thyroid hormone activity reduces the half-life of insulin via increased degradation into biologically inactive molecules. Our case emphasizes the need to consider thyrotoxicosis as an independent risk factor for development of DKA in appropriate clinical settings, especially when tachycardia persists despite resolution of DKA and infection has been ruled out. Women with Type 1 Diabetes have been found to have a higher prevalence of Graves’ disease. Correction of underlying hyperthyroidism decreases the insulin requirements in these patients.

Superior mesenteric artery syndrome coexists with Nutcracker syndrome in a female: a case report

BackgroundSuperior mesenteric artery (SMA) syndrome, also known as Wilkie’s syndrome or Benign duodenal stasis, is a rare benign disease. It could threaten the life if the manifestation is severe and the treatment is inappropriate. In the patients with SMA syndrome, the third portion (transverse part) of the duodenum is compressed externally between the SMA and abdominal aorta (AA) leading to duodenal stasis and gastrointestinal obstruction. SMA syndrome may rarely combine with Nutcracker syndrome when left renal vein (LRV) was compressed between SMA and AA.Case presentationA 32-year-old female patient presented with complaints of gradually severe bloating, epigastric pain, left flank ache, nausea and occasional vomiting of 1 month’s duration. The epigastric and left flank ache was aggravated when the patient was supine and relieved in a prone or left lateral decubitus. The abdominal bloating was associated with early satiety. The vomiting always started 40 min after meal. The patient gave a history of urine stone with drotaverine hydrochloride tablets treatment for two weeks before the gastrointestinal symptoms arising. The patient had no significant surgical history, but had a rapid weight loss of approximately 10 kg with a body mass index (BMI) from 21 kg/m2 to less than 18 kg/m2 over the last two months. An abdominal examination revealed upper abdominal tenderness and distention. The urine routine examination showed no significant abnormality. The findings of initial blood tests and other laboratory investigations were unremarkable.ConclusionsThis case reports a female patient with SMA syndrome with Nutcracker syndrome predisposed by Antispasmodics. We highlight the importance of the combination therapy of long-term nutritional supporting and prokinetic agents. Rehabilitating practice after discharge is beneficial to reduce recurrence.

Recurrent Aphthous Stomatitis as a Result of Zinc Deficiency.

The purpose of this study is to evaluate the results of patients, with a chief complaint of recurrent aphthous stomatitis (RAS), who were found to have zinc deficiency as the predisposing factor and received appropriate replacement therapy. A retrospective study was conducted using data from the medical records of patients with a chief complaint of RAS. Patients with potential ulcer-causing conditions were excluded. All patients were intraorally examined to rule out trauma-associated aetiologies. Blood tests were ordered to measure total blood count, serum transferrin, ferritin, zinc, folic acid and vitamin B12 levels. A total of 48 patients, 34 with zinc deficiency and 14 with both zinc and iron deficiencies, were included in this study. Patients received an initial three-monthly replacement treatment and blood tests for the certain deficiencies were repeated at the end of this time interval. Two patients with zinc deficiency reported no relief due to incorrect intake of tablets with milk. Following correct instructions, all patients reached normal serum mineral levels and reported no recurrences. All patients remained asymptomatic and their mineral levels were monitored in every 3 months to detect any abnormalities. Overall mean follow-up for this study was 12.06 months (range: 8-28 months, SD: ± 5.7). Zinc deficiency should be considered and investigated as part of the diagnostic process of RAS. A simple blood test may aid in correct diagnosis and complete resolution of this recurring condition rather than constant prescription of certain medicines to suppress the symptoms.

A Case Report of a Patient with Myelodysplastic Syndrome Who Has Lower Back Pain

Objectives This case aims to describe management of a patient with myelodysplasitc syndrome who has lower back pain. Methods A 75-year-old female patient with myelodysplasitc syndrome was hospitalized from February 28, 2018 to March 14, 2018. The patient was treated with Azacitidine at Bundangjyesaeng Hospital, and lower back pain worsened without any reason. The patient was willing to undergo traditional Korean medical treatment, and Wonyuksayuk-tang was chosen considering both hematopoiesis dysfunction and lower back pain. Results The patient was diagnosed with myelodysplatic syndrome after bone marrow aspiration and biopsy at Bundangjyesaeng Hospital. After the Wonyuksayuk-tang treatment, platelet levels increased about 50% compared with initial blood test results. In addition, lower back pain and general weakness were slightly improved. Conclusion It is important to manage the quality of life of patients with myelodysplastic syndrome. This case suggests that traditional Korean medicine has a beneficial effect on the management of myelodysplastic syndrome. Keywords: myelodysplastic syndrome, lower back pain, Wonyuksayuk-tang

