Initial Hospital Presentation Research Articles

Management of pancreatic and duodenal trauma in childhood: a university hospital experience over a 10-year period

PurposeDuodenal/pancreatic injuries occur in less than 10% of intra-abdominal injuries in pediatric blunt trauma. Isolated duodenal/pancreatic injuries occur in two-thirds of cases, while combined injuries occur in the remaining. This study aimed to investigate pediatric patients with pancreatic and duodenal trauma.MethodsData from 31 patients admitted to Atatürk University, Medical Faculty, Department of Pediatric Surgery for pancreatic/duodenal trauma between 2010 and 2019 were retrospectively analyzed. Age/gender, province of origin, duration before hospital admission, trauma type, injured organs, injury severity, diagnostic and therapeutic modalities, complications, hospitalization duration, blood transfusion requirement, and mortality rate were recorded.ResultsTwenty-four patients were male, and 7 were female. The mean age was 9 years. The leading cause was bicycle accidents, with 12 cases, followed by traffic accidents/bumps, with 7 cases each. Comorbid organ injuries accompanied 18 cases. Duodenal trauma was most commonly accompanied by liver injuries (4/8), whereas pancreatic injury by pulmonary injuries (7/23). Serum amylase at initial hospital presentation was elevated in 83.9% of the patients. Thirty patients underwent abdominal CT, and FAST was performed in 20. While 54.8% of the patients were conservatively managed, 45.2% underwent surgery.ConclusionBecause of the anatomical proximity of the pancreas and the duodenum, both organs should be considered being co-affected by a localized trauma. Radiologic confirmation of perforation in duodenal trauma and an intra-abdominal pancreatic pseudocyst in pancreatic trauma are the most critical surgical indications of pancreaticoduodenal trauma. Conservative management’s success is increased in the absence of duodenal perforation and cases of non-symptomatic pancreatic pseudocyst.

Abstract WP209: Changes In Serum Superoxide Dismutase 3 (sod3) Following Acute Ischemic Stroke: A Pilot Study

Introduction: Acute ischemic stroke (AIS) elicits peripheral immune activation and reactive inflammatory changes within the lung that contribute to cerebral reperfusion injury. Expression of the antioxidant SOD3 within the lung exerts an intrinsic anti-inflammatory bias on the systemic vasculature. In preclinical models, lung and serum SOD3 levels decline acutely following AIS, while enforced lung SOD3 expression blunts post-stroke inflammation and reperfusion injury. Linking changes in serum SOD3 with stroke severity in a clinical context could have important diagnostic and therapeutic implications. Objectives: 1) Compare serum SOD3 levels among AIS patients vs. controls at initial hospital presentation; 2) Evaluate changes in serum SOD3 in AIS patients during hospitalization; 3) Establish whether serum SOD3 levels correlate with stroke severity. Methods: Inclusion criteria : patients (≥18 years) presenting with AIS (n=7) not treated with either tPA or thrombectomy. Patients with MRI-negative TIA or stroke mimics served as controls (n=8). Exclusion criteria : history of stroke or ICH, seizure at presentation, infection or trauma in the past 30 days, malignancy, autoimmune disease, or major surgery within 90 days. Analyses: Baseline (12-24 hours from LKN) and serial serum samples (1-7 days) were analyzed by automated capillary Western for total SOD3 and compared against the presenting NIH stroke scale score. Results: Analyses revealed 35% (range +9% to -53%) lower initial SOD3 levels in patients with acute ischemic stroke vs. controls, with NIHSS scores ranging from 0 to 10 (median 0.5). Median SOD3 levels in AIS patients were 45,204, 31214, and 41,133 AUC (area under curve) at 12, 24, and 72 hours, respectively. While differences between median peak to nadir SOD3 levels were significant (52117 ± 16052 vs. 27798 ± 7529, p=0.015, two-tailed t-test) in AIS patients, serum SOD3 levels did not correlate with stroke severity. Conclusion: These results suggest minor ischemic stroke is associated with acute reductions in serum SOD3. While further study is required, this finding has potential clinical implications when considering the potential utility of SOD3 as a disease marker and potential therapeutic in the setting of AIS.

