Initial Laboratory Research Articles

P894 Diagnostic yield of routine stool pathogen tests during the relapse of Inflammatory Bowel Disease

Abstract Background To make the diagnosis of Inflammatory bowel disease (IBD) flare, it is traditionally necessary to exclude infectious colitis, including bacteria and parasites. Furthermore, Infectious colitis prevalence varies between geographic areas of the world. It has been a routine clinical practice of sending broad stool testing and cultures to the laboratory before starting targeted therapy for IBD flare. The purpose of this study is to examine the yield of stool testing in adult patients with inflammatory bowel disease flare. Methods It is a retrospective study. We reviewed the medical records of the admitted patients with IBD flare at Mount Sinai Hospital, Toronto, Canada between October 2018, and August 2019. We used a computer-generated list of patients admitted with a diagnosis of IBD. We excluded patients with no confirmed diagnosis of IBD or admitted for reasons other than IBD flare. A number of variables were recorded, such as the patient's demographics, concurrent and previous IBD therapy, steroid use, presenting symptoms, vital signs, and the results of the initial laboratory investigation Results This study included 96 adult patients admitted with IBD flare. A total of ninety-four of our samples were tested for C. difficile at the time of admission. Only 9.4% were positive for C. difficile. Six of them had ulcerative colitis and three had Crohn’s disease. The percentage of patients evaluated with stool cultures was 86%, while the percentage of patients evaluated for ova and parasites was 51% at the time of patient admission. Only 34% of the population had colonic biopsies stained for Cytomegalovirus (CMV) of which 74% had ulcerative colitis. None of the stool cultures nor CMV tests were positive in our population. The risk of acquiring C difficile infection was not significantly correlated with the patient's disease phenotype, the biological therapy they were receiving, or their smoking history. In our sample, clinical tests and routine laboratory tests did not predict infectious colitis. The CRP level, as well as the neutrophil and eosinophil counts, were not associated with positive C. difficile infection. Conclusion In IBD flare, we did not routinely identify pathogens besides C difficile. Aside from areas where bacterial or parasitic infections are prevalent, routine stool testing with cultures and parasites has a low yield.

Two ischemic stroke events within 48 h: a case report of an unusual presentation of thrombotic thrombocytopenic purpura

BackgroundThrombotic thrombocytopenic purpura (TTP) considers a rare cause of ischemic stroke (IS). We reported a case of a newly diagnosed patient with acquired immune-mediated TTP (iTTP), in whom two IS events developed during 48 h.Case presentationA 59-year-old diabetic male was presented to the hospital 24 h after symptoms onset, including left hemiparesis, dysarthria, and decreased consciousness. A brain CT scan was performed with the suspicion of acute IS, indicating infarct lesions in the right middle cerebral artery (MCA) territory. The patient was not eligible for thrombolytic therapy due to admission delay. Over the next 24 h, the patient’s neurological condition deteriorated, and the second brain CT scan showed new ischemic lesions in the left MCA territory. Initial laboratory evaluation indicated thrombocytopenia without evidence of anemia. However, in the following days, thrombocytopenia progressed, and microangiopathic hemolytic anemia (MAHA) developed. The ADAMTS-13 (a disintegrin and metalloproteinase with a thrombospondin type 1 motif, member 13) activity and inhibitors assay confirmed the diagnosis of iTTP. The patient underwent plasma exchange activity and inhibitors assay confirmed the diagnosis of iTTP. The patient underwent and pulse IV methylprednisolone. Rituximab was also added due to the refractory course of the disease. After a prolonged hospital course, he had considerable neurologic recovery and was discharged.ConclusionsClinicians should consider two points. First, TTP should be considered in any patient presenting with IS and having thrombocytopenia or anemia without other symptoms of TTP. Second, worsening the patient's condition during hospitalization may indicate a new stroke and should be investigated immediately.