Low mood, visual hallucinations, and falls \u2013 heralding the onset of rapidly progressive probable sporadic Creutzfeldt\u2013Jakob disease in a 73-year old: a case report

BackgroundCreutzfeldt–Jakob disease is a rare and rapidly fatal neurodegenerative disease. Since clinicians may see only very few cases during their professional career, it is important to be familiar with the clinical presentation and progression, to perform appropriate investigations, and allow for quick diagnosis.Case presentationA 73-year-old British Caucasian woman presented with acute confusion of 2 weeks’ duration on a background of low mood following a recent bereavement. Her symptoms included behavioral change, visual hallucinations, vertigo, and recent falls. She was mildly confused, with left-sided hyperreflexia, a wide-based gait, and intention tremor in her left upper limb. Initial blood tests, computed tomography, and magnetic resonance imaging of her brain showed no significant abnormality. Following admission, she had rapid cognitive decline and developed florid and progressive neurological signs; a diagnosis of prion disease was suspected. A lumbar puncture was performed; cerebrospinal fluid was positive for 14–3-3 protein, real-time quaking-induced conversion, and raised levels of s-100b proteins were detected. An electroencephalogram showed bilateral periodic triphasic waves on a slow background. The diagnosis of probable Creutzfeldt–Jakob disease was made.ConclusionsThis case report highlights key features in the initial presentation and clinical development of a rare but invariably rapidly progressive and fatal disease. It emphasizes the importance of considering a unifying diagnosis for multifaceted clinical presentations. Although it is very rare, Creutzfeldt–Jakob disease should be considered a diagnosis for a mixed neuropsychiatric presentation, particularly with rapid progressive cognitive decline and development of neurological signs. However, to avoid overlooking early signal change on magnetic resonance imaging, it is important to take diffusion-weighted magnetic resonance imaging for all patients with neuropsychological symptoms. Importantly, early diagnosis also ensures the arrangement of suitable contamination control measures to minimize the risk of infection to health care professionals and other patients.

Monomorphic ventricular tachycardia due to protease inhibitor intoxication by atazanavir.

Atazanavir is a protease inhibitor approved for use in combination with other antiretroviral drugs for the treatment of human immunodeficiency virus infection. Atazanavir and other protease inhibitors can sometimes induce corrected QT prolongation and ventricular arrhythmia. A 40-year-old man with no comorbidities, except human immunodeficiency virus 1 infection, presented with palpitations 3 days after an overdose of 150 caps of atazanavir, with suicidal intent. His initial electrocardiogram showed monomorphic ventricular tachycardia, and hyperbilirubinemia was observed in his initial blood test. Immediately after magnesium sulfate infusion, his ventricular tachycardia was converted into junctional bradycardia with prolonged corrected QT. After 3 days of close observation in the intensive care unit, the corrected QT prolongation and hyperbilirubinemia were normalized.

Thromboelastometric Profile and Acute Coagulopathy of the Polytraumatized Patient: Clinical and Prognostic Implications