Follow-Up Chest X-rays in Minor Chest Trauma with Fewer Than Three Rib Fractures: A Justifiable, Habitual Re-Imaging Industry?

Objective: We evaluated the necessity of follow-up chest X-rays (CXRs) to exclude a pneumothorax after 1 week of initial hospital presentation in patients with no signs of respiratory distress and fewer than three rib fractures. Materials and Methods: Adult patients with fewer than three fractured ribs who presented at our Level I trauma center between 2015 and 2017 were evaluated retrospectively. Patients with sternal fractures, who had suffered a polytrauma, or were primarily treated with a chest tube were excluded. The patients' and fractures' characteristics, trauma mechanism, median follow-up time, and the number of required secondary interventions were recorded. Results: This study included 249 patients, 137 (55.0%) of whom were male, with a median age of 64.34 years. In 150 patients (60.2%) one rib was affected, in 99 patients (39.8%) two ribs were affected, with the fractured ribs being true ribs (1-7) in 72 cases (28.9%), false ribs (8-12) in 151 cases (60.6%), and both in 26 cases (10.4%). The affected thorax half was the left side in 124 cases (49.8%) and both thorax halves in 4 cases (1.6%). The median follow-up time was 9 ± 4 days. In the follow-up CXRs, six patients (1.6%) required delayed intervention (tube thoracostomy): one case of hemopneumothorax and five cases of pneumothorax. All of the patients fully recovered. Conclusions: Planned CXR follow-ups revealed only a small number of complications that needed intervention and therefore seem not to be necessary. Symptom-triggered reappearance seems to be more sufficient and economical compared to habitual reimaging.

S2994 Fulminant Liver Failure Due to Budd-Chiari Syndrome Triggered by Strenuous Exercise

Introduction: This case illustrates the complexity of diagnosis of Budd-Chiari syndrome especially with an atypical presentation. Case Description/Methods: A 27-year-old man in his usual good state of health attended an all-day police academy fitness test. That evening he developed abdominal pain, nausea, vomiting, and diarrhea. He left work the next day due to these symptoms and progressive confusion. His family called EMS and he was transported to a local emergency department where he was found to be hypothermic, tachycardic, and hypoxemic. Labs were notable for acute kidney injury with creatinine 1.7, lactate 11.8, total bilirubin 1, AST 116, and ALT 95. He was begun on 2 vasopressors and empiric antibiotics. CT Abdomen noted a possible mesenteric thrombus; he was taken emergently to the operating room, but no bowel ischemia was found. His laboratory tests increased over the next 3 days reaching total bilirubin 3.0, AST 8560, ALT 5880, alkaline phosphatase 92, albumin 2.7, creatinine 3.1, INR 5.06, WBC 34.5, and ferritin 18,724. He was subsequently transferred to a tertiary center where his mental status worsened, and he was intubated. A transjugular liver biopsy demonstrated perivenular coagulative necrosis involving 80% of the hepatic parenchyma, and a hepatic venogram noted extensive portal vein thrombus. He had no history of taking any medications on a regular basis and did not take acetaminophen. An acetaminophen level was negative. Orthotopic liver transplantation was performed on the sixth day after his initial hospital presentation. During the surgery the patient was noted to have extensive thrombus involving the portal system including the main portal vein as well as the superior mesenteric vein, and thrombus in the hepatic veins. Testing for hypercoagulable state was positive for JAK2 V617F mutation, and he was begun on treatment with hydroxyurea. Discussion: His development of Budd-Chiari syndrome is felt to be due to this hypercoagulable state combined with dehydration from strenuous exertion. There was no hepatomegaly noted on imaging which had led to confusion regarding the diagnosis of Budd-Chiari syndrome, but the occlusion of the portal vein in this patient resulted in decreased blood flow to the liver and prevented the development of hepatomegaly. His initial development of lactic acidosis, leukocytosis, and elevated ferritin is felt to be the result of marked hepatic necrosis from the Budd-Chiari syndrome but had led to confusion over the possibility of septic shock or bowel ischemia.