Severe hyponatremia as presenting symptom of small cell lung carcinoma

Abstract A 62-year-old female patient was admitted to ICU in our clinic with symptomatic severe hyponatremia with complaints of fatigue, vertigo, paresthesia of upper extremities and three episodes of loss of consciousness in the past month. She had been hospitalized two weeks before in neurology clinic because of the same symptoms. CT of the brain, EEG, ophthalmology examinations were negative. She did not complain of hemoptysis, cough, weight loss, fever, chest pain or dyspnea. Nephrologist was consulted and renal origin of the hyponatremia was excluded, before admission. Initial laboratory tests were glucose:5,47 umol/L,sodium:109 mEq/L,potassium;4.5 mEq/L,urea 3,9 umol/l;creatinine:52,7 mol/l,calcium:1,22umol/L,TSH 5;Cortisol 819nmol/L;ACTH:16,34 pg/ml. Her medical history included hypertension, primary hypothyroidism and history of smoking. Upon laboratory findings of low serum osmolality, high urine osmolality, high urine sodium levels and clinical euvolemia, and in the absence of renal, pituitary disfunction, adrenal insufficiency, inappropriate ADH syndrome was diagnosed and initially was treated with 3% NaCl. Since this treatment had no effect, it was started with fluid restriction, per os sodium intake was increased and therapy with loop diuretic was initiated, which resulted in correction of the hyponatremia. For the etiology consideration of inappropriate ADH syndrome CT of the thorax was performed, which revealed a neo infiltrative process with atelectasis in the poster basal segment of the left lobe. Histopathological sampling from the biopsy of the mass revealed small cell carcinoma of the lung. Metastasis were not detected. Since basal morning cortisol level was above upper range, with inappropriate measurements of ACTH constantly above 15 pg/ml, additional tests for ectopic Cushing syndrome were done. Overnight 1mg dexamethasone suppression test showed absent suppression of the morning cortisol values of 656nmol/L and ACTH of 22,14 pg/ml and absent circadian rhythm of cortisol secretion, with high measurements of midnight serum cortisol of 652 nmol/L. Diagnosis of ectopic Cushing syndrome and SIADH as part of paraneoplastic syndrome in small cell lung carcinoma was made. It is to be noted that patient had no significant symptoms or signs of hypercortisolemia. We report here a case of small cell carcinoma of the lung whose first presentation was with symptomatic hyponatremia as a result of inappropriate ADH syndrome. The most common neoplasms associated with hyponatremia are various forms of lung cancer. Because of the aggressive nature of the disease, the most common manifestation of small cell carcinoma of the lung is a metastatic one. Therefore, identifying the disease in earlier stages is very important. Unfortunately, these patients have low rates of survival and face a very poor prognosis even with treatment. The presence and early identification of paraneoplastic syndromes can be beneficial in this context.

A newly developing case of adrenal insufficiency developing after Coronavirus disease

Abstract Introduction Although some short and long-term effects of severe acute respiratory syndrome coronavirus 2(SARS-CoV-2) infection on the endocrine system are shown, there are still much more remaining to be clarified. A few case reports have shown that adrenal insufficiency can develop after COVID-19 infection due to adrenal hemorrhage or infarction. However, the exact effects of infection on cortisol dynamics are still poorly understood. This case report highlights an unusual case of acute adrenal insufficiency in a Covid-19. Clinical Case A 30-year-old female patient with no history of chronic disease applied with complaints of nausea, abdominal pain, and weakness for nearly 2 weeks. She was hospitalized. Her vitals were stable at the admission. Her initial laboratory evaluation showed serum sodium: 119 mEq/L, potassium: 5.38 mEq/L, creatinine: 1.35 mg/dL, aldosterone 2.33 ng/dL (1.46–17.4), plasma renin activity 40.56 ng/ml/h (0.06–4.69). Hemogram and liver function tests were normal. The basal ACTH value was measured 1142 pg/mL (7.2–63.3), and cortisol was 0.29 (6.24–18).The diagnosis of tuberculosis was ruled out with the quantiferon and the PPD test performed. In the detailed questioning of the patient, it was learned that she had Covid-19 infection about 3 months before the onset of symptoms. In this process, the patient's skin color was significantly darkened, and it was confirmed in comparison with the old photographs and from the patient's declaration. She was diagnosed with adrenal crisis, and corticosteroid therapy (80 mg/day intravenous methylprednisolone) and intravenous hydration were started. On the other hand, imaging and endoscopic evaluations were performed to exclude other intra-abdominal pathologies. No pathology was detected. Adrenal glands were normal in abdominal tomography. Stress dose steroid therapy was adjusted by reducing the daily dose. In the follow-up, the patient's complaints decreased and disappeared. Fludrocortisone was added to her treatment because electrolyte disturbances continued as hyponatremia and hyperkalemia. In the first week of treatment the patient's electrolyte disturbances improved and she was discharged with oral hydrocortisone and fludrocortisone treatment. The patient's skin color was observed lighter than before in the control examination, one week after discharge. Conclusion Although cases of adrenal insufficiency due to Covid-19 infection are found in the literature, their number is limited. The underlying causes are usually shown as hemorrhage and thrombosis. The absence of these findings in our case supports that the underlying cause is autoimmune and brought a different perspective to the issue. Our case also drives attention to the evaluation of patients in terms of adrenal insufficiency not only in the acute period but also in the later periods, since the diagnosis was made 3 months after the disease.