IntroductionAbout 25%–35% of polytraumatized patients have a profound alteration of hemostasis on arrival at the hospital (acute traumatic coagulopathy [CAT]). Viscoelastic tests (ROTEM®) measure the hemostatic capacity and provide an early detection of CAT. The objectives of this study are to describe the initial thromboelastogram of these patients and to determine the prevalence of CAT according to predefined thromboelastographic profiles. MethodsSingle-center, observational, prospective study in polytraumatic patients. Initial blood and thromboelastographic test (ROTEM®) were made, and pre-hospital, hospital, transfusion, initial surgical/angiographic interventions, cardiac arrest and mortality data were collected. ROTEM®-based, patients were classified as: normal, hypercoagulable, hypocoagulable, hypocoagulable+hyperfibrinolytic and isolated hyperfibrinolysis. ResultsOne hundred and twenty-three patients were analyzed. 32 cases (26%) with CAT: 15 patients with hypocoagulability, 9 with hyperfibrinolysis alone and 8 with hypocoagulability+hyperfibrinolysis. The CAT group, related to the normal group, presented higher ISS (23 vs 16, P<.01), higher blood products transfusion (2.5 vs 0; P=.001), more cardiac arrest (19 vs 1%, P<.01), and higher mortality (34 vs 5%, P<.01). The subgroup with hypocoagulability/hyperfibrinolysis, related to the groups with hypocoagulability or hyperfibrinolysis alone, presented a higher ISS (41 vs 25 vs 15, P<.01), higher angiographic procedures (62% vs 13% vs 0%, P<.01) and higher mortality (75% vs 33% vs 0%, P=.05). ConclusionsTwenty-six percent of the polytrauma patients presented early coagulopathy assessed by thromboelastography. It is associated with higher consumption of blood products and lower survival. The presence of hypocoagulability+hyperfibrinolysis is associated with greater severity and a higher requirement of blood products.

Hepatic transaminases as predictors of liver injury in abdominal trauma

Background: Our aim was to determine the usefulness of hepatic transaminases as hematological markers to predict the presence and severity of liver injury in adult patients with abdominal trauma.Methods: This is a retrospective study of patients admitted with abdominal trauma (blunt and penetrating) over a three-year period. Grading of liver injury was based on CT-scan or surgical findings. Patients in whom liver enzymes were estimated in the first 48 hours were included.Results: Out of the 66 patients in the study, 23 (63.89%) patients had minor liver injuries, while 13 (36.11%) had major liver injuries. Injury was blunt in 63 (95.45%) and penetrating in 3 (4.54%) patients. The mortality rate was 7.57% (n=5). The median SGOT and SGPT levels in the liver injury group were higher than those in the non-liver injury group SGOT (209LI vs. 43.5) U/L and SGPT (283.22 vs. 72.97) U/L, respectively, (p=0.001). Receiver operating characteristic (ROC) curve assessment, showed the optimum SGOT and SGPT thresholds to be &gt;112.5 and &gt;120.5U/L respectively, which were strongly associated with the presence of liver injuries. There was significant correlation between liver transaminases with grade of liver injury, SGOT (p=0.013) and SGPT (p=0.004).Conclusions: SGOT and SGPT values &gt;112.5 and &gt;120.5U/L respectively, are strongly suggestive of liver injury. Hepatic transaminases are useful screening hematological markers for liver injuries and should be included in the initial trauma blood test panel and may guide in the decision making especially in medical centers with limited facilities.

Cytomegalovirus-mononucleosis-induced thyroiditis in an immunocompetent patient.

Enteroviruses, including coxsackieviruses and Echovirus, are well known pathogens responsible for the development of thyroiditis. We describe the case of a 49-year-old woman with no personal or family history of thyroid disease who presented to the emergency room with a two-week history of daily fevers up to 39°C, a sore throat, occasional palpitations and diaphoresis, decreased appetite and an unintentional 10 kg weight loss over the same time course Physical examination revealed mild tachycardia, an intention tremor and a normal-sized, nontender thyroid gland without palpable nodules. The remainder of the physical examination was unremarkable and without stigmata of Graves’ disease. Her initial blood tests revealed overt thyrotoxicosis, elevated liver enzymes, an elevated C-reactive protein, a negative monospot and a positive CMV IgM antibody. Thyroid sonography revealed areas of hypoechogenicity and relatively low vascularity. Fine-needle biopsy showed a lymphocytic infiltrate. The patient was treated symptomatically with propranolol. On follow-up, the patient became euthyroid, and her liver enzymes normalised. Previous cases of CMV-induced thyroiditis occurred in immunosuppressed patients. This is the first reported case of a CMV-mononucleosis-induced thyroiditis in an immunocompetent adult patient and serves as a reminder that viral illnesses are a common cause of thyroiditis with abnormal liver enzymes.Learning points:The differential diagnosis of thyrotoxicosis with abnormal liver enzymes includes severe hyperthyroidism and thyroid storm caused by Graves’ disease as well as the thyrotoxic phase of a thyroiditis, usually caused by a virus such as coxsackievirus or, in this case, cytomegalovirus.Cytomegalovirus appears to be a recently recognized causal agent for thyroiditis, both in immunosuppressed and immunocompetent patients.Careful follow-up of thyroid function tests in patients with thyroiditis allows clinicians to determine if patients’ thyroid hormone secretion normalizes or if they remain hypothyroid.