Epidemiology and treatment outcomes in pediatric patients with post-injection paralysis

BackgroundPost-injection paralysis (PIP) of the sciatic nerve is an iatrogenic paralysis that occurs after an intramuscular injection, with resultant foot deformity and disability. This study investigates the epidemiology and treatment of PIP in Uganda.MethodsHealth records of pediatric patients surgically treated for PIP at the CoRSU Rehabilitation Hospital from 2013 to 2018 were retrospectively reviewed. Pre-operative demographics, perioperative management, and outcomes were coded and analyzed with descriptive statistics, chi-square for categorical variables, and linear models for continuous variables.ResultsFour-hundred and two pediatric patients underwent 491 total procedures. Eighty-three percent of reported injection indications were for febrile illness. Twenty-five percent of reported injections explicitly identified quinine as the agent. Although ten different procedures were performed, achilles tendon lengthening, triple arthrodesis, tibialis posterior and anterior tendon transfers composed 83% of all conducted surgeries. Amongst five different foot deformities, equinus and varus were most likely to undergo soft tissue and bony procedures, respectively (p=0.0223). Ninteen percent of patients received two or more surgeries. Sixty-seven percent of patients achieved a plantigrade outcome; 13.61% had not by the end of the study period; 19.3% had unreported outcomes. Those who lived further from the facility had longer times between the inciting injection and initial hospital presentation (p=0.0216) and were more likely to be lost to follow-up (p=0.0042).ConclusionPIP is a serious iatrogenic disability. Prevention strategies are imperative, as over 400 children required 491 total surgical procedures within just six years at one hospital in Uganda.

The Utility of Laboratory Parameters for Cardiac Inflammation in Heart Failure Patients Hospitalized with SARS-CoV-2 Infection.

COVID-19 has been associated with cardiovascular consequences, including myocardial infarction, thromboembolic events, arrhythmia, and heart failure. Numerous overlapping mechanisms, such as the IL-6 dependent cytokine storm and unopposed angiotensin II stimulation, could be responsible for these consequences. Cardiac damage is hypothesized to be a consequence of the direct viral infection of cardiomyocytes, resulting in increased metabolic demand, immunological activation, and microvascular dysfunction. Patients with pre-existing chronic heart failure are therefore at increased risk of decompensation, further heart damage, and significant health deterioration. Based on the aforementioned assumptions, we developed a study aiming to provide a detailed description of changes in biological parameters and cardiac injury markers of patients with heart failure and SARS-CoV-2 infection by correlating them with the clinical presentation and COVID-19 vaccination status, to predict the probability of ICU admission based on their initial hospital presentation. A two-year retrospective study was performed on heart failure patients with a history of SARS-CoV-2 infection and detailed records of biological biomarkers; a total of 124 eligible patients with COVID-19 and 236 without COVID-19 were recruited. Patients with heart failure and SARS-CoV-2 infection had significantly elevated baseline biological parameters and cardiac markers compared to those without COVID-19. Several cardiac injury markers were identified as significant independent risk factors for ICU admission: CK-MB (HR = 4.1, CI [2.2–6.9]), myoglobin (HR = 5.0, CI [2.3–7.8]), troponin-I (HR = 7.1 [4.4–9.6]), troponin-T (HR = 4.9, CI [1.7–7.4]). The elevation of a basic panel of acute inflammation markers (CRP, IL-6, fibrinogen), D-dimers, and BNP was also a significant risk factor. The follow-up of survivors at four weeks after viral clearance determined a worsened clinical picture by NYHA classification, worsened cardiac ultrasound findings, and a mild improvement in cardiac and inflammatory markers. Increased levels of myocardial damage parameters in association with cardiac ultrasound findings and basic inflammatory markers may enable early risk assessment and triage in hospitalized heart failure patients infected with SARS-CoV-2.

Advanced Bronchogenic Carcinoma with Secondary Liver Metastasis and Sepsis as an Initial Hospital Presentation; The Shortcomings of Preventive Care Medicine in Nigeria

Chronic diseases are the most prevalent worldwide. Evidence-based medicine points to primary care as the most effective tool to minimize the burden through primary prevention and early detection of diseases. In keeping with this, the primary care arm of medicine can be regarded as the gatekeeper of public health. The rising incidence of chronic diseases indicates that the primary care system may fail to live up to its responsibility. We present a case of an elderly male who came to the hospital with advanced bronchogenic carcinoma, secondary liver metastasis, and sepsis. He presented for the first time in over a year since he started experiencing symptoms. He had no contact with his primary care physicians, nor was he vaccinated against the influenza virus or the coronavirus.