An unconventional case of hypokalemia

Abstract Hypokalaemia is a common clinical problem. The underlying pathophysiology maybe one of them: insufficient potassium intake, excessive urinary or GI losses, and transcellular shifts. Clinical Case 36/F presented with c/o B/L lower limb weakness for 3 days. She had no respiratory or swallowing difficulty and was able to move her neck muscles. No bowel or bladder incontinence. The patient was not on diuretics. A significant past history of similar complains 4 years & 2years back. Both times, she was evaluated to have hypokalemia and was treated with oral and IV K supplements. But, cause was not determined. She was diagnosed with T2DM 4 years back when she presented with irregular menses. Her other medical problems included PCOS (on OCPS), hypertension and dyslipidemia. There is a strong family h/o diabetes, & a family h/o breast CA. There were no symptoms of recent or chronic vomiting or diarrhea. She did not have any symptoms of thyrotoxicosis and was not taking beta-adrenergic agonists. She also denied treatment with corticosteroids. O/E, the patient was obese. BMI-29.0kg/m2, HR, 90bpm, BP 150/100mmHg. Acanthosis nigricans was + around the neck. The rest of the examination was normal. Initial lab results - K level 2.0mmol/L. 24hr urinary K-21mEq/day. ABG-Ph 7.49, bicarbonate 26.2mmol/L. S. Mg 1.5mg/dl. Plasma renin 5.09ng/dl, plasma aldosterone 0.63µiu/ml, A/R ratio of 8.08. The possibility of Cushing's syndrome was considered. Further evaluation, baseline 8am cortisol 19.6µg/dl. 1mg screening overnight dexamethasone suppression test (DST) - 17.56µg/dl (<1.8µg/dl). As it was positive, a confirmatory 0.5mg low dose DST was done. The 3rd day 8am S.Cortisol was 10.8 µg/dl (43.15% suppression). S.ACTH level-196pg/ml. A 24hr urinary cortisol-1284µg/dl. To differentiate between Pituitary and Ectopic Cushing's, overnight 8mg DST done. Baseline S.Cortisol repeated, 24µg/dl. After suppression, 15.9µg/dl (33.75%). MRI pituitary performed, a well-defined heterogeneously enhancing mass lesion (measuring 15×13 x11 mm) was noted in the sella with mild suprasellar extension. Cushing's disease - ACTH producing pituitary macroadenoma with mild suprasellar extension with no compressive features, presenting as hypokalemic paralysis Treatment: Transsphenoidal resection of the tumor S.cortisol repeated after 2 months-4.80µg/dl, after 3 months - 4.19µg/dl. T. Prednisolone 5mg was started, OD. S.cortisol repeated after 5 months - 10.65µg/dl. S. ACTH repeated after 1 month of surgery 101pg/ml. 4 months later, I/v/o persistent hyperpigmentation and poor glycemic control, MRI Pituitary repeated, some residual tissue noted. Patient was subjected to a session of radiotherapy and is currently doing well. Conclusion An unusual case of hypokalemia with no obvious features of Cushing's Disease, presented as hypokalemic paralysis and metabolic syndrome, with features of ACTH excess.