Perfil tromboelastométrico y coagulopatía aguda del paciente politraumatizado: implicaciones clínicas y pronósticas

IntroductionAbout 25-35% of polytraumatized patients have a profound alteration of hemostasis on arrival at the hospital (acute traumatic coagulopathy [CAT]). Viscoelastic tests (ROTEM®) measure the hemostatic capacity and provide an early detection of CAT. The objectives of this study are to describe the initial thromboelastogram of these patients and to determine the prevalence of CAT according to predefined thromboelastographic profiles. MethodsSingle-center, observational, prospective study in polytraumatic patients. Initial blood and thromboelastographic test (ROTEM®) were made, and pre-hospital, hospital, transfusion, initial surgical/angiographic interventions, cardiac arrest and mortality data were collected. ROTEM®-based, patients were classified as: normal, hypercoagulable, hypocoagulable, hipocoagulable +hyperfibrinolytic and isolated hyperfibrinolysis. ResultsOne hundred and twenty-three patients were analyzed. 32 cases (26%) with CAT: 15 patients with hypocoagulability, 9 with hyperfibrinolysis alone and 8 with hypocoagulability +hyperfibrinolysis. The CAT group, related to the normal group, presented higher ISS (23 vs. 16, P<.01), higher blood products transfusion (2.5 vs. 0; P=.001), more cardiac arrest (19 vs. 1%, P<.01), and higher mortality (34 vs. 5%, P<.01). The subgroup with hypocoagulability/hyperfibrinolysis, related to the groups with hypocoagulability or hyperfibrinolysis alone, presented a higher ISS (41 vs. 25 vs. 15, P<.01), higher angiographic procedures (62% vs. 13% vs. 0%, P<.01) and higher mortality (75% vs. 33% vs. 0%, P=.05). ConclusionsTwenty-six percent of the polytrauma patients presented early coagulopathy assessed by thromboelastography. It is associated with higher consumption of blood products and lower survival. The presence of hypocoagulability +hyperfibrinolysis is associated with greater severity and a higher requirement of blood products.

Acalculous Gangrenous Cholecystitis in Absence of Typical Risk Factors

Acute acalculous cholecystitis (AAC) is typically seen as a complication in severely ill, hospitalized patients. We report a case of acute gangrenous acalculous cholecystitis in an outpatient. 47-year-old African-American male presented with acute onset of epigastric abdominal discomfort and multiple episodes of vomiting persisting over one day. He denied having any fever or chills, change in bowel habits, dysphagia, weight loss, change in appetite, blood in stools, recent travel history or NSAID/alcohol use. He had a history of hypertension and hyperlipidemia. On exam, he was afebrile, BP 100/60 mmhg, HR 110 /min. He had tenderness in the epigastrium and right upper quadrant of his abdomen. Murphy's sign was positive. The initial blood tests including liver function tests and lipase were normal except for an elevated white cell count. An US of RUQ was obtained revealed, gall bladder wall thickening along with edema and pericholecystitc fluid collection. No gall stones were seen. Blood cultures were obtained, and the patient was started on antibiotics empirically. A HIDA scan revealed no uptake of contrast in the gall bladder one hour after contrast admission, confirming the diagnosis of AAC. Surgery was consulted and cholecystectomy was performed. Removed gall bladder appeared inflamed with early signs of gangrene. Acute acalculous cholecystitis (AAC) is defined as inflammation of the gall bladder without presence of gallstones. It is typically seen in severely medically or surgically ill, hospitalized patients. Altthough not common, cases of AAC in out patients with no significant risk factors have been reported. Physical examination and laboratory data are often unreliable in diagnosis of AAC, and diagnosis mainly rests on imaging studies. AAC has an extremely fulminant course leading to gall bladder gangrene in 50% of patients and perforation in 10 % of patients. Even with treatment, the mortality rate is about 30%. Hence, early diagnosis and treatment are warranted. In very few patients, atherosclerosis-causing changes in microcirculation of gall bladder, atherosclerotic changes can leading to ischemia at cellular level, thereby causing inflammation have been postulated to be causing AAC. Our patient presented in the outpatient setting and was diagnosed to have acute gangrenous acalculous cholecystitis. Given the high mortality rates AAC should be kept in dfferentials even in the outpatient settings.