Impact of Pre-Hospital Activation of STEMI on False Positive Activation Rate and Door to Balloon Time

Pre-hospital identification of ST-segment elevation myocardial infarction (STEMI) by paramedical staff reduces reperfusion time. However, the impact of this approach on the rate of unnecessary activation of coronary catheterisation lab (CCL) remains unclear. The study reviewed consecutive STEMI patients over 3 years (July 2015 to June 2018) from all primary percutaneous coronary intervention (PPCI) centres and inter-hospital transfers (IHT) from non-PPCI capable centres in Western Australia. Out-of-hospital cardiac arrests (OOHCA) and STEMI calls for in-patients receiving treatment for other medical reasons were excluded. During the 3 years study period, 1,736 STEMI cases were recorded. Pre-hospital (PH) activation occurred in 799 (46%) cases. Median door to balloon time (D2BT) was 68 minutes (IQR 63 mins). D2BT for PH activation (40 min [IQR 25 min]) was significantly lower than both the PPCI centre emergency department (ED) activation (86 min [IQR 55 min]) and IHT activation groups (108 min [IQR 55 min]), p-value <0.00001. In PH activation group 98% patients received primary PCI in less than 90 minutes compared to 54% and 26% patients in the ED and the IHT activation groups, respectively. False positive STEMI activation rate was lower in the PH activation group (2.75%) compared to ED activation (5.4%) and IHT group (6%), p-value 0.0115. The false positive rate did not vary significantly between working hours and out-of-hour calls (5% vs 4%, p-value=0.304). Pericarditis, coronary artery disease other than STEMI, atypical chest pain, and stress induced cardiomyopathy were the common diagnoses in false positive activations. Pre-hospital activation of STEMI leads to reduced door to balloon times without a significant increase in inappropriate procedures, though false positive activation rates are unclear. The majority of STEMI patients transferred from non-PPCI centres failed to receive reperfusion therapy within 90 minutes of initial hospital presentation. Further studies are required to assess the benefits of thrombolysis in selected patients in inter-hospital transfer group.

Moyamoya Disease in a Young Female With Neurofibromatosis Type 1

Moyamoya disease (MMD) is a rare cerebrovascular disease characterized by progressive stenosis of the terminal portions of the internal carotid arteries (ICAs) and the development of a network of abnormal collateral vessels. This case depicts a 25-year-old African American female patient with neurofibromatosis type 1 (NF-1), whose initial hospital presentation occurred in a hypertensive emergency setting. Surveillance studies with magnetic resonance imaging (MRI) revealed multiple asymptomatic right cortical strokes. Genetic testing evidenced a novel, unique pathogenic variant on the NF-1 gene. The patient underwent combined bypass surgery first and then was placed on aspirin and a blood pressure control regimen. Our case illustrates the need for clinicians to include moyamoya disease in the list of differential diagnoses when encountering a young patient, without major risk factors, presenting with ischemic stroke. It should be considered even with no known history of previously diagnosed MMD or NF-1, as these pathologies may have yet to be evaluated in subclinical cases.

Association of Hospital Telestroke Adoption With Changes in Initial Hospital Presentation and Transfers Among Patients With Stroke and Transient Ischemic Attacks