YIELD OF SERIAL TESTING FOR TUBERCULOSIS EXPOSURE IN THE STUDY OF A PROSPECTIVE ADULT RESEARCH COHORT WITH INFLAMMATORY BOWEL DISEASES (SPARC IBD)

Abstract BACKGROUND More than 2 million Americans have Inflammatory Bowel Diseases (IBD), including Crohn’s Disease or Ulcerative Colitis. Although tuberculosis is uncommon in the United States, patients with IBD are at an increased risk for active tuberculosis infection due to the immunosuppressant therapies used to treat IBD. Due to this risk, testing for latent tuberculosis is recommended prior to and intermittently throughout administration of most IBD medications. The utility of this practice in a country with a low incidence and prevalence of tuberculosis is unknown. We aimed to determine the proportion of initial and subsequent tuberculosis tests that are positive, negative, or indeterminate. METHODS Data were acquired from SPARC IBD, a component of the Crohn’s & Colitis Foundation’s IBD Plexus research platform. SPARC IBD is a prospective cohort study conducted at 18 centers throughout the USA and includes more than 4,000 patients. Data are collected from SPARC IBD case report forms and the IBD Smartform, diagnoses, test results and prescriptions within the linked electronic medical records. Patients with one or more interferon gamma release assay (IGRA) test for latent tuberculosis were included in this study. The outcome investigated was a positive, negative, or indeterminate lab result. The proportion of positive and indeterminate tests were computed with 95% confidence intervals (CI). Fisher’s exact test was used to detect a change in positive test proportions following a negative test compared to initial lab results. RESULTS A total of 687 patients with one or more IGRA test were identified. The median age was 37 (IQR 27-50) with 54% female patients. Of the initial lab results, 644 tests were negative (93.7%, 95% CI, 91.7, 95.4), 37 were indeterminate (5.4%, 95% CI, 3.8, 7.3), and six were positive (0.9%, 95% CI, 0.3, 1.9). Following an initial negative result, 269 patients received a second test, of which five were positive (1.9%, 95% CI, 0.6, 4.3). Following two consecutive negative results, 142 patients received an additional IGRA test, of which one was positive (0.7%, 95% CI, 0.02, 3.9). The proportion of positive tests was not significantly lower following one negative (p = 0.20) or two consecutive negative tests (p > 0.99). POTENTIAL LIMITATIONS Many patients only had one test for latent tuberculosis, and it is unclear if the initial IGRA labs in our dataset were their first latent tuberculosis tests. CONCLUSIONS Based on the findings of this study, there appears to be value in continued serial testing following a negative result even in the United States, despite the overall low incidence of tuberculosis.

Evolving Role of [18F]Flurocholine PET/CT in Assessing Primary Hyperparathyroidism: Can It Be Considered the First-Line Functional Imaging Approach?

The accurate detection of hyperfunctioning parathyroid tissue (HFPT) is pivotal in the preoperative assessment of primary hyperparathyroidism (PHPT). PET/CT using [18F]fluorocholine ([18F]FCH) showed superior diagnostic performance compared to conventional functional imaging modalities. We aimed to evaluate the diagnostic performance of [18F]FCH PET/CT as a first-line functional imaging approach in patients with clinically diagnosed PHPT. The imaging and clinical data of 321 PHPT patients, including 271 overt PHPT and 50 mild PHPT, who underwent [18F]FCH PET/CT as first-line imaging were analysed in this retrospective study. Histopathology was the reference standard. In case of no available histopathology evaluation (conservative management), imaging and clinical follow-ups were considered reference standards. In the overt group (n = 271), [18F]FCH PET/CT showed sensitivity, specificity, positive predictive value (PPV), negative predictive value (NPV), and accuracy of 0.99, 0.91, 1.00, 0.80, and 0.99, respectively. Regarding the correlation of the index lesions and initial laboratory data, all [18F]FCH PET/CT parameters (SUVs, SULs, and mSAD) were significantly correlated with the serum iPTH level. Additionally, SUVmax, SULpeak, and mSAD were significantly associated with the serum calcium level. In the mild group (n = 50), [18F]FCH PET/CT showed a sensitivity, specificity, PPV, NPV, and accuracy of 0.93, 0.75, 0.95, 0.67, and 0.90. In conclusion, [18F]FCH PET/CT revealed high diagnostic performance in the detection of HFPTs and the potential to be considered as a first-line imaging modality in the assessment of PHPT, including both overt and mild types. However, its cost-benefit concerning the clinical impact of early PHPT detection should be investigated in future studies.

Initial clinical and laboratory parameters triaging non-pharmaceutical acute pediatric poisoned patients for potential adverse outcomes: a three-year retrospective study.