An elderly-onset rheumatic syndrome: is it RS3PE?

It is presented a case of a 75-year-old Caucasian male patient who was admitted to hospital with a history of painful swollen hands and feet, associated with worsening mobility. Examination revealed bilateral pitting edema of dorsum of hands and feet. Initial blood test showed 10.7 g/L hemoglobin with normochromic and normocytic anemia, raised inflammatory markers (erythrocyte sedimentation rate 60 mm, C-reactive protein 16.73 mg/dL) and normal white blood cells count. Autoantibody screen and rheumatoid factor were negative, with positive HLA-B27. Radiological findings of hands and feet did not show any erosions. The patient was also screened and investigated for associated malignancies; the tumor markers and the computed tomography thorax/abdomen were reported as normal. The patient responded extremely well to low dose prednisolone at 20 mg daily dosage. Further follow up 5 weeks later on tapering dose of prednisolone showed complete resolution of signs and symptoms without any further flare-ups. Remitting seronegative symmetrical synovitis with pitting edema is a definite syndrome, a rare subset of polyarthritis with favorable outcome and has a good prognosis in older patients. This case illustrates the interesting diagnosis exercise that is needed, once the multiple conditions that may be related with the disease support that this is a syndrome with potentially heterogeneous etiologies. Looking for underlying malignancy is recommended.

Analysis of an 8-hour acetylcysteine infusion protocol for repeated supratherapeutic ingestion (RSTI) of paracetamol

Objectives: In Australia, the treatment guideline for patients with repeated supratherapeutic ingestion (RSTI) of paracetamol recommends an abbreviated acetylcysteine regimen if the paracetamol concentration is low (<10 mg/L) and alanine aminotransferase (ALT) is normal or static after 8 hours of infusion. There are currently no studies of this recommendation.Method: A retrospective review of paracetamol overdose presentations from October 2009 to August 2016 in two hospital toxicology networks was performed. All cases of RSTI treated with acetylcysteine were extracted.Results: Of the 2249 paracetamol overdose presentations, 91 cases of RSTI were treated with acetylcysteine. Median time to initial blood tests was 6 hours post-last paracetamol dose (IQR 4–6). Sixty-three (69%) presentations had an initial detectable paracetamol concentration, median 30 mg/L (IQR 18–60). Median ALT on presentation was 48 IU/L (IQR 18–109). After 8 hours of acetylcysteine infusion, median ALT was 34 IU/L (IQR 16–71) in those receiving abbreviated treatment and 74 IU/L (IQR 40–231) in those continuing acetylcysteine. Thirty-nine presentations (43%) had an abbreviated regimen. Nine (10%) patients had an initial ALT ≥50 IU/L and subsequently developed hepatotoxicity (ALT >1000 IU/L). No patients with an initial ALT <50 IU/L developed hepatotoxicity. Median duration of acetylcysteine infusion for those receiving a non-abbreviated regimen was 20 hours (IQR 20–25) vs. 10.4 hours (IQR 4.8–12.0) who received an abbreviated regimen. There were no re-presentations with hepatotoxicity.Conclusions: An 8-hour acetylcysteine infusion regimen for treatment of paracetamol RSTI may be safe and is likely to reduce length of stay for patients at low risk of hepatotoxicity. Larger prospective studies are needed to examine the efficacy of this abbreviated acetylcysteine protocol.

ORAL LIPOMA IN THE TONGUE: A CASE REPORT

Lipoma is the most common benign tumor that occurs at any region where adipose tissue is present. However, as the tongue is devoid of adipocyte it is an extremely rare site for development. Herein we report the case of an 82-year-old male patient that complained about an asymptomatic volume increased during 10 years, with exacerbation during the last month. Examination revealed a 4 cm nodular lesion that was located on the right dorsal region of the tongue. After initial blood tests and Doppler ultrasound that suggested benign tumor without neovascularization, it was performed an excisional biopsy that demonstrated squamous epithelium and an underlying zone displaying a lesion enclosed by a thin collagen fiber capsule and composed of lobules of mature adipose tissue. These findings were consistent with lipoma. The tumor was completely excised and after 6 months of follow-up, there was no recurrence of the lesion.