It has been proposed that the implementation of telestroke services (a web-based approach to using video telecommunication to treat patients with stroke before hospital admission) changes where patients with stroke symptoms receive care, but this proposal has not been rigorously assessed. To assess whether the implementation of telestroke services is associated with changes in where and how patients initially present with stroke symptoms, in their decision to be transferred to another hospital, and which hospitals they are transferred to. This cross-sectional study compared changes in stroke systems of care between a sample of 593 US hospitals that adopted telestroke during the period from 2009 to 2016 but were not comprehensive stroke centers, major teaching hospitals, or thrombectomy-capable hospitals vs 593 matched control hospitals without telestroke based on rural location, critical access hospital status, bed size, primary stroke center status, presence of hospital alternatives in the community, hospital stroke volume, census region, and ownership. With the use of data on 100% of Medicare fee-for-service beneficiaries, all stroke and transient ischemic attack admissions from 2008 to 2018 were identified. For each hospital pair (telestroke plus matched control), the telestroke hospital's implementation date and difference-in-differences approach were used to quantify the association between telestroke implementation and changes in care from 2 years before implementation to 2 years after implementation. Models also controlled for differences in observed patient characteristics. Hospital stroke volume, patients' ambulance transport distance to initial hospital, hospital case mix, interhospital transfer proportion, and size of the receiving hospital for transferred patients. Of the 669 telestroke hospitals and 2143 potential control hospitals, 593 hospital pairs were matched; in each category, 261 hospitals (44.0%) were located in a rural area, 179 (30.2%) were primary stroke centers, and 130 (21.9%) were critical access hospitals. The changes in the preimplementation to postimplementation period were similar at telestroke and control hospitals in mean annual stroke volume (telestroke hospitals, decreased from 79.6 to 76.3 patients; control hospitals, decreased from 78.8 to 75.5 patients [-3.3 patients per year for both; difference-in-differences, 0.009; P ≥ .99]). Similarly, no differences were seen in ambulance transport distance, case mix, interhospital transfers, or bed size of receiving hospitals among transferred patients. This study suggests that, across a national sample of hospitals implementing telestroke, no association between telestroke adoption and changes in stroke systems of care were found.

A-58 Unusual Presentation of Anti-NMDAR Encephalitis in a Young Adult Male: A Case Study

Abstract Objective To illustrate an unusual presentation of anti-n-methyl-D-aspartate-receptor (anti-NMDAR) encephalitis in a young adult male. Anti-NMDAR encephalitis is an autoimmune-mediated disorder with psychiatric and neurological features that can have lasting impact on cognition. Unique presentation, diagnosis, and assessment are presented. Method Patient is a 28-year-old, Caucasian male with a history of bipolar disorder. Initial hospital presentation was characterized by headache, tremor, and acute altered mental status. Imaging revealed chronic meningitis with diffuse leptomeningeal enhancement/multiple cranial nerve enhancement, hydrocephalus, and Chiari I malformation. He underwent external ventricular drain (EVD) placement and was discharged upon stabilization. He presented 1 month later with symptom recurrence and interval development of hydrocephalus. CSF studies were positive for NMDAR antibody. He was treated with immunotherapy. His 3-month long hospitalization was complicated by acute respiratory failure and intracerebral and intraventricular hemorrhages. He was discharged to 1 month of inpatient rehabilitation. Results Neuropsychological assessment was completed 4 months following discharge from rehabilitation. Visual deficits due to grade 1 papilledema complicated testing. Results revealed frontal deficits (focused attention, processing, and executive functions), with intact verbal learning/memory. This deviates from previous literature that specify verbal memory dysfunction as a core long-term outcome of anti-NMDAR encephalitis. Conclusions This case highlights an unusual presentation and neuropsychological assessment of anti-NMDAR encephalitis. Rare presentations of anti-NMDAR encephalitis can preclude clinical diagnosis and compromise long-term cognitive outcomes if not rapidly and effectively treated. Additionally, mood symptoms may have been early manifestation of the patient’s disease process. Despite acute complications, he demonstrated remarkable functional and cognitive recovery.

Longitudinal Course of Traumatic Brain Injury Biomarkers for the Prediction of Clinical Outcomes: A Review.

Protein biomarkers are often measured at hospital presentation to diagnose traumatic brain injury (TBI) and predict patient outcomes. However, a biomarker measurement at this single time point is no more accurate at predicting patient outcomes than less invasive and more cost-effective methods. Here, we review evidence that TBI biomarkers provide greater prognostic value when measured repeatedly over time, such that a trajectory of biomarker concentrations can be evaluated. PubMed, Google Scholar, and Cochrane Central Register were searched to identify studies from the last decade in which established TBI biomarkers had been measured at more than one time point following acute TBI, and which related their findings to patient outcomes. Twenty-two studies were identified, 18 of which focused on adults and 4 of which focused on children. Three general biomarker trajectories were identified: persistently high, persistently low, and reversal of decreasing concentrations. Downtrend reversal was highly specific to predicting poor patient outcomes. Four studies demonstrated that biomarker trajectories can be affected by therapeutic interventions. Additional studies demonstrated that biomarkers measured at a later time point offered superior prognostic value than a single measurement obtained at initial hospital presentation. Among other details, longitudinal biomarker trajectory assessments may identify ongoing injury and predict patient deterioration before clinical symptoms develop and thus help guide therapeutic interventions.

Multiple Biomarker Approach to Risk Stratification in COVID-19

Multiple Biomarker Approach to Risk Stratification in COVID-19

Testing-on-a-probe biosensors reveal association of early SARS-CoV-2 total antibodies and surrogate neutralizing antibodies with mortality in COVID-19 patients

The association of mortality with the early humoral response to SARS-CoV-2 infection within the first few days after onset of symptoms (DAOS) has not been thoroughly investigated partly due to a lack of sufficiently sensitive antibody testing methods. Here we report two sensitive and automated testing-on-a-probe (TOP) biosensor assays for SARS-CoV-2 viral specific total antibodies (TAb) and surrogate neutralizing antibodies (SNAb), which are suitable for clinical use. The TOP assays employ an RBD-coated quartz probe using a Cy5-Streptavidin-polysacharide conjugate to improve sensitivity and minimize interference. Disposable cartridges containing pre-dispensed reagents require no liquid manipulation or fluidics during testing. The TOP-TAb assay exhibited higher sensitivity in the 0–7 DAOS window than a widely used FDA-EUA assay. The rapid and automated TOP-SNAb correlated well with two well-established SARS-CoV-2 virus neutralization tests. The clinical utility of the TOP assays was demonstrated by evaluating early antibody responses in 120 SARS-CoV-2 RT-PCR positive adult hospitalized patients. Higher TAb and SNAb positivity rates and more robust antibody responses at patient's initial hospital presentation were seen in inpatients who survived COVID-19 than those who died in the hospital. Survival analysis using the Cox Proportional Hazards Model showed that patients who had negative TAb and/or SNAb at initial hospital presentation were at a higher risk of in-hospital mortality. Furthermore, TAb and SNAb levels at presentation were inversely associated with SARS-CoV-2 viral load based on concurrent RT-PCR testing. Overall, the sensitive and automated TAb and SNAb assays allow the detection of early SARS-CoV-2 antibodies which associate with mortality.

C-reactive protein and clinical outcomes in patients with COVID-19.

BackgroundA systemic inflammatory response is observed in coronavirus disease 2019 (COVID-19). Elevated serum levels of C-reactive protein (CRP), a marker of systemic inflammation, are associated with severe disease in bacterial or viral infections. We aimed to explore associations between CRP concentration at initial hospital presentation and clinical outcomes in patients with COVID-19.Methods and resultsConsecutive adults aged ≥18 years with COVID-19 admitted to a large New York healthcare system between 1 March and 8 April 2020 were identified. Patients with measurement of CRP were included. Venous thrombo-embolism (VTE), acute kidney injury (AKI), critical illness, and in-hospital mortality were determined for all patients. Among 2782 patients hospitalized with COVID-19, 2601 (93.5%) had a CRP measurement [median 108 mg/L, interquartile range (IQR) 53–169]. CRP concentrations above the median value were associated with VTE [8.3% vs. 3.4%; adjusted odds ratio (aOR) 2.33, 95% confidence interval (CI) 1.61–3.36], AKI (43.0% vs. 28.4%; aOR 2.11, 95% CI 1.76–2.52), critical illness (47.6% vs. 25.9%; aOR 2.83, 95% CI 2.37–3.37), and mortality (32.2% vs. 17.8%; aOR 2.59, 95% CI 2.11–3.18), compared with CRP below the median. A dose response was observed between CRP concentration and adverse outcomes. While the associations between CRP and adverse outcomes were consistent among patients with low and high D-dimer levels, patients with high D-dimer and high CRP have the greatest risk of adverse outcomes.ConclusionsSystemic inflammation, as measured by CRP, is strongly associated with VTE, AKI, critical illness, and mortality in COVID-19. CRP-based approaches to risk stratification and treatment should be tested.

Lymphocyte Count is a Universal Predictor to the Health Status and Outcomes of Patients with Coronavirus Disease 2019 (COVID-19): A Systematic Review and Meta-Regression Analysis

Background: This study aimed to evaluate the prediction capabilities of clinical laboratory biomarkers to the prognosis of COVID-19 patients. Methods: Observational studies reporting at least 30 cases of COVID-19 describing disease severity or mortality were included. Meta-data of demographics, clinical symptoms, vital signs, comorbidities, and 14 clinical laboratory biomarkers on initial hospital presentation were extracted. Taking the outcome group as the analysis unit, meta-regression analysis with the generalized estimating equations (GEE) method for clustered data was performed sequentially. The unadjusted effect of each potential predictor of the three binary outcome variables (i.e., severe vs. non-severe, critically severe vs. non-critically severe, and dead vs. alive) was examined one by one by fitting three series of simple GEE logistic regression models due to missing data. The worst one was dropped one at a time. Then, a final multiple GEE logistic regression model for each of the three outcome variables was obtained. Findings: Meta-data was extracted from 76 articles, reporting a total of 26,627 cases of COVID-19. Patients were recruited across 16 countries. The number of studies (patients) included in the final models of the analysis for severity, critical severity, and mortality was 38 studies (9,764 patients), 21 studies (4,792 patients), and 24 studies (14,825 patients), respectively. After adjusting for the effect of age, lymphocyte count mean or median ≤ 1.03 (estimated hazard ratio [HR] = 46.2594, p Interpretation: Lymphocyte count should be closely watched for COVID-19 patients in clinical practice.Funding: None to declare. Declaration of Interest: None to declare.

Risk Assessment Using Risk Scores in Patients with Acute Coronary Syndrome.

Risk scores are widely used in patients with acute coronary syndrome (ACS) prior to treatment decision-making at different points in time. At initial hospital presentation, risk scores are used to assess the risk for developing major adverse cardiac events (MACE) and can guide clinicians in either discharging the patients at low risk or swiftly admitting and treating the patients at high risk for MACE. During hospital admission, risk assessment is performed to estimate mortality, residual ischemic and bleeding risk to guide further in-hospital management (e.g., timing of coronary angiography) and post-discharge management (e.g., duration of dual antiplatelet therapy). In the months and years following ACS, long term risk can also be assessed to evaluate current treatment strategies (e.g., intensify or reduce pharmaceutical treatment options). As multiple risk scores have been developed over the last decades, this review summarizes the most relevant risk scores used in ACS patients.

P0783PREVALENCE AND PROGNOSIS OF HYPERKALAEMIA IN PEOPLE HOSPITALISED WITH AND WITHOUT AKI

Abstract Background and Aims Hyperkalemia is a clinical emergency associated with kidney diseases and hospital mortality. It may be apparent on initial hospital presentation, or develop during the course of admission, and can occur in the context of AKI. The prevalence of hyperkalemia across these different presentations and contexts is not well described. No work has previously described whether the prognosis of hyperkalemia varies depending on timing of presentation, or on AKI status defined by KDIGO creatinine change biochemical criteria. Method We constructed a cohort of all adult residents in Grampian (North Scotland) admitted to hospital in 2012 (n=28462). We used a validated and replicated KDIGO based definition of AKI to identify AKI using serial serum creatinine values. We determined the presence of hyperkalemia (serum potassium &amp;gt;= 6 mEq/L) both on first blood test on presentation to hospital, and also during the course of hospital admission. We explored the outcome of 30 day mortality within subgroups of AKI status and timing of hyperkalemia. Covariates of interest included age, CKD, medications prescribed in the preceding 90 days and comorbidities (ICD-10 hospital episode codes). The relationship between hyperkalemia and 30 day mortality was determined using multivariable logistic regression. Results Of 28462 hospital admissions, 247 (0.9%) presented with hyperkalemia, whereas 560 (2.0%) had hyperkalemia during the course of hospital admission. Hyperkalemia was common in the presence of AKI (4.2% at hospital presentation, 9.3% during hospital admission and rising to 24.5% during AKI stage 3). Hyperkalemia was uncommon in the absence of AKI (0.3% and 0.7% respectively) (OR AKI vs no AKI 13.9, 11.6-16.6). Other factors associated with hyperkalemia were male gender (OR 1.5, 1.3-1.8), age &amp;gt;70 years (OR 2.4, 2.0-2.9), CKD based on eGFR or proteinuria (5.5, 4.6-6.5), diabetes (OR 3.4, 2.8-4.0), heart failure (OR 3.0, 2.4-3.7), RAAS blockers (OR 2.4, 2.0-2.9), trimethoprim containing antibiotics (OR 2.2, 1.7-2.8)), non-RAAS antihypertensives (OR 1.7, 1.4-2.0), but not NSAIDs (OR 0.9, 0.7-1.1). Hyperkalemia mortality (AKI vs no AKI) was 31% vs 29% when presenting at admission, or 34.3% vs 27.8% when occurring during hospital admission. Although absolute risks were similar irrespective of AKI, the excess relative mortality risk associated with hyperkalemia was lower for those with AKI (OR 2.7, 2.1-3.4) than those without AKI (OR 9.5, 6.8-13.2), which may be explained by a higher mortality for those with AKI even without hyperkalemia. Conclusion Hyperkalemia is associated with a high mortality even in the absence of AKI and irrespective of the timing of presentation. Management protocols should draw attention to this poor prognosis across all clinical contexts. As hyperkalemia usually occurs within the context of AKI, it should prompt clinicians to consider ongoing close observation for emerging AKI even when AKI is not yet evident on blood tests.

1461 Pseudomembranous Colitis, Bowel Ischemia, and Phentermine: A Case Report

INTRODUCTION: Pseudomembranous colitis, though classically associated with Clostridium difficile infection, can be a consequence of other disease processes including severe ischemic colitis. Several drugs have been proposed to predispose to colonic ischemia including the appetite suppressant phentermine. We present a case of pseudomembranous colitis from severe bowel ischemia that likely was compounded by concomitant phentermine use. CASE DESCRIPTION/METHODS: A 55-year-old obese Caucasian female with hypertension presented with a week of abdominal pain and progressively worsening diarrhea that had subsequently turned bloody. She was a former smoker. Medication history was significant for using a family member's weight loss medication Phentermine 37.5 mg daily for several days prior to developing gastrointestinal symptoms. At presentation she was mildly hypotensive needing fluid resuscitation and brief vasopressor support. Laboratory profile was significant for acute kidney injury with creatinine 8.86 mg/dl, lactic acid 3.2 mmol/L and white blood cell count 12.3 k/uL. A non-contrast CT abdomen showed findings suggestive of acute colitis involving the splenic flexure and descending colon (Figure 1). Supportive care and broad-spectrum antibiotics were continued. Multiple stool studies were negative for clostridium difficile infection, bacterial cultures, and assays for ova and parasites. Antineutrophil antibodies and antineutrophil cytoplasmic antibodies were negative as well. Flexible sigmoidoscopy revealed severe ulcerations covered by thick exudate of the rectum and sigmoid colon (Figure 2). Histopathology of biopsy specimens showed colonic mucosa with fibrinopurulent surface adherent exudate with abundant neutrophils consistent with pseudomembranous colitis (Figure 3). Patient recovered with supportive care alone and was subsequently discharged with instructions not to use Phentermine again. DISCUSSION: Our patient, with risks for vascular disease, had several days of abdominal pain with diarrhea. At the time of her initial hospital presentation, she was hypotensive likely from gastrointestinal volume loss. The inciting event for her colonic ischemia is unclear. Possibilities include Phentermine induced colonic ischemia that was further compounded by volume loss vs prodrome of gastroenteritis leading to volume loss and hypovolemia with subsequent colonic ischemia compounded by patient's Phentermine use. Phentermine use in this patient would have been contraindicated secondary to her vascular risk factors.

Access delays to essential surgical care using the Three Delays Framework and Bellwether procedures at Timor Leste’s national referral hospital

ObjectivesOur objectives were to characterise the nature and extent of delay times to essential surgical care in a developing nation by measuring the actual stages of delay for patients receiving...