Identifying high-risk pediatric patients with non-pharmaceutical poisoning is crucial to avoid prospective complications and decrease the evident hospital economic burden. Although the preventive strategies have been well studied, determining the early predictors for poor outcomes remains limited. Therefore, this study focused on the initial clinical and laboratory parameters as a triage of non-pharmaceutical poisoned children for potential adverse outcomes taking the causative substance effects into account. This retrospective cohort study included pediatric patients admitted to Tanta University Poison Control Center from January 2018 to December 2020. Sociodemographic, toxicological, clinical, and laboratory data were retrieved from the patient's files. Adverse outcomes were categorized into mortality, complications, and intensive care unit (ICU) admission. Out of enrolled 1,234 pediatric patients, preschool children constituted the highest percentage of the patients investigated (45.06%), with a female predominance (53.2%). The main non-pharmaceutical agents included pesticides (62.6%), corrosives (19%), and hydrocarbons (8.8%), mainly associated with adverse consequences. The significant determinants for adverse outcomes were pulse, respiratory rate, serum bicarbonate (HCO3), Glasgow Coma Scale, O2 saturation, Poisoning Severity Score (PSS), white blood cells (WBCs), and random blood sugar. The cutoffs of serum HCO3<17.55mmol/l, WBCs >8,650 cells/microliter, and PSS>2 points were the best discriminators for mortality, complications, and ICU admission, respectively. Thus, monitoring these predictors is essential to prioritize and triage pediatric patients who require high-quality care and follow-up, particularly in aluminum phosphide, sulfuric acid, and benzene intoxications.

ALUMINUM AND STEEL WELDING WITH 500 W FIBRE LASER

The study of the process of laser welding of various aluminum-steel joints is necessary to promote the possibility of realization of new products and designs in instrumentation and mechanical engineering. Laser welding, due to its many advantages, is considered a very promising process of joining different materials, although its application in industry is still limited. Welding aluminum with steel using laser sources is a challenging task mainly due to the formation of brittle intermetallic joints (IMC) at the joint interface. This paper aims to give a brief overview of some new research on laser welding of aluminum to steel, as well as to point out some of our initial laboratory research in this direction.[1]

Use of Clinical Decision Support to Improve the Laboratory Evaluation of Monoclonal Gammopathies

There is considerable variation in ordering practices for the initial laboratory evaluation of monoclonal gammopathies (MGs) despite clear society guidelines to include serum free light chain (sFLC) testing. We assessed the ability of a clinical decision support (CDS) alert to improve guideline compliance and analyzed its clinical impact. We designed and deployed a targeted CDS alert to educate and prompt providers to order an sFLC assay when ordering serum protein electrophoresis (SPEP) testing. The alert was highly effective at increasing the co-ordering of SPEP and sFLC testing. Preimplementation, 62.8% of all SPEP evaluations included sFLC testing, while nearly 90% of evaluations included an sFLC assay postimplementation. In patients with no prior sFLC testing, analysis of sFLC orders prompted by the alert led to the determination that 28.9% (800/2,769) of these patients had an abnormal κ/λ ratio. In 452 of these patients, the sFLC assay provided the only laboratory evidence of a monoclonal protein. Moreover, within this population, there were numerous instances of new diagnoses of multiple myeloma and other MGs. The CDS alert increased compliance with society guidelines and improved the diagnostic evaluation of patients with suspected MGs.

Tell me more, tell me more: repeated personal data requests increase disclosure

Abstract Personal data is of great commercial benefit and potential sensitivity. However, for the consumers who provide their personal data, doing so comes with potential costs, benefits and security risks. Typically, consumers have the option to consent to the use of personal/sensitive data but existing research suggests consumer choices may only be weakly related to their concerns (the privacy paradox). Here, we examine if the repetitive nature of data requests alters behaviour but not concern, therefore, explaining the divergence. This work is theoretically grounded in ‘Foot in the door’ research in which small initial requests facilitate subsequent larger requests. An initial laboratory study asking for real, personal data demonstrated increased information disclosure at a subsequent request. A second online study replicated the increased information disclosure effect and found no change in associated privacy concern. We find this supports foot-in-the-door as one explanation of the privacy paradox. We suggest ways for businesses and consumers to encourage an acceptable level of disclosure to match personal beliefs for mutual trust and benefit.

Integrating biological and chemical CO2 sequestration using green microalgae for bioproducts generation

Microalgae cultivation is considered an attractive negative emission technology (NET) due to its ability to remove carbon dioxide (CO2) from the atmosphere as well as from flue gases. Moreover, some microalgae can uptake dissolved carbon in the form of bicarbonate (HCO3-) and grow well by removing nutrients from various wastewater effluents without competing with freshwater resources. Conventional carbon mineralization is another NET where carbon is fixed into carbonate minerals such as calcite (CaCO3), magnesite (MgCO3), nesquehonite (MgCO3-3H2O), and nahcolite (NaHCO3), which can be reused in various applications such as construction and cosmetics, and in this case, to supply carbon to microalgae. Previous initial laboratory studies demonstrated the possibility of using metastable carbonates as a source of carbon for biomass growth of the freshwater microalga Scenedesmus obliquus. In this study, we present results from an experimental and modeling work where 100 L open raceway reactors were used to grow an algae polyculture using industrial nitrogen-rich wastewater. In addition, carbonates such as MgCO3-3H2O and sodium carbonate (Na2CO3) were added to the ponds to primarily buffer the pH and maintain it within the acceptable algae physiological values and to provide extra carbon to the cultures. Cultures using BG-11 growth medium and without addition of carbonates were run as controls. Continuous online monitoring of pH, temperature, and dissolved oxygen was performed while nutrients content and dry weight of algae culture were measured offline daily. A mathematical model coupled with geochemistry was implemented to describe the overall process of algae growth, carbonate dissolution, and solution composition. Biomass harvested from the raceway reactors was concentrated and oil and fatty acid methyl esters (FAME) content were determined. Results showed that biomass and oil content obtained were comparable to controls, indicating a successful metabolic-based pH control by the addition of carbonates in the ammonium-based media. Furthermore, FAME analysis revealed different profiles depending on the source of carbon used. Overall, this study suggests that integrating both types of NET strategies can contribute to the reduction of carbon emissions while producing biomass that can be further processed to generate a variety of bioproducts.

Erythrodermic psoriasis eruption following COVID-19 vaccination

Sir, Psoriasis is a chronic inflammatory skin condition affecting roughly 2% of the population. Erythrodermic psoriasis (EP) is its rare and severe variant [1]. It is characterized by acute flare-ups induced by various factors, yet some reports have described the onset or flare-up of EP induced by vaccination. To our knowledge, only two such cases following COVID-19 vaccination have been reported. Herein, we report a case of an EP flare-up after COVID-19 vaccination. A 47-year-old male was referred by our emergency department with diffuse erythema, desquamation, fever, and a poor general condition, arising ten days after the reception of the first dose of the Sinopharm vaccine. He had a history of plaque psoriasis, yet used only topical treatments. He denied any past vaccination-related reaction, recent medication changes, or recent infection. A physical examination revealed diffuse erythema and desquamation on the entire body (Fig. 1a). Initial laboratory investigation revealed hyperglycemia and incidentally discovered diabetes. A COVID-19 PCR test was negative and the peripheral blood smear was normal. He had no history of malignancy and the tumor marker tests were negative. Histopathology was also compatible with erythrodermic psoriasis. He was, thus, diagnosed with the exacerbation of erythrodermic psoriasis associated with the administration of CoronaVac. We commended methotrexate and local treatment with very good improvement.

Outcomes of patients admitted to the intensive care unit with community-acquired pneumonia in a tertiary care center in Riyadh, Saudi Arabia.

Community-acquired pneumonia (CAP) is a leading cause of intensive care unit (ICU) morbidity and mortality. Despite extensive international epidemiological and clinical studies to improve those patients' outcomes, local statistics in Saudi Arabia are limited. The objective of this study is to describe the clinical characteristics and outcomes of patients admitted to the ICU with the diagnosis of CAP reflecting the experience of a tertiary center over an 18-year period. A retrospective cohort study included all consecutive adult ICU patients diagnosed with CAP between 1999 and 2017. Baseline demographics, patients' risk factors, and initial admission laboratory investigations were compared between survivors and nonsurvivors. A multivariate regression model was used to predict mortality. During the study period, there were 3438 patients admitted to the ICU with CAP (median age 67 [Quartile 1, 3 (Q1, Q3) 51, 76] years) and 54.4% were males, of whom 1007 (29.2%) died. The survivors compared with nonsurvivors were younger (65 vs. 70 years), less likely to have chronic liver disease (2.4% vs. 10.5%), chronic renal failure (8.1% vs. 14.4%), and be immunocompromised (10.2% vs. 18.2%), and less frequently required mechanical ventilation or vasopressors (46.2% vs. 80.5% and 29.6% vs. 55.9%, respectively). Acute Physiology and Chronic Health Evaluation (APACHE) II score was significantly higher among nonsurvivors (median score 26 vs. 20) with a longer duration of mechanical ventilation and ICU stay. Using a multivariate regression model, age, APACHE II score, bilirubin level, vasopressors, and mechanical ventilation were significantly associated with increased mortality, while diabetes was associated with lower mortality. Around one-third of patients admitted to the ICU with CAP died. Mortality was significantly associated with age, APACHE II score, vasopressor use, and mechanical ventilation. A comprehensive national registry is needed to enhance epidemiological data and to guide initiatives for improving CAP patients' outcomes.

Changes in Blood Thallium Concentration during and after Prussian Blue Administration

Prussian blue is an antidote for acute thallium poisoning that binds to thallium in the gastrointestinal tract, thereby increasing thallium fecal excretion. However, the effects of Prussian blue monotherapy in humans remain unknown. A 66-year-old male ingested approximately 50 mL of liquid thallium rodenticide (thallium sulfate: 2%), a lethal dose, and presented to our hospital 40 hours after ingestion. The initial laboratory test results were normal. On the second day of admission, oral Prussian blue ordered from outside the hospital was started at a dose of 3 g every eight hours, and the whole blood thallium concentration was measured on consecutive days using inductively coupled plasma-mass spectrometry. On the fourth day, however, he complained of respiratory discomfort, and moderate acute respiratory distress syndrome was diagnosed via chest computed tomography (CT) scan and PaO2/FiO2 ratio. Endotracheal intubation was performed, and Prussian blue was discontinued because of medical costs. The patient died of respiratory failure on the ninth day after admission. The half-life of thallium in whole blood was 53 h under Prussian blue administration.

Acute Pancreatitis Mimicking Acute STEMI Infarction

A 54-year-old male with the history of pancreatitis, arterial hypertension and diabetes was presented to cardiologist with epigastrial pain, inferior STEMI and hypotension. Initial laboratory findings were delayed because of hemolytic serum that caused administration of invasive procedures for ruling out myocardial infarction. The condition causing hypotension was necrotic pancreatitis. This case report highlights the importance of thinking of other not very likely diagnoses in patients with STEMI infarction and the importance of obtaining laboratory findings in time.

PS-R03-5: HYPOTENSIVE AND HYPERGLYCEMIC EFFECTS OF DIAZOXIDE IN A CASE OF INSULINOMA

Case report: We report the case of sporadic insulinoma in a 70-year-old female with breast cancer and hypertension treated by irbesartan 100 mg and benidipine 8 mg, who presented with a 1-month history of episodic tremulousness, diaphoresis, increased hunger, confusion and fainting. Initial laboratory investigations showed low blood glucose (21 mg/dL) and high blood insulin (107 μU/mL) levels. The hypoglycemic symptoms were relieved greatly by glucose administration and Whipple's triad for insulinoma was met. An abdominal contrast-enhanced computed tomography scan showed a 12 mm, small, well demarcated, heterogeneously enhancing lesion within the tail of pancreas without dilatation of pancreatic duct. The site also showed a well-defined accumulation of boundaries on PET-CT. Patient was diagnosed with insulinoma. Since Patient did not initially wish to undergo surgery, blood glucose control was performed by taking diazoxide 225 mg, gradually reduced to 50 mg. Before and after taking diazoxide, blood glucose increased from 75 ± 40 mg/dL to 124 ± 35 mg/dL significantly (p &lt; 0.05). On the other hand, blood pressure was significantly reduced from 141 ± 3/78 ± 3 mmHg to 126 ± 3/75 ± 3 mmHg. Benidipine was withdrawn to about 130/80 mmHg. Then, Patient changed her mind and underwent laparoscopic caudal pancreatic resection. Histopathological examination of the pancreatic mass confirmed neuroendocrine tumor (insulinoma). Patient had an uneventful recovery. Blood pressure re-increased above 140/90 mmHg and benidipine was resumed. Although diazoxide suppresses insulin secretion in the pancreas due to its KATP channel opening action and improves hypoglycemic attacks with insulinoma, it also acts on the KATP channel of vascular smooth muscle and show a hypotensive effect. It is important to pay close attention not only to blood glucose but also to blood pressure fluctuations when using diazoxide.

Echocardiographic Findings of Covid-19 Patients in Canton Sarajevo During the Third Wave of the Covid-19 Pandemic.

Increasing evidence indicates that COVID-19 may result in cardiac issues in certain individuals, such as myocarditis, arrhythmias, and heart failure. Ongoing research on echocardiographic manifestations is still limited. To investigate the incidence and patterns of left and right ventricular dysfunction in COVID-19 patients. This study retrospectively observed COVID-19 patients admitted to the Clinical Center of University of Sarajevo during the third wave, with a particular focus on cardiac evaluations. Our patients, predominantely male 155 (72.4%), with a mean age of 66.2±11.4, having hypertension 86 (40.1%), diabetes mellitus 61 (28.5%), hyperlipidemia 144 (67.3%), were active smokers 87 (40.6%), had family history of cardiovascular diseases 123 (57.5%) and were COVID-19 positive 95 (44.4%), presented because of chest pain 78 (36.4%), dyspnea 103 (48.1%), palpitations 67 (31.3%), fatigue 106 (49.5%) and peripheral oedema 30 (14.0%). COVID-19 patients reported much higher symptoms of dyspnea (65 (68.4%) vs 38 (31.9%)) and fatigue (73 (76.8%) vs 33 (27.7%)) than COVID-19 negative patients. On the initial laboratory report, COVID-19 patients had a significantly (p<0.05) higher mean score of C-reactive protein (24.0±4.8 vs. 6.0±2.1), D-dimer (1.6±2.5 vs 0.8±0.6), ALT (94.8±17.2 vs 36.5±19.9) and creatinine (128.0±80.8 vs. 93.4±40.1) when compared to COVID-19 negative patients. COVID-19 patients had enlarged left atrium diametes (31.6±5.6 vs 27.5±5.3), enlarged left ventricular diameter both in systole (27.9±18.1 vs 23.3±16.3) and diastole (39.3±24.1 vs 34.9±22.7), reduced left ventricular ejection fraction (53.5±9.2 vs 59.8±4.3) and elevated right ventricular systolic pressure (37.0±16.4 vs 35.1±8.6). COVID-19 patients had enlarged left atrium, enlarged systolic and diastolic left ventricular diameter, reduced left ventricular ejection fraction and elevated right ventricular systolic pressure.

Factors Associated With Short-Term Outcomes of Burr-Hole Craniostomy Associated With Brain Re-Expansion and Subdural Hematoma Shrinkage for Chronic Subdural Hematoma.

Chronic subdural hematoma (CSDH) is a commonly encountered neurosurgical pathology that frequently requires surgical intervention. With an increasingly aging demographic, more older people and patients with comorbidities will present with symptomatic CSDH. This study evaluated clinical and laboratory factors affecting the short-term outcomes of CSDH after surgical intervention. We retrospectively analyzed 170 patients who underwent burr-hole trephination for CSDH in a single institution from January 2019 to December 2021. All patients were examined for risk factors and evaluated for hematoma thickness change and midline shifting on brain computed tomography (CT) scans at 3 days after burr-hole trephination. This consecutive series of patients included 114 males (67.1%) and 56 females (32.9%); mean age 72.4±12.5 years. Renal disease (p=0.044) and prior intracranial hemorrhage (p=0.004) were clinical factors associated with poorer prognosis. A statistically significant association was found between initial laboratory findings, including high creatine kinase (p=0.025) and low platelet (p=0.036) levels, and CT findings 3 days postoperatively. The 3-day mean arterial pressure and postoperative ambulation were not significantly associated with outcomes. Burr-hole craniostomy is an effective surgical procedure for initial CSDH. However, patients with a history intracranial hemorrhage and abnormal laboratory findings, such as low platelet levels, who underwent burr-hole trephination had poor short-term outcomes. Therefore, these patients should be carefully monitored.

Clinical characteristics, course and outcome of critically ill COVID-19 patients with previous or current TB admitted in ICU of a tertiary care COVID centre of Indian subcontinent.

Clinical characteristics, course and outcome of critically ill COVID-19 patients with previous or current TB admitted in ICU of a tertiary care COVID centre of Indian subcontinent.