HbA1c screening for new onset diabetes following acute coronary syndrome: is it a worthwhile test in clinical practice?

BackgroundDiabetes and pre-diabetes are prevalent in acute coronary syndrome (ACS) and relate to adverse outcomes. This study used HbA1c to screen for degrees of glucose intolerance amongst patients without known diabetes presenting with ACS.MethodsOver a 1-year period (June 2014–2015) consecutive patients admitted to a single centre cardiology unit with an initial diagnosis of ACS without prior diabetes diagnosis were electronically referred to our diabetes team. Patients were screened for the presence of diabetes by use of an initial HbA1c blood test on day 2 or 3 post admission. If abnormal (≥42 mmol/mol; ≥6.0%), patients were invited for a repeat HbA1c at 2 weeks, and if an intermediate result (42–47 mmol/mol; 6.0–6.4%), for an oral glucose tolerance test (OGTT) at 3 months. Patients were diagnosed with Type 2 diabetes if the repeat HbA1c result was high (≥48 mmol/mol; ≥6.5%) or the OGTT at 3 months confirmed the diagnosis. Other data collected included baseline demographics, risk factors and any history of cardiovascular disease. All patients with ACS were stratified according to the diagnosis and subsequent management.ResultsWe screened 399 patients in total. The mean age was 65 ± 14 years, 268 (67%) were men, 290 (73%) were Caucasian, 95 (24%) were South Asian and 14 (4%) were Afro-Caribbean ethnicity. Of all patients, 57 (14.3%) were diagnosed as pre-diabetes and 43 (10.8%) newly diagnosed diabetes. During the study 28 (7%) patients could not be classified; 6 (1.5%) patients died during the study and 22 (5.5%) patients were missing either initial or repeat HbA1c and were subsequently lost to follow up. Of the baseline variables assessed, there were significantly more patients of South Asian ethnicity in the diabetes group compared to the normal group (42 vs 20%; p = 0.003). There was no difference in detection rates in patients with more severe ACS requiring percutaneous or cardiac surgical intervention.ConclusionsThe use of a simple HbA1c screening method in clinical practice can detect new onset diabetes in approximately 1 in 10 high-risk post ACS patients.

Hematologic parameters to predict negative cerebrospinal fluid examination results among neurologically intact patients who underwent lumbar puncture on suspicion of central nervous system infection.

ObjectiveCerebrospinal fluid (CSF) examination is mandatory whenever central nervous system (CNS) infection is suspected. However, pleocytosis is not detected in a substantial number of suspected patients who undergo CSF examination. This study aimed to identify parameters that can aid in predicting negative CSF examination results (defined as a white blood cell count of <5 cells/high-power field).MethodsThe study included 101 neurologically intact patients who underwent lumbar puncture because of suspicion of CNS infection. Patients were divided into negative and positive CSF examination groups, and their initial blood tests were comparatively analyzed.ResultsThe negative group had a significantly higher proportion of neutrophils in white blood cells (81.5% vs. 75.8%, P=0.012), lower proportion of lymphocytes in white blood cells (9.3% vs. 16.7%, P=0.001), a higher neutrophil-to-lymphocyte ratio (9.1 vs. 4.4, P=0.001), a lower lymphocyte-to-monocyte ratio (1.6 vs. 2.4, P=0.008), and a higher C-reactive protein level (21.0 vs. 5.0 mg/L, P<0.001) than the positive group. In the receiver-operating characteristic analysis, neutrophil-to-lymphocyte ratio and C-reactive protein had an area under the curve of >0.7, and the best cutoff values were 6.0 (accuracy 70.3%) and 12.7 mg/L (accuracy 76.2%), respectively.ConclusionThe neutrophil-to-lymphocyte ratio ≥6 and C-reactive protein level ≥12.7 mg/L was significantly associated with negative CSF examination